Online buzz about Ezra Klein’s Washington Post article energetic and thoughtful; but missing key data

Posted on May 4, 2013 by Kenneth D Coburn MD MPH

Post Updated May 5, 2013 - The thorough article by Ezra Klein in the Business section of the Sunday Washington Post on 4/28/2013 and available at WonkBlog (CLICK HERE) was based on Mr. Klein spending 2 full days directly observing the work of our nursing team and learning about our program.  Much of the online buzz about the article, the HQP program, and the merits or pitfalls of continued CMS support for HQP's program has been thoughtful – generally leaning in favor of continued support for HQP's work.  Unfortunately, most discussions are taking place without important data about the HQP program's performance.

For example, very few online discussants have been able to find (not surprisingly) the 4th Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration commissioned by CMS and compiled by Mathematica Policy Research, Inc. March 2011 which reported:
Among high-risk participants, HQP’s model of Community-based Advanced Care Management reduced deaths -30.4% (p=0.03), hospitalizations -38.8% (p<0.01), emergency room visits -37% (p=0.05), average monthly Part A and B Medicare expenditures -$511 (-35.5%, p=0.01), and average monthly net expenditures (including program fees) -$397 (-27.6%, p=0.05).  To see this report in its entirety CLICK HERE - scroll down past the nearly blank cover page to get to the report.

For a full summary of all primary studies reporting on the HQP program CLICK HERE.

Note also that the HQP program has also been evaluated by Aetna for more than 3 years and according to Aetna's Medical Economics division found to reduce hospitalizations and save money among high-risk Medicare Advantage members.  See previous press releases by Aetna on this HERE (Jan 2013) and HERE (Nov 2011).  Aetna has just renewed and expanded their contract with HQP through 2015.
For more information about HQP visit http://hqp.org

Thanks for everyone's interest and thoughtful, considered discussions.  In short, the HQP program has shown significant net savings, fewer hospitalizations, and better health outcomes in higher-risk Medicare beneficiaries. To date it has not saved net dollars among low / moderate risk populations.  The model (what we call an Advanced Preventive Service) differs from many nurse care management programs in having a more extensive portfolio of preventive services and more rigorous process monitoring to manage service delivery reliability.  We believe these characteristics are reproducible and scaleable, but of course that needs to be tested and proven.  In partnership with others interested in advancing this field and on behalf of millions of chronically ill older Americans who could benefit from such care, we hope to have that opportunity.
Best,
Ken Coburn, MD, MPH
CEO and Medical Director, Health Quality Partners

Posted in CMS, HQP Advanced Preventive Service, HQP Community Care Management, Learning to Discern, Medicare Advantage, Medicare Coordinated Care Demo, News at HQP, Research | Comments Off

Effective Health Policy Depends on High Quality Health Systems (Services) Research

Posted on February 10, 2013 by Kenneth D Coburn MD MPH

Nobody argues with the idea that the next big advance in cancer care or HIV vaccine development requires a significant commitment to research.  Nor would anyone argue that the quality of that research needs to be excellent or that it must yield reliable information and insight about what actually works and what doesn't.  Would anyone invest in a global immunization campaign with a vaccine not proven effective in rigorously conducted trials?  Of course not.

Tragically, when it comes to health care policy, the need for rigorous, long-term, high quality health systems research, is often over-looked, underappreciated, or pushed aside for expediency.  Launching large-scale health policy initiatives without a clear understanding of precisely how care will be delivered more effectively to improve health outcomes is the equivalent of launching a massive immunization campaign not knowing whether the vaccine in the syringe is effective.  More accurately – in the case of recent CMS, Center for Medicare and Medicaid Innovation initiatives focusing on payment reforms (like ACOs, Medicare shared savings, and bundled payments) – it's like starting the immunization campaign and telling each enlisted organization to come up with their own vaccine as they go.  Never mind that most such organizations have relatively little capital, expertise, or experience in conducting such research or that a critical review of the results from their respective "labs", to date, show little high quality research conducted and scant evidence of effective interventions.  

Payment Reforms Do Not Reduce the Need for Health Systems Research

The current massive allocation of resources and attention dedicated to fast-tracking payment reforms while providing comparatively less support for sustained health systems research appears to be based on 3 assumptions.

