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News Roundup: May 6, 2013

Partnering with home health and hospice

Published by Healthcare Finance News
Stephanie Bouchard
May 2, 2013

A dominating theme in healthcare today is collaboration and partnership across all sectors of the industry in order to create a continuum of care. For the continuum of care to happen, partnerships must be struck between healthcare entities that haven’t necessarily worked much together in the past. An early April webinar addressed how such partnerships can be successfully formed.

“Integrated is the business model of the future,” declared Elaine Stephens, RN, executive vice president for home and community services at Masonic Health System of Massachusetts during Irving Levin Associates’ “Negotiating Profitable Home Health Care and Hospice Partnerships” webinar.

Over the last 12 years, Masonic has steadily created a home- and community-based health system that provides home care, skilled care, hospice and other services to more than 200 towns in Massachusetts. Masonic’s goal has been to move from siloes to an integrated system.

“Providing integrated care and putting together a model of care that will enable different levels of care to be provided is, I think, critical for a model for the future because people are going to go and need different types of care, sometimes even simultaneously.”

Masonic has been ahead of the curve but others in the healthcare industry are beginning to catch on.

“… there’s no doubt there’s a huge movement towards home- and community-based care services,” said William Dombi, vice president for law at the National Association of Home Care and Hospice.

That movement is being spurred by a number of factors, Dombi said, including an aging population using more of the services offered by home care and hospice; the greater push by the federal government and others to moving paying for long-term care out of institutional settings to home-based settings; increasingly restrained budgets; the low capital expense needed for home care; and the home care and hospice industries are creating jobs.

Partnerships offer a way to tap the already-established skill sets of each partner and enhance revenue without financially investing too much, said Dombi. And while there is a lot of opportunity out there for partnerships, he cautioned, it’s not a completely free marketplace.

The federal government has been scrutinizing relationships between skilled nursing facilities and hospice companies, for example, and others where a facility may be in a position to influence referrals. “The antifraud laws become, definitely, a factor in determining what your business model may look like,” he said.

Legalities are just one aspect organizations must consider when contemplating partnering, said Lori Peterson, founder of Collaborative Consulting.

“Sometimes the idea of new service development and partnership can be a bit overwhelming, so I highly recommend that your organization go through some sort of process to identify what new service makes sense and is partnership and collaboration a strategy that is most appropriate for your organization,” she said.

Some of the considerations organizations need to think about, she said, include:

understanding what the organization is trying to accomplish by partnering or collaborating
understanding what the needs are in your organization’s market and how you can meet those needs
determining what you want in a partner
understanding emerging trends
determining if your organization is ready for a partnership or collaboration.

Apple products aid healthcare, dominate mHealth market

Published by Fierce Mobile Healthcare
Greg Slabodkin
April 29, 2013

Apple, first with the iPhone and then the iPad, has "accidentally" revolutionized healthcare, so argues a blog post on The Motley Fool financial website. Although it was not Steve Job's intention, argues the author, doctors and other health-care professionals are using Apple's devices in ground-breaking ways.

The article argues that physicians love their iPhones and iPads, quoting various studies: "A study by Manhattan Research in 2011 found that 75 percent of physicians owned at least one Apple product. Vitera Healthcare's 2012 survey of healthcare professionals backed up this high number. The company's study found that 60 percent of respondents used an iPhone and 45 percent owned an iPad."

Similarly, an October 2012 report from research firm KLAS found more healthcare providers use Apple than any other device, which is fueled by "user preference as physicians bring their own devices into organizations to help them provide patient care."

As the Motley Fool piece points out, mobile apps running on Apple devices have "opened the door for clinicians to instantly access a world of medical information at the point of care." As an example, the author points to WebMD's Medscape app, which ranks first among the most-frequently downloaded iPhone and iPad medical apps, allowing physicians to check drug interactions, look up information about procedures, and see medical news updates on the fly.

Another example cited by the author is an app that allows radiologists to view MRIs as well as CT, PET, and SPECT scans on iPhones and iPads which received U.S. Food & Drug Administration approval in 2011. And, the FDA recently approved the use of a portable ophthalmoscope with an iPhone for doctors to view retinal images.

