View
216
Download
0
Category
Preview:
Citation preview
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
1/26
StatementofKennethE.Thorpe,PhD
SenateSpecialCommitteeonAging
HearingOn
StrengtheningMedicareforTodayandtheFuture
Wednesday,February27,2013,3:00pm.
Dirksen106
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
2/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
2
Goodmorning,Senators.Thankyouforinvitingmeheretodaytodiscusstheurgentneed
toreformhealthcaredeliveryintheUnitedStatesandthepivotalrolethatprimarycare
providersmustplayinachangedsystem.IamKenThorpe,chairmanofthedepartmentof
healthpolicyandmanagementatEmoryUniversity.IalsoleadthePartnershiptoFight
ChronicDisease,anationalcoalitionofpatients,providers,communityorganizations,
businessandlaborgroups,andhealthpolicyexpertsthatisworkingwithstate
partnershipstopreventchronicillnessandreformhowwedelivercaretopatients.In
addition,IsitontheboardofthePartnershipfortheFutureofMedicare.
Craftingeffectivesolutionstofurtherreductionsinthegrowthinentitlementprograms
requiresaclearunderstandingofwherethedollarsarespent,andthefactorsdrivingthe
growthinspending.Todate,simplycuttingpaymentstoprovidersandMedicare
Advantageplanswillachievebudgetsavings,buttheydonotreducecostsandovertime
mayultimatelyreduceaccesstocare.VirtuallyallthespendingintheMedicareprogramis
associatedwithchronicallyillpatients.Highandrisingprevalenceofchronicdiseasessuch
asdiabetesareakeycontributortothegrowthinMedicarespending.Yetdespitethe
centralrolethatchronicdiseaseplaysinMedicare,theprogramdoesnotcoverlifestyle-
relatedpreventivebenefitsandcurrentlydoesnotprovidecomprehensivecare
coordinationformostpatients.AkeydirectionforreformingMedicareneedstofocuson
reducingtheriseinpreventablechronichealthcareconditions,andintroducingevidence-
basedelementsofcarecoordinationintotraditionalMedicare.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
3/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
3
Fortunately,wehaveasubstantialbodyofpublishedresearchhighlightingtheimpactthat
keyelementsofcarecoordinationandpreventionhaveonreducingspendingand
improvingquality.ComponentsofthesedataarederivedfromtheexperienceofMedicare
Advantageplans,animportantpartoftheMedicareprogram,aswellasothercare
coordinationinitiativesintheprivatesector.1Identifyingthebestpracticetechniquesand
adoptingthemintotraditionalMedicareshouldbeakeyfocusofentitlementreform.These
keypreventionandcarecoordinationinitiativesthathaveprovenclinicallyeffectiveand
costreducingincludetransitionalcare,comprehensivemedicationmanagement,health
coaching,andteambased,wholepersonfocused,care.Inadditiontocarecoordination,
makingevidence-basedprogramslikethediabetespreventionprogram,aprogramwith
establishedresultsthatreducetheincidenceofdiabetesandrelatedchronicconditions
amongadults(andseniorsinparticular)shouldbeaddedtotheMedicareprogram.
IntroductionofthesepreventiveandcarecoordinationinitiativesintotraditionalMedicare
willslowthegrowthinspendingandimprovethequalityofcareprovided.
VirtuallyallthespendingintheMedicareprogramisassociatedwithpatientswithmultiple
largelyunmanagedchronicconditions.Recentresearchexaminingthegrowthinspending
intheMedicareprogramfoundthat:
1Thorpe,KE,TheMedicareAdvantageExperience:LessonsforReformtoOriginalMedicare.manuscript.,
December2012.EmoryUniversity.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
4/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
4
About95percentofspendingintheprogramisassociatedwithpatientswithoneormorechronichealthcareconditions;2
Over53percentofMedicarepatientsweretreatedforfiveormorechronicconditionsduringtheyear.Thesepatientsaccountedfornearly78oftotalMedicare
expenditures.3(SeeAppendix1).
MostoftheriseinMedicarespendingistracedtorisingratesoftreateddiseaseprevalenceandincreasedintensityoftreatment;
Nearly85percentofthegrowthinMedicarespendingsincethelate1980sisassociatedwithpatientstreatedforfiveormoremedicalconditions;(tabulationsfrom
Appendix1).
Risingratesofobesityamongseniorsaccountsforapproximately10percentoftheincreaseinspending;4
TwentypercentofhospitalizedMedicarepatientsarereadmittedtothehospitalwithina30daywindow.Thesereadmissionsarepotentiallypreventableandcould
accountformorethan$500billioninspendingoverthenextdecade.5
One-fourthofalladultswenttoanemergencyroomforaconditionthatcouldhavebeentreatedinamorecost-effectivenon-emergentsetting.
