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Why Don’t We First Do What Works?

President Barack Obama has stated that health reform should be guided by a simple principle: “Fix what’s broken and build on what works.— But the health reform bills to date have been criticized for adding costly health care programs that are laudable in isolation but unproven in widespread practice. [IMGCAP(1)]There has been insufficient focus on the acknowledged No. 1 problem that threatens the financial viability of Medicare and on existing solutions that could be implemented immediately. Medicare’s costs are highly concentrated in a small percentage of chronically ill beneficiaries who have poor outcomes because of a health care delivery system designed to treat acute episodes of illness. Research by Johns Hopkins University and the Congressional Budget Office shows that the top 10 percent of Medicare beneficiaries account for 66 percent of Medicare costs and nearly all of the growth in Medicare costs. By contrast, the bottom 50 percent of Medicare beneficiaries only account for 4 percent of costs. Health reform that fails to focus on the highest-cost patients will drive up health care costs while failing to improve the quality of health care for those who need it most. According to the CBO, even a small percentage reduction in spending for these high-cost beneficiaries could result in “large savings— for Medicare. The current Medicare fee-for-service system needlessly increases health care costs and produces poor outcomes for chronically ill beneficiaries because it provides fragmented, volume-driven care that is usually activated only when people are sick enough to go to the emergency room and hospital. They remain in the hospital long enough to be stabilized then are sent home until they again become sick enough to be rehospitalized. These high-cost beneficiaries see an average of 13 different physicians, fill 50 different prescriptions, account for 76 percent of all hospital admissions and are 100 times more likely to have a preventable hospitalization than beneficiaries without chronic illnesses. We can and must do better.A solution already exists. Hundreds of physician and nurse practitioner house calls programs across the U.S. have proven effective for decades in reducing health care costs for these high-cost beneficiaries while producing better outcomes and patient satisfaction. For example, the Department of Veterans Affairs’ Home-Based Primary Care program operates in 48 states and in more than 130 locations, has reduced inpatient days by 62 percent and has reduced expenditures by 24 percent for high-cost patients with chronic disease. Similar or better results have been achieved by established house calls programs in Washington, D.C.; Boston; New York; Richmond, Va.; San Diego; Indianapolis; north-central Nevada and many other locations. Physician house calls are as old as medicine itself but now have become more efficient with the use of new information, monitoring and diagnostic technologies. These are programs that work but are small because of a lack of funding by public and private insurance for care coordination.Fortunately, one health reform proposal adopts this proven approach to target Medicare’s biggest fiscal problem. The Independence at Home Act (H.R. 2560, S. 1131) targets the highest-cost Medicare beneficiaries with the worst outcomes, requires minimum savings of 5 percent and better outcomes annually, and incorporates the proven physician/nurse practitioner-directed house call team approach. Because it is based on health care delivery models that already exist, it can be implemented immediately with little or no additional cost. The bill, introduced by Rep. Ed Markey (D-Mass.) and Sen. Ron Wyden (D-Ore.), has strong bipartisan support in the House (17 sponsors) and Senate (11 sponsors), and has been endorsed by broad range of organizations representing consumers, providers, practitioners, technology companies and caregivers. If the IAH Act only achieved the minimum savings prescribed in the bill, it could reduce Medicare’s annual costs by $15 billion a year or $150 billion over 10 years. This bends the health care spending curve in the right direction. A July 25 letter from the CBO noted that if health reform is to reduce health care costs, it must move away from the fee-for-service system, establish explicit, feasible savings goals, and share savings with providers who achieve those goals. The IAH Act contains all of those elements. When a patient arrives in the emergency room bleeding to death, we do not initiate smoking cessation and weight reduction programs. We apply proven methods to address the emergency and stabilize the patient. Our health care delivery system is hemorrhaging money. Let’s triage the patient and focus first on proven approaches to stabilize the situation. We all have an interest in this patient’s survival. C. Gresham Bayne is a fellow with the American Academy of Emergency Medicine and past president of the American Academy of Home Care Physicians.