Managing End-of-Life Care in Complex Patients Can Reduce Costs Without Shortening Life

“Patient-centered management” is an emerging comprehensive patient-focused collaboration that includes end-of-life and pain management, education, provider coordination, and patient advocacy. It emphasizes the selection and coordination of services from the patient’s perspective and considers all of the patient’s circumstances.

Managed care organizations seem best positioned to use patient-centered management with complex patients and healthcare providers, but the economic benefits of patient-centered management are not clear. Today, many managed care organizations concentrate on “case management,” which includes the identification and coordination of plan benefits and ancillary services. Case management tends to focus on services while patient-centered management focuses on the broader context of the patient. The key question addressed in this study is whether patient-centered management can reduce utilization costs in complex patients over case management without sacrificing life span.

Objective: Determine the effect of intensive patient-centered management on service utilization and survival.

Study design: Prospective cohort study of 756 patients (having a life-limiting diagnosis with multiple co-morbid conditions, 75% were oncology patients) in California covered by a large commercial HMO from February 2003 through December 2004. Group membership determined assignment to the patient-centered management cohort versus usual management cohort after blindly screening for clinical complexity. Both cohorts accessed the same delivery system, utilization management practices, and benefits.

Methods: Intervention was intensive patient-centered management involving education, home visits, frequent contact, and goal oriented care plans.

Results: Roughly half (358) of the 756 patients received patient-centered management (PCM). More PCM oncology patients elected neither chemotherapy nor radiation (42% increase over usual management oncology patients). PCM patients had reductions in inpatient diagnoses indicative of uncoordinated care: nausea (-44%), anemia (-33%), and dehydration (-17%). PCM patients had utilization reductions: -38% inpatient admissions (95% confidence interval [CI], 37-38%), -36% inpatient hospital days (95% CI, 35-37%), and -30% emergency room visits (95% CI 29-31%). PCM patients had utilization increases: 22% homecare days (95% CI, 20-23%) and 62% hospice days (95% CI, 56-67%). Overall costs were reduced by -26% (95% CI, 25-27%). Patient lives were not shortened (26% of PCM decedents versus 28% usual management) (P=0.80).

Conclusions: Intensive patient-centered management can sharply reduce utilization and costs over usual management without shortening life.

Keywords: patient-centered care, managed care programs, patient care management, case management, complex patients, case management, anonymized data, HIPAA, Medicare, end-of-life care, critically ill patients