Category Archives: System Thinking

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!

Preventing the “unpreventable”; overcoming health services research that stalls innovation

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 on 12/15/2013.  It is reproduced here, again. Join HQP in preventing the unpreventable.

Health Policy Based on Learning Needed for System Improvement

A close 5-4 Supreme Court decision has upheld the constitutionality of the Patient Protection and Affordable Care Act, America’s sweeping health reform law. Some vow to continue to work toward its repeal. For now, however, it seems that a tenuous stability as far as federal health policy is concerned may be emerging. If so, such stability could help our country get on with the hard and complicated work of the R&D on system improvement we need in health care.

Regardless of one’s political orientation, challenging facts about the U.S. health care system remain; it simultaneously develops the most advanced, innovative, treatments in the world, fails to provide all of its citizens with basic health services, is phenomenally expensive, fragmented, and poorly designed to address the needs of an aging, chronically ill population (the latter being an attribute we share with health systems worldwide). There are no easy fixes for our system, but there is great potential in undertaking serious, sustained, well-supported and thoughtfully conducted experiments to learn how we can improve – at the level of system design.

Yet to conduct these kinds of large-scale, long term trials requires a fundamental commitment for doing so; a constancy to purpose born from a widely shared belief that our best chance for improvement is through knowledge. On this Independence Day, may we all agree to undertake the hard work needed to be free, strong, vibrant, and healthy.