Physicians in Supporting Roles in Chronic Disease Care: The CareMore Model

The ultimate goal of U.S. health care is to ensure the best possible health of all Americans. Accordingly, the care provided needs to be of high quality, user friendly, and efficient. Geriatrics has been a leader in attempting to develop new models of care that meet these principles and can be broadly diffused. These models have usually been developed in academic settings and rigorously evaluated, and their developers have struggled to find avenues for dissemination. Simultaneously, and usually independently, there has been a substantial amount of innovation in practice settings, particularly those receiving capitated payments, where performance on these metrics is tightly linked to viability. In most of these nonacademic healthcare delivery systems, traditional randomized clinical trial designs to evaluate effectiveness are too rigid, too expensive, and take too long to achieve results. Nor are there any incentives for these organizations to publish or disseminate their innovations. Nevertheless, some of the models of care that have been implemented provide important lessons for the future of healthcare delivery. One such model is CareMore, developed in Southern California. Upon entering the CareMore Care Center in Downey, California, there is nothing particularly striking. It is a renovated bank building with high ceilings and a packed waiting room, typical of many urban multispecialty practices, but this is not a medical practice, per se. All of these patients have their own primary care physicians (PCPs), and there are few physicians on site. Nurse practitioners are using several examining rooms to see patients, but the real action is going on in many rooms filled with computer monitors and phone banks staffed by nurse practitioners and medical assistants. These members of the team are proactively and intensely managing chronic illnesses of CareMore’s Medicare Advantage beneficiaries. If this seems like the wrong way to deliver health care, consider CareMore’s remarkable performance on quality, cost, and patient satisfaction. CareMore seniors with diabetes mellitus have an average glycosylated hemoglobin level of 7.08, and the amputation rate is 78% less than the national average for people with diabetes mellitus with wounds. Hospitalizations for end-stage renal disease are 42% less than the national average. Thirty-day rehospitalization rates are 13.6%, compared with 20% in the overall Medicare population. The average length of hospital stay is 3.0 days. Overall, CareMore has estimated that payers’ risk-adjusted total per capita health spending is 15% below the regional average. On the 2009 annual Consumer Assessment of Healthcare Providers and Systems, CareMore scored 8.81 out of 10; the national average was 8.47, and the California state average was 8.57. CareMore is a for-profit, privately held corporation that offers several special needs plans in addition to moretraditional Medicare Advantage Part C coverage. It insures 43,000 members, 20% of whom have Medicare and Medicaid. The average age of CareMore members is 72, 45% are Hispanic, 34% have diabetes mellitus, 40% have hypertension, and 50% have an annual income of $30,000 or less. The CareMore model is a remarkable departure from the practice of medicine that developed in the 20th century. It is team based, evidence based, information technology based, and high touch. Yet contrary to the concept of the team being built around the PCP, the PCP is only one of many components of CareMore’s healthcare delivery model. Although CareMore’s services have been added incrementally, the philosophy of providing high quality at lower cost has been persistent. A component of its mission statement relates directly to cost: to ‘‘protect precious financial resources of seniors and the Medicare Program through innovative methods of managing chronic disease, frailty, and end of life.’’ In keeping with this philosophy, CareMore members have no copayments or deductibles. Nevertheless, CareMore remains highly profitable. How do they do it? According to a senior official, ‘‘CareMore has not tried to change or work through the conventional system but has built a new model that recognizes the increased demands of the chronically ill.’’ This model focuses on intensive management of frail and chronically ill members ( 15% of members), who account for 70% of medical costs, as well as close monitoring of nonfrail members and aggressive management of chronic conditions to delay the onset of frailty. Once seniors enroll in CareMore, they are encouraged (80% do so) to have a 1-hour Healthy Start visit at a CareMore Care Center (there are 11 in Southern California) with a medical assistant and nurse practitioner or locum tenens physician. During this visit, the member receives point-of-care laboratory testing; an inventory of diseases and conditions is obtained; screening is performed for conditions such as dementia, depression, and falls; medications DOI: 10.1111/j.1532-5415.2010.03237.x