May 022013

Last Sunday’s Washington Post (April 28, 2013) featured a long, thoughtful article by Ezra Klein describing an effective house visits program, Health Quality Partners, that is about to lose its CMS funding. The article, “If This Was a Pill, You’d Do Anything to Get It,” ( generated several hundred comments and lots of social media activity.

Klein describes CMS’ plan to end funding for a home health visit program developed by Pennsylvania’s Health Quality Partners. First developed as part of a demonstration created in the wake of the 1997 Balanced Budget Act, this little program has achieved great successes. An independent evaluation found that Partners, one of 15 in that demonstration project, reduced hospitalizations by one-third, and cut Medicare costs by one-fifth.

Despite that track record, CMS has notified Health Quality Partners that CMS funding will end in June. Over the years, it seems, CMS has learned something from the ongoing demonstration—but its attention has now turned to other projects, ones that it hopes will prove to be scalable, and in which it will invest tens of millions of dollars via the Center for Medicare and Medicaid Innovation (CMMI).

This seems—to Klein, to me, and to many people who commented on the article—a little counter-intuitive: If a new treatment or procedure had led to this kind of result, investors and patients would line up to support it and demand it.  But CMS appears to be stymied by good reports from one particular community about its own particular situation. To be sure, learning from the one gem in a demonstration program with more than a dozen that did not make the grade is difficult, perhaps more difficult to pull off than interpreting a clinical trial or testing an investigational new drug.

There are risks, to be sure, in assuming that what works in Doylestown, PA,  will be equally effective in St. Louis, Missouri, or in thinking that the concerns and solutions experienced in one community can be addressed by solutions devised by another. Communities are so varied in how they operate, and no one solution is likely to work for each.

Even so, many communities find that their frailest residents benefit from the kind of one-on-one attention to care that house calls can provide.  Each clinical service program must address real risks to effectiveness and efficiency—here, an obvious issue is how to target people for whom such a service is a necessity, one that helps them to remain independent and out of the hospital, rather than those for whom it would mostly be a convenience?  Also, how can incentives be structured so that profits are not a chief motivating factor—and so that costs are contained while care and outcomes improve? These issues require ongoing attention—from communities, from the health care industry, and from CMS, as they work to reshape  the health care industry to a framework that includes better care and services for the oldest among us.

As the country’s leaders and policymakers increasingly turn attention to the looming challenges created by aging Boomers, many look to individual communities and their successes.  In fact, it is likely that the solutions we need—and find—will hinge on what different communities are allowed to assemble: What each identifies as priorities, how each allocates resources, and where each turns its energies. Learning how other communities succeed at this hard work will be critical for others testing for inspiration and ideas. Dismantling a successful program—without even testing whether its principles can be adopted elsewhere or it can grow to scale–hardly seems to make sense.  Continuing to learn from it, and deliberately adapting it in ways that work elsewhere, seems to be a more responsible response. Throughout our history, we’ve turned to outliers to point the way—and inspire—others along the journey.

key words: home health care, house calls, CMS, coordinated care, frail elders