Collectively,thesedatahighlighttheneedforpolicyproposalsthataredesignedtoreduce
theriseintheincidenceofpreventablechronicdisease,moreeffectivelymanageand
engagechronicallyillpatients,andreduceclinicallyunnecessaryuseofhealthcare
services.
Theremainingpartofmytestimonywillfocusonthreeissues.First,whatchangeshasCMS
madetostartintroducingelementsofcarecoordinationintothetraditionalMedicare
2http://www.fightchronicdisease.org/sites/fightchronicdisease.org/files/docs/Thorpe%20-%20Care%20Coord%20Savings%20-%20Final-1.pdf
3http://content.healthaffairs.org/content/25/5/w378.full.pdf+html
3http://content.healthaffairs.org/content/28/5/w822.full
5http://nyshealthfoundation.org/uploads/general/conversation-with-kenneth-thorpe-diabetes-prevention-program.pdf
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
5/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
5
program.Second,howcanweacceleratetheadoptionofteambasedcarecoordinationin
traditionalMedicare?Alongtheselines,whatdothepublishedrandomizedtrialsplusthe
experiencewiththeprivatesectortellusabouttheelementsofcarecoordinationthat
improvequalityandhealthoutcomesandreduceMedicarespending?Third,howcanwe
replicateandscalethesebestpracticesintotraditionalMedicareoverthenextcoupleof
years.TheMedicareprogramneedstopivotquicklyfromapilotmentalitytothe
implementationofbestpracticesprogramwide.
ProgresstoDate
Medicarecurrentlycoversseveralpreventiveservices,includingawiderangeofclinical
preventiveservices.Inaddition,theprogramalsocoversaninitialpreventionphysical
exam,andanannualwellnessvisitthatcouldincludeahealthriskappraisalanda
personalizedpreventioncareplan.Howeverwhiletheprogramiswellsuitedtoidentifying
at-riskseniors,itdoesnotcoverservicesthatwouldallowseniorstoaddresstheserisk
factors.Forinstance,Medicaredoesnotcoverintensivelifestyleinterventionslikethe
diabetespreventionprogramorFDAapprovedobesitymedicationsdesignedtoassist
obeseseniorsatriskforarangeofchronicconditions.Inshort,Medicarewillhighlightthe
needforanactionplanandidentifyat-riskseniors,butprovidesnocoveragethatwould
actuallyassistseniorsinhelpingmeetlifestylegoalspersonalizedcareplan.Moreover,
Medicarehastraditionallynotcoveredanycarecoordinationthatwouldengageseniors
withmultiplechronicconditionstoremainhealthyandoutofthehospital,ERorclinic.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
6/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
6
TheCenterforMedicareandMedicaidServices(CMS)hasstartedtointroduceelementsof
carecoordination,thoughinawaythatmayinhibittheabilitytoallowbestpracticeteam
basedapproachesflourishintheprogram.Aspartofits2013MedicarePhysicianFee
Schedule,theCentersforMedicareandMedicaidServices(CMS)startedtointroduce
elementsofcarecoordination.The2013feeschedulenowincludesnewcodes(HCPCSG-
code)thatwillallowphysicianstoreceiveabundledpayment(onlyabout$55onaverage)
toprovidetransitionalcareservicestopatientsdischargedfromahospital,nursinghome
orrehabilitationfacility.6Whilethisiscertainlyanimportantfirststarttowardintroducing
carecoordinationintotraditionalMedicare,transitionalcaremanagementislikelybest
providedbytrainednursepractitioner,ornursecoachesusingevidence-basedmodelsthat
Iwilldiscussfurtherbelow.Moreover,usingmultiplebillingcodesmaymakethetransition
toteambasedcare(nurses,nursepractitioners,mentalhealthworkers,pharmacists,social
workersandothers)thatprovideabroaderrangeofcarecoordinationfunctionsdifficultto
achieve.
OptionsforIncludingEvidence-BasedPreventionandCareCoordinationinto
TraditionalMedicare
Designingevidenced-basedpreventionandcarecoordinationapproachesfortraditional
Medicarerepresentsamajorpolicychallenge.Oneplacetostartistoexaminethe
6BindmanA,BlumJ,KronigR.MedicaresTransitionalCarePayment-ASteptowardtheMedicalHome.NEJM
2013;368(8):692-694.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
7/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
7
experiencewithMedicareAdvantageandseewhatevidenceexistsaboutbestpractice
approachesforreducingcosts,improvingqualityandensuringpatientsatisfactionthat
couldbemadeavailabletothosebeneficiarieswhoaccountforthelargestsegmentofthe
MedicarepopulationthoseintraditionalMedicare.InadditiontoMedicareAdvantage,
thereisaconsiderablebodyofpublishedresearchthathasevaluatedcoreelementsofcare
coordination.RecentpublicationshavedemonstratedthatinnovativeMedicareAdvantage
programscanreducetotalMedicarespendingandprovidethesameorbetterqualityof
carethantraditionalMedicarebyupto15to20percent.7Howdotheseplansachieve
thesesavings?Theyusepredictivemodeling,targetinterventionstowardhigh-riskseniors,
transitionalcare,highriskcasemanagement,medicationtherapy,managementand
adherence,healthcoaching,andteam-basedcare,amongothers.8Thedataalsohighlight
theimportanceofcloseinteractionandintegrationofcaremanagersandphysician
practices.HealthteamsinVermontandNorthCarolinaaregoodexamplesofthisclose
interactionbetweencarecoordinatorsandproviderspractices.Largerandomizedtrials
havealsoevaluatedtheimpactofcomprehensivelifestylemodificationinterventionssuch
7MilsteinA,GilbertsonE.AmericanMedicalHomeRuns,Fourreallifeexamplesofprimarycarepracticesthat
showabetterwaytosubstantialsavings.HealthAff(Millwood)2009;28(3):1317-1326,andLandonBEetal.
