I’ve had the distinct privilege, as an AARP-sponsored scholar-in-residence at the National Center for Complex Health and Social Needs to continue evolving the ideas spurred by my DrPH dissertation research on innovating ways to replicate models of care for vulnerable populations that while more effective, are also more difficult to spread. Last week, Health Affairs Blog published a post that I wrote with colleagues from the Camden Coalition of Healthcare Providers on this subject. To give it a read click here. There are some exciting new approaches that we can take to this problem and a path to do so that can build a field of practical knowledge we need to transform our health care system for the better.
An article in the May 2017 issue of Health Affairs, Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO by John Hsu and others from the Massachusetts General Hospital and Partners HealthCare in Boston, provides more evidence that care management interventions can meaningfully contribute to the performance of an ACO. Doing so, however, is neither fast nor easy.
Here are a few key takeaways (which parallel my own experience):
1. Target higher-risk populations with modifiable risk factors which your program is specifically designed to address
2. Stay constant to purpose … utilization (ER visits and hospitalizations) may even go up at first … but will, as participants are in the the care management program longer, progressively decline over time (most notably at 13+ months)
3. Sophisticated analytics and study designs are required to assess the impacts of such programs in ‘real-world’ implementations (i.e., without a randomized controlled trial)
4. Inability to serve the entire target population should not deter continued implementation – enroll as many as current resources permit and continue to work toward expanding capacity
The care management program described in the article shares some attributes with HQP’s Advanced Preventive Care model. One of the authors of the Health Affairs article was also an author on a 2014 issue brief for the Commonwealth Fund that identified HQP’s model as one of four (out of 18 successful models reviewed) having the highest quality evidence of effectiveness in managing populations with complex chronic disease. The details of a care management program’s design and implementation are critical to its success, with many varieties of “generic” care management have been found to be ineffective.
While not quick or easy, the path to improving population health – from both a health outcomes and cost perspective – is becoming clearer. The advantage will go to those with the know-how, relentless commitment to innovation, and constancy to purpose.
I had a great time participating in the amazing work of the Camden Coalition of Healthcare Providers (CCHP) at their March 18, 2014 Clinical Champion Leadership Workshop. The program is helping leaders of “hot-spotter” organizations of all shapes and sizes from around the country learn how to advocate for and advance the effectiveness of care models serving the most vulnerable populations. For more information about that experience and the Camden Coalition click here.
I also had the great privilege of delivering the Keynote Closing address to the Population Health Colloquium on March 19. It was a wonderful opportunity to tell the story of what my team at HQP has learned about designing models of effective advanced preventive care. The principles and disciplined approach to health care delivery system design we’ve uncovered addresses the gap between traditional public health and primary care. It could do much to improve our health system and the health of vulnerable populations. Learn how HQP applies design principles (person-centeredness, population-relevance, and reliability) and operational domains (standards, staff training, participant education, data management and decision support, and analytics) to create effective models of advanced preventive care. Here’s a video clip of my keynote, generously provided by the CCHP:
Health service research is usually expected to jumpstart rather than stall innovation in health care delivery. Except when it doesn’t. And when it doesn’t, it can deter policy makers, funders, and health leaders from maintaining the constancy to purpose required for breakthrough innovations. In the June 26, 2013 issue of JAMA, Joynt et al. used Medicare claims data and a health systems research classification schema to analyze the percentage of Medicare admissions that are “preventable” vs. “nonpreventable.” They did this for “high cost” and “non-high-cost” Medicare beneficiaries. A relatively small percentages of Medicare hospitalizations were deemed to be “preventable” (10-17%) according to this methodology. This conclusion is a buzzkill for generating commitment to invest in innovations in preventive heatlh. Worse yet, it’s wrong.
For one, the schema for classifying admissions as “preventable” or “nonpreventable”, promulgated by AHRQ is a model that has outlived its usefulness in the age of population health. As the late George E.P. Box (statistician with major contributions to quality control, time-series analysis and Bayesian inference) said, “All models are wrong, but some are useful.” And some are not. Such appears to be the case with this AHRQ schema. On what grounds can one make such an assertion? Two; face validity and empiric experience from a 12-year intensive randomized controlled trial of a new model of advanced preventive care.