Assumption #1 – policy innovations (in this case, payment reforms) that begin as large-scale initiatives are more efficient because they obviate the need to commit additional time and effort to take interventions to scale or broadly disseminate best practices.  Not true.  Across the funded sites in the new payment reform programs, there will be a variety of models tried (codified to varying degrees) with a broad range of effectiveness.  This will become apparent if enough resources and rigor are put into the evaluation of these programs.  The task of figuring out what worked best and encouraging others to adapt effective models to different settings and contexts still remains.  In other words, the challenge of disseminating innovations is merely deferred, not eliminated.  In the short term, we might imagine that we are quickly moving the needle on a large scale – but that will not be true unless highly effective exemplars are reliably identified and their models widely adopted.

Assumption #2 – the expectation that large numbers of organizations can suddenly develop new delivery models that improve health outcomes and lower costs seems to rest on a naive assumption that this type of innovation (system redesign) is not complex and is largely dependent on organizational motivation.   But there is little evidence to suggest that such innovations in delivery systems require less exploratory research, experimentation, analytical expertise or time than do biomedical or public health breakthroughs.  Successful system redesign may require as much disciplined, iterative research as that required to develop an effective HIV vaccine or cancer treatment – in fact, it might require more.  Underestimating the need for sustained systems research could pose a significant barrier to progress.

Assumption #3 – with cost saving "guarantees" to Medicare built into many of the new payment reforms, who cares whether participating organizations come up with better models of care delivery or not? – CMS will still save money for Medicare.  This is shortsighted because health care organizations that try and fail to achieve a sustainable model of care will lose faith, withdraw from the effort, signal others to stay away, and mobilize political opposition to future reforms.  In the worst-case scenario, trumpeting the success of models that turn out to be unsustainable erodes confidence that system innovations can lead to meaningful improvement.  

Example: Without Good Evidence State Program In Jeopardy

A case in point is Community Care of North Carolina, a statewide approach to controlling Medicaid costs using a medical home care management model.  The program offers providers considerable flexibility with respect to the specifics of implementation and is delivered differently by different provider networks across the state (i.e., high degree of local variation).  Controversy has sprung up about the validity and continued relevance of earlier actuarial analyses used to evaluate the program's overall impact.  In the absence of more direct and ongoing research methods, doubts about the program’s effectiveness have grown.

Quotes from a performance audit of North Carolina's Medicaid program issued January 2013 (click here for the full audit) highlight the need for a solid evidence base even in the case of one of the nation’s longest running and most often showcased large-scale deployment of the Patient Centered Medical Home model.

“While North Carolina Medicaid relies on several strategies to control consumption, the single strategy that is invested with creating the greatest cost savings is Community Care of North Carolina (CCNC). The State expected to save $90 million per year with CCNC during SFYs 2012 and 2013, but fell $39.5 million short of its goal in 2012. CCNC is a form of managed care that provides case management services in a medical home environment. It is assumed to provide savings in providing medical services to participants. More than a decade of data exists that would allow a study by medical researchers on whether the medical home model truly saves money and/or results in better medical outcomes. It would be a service to the nation as well as North Carolina to use this data to genuinely evaluate the questions associated with medical homes.”

One recommendation coming from the audit;

“The State of North Carolina should engage medical researchers to perform a scientifically valid study based upon actual data to determine whether the CCNC model saves money and improves health outcomes.”

CMS Halts Research Without Offering a Plan to Promote the Most Effective Model of Medicare Care Management

CMS recently notified Health Quality Partners (HQP) that it plans to terminate the long-running research HQP has been successfully conducting for over 11 years, in the Medicare Coordinated Care Demonstration (MCCD) despite having approved a new phase of research just 3 years ago, which was designed to validate the significant cost savings seen among higher-risk beneficiaries in prior subgroup analyses.  The HQP community-based nurse care management program represents a new category of system redesign that fills the void between medical care and public health; an Advanced Preventive Service.

