Successful home management and the hospital bottom line

Remember this?  Ezra Klein does, and so do I:

Thirty-four programs participated in the Medicare case management demonstration project over two decades.  His piece investigates one of the four home management programs that succeeded and kept seniors healthier and out of the hospital.

If you recall the conclusions, high touch, low-tech approaches to chronic care management (visiting patients at home) won out over telephonic and less sociable forms of outreach.  He proceeds to describe how Medicare and congress continually fund the wrong types of programs.   His lesson: sexy wins and boring loses.

Many quotes resonated—a slew on what our system needs to correct, but the one below stuck and hit closest to home:

“This, too, is a legacy of a health system built for acute care. Hospitals make money when they do more to patients. They lose money when their beds are empty. Put simply, Health Quality Partners makes hospitals lose money. “There’s no doubt that it’s a hit to the bottom line,” says Rich Reif, the former CEO of Doylestown Hospital, which worked with HQP.

…That makes models like Health Quality Partners something of a threat. “If we scaled what Ken is doing,” Brenner says, “you would probably shut down a third of the hospitals in the country. It is a disruptive innovation.  It just guts the current business model.”

Most providers employed by hospitals know the drill: increase throughput, implement regulatory changes, monitor hospital measurement and report cards, and of course, reduce costs.  However, despite the growth of “hospital as laboratory” and rise of the inpatient practitioner, we must face facts.  We receive our salary from the beast we wish to slay.

Care management done right and transitions executed properly keep folks out of hospitals and reduce profits.  The piece describes patients in need of greater care outside of, as opposed to inside the hospital.  If HQP gives a glimpse of the future, the exponential growth of our field will flatten, if not fall.  Sucks for us and I cannot help but think of Upton Sinclair’s quote:

“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”

Balancing the growth of our field and the transformation of hospital from profit to cost center will force us to think about priorities.  Resources do not grow on trees.

Lastly, one caveat, and I am surprised Klein glossed over an important point.  Like Gunderson (advanced care planning), Mayo (egalitarian efficiency), Kaiser (information technology), and the Camden Coalition (scaling outlier care), they all reflect the pinnacle of what our system may be capable of, but can’t deliver en masse.  Look at one hundred programs serving focused populations, and you will invariably discover two or three hitting the ball out of the park.  Dissecting reproducible from confounding local factors and how they contribute to demo success complicates how we implement national programs.  We must examine the findings in context.  Whether HQP as white knight represents signal or noise must await further trial.

UPDATE: Aaron Carroll’s take on article here (a different perspective), but more curious, see Figure 1 on page 22 of CBO report assessing demonstration results.  I don’t see the cost savings Ezra mentions in his piece.