Multimorbidity and a Comprehensive Medicare Care‐Coordination Benefit

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’’Fthe very subset of older persons most likely to be referred to geriatricians. We take care of them every dayFthe 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 currencyF 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 issueFcare of very ill older personsFand 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 bankFindeed 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 costneutral and often cost-saving manner. Efforts continue to build on these examples, leading to a comprehensive carecoordination 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.’’ 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 care and at least 1 million older people needing chronic medical home care. 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 DOI: 10.1111/j.1532-5415.2005.00504.x