We continue to do the same thing and expect a different result. CPC+ is a fee-for-service model with supplemental payments based on the complexity of the patient. Dementia patients produced a supplemental payment of $100 per patient with dementia per month. They paid the most for patients in whom savings could not be generated. The most costly 5% of patients generate half the cost, but this population is not all the same. It is divided into thirds. One third are end stage patients who will continue to be very costly no matter what you do. Dementia patients fall into that category along with patients on dialysis or stage 4 heart failure. One third have a severe, one-time catastrophe like an auto accident and costs cannot be predicted or lowered there either. The third that can produce big gains have a set of chronic conditions that can be more effectively managed to pull them out of the 5% or prevent their entry into it. That is the third that I write about all the time. A patient with hypertension, diabetes, high cholesterol, a history of a heart attack, stage 1-3 congestive heart failure, and stage 3 chronic kidney disease would fit this model. To save money, you must focus on the right population. Some dementia comes from multiple small stroke (multi-infarct or vascular dementia) If we identify the patient with a small stroke and begin optimal medical therapy earlier, dementia can be prevented and costs averted.
There is also evidence about the intervention that works. I can find no evidence that the practices in CPC+ employed advanced medical home teams aimed at a related set of chronic conditions. The only intervention that consistently moves the needle is an advanced medical home team including nurse practitioners and/or pharmacists who are authorized to make changes based on a protocol in real time without checking with the doctor. The most effective protocols for related cardiometabolic conditions include lisinopril or losartan and spironolactone or eplerenone for hypertension. A statin for high cholesterol and metformin for diabetes. SGLT2 inhibitors can be added as the second drug for diabetes if needed for glucose control. These medications have more effect than would be expected in protecting cells and organs than would be expected from their impact on the target risk factor. In combination, they dramatically reduce mortality, heart attack and stroke while also lowering the total cost of care. When will we make the patient-centered changes that will improve health and save money? We have the evidence of what works. For some reason, we just don't do it.
In addition, metabolic dysfunction is present in ALL stages of cardiovascular diseases, it must be optimized to maximize the effectiveness of OMT.