Finding the best approaches to managing chronic care

Finding the best approaches to managing chronic care
3/30/2009 10:29:36 AM
First Word

Mark E. Neumann

On a typical sports team, whether it's baseball, football, hockey, or my favorite-automobile racing- members have a specific position or task: short stop, tight end, goalie, tire changer. Individual responsibilities are combined to form a cohesive team effort. Chronic care is no different. It demands the same team approach, mainly because it involves multiple disciplines.

Treating the disease at pre-dialysis stages is a challenge. The need is there; screenings of individuals has helped us identify more than 26 million people in the United States with some stage of kidney disease.

How do we create a continuum of care that is cost effective?

In December 2005, The Centers for Medicare & Medicaid Services launched a demonstration to test the effectiveness of disease management for patients with kidney disease. DaVita Inc., through its VillageHealth subsidiary, and Fresenius Medical Care North America, through its Fresenius Medical Care Health Plan, were selected for the four-year demonstration, which set a capitated payment for ESRD care. Patients in California, Pennsylvania, Texas and Massachusetts are part of the demonstration that continues for both providers through the end of this year. CMS reserves 5% of the capitation rate for incentive payments related to quality improvement.

During that time period, DaVita participated in a second demonstration with CMS as part of the agency's Care Management for
High Cost Beneficiaries program. DaVita's program, called the Key to Better Health, applied disease management principles to treating patients at pre-dialysis stages. The three-year project had healthy enough results that it is being extended another three years in the Long Island, N.Y. area. Under the new contract, only patients with Stage 4 and Stage 5 (end-stage) will be included.

The contract was one of three demonstrations that CMS extended for treating chronic care patients. CMS said the demonstrations have three goals:

* Increase adherence to evidence-based care

* Reduce unnecessary hospital stays and emergency room visits

* Help participants avoid costly and debilitating complications

DaVita hopes to develop a integrated care management approach for ESRD patients in the dialysis facility. If that proves successful, the provider would later apply the same combined learning outside the dialysis facility to CKD patients.

Allen Nissenson, MD, chief medical officer for DaVita, said successful integrated care also relies on more patient buy-in, especially in the end-stage care process. "We're focused on patient involvement (in the KTBH demonstration). We want to motivate patients to be fully engaged," Nissenson said.

Creating incentives
For integrated care to work, nephrologists will need to take on a larger role in the care of the ESRD and CKD patient. "The current payment structure must create an incentive for a considerable investment in comprehensive patient management by enabling providers to keep the savings that result from the better outcomes these investments create," Nissenson said.

And, if nephrologists take on a "principal care" role and provide more comprehensive management of the ESRD or CKD patient, there must be appropriate incentives for that level of care.

Integrated care management for chronic diseases has been considered before. In a study published Feb. 11 in the Journal of the American Medical Association, researchers reviewed the outcomes of 15 demonstration projects of coordinated care programs for Medicare beneficiaries with chronic illnesses. Only two of those programs reduced hospital admissions, and none of the programs generated net savings. What did work: higher rates of in-person contact, instructions for patients on how to take their medications, timely information on patient hospitalizations, and good communication with physicians.

Conclusion
If we are looking at teamwork, individuals with ESRD or CKD can benefit from access to multiple specialists. The key is coordinating the tasks and putting together the right game plan.

Mr. Neumann has been the executive editor of NN&I since 1989.

http://www.nephronline.com/features.asp?F_ID=420