AnalysisofMedicareAdvantageHMOsComparedwithTraditionalMedicareShowsLowerUseofManyServices
During2003-2009,HealthAff(Millwood).2012;31(12):2609-2617andCohenR,etal.MedicareAdvantageSpecial
NeedsPlansBoostedPrimaryCare,ReducedHospitalUseamongDiabeticPatients.HealthAff(Millwood)2012;
31(1):100-119.
8http://content.healthaffairs.org/content/31/6/1156.full
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
8/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
8
astheDiabetesPreventionProgramandtheStanfordChronicDiseaseManagement
Program.9
Ihaveoutlinedseveralstepsthatwouldbeneededtointegrateevidence-basedprevention
andcarecoordinationintothetraditionalMedicareprogram.Carecoordinationcouldbe
offeredasanopt-outserviceforallpatientsinthetraditionalMedicareprogram.The
serviceswouldbeofferedbyhealthplans,homehealthagencies,managedcarevendors,or
othersthatcouldprovidetherangeofservicesoutlinedbelow.Carecoordinatorswouldbe
selectedthroughcompetitivebidding.Anotheroptionwouldbetogiveseniorsofchoiceof
stayingintraditionalMedicare(withnopreventionandcarecoordination)orselectinga
newversionoftraditionalMedicare,MedicarePlusthatwouldincludethecare
coordinationservices.
TransformingtraditionalMedicarewouldrequirethefollowingsteps:
1. TransitionAwayfromFee-for-Service
AkeytointroducingcarecoordinationintotraditionalMedicareistotransitionawayfrom
fee-for-servicepaymentsandasastartreplaceitwithmorebundledpayments.The
incentivestoincreasethevolumeofservicesinfee-for-serviceruncompletelycounterto
theincentivestoprovideclinicallyeffectivecarecoordination.Asfee-for-serviceisphased
outovertime,itwouldbereplacedbybundledpaymentsfor(most)hospitaladmissions
9http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61457-4/fulltextand
http://patienteducation.stanford.edu/programs/cdsmp.html
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
9/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
9
thatincludeallcoveredpost-acutecareservices30daysafterdischarge.Thereisbroad
agreementthatMedicaresfee-for-service(FFS)paymentmodelisoutdated,drivesup
additionalvolumeofservicesandmustbereplacedtoimprovehealthcaredelivery.Our
entirehealthcaresystemisbuiltaroundFFSandupdatingourcurrenthealthcaredelivery
structurewillsetthestageforaninnovative,high-qualityhealthcaresystem.However,
transitioningawayfromFFSwillnotbeeasyandwillnothappenovernight;reformingthe
Medicaresystemsothatitpaysforqualitywillrequiresignificantdatacollectionand
monitoring,updatestoregulations,andtestingandscalingofnewandinnovativepayment
modelsandincentives.AdvancingtheseobjectivesandfacilitatingagradualshiftfromFFS
medicinewilltaketimeandwillthereforelikelyoccurinstagesandleadtoanumberof
newpaymentmodelreforms.Asaninterimstep,broaderuseofbundledpaymentswith
qualitycontrolsfocusedonhealthimprovementwouldprovideausefultransitionalstep.
Physicianpracticesthatworkwithhealthteamstoprovidecarecoordinationservices
(outlinedbelow)shouldreceiveabundledpaymentaspartoftheircollaborationwiththe
healthteams.