It has been shown to save lives, reduce hospitalizations, and lower cost among higher-risk beneficiaries (click on any of the following to see; Summary Slide by HQP, Third Report to Congress 2008, Fourth Report to Congress 2011, Health Affairs 2012, PLoS Medicine 2012).  Given that the average life expectancy of Americans aged 65 is over 19 years, the durable longitudinal effectiveness (validated out to 4 years) of HQP’s program seems to be just what Medicare needs.  HQP has requested CMS reconsider its decision and continue its support of HQP's research in order to further advance this critical knowledge base.  In addition, it seems an opportune time for CMS to consider supporting pilots or demonstrations to test the replication and scalability of the program in other areas of the country wishing to implement this model.

We Need Both – Payment Reform to Spur Action and High Quality Health Systems Research

The issue is not pitting payment reforms against health systems research or trading one off for the other.  The best hope for transforming the American health care system is a good balance and integration of these two important drivers of health system innovation.  Achieving such a balance is a very complex challenge for the dedicated people at HHS, CMS, AHRQ, CDC, and other federal agencies.  But such efforts, especially if undertaken in collaboration with states, is our best shot at creating a higher quality, person centered, preventive, and fiscally responsible health system.

Posted in Accountable Care Organizations, Care Coordination, CMS, Health Reform, Learning to Discern, Medicare Coordinated Care Demo, Patient Centered Medical Home, Research, Systems Thinking | Comments Off

Medicare Advantage vs traditional Medicare; Best quality?

Posted on January 19, 2013 by Kenneth D Coburn MD MPH

A recent NY Times Economix blog post by Professor Uwe E. Reinhardt, Comparing the Quality of Care in Medicare Options, notes the lack of good research available to evaluate whether there is a difference in the quality of care provided by Medicare Advantage (MA) plans vs. traditional Medicare.  He goes on to say that given the evidence that is out there, he leans toward giving the MA plans the edge.  HQP’s experience in this regard is still evolving, but may be instructive, and seems to be in accord with Dr. Reinhardt’s tentative conclusion.

HQP’s journey to develop an innovative new delivery model to improve the health of vulnerable populations began over 12 years ago.  The basic idea was simple.  Find a way to more effectively prevent complications among the chronically ill.  How?  Develop a robust bundle of preventive services matched to the needs of a target population then deliver it in a highly reliable, individually-customized way through a proactive, engaging, supportive, accessible, and ongoing service.  We call the program developed using this disciplined approach to design and implementation, an Advanced Preventive ServiceSM model of care.

The HQP team has had the extraordinary opportunity to test its Advanced Preventive Service program in the Medicare Coordinated Care Demonstration (MCCD).   This taxpayer funded demonstration was enacted by Congress in the Balanced Budget Act of 1997.  In effect, Congress told CMS to try something new to improve quality and lower cost and, in this case, also specified what kind of program they should try.  CMS eventually launched the demonstration in 2002.  Fast forward 11 years, to today.

The Advanced Preventive Service program has proven to be a breakthrough in health services delivery.  It lowers cost, reduces hospitalizations, and improves the health outcomes and experience of care for a complex, expensive, and rapidly growing segment of our population – chronically ill older adults.  After many years of rigorous testing, using the gold-standard of a randomized clinical trial analyzed on an intention to treat basis, our results have been published in multiple Reports to Congress, peer-reviewed journals, and presented at national conferences.  A summary slide of these results is available (click here) and you can link to the full article published in PLoS Medicine describing how our Advanced Preventive Service program lowered all-cause mortality 25% (click here).

Amazing right?  This new innovation can make a significant contribution to transforming our current system from a sick care model that flounders to serve an aging, increasingly chronically ill population to one designed for the modern era – more preventive and more effecitve at addressing the root causes of illness and suffering.  So which payers will make this breakthrough program available to those who can benefit?  CMS who tested and proved its value?  Or MA plans?

CMS has indicated to HQP that it plans to terminate the MCCD at the end of June 2013, but has not provided any indication about how or whether CMS plans to make the Advanced Preventive Service program available to eligible beneficiaries in traditional Medicare.  The apparent lack of urgency by CMS in this regard is perplexing in light of the cost savings and better outcomes for higher-risk beneficiaries associated with the program, the crisis of Medicare solvency and quality, the ballooning national debt, and the authority available to the Secretary of HHS to adopt new innovations that really work.  At the very least, HQP hopes to be granted access to data collected during the demonstration so that HQP can advance the research needed to further innovate and improve this model.  Unfortunately all such requests of CMS have so far gone – unanswered.  Meanwhile, Aetna, on the basis of HQP's MCCD results, has already been providing HQP's Advanced Preventive Service program to its high-risk Medicare Advantage members for more than 2 years; click here to see Aetna’s most recent press release.