No one can deny Apple's sheer dominance among doctors. However, clinicians aren't the only ones leveraging Apple devices for mHealth apps. According to the article, as of last year, the App Store included more than 13,600 health-related apps for consumers for everything from monitoring sleep cycles to helping expectant mothers through their pregnancies.

"While it's true that Apple products aren't the only ones used in healthcare, the company's devices still dominate the industry," the article observes. "And these products ushered in a revolution in how medical professionals and patients access data and communicate with each other."

Patient Outcomes Improve Under Single Home Health Aides

Published by Home Health Care News
Jason Olivia
April 29, 2013

Individuals receiving home health services stand to experience better outcomes if cared for by the same aide day in and day out, according to a recent study by SAGE Publications.

Patients who see the same home health aide across a series of visits have a higher likelihood of improving in various activities of daily living (ADLs) compared to patients whose care is provided by multiple aides, according to the study Continuity in the Provider of Home Health Aide Services and the Likelihood of Patient Improvement in Activities of Daily Living.

Based on cases from the Visiting Nurse Service of New York (VNSNY)—a large, urban, non-profit Medicare certified home health agency—the study found that individuals who were cared for continuously by the same aide had a 93% chance of improving their ADLs.

Those who experienced low-continuity of care—meaning care was spread out among various aides over the course of a home health service period—were approximately 14%-15% less likely to improve their ADLs between home health admission and discharge than individuals who were always visited by the same aide.

Also of note in the report, cases where patients had moderate-continuity did not significantly differ from higher continuity cases in their likelihood of ADL improvement.

Although a majority of cases in the study’s population improved in the number and severity of ADLs between admission and discharge, researchers note that the odds of improvement among cases with high continuity are greater than those for low continuity.

“Ideally, patients should receive services from a single aide over the entire period of home care,” writes the study’s lead author David Russell, Ph.D, Center for Home Care Policy & Research at VNSNY. “However, a number of staffing constraints and operational obstacles often present a challenge to achieving this goal.”

Home health agencies often provide around-the-clock care and have several staff to cover different shifts, but sometimes these staff members carry multiple case loads and have limited time for care planning, monitoring and review, says Russell.

One strategy to combat this, according to the report, could be to use primary provider teams in conjunction with backup provider teams to limit the number of aides who visit a patient.

A second strategy the study proposes is to focus on reducing the number of cases with low levels of continuity, and work to improve this group to a more moderate level.

Although the study was based on one non-profit Medicare-certified home health agency, the findings build upon extensive research that suggests a continuity in the relationship between a patient and his or her caregiver increases the odds of positive patient outcomes.

If this was a pill, you’d do anything to get it

Published by The Washington Post
Ezra Klein
April 28, 2013

When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It’s not his graph, he’s quick to say. Coburn is not the sort to take credit for other’s work. But it’s a graph that explains why he’s doing what he’s doing. It’s a graph he particularly wishes the folks who run Medicare would see, because if they did, then there’s no way they’d be threatening to shut down his program.

The graph shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it’s below 100. When’s the last time you heard of an American dying from diarrhea?

“For all the millennia before this in human history,” Coburn says, “it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases.”

With chronic illnesses like diabetes and heart disease you don’t get better, or at least not quickly. They don’t require cures so much as management. Their existence is often proof of medicine’s successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today’s medical system: Its successes have changed the problems, but the health-care system hasn’t kept up.

Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. “This is the Willie Sutton rule,” he says. “If 80 percent of the spending is going to patients with five or more conditions, that’s where our health-care system needs to go.”

Health Quality Partners is all about going there. The program enrolls Medicare patients with at least one chronic illness and one hospitalization in the past year. It then sends a trained nurse to see them every week, or every month, whether they’re healthy or sick. It sounds simple and, in a way, it is. But simple things can be revolutionary.

Most care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. That model has mostly been a failure. And while many health systems send a nurse regularly in the weeks or months after a serious hospitalization, few send one regularly to even seemingly healthy patients. This a radical redefinition of the health-care system’s role in the lives of the elderly. It redefines being old and chronically ill as a condition requiring professional medical management.