2. AddInterventionsthatAvertDiseaseAmongOverweightandObeseAdultsintotheMedicareprogram
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
10/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
10
Perhapsthebest-knownlifestylemodificationprogramistheDiabetesPreventionProgram
(DPP).RandomizedtrialsofotherprogramssuchastheStanfordChronicDisease
ManagementProgramproduceresultssimilartotheDPP.TheoriginalDPPprotocolwas
deliveredtooverweight,pre-diabeticadultsonaone-on-onebasis.Thelargescale
randomizedtrialoftheDPPfoundthatlifestyleinterventionreducedtheprevalenceof
diabetesby58percentrelativetoplacebo.Thereductionindiabetesprevalence(aswellas
hypertension)wastracedtoa7percentreductioninweightamongparticipants.The
largestreductionsinweightanddiabetesprevalenceoccurredamongparticipantsaged60
andolder.Those60andolderlostanaverageof8.2percentoftheirstartingweightafter
12monthscomparedto7.5percentforthoseaged45to59and6.6percentforadults
underage45.10Asaresult,theprevalenceofdiabeteswas71percentlowerthanplacebo
forthose60andoldercomparedtotheoverallaverageof58percent.11.Inotherwords,
amongevery100overweightorobeseadultswhocompletedtheintensivelifestyle
intervention19outofanexpected33failedtodevelopType2diabetes.Forthose19
individuals,thesocialandfinancialcostsofanewdiabetesdiagnosisforsuchnecessities
asadditionaltests,diabeteseducation,glucosemeters,teststrips,andmoreintensive
managementofothercardiovascularriskfactorswereavoided.Moreover,forevery100
adults,8avoidedtheneedforbloodpressureandcholesterolmedications.
MakingtheDPPacoveredbenefitundertraditionalMedicarewouldsavetheprogram
moneyandimprovehealthoutcomes.Thisproposalwouldbuildonthefoundationofthe
10http://www.nejm.org/doi/pdf/10.1056/NEJMoa012512
11http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
11/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
11
YMCAcommunitybaseddiabetespreventionprogramsinplace,andcurrentlyunder
expansion.Thisproposalwouldallowpre-diabeticorotheratriskseniors(basedonthe
resultsoftheirwellnessplanandaspartofthepersonalizedpreventionplandevelopedby
theirphysician)overweightandobeseseniorswouldbeeligibletoenrollintheprogram.
Dependingonparticipatingrates,justenrollingonecohortofoverweight,pre-diabetic
seniorsintotheprogramwouldgenerateanetsavingstoMedicareofabout$2to$4Billion
over10yearsandmorethan$6to15Billionduringthelifetimesofthoseparticipatingin
theprogram.12Similarconsiderationshouldbegiventoincludingtherecentlyapproved
FDAweightlossdrugsasacoveredMedicarebenefitinlightoftheimpacttheyhaveon
weightloss(around10to15percentreductions).
3. ContractwithhealthteamstoprovidecarecoordinationforchronicallyillMedicarepatients.
OverhalfoftheMedicarepopulationisundertreatmentfor5ormorechronichealthcare
conditions.Theseincludementalhealth,behavioralhealth,andcardiovascularevents
amongothers(diabetes).Effectiveprovisionofteam-basedprimarycarehasbeenshown
12ThorpeKEandYangZ.Enrollingpeoplewithprediabetesages60-64inaprovenweightlossprogramcouldsave
Medicare$7Billionormore.HealthAff(Millwood)2011;30(9):1673-1679
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
12/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
12
toimprovethequalityofcareatlowercosts13.Thereforeeffectivecomprehensiveclinical
engagementrequiresmulti-specialtyteamsofproviderswiththeflexibilitytousetheir
resourcesbasedonthepatientsneeds.Thereisagrowingbodyofevidencethathas
identifiedthekeyfunctionsperformedbyhealthplansandsuccessfulcomprehensive
team-basedcarecoordinationmodelsinmanagingchronicallyillpatients.Health(or
chroniccare)teamsincludeaclinicalleader(nurse,nursepractitioner)coordinatingthe
careplanprovidedbythephysician,nurses,nursepractitioners,pharmacists,social
workers,behavioralhealthspecialistsandhealthcoaches.Theseteamswouldprovidethe
followingevidencebasedfunctionswhencoordinatingcarel.14Coordinationofcareforall
coveredMedicareservicesutilizingateam-basedapproach
Approachesthatprovideawholepersonfocusonpreventingdiseaseandmanagingacute,andmentalhealthservices
Medicaladvicefromacarecoordinatoravailable24/7 Assessmentofpatientriskperhapsanddevelopmentofanindividualizedcare
plan
ComprehensiveMedicationManagement Transitionalcareandhealthcoaching Regularcontactwithenrollee Closeintegrationofthecarecoordinatornurseandprimarycare(and
specialist)physicians
13MedicarePaymentAdvisoryCommission.2008.ReporttotheCongress:Reformingthedeliverysystem.
WashingtonDC:MedPAC.
14
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
13/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
13
Evidence-basedhealthcoachingtotrainpatientself-managementskillsandfacilitatebehaviorchange.
Theseactivitiesprovidethefoundationforcostsavingsmovingforwardandimproved
healthoutcomeswhencoordinatingcareforchronicallyillpatients.Eachofthemajor
functionsoutlinedabove(transitionalcare,medicationadherence,healthcoaching)have
severalpublishedrandomizedtrialsshowingtheyindividuallyresultinimprovedhealth
outcomesatlowerlevelsofhealthcarespending.Collectivelytheyserveasapowerful,
team-basedapproachtogeneratesubstantialprovensavingsandimprovedqualityofcare.
