Monday, August 25, 2014

CMS Succumbs to Disease Management Style Spin?

If, thanks to the medical home or disease management, you've witnessed the improvements in patients' care, you've also probably been frustrated by those silly skeptics' insistence on validation. But for traditional research designs, statistical significance, valid comparators and publication in obscure scientific journals, the face validity of nurse-led care management for high risk patients could have ushered in a new era in primary care.

Darn those academic-actuary-statistician-weenies! And double darn CMS for falling for them and not funding the medical home and disease management!

Which is why Population Health Blog readers may enjoy this bit of peer-review schadenfreude. It appears a recent CMS pronouncement that its own "Partnership for Patients Program" prevented early elective deliveries and reduced readmissions is highly suspect, thanks to "a weak design, a lack of valid metrics, and a lack of external peer review for its evaluation." 

Yikes.

It appears the amateurs at CMS used a pre-post design, selected start and stop evaluation points to gin up the outcomes, relied on imperfect administrative data and never bothered with having its outcomes validated by independent review. As a result, we really don't know if the billion of dollars that went into PPP did any good at all.

The PHB appreciates the point. Scientific discipline and peer review go a long way making sure that consumers are getting their money's worth. Now that CMS has gone from an agnostic payer to the centerpiece of health reform, there's a huge risk that its bureaucrats will succumb to shortcuts and spin.

Taxpayers deserve better.  And so do patients.

Image from Wikipedia

Wednesday, August 20, 2014

Just What Is "Patient Engagement" in Health Care?

According to this paper by Barello et al in the Journal of Participatory Medicine, the muddled answer depends on when it was used as well as your professional background.

Using a densely written "lexicographic qualitative analysis" to dive into over 250 scientific papers, the authors found that the term has evolved and may still be in its infancy. When it first began to regularly appear about 15 years ago, the term "patient engagement" was used in behavioral and nursing contexts to describe a dimension of established one-on-one provider-patient care.  Since then, it's been used in a biomedical sense to portray a new relationship between a system and a patient.

The authors point out that how "engagement" is achieved depends on a spectrum of patient perspectives that range from unaware to really motivated.  The Population Health Blog suggests that one way to think about it may be the transtheoretical "readiness to change" model.

The one thing that has been missing in the scientific papers is the patients' perspective.  Ironically, no one has asked and cataloged their answers in any systemic manner.

Last but not least, it's unclear if real purpose of achieving patient "engagement" is greater autonomy, relationship-building, making health care more responsive, reducing costs, or improving public health.  As a result, it's a catchphrase has become all things to all people.

While this lacks the all-important input of folks like this and may also be an exercise in tautology, the Population Health Blog managed to extract something of a definition for the term: a span of cognitive processes that seeks participation, compliance, learning  and self-management in health care, including disease, prevention and health.

Image from Wikipedia

  

Monday, August 18, 2014

Doubling Down on Accountable Care Organizations and Health Information Networks

Want to achieve effective health care, reduced costs, increased quality, population health, widespread prevention and seamless health information access? 

It's easy, says  this article in Population Health Management: mix one part PHO with one part HRB to create a HAPPI.

The Population Health Blog was confused too, but that's what's proposed by three smart academics from Johns Hopkins, Arizona State University and UC Berkeley.

As the PHB understands it, Population Health Organizations (PHOs) would be responsible for all medical, public health, community and social services in a defined geographic area and coordinate them with local education, housing and labor. Much of it would be paid for by a pooled risk-adjusted global or capitated payment (budget) from all insurers.

Each organization would be paired with a Health Record Bank (HRB), which would act as a huge data warehouse that not only stores all medical information, but any other publically available information on every individual enrolled in the PHO. The HRBs would be owned and operated by "trusted custodial organizations." Data access would be ultimately controlled by each patient.

The authors believe that patient payments would be a source of additional revenue for their PHOs. Examples include buying "apps" that are tailored to their individual health needs, or selling their personal health information, especially if it means helping physicians buy an electronic health record or access cutting edge research.

Combine a PHO and HRB and you have a Health and Prevention Promotion Initiative (HAPPI). Its size and scale would warrant contributions from community and provider organizations "without the need for additional reimbursement or outside funding." It would efficiently "align incentives" for insurers, hospitals and ACOs - with money left over for prevention, care coordination, decision support and a learning health system.

Breathtaking, isn't it?  If any PHB readers thought accountable care organizations (ACOs) and health information networks (HINs) weren't big enough, along comes Tyrannosaurus rex-sized PHOs, HRBs and HAPPIs. 

The PHB worries that while we'd want to see how pint-sized ACOs (not a slam dunk) and HINs (likewise not a slam dunk) perform before we apply the massive steroid doses, the opposite could happen: their messy failure could be just the justification for doubling down and going even bigger

As pointed out in a recent Wall Street Journal Notable and Quotable:

Economist Michael Munger writing in the Freeman, Aug. 11:

When I am discussing the state with my [academic] colleagues, it's not long before I realize that, for them, almost without exception, the State is a unicorn. I come from the Public Choice tradition, which tends to emphasize consequentialist arguments more than natural rights, and so the distinction is particularly important for me. My friends generally dislike politicians, find democracy messy and distasteful, and object to the brutality and coercive excesses of foreign wars, the war on drugs, and the spying of the NSA.
 