With respect to face validity, several categories of “nonpreventable” conditions per the AHRQ schema are clearly preventable according to many studies in preventive and public health research. A few examples; orthopedic fractures related to falls, ischemic heart disease, stroke, kidney failure, peripheral vascular disease, and others; many of which are among the most powerful drivers of health care costs. Because these conditions are not easily and quickly prevented solely by a short-term increase in visits to physicians they are classified as “nonpreventable”. Is that the extent of our thinking about the possibilities for preventing these forms of human suffering and their associated hospitalizations and costs? Is that all we’ve got?
The authors do acknowledge that, “… while a proportion of these very expensive inpatient episodes may be potentially preventable, … , their prevention would likely require a long time horizon and substantial investments in population wellness.” Then to complete their kiss of death for investments in prevention, they go on to say … “Such investments are critically important for ensuring the health of the population, but the time frame needed to see cost savings is likely years, not weeks or months.” Anyone familiar with the realpolitik of health policy in the U.S. today would interpret this to mean … this area of health system innovation is dead and won’t be funded for the foreseeable future. We want savings and we want it now – not years from now – and there isn’t enough savings through prevention in the near term to make it worthwhile. At least that’s how these authors chose to interpret their data.
High quality research shows that the most innovative of preventive programs for vulnerable Medicare beneficiaries can yield significant results in a much shorter time. Ironically, Joynt et al. cite not one, but two such papers related to the Medicare Coordinated Care Demonstration as evidence that their “… findings may shed light on why many recent efforts to control costs for these medically complex, high-utilizing patients, including the Medicare Coordinated Care Demonstration (MCCD) programs, have failed to do so.” This is ironic because these same publications also highlight one of the original 15 programs in the MCCD, Health Quality Partners (HQP), as successful in reducing hospitalizations and cost among complex, high-cost Medicare beneficiaries.
From the 2009 JAMA paper that Joynt et al. cite, HQP’s positive impact among high risk beneficiaries was described as follows; ” … for this subgroup [highest severity cases] both differences were large (-29% for hospitalizaitons and -20% expenditures) and statistically significant (P=.009 and P=.07, respectively).” And from the more recent June 2012 Health Affairs article “… Health Quality Partners, reduced hospitalizations by 30 per 100 beneficiaires (33 percent; p=0.02).” Not cited by Joynt et al., was the finding from a July 2012 PLoS Medicine article (also reported in CMS’ Fourth Report to Congress on the MCCD) that the HQP program was associated with ” … a 25% lower relative risk of death (hazard ratio [HR] 0.75 … the adjusted HR was 0.73 (95% CI 0.55-0.98, p=0.033).”
And finally, the Fourth Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration of March 2011, reported that HQP’s program had no statistically significant impact on “potentially preventable hospitalizations” (using the same AHRQ criteria as that used by Joynt et al), yet produced a 39% decrease in overall hospital admissions (p<0.01). Either HQP’s program prevents the unpreventable or we seriously need to rethink our assumptions about what is preventable as we pioneer new models of care.
Is it unusual that only HQP’s program has had such effectiveness within the MCCD? By most innovators’ standards a 1 in 15 ‘hit rate’ of success is very high. Think about how many compounds were screened to find a few promising HIV or cancer therapies. Or the number of lightbulb designs tried by Edison. Do health service researchers, policy makers, and health bureaucrats understand the nature of innovation? Do they see the relationship between Einstein’s self-assessment “It’s not that I’m so smart, it’s just that I stay with problems longer,” and the need for constancy to purpose to solve our most challenging problems in health care? Do they understand that just labeling a bunch of different programs having different design and performance characteristics with the same categorical name (care coordination, care management, etc.) doesn’t make them all the same? If not, our health care woes are just beginning.
Note: This post was written by me (Ken Coburn, MD, MPH) and originally posted at http://www.hqp.org/blog/?p=547 on 12/15/2013. It is reproduced here, again. Join HQP in preventing the unpreventable.