People With Chronic Conditions Account for 84 Percent of All Health Care Spending
Health Quality Partners (HQP) developed an experimental Medicare program in the small town of Doylestown, Pa, not far from Philadelphia, that cut mortality rates 25 percent, cut Medicare costs by 22 percent and reduced hospitalizations by 33 percent. HQP published the results of their double blind peer reviewed study to rave reviews from the medical research community. HQP succeed to cut costs while improving quality, something all competing experimental programs had failed to do. Medicare, not Social Security is the "entitlement" program with large projected cost increases that threaten to break the budget. HQP's program appears to be just what the doctor ordered to cure our long term budget problems and the problem of how to care for aging Boomers. However, Medicare recently notified HQP they are going to terminate the program in June, with no follow on.
Health Care Spending Increases With the Number of Chronic Conditions.
Just about everything in the media about cutting health care costs is wrong. Washington Post's Ezra Klein just got it right. The best, in fact the only reasonable way, to cut costs is active health management to keep people with chronic conditions as healthy as possible to keep them out of the hospital. The costs involved with hospitalization of patients with chronic conditions are enormous. 84% of all health care spending is on people with chronic conditions and the lions share of that is on hospitalization and tests and procedures done in the hospital. HQP had a simple, but revolutionary idea, for cutting costs and improving health: weekly home nurse visits for Medicare patients with chronic conditions who had been hospitalized.
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.
What Did the Researchers Do?
The researchers recruited eligible patients aged 65 years and over with heart failure, coronary heart disease, asthma, diabetes, hypertension, and/or hyperlipidemia who received traditional Medicare—a fee for service insurance scheme in which beneficiaries can choose to receive their care from any Medicare provider—from participating primary care practices in Pennsylvania. The researchers then categorized patients according to their risk on the basis of several factors including the number of chronic diseases each individual had before randomizing patients to receive usual care or the nurse-led intervention. The intervention included an individualized plan comprising education, symptom monitoring, medication, counseling for adherence, help identifying, arranging, and monitoring community health and social service referrals in addition to group interventions such as weight loss maintenance and exercise classes.

Older Adults Are More Likely to Have Multiple Chronic Conditions. 73% of Americans aged 65+ have 2 or more chronic conditions.
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.
What Did the Researchers Find?

The researchers checked whether any participating patients had died by using the online Social Security Death Master File. Then the researchers used a statistical model to calculate the risk of death in both groups.

Of the 1,736 patients the researchers recruited into the trial, 873 were randomized to receive the intervention and 863 were in the control group (usual care). The researchers found that 86 (9.9%) participants in the intervention group and 111 (12.9%) participants in the control group died during the study period, representing a 25% lower relative risk of death among the intervention group. However, when the researchers considered other factors, such as sex, age group, primary diagnosis, perceived health, number of medications taken, hospital stays in the past 6 months, and tobacco use in their statistical model, this risk was slightly altered—0.73 risk of death in the intervention group.

This program succeeded where others failed because it sent nurses to the home instead of having nurses make phone calls from a distance. Every phone based program failed. The weekly house call by the nurse made all the difference in the world. But Medicare is not welcoming this model of care.

“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. “As we design new models and demonstrations, we are integrating lessons from this experience into those designs.”

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 has other plans. Medicare administrators intend to change the model of payment to an HMO model of a flat fee per patient. This model has been tried before, but failed to cut costs because it gave incentives to attract the healthiest patients, not incentives to make the sickest patients healthier. HMOs carefully designed programs to discourage participation by patients with multiple chronic conditions.
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. After all, HQP worked, but most of the programs in the demonstration didn’t. It notes that HQP is a relatively small program that only ever treated a couple of thousand people. 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.

The Health Quality Partners model conflicts with the business model of many of the corporate players in the health care business by keeping patients healthy. The HMO model milks paying patients like cash cows while rationing the quality of care to the poor and elderly, something the corporate players are already experts at doing.

What Do These Findings Mean?

These findings suggest that that community-based nurse care management is associated with a reduction in all-cause mortality among older adults with chronic illnesses who are beneficiaries of the fee for service Medicare scheme in the United States. These findings also support the important role of nurses in improving health outcomes in this group of patients and show the feasibility of implementing this program in collaboration with primary care practices. Future research is needed to test the adaptability, scalability, and generalizability of this model of care.

All Americans should be outraged that plans to ration health care continue to be developed while programs that could improve care while cutting costs are left to wither on the vine.


My wife, kossack Tbirchard is a practicing Ob/Gyn, and I did her medical billing and business management for several years when she ran a private practice on Kauai

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