HEALTH REFORM: Evidence-Based Change You Can Believe In (Part 2)

We posted the other day on the Kaiser Family Foundation-commissioned paper on delivery system reform. In short, Mathematica's Randall Brown concluded that the ideas getting the most attention (medical homes, health IT, ACOs, bundling etc) are worthwhile and may save in the long run but aren't likely to save much in the first five to 10 years. In the promised, albeit slightly belated, part 2 of this post, let's look at how he thinks we can get results faster.

Making dramatic changes in the health care delivery system takes time. While that shift is underway, Brown writes, we have "solid evidence" on strategies for managing patients with serious chronic diseases in ways that reduce hospitalization and rehospitalization. It saves money, and keeps patients healthier.

We also have "less rigorous" but still encouraging evidence on how to address geographic disparities in the practice of medicine and use of resources. The goal is to find approaches that help doctors understand -- and  incentives to change -- the way they themselves practice and how they stack up against other doctors and other regions.

These programs and initiatives can be phased in with tweaks to the current fee-for-service system -- although Brown is not arguing that we shouldn't also make longer term initiatives to reform that system, but it's a heavier and longer-term lift. (And since we've written about a lot of these ideas before, we are feeling affirmed.)

On chronic disease, Brown sees significant savings from nurse-led interventions (and by nurse-led, he does not mean most commercial disease management companies) for the chronically ill, particularly those with congestive heart failure, coronary artery disease, COPD, and other diseases associated with multiple hospitalizations. Relatively simple nurse-interventions could save $30 billion or more over 10 years, according to the data he has analyzed, and it can work in settings ranging from urban academic medical centers to rural integrated delivery sytems. Right now, we don't have good ways of paying for these programs, but health reform would change that. Some pilot programs have found that hospitalizations can be reduced for high-risk patients by nine to 24 percent over three years.

One key to success: targeting the right group. It's sort of like the Three Bears -- they can't be too sick, or not sick enough, they have to be just the right sick for this kind of care. Other characteristics of successful care management:

• Personal (not just telephone) contact every four to six weeks
• Good and ongoing working relationship and coordination with patients' primary care team
• Timely information on hospitalizations and ER visits, so they could intervene quickly in a crisis and reduce the risk of another crisis
• Strong medication management to monitor for bad reactions, dangerous interactions or overlapping medications, and to ensure that patients filled their prescriptions
• Strong patient self-care education, including recognition of early signs that a patient may be headed for a crisis or a bad episode
• Social support services, from transportation and meals to identifying depression and isolation
• Serving as a "communication hub" between patients and their multiple providers

Brown also reports that protocols for transitional care, whether nurse-directed like Mary Naylor's program at Penn or patient self-management like Eric Coleman is doing in Colorado, are big savers. Some of the health bills in Congress contemplate providing a transitional care benefit so that the hospital or other provider that takes the time to make sure that the patient has a safe, error-free transition from one health care setting to another (for instance, hospital to nursing home) can get paid for it. It is an essential part of patient care. It's something Dr. Joan Teno at Brown talked about in this piece I wrote for the Washington Post a few months ago -- and if I had the space, her list of what can and does go wrong time and time again would have been much longer. Ken Thorpe also recently wrote about care transition models on the Health Affairs web.

The third area -- geographic disparity in how intensively and expensively we provide medical care -- is a bit more challenging but would have a bigger pay-off, Brown writes. So far, results have been mixed, but CMS has put the infrastructure in place to build on what we know. The clumsily named Resource Use Reporting (RUR) project (we are so tempted to suggest they change it to "I am health reform, hear me RUR") lets doctors know how they stack up in terms of how well they use Medicare resources compared to other physicians locally and nationally. The stats are adjusted for patient case mix and regional prices. Brown says, "This project will, for the first time, show physicians how their own prescribed care and referral patterns compare to others. If payment changes are made that reward only efficient levels of care, the savings could be significant." (This relates to the NPR piece on the tons of data CMS has but isn't sharing with docs we told you about last month). This can work within the current system, where most doctors are not on the staff of large systems like Kaiser or Geisinger. The goal is efficient quality care, not haphazard cost control. Similar data should be shared on end of life care -- not to "ration" it, but to make sure we are providing the appropriate high-quality care in an efficient way.

Brown also reminds us that changing health care is not a one-shot deal but an ongoing process. He recommends maintaining a "learning laboratory" of care coordination programs to test variations and adaptations of interventions that we know work. We want to put knowledge of what works into effect quickly. And we also want to share what we learn from initiatives that don't work, so we don't keep reinventing broken wheels.