A Medical Experiment with Positive Results
July 2, 2013 11:12 PM   Subscribe

Health Quality Partners is an experimental program that uses home visits to Medicare patients to improve health. It also cuts costs. Scheduled to shut down this week, the program has gotten a reprieve.
This is the third time Medicare has almost shut Coburn’s program down, only to give it an extension at the last minute. “We really have got to figure out how to get beyond this cycle with Medicare,” Coburn sighed.

Still, for those who want to see the health-care system move towards a new model that emphasizes the management of chronic illnesses rather the treatment of acute illnesses, HQP’s reprieve is a big deal.
posted by kristi (17 comments total) 9 users marked this as a favorite
My mom has gotten visits. They got medicare to pay for a new hospital bed and wheelchair ramp. It's worth it to have around.
posted by Malice at 12:37 AM on July 3, 2013

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. [snip]

According to an independent analysis by the consulting firm Mathematica, HQP has reduced hospitalizations by 33 percent and cut Medicare costs by 22 percent.
It costs less and it improves patient health, so of course they want to shut it down.
posted by pracowity at 12:48 AM on July 3, 2013 [13 favorites]

Amen, pracowity! Increasing costs benefits both the companies privatizing hospitals, and perhaps ultimately even the insurance companies, i.e. everyone with lobbyists.

Actual costs for health care have fallen dramatically with increased automation, improved out patient treatment, information technology, and drug patents expiring, well few new patented drugs beat out their odder off patent versions.

HQP is basically out patient treatment tailored towards the elderly. Ain't surprising it cuts costs and improved results, like all sensible out patient treatment.
posted by jeffburdges at 2:09 AM on July 3, 2013 [1 favorite]

Wow, that's a pretty significant result. Sounds like further trials ought to be done, especially if Medicare has the authority to do so without approval from Congress.

As the article states, pushback from the industry will be pretty fierce. Hospitals have been going private at a high rate and new facilities have been popping up like weeds in the last decade. They're not going to be at all pleased about having to dispose of that any time soon. Of course, it seems like you could just convert them into nursing homes and still make a mint, but that's much riskier than using regulatory capture to ensure your business model isn't threatened.
posted by wierdo at 2:13 AM on July 3, 2013

Combine a system like this with things like mobile dialysis units and a lot of people who currently spend half their time at or going to and from the hospital would have much improved lives.
posted by pracowity at 3:15 AM on July 3, 2013

This appears to be the results of the experiment: Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries.

Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care.

So worth further investigation, does help with care, but doesn't save money. And the usual concerns about trials apply: when it's rolled out nationally, not run by these particular talented and dedicated individuals, will it still work?

Malice's comment is an excellent example:

My mom has gotten visits. They got medicare to pay for a new hospital bed and wheelchair ramp.

That's better care, not less spending.

The exact cost/benefit is very complex no doubt. I feel that this is a good policy, though, and should be pursued further.
posted by alasdair at 4:12 AM on July 3, 2013

The piece really did justice to the nurse's role. As a former visiting nurse, it's been my experience that even the most disorganized home is a better learning environment than the hospital. Doctors' discharge orders to the patient are generic, rigid and seldom followed. It takes some creativity to adapt them to the patient's lifestyle. It takes time and diplomacy to match interventions with the patient's willingness to change.

It's really the simplest things that are hard to implement, and the nurse working with the patient in the home with the family can actually make a difference. What's interesting is that small improvements seem to be having noticeable effects.
posted by klarck at 4:29 AM on July 3, 2013 [1 favorite]

I got really excited about the possibilities of e-health, automation, home treatment and all that good stuff about fifteen years ago. Not only did the stuff clearly work, but it was equally clearly the only sane way forward given the demographic time bomb and the way technology was going. It was the only way to make the numbers work - and, from what I could see, it had the additional benefits of being humane, effective and conducive to bringing the patient into the system, instead of being some sort of end node.

The cherry on the cake was that, in a country with one of the most integrated health systems in the world, the UK was the ideal place to solve the many problems about channels, regulation, education, monitoring and evaluation.

Since then, I have had an education and a half into the realpolitik of the health industry. The knowledge of what might have been dribbles an extra few drops of acid into the wound as I watch the NHS being dismantled.
posted by Devonian at 4:43 AM on July 3, 2013

In my daydreams, hospitals, schools, and prisons are all forbidden from being for-profit institutions.
posted by fings at 5:05 AM on July 3, 2013 [6 favorites]

In my daydreams, hospitals, schools, and prisons are all forbidden from being for-profit institutions.