Abriefsummaryofsomeoftherandomizedtrialshighlightingtheclinicaleffectivenessand
costsavingsassociatedwiththesecarecoordinationfunctionsispresentedbelow.
TransitionalCare.
TwoofthebestknownmodelsoftransitionalcarehavebeendevelopedbyEricColemanat
theUniversityofColoradoandMaryNaylorattheUniversityofPennsylvania.Theteamat
Penndefinestransitionalcareasprovidingcomprehensivein-hospitalplanningandhome
follow-upforchronicallyillhigh-riskolderadultshospitalizedforcommonmedicaland
surgicalconditions.TheheartofthemodelistheTransitionalCareNurse(TCN),who
followspatientsfromthehospitalintotheirhomesandprovidesservicesdesignedto
streamlineplansofcare,interruptpatternsoffrequentacutehospitalandemergency
departmentuse,andpreventhealthstatusdecline.WhileTCNisnurse-led,itisa
multidisciplinarymodelthatincludesphysicians,nurses,socialworkers,discharge
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
14/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
14
planners,pharmacists,familycaregivers,andothermembersofthehealthcareteaminthe
implementationoftestedprotocolswithauniquefocusonincreasingpatients'andfamily
caregivers'abilitytomanagetheircare.ForthemillionsofAmericanswhosufferfrom
multiplechronicconditionsandcomplextherapeuticregimens,TCMemphasizes
coordinationandcontinuityofcare,preventionandavoidanceofcomplications,andclose
clinicaltreatmentandmanagement-allaccomplishedwiththeactiveengagementof
patientsandtheirfamilyandinformalcaregiversandincollaborationwiththepatient's
physicians.Moreinformationisavailableathttp://www.transitionalcare.info/.
Asecondmodel,developedbyEricColemanusestransitioncoachestotrainpatientsand
familycaregivershowtomanagetheircare.Transitioncoachesaregenerallynot
physicians,butarenursepractitioners,nurses,orcommunityhealthworkers.Tosmooth
transitionsfromhospitaltohome,theCareTransitionsIntervention(CTI)usescoaching
andhomevisitsbytrainedcarecoordinators.Thecoachmakesonehomevisitandseveral
phonecallstothepatientovera30daywindow.Moreinformationonthisprogramis
availableatwww.caretransitions.org.
Accordingtorandomizedtrials,bothprogramsreducedramaticallyhospitalreadmission
rates.AmongMedicarepatients,theTCIprogramreduced30dayreadmissionsby30
percent.andat90dayshospitalcostsby25percent.15RandomizedtrialsoftheTCN
15ColemanEA,etal.TheCareTransitionsIntervention,ResultsofaRandomizedControlledTrial.ArchInternMed.
2006;166:1822-1828
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
15/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
15
modelhavedemonstratedreductionsinreadmissionsof56percentwithsimilar
reductionsintotalMedicarespendingafteroneyear.16
ComprehensiveMedicationManagement
Poormedicationmanagementaddssubstantiallytotheoverallcostofhealthcare,bysome
estimatesaddingover$200billionperyearinadditionalhospitalandotherspending.17
Comprehensivemedicationmanagementprovidedaspartofanintegratedhealthteamhas
showntosaving$1.29inhealthcarespendingforevery$1spenttoadministerthe
program.18Moreover,arecentlysummaryofthepublishedresearchliteraturebythe
CongressionalBudgetOffice(CBO)foundthatadherenceandpersistencyintaking
medicationsalsoreducesspending.SpecificallytheCBOfoundthatevery1percent
increaseinprescriptionsfilledwouldreduceMedicarespendingby0.25percent.19Under
thePartDprogram,drugplansmustoffermedicationtherapymanagementprogram
(MTM).However,thecriteriafortargetingMedicarebeneficiariesenrolledinPartDplans
16MDNaylor,DABrooten,RLCampbell,GMaislin,KMMcCauley,J.S.Schwartz.Transitionalcareofolderadults
hospitalizedwithheartfailure:arandomized,controlledtrial.JournaloftheAmericanGeriatricsSociety.May
2004;52:675-84.Seealso:MDNaylor,DBrooten,RJones,etal.Comprehensivedischargeplanningforthe
hospitalizedelderly.AnnalsofInternalMedicine1994;120(June):999-1006. MD Naylor, DA Brooten, R Campbell,
et al. Comprehensive discharge planning and home follow-up of hospitalized elders. Journal of the American
Medical Association 1999; 281:613-20. MD Naylor. Transitional care of older adults. Annual Review of Nursing
Research. 2003; 20:127-47.
17JohnsonJA,BootmanJL.Drug-relatedmorbidityandmortality:acostof-illnessmodel.ArchInternMed.1995;155:1949195618D. Ramalho de Oliveira, A. Brummel, and D. Miller, Medication Therapy Management: 10 Years of Experience
in a Large Integrated Health Care System,Journal of Managed Care Pharmacy 16, no. 3 (April 2010): 18595.
