Bob Master is providing individualized and coordinated primary care for patients with complex health needs in a way that reduces hospitalizations and nursing home placements and thus saves costs.
The New Idea
A physician with more than thirty years of experience serving low-income, elderly, and disabled patients, Bob is a pioneer of patient-centered healthcare in the United States. He founded the Commonwealth Care Alliance (CCA) to bring high-quality and personalized care to people with complex medical and behavioral health needs, resulting in improved health and better self-management of chronic illness, and thus reducing hospitalizations and institutionalizations.
In a country facing a healthcare crisis—one characterized by rapidly rising costs, an aging population, and sometimes inefficient and ineffective care—Bob’s paradigm actually improves quality while reducing cost. His nonprofit health alliance serves high needs patients—in particular the elderly and the disabled—many of whom are Medicare and Medicaid “dual eligibles” and account for a huge percentage of healthcare expenditures. CCA uses the savings from reduced hospitalizations and nursing home placements to provide a wide range of individualized round-the-clock services in the home and community through multidisciplinary teams. Bob’s innovation lies not only in the low-cost delivery of tailored care but also in the financing of that care, in the coordination and simplification of complicated health systems like Medicare and Medicaid, and in the use of computer technology to both deliver care and measure results.
Today this model is flourishing in Massachusetts and is regarded by many in the field as a paradigm of high-quality, integrated, preventive care essential for the future of healthcare in this country. Armed with robust proof of cost reduction, and backed by many in the healthcare industry, Bob is seeking to scale his model to reach larger numbers of society’s most vulnerable citizens.
The cost of healthcare in the U.S. has reached a crisis. National health expenditures surpassed $2.6 trillion in 2010, nearly 18 percent of U.S. GDP and almost four times the $714 billion spent in 1990. Expenditures are projected to rise above $4.5 trillion by 2020, driven by an aging population, the increased prevalence of chronic diseases like diabetes and obesity, and rising technology and administrative costs. Stemming this growth has become a major policy priority, as the government, employers, and consumers increasingly struggle to keep up with healthcare costs.
Approximately 50 percent of health spending is government spending—mostly in the form of Medicare, Medicaid, and cost-sharing subsidies. Medicare was founded in 1965 to provide healthcare for seniors and for people with permanent disabilities. Medicaid was also founded in 1965 to provide free or low-cost care to certain categories of low-income Americans. Between 8 and 9 million Americans are eligible for both Medicare and Medicaid—often referred to as “dual eligibles” and consisting largely of low-income elderly and disabled individuals, one-third of whom have significant limitations in the activities of daily living. Although they comprise only 18 percent of people on Medicaid, dual eligibles account for nearly half of the program’s spending on medical services and more than a quarter of all Medicare expenditures.
This population is so costly in large part because of their frequent (and as Bob argues, in many cases unnecessary) hospitalization and institutionalization, a troubling trend within the Medicare and Medicaid populations more generally. For example, inpatient hospital services accounted for over one-third of the $374 billion of Medicare benefit payments in 2006. And in 2003, 10 percent of Medicare beneficiaries accounted for over two-thirds of Medicare spending. Meanwhile, in 2005, 4 percent of Medicaid beneficiaries accounted for nearly half of the program’s $317 billion expenditures. Within the health sector, this is referred to as the 20/70 rule—where 20 percent of beneficiaries account for 70 percent of costs.
Sadly, despite the high cost of treating patients with complex needs—care for the elderly, disabled and poor—is often fragmented and outcomes are poor. A 2001 analysis of Medicare found that the average beneficiary with at least one chronic condition saw eight different physicians per year. Many had infrequent access to a primary physician and thus little guidance as to how to maintain their health. Communication with patient families and caregivers was inadequate, and patients were frequently sent to distant testing sites despite their limited mobility. Patients were also expected to make their own appointments and arrange their own transportation resulting in missed treatments and medication. Because of such fragmentation and lack of guidance, good preventive care becomes very difficult. Beneficiaries are more likely to experience acute episodes and check themselves into a hospital or a nursing home. This then drives up the cost of care dramatically and unnecessarily. Bob refers to such institutionalization as missed opportunities to manage chronic illness.
In addition to the difficulties of delivering quality care to dual eligibles and other similar patients, financing that care represents another challenge. Individuals with complex health needs constitute a “high risk” for insurers and payers. And even those covered by government-sponsored healthcare must navigate up to three systems, the financing of which remains separate in most cases. Finally, it is difficult for nonprofits like CCA to raise the equity and hold cash reserves required by law for health insurers.
Bob’s goal is to bring better care to people with complex medical, social, and behavioral health needs, and central to that goal is improving the management (and often self-management) of chronic illnesses. This means focusing on what it takes for each patient to maintain his or her health, and often reducing unnecessary procedures and in particular hospitalizations. Bob is careful to distinguish between achieving savings by “rationing” care in the form of reduced benefits and “rationalizing” care where patients get only what they need, when they need it, to stay healthy. In his rationalizing model, enough money is saved from reducing hospital visits and nursing home placements that you can afford to provide tailored care—this is the key.
Nearly forty years ago, Bob and a fellow physician began experimenting with a model of ongoing primary care that could be delivered to patients through a system of on-site visits by nurse practitioners. Both were disillusioned by the lack of organized care for the chronically ill and disabled and sought to make care more personal and efficient. Their efforts evolved into the Urban Medical Group of Boston, which by 1980 was achieving promising results. For example, the average annual hospitalization rate for their ambulatory elderly patients was 559 days per 1,000 patients, compared with an expected rate of 1,300 days. Bob began to contemplate ways to scale up the model and navigate the complex regulations and funding streams of both Medicare and Medicaid.
