Care Management: From Channeling to Grace

Abstract

Chronic care is a major driver of Medicare expenditures. Over the past 40 years, there have been many attempts to manage and coordinate care in those with chronic conditions. Fragmentation in our healthcare delivery system is commonly given as a reason for the high cost of health care in the United States. The existing Medicare payment system further exacerbates this fragmented care. Medicare patients often see multiple specialists, and an inverse relationship has been noted between specialty care, high costs and quality of care. Various models have been developed to try to reduce fragmentation. The Channeling demonstration was one of the first to provide comprehensive case management to the frail elderly. Channeling made patients and caregivers a little happier, but failed to demonstrate any cost savings. Integrated Delivery Systems have been proposed as a means towards more successful care coordination, but still founder without the ability to affect clinical care decisions. The geriatric medical approach to care has demonstrated the ability to reduce hospital utilization and overall health care costs. Examples include GeriMed of America, Senior Care of Colorado, GRACE and PACE. One of the reasons that care coordination hasn’t evolved has been due to a lack of an effective payment model to support such efforts. Fee-for-service will continue to provide roadblocks for the successful implementation of care coordination programs and a geriatric medical approach to care. Successful models must combine a geriatric medical approach to care with a care coordination model that effectively disseminates evidence based information so as to impact the actual delivery of care.