19CongressionalBudgetOffice,OffsettingEffectsofPrescriptionDrugUseonMedicaresSpendingforMedical
Services.CBOWashingtonDCNovember2012.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
16/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
16
arethosewithmultiplechronicconditions(maximumof3)andwithexpectedannualdrug
spendingfor2013of$3,144.20However,thecurrentMTMprogramwouldnotinclude
patientswithhighPartAandBmedicalcoststhatmaynotbeappropriatelytaking
medications(non-adherent,etc)andwouldnothitthe$3,144spendingthreshold.Indeed,
poormedicationmanagementhasbeenlinkedto32percentofallhospitalizationsanda
keycauseofpreventableadverseeventsamongMedicarepatients.21Recentstudieshave
demonstratedthatteambasedmedicationmanagementcare,aspartofanoverallcare
coordinationclinicalstrategy,reducedthegrowthinspendingby11percent.22
AspartofthenewcarecoordinationservicesintraditionalMedicare,thecurrentMTM
programshouldbebroadenedandintegratedintotheoverallsetofcarecoordination
servicesprovided.Apharmacistworkingaspartofthecarecoordinationteamwouldwork
withpatientsthathavehighprioryeartotalMedicarespending(notjustthosewithhigh
PartDspending)toresolvedrugtherapyissues(drugeffectiveness,dosage,compliance
andadherence).Thisbroaderapproachwould,aspartoftheoverallcarecoordination
team,linkmedicationmanagementandresolvingdrugtherapyproblemstoclinical
improvementsinseniors.Substantialworkhasalreadybeencompletedonthedesignof
20http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Memo-
Contract-Year-2013-Medication-Therapy-Management-MTM-Program-Submission-v041012.pdf
21atwww.oig.hhs.gov/oei/reports/oei-06-09-00090pdf,andSmithM,etal.,Whypharmacistsbelonginthe
medicalhome.HealthAff(Millwood)2010;29(5):906-913
22IsettsB.etal.Managingdrug-relatedmorbidityandmortalityinthepatientcenteredmedicalhome.MedCare
2012;50:994-1001
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
17/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
17
suchabenefitfromthePatient-CenteredPrimaryCareCollaborativeandtheAgencyfor
HealthcareResearchandQualityInnovationExchangeQualityToolkit.
HealthCoachingandPatientLiteracy
Coachingprovidespatientswithoneormorechronicconditionstounderstandtheircare
plan,participateinshareddecisionmakingwiththeirhealthcareproviders,andmore
effectivelynavigatethehealthcaresystem.Understandthecareplan,andworkingto
consistentlyexecuteitisanimportantapproachforreducingunnecessaryutilizationof
healthcareservices.TheHealthEffectivecoachingempowersindividualswithawide
rangeofconditionsincludingbutnotlimitedtochronicconditions,toparticipatein
medicaltreatmentdecisionswiththeirdoctors.Coachingwouldbeanotherkeycomponent
ofcarecoordinationservicesprovidedintraditionalMedicare.Alargerandomizedtrial
conductedbyHealthDialogandpublishedintheNewEnglandJournalofMedicineutilized
telephonichealthcoachingtoworkwithalargepopulation(morethan174,0007,000of
whomwereMedicarepatients)ofpatients.23Thisrecentrandomizedtrialshowedthat
totalhealthcarespendingwas3.6percentlowerinthetreatmentgroup(yieldingabouta3
percentnetsavingsafteraccountingforthecostoftheintervention).Thissingle
componentofcarecoordinationalonereducedhospitalizationsinthetrialby10percent
andtotalspendingbymorethan3percent.
23WennbergDEetal.Arandomizedtrialofatelephoniccaremanagementstrategy.,NEJM2010;313(13):1245-
1255.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
18/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
18
Conclusion
Aconsiderablebodyofpublishedresearch,manyfromrandomizedcontrolledtrials,has
highlightedtheclinicalcarecoordinationfunctionsthatimprovepatientqualityandreduce
costsintheMedicareprogram.Overtime,entitlementreformwillhavetofindquality
enhancingapproachesthatalsoreducecosts.Addingintensivelifestyleprogramslikethe
DPPwouldconservativelyreduceMedicarespendingby$4billionoverthenexttenyears,
andover$15billionoverthelifetimeofoverweightprediabeticMedicarepatients.Rising
ratesofpreventablechronicillnessisamajordriverofrisingspendingintheprogram,and
addingeffectiveprogramsliketheDPPwouldaddresstheselong-termtrends.
