Care management is another of those buzz words that means different things to different people. The notion became popular when CMS began to penalize hospitals for excessive readmissions within 30 days of discharge. Heart failure is the second most common diagnosis billed to Medicare and people who are sick enough to require admission tend to do poorly. One study found the two year survival rate was 17% and the likelihood of a second admission within a year was very high. Blum and associates have published a modeling study of transitional care services after hospitalization of patients with heart failure to determine the effectiveness of three different transitional care services. Using published data the authors estimated the cost-effectiveness of a nurse-provided post-hospital visit(s) in the patient’s home, nurses case management, and specialized disease management clinics compared to “usual care,” which typically included in-patient hospitalization and early follow up post discharge with the primary physician or the cardiologist (or both.)
In their cost analysis, they used an estimate for nurse home visits of $1,214 and reported the data in terms of quality-adjusted life years (QALY). The model for a patient aged 75, discharged from the hospital with a diagnosis of heart failure estimated a life-expectancy of 2.98 years and experienced an average 2.91 hospitalizations. The home visits were projected to extend life an average of four months and reduce hospitalizations by 10%. The increased survival translated to an increase in life-time health costs of $4622. Translating this into QALY, the authors estimate the intervention cost $19,570 per QALY, well within the customary $50,000/QALY threshold for an intervention. The authors did a sensitivity analysis and compared the three interventions and found that when the cost was $50,000/QALY, nurse case-management became more cost-effective, and when it was $100,000/QALY, disease management clinics became cost-effective. At all levels, though, intervention was more cost-effective than “usual” care.
The accompanying editorial applauded the work but noted most patients do not receive transitional care management. After noting some caveats about the paper, she posited three reasons why transitions programs have not become standard of care.
“First, an important consideration is that systems interventions are not equivalent to medications…Second, systems intervention, unlike medications, have upfront costs that must be shouldered by health care providers and may or may not be subsequently reimbursed by payers…It is not clear whether the penalties for rehospitalizations or the putative benefits of the programs have been substantial enough for hospitals to invest heavily in them, particularly given that successful interventions not only have intrinsic cost to providers, but also reduce revenue from subsequent hospitalizations. Third, the authors demonstrate that the programs increase costs to insures in the long term despite being clearly beneficial to patients.”
This need not imply cynical money-grubbing by hospitals. There are costs in addition to financial in that resources and attention are also in short supply. Building a nurse home visit program means diversion of nurses from some other task. During the startup phase of the program the costs in time, attention and people far exceeds the number of patients who can be treated, so the costs per QALY are much higher than when an established program can treat a large number of patients as was assumed in the modeling study.
This paper and editorial, though, illustrate the cross purposes that afflict the practice of medicine today. Providing transitional care to all patients with an index heart failure admission is not likely to hurt the patient and may, on average, extend survival and reduce morbidity, both good things from the patient’s perspective. From the hospital’s point of view, it is an unfunded mandate to spend money and reduce their future admissions. Since they are paid by admissions, this is a double jeopardy. For the physicians, who are paid by contact, providing additional contacts on someone else’s budget is not a problem, but typically what happens is the nurse ends up calling the doctor, who is then expected to address the issues without a face-to-face visit, which is generally not reimbursable to the physician for his/her time and expertise. For the insurance company, this is probably a net reduction in expenditure per patient per year, but CMS does not benefit from this, as their primary issue is living within Congressional mandates to control expenditures. It is really a matter of reducing total dollars, not to whom the check is made.
I don’t list all these issues to suggest anyone is acting malevolently. After all, hospital administrators, patients, and physicians are all struggling with competing demands for time and energy. And all programs cost money, because the participants in these efforts all need to be paid and supplies and facilities must be provided by someone. I don’t have a glib solution to the challenge. However, I do think we are going to need some sort of method for comparing relative costs, including opportunity costs, when deciding about various programs. We have some idea from this study about the costs/benefits of three interventions following a hospital admission for heart failure, but what about with other common ailments like ESKD, COPD, diabetes? If the goal is cost-effective expenditures, how to we decide to fund one or two programs when there are ten that seem worthwhile, but unproven? I am open to suggestions.
25 February 2020
 Blum MR, Oien H., Carmichael HL, Heidenreich P, Owens DK, Goldhaber-Fiebert JD. Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure. Ann Intern Med 2020;172:248-257. doi: 10.7326/M19-1980.
 Horowitz LI. Taking Care Transitions Programs to Scale: Is the Evidence There Yet? Ann Intern Med 2020;172:285-286. doi: 20.7325/M19-3872.
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