If this was a pill, you'd do anything to get it
By Ezra Klein, Washington Post, April 28, 2013
When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It's a graph that explains why he's doing what he's doing. It's a graph he particularly wishes the folks who run Medicare would see, because if they did, then there's no way they'd be threatening to shut down his program.
The graph shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it's below 100. When's the last time you heard of an American dying from diarrhea?
"For all the millennia before this in human history," Coburn says, "it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn't have 85-year-olds with chronic diseases."
With chronic illnesses like diabetes and heart disease you don't get better, or at least not quickly. They don't require cures so much as management. Their existence is often proof of medicine's successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today's medical system: Its successes have changed the problems, but the health-care system hasn't kept up.
Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions--with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. "This is the Willie Sutton rule," he says. "If 80 percent of the spending is going to patients with five or more conditions, that's where our health-care system needs to go."
Health Quality Partners is all about going there. The program enrolls Medicare patients with at least one chronic illness and one hospitalization in the past year. It then sends a trained nurse to see them every week, or every month, whether they're healthy or sick. It sounds simple and, in a way, it is. But simple things can be revolutionary.
Most care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. That model has mostly been a failure. And while many health systems send a nurse regularly in the weeks or months after a serious hospitalization, few send one regularly to even seemingly healthy patients. This a radical redefinition of the health-care system's role in the lives of the elderly. It redefines being old and chronically ill as a condition requiring professional medical management.
Health Quality Partners' results have been extraordinary. According to an independent analysis by the consulting firm Mathematica, HQP has reduced hospitalizations by 33 percent and cut Medicare costs by 22 percent.
Others in the profession have taken notice. "It's like they've discovered the fountain of youth in Doylestown, Pa.," marvels Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers.
Now Medicare is thinking of shutting it off.
Of 15 proposed HHS programs, four improved patient outcomes without increasing costs. Only HQP improved patient outcomes while cutting costs. So Medicare extended it again and again--now it's the only program still running under the demo. But Medicare has notified Coburn that it intends to end HQP's funding in June.
Medicare's official explanation is carefully bureaucratic. "The authority that CMS had to conduct this specific demonstration, which predated the health care law, did not allow us to make the program permanent and limited our ability to expand it further," says Emma Sandoe, a spokeswoman for the Centers on Medicare and Medicaid Services.
Every expert I spoke to--as well as a plain reading of the law--disagrees. If they wanted to make HQP permanent, or scale it up in a big way, Medicare has the power to do so. Then there's this: "Thanks to the health care law, we can now test new, innovative models for delivering health care and expanding models that show promise," Sandoe continues. "With this new authority, we can take best practices to scale and provide more incentives to deliver high-quality health care at lower costs."
Medicare is referring to the newly created Center for Medicare and Medicaid Innovation, which gives the program power to create and expand projects without congressional authorization. This authority could also be used to create projects based on HQP's lessons. It's not. Instead, Medicare has created a raft of projects and experiments meant to move the system from fee-for-service toward pay-for-quality--with the hope that if they can get the payment incentives right, then the market will have reason to support programs like HQP.
To Health Quality Partners and its defenders, Medicare's decision is ludicrous. "We're spending tens of billions of dollars now on Medicare innovation where Medicare already discovered something amazing and now they're forgetting what they discovered?" Brenner says. "It's an amazing government moment."
But to Medicare, it's not so much forgetting as being realistic. For a program the size of Medicare, working to scale up a small operation like HQP seems less likely to deliver a big return than working to change the payment structure that governs the entire system.
This drives Coburn crazy. "People always ask if what we do is scalable. Well, define scalable. It's less difficult than open-heart surgery, which is one of the most common surgeries in the country, and it's more difficult than giving a vaccine. There's this amazing double standard in medicine. For the kind of thing we do, if it's more difficult than making a phone call once in awhile, then it's not scalable. But you provide enough economic incentives and all of a sudden every hospital has an open-heart surgery program."
Brenner puts it more vividly. "There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you'd say, 'Of course I want that.' But then you'd say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you'd say, no, you just have to have a nurse come visit her every week."
I asked a half-dozen seniors what difference Health Quality Partners made in their lives. Every one of them began the same way: They could ask their nurse questions, they said with evident relief. They could get help understanding and navigating their doctor's orders. They didn't feel like they were being a burden if they needed to ask one more thing, or have their medications explained to them again.
