Successful home management and the hospital bottom line

By  |  April 28, 2013 | 

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.


  1. Ken Coburn, MD, MPH April 28, 2013 at 10:06 pm - Reply

    Thanks for this thoughtful piece. The success of the HQP model does depend on a number of things that Ezra Klein either could not fit into his article and/or chose not to because it would have bored general readership to tears. Extensive staff training, significant use of real-time data and process measurement with advanced reports and analyses used for performance management, etc., etc.

    I also believe that any big system transformation that could be catalyzed by a successful community-based advanced preventive model ascending to a more important position in the pecking order will occur gradually – not suddenly. I don’t think hospitals will face a major disruption in revenues in the short, or even “mid” term. Some percent of hospital nurses and docs might decide to try helping run the community preventive service in their regions.

    Finally, I totally agree that more testing and rigorous evaluation, along with ongoing improvement efforts is necessary to determine whether, on a national basis and over the long run, HQP’s outlier results will be determined to represent signal or noise. We’re hoping to get the chance to find out.

    Ken Coburn, MD, MPH
    CEO and Medical Director, Health Quality Partners

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About the Author:

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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