Mr. Chairman, Senator Harkin, and members of the Subcommittee, my name is Dave Hickman, and I am serving as Director of Clinical Integration for Mercy Health Network based in Des Moines, Iowa. I am a Registered Nurse and a Fellow of the American College of Healthcare Executives.
I want to thank you for this opportunity to bring information to you about a telemanagement program Mercy Health Network has used that is lowering the cost of care and increasing the quality of life for people with congestive heart failure.
Mercy Health Network is comprised of 1,792 staffed inpatient beds in five medical centers and 28 rural hospital affiliates; 104 clinics, numerous home care, hospice, long-term care facilities and senior housing facilities across Iowa. Our 1,637 affiliated physicians provide 1.9 million emergency and outpatient visits per year to a primary and secondary service population of 1.2 million people. Mercy Health Network is a joint operating agreement between Catholic Health Initiatives, Denver, Colorado, and Trinity Health, Novi, Michigan.
The Problem: Patient Non-Compliance, Frequent Readmissions
Approximately 4.8 million Americans have congestive heart failure (CHF) today. After age 65, the incidence approaches 10 of every 1000 Americans. From 1979 to 1999, hospital admissions for CHF increased 155%. It is one of the most frequent diagnoses in American hospitals today. It is estimated that CHF hospitalizations account for approximately 5 billion dollars in annual cost to the Medicare budget.
Of all hospital admissions for CHF from the Emergency Department (ED), approximately 80% are repeat visits to the ED. And, approximately 80% of ED visits for CHF result in an inpatient admission. Data indicates that within a month of discharge from the hospital, about 20% of CHF patients will be re-admitted to the hospital for CHF. Within six months of discharge, about 50% will be re-admitted.
Half of all readmissions to the hospital are caused by patients not following the diet and medication treatment plan prescribed by their physician. Another 20% of readmissions are caused by patients not seeking care when symptoms are beginning to get worse. Clearly, the problem can be reduced if patients can learn to be compliant with treatments prescribed by their physicians, and learn to recognize early warning signs of a worsening condition.
Clearly, congestive heart failure is a large, growing and costly problem for the American healthcare system. And, clearly, the problem can be reduced if solutions can be found to improve patient’s compliance with treatments prescribed by their physicians, and if patients can learn to recognize early warning signs of a worsening condition.
The Solution: Frequent Monitoring by Case Managers Using Telemanagement Tools Since 1993, Mercy Health Network medical centers have recognized the need to case manage high-cost, high-risk patients who have experienced frequent ED re-visits and hospital re-admissions for various chronic illnesses, many of whom have CHF. MHN medical centers have implemented community-based and/or inpatient-based case management designed to intervene at key points in a patient’s disease progression to improve clinical and financial outcomes. Each of our medical centers has invested in CHF case managers. They closely monitor the clinical conditions of CHF patients after they have left the inpatient setting to prevent an exacerbation of their illness and a readmission to the hospital.
At Mercy Medical Center-Des Moines, clinical and administrative leaders recognized in 1999 that their ability to case manage their large CHF population was limited by the number of patients that a case manager could realistically contact at the frequency necessary to be effective. William Wickemeyer, M.D., medical director for the CHF program for the Iowa Heart Hospital at Mercy, and Deborah Willyard, R.N., CHF case manager, purchased, through a grant from the National Retirement Foundation, the Tel-AssuranceTM telemanagement system as a tool to assist case managers become more effective and increase their caseload of CHF patients. Tel-AssuranceTM was designed by cardiologist Randall Williams, M.D. from Northwestern University and founder and CEO of Pharos Innovations.
The CHF telemanagement program used by Mercy Health Network medical centers is relatively straightforward in the following steps: 1. Patients with high readmission rates are enrolled in the CHF telemanagement program by their physician. Because body weight is an important indicator of fluid balance and how efficiently the heart is pumping, the physician pre-determines an acceptable body weight, and the case manager enters it into the computer. 2. Patients enrolled in the telemanagement program use their touchtone phone to call a toll-free number to our telemanagement computer everyday between 4 a.m. and 12 noon. In this phone call to an automated attendant, the patient answers the same survey of seven questions everyday. The first six questions ask patients about their symptoms, e.g. “Have you felt more short of breath in the last day?”, and the seventh question asks the patient to enter their morning weight. 3. Between 12 noon and 1:00 p.m., the computer calls any patient back that did not call in before noon. 4. At 1:00 p.m., the computer software compares the patient’s morning report to the pre-set parameters. If the patient answered “yes” to any symptom question or if the morning weight exceeds the acceptable weight, a variance report is sent to the case manager for follow-up.
With our current telemanagement system, Tel-AssuranceTM, patients enrolled in the program need only a touchtone phone and bathroom scale.
