But another way I read your point is, if you could somehow take out the people who were called, and look at everyone else, and the event rate fell, you certainly couldn’t claim credit for that

Saving 5% net requires roughly 10% of gross savings. Since hospital cost is about 50% of total expense, that’s 20% savings in hospital costs, since nothing else is avoidable through DM and other costs often rise a little.

Since even optimistically only about half of all admits are even possibly avoidable through DM, that means you’d have to avoid 40% of all avoidable hospitalizations overall, no easy feat when you only have conversations with about half of all members. That would mean 80% avoidance among those engaged members.

Since many avoidable hospitalizations follow closely on the heels of previous hospitalizations, one would have to save more than 100% of all avoidable hospitalizations occuring in the engaged population following the date when the data had finally been received by the vendor that indeed the engaged member had had a hospitalization.

And while I know your co-author disagrees with me on whether it is possible to save more than 100%, I maintain that it isn’t.

Having said that I was as surprised as anyone that the programs didn’t cover their costs and I think this very thoughtful posting suggests many good explanations for that.

The way to measure outcomes — the way the plurality of payors now measure — is to look at trends in event rates. Totally transparent. And yet with all the analyses done by CMS and suggested on this posting, no one suggested simply seeing if the adverse event rates for the study population improved relative to the control group.

The tools required to bring us to the next level are more complex, more costly and harder to scale (at least at present). They involve components that serve to educate patients about their illness in real time and in the teachable moment, to derive real-time, true illness-relevant data from those patients and use that data as a substrate for coaching, again at the very moment when coaching makes a difference. Our work at the Center for Connected Health is testament to how valuable this sort of approach can be, but also how challenging it is to scale.

Medicare patients are indeed different than commercial patients, but as you say we need to learn from this grand experiment and move forward because if we don’t find ways to improve the quality of care for this population while controlling costs we’ll continue to see an unacceptable financial drain on our country.

There is hope. some of the ‘Care Management for High Cost Beneficiary’ demonstration projects are showing they can achieve the financial targets set by CMS while improving the care of the beneficiaries covered. Our success in doing so at MGH has been through the implementation of a model that looks a whole lot like the medical home.

So perhaps the answer is a mix of motivated providers, incented the right way, with the right patient facing technologies and support staff.