June 21, 2018
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If this was a pill, you’d do anything to get it

By Ezra Klein, The Washington Post

Update:  July 1 was the day that Health Quality Partners — the wildly successful Medicare experiment I profiled back in April — was supposed to shut down. But on Thursday, Medicare hit “snooze” on the doomsday clock. HQP, they said, could have another 18 months. Here’s their reasoning:

Extending the demonstration will allow CMS to conduct a more robust evaluation of HQP’s model and to determine which findings are credible.  In addition, the extension will permit HQP to increase enrollment of the targeted subset of high-risk beneficiaries and to test the coordinated care model over a longer period of time.  Without the extended demonstration period, CMS would not be able to determine if HQP’s recent focus on a small subset of high-risk beneficiaries has been successful.

Reached by phone Monday, Ken Coburn was understandably relieved. “It’s amazing and wonderful and such a huge relief for the people we’ve been serving,” he said. But he was also frustrated. HQP came so close to the deadline that they had to begin disenrolling patients and shutting down operations. Now they have to prove to Medicare that they can expand, but first they have to undo the damage the near-death experience inflicted on their program.

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. The April article began like this:

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 not his graph, he’s quick to say. Coburn is not the sort to take credit for other’s work. But 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.

 The rest of the April article is here.


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