Health Quality Partners’ results have been extraordinary. According to an independent analysis by the consulting firm Mathematica, HQP has reduced hospitalizations by 33 percent and cut Medicare costs by 22 percent.
Others in the profession have taken notice. “It’s like they’ve discovered the fountain of youth in Doylestown, Pa.,” marvels Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers.

Now Medicare is thinking of shutting it off.

Lucrative potential

The origin of Doylestown’s fountain of youth is not particularly mysterious or mythic. It can be found on Page 93 of the 1997 Balanced Budget Act. Under “Subchapter D — Other Projects,” there are two pages of dull legislative language authorizing Medicare “to conduct demonstration projects for the purpose of evaluating methods, such as case management and other models of coordinated care, that (A) improve the quality of items and services provided to target individuals; and (B) reduce expenditures.”

In the health-care world, however, these yawn-inducing paragraphs sounded like the beginning of a revolution — or, perhaps, a gold rush.

The project was remarkable in two ways. First, it used the gold standard of experimental design: Randomized-controlled trials. Each of the 15 programs — of which HQP was one — would see some seniors enrolled in the program and some left out. The assignment would be random, and the groups similar — that would let the researchers be certain that whatever differences they saw between the groups were attributable to the care they received rather than, say, the company’s success at signing up healthier seniors. “We did it that way so nobody would ever question the validity of the findings,” says Randall Brown, a senior fellow at Mathematica Policy Research, the outside evaluator Medicare hired to judge the programs.

The second unusual feature was that the secretary of Health and Human Services had the authority to scale it up.

Typically, Congress keeps tight hold of the reins on these kinds of experiments. But not this time. As long as the programs were increasing quality without increasing costs, the secretary could “continue the existing demonstration,” “expand the number of demonstration projects,” or even “issue regulations to implement, on a permanent basis, the components of the demonstration project that are beneficial to the Medicare program.” It was, for an experiment of this type, an extraordinary, and extraordinarily rare, amount of authority.

That made it potentially very, very lucrative. A midsize care-management company that proved itself in this demo could, theoretically, get the green light to provide services to every chronically ill Medicare patient. Everyone understood the implications immediately: There were billions of dollars on the table. And there were plenty of for-profit companies who were certain they’d be able to get them.

“I was at conferences when this was all getting underway,” Brenner says. “These huge vendors from these really big companies had gotten into this. I remember all these really well-dressed people strutting on the stage. They thought they were going to get access to the gold mine of health care. I remember seeing them speak and thinking, ‘I can’t be this dumb.’ I couldn’t understand how their models would work. I’ve never seen a telephone call change behavior.”

Their models — and their telephone calls — didn’t work. Program after program either failed to help patients, save money or both. “You’ll see some disease management programs out there led by MBAs or people who used to be doctors and are now businessmen,” Brown says. “They’re totally different kettles of fish. They tend to be telephonic, and the telephone centers might be in California or Missouri. They don’t work. We’ve shown it time and time again.”

But Health Quality Partners, with its emphasis on continuous nurse-to-patient contact, did work. Of the 15 programs, four improved patient outcomes without increasing costs. Only HQP improved patient outcomes while cutting costs. So Medicare extended it again and again — now it’s the only program still running under the demo. But Medicare has notified Coburn that it intends to end HQP’s funding in June.

Medicare’s official explanation is carefully bureaucratic. “The authority that CMS had to conduct this specific demonstration, which predated the health care law, did not allow us to make the program permanent and limited our ability to expand it further,” says Emma Sandoe, a spokeswoman for the Centers on Medicare and Medicaid Services. “As we design new models and demonstrations, we are integrating lessons from this experience into those designs.”

Every expert I spoke to — as well as a plain reading of the law — disagrees. If they wanted to make HQP permanent, or scale it up in a big way, Medicare has the power to do so. Then there’s this: “Thanks to the health care law, we can now test new, innovative models for delivering health care and expanding models that show promise,” Sandoe continues. “With this new authority, we can take best practices to scale and provide more incentives to deliver high-quality health care at lower costs.”