In 1990 after a term as the Medical Director of Massachusetts Medicaid, Bob founded the Community Medical Alliance, an experimental HMO caring for individuals with severe disabilities and AIDS under a pre-paid financing arrangement with Massachusetts Medicaid. This innovative funding model—one of the first in the country—was flexible enough to cover non-traditional benefits like home care, durable medical equipment, home infusion therapy, mental health and substance abuse treatment, adult day care, and case management. In the Alliance, nearly 90 percent of severely disabled member visits occurred at patients’ homes. Again Bob saw cost reductions despite individualized care: Monthly medical costs for members with severe disabilities fell from $2,228 in 1991 under fee-for-service reimbursement to $1,207 in 1996 under capitated reimbursement. After his group was incorporated into the Neighborhood Health Plan, a nonprofit HMO, Bob founded the Commonwealth Care Alliance (CCA) to expand his model to a broader population.
Today the CCA focuses on the elderly and the disabled, and more recently on individuals with mental health and substance abuse needs. Recipients are pooled into their respective plans—the Senior Care Options Plan, Disability Care Program, and Complex Care Needs Program—and receive a full spectrum of medial and social services. At the core of the CCA are multidisciplinary teams of physicians and nurse practitioners that work collaboratively to provide assessments, care planning, round-the-clock availability, intensive medical and behavioral heath care, and social support services in the home and community. Services are personalized and range from diabetes management to nutritionist consultations to rides to medical appointments and even to church. A premium is put on prevention and self-management, with many participants voluntarily attending weekly sessions on topics including how to deal with fatigue, pain, and isolation; exercise for improving strength and endurance; appropriate use of medications; effective communication with family, friends and health professionals; and making informed treatment decisions. Participants also work with instructors to develop individual action plans with goals specific to their health status.
CCA invests millions of dollars each year ($3.24M in CY2008) to create its multidisciplinary teams, financing services above and beyond what traditional payers for primary care would routinely reimburse for the infrastructure necessary to promote home medical management, 24/7 continuity of care, and the ability to substitute home and community services for hospital and nursing home care. That investment is made in the form of people (e.g. nurse practitioners and geriatric social workers) as well as in the supports to these people resources (e.g. electronic medical records). CCA integrates all components of care either directly or through subcontracts.
CCA has helped produce noteworthy cost reductions while maintaining the highest quality of care. Significantly reduced use of nursing homes by eligible seniors, for example, was a major reason that the average growth in total medical spending for CCA seniors grew just 2.1 percent from 2004 to 2009, well below fee-for-service growth rates. For disabled patients, monthly medical costs were $3,601 in 2008 compared with $5,210 for Medicaid fee-for-service patients. Meanwhile, in 2009 CCA scored in the 90th percentile or above on Healthcare Effectiveness Data and Information Set measures for comprehensive diabetes care, monitoring patients on long-term medication, and access to preventive services. Testimonials from providers and patients alike confirm satisfaction with CCA’s model of efficient, personal, and compassionate care.
As a result of Bob’s work, the idea of patient-centered care has permeated the U.S. healthcare system. Bob has been instrumental in bringing many pilot clinical models to meaningful scale, and others are now copying and adopting his model, including his innovation in financing. The potential implications of his work—both in terms of cost reductions and the integration of entitlements programs like Medicare and Medicaid—are enormous. Over the past five years, CCA has expanded its network from 6 to 21 enhanced primary care “medical homes” that are in varying states of evolution in Massachusetts. It directly manages care for more than 4,000 seniors, overseeing approximately $180 million of Medicare and Medicaid. Bob and his team are now refining a new Disability Care Institute in partnership with health organizations in New York and Wisconsin to create a platform that that can be easily and efficiently used by others and implemented on the ground with the same quality level of care. As he spreads his work financing remains a challenge, though Bob is optimistic that the Affordable Health Care Act will create new flexibility and enable his model and similar ones to flourish.
Bob is a practicing physician, board-certified in internal medicine with over thirty years of experience in the clinical management of patients with advanced chronic illness and disability. In 2003 Bob was awarded a Soros/Open Society Institute two-year fellowship and concurrently became the President and CEO of CCA.
Bob cites his teenage years as being formative for his career path. A son of immigrants living in Boston, Bob was responsible for taking his parents and grandparents to the hospital for illnesses. Because they did not have money—and because this was before Medicare—they were relegated to treatment in the basement. The indignity and inequity was apparent to Bob, and stayed with him through medical school. As he trained with Boston City Hospital, Bob became involved in the early community healthcare center movement to lower barriers to good health in low-income communities. He witnessed firsthand how the lack of insurance had real negative effects on people’s health and quality of life—and of course this had downstream effects on the high cost of hospitalizations that were ultimately a function of missed opportunities.
As a medical intern, Bob became convinced that the traditional model of care—staying in your cubicle and having people come through every 15 minutes or so—wasn’t working, especially for patients with complex health needs. He also recognized he would not have much impact without reorganizing how care was managed and delivered, but would have to make comprehensive reforms. And this included figuring out a way to finance better care, particularly for those with no health insurance.
Bob was the first physician and Medical Director at the Upham’s Corner Health Center, and founder of the Urban Medical Group in Boston until 1985, where new approaches to nursing home and home medical care using nurse practitioners were defined; approaches that transferred hospital level services to the home and to the community.
From 1988 to 1995 Bob was the Chair of the Health Services Department of the Boston University School of Public Health and remains on the faculty as an Associate Professor of Public Health, teaching courses in managed care and special population programs.