Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries

CONTEXT: Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication. OBJECTIVE: To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries. DESIGN, SETTING, AND PATIENTS: Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. INTERVENTIONS: Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely. MAIN OUTCOME MEASURES: Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators. RESULTS: Thirteen of the 15 programs showed no significant (P<. 05) differences in hospitalizations; however, Mercy had 0. 168 fewer hospitalizations per person per year (90% confidence interval CI, -0. 283 to -0. 054; 17% less than the control group mean, P=. 02) and Charlestown had 0. 118 more hospitalizations per person per year (90% CI, 0. 025-0. 210; 19% more than the control group mean, P=. 04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners HQP, Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (-84; 90% CI, -171 to 4; P=. 12; -358; 90% CI, -934 to 218; P=. 31; and -112; 90% CI, -231 to 8; P=. 12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. CONCLUSIONS: Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. TRIAL REGISTRATION: clinicaltrials. gov Identifier: NCT00627029.