Physicians are brusque, and harried, and they talk quickly and confidently, and chronically ill seniors often leave with complicated instructions and a hazy understanding of how to follow them. "In a doctor's office, a lot of people, especially older people, feel pressure to get out because they know the doctor is busy and they're a bit intimidated," says Bill Allen, a friendly 78-year-old who is also a patient of nurse Graefe's. "Because she's here in our home, you can feel more free to ask her anything. It's great."
We think of the hospital as a place people go to get better. At Health Quality Partners, the view is that a hospital is a place where seniors get worse. "Being in the hospital for three days or five days sets them back to a point where they'll never regain what they were," says Sherry Marcantonio, chief program architect of HQP. "That's where the scales tip. That's where people end up needing a nursing home." Keeping seniors out of the hospital, which is a core focus of its program, cuts costs and saves lives, but it also preserves quality of life--a measure often ignored in these discussions. There's a good argument to be made that if a program like HQP cost slightly more than traditional Medicare but cut hospitalizations by a third, it would still be worth it. The point of health care, after all, is to keep people healthy. But HQP saves money--and lots of it.
Medicine has been so focused on what doctors can do in the hospital that it has barely even begun to figure out what can be done in the home. But the home is where elderly patients spend most of their time. It's where they take their medicine and eat their meals, and it's where they fall into funks and trip over the corner of the carpet. It's where a trained medical professional can see a bad turn before it turns into a catastrophe. Medicine, however, has been reluctant to intrude into homes.
For the most part, the medical system treats the old very much like it treats the young. It cares for them when they're sick and ignores them when they're well.
At another time, these functions would have been filled by the family, who would be right in the other room, and who would know if their mother looked different than she had a few weeks ago. But few of today's elderly live with their children. Many don't even live in the same state, or they don't have any contact with their children, or they don't have children.
A recent study in the Proceedings of the National Academy of Sciences found that after adjusting for demographic factors and underlying health, social isolation increased the likelihood of death among the elderly by a stunning 26 percent. "People with few social contacts may not have people around them who can give them advice, recommend that they go to a doctor with symptoms, ensure that they maintain healthy lifestyles, or perhaps they don't have anyone around when they experience acute symptoms," says Andrew Steptoe, the lead author on the study.
We've been conditioned by "Grey's Anatomy" and hospital rooms to believe that saving lives is a complicated, heroic business. And it is--after people get very sick. But keeping them from getting very sick doesn't necessarily require the discovery of new molecules. It requires someone who has a relationship with them to stop by once a week to see how they're doing. The problem is, it's hard to make money off it.
If you go into the hospital for heart surgery and you end up getting a central-line infection, you'd hope that the hospital would be penalized for it. The opposite, in fact, is true. According to a new study in the Journal of the American Medical Association, surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients.
This, too, is a legacy of a health system built for acute care. Hospitals make money when they do more to patients. They lose money when their beds are empty. Put simply, Health Quality Partners makes hospitals lose money. "There's no doubt that it's a hit to the bottom line," says Rich Reif, the former CEO of Doylestown Hospital, which worked with HQP.
Reif's answer for why he worked with a group that cost him money is simple: His hospital was unusual. In 1895, 14 women came together to form Doylestown's "Village Improvement Association," which was dedicated to "the health and beauty" of the community. The association actually owned Doylestown Hospital, and its mission was the hospital's mission. "I did get some heat from my senior management team," Reif says. "When you're doing annual budgets you see reduction in revenue. But I could always come back and say, 'Wasn't that our responsibility?'?"
But not all hospitals are run by the local Village Improvement Association. Many seek to turn a profit. That makes models like Health Quality Partners something of a threat. "If we scaled what Ken is doing," Brenner says, "you would probably shut down a third of the hospitals in the country. It's a disruptive innovation. It just guts the current business model."
"This is about power and money," Brenner says. "The largest group in the top one percent of income in America are physicians."
The chronic-care focused system that Coburn is pioneering is more about nurses than doctors, more about home visits than hospitals, and more about human interaction than high-tech intervention. A system based on managing chronic care is a truly different system from the one we have today. Health Quality Partners was lucky to find a hospital that wanted to work with it. But many hospitals wouldn't want to work with a program dedicated to sharply reducing their revenue stream. And without cooperation from the hospital and a patient's doctors, the HQP model would fail.