Reinhardt notes that what passes for evidence when comparing quality in Medicare Advantage plans vs. traditional Medicare, is largely anecdotal – story-based.  At this point in the unfolding story of HQP’s pioneering work and Medicare's evolution, whether CMS will be able to harness proven innovations that improve the quality of care to traditional Medicare beneficiaries remains a mystery.  Millions of Americans are counting on them to do so.  Their decisions will do much to shape the next chapter in that story.

Advanced Preventive Service is a service mark of Health Quality Partners for its line of highly-effective preventive health programs.

Posted in CMS, HQP Advanced Preventive Service, Medicare Advantage, Medicare Coordinated Care Demo, Quality, Research | Comments Off

HQP’s Partnership with Aetna; Advancing A Model that Works

Posted on January 15, 2013 by Kenneth D Coburn MD MPH

The American health care system desperately needs a way to prevent complications of chronic disease that works.  Aetna’s recent news of its 2-year experience offering HQP’s program to higher-risk Medicare Advantage members is the latest in a long line of evidence that HQP’s model of nurse care management works. [click here for Aetna's press release]  As compelling as the most recent Aetna data is (hospital admissions reduced 15%, outpatient services by 17%, and overall hospital expenditures 16%) it actually understates the effectiveness of the program – by a wide margin.  Why?

Of the 1,200 higher-risk members HQP was authorized to serve, only 170 (14%) transitioned from the quality monitoring arm of the program into the advanced care management intervention – though many more could have benefited from the intensive intervention.  The evaluation of the program was undertaken by comparing the outcomes of the full 1,200 member roster to outcomes among similar members not in the HQP program.  A rigorous intention to treat, difference-in-differences approach to analysis.   Had more members been enrolled into HQP’s intensive service, a greater overall cohort impact would have been realized – probably closer to the 25-39% reduction in hospitalizations seen with HQP’s program in the Medicare Coordinated Care Demonstration. [click here to see those data]  The relatively low enrollment into the intensive arm of the HQP program had to do with remediable budgetary, structural, and operational constraints appropriate for a pilot phase of work – not a lack of member or physician interest in or satisfaction with the program.  HQP and Aetna are now working together to build on our shared experience to make changes that will allow the model to be even more effective going forward.

There is an incredible amount of uncertainty as to whether and to what degree recent health care reform and innovation efforts are making a difference.  Have the billions spent on Healthcare Information Technology (HIT), Big Data, Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMHs), and Bundled Payments (BPCI) improved the health of the nation and lowered the cost of health care?  It’s hard to tell at this point.  Maybe its too soon to know, and some of these efforts will yet yield better health and lower cost with more time and research.  They are conceptually appealing and each have their constituencies,  but to date – there is little compelling evidence that they work.  They sure are BIG BETS though, involving lots of money and lots of uncertainty.  By contrast, the HQP model of community-based nurse care management has a sustained record of effectiveness whether sponsored by CMS, provider organizations, or health plans.

To learn more about HQP and its programs and services visit our website at: http://hqp.org

Posted in Collaborations and Partnerships, Health Reform, HQP Community Care Management, News at HQP | Comments Off

HQP Cloud Launch: innovation for scale, reliability, replication

Posted on October 22, 2012 by Kenneth D Coburn MD MPH

Today, HQP launched it’s new platform for data management, analysis, and service – in the cloud.  Our nurse care managers are all equipped with iPads.  Data capture directly into a secure, private cloud server from the field better supports our team’s work flow and offers unlimited scalability.  HQP’s advanced analytics, patient education materials, key protocols and references are now always at the fingertips of each care manager – wherever they are.  This is a great beginning with much more innovation ahead.  Next phases of development are to include more comprehensive data capture, a more user-firendly interface, and real-time decision support to make it easier to reliably deliver best practice care management.  Exciting stuff.  Who wants to help?  Anyone want to try out our system? To contact us - CLICK HERE.

