CMS demo targets patients with complex needs

Wednesday, August 31, 2005

WASHINGTON -- CMS has chosen six organizations -- three physician-based, two integrated and one disease management -- to rein in the costs of patients with complex medical needs.
The Care Management for High Cost Beneficiaries demonstration differs from previous disease management programs run by CMS in that it is provider-based, as opposed to using third-party vendors. It will test the ability of direct care provider models to coordinate care for high-cost/high-risk beneficiaries by providing them with clinical support beyond traditional settings to manage their conditions.
To cover administration and management costs, the participating organizations will receive a monthly fee for each beneficiary, but they will be required to meet established performance standards for achieving savings to Medicare. Savings projections for each organization will be based on past performance in a commercial market.
According to Suneel Ratan of ACCENT, a consortium of physician clinics in Oregon and Washington and one of the chosen organizations, Medicare's savings requirement is pretty straightforward.
"All of the projects are required to guarantee savings of 5% of government Medicare expenditures for the intervention group net of the intervention," he said. "In terms of the savings we will achieve, the key variable is utilization, and particularly inpatient hospitalizations."
Ratan said their consortium will work with patients with disease states like COPD, congestive heart failure and diabetes. He said that Accent's concept is that doctors using their program to coach and monitor patients can spot problems early, or prevent them from happening to begin with, thus preventing some hospitalizations.
HME suppliers will be involved in the demonstration project to the degree that if home medical equipment is needed, it will be provided, according to CMS. The ACCENT program has developed a system of care around a piece of equipment, called the Health Buddy, in conjunction with provider education and support.
According to CMS, the demonstration project will target Medicare beneficiaries who often don't get prevention-focused care. Patients for the participating organizations will be identified by CMS based on a combination of clinical diagnoses, cost and risk cutoffs, and they'll be different for each site.
"What we pay for is a bundled fee for a package of services delivered as needed," said a CMS official.
"We're really taking an understanding of someone's risk profile and customizing the services, with the end goal being keeping them out of the hospital. The services are customized between and within a program."