The Results: Cost Savings, Healthier and Satisfied Patients
In their first year in 2000, case managers at Mercy Medical Center-Des Moines decreased re-admissions to the hospital by 84.4% and tripled their caseload (from 30 to 90) without adding additional case managers using telemanagement.
One of the purposes of Mercy Health Network is to identify best practices, and then replicate them throughout the network. In 2001, the CHF telemanagement program was replicated to our other four medical centers. In the first year of the program, case managers decreased re-admissions to the hospital for CHF by 86.2% collectively using the telemanagement system. Mercy Medical Center-Sioux City decreased readmissions by 100% using an innovative combination of telemanagement and palliative care. Daily patient call-in compliance rate was 93%. On a five-point scale, average patient satisfaction was 4.8 (very satisfied). Patients made comments such as “It gives me peace of mind” and “Someone is caring for me everyday.”
Estimated cost savings of the telemanagement project are worth noting. Avoided admissions were estimated at 202. Based upon typical reimbursement and payment models, von Ebers & Associates estimated that health insurance (Medicare, Medicaid, Blue Cross, commercial insurance) gross savings was between $627,000 and $668,000. The savings to patients was estimated at $167,000 to $209,000. The estimated hospital savings was $152,485. The estimated total net savings for 182 patients was between $921,485 and $1,004,485. And there may have been additional savings by avoiding post-hospitalization office visits. By contrast, the estimated cost of Mercy Health Network’s CHF telemanagement program was about $25,000, excluding the cost of case managers. Costs including newer software versions and case manager salaries are estimated at $187,000. While the return on investment for hospitals is about breakeven, the ROI for health insurance, patients and hospitals collectively is about 5 to 1.
The Keys: Early Intervention and Teaching by Case Managers
In the first year that all five medical centers used the congestive heart failure telemanagement program, hospital readmissions were reduced by 86.2%. We believe that the program was successful because early warning signs of an exacerbation of the CHF were identified and acted upon by case managers. Often, patients are found to be not following their physician’s treatment plan for diet restrictions and medications. Case managers respond by re-teaching patients the importance of following the treatment plan. Over time, patients with CHF change their behavior and follow the treatment plan more often, and they learn to recognize these signs and to notify their case manager or physician when necessary.
Case managers intervene to break the cycle of frequently repeating hospital readmissions. Telemanagement is a tool that helps case managers be more effective. Our case management approaches and successes are further outlined in a chapter of a book to be published this summer by Health Administration Press titled Thinking Forward: Six Strategies for Highly Successful Organizations by John Griffith and Kenneth White with Patricia Cahill, featuring the work of selected Catholic Health Initiatives’ facilities.
Mercy Health Network medical centers utilize CHF telemanagement for two reasons. First, because Iowa’s average Medicare reimbursement is so inadequate (lowest in the United States), costs exceed reimbursement for every CHF admission for most of our medical centers. Out of necessity, we reduce our CHF admissions to avoid further financial losses. Hospitals receive no reimbursement to provide case management. We invest in case managers and telemanagement systems at our own expense.
Second, and more importantly, the CHF telemanagement program keeps people healthier and at home where they want to be.
Collaboration to Replicate Success
Earlier this year, Mercy Health Network co-founded the Iowa Chronic Care Consortium along with the Iowa Health System, Des Moines University, the Iowa Farm Bureau Federation, and the Iowa United Auto Workers. The purpose of the Iowa Chronic Care Consortium is to improve the health and productivity of Iowans through the routine practice of innovative, proactive chronic care strategies.
Mercy Health Network is committed to participation in the Iowa Chronic Care Consortium because we believe that our telemanagement program is a breakthrough in decreasing the cost of care and increasing the quality of life for people with CHF, and we are willing to collaborate with other providers in the state to achieve the same results as we have.
Through the Consortium, Mercy Health Network will be expanding our telemanagement program to heart failure patients in more remote rural locations and to diabetes patients in our urban medical centers.
Recommendations
We acknowledge that the causes of rising health care costs are complex, and the solutions are difficult to identify. We believe, however, the data indicates that our CHF telemanagement program could be a model for improving the care of persons with CHF.
We offer the following recommendations: 1. Review Mercy Health Network’s telemanagement results this Fall after we complete another year of using the telemanagement system 2. Review the comparative results of the telemanagement demonstration projects conducted by the Iowa Chronic Care Consortium in 2004; and, 3. If the data from these projects shows the same cost savings as our previous studies, we would recommend that Congress consider adding case management as a reimburseable service to the Medicare and Medicaid programs to incent hospitals to provide case management.
Mr. Chairman, I am grateful for the opportunity to present this information to your Subcommittee. We appreciate the assistance that your Subcommittee provides for the healthcare community, and particularly acknowledge the consistent support provided by our good friend Senator Harkin.
I would be happy to answer any questions from you and your Subcommittee members at this time.