Posted in Uncategorized | Comments Off

An Escape Fire for the U.S. health system

Posted on October 14, 2012 by Kenneth D Coburn MD MPH

The movie “Escape Fire: The Fight to Rescue American Healthcare” (@EscapeFire, http://www.escapefiremovie.com/) is a thoughtful and compelling explanation of; the primary threats to the health of Americans, the key flaws of the U.S. health care system, and the dramatic change in thinking required to improve it.  What’s needed are more reliable and robust preventive services, especially targeting those at highest risk for avoidable complications of chronic disease. That is exactly what the advanced care management model developed by HQP offers.  There is now overwhelming evidence that the HQP model can improve health and lower cost among those at higher risk for poor health (see http://hqp.org/index.php/results).  Isn’t it time to strengthen our commitment to the continued R&D required to further enhance this model (and others like it having strong evidence of effectiveness) and promote its widespread use?

visit the website for Health Quality Partners (HQP) at http://hqp.org

Posted in Health Reform, HQP Community Care Management, Medicare Coordinated Care Demo, Public Health Trends, Systems Thinking | Comments Off

Berwick: The Future Healthcare System We Need is Beginning to Take Shape

Posted on September 30, 2012 by Kenneth D Coburn MD MPH

I have enormous respect for Dr. Don Berwick – a brilliant, clear, and articulate health care leader, committed to advancing affordable, quality health care for all.  Apart from his insights and skills related to improving our health care system, he withstood the  maelstrom of Washington politics with grace and professionalism.  A brief Q&A style interview with Don is available through the Commonwealth Fund website – click HERE to watch (10 mins) “Don Berwick: Reflections on the Affordable Care Act.”  Not only does Don describe aspects of the Affordable Care Act that he believes is helping to improve our health care system, but he offers further insights into how a future health care system should function differently and the changes in thinking required of health care leaders to bring it into reality.

The connection to the work of Health Quality Partners (HQP; http://www.hqp.org)?  To achieve a more affordable, accessible, and higher quality health care system it will be necessary to aggressively develop and deploy effective preventive models like HQP’s nurse care management program – providing care that does not begin or end at some business unit boundary or operational or informational silo (e.g., hospital, physician office, community organization, family).  A service that makes the whole system work better to avoid preventable human suffering and expenditures.  We have one that’s already been proven through 11 years of intensive research.  What are we waiting for?

Posted in Health Reform, HQP Community Care Management, Systems Thinking | Comments Off

Evidence supporting scalability of effective models indicates enormous possibility

Posted on September 16, 2012 by Kenneth D Coburn MD MPH

In the June 2012 article in Health Affairs by Brown et al., “Six Features of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions of High Risk Patients” a subgroup of patients was defined using criteria available in Medicare claims data;

[(HF, CAD, or COPD) AND ≥1 hospitalization in prior year]
OR [(diabetes, cancer (not skin), stroke, depression, dementia, atrial fibrillation, osteoporosis, rheumatoid arthritis/osteoarthritis, or chronic kidney disease)
AND ≥2 hospitalizations in the prior 2 years]

Members of this subgroup participating in the Health Quality Partners (HQP, http://www.hqp.org) program had -33% fewer hospitalizations (p=0.02), -30% lower Part A & B Medicare expenditures (with program fees excluded) (p=0.045) and -21.5% lower net costs (program fees included) (p=0.15).  All terrific stuff and since the emphasis of this particular analysis was to identify common elements of successful programs, using complex subgroup definitions for that purpose is fine.  However, there are significant real-world challenges in trying to use such complex eligibility criteria for program implementation.  In the HQP experience, it remains hugely challenging to cobble together a patchwork of collaborative data sharing agreements with hospitals and primary care practices in order to serve a geographic region.  Complex criteria sets such as these make that job harder.  Having worked many years with the authors of this article I know that they too are fully aware of and appreciate this concern, but the inexperienced reader might confuse or meld these two separate issues: finding common elements of successful programs vs. defining the “best” target population for scaling effective care management interventions.

