New health care model adapts to changing realities

Can Medicare move out of hospitals and into homes?

Ever forget to take your pills or simply fail to measure your blood sugar or some other routine health care daily chores? Would it help you remember if you knew that a nurse was coming by regularly to check in and make sure you were doing what you were supposed to do?

Simple things sometimes can be revolutionary. A Medicare experimental program, being tested in Doylestown, Pa., that brings a nurse to regularly visit you for continued care – even when you aren’t seriously ill – has been given an 18 month reprieve from being shut down. If it is successful and implemented on a much wider scale, it could change the direction of health care.

The idea of continued consistent care, in the form of home visits by a nurse, has Medicare officials paying attention, and hospitals and doctors worried because the success of the program could cost hospitals important dollars at a time of tight budgets.

At least for the next 18 months, this Medicare experiment from a company called Health Quality Partners (HQP), has been spared from being shut down. It came so close to being killed off in late June that they recently began to disenroll patients and shut down operations until Medicare extended the program at the beginning of July.

Ken Coburn, who runs HQP in Doylestown, Pa., likes to show visitors a graph that explains why he’s doing what he’s doing. As he explained to Washington Post columnist Ezra Klein, who wrote about it last spring, if Medicare could see the graph, they wouldn’t even think about threatening to shut down his program.

The graph, using numbers from the Centers for Disease Control and Prevention, 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 told the Washington Post, “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 20th century. You didn’t have 85 year olds with chronic diseases.”

Longer lives and more chronic conditions

With chronic illnesses like diabetes and heart disease, getting better isn’t the focus. It’s not about a cure as it is about managing the situation. 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: The change to living with chronic illness has changed the problem and the health care system simply hasn’t kept up. So Coburn and HQP are attempting to adjust to changing medical needs – seniors with multiple chronic conditions.

Medicare experts, like Kenneth Thorpe, who chairs 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,” Thorpe 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.”

Thorpe understands this from his former role as Deputy Assistant Secretary of Health Policy at the U.S. Department of Health and Human Services, where he coordinated all financial estimates and program impacts of President Clinton’s efforts to get health care reform back in the mid-1990s.

Even lawmakers on Capitol Hill, like Sen. Ron Wyden, D Ore., are starting to emphasize the need to deal with chronic care. In a recent speech, Wyden noted that about 70 percent of Medicare patients have two or more chronic health conditions and account for more than 90 percent of Medicare spending — or roughly $500 billion each year.

So Coburn and HQP have been enrolling Medicare patients with at least one chronic illness and one hospitalization in the past year. They then send a trained nurse to see these patients every week, or every month, whether they’re healthy or sick. It sounds simple and, in a way, it is. But that doesn’t mean it isn’t a profound change in the way care is given.

Throughout the United States, most care management systems rely on nurses sitting in call centers, checking up on patients over the phone. But that model, the Washington Post’s Klein argues, has mostly been a failure. Many health systems send a nurse regularly in the weeks or months after a serious hospitalization, but few send one regularly to even seemingly healthy patients.

HQP results are impressive – even if the number of patients has been somewhat limited. 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.

But could this program be implemented on a much larger basis and would it have the same effects?

“There is a bias in medicine against talking to people and for cutting, scanning and chopping into them,” Brenner told the Washington Post. “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.”

Homes for hospitals

Most people think of hospitals as places to go to get better when you are sick. But HQP sees the hospital as a place where seniors get worse, often setting them back to a point where they never regain what they were.

Keeping seniors out of the hospital, which is a core focus of HQP’s program, cuts costs and saves lives, but it also preserves quality of life — a measure often ignored in these discussions. Some would argue 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 idea is to keep people healthy, and yet, HQP also saves lots of money.

“If there is a secret to the success of Health Quality Partners at preventing hospitalizations,” Klein argues, it’s this: “No one else is checking in with patients every week. Medical technology — from pills to devices to surgical procedures — is so advanced and so competitive that making further gains requires enormous investment and rarely brings high returns.

“But the exciting field of knocking [on a patient’s door] is almost totally empty. 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.”

Times have also changed in how and where family members are. In the past, these functions would have been filled by the family, who would be in the next room and who would know if their mother looked different than she had a few weeks ago. But these days, few of today’s seniors live with their children.

Adapting to this new model of care could definitely be seen as a threat to hospitals. As Camden Coalition’s Brenner told Klein, “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.”

But that’s exactly where Medicare’s efforts to change its payment model from fee for service to quality of care could actually help HQP and other hospitals pushing to band together into accountable care organizations. These ACOs get a flat fee for all care related to a patient. If they spend less, they could keep the difference.

ACOs are the latest push in health care and it will be a while to see if they will be a game changer. As Klein argued in his Washington Post column, “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,” Klein argues.

Also contributing to this story was the Washington Post.

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