Medicare is referring to the newly created Center for Medicare and Medicaid Innovation, which gives the program power to create and expand projects without congressional authorization. This authority could also be used to create projects based on HQP’s lessons. It’s not. Instead, Medicare has created a raft of projects and experiments meant to move the system from fee-for-service toward pay-for-quality — with the hope that if they can get the payment incentives right, then the market will have reason to support programs like HQP.

To Health Quality Partners and its defenders, Medicare’s decision is ludicrous. “We’re spending tens of billions of dollars now on Medicare innovation where Medicare already discovered something amazing and now they’re forgetting what they discovered?” Brenner says. “It’s an amazing government moment.”

But to Medicare, it’s not so much forgetting as being realistic. After all, HQP worked, but most of the programs in the demonstration didn’t. It notes that HQP is a relatively small program that only ever treated a couple of thousand people. For a program the size of Medicare, working to scale up a small operation like HQP seems less likely to deliver a big return than working to change the payment structure that governs the entire system.

This drives Coburn crazy. “People always ask if what we do is scalable. Well, define scalable. It’s less difficult than open-heart surgery, which is one of the most common surgeries in the country, and it’s more difficult than giving a vaccine. There’s this amazing double standard in medicine. For the kind of thing we do, if it’s more difficult than making a phone call once in awhile, then it’s not scalable. But you provide enough economic incentives and all of a sudden every hospital has an open-heart surgery program.”

Brenner puts it more vividly. “There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you’d say, ‘Of course I want that.’ But then you’d say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you’d say, no, you just have to have a nurse come visit her every week.”

Making the house call

Here’s what I thought would happen when I went with Patty Graefe, a Health Quality Partners’ nurse, on her daily rounds: I thought I would see a highly skilled medical professional showing off her success stories. I thought I would meet seniors who were overwhelmed by their illnesses a few years back, but since signing up for the program, were now carefully protecting their health. Nothing else, I figured, could possibly justify the numbers HQP seemed to be producing.

Instead, I met Paul and Betty Bradfield.

Getting to the Bradfield’s house is harrowing. You drive over a stone bridge that looks neither wide enough nor structurally sound enough to support a car. You nose up a curving road that has been cut into a steep hill. You walk past a giant pile of wood into the sort of old, rickety farmhouse that quickens the step of kids on Halloween. It’s a place I might be scared to live. It’s a place I’m definitely scared to find Paul and Betty living.

Paul, at 83, suffers from serious heart failure and mild cognitive impairment. A year ago, he climbed a ladder to change a birdfeeder at 10 o’clock at night. He fell, breaking his neck. Betty, at 80, is legally blind and has diabetes.

The Bradfields are warm hosts, and clearly glad to see Patty. But their situation isn’t good. “I messed up on my medication this week,” Paul says, shortly after we walk in the door. He’s not sure how. It’s possible he took a double dose. Or it’s possible that he skipped a dose. And he’s already thrown away the evidence. “I’m not worried about the mess-up,” Graefe says kindly. “I just need to figure out if you took a double dose.” She makes a note to call Paul’s doctor.

Graefe has been a nurse for 28 years. She has worked in cardiac wards and with patients in rehab. She has been in hospitals, in call centers, and now on home visits. “This is the best nursing I’ve ever done in my life,” she says. “And that’s because it’s really all about nursing.”

As a hospital nurse, Graefe worried she wasn’t able to build the trust she needed with her patients. “I dealt with a lot of heart failure,” she says. “A patient would come in, filled with fluid. You’d ask them whether they were taking their medicine. Or if they were eating right. The patient gets almost defensive because we always assume they’re doing something wrong. I found that the hospital setting wasn’t the best place for these conversations.”

I asked a half-dozen seniors what difference Health Quality Partners made in their lives. Every one of them began the same way: They could ask their nurse questions, they said with evident relief. They could get help understanding and navigating their doctor’s orders. They didn’t feel like they were being a burden if they needed to ask one more thing, or have their medications explained to them again.

Physicians are brusque, and harried, and they talk quickly and confidently, and chronically ill seniors often leave with complicated instructions and a hazy understanding of how to follow them. “In a doctor’s office, a lot of people, especially older people, feel pressure to get out because they know the doctor is busy and they’re a bit intimidated,” says Bill Allen, a friendly 78-year-old who is also a patient of Graefe’s. “Because she’s here in our home, you can feel more free to ask her anything. It’s great.”