In tables in the Appendix to the article another, simpler subgroup is defined as;

HF, CAD, or COPD

Just having one or more of these 3 conditions meets this subgroup criteria; no other prior hospitalization usage, other co-morbidities, etc.  This group is a lot easier to “find” prospectively with data readily available in primary care practices (their billing data).  In the demonstration, HQP randomized 695 individuals meeting these criteria (43% of all those in the study) vs. just 273 (17% of those enrolled) of the more complex subgroup above.  Results for this simpler, more easily identified subgroup?  For HQP’s program, not bad; -25% fewer hospitalizations (p=0.005), -20% lower Parts A & B Medicare expenditures (-$220 per person per month) (p=0.02), and -10% net savings when program fees were included (-$116 per person per month) (p=0.22).  There are plenty of challenges to scaling highly-effective care management programs like HQP’s.  One challenge we can and should avoid is making the criteria set for eligibility needlessly restrictive and difficult to implement – especially when the evidence supports a wider population of people who can benefit.  With each larger scale cycle of testing, the criteria can be further refined (and coned down, if necessary), but in the meantime, we should encourage the use of target group criteria that are feasible to implement and support system redesigns with the greatest possible chance of successfully transforming our health care system for the better.

This same blog article is also posted on my personal blog, Health System Design Learning Journal at http://kencoburn.com/main/

Posted in Care Coordination, CMS, HQP Community Care Management, Learning to Discern, Medicare Coordinated Care Demo, Research, Systems Thinking | Comments Off

A New Model of Prevention – So Good it Saves Lives AND Money

Posted on July 18, 2012 by Kenneth D Coburn MD MPH

HQP’s nurse care management model is such an effective preventive intervention that it saves lives among chronically ill older adults. That’s the take away from a study undertaken by the the team at HQP and just published in PLoS Medicine. Read the full report here; http://dx.plos.org/10.1371/journal.pmed.1001265

Posted in Care Coordination, HQP Community Care Management, Medicare Coordinated Care Demo, Research | Comments Off

Health Care Transformation Could Power Economic Recovery, Create Jobs and Lower Health Care Costs

Posted on August 5, 2011 by Kenneth D Coburn MD MPH

As the stock markets head south, job creation remains moribund, consumer confidence slides, and the approval rating of Congress reaches a new historic low (that’s pretty darn low), the U.S. economy faces a daunting possibility of a double dip recession with no clear way to stimulate new growth and create jobs.  Why don’t we seize this crisis as an opportunity to truly transform health care for the better?  While it may seem counterintuitive (most meaningful system redesigns do), doing so could create significant numbers of good jobs here at home AND lower overall health care costs.  Here’s how.

The most powerful transformative healing force in our health care system are the people working within it.  Not EMR’s and their bits and bytes, but living, breathing, highly imperfect, dedicated, and passionate human beings.  As important and as useful as Health IT is for helping people heal themselves and one another, and for improving the safety and reliability of care, it is still only a tool to help the healers.  Not the source of healing itself.  The nearly decade long experience of Health Quality Partners in the Medicare Coordinated Care Demonstration (MCCD) proves that we can improve health outcomes, create good paying new jobs, and lower overall health care costs.(1)

The most obvious opportunity for job growth is in developing the ranks of the the next generation of nurse care managers and primary care physicians.  By targeting higher-risk chronically ill older adults to receive the kind of advanced community-based care management system designed by HQP, about 16% of the nations 48 million Americans on Medicare (about 7.7 million) could benefit – being given the chance for a better quality of life, fewer hospitalizations, and lower overall health care costs.  Doing so could create over 100,000 new nursing jobs, thousands more administrative, IT, and other jobs, and strengthen the numbers and support the role of primary care physicians.  We know through long-term population trials like MCCD that this can work.  There is a great opportunity to innovate other variations of healer-driven team models (with several other disciplines included) to serve other vulnerable populations in their communities too.

There is no doubt that taking these new models of health care delivery to large scale and adapting them for local conditions while maintaining their effectiveness is a big challenge, but it is one that has clear and measurable performance parameters and about which we have already learned a great deal.  Perhaps we can use our current crisis to force us to think differently and more courageously about transforming our health care delivery system. Not only through better use of bits and bytes, but through humans working together in new ways, in new roles, and using new skills and processes.

(1) Fourth Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration available here
More about HQP and its community-based advanced care management model can be found here

Posted in Care Coordination, Collaborations and Partnerships, HQP Community Care Management, Medicare Coordinated Care Demo, Research, Systems Thinking, Uncategorized | Comments Off