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Correspondence: Address correspondence to John A. Capitman, PhD, Schneider Institute for Health Policy, Brandeis University Heller School, 415 South Street, Waltham, MA 02454. E-mail: capitman{at}brandeis.edu
Although there are important exceptions, the literature on managed community care has had difficulty showing cost effectiveness. In this context, cost effectiveness is generally defined as substitution (avoiding hospital and nursing home expenditures) or as efficacy (achieving more positive morbidity and mortality outcomes). For the past several years, William Weissert and his colleagues have sought to increase cost effectiveness by developing a framework for "titrating" community care. They argue that if services were allocated on the basis of the potential to avoid undesirable outcomes, then more resources would be devoted to those with greater risk and greater average benefit would result. Using data from the Arizona Long Term Care System (ALTCS), Weissert and his colleagues have explored the heterogeneity of chronically ill elder program participants with respect to mortality, hospitalization, nursing home use, and functional status. They have made the following arguments.
First, individual long-term care participants have differential risks for these outcomes that can be reasonably estimated from assessment data (Chernew, Weissert, & Hirth, 2001). Second, although the community-care literature offers at best inconclusive evidence for the benefits of services in reducing these risks, it is possible to assert that services have small but consistent (invariant with respect to risk level) impacts on reducing risks in the four areas (Miller & Weissert, 2000). Third, the benefits of avoiding each of the four outcomes can be expressed in dollar terms (that are again invariant with respect to risk level or other factors; see Weissert et al., 2001).
The three elements (risk, impact of services on reducing risk, and benefit in dollars) can be combined to estimate the relative value of community care for individuals, guide resource allocation, or establish reimbursement levels.
Weissert and colleagues acknowledge the host of data limitations and technical concerns that limit the precision and generality of the effectiveness and risk-weighted value (ERV) estimates they have derived from the Arizona program experience. Nonetheless, they assert the potential value of ERV concepts and information in redirecting the attention of community-care program managers and practitioners. This may be too large a leap because some of their underlying assumptions may not survive focused tests. In particular, it seems unlikely that the value of community care in reducing the four risks is invariant across risk levels or insensitive to the particular combinations of services and supports allocated. Similarly, it seems unlikely that various outcomes are evaluated in the same ways by individuals from diverse social contexts or at diverse phases in the disease and disablement process.
In this issue, Weissert and colleagues extend their ideas to care-planning decisions by ALTCS case managers (Weissert, Hirth, Chernew, Diwan, & Kim, 2003). They taught case managers ERV concepts and offered them information about anticipated risks and relative potential benefits of care (in relation to mortality, nursing home and hospital use, and functional status) for a varied group of hypothetical cases. Compared with case managers given only assessment data, those exposed to ERV rankings developed care plans that were on average less costly, devoted more resources to medical care, and were more closely correlated with risk ratings. Although these results support the conclusion that care-management choices can be influenced by an explicit resource-allocation paradigm and associated information, it should also be noted that ALTCS practitioners work in a capitated managed-care setting and thus face different care-planning opportunities, constraints, and incentives than those in other settings. It is yet to be seen, as Weissert and colleagues note, whether ERV-influenced resource-allocation choices would be sustained in real-world practice (with more potential influence on care plans of personal interactions with individual clients-caregivers). Furthermore, even if new allocation patterns were achieved, it is yet to be demonstrated that actual outcome patterns would shift in the hypothesized ways.
Beyond these specific questions about the impacts of implementing the ERV paradigm on real-world care planning, it seems to me that Weissert and colleagues are seeking solutions to the wrong problem. I am convinced that basing community-care evaluation on substitution and efficacy is only relevant to the limited set of circumstances when these services are offered as an explicit extension of medical care, as in some postacute home health and adult day care situations. More often, community care is provided as a societal effort to fairly respond to the disablement process. Disablement can be viewed as serial transitions over time in the ability to enjoy age-appropriate participation in the public and private spheres, with different diseases and limitations producing diverse patterns of stability and change as a function of social location and other factors. The societal press to be fair in our response to disablement means that community care is best judged on how well elders and informal caregivers are helped to solve daily personal care, household maintenance, social support, and communal participation problems. Evidence that meeting these needs reduces demand for medical-care services or alters the course of the disablement process is largely irrelevant given these program goals.
From this perspective, our challenge in community care is to figure out the least costly and most sustainable ways to respond to disablement while promoting the autonomy and well-being of chronically ill elders and their caregivers (Capitman, 2003). Budgeting and reimbursement have to be based on how much our society is willing to devote to a fair response to disablement rather than on expected returns on investment as lowered health care costs or reduced morbidity and mortality.
There seems little doubt that care managers could benefit from additional training on how to elicit and hear the views of elders and caregivers about the life problems faced during disablement. Care managers need constant refreshers on maintaining humility with respect to the relative value of community-care services compared with current and accumulated physical and psychological impacts of social locations and social networks. They may also benefit from new skills in navigating delivery systems and helping elders or caregivers reconcile personal goals, resources, and behaviors. The ERV approach seems to move in the opposite direction. It promotes care manager arrogance about the value of care and discounts the diversity of disability-related and social-context barriers to achieving a quality life.
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Decision Editor: Linda S. Noelker, PhD
Received for publication June 2, 2003. Accepted for publication June 24, 2003.
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