As a nurse, Graefe’s style is practical and nonjudgmental. It seems obvious that chronically ill seniors should take their medicine. But Graefe doesn’t see the situation as quite so black-and-white. “You have to find out why a patient isn’t taking their medicine,” she says. “In the case of heart failure, the water pill has a lot of side effects. Imagine losing control of your bladder. Not being able to go out because you always need a bathroom. We’re talking about adults here.”

This is, to me, the surprise of accompanying Graefe on her rounds. Despite the years-long relationships, she’s not turned her patients into highly effective self-caregivers. Everyone we see admits to missing their medicine or making bad diet decisions or slacking on exercise routines. Graefe just laboriously pushes them to make slightly better decisions on the margins. The Bradfields, for instance, are, after years of cajoling, finally readying themselves to enter assisted living — something that might not have happened at all without Graefe’s nudging.
Because she has been to patients’ homes so many times before, she can see when something has changed and things are about to go very wrong. And she’s got the personal relationship to intervene. Allen, who suffers from lung problems but hates to take medicine, recalls a bad cold he had a few weeks ago. “Because of Patty’s insistence, I ended up using the — what do you call it? — the nebulizer. I probably wouldn’t have done it without her. And I probably would have ended up with pneumonia again. I’m sure that’s what got me through.” It also saved Medicare money, and perhaps saved Allen’s life.

We think of the hospital as a place people go to get better. At Health Quality Partners, the view is that a hospital is a place where seniors get worse. “Being in the hospital for three days or five days sets them back to a point where they’ll never regain what they were,” says Sherry Marcantonio, chief program architect of HQP. “That’s where the scales tip. That’s where people end up needing a nursing home.” Keeping seniors out of the hospital, which is a core focus of its program, cuts costs and saves lives, but it also preserves quality of life — a measure often ignored in these discussions. There’s a good argument to be made that if a program like HQP cost slightly more than traditional Medicare but cut hospitalizations by a third, it would still be worth it. The point of health care, after all, is to keep people healthy. But HQP saves money — and lots of it.

If there is a secret to the success of Health Quality Partners at preventing hospitalizations, it’s this: No one else is checking in with the Bradfields or the Allens every week. Medical technology — from pills to devices to surgical procedures — is so advanced and so competitive that making further gains requires enormous investment and rarely brings high returns. But the exciting field of knocking-on-the-Bradfield’s-farmhouse-door is almost totally empty. Medicine has been so focused on what doctors can do in the hospital that it has barely even begun to figure out what can be done in the home. But the home is where elderly patients spend most of their time. It’s where they take their medicine and eat their meals, and it’s where they fall into funks and trip over the corner of the carpet. It’s where a trained medical professional can see a bad turn before it turns into a catastrophe. Medicine, however, has been reluctant to intrude into homes.

For the most part, the medical system treats the old very much like it treats the young. It cares for them when they’re sick and ignores them when they’re well. Coburn’s basic insight is a discomfiting one. He doesn’t really believe in “better,” at least not for elderly, chronically ill patients. He wants someone going over frequently to see if they’re depressed, if their color is good, if they understand their medications, if there’s anything they need. This isn’t medicine so much as it’s supervision.

At another time, these functions would have been filled by the family, who would be right in the other room, and who would know if their mother looked different than she had a few weeks ago. But few of today’s elderly live with their children. Many don’t even live in the same state, or they don’t have any contact with their children, or they don’t have children.

A recent study in the Proceedings of the National Academy of Sciences found that after adjusting for demographic factors and underlying health, social isolation increased the likelihood of death among the elderly by a stunning 26 percent. “People with few social contacts may not have people around them who can give them advice, recommend that they go to a doctor with symptoms, ensure that they maintain healthy lifestyles, or perhaps they don’t have anyone around when they experience acute symptoms,” says Andrew Steptoe, the lead author on the study.

