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Home-Based Senior Care Program Has Limited Benefits

Overhaul of Medicare financing system may be needed, experts say

TUESDAY, Dec. 11 (HealthDay News) -- An intensive, home-based program to improve medical care for low-income seniors produced mixed results, a geriatrics team reports.

Failure to get better outcomes indicates the need for a new analysis of how Medicare pays for the care for older Americans, experts said.

"We were able to stabilize medical care for these people, who often have an up-and-down experience with medical care," said Dr. Steven R. Counsell, a professor of geriatrics at Indiana University and lead author of a report in the Dec. 12 issue of the Journal of the American Medical Association. "The main thing that did not change was physical function. The program did not prevent decline."

Some improvements were evident in the two-year course of the program, which included care management by nurse practitioners and social workers who collaborated with a primary-care physician and a geriatrics interdisciplinary team guided by protocols for common conditions of aging.

Better improvement in general health, vitality, social functioning and mental health were noted in the 474 older people, as compared to a group of 477 getting usual care in community-based medical centers. Emergency room visits decreased for the intervention group, but the death rate did not decline.

The program was run under Medicare, which placed limits on how it was financed, Counsell said. In general, Medicare pays for specific treatments of specific conditions, so that most of the efforts to coordinate care were not reimbursed, he said.

"But we were hoping that this kind of coordinated care would show improvement in many areas," Counsell said.

The program results indicate a need for a basic revamping of Medicare financing, said Dr. David B. Reuben, a professor of medicine at the University of California, Los Angeles, who wrote an accompanying editorial.

"Medicare, for the most part, pays for physical services," Reuben said. "If care is provided that doesn't fall into the category of one of those services, it isn't paid for. So, coordination of special services is not reimbursed."

The partial success of the program indicates that "a new model is achievable" under Medicare, Reuben said, "but the time is ripe for a thorough re-evaluation of how Medicare pays for services. It really needs to be freshened up. We can have fee for service, but we have places where we must fill in the gaps, and one of the big gaps is coordination of care."

Counsell said he and his colleagues are going through data collected in the program to determine whether it makes sense financially. "Armed with some further information and a cost analysis, we are looking at how much the program cost and how much was saved and who benefits the most," he said.

Elements of the program could be adapted for use with special populations, such as nursing home patients and those with chronic illnesses, Counsell said, working through organizations that deliver managed care to selected groups.

"There has to be a different infrastructure," Reuben said. "If the method of financing is good, good infrastructure tends to follow."

More information

Details on health care for the elderly is provided by the American Geriatrics Society.

SOURCES: Steven R. Counsell, M.D., professor, geriatrics, Indiana University, Indianapolis; David B. Reuben, M.D., professor, medicine, University of California, Los Angeles; Dec. 12, 2007, Journal of the American Medical Association

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