About95percentoftotalMedicarespendingisassociatedwithchronicallyillpatients.Yet,
traditionalMedicaredoeslittletodaytoengagethesepatientstokeepthemhealthyandout
ofthehospital,emergencyroomsandclinics.Theteambasedapproachtocare
coordinationoutlinedabovecouldbescaledandreplicatedquickly(within2years)
throughouttheMedicareprogram.Thiswouldproviderapidimprovementsinthequality
ofcareprovidedtopatientswithsubstantialreductionsinspending.Basedonsuccessful
programslikeCaremore,XLHealth,andgrouppracticesliketheMarshfieldClinicand
Geisinger,overthenexttenyearsMedicarecouldeasilysavecloseto$300billionoverthe
nextdecade.Thesechangestotheprogramreallywouldconstitutehealthreforms,
reformsthatreducetheincidenceofchronicdiseaseandprovidemoreeffective
managementofpatientswithmultiplechronicconditions.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
19/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
19
Thankyouagainfortheopportunitytodiscussthesevitalreforms.Imhappytotakeyour
questions.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
20/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
20
References
1. GovernmentAccountabilityOffice,MedicarePhysicianPayment:CareCoordinationProgramsUsedinDemonstrationShowPromise,butWiderUseofPayment
ApproachMayBeLimited(GAO0865),Washington,DC:GAO,2008.
http://www.gao.gov/new.items/d0865.pdf(accessedOctober28,2008).
2. A.LiebhaberandJ.M.Grossman,PhysiciansMovingtoMid-Sized,Single-SpecialtyPractices,JournalofGeneralInternalMedicine20,no.10(2005):953957
3. P.R.Orszag,Director,CongressionalBudgetOffice,TheMedicareAdvantageProgram:EnrollmentTrendsandBudgetaryEffects,Testimonybeforethe
CommitteeonFinance,UnitedStatesSenate,April11,2007.CentersforMedicare
andMedicaidServices(CMS),NationalHealthExpenditures2007Highlights,
http://www.cms.hhs.gov/NationalHealthExpendData/downloads/highlights.pdf
(accessedApril7,2009).
4. B.Starfield,L.Shi,andJ.Macinko,ContributionofPrimaryCaretoHealthSystemsandHealth,MilbankQuarterly83,no.3(2005):457502.
MedicarePaymentAdvisoryCommission(MedPAC),ReporttotheCongress:
PromotingGreaterEfficiencyinMedicare(Washington,DC:MedPAC,2007).
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
21/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
21
MedicarePaymentAdvisoryCommission(MedPAC),StatementofMarkE.Miller,
ExecutiveDirector(September16,2008),
http://www.medpac.gov/documents/20080916_Senpercent20Fin_testimony
percent20final.pdf(accessedApril1,2009).
5. CentersforDiseaseControlandPrevention(CDC),ChronicDiseaseOverview,2005,http://www.cdc.gov/nccdphp/overview.htm(accessedApril1,2009).
6. 6G.F.Riley,LongTermTrendsInTheConcentrationOfMedicareSpending,HealthAffairs,May/June26,no.3(2007):808816.
7. K.E.ThorpeandD.H.Howard,TheRiseinSpendingAmongMedicareBeneficiaries:TheRoleofChronicDiseasePrevalenceandChangesinTreatmentIntensity,Health
AffairsWebExclusive,2006:w378w388.
8. P.R.Orszag,April11,2007.CongressionalBudgetOffice(CBO),High-CostMedicareBeneficiaries(Washington,D.C.:CBO,May2005),
http://www.cbo.gov/ftpdocs/63xx/doc6332/0503MediSpending.pdf(accessed
April7,2009).InstituteofMedicine,RewardingProviderPerformance:Aligning
IncentivesinMedicare(Washington,DC:NationalAcademiesPress,2006).
E.Wagner,C.Davis,J.Schaefer,M.VonKorff,andB.Austin,ASurveyofLeading
ChronicDiseaseManagementPrograms:AreTheyConsistentwiththeLiterature?,
ManagedCareQuarterly,1999Vol.7,No.3,pp.5666.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
22/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
22
J.Chodosh,S.C.Morton,W.Mojica,M.Maglione,M.J.Suttorp,L.Hilton,S.Rhodes
andP.Shekelle,Meta-Analysis:ChronicDiseaseSelf-ManagementProgramsfor
OlderAdults,AnnalsofInternalMedicine143,no.6(2005):427438.
T.Bodenheimer,E.H.Wagner,K.Grumbach,ImprovingPrimaryCareforPatients
withChronicIllness,JournaloftheAmericanMedicalAssociation288,no.19
(2002):17751779
T.Bodenheimer,E.H.Wagner,K.Grumbach,ImprovingPrimaryCareforPatients
withChronicIllness:TheChronicCareModel,Part2,JournaloftheAmerican
MedicalAssociation288,no.19(2002):19091914.
T.Bodenheimer,K.Lorig,H.Holman,K.Grumbach,PatientSelf-Managementof
ChronicDiseaseinPrimaryCare,JournaloftheAmericanMedicalAssociation288,
no.19(2002):24692475.
