The Epidemic of Chronic Disease: Medicare Health Support as a Response

1. The Epidemic of Chronic Disease:Medicare Health Supportas a Response

2. Growing Prevalence of Chronic Conditions 141 M 125 M Source: RAND

3. 70 Million Americans with Multiple Chronic Conditions in 2010 70 Million 60 Million Source: RAND

4. Beneficiaries With 5 or More Chronic Conditions Account for Two-Thirds of Medicare Spending Source: Medicare 5% Sample, 2001

5. Context Fee-For-Service Medicare • 35 million people • $281 billion/year (projected 2005)

6. What is Medicare Health Support (MHS)? • Enacted in Medicare Modernization Act • Three year randomized controlled studies of chronic care management in fee-for-service Medicare • Conditions: Heart failure and complex diabetes (95% have co-morbidities) • Eight pilot programs, with one in Maryland/DC • Size per program: 20,000 beneficiaries in intervention group, 10,000 beneficiaries in control group • Awardees have 100% risk for fees to improve costs a net 5% over control group • Program may be expanded to entire nation after two years

7. Program Locations

8. Key Program Features • Voluntary • No charge to participants • No change in Medicare benefits, choice of providers or claims payment • Supportive, not restrictive • Not a substitute for current care

9. Expected Results • Improved health and quality of life • Lower average Medicare costs • Reduced complications, emergencies and hospital admissions • Increased adherence to evidence-based care guidelines • Better coordination of care through use of new health information and communication technologies

10. American Healthways • Founded 1981 • Operate the most sophisticated care management centers in the country • Every care enhancement program designed to support the patient-physician relationship

11. American Healthways MHS Program • Disease Management for 76% • Telephonic, RNs • Outbound scheduled calls • Geriatric assessments • Improve adherence to physician care plan • Patient empowerment • Intensive Case Management for 20% • Telephonic and face-to-face, RNs and Geriatric NPs • High risk for hospitalization • Coordination with physician(s) • Coordinate community resources • Long Term Care Management for 4% • Face-to-face in nursing homes, RNs and Geriatric NPs • End-of-life planning, pain & palliative care, hospice referral • Early detection of potentially reversible causes of hosp admissions

12. Medicare Health Support Goals • Improved quality of care • Increased beneficiary and provider satisfaction • Medicare cost savings Win - Win - Win for beneficiaries, providers and Medicare