Category Archives: Scalability

A rare delivery system reform – using a little know-how

Better Care Lower Cost Act - a rare delivery system reform
Better Care Lower Cost Act press conference Jan 2014

Insurance and payment reforms are often (wrongly) equated with delivery system reform.  Or they are assumed to be all that is required to ‘incentivize’ stakeholders to ‘transform’ their systems of care through ‘innovation’.  Lamenting the repeated failures of such efforts, yesterday a colleague remarked to me, “… maybe a little know-how would help”.  Now a new bill introduced into the Senate by Ron Wyden, D-Ore. combines the necessary alignment of financial incentives with a “little know-how” to make it more likely that we can have better health and lower cost for chronically ill Medicare beneficiaries.  The know-how comes in the form of incorporating key elements of care delivery that we have learned through many years of hard work and rigorous research are essential to improving chronic care.

What Kinds of Know-How?

Things like; a comprehensive assessment to individualize care, a care plan, collaboration among a team of providers, a commitment to develop and use measures of patient-centeredness, and many others.  The bill also recognizes the value of continuing to advance our knowledge of this still emerging field by establishing Chronic Care Innovation Centers, “to develop and implement a sustained research agenda in the field of chronic care.”  There is no question that the challenges are great, constancy of purpose is required, and no one bill or demo project will solve everything.  But a good proof of concept already exists.  The work and results my team at Health Quality Partners (HQP) have achieved in traditional fee-for-service Medicare and Medicare Advantage populations is one such example.  This should drive us boldly forward with discipline and a burning hunger to further improve these models.  Models that will work everywhere, even in areas of the country lacking mega-integrated-health-systems.  

Disseminating these kinds of new care models on a larger scale will take more than simply trusting to the current chaotic, often conflicting ‘health care market forces’ now in play in the U.S.  Leaders from physician groups, health systems, public health, and health insurance plans, willing to commit to these kinds of new care models need a better framework that provides the right incentives, flexibility, and a little know-how.  That’s what the “Better Care, Lower Cost Act” offers.

See for Yourself

Here are links to the press conference announcing the bill and a copy of the bill itself.  There is a lot in the bill, but the language is clear and it’s worth a read and reflection.
YouTube clip of the press conference: YOUTUBE_PRESS_CONFERENCE_CLIP
A pdf of the bill: FINAL_BETTER_CARE_LOWER_COST_ACT_011414

The Bill’s Sponsors

Senators Ron Wyden, D-Ore., and Johnny Isakson, R-Ga., and Representatives Erik Paulsen, R-Minn., and Peter Welch, D-Vt.  I got to briefly meet these members of Congress before the press conference and I was impressed with their thoughtfulness, desire to solve real problems, and their commitment to putting vulnerable chronically ill, older Americans above politics.  Bravo and thanks!

Evidence Supports Scalability of Effective Models: Enormous Possibility

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, 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 a complex eligibility criteria for program implementation and scalability.

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;


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 the HQP blog at