S.M.Foote,Population-BasedDiseaseManagementUnderFee-For-Service
Medicare,HealthAffairsWebExclusive2003:W3342356.
CentersforDiseaseControlandPrevention,ChronicDiseaseOverview(2008),
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
23/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
23
http://www.cdc.gov/nccdphp/overview.htm(accessedFebruary12,2008).
D.Peikes,A.Chen,J.Schore,andR.Brown,EffectsofCareCoordinationon
Hospitalization,QualityofCare,andHealthCareExpendituresAmongMedicare
Beneficiaries:15RandomizedTrials,JAMA301,no.6(2009):603618.
9. 9D.Peikes,A.Chen,J.Schore,andR.Brown,2009.
B.W.Jacketal.,AReengineeredHospitalDischargeProgramtoDecrease
Re-hospitalization,AnnalsofInternalMedicine150,no.3(2009):178187.
E.A.Colemanetal.,PreparingPatientsandCaregiverstoParticipateinCare
DeliveredAcrossSettings:TheCareTransitionsIntervention,Journalofthe
AmericanGeriatricsSociety52,no.11(2004):18171825.
M.D.Nayloretal.,ComprehensiveDischargePlanningandHomeFollow-upof
HospitalizedElders:ARandomizedClinicalTrial,JournaloftheAmericanMedical
Association281,no.7(1999):613620.10B.Starfield,L.Shi,andJ.Macinko,
ContributionofPrimaryCaretoHealthSystemsandHealth,MilbankQuarterly83,
no.3(2005):457502.
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
24/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
24
MedicarePaymentAdvisoryCommission(MedPAC),ReporttotheCongress:
PromotingGreaterEfficiencyinMedicare(Washington,DC:MedPAC,2007).
MedicarePaymentAdvisoryCommission(MedPAC),StatementofMarkE.Miller,
ExecutiveDirector(September16,2008),
http://www.medpac.gov/documents/20080916_Senpercent20Fin_testimony
percent20final.pdf(accessedApril1,2009).
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
25/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
25
Table1.DistributionofHealthCareSpendingAmongMedicareBeneficiaries,ByNumberofTreated
MedicalConditions,1987,1997,2002,2009
MedicareBeneficiaries **2009dollars**
1987
NumberofConditions
Numberof
BeneficiariesAffected
(millions)
Percentof
BeneficiariesAffected
AmountofHealth
Spending
($millions)
PercentofTotal
HealthSpending
0 2.8 9.5 653.7 0.4%
1 4.1 14.1 13,389.9 7.4%
2 4.6 16.1 18,284.6 10.1%
3 4.6 15.8 26,326.6 14.5%
4 3.9 13.5 27,895.5 15.4%
5ormore 9.0 31.0 94,408.6 52.2%
Total 29.0 100.0 180,959.0 100.0%
1997
NumberofConditions
Numberof
BeneficiariesAffected
(millions)
Percentof
BeneficiariesAffected
AmountofHealth
Spending
($millions)
PercentofTotal
HealthSpending
0 3.1 8.4 1,461.6 0.5%
1 4.1 11.1 11,691.0 4.4%
2 4.7 12.8 17,110.0 6.4%
3 5.3 14.6 27,074.0 10.1%
4 5.0 13.6 35,569.6 13.3%
5ormore 14.4 39.5 175,190.0 65.3%
Total 36.6 100.0 268,096.1 100.0%
2002
NumberofConditions
NumberofBeneficiariesAffected
(millions)
Percentof
BeneficiariesAffected
AmountofHealthSpending
($millions)
PercentofTotal
HealthSpending
0 2.5 6.3 605.1 0.2%
1 3.0 7.5 9,414.7 2.6%
2 4.5 11.5 15,351.5 4.2%
3 4.6 11.8 26,776.0 7.4%
4 5.0 12.7 33,391.3 9.2%
5ormore 19.8 50.2 275,729.5 76.3%
Total 39.4 100.0 361,268.1 100.0%
2009
NumberofConditions
Numberof
BeneficiariesAffected
(millions)
Percentof
BeneficiariesAffected
AmountofHealth
Spending
($millions)
PercentofTotal
HealthSpending
0 2.8 6.4 1,798.3 0.4%
1 3.0 6.7 6,665.2 1.4%
2 4.2 9.5 20,843.2 4.5%
3 4.9 11.0 30,824.0 6.7%
4 5.8 13.2 43,819.5 9.5%
5ormore 23.6 53.3 359,050.0 77.5%
Total 44.3 100.1 463,000.2 100.0%
7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future
26/26
StatementofKennethE.Thorpe,PhD
SenateSelectCommitteeonAging,February27,2013
26
Source:Authorstabulationsbasedondatafromthe1987NationalMedicalExpenditureSurvey(NMES)andthe1997and2002MedicalExpenditurePanelSurvey(MEPS).
Note:Totalsmaynotaddto100becauseofrounding.
Recommended