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Expenditures
We found that the average rate of growth in estimated Medicare PBPM expenditures for CCM beneficiaries relative to the comparison beneficiaries decreased in the 12- and 18-month follow-up periods, with a $28 decrease in the 12-month follow-up period and $74 decrease in the 18-month follow-up period (Figure III.7). The rate of growth in Medicare expenditures excluded the CCM fees paid to professionals and facilities. The average rate of growth in the 6-month follow-up period increased by $14 on average, but the estimated impact was not statistically significant. The decreased rate of growth was driven by reductions in facility expenditures for inpatient hospital services, skilled nursing facility services, and outpatient services. (Outpatient services include the facility payment for emergency and observation services, outpatient clinic services, and tests and imaging services billed by hospitals.) We found that the rates of growth for professional services, including services provided by physicians and other health professionals, and for home health services increased during the follow-up periods. This partially offset decreases observed within other types of service expenditure categories.
Source: Medicare 2014-2016 enrollment and FFS claims data
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Our Patients
Edna
Knowledge.
We take the time to gather information about the patient.
Edna is 88 years old. She has lived a long, great life. Her health is declining daily, but her family doesn’t check in on her or take care of her - she’s on her own. She keeps up with her doctor appointments when she can, but doesn’t have the knowledge in healthcare to understand her options (if any). Edna is on Medicare and doesn’t really understand much when it comes to her healthcare.
Heart.
We empathize with our patients and meet them where they are.
Problem:
Edna's health is declining and no one is taking care of her.
How is she feeling?
Isolated and alone
What does Edna hope to achieve?
Someone to notice her and help her navigate the complexity of the system, her medications, etc.
What’s standing in her way?
Edna doesn’t know anything outside of her doctor appointments and what that doctor tells her.
Understanding.
We influence our patients by developing a deep understanding of their wants and needs helping them to reach their goals.
Robert
Knowledge.
We take the time to gather information about the patient.
Robert is 75 years old. He is really enjoying life and has recently started traveling a lot. He has several heart conditions, and he is aware of his healthcare concerns. He is struggling to be consistent with his medications and monitoring his symptoms. He really does want to stay healthy, but he needs some help staying consistent without slowing down his lifestyle.
Heart.
We empathize with our patients and meet them where they are.
Problem:
Robert needs to establish a better routine and plan for acknowledging his symptoms.
How is he feeling?
Frustrated but also motivated
What does Robert hope to achieve?
Someone to help him create a plan that honors his lifestyle and respects his health needs.
What’s standing in his way?
Robert is known for his noncompliance at his doctor’s office. He is limited to short, infrequent interactions with his provider and team. He needs more time, attention, and education about his conditions to meet his goals.
Understanding.
We influence our patients by developing a deep understanding of their wants and needs helping them to reach their goals.
Lila
Knowledge.
We take the time to gather information about the patient.
Lila is a 84 year old who loves life. She is surrounded by family gatherings and visitors. She can be very stuck in her ways, but when she understands a request she is happy to comply. Her granddaughter calls her and reminds her to check her blood pressure daily. She always writes down “her numbers” but she doesn’t really know what they mean. She has congestive heart failure and her weight fluctuates often and she periodically complains of swelling mostly in her legs. She doesn’t like getting on the scale because she doesn’t like knowing her weight and she’s fallen a few times.
Heart.
We empathize with our patients and meet them where they are.
Problem:
Lila keeps up with her blood pressure, but she isn’t sure what to do with her numbers. She’s inconsistent with measuring her weight, but this is also due to being unsteady on her feet.
How is she feeling?
Anxious
What does Lila hope to achieve?
Getting answers (and her family members want them too) .
What’s standing in her way?
Lila needs a nurse that she can talk to regularly that will be patient with her. Her family wants reassurance they are helping in the right way or guidance on how to do better. They all want to be proactive rather than reactive, but they know the provider is very busy and they don’t know what constitutes a visit to the doctor, UC, or ED.
