There was a man with tongue of wood

Medicare is abandoning the one experimental program that works. So claims Ezra Klein of the Washington Post in “If this was a pill, you’d do anything to get it.”

Klein describes a program by Healthy Quality Partners (HQP) where nurses make home visits to geriatric patients with chronic illnesses. It has been subsidized by Medicare as an experiment, in which some randomly chosen patients receive the intervention while some do not. The results have been better outcomes at lower cost to Medicare per the article as well as a study published last July.

Let’s assume that the claims are true: better outcomes and lower costs. How do we take an experiment, and by definition experiments have a beginning and an end, and generalize it into practice?

There are numerous possibilities:

First, we could do what the article implies: provide more government funds to Healthy Quality Partners, instructing them to expand the experiment operationally beyond the 1,736 members in Pennsylvania. I am assuming that maintaining indefinitely a small-scale experiment that works makes no sense–onward and upward.

Second, we could change the reimbursement scheme at Medicare to provide reimbursement for such services so that anyone in the country could create a similar program with the financial incentive of knowing that Medicare would reimburse the services.

Here is how that second possibility has developed:

The Clinical Procedure Terminology (CPT) codes were created and are owned by the American Medical Association. Recently Medicare adopted additional CPTs for coding reimbursement for coordination of care services.

A statement by the American Nurses Association (ANA) is enthusiastic about the addition of the codes. Note: the ANA participates on the AMA CPT and RVU Update Committee.

Eileen Shannon Carlson RN, JD of the ANA points out that it is rare for CPTs to be adopted that only apply to nurses, as do two of chronic care coordination additions.

To be fair, the new codes only reimburse care coordination after a hospitalization and for a short period of time, why the HQP initiative addressed the needs of the elderly with chronic conditions. Nonetheless, I can imagine the next step being a protocol to target care coordination for the elderly independent of a hospitalization. Contrary to much in the popular press, government programs are very aware of spending dollars and getting value in return, so they limit risk by taking baby steps in developing programs.

Ezra Klein may well be correct, or he might be underestimating the challenge of turning a large ship, particularly when the upfront costs of such a turn may be prohibitive. What do you think?