Many articles in this Journal share a common theme: the exponential growth in the number of older persons (Medicare enrollees), of which a small fraction has serious illness and needs substantial care. This subset contains a large and rapidly growing number of individuals who consume the majority of healthcare resources. Geriatricians are inured to this information, because we read it so much. We live it. We know who populates the “small fraction”—the very subset of older persons most likely to be referred to geriatricians. We take care of them every day—the very old with multiple competing illnesses, who face pervasive polypharmacy, impaired access, and a fragmented, silo-like care-delivery system that synergize to threaten our favorite patients. The currency of our daily existence is the phone calls to home care agencies, “potentially avoidable” emergency department visits and attendant hospitalizations, nursing home rounds, drives to house calls, piles of forms to sign, and lengthy family conferences with the care team and worried relatives on speaker-phone from a thousand miles away, discussing complex rehabilitation or end-of-life care. We experience simultaneously frustration and deep satisfaction every day caring for these people. We think: if only we had the resources to do simple medical case management with low-tech evaluation and hands-on helpers, we could save Medicare billions. We err in assuming that others truly comprehend the reality we experience and what we mean when we say how we intend to fix things. When policy-makers see these words, they see different issues and experience their own angst. Like us, they are intelligent and altruistic, but they have a different currency—influential lobbying groups with competing interests, complex legislation with enormous budgetary implications that are impossible to fully comprehend now much less in the future, and a pressing constituency (in which we are one small voice). Many policy-makers have an abiding interest in the care of older persons, sometimes fueled by personal experience. But they are not clinicians and do not view our issues with a clinical gaze. As a society (both the U.S. citizenry and the American Geriatrics variety), we confront a big issue—care of very ill older persons—and we need to speak a simple common language when designing solutions. Some progress has been made in designing eligibility schemes and benefits for the “small fraction.” Notable examples include Program for All-inclusive Care for the Elderly (PACE) for dually eligible, dependent older persons and the Hospice Medicare Benefit. This important legacy shows that care coordination can work for subgroups of Medicare enrollees, enabling comprehensive, high-quality services without breaking the bank—indeed even mitigating the overall economic effect of care. In these models low-tech, service-intensive care for small numbers of patients, either brought to the home (hospice) or delivered at a central location (PACE), actually improves quality of life in a cost-neutral and often cost-saving manner. Efforts continue to build on these examples, leading to a comprehensive care-coordination benefit to all Medicare enrollees with complex illnesses. Cigolle et al. help us move forward in this issue of the Journal with their study “Setting Eligibility Criteria for a Care-Coordination Benefit.”1 They engage in a cross-sectional analysis of data from the Health and Retirement Study to explore various “cutpoints” to define eligibility for a comprehensive Medicare care coordination and case management benefit directed to people with advanced chronic illness and debility. The authors start with a reasonable, although restrictive, framework: four or more severe, complex medical conditions with one functional dependency, which would apply to about half a million Medicare beneficiaries. Using cognitive impairment plus functional dependency as criteria would include about 1.5 million, and combining medical complexity, cognitive impairment, and functional dependency takes us to 2 million, or about 6% of beneficiaries. Geriatricians and gerontologists certainly recognize the importance of cognitive impairment as a driver of work effort for case managers. Although the exact description of what constitutes “severe, complex medical conditions” could not be addressed with the available data, this definition should be relatively easy to create by consensus. These numbers are manageable and are similar to previous estimates based solely on activity of daily living criteria of the frail, immobile elder population that might need home care services; up to 1.3 million qualifying for home-based care2 and at least 1 million older people needing chronic medical home care.3 From a policy and planning perspective, it is vital to understand the size and characteristics of the population most likely to benefit from more-intensive comprehensive care coordination. The current analysis adds the dimension of medical illness to a framework previously limited to functional status parameters. A parallel effort is underway at the National Institutes of Health (NIH). Several excellent thinkers and investigators are working together on the concept of “multiple morbidity.” This is an important change in semantics. We are used to thinking of “comorbidity” (illnesses coexisting with an index or primary diagnosis) when caring for, or doing research on, frail older people. This older terminology implies that one diagnosis is more important than the others and that, if we treat that one, it will make everything much better. This concept, which in part drives the enthusiasm for disease state management, pervades medical thinking and diagnostics in ways perhaps only a geriatrician could fully appreciate. As pointed out in the final article of the series “High and Rising Healthcare Costs,”4 disease management programs focusing on a single condition might not necessarily focus on high-user interventions. Hence, disease management may or may not cut costs and may collide with other efforts to control utilization, particularly in the setting of multiple comorbidities. When we care for an older, multiply ill person (such as those that meet criteria suggested by Cigolle et al.), their “chief complaint” offers a nice opening sentence but ultimately may not be helpful in evaluation—Occam's razor rusts from disuse when we manage most geriatric syndromes. Even our billing and medical record systems rely heavily on the primary diagnosis. Hospice teams face the difficult conundrum of picking one of many active diagnoses to list as the “terminal condition” when it is really multiple conditions together that are making the patient ill; they default to “debility not otherwise specified,” which the Centers for Medicare and Medicaid Services then contests. Being stuck in this pervasive thinking is like being lost in the forest, looking at individual trees. The term “multimorbidity” helps us see the whole forest. At the 2005 American Geriatrics Society National Meeting, Drs. Silliman, Studenski, Moore, and Ritchie presented findings from the NIH/National Institute on Aging (NIA) R13 Conference Panel on multiple morbidity. Several sensible ideas were presented, including quantification of the costs incurred by persons with increasing levels of morbidity and how multimorbidity and debility conspire to magnify health services needs. Concurrently, there were a number of excellent presentations on PACE, now a well-developed (though limited) part of the care landscape. And the affiliated American Academy of Home Care Physicians National Meeting highlighted community outreach programs in Philadelphia, Pennsylvania; Nevada; Washington, DC; and Baltimore, Maryland that use house calls as the key care-delivery strategy. These programs, which require less initial capital investment than PACE and are more inclusive, serve persons with multimorbidity and enough debility to be homebound. The data show that comprehensive, high-quality, cost-effective care can be delivered to these patients in their own home when committed providers take on the challenge and are reimbursed appropriately. Thus, from a research and care-provision standpoint, the elements exist to define eligibility and deliver care to the “small fraction” of Medicare enrollees with multimorbidity. Based on studies like the one by Cigolle et al., one might envision cross-cutting, multimorbidity eligibility criteria that would allow access to PACE, hospice, or comprehensive house call/home hospital programs already in existence in many geriatric-friendly locales, with a similar managed care payment structure. Patients, medical providers, and policy-makers have nothing to lose and much to gain by adopting such a measure if even a “small fraction” of the 78% of national healthcare expenditures now devoted to chronic illness care could be saved.5 The group from Ann Arbor takes us another step closer to this important goal in this issue of the Journal, and their results, as well as the deliberations of the NIH/NIA R13 Conference Panel, should inform implementation of the Medicare Modernization Act. Financial Disclosure(s): Both authors, Drs. McCormick and Boling, indicate no financial support for research, consultantships, speakers forum, or any company holdings (e.g., stocks) or patents pertinent to this article. Author Contributions: Both authors contributed equally to concept, design, and preparation of this manuscript. Sponsor's Role: There was no sponsor for the design, analysis or preparation of paper.
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McCormick et al. (2005) studied this question.