This happens roughly the same time politicians are forbidden from being for-profit institutions.
posted by zombieflanders at 5:41 AM on July 3, 2013 [1 favorite]

I am not sure I understand the point of looking at a semi-related experiment versus an actual analysis of the results of this particular program, alasdair. And things like new hospital beds and wheelchair ramps could well represent decreased spending if they prevent hospitalizations.
posted by Nothing at 6:04 AM on July 3, 2013

The exact cost/benefit is very complex no doubt.

Absolutely. There's actually a deep epistemological problem buried here. The formal evaluation of the Medicare Coordinated Care Demonstration, of which this was a part, found that two of the programs (HQP and one other, QMED) improved quality and lowered costs. The other 13 sites did not show statistically significant improvements or lower costs. In each site, patients were randomized into treatment and non-treatment groups. [Something similar has been found for the HeadStart program overall.]

So what are we to do with mixed results like these? A clinical trial of a drug that is 20% effective is really 100% effective to 20% of the population, and not helpful to 80%. In the HQP case, the intervention (an organizational change with some real shifts in the socio-cultural work status of nurses and doctors) was effective as designed and implemented in two sites, and ineffective in the others (at least in cost terms).

Thus we can conclude that if, ahead of time, we could identify those sites where this intervention would be most effective, and target the program there, then, the results would show positive benefit/cost. Brown et al (2012) [pay wall, sorry] from Mathematica went to great lengths to describe these features.

This is essentially the same argument made for genetic medicine and other targeted pharmaceutical interventions: they would not pass a clinical trial with a randomized general population, but in sub-group analysis or "heterogeneity of treatment effect" analysis, they can be shown to be effective.

Or, we have the converse, which is that universally applying the program would not be cost effective. For example, CBO took these results and those of other sites and demonstrations, and said that, on net, coordinated care and disease management are not (statistically significant) improvements over the status quo.
posted by PandaMomentum at 12:09 PM on July 3, 2013

PandaMomentum, I think the differences between these programs are pretty important - it's not the same as giving the same drug to patients in 15 different programs and seeing that it's only effective in 20% of the cases. The significant differences between these different programs are likely to account for the differences in both costs and outcomes.

From the formal evaluation you linked to:

"Caseload size varied widely, from a low of 36 patients per coordinator to a high of 155. Care coordinators across the 15 programs contacted patients from just over once a month to twice a week, on average."

"Of the 15 programs, 10 conducted at least part of the assessment in person." (So 5 didn't conduct any part of the assessment in person.)

"Six programs routinely included physicians in care planning, either by eliciting their input to the care plans or by asking them to review plans. Two programs consulted physicians on a case-by- case basis, while the others did not involve physicians in care planning."

And most important:

"All 15 programs routinely monitored patients, primarily by telephone. Many (11) also monitored patients in person, but most of those did so infrequently."

(Emphasis mine. All quotes from p. 8.)

A program that checks in with patients once a month is likely to get different results than one that checks in with patients twice a week.

A program that checks in with patients by phone is likely to get very different results than one that visits them at home. I think the original Krugman article I linked to makes a point of discussing the bottom-line oriented managers of other programs who were all excited about implementing call centers - and how badly those programs fared - compared to HQP's home visit approach.

If I were a Medicare administrator in charge of this program, my next step would be to implement identical programs similar to HQP's program - with an emphasis on home visits instead of phone calls - in multiple regions to see whether the results could be replicated. If so, I would then try to scale it further.

But discounting HQPs results simply because they're lumped in with other programs using significantly different approaches doesn't seem like good science or good medicine.
posted by kristi at 1:14 PM on July 3, 2013 [1 favorite]

Closer monitoring of chronic illnesses is guaranteed to save both money and lives. This article appeared in the local rag this am, and it addresses a particular condition by intensive monitoring and care.
posted by Mental Wimp at 1:30 PM on July 3, 2013

@JeffBurdges: Amen, pracowity! Increasing costs benefits both the companies privatizing hospitals, and perhaps ultimately even the insurance companies, i.e. everyone with lobbyists.

I'm currently engaged with a top-tier insurance company who is piloting exactly this type of service with a home health care company. The same firm is also devoting resources to pilots in the remote monitoring and medication adherence areas, again in an attempt to see if it creates a healthier (and therefore cheaper) population.

I can state with certainty that their goal is to create a healthier population. One of their biggest frustrations is that most of the seemingly obvious things (such as paying for weight loss and exercise) don't cause any behavioral changes in their population.


It's also worth noting that there are so many companies attacking exactly this opportunity right now that it's quite likely that this one is getting dumped not because they're bad, but because another pilot program has shown even stronger results.
posted by grudgebgon at 5:06 PM on July 3, 2013

The company I work for is doing something similar for Medicare/Medicaid dual eligibles in far South Texas. It's mostly targeted at members who need mental health services in addition to medical services. I can say it has tremendously helped the members who are enrolled.
posted by Gridlock Joe at 7:08 PM on July 3, 2013

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