But their solution is, without exception, to expand the power of "the State." That seems literally insane to me—a non sequitur of such monstrous proportions that I had trouble taking it seriously.
 
Then I realized that they want a kind of unicorn, a State that has the properties, motivations, knowledge, and abilities that they can imagine for it. When I finally realized that we were talking past each other, I felt kind of dumb. Because essentially this very realization—that people who favor expansion of government imagine a State different from the one possible in the physical world—has been a core part of the argument made by classical liberals for at least three hundred years.

Image from Wikipedia

Thursday, August 14, 2014

17 Reasons Why Care Management Is Probably Not Going To Be in a Clinic Near You Anytime Soon

Here's a good review of all the reasons why care management has not become a routine part of patient care. 

As policymakers, reformists, consultants and architects plan for a population and outcomes-based future, they'd be wise to think about the review's 17-point reality check.

1) Start-up costs are considerable;

2) Costly to maintain;

3) Multi-year time horizon for any return on investment;

4) Any success undercuts future traditional fee-for-service revenue;

5) Can't be broken down into discreet 'reimbursible" units for fee-for-service payments;

6) It's paid for with still-novel-experimental capitated payments and/or shared savings;

7) The link between increased quality today and downstream savings tomorrow is still tenuous;

8) Complicates primary care by introducing more uncertainty;

9) Non-physician manager training is time-consuming and costly;

10) It's a resource that is best reserved for high risk patients, not all patients;

11) Doesn't fit into long-standing clinical workflows in established clinics;

12) Primary care already has enough challenges and implementing care management is not a priority;

13) Most EHRs are not configured to document or support non-physician care;

14) Decision-makers need additional information on expected net savings;

15) It relies on a lot of outside-the-doc-comfort zone behavioral, vs. "medical" health interventions;

16) It requires considerable data support;

17) It's often balkanized by multiple payers.

But be of good cheer. Jimmy Cliff reminds us that half the battle is knowing what you're up against.


Wednesday, August 13, 2014

The Just Right "Sweet Middle" of Care Management

Finding the "just right" middle
If you're interested in care management (definition here), there's a supportive case report in the August 7 edition of the New England Journal.

But it also makes a important point that appears to have been missed by the Editors.

The Population Health Blog explains.

The case revolves around a fragile cancer patient with abnormal blood chemistries and distributed locations of care. The author describes how care management successfully improved the patient's safety, required a lot of physician-to-physician communication and relied on care management's "reach" outside the four walls of the primary care clinic.

All good points.

However, what's also true is that prior to the cancer diagnosis, this was an otherwise well patient with post-discharge needs that were amenable to care management intervention.  In other words, this patient was "high risk, high impact." These individuals make up the narrow middle in the span of patients who range from otherwise well (destined to do OK) to disastrously complicated (destined to do poorly no matter what). 

The Population Health Blog doubts the case would have been so meaningful or successful with a routine surgery patient (stable and OK) or someone with metastatic spread of the cancer (a disaster).

The Population Health Blog is all for patient safety, doc-to-doc communication and distributed care management.  However, they're not going to be of equal benefit for every patient.  If the intent is to "save money" by reducing avoidable health care utilization, it's best aimed at the patients in the middle.

Like this one.

Tuesday, August 12, 2014

Quality Improvement Ver. 2.0?

Throughout its medical career, it's safe to say that the Population Health Blog has been quality-improvement ("QI") averse. While the PHB "got" the need for measurable outcomes, the jargon ("barrier analysis"), expertise (careerism) and culture (heavy on "administration") made it treat QI like an EHR alert: something to be tolerated, not embraced.   

After reading this on-line AHRQ manuscript on primary care QI, however, the PHB is reconsidering the topic.

Naturally, for all the wrong reasons.
 
The PHB explains.

According to the brief:

1) QI can be defined as continuously assessing performance over time to make ongoing adjustments in care processes  Like it or not, QI is being increasingly linked to licensing, accreditation, public reporting, media scrutiny, payor involvement and growing patient consumerism. It's true for hospitals, and it's just a matter of time until that extends to the outpatient arena.

2) Unfortunately, QI needs the three things that are in short supply in most outpatient settings: staffing, resources and commitment. Two other challenges include the never-ending work of patient care and the lack of any direct or indirect financial benefit. 

3) As a result, if primary care practices are going to meaningfully "do" QI, they'll need external support.  That means personnel/consultants who can train, provide technical assistance, find resources or suggest best practices. Large health systems may be able to adapt this from their hospital QI programs.  Smaller or independent clinics may have to turn to the overlapping regional alphabet soup of AHECs, RECs, QIOs, PBRNs, payer, employer and professional initiatives paid for by the Feds, states, insurers and foundations.  The chances of success will be greater if there are financial incentives (such as a piece of any shared savings) and networked learning involving other like-minded clinics.

