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Stanford University School of Medicine

In Capitol Hill meeting, Stanford researchers present alternatives to insurance cutbacks

High-quality health care tends to be expensive, but if you ask Brian Brady, MD; Nicholas Bott, PsyD; and Vicky Woo, MD, they'll tell you it doesn't have to be. Working with Arnold Milstein, MD, director of Stanford's Clinical Excellence Research Center, this trio of researchers are using their CERC health care re-design fellowship to craft new ways to deliver top-notch health care at reduced cost.

As part of their fellowships, Brady, Bott and Woo have developed several innovative approaches to U.S. health care as alternatives to current proposals to cut back insurance coverage for poor and near-poor Americans. Last month, the fellows were invited to present these ideas at a meeting with the majority senior health staff of the House Ways and Means and Energy and Commerce Committees.

I corresponded with Brady to learn more about their CERC-designed care delivery methods, which encompassed maternity care, chronic and end-stage renal disease care, medication-sensitive chronic illness and hospitalization of dementia patients. Here's what Brady had to say:

What are the current proposals to cut back insurance coverage for poor and near-poor people living in the U.S.?

Republican-led legislation to repeal and replace the Affordable Care Act has proposed reducing some of the ACA’s subsidies to cover patients insured in the health insurance exchange program as well as restricting the growth in federal Medicaid funding. For poor and near-poor individuals and families, these changes would reduce the affordability of comprehensive health insurance coverage.

What are the CERC-designed delivery care methods that you and your colleagues presented?

During our meeting, fellows presented a component of their care model with the highest cost-saving potential. Vicki [Woo] focused on creating hospital-affiliated birth centers for low risk pregnancies, a practice employed in the U.K. shown to attain the same outcomes as more expensive traditional hospital labor and delivery units. Nick [Bott] highlighted the opportunity to protect inpatients with dementia from acute delirium and its acceleration of functional and cognitive decline. I discussed the opportunity to improve the value of kidney care by standardizing shared decision making between nephrologists and their patients since it leads to more patients undertaking dialysis at home rather than in free-standing dialysis centers.

Can you give an example of how your delivery care methods would work?

CERC’s care delivery models draw from the best available research evidence and national and international clinical bright spots, where high-quality care is provided at lower than average per capita cost. In our Chronic Kidney Disease model, fellows uncovered compelling evidence demonstrating the quality of life benefit and lower healthcare spending for home dialysis as compared to in-center dialysis. For each patient dialyzing at home instead of in a traditional outpatient dialysis unit, Medicare saves about $14,000 per patient annually and patients’ quality of life is better.

What evidence supports your estimate of reductions in national health spending and quality gains associated with your care delivery methods?

The evidence supporting the quality gains and estimated cost savings derives from the peer-reviewed literature. When the evidence is unclear, we seek expert opinion from health system leaders. Our fellows’ estimates are then subject to review and refinement by a health economist who helps us refine our estimates.

Was there anything about this project or research in this area that was unexpected? 

Most of us found surprising that well-validated ideas take, on average, seventeen years to embed into clinical practice. As fellows, we assemble these 'diamonds on the desert floor,' plan for their rigorous evaluation and recruit pilot sites to test and refine.

Brady told me they discussed opportunities to integrate their CERC-designed care delivery methods into the CHRONIC Act that was recently passed by the Senate and now awaits House action. As for next steps, Brady said that soon the Congressional staff would arrange a follow-up discussion between Brady, Bott and Woo and the Congressional Budget Office. This, he said, will give them an opportunity to share their estimate of federal budget savings from adopting their CERC-designed care delivery methods.

Previously: High-value oncology practices include “support for the patient journey”Identifying ‘high-value’ practices in primary care; a Stanford study pinpoints key attributesTo reduce the costs of medications, Stanford fellows flew to New ZealandHealth-care policy expert Arnold Milstein weighs in on Medicare’s plan to prioritize “value over volume”
Photo by Arend

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