Aetna’s View on Building Effective Care Management in Medicare

Aetna applauds the Centers for Medicare & Medicaid Services (CMS) plan to begin paying Medicare providers, including professionals under doctors’ supervision, for chronic care management. This is a good first step in facilitating better care for patients and improved health outcomes. We will need to drive beyond funding, however, to realize the full potential of care management.

More than 70 percent of the cost within Medicare is generated by a population with four or more chronic conditions that are often managed independently by several practitioners, according to data from Medicare and from Aetna. While many doctors and specialists effectively manage the care of their own patients, care providers don’t tend to effectively coordinate care with other doctors treating the same patient. The result is less-than-optimal health outcomes, delays, lack of patient satisfaction, duplicated tests, sometimes harmful treatment interactions, and high cost. In an environment without coordination, the care provided has been compared to building a house without a general contractor — it is not only inefficient but it is prone to errors of omission and commission. What’s missing within the care delivery system for Medicare patients is coordinated, sustained care management across different care settings.

Building effective, coordinated care management is complex and requires the following components that are difficult to achieve but crucial to success:

  • Selecting, training, mentoring and monitoring case managers to ensure they have necessary skills and experience to deliver the right level of case management; and
  • Measuring the results of services provided by or through Medicare-participating providers to understand the effectiveness of that care and to support continuous improvement in quality.

Many Medicare Advantage health plans have long recognized the value of coordinated care management. These plans have been evolving over decades and are continuously enhanced.

Care management programs for Medicare Advantage need to include robust case management, including nurses who are embedded within physicians’ offices when possible, and disease management that helps a patient and all of her different doctors more easily and safely manage multiple conditions. Nurses in special programs and other services, such as remote monitoring, should be available to support particularly vulnerable populations with risk factors such as high blood pressure or who are transitioning from hospital to home. Aetna has programs like this. In addition to improved patient engagement and care, the programs currently result in a nearly 20 percent reduction in the number of days patients were in the hospital for acute care compared to unmanaged Medicare.

Advanced illness is a particularly striking example of an opportunity to address a seriously unmet need. Aetna provides a specialized, high-touch care management program, Aetna Compassionate Care, for Medicare Advantage members with advanced illness who choose to participate. Specialized Aetna case managers provide patients with expert counseling in how to manage their illness, as well as in palliative care. By developing trust-based and meaningful connections, the care manager relationships contribute to member and family satisfaction rates consistently above 90 percent in surveys. Also, advanced illness represents 28 percent of Medicare cost – 80 percent of which is acute hospital care that serves little clinical or psychosocial purpose (data from Dartmouth Atlas 2008).

Through our program we have seen acute hospital days reduced by 80 percent, resulting in improved quality of life and cost savings. If such care coordination were “standard of care” for all Medicare members, we could improve how we provide — or do not provide — needed health care services, while lowering costs.

Medicare providers can draw from the experience of health plans and providers in many cases to help build the infrastructure needed to deliver effective care management, from training and delivering support to monitoring and evaluating results. Such collaboration can produce results better than either can produce alone. As a result, the nation’s dollars that support care management within Medicare could have the highest impact on quality and cost.

Editor’s Note: You can read this story and more directly from Aetna here:

About the Author: Randall Krakauer, M.D.

Randall Krakauer, M.D., is Vice President and national medical director for Medical Strategy at Aetna. He is a recognized leader in geriatric care and board certified in internal medicine and rheumatology.




Morning Consult