We’ve been conditioned by “Grey’s Anatomy” and hospital rooms to believe that saving lives is a complicated, heroic business. And it is — after people get very sick. But keeping them from getting very sick doesn’t necessarily require the discovery of new molecules. It requires someone who has a relationship with them to stop by once a week to see how they’re doing. The problem is, it’s hard to make money off it.

The uneven legacy

If you go into the hospital for heart surgery and you end up getting a central-line infection, you’d hope that the hospital would be penalized for it. The opposite, in fact, is true. According to a new study in the Journal of the American Medical Association, surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients.

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.

Reif’s answer for why he worked with a group that cost him money is simple: His hospital was unusual. In 1895, 14 women came together to form Doylestown’s “Village Improvement Association,” which was dedicated to “the health and beauty” of the community. The association actually owned Doylestown Hospital, and its mission was the hospital’s mission. “I did get some heat from my senior management team,” Reif says. “When you’re doing annual budgets you see reduction in revenue. But I could always come back and say, ‘Wasn’t that our responsibility?’ ”

But not all hospitals are run by the local Village Improvement Association. Many seek to turn a profit. 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’s a disruptive innovation. It just guts the current business model.”

This is where Medicare’s focus on changing that payment model could help programs like HQP. It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient. If they spent less, they could keep the difference. In theory, this should push them to partner with tested organizations like HQP that have a proven ability to help them spend less. But many experts are skeptical that ACOs will be the game changer Medicare hopes.

“I don’t have a lot of confidence in the ACOs working out,” Mathematica’s Brown says. “None of the ACOs you talk to are willing to say which hospital they’ll close. And the only way to save big money in a system is to reduce hospitalizations. That means you need fewer hospital beds. You can’t make money off of an empty hospital. So until they’re talking about closing some local hospitals to realize the gains from reducing hospitalization, they’re not going to be saving much money.”

Robert Berenson, a Medicare expert at the Urban Institute, is also skeptical. “To understand ACOs, you have to go back to the physician group practice demo. That was the basis for the ACOs. It was the model adopted into law in the Affordable Care Act. It was these 10 multispecialty groups, and the idea was we’ll pay you fee-for-service and if your total spending comes in under the control group’s costs, you get to share the savings. Everybody thought it was a great success, but when the results came in, it didn’t save any money at all. The one exception was a plan called Marshfield, perhaps because it wasn’t based in a hospital and so could keep people out of hospitals.”

This is a tough truth of the health-care system: It’s got a lot of incumbents, and a lot of fixed costs, and reforming the way care is delivered will mean creating a lot of losers. “This is about power and money,” Brenner says. “The largest group in the top one percent of income in America are physicians.”

The chronic-care focused system that Coburn is pioneering is more about nurses than doctors, more about home visits than hospitals, and more about human interaction than high-tech intervention. A system based on managing chronic care is a truly different system from the one we have today. Health Quality Partners was lucky to find a hospital that wanted to work with it. But many hospitals wouldn’t want to work with a program dedicated to sharply reducing their revenue stream. And without cooperation from the hospital and a patient’s doctors, the HQP model would fail.

The only payer with the size and the incentives to push something like HQP is Medicare. “For them to say it’s not their responsibility to scale a program like this is ridiculous,” Brenner says. “They send market signals all the time. One day it’s an experimental oncology procedure and the next day everyone is using biologicals. That’s because of them and what they pay. They’re the ones who scale this stuff. It feels to me like they’re scared to pull a lever on a very clear market signal. But if they said here’s Ken Coburn’s model, here’s the code for it, here’s how much we’ll pay for it, and, by the way, we’ll overpay for it, because we think it’s important, the marketplace would drive that.”

They could stop far short of that, of course. They could begin another demonstration project that took the lessons of HQP and used them to seed 15 more programs. There is, after all, a flip-side to the skepticism over whether the program can scale. It’s possible Coburn’s model, which has been run on a shoestring budget, could, with real resources, be improved. Coburn is quick to agree. “I really think we’re just at base camp. There are so many contributors to health the system isn’t addressing right now. As proud as I am of what we’re doing, I think we’re just scratching the surface of this stuff.”

It wouldn’t cost Medicare very much to find out. Quests for the fountain of youth have been launched from far flimsier maps.