The PHB's knows the AHRQ authors mean well, but wonders if it isn't time to start thinking about QI Ver. 2.0.  It would involve some of the following elements:

Turn key: easy to import with absolute minimum fuss, time to implementation, workflow disruptions and reliance on human guidance.

A contracted entity can remotely tap computerized billing, insurance claims or electronic record systems in a matter of days, letting the docs continue to focus on patient care.  If patient surveys are necessary, use text messaging or interactive voice response.

High tech: Cloud-based data collection, storage and reporting.  All the better if it's automated and scalable.

Once the data are collected, computers can calculate trends, means, standard deviations and statistical significance.  The process can be standardized and auditable.

Decision support: Link any insights to the artificial intelligence that guides patient care.

As point-of-care guidance on diagnosis or therapy grows more sophisticated, it can use the clinic's QI data to change processes and improve outcomes.

By the way, the PHB suggests one entity that is best able to champion this are the population-health care management programs.  They understand the need, possess much of the technology and could use QI to further their value proposition.

Image from Wikipedia

Thursday, August 7, 2014

Corporate Jargon You Can Sing Along To

Naturally, the corporate-minded Population Health Blog could not resist:



(By the way, this wacky petition may be just the thing to prevent future Super Bowl wardrobe malfunction chicanery.)

Wednesday, August 6, 2014

The Italics and Dot-Dot-Dot Edition of the Cavalcade of Risk

Welcome to your latest edition of the Cavalcade of Risk.  The Population Health Blog is pleased to offer this linked summary of some of the best and latest bloggery dealing with economic risk.

Knowing how busy readers are, this particular edition wanted to focus on the "bottom line" of each entry. The most important insight is at the end of each paragraph.....

Enjoy!

Auto

Wondering if that non-performing capital assessment called a "parked car" can be addressed by "peer-to-peer car sharing?'  Well, if you think you can grab a portion of Hertz's market share by renting that car, you may want to pause and think about what your automobile insurance has to say about it.  Hank Stern over at the Insure Blog points out that a wreck may not be covered leaving you personally responsible for another party's injuries....

Workers Comp

Did you know that employers can be arbitrary, hostile and vindictive?  That employees can be sullen, suspicious and uncooperative?  Toss in a significant  job injury, and you've got is what AMAXX Blog writer Michael Stack describes as an unwritten part of a workers compensation adjuster's job description: being a peacemaker. Employees ultimately do better if they get to work sooner rather than later, and bosses do better they step back and let the workers comp adjuster deal with any possibility of malingering....

Data Privacy

After Target and eBay, your company's (or, come to think about it, government's) databases may not only be next, that possibility is greater than you realize.  RJ Weiss at the Weiss Insurance Agencies does readers a service by summarizing some of the numbers around the risk of data breaches, including a cost of $195 to $246 per record, an average loss of 2.8% of customers and that having strong preventive measures in place can reduce your cost by $8.98 per record.  Important sources of break-ins include those portable devices and sloppy third parties....

Health Insurance

We'd all like to think that hospitals are working hard to reduce costs and increase quality thanks to the government's value-based purchasing initiative.  Jason Shafrin of the Healthcare Economist summarizes a recent peer-reviewed publication on the topic and the bottom line answer is "not exactly." While results may be more a function of the baseline that was used, there was no discernible impact on clinical process or patient experience performance for Medicare beneficiaries....

Speaking of payment initiatives, your host's Population Health Blog (PHB) takes a look at another recent scientific publication that examines how a statewide bundled payment program stumbled.  The process was stymied by the usual payer-provider tensions, inadequate information technology, regulatory concerns and difficulties on defining just what makes up an "episode of care." It turns out that getting bundled payment off the ground is far harder than it looks.... 

Getting health insurance between jobs should be easy, but it's not. Louise over the Colorado Health Insurance Insider cuts through the noise of Obamacare and the individual market by offering up some useful insights, including the definition of a "qualifying event," the 60-day rule and the option of using Medicaid to trigger a qualifying event to navigate the 60-day rule....

The next host of the Cavalcade of Risk is Paul Dzielinski.  The PHB is looking forward to his hosting debut!

Tuesday, August 5, 2014

Think Bundled Payment is Inevitable? Think Again

Getting bundles of these is easy?
This just published Health Affairs article finds some flies in the bundled payment ointment.  The summary below speaks for itself.

In 2010, California's Integrated Healthcare Association and RAND piloted a bundled payment with gain-sharing arrangement for a set of orthopedic surgery procedures. Six commercial health insurance plans, eight hospitals and one independent practice association (IPA) agreed to participate in a uniform payment program. There were technical consultants, a steering committee, and physician committees that presided over deciding which services would be included in each of the orthopedic bundles.

Problems abounded. There were delays, fewer than anticipated surgeries, doubts about whether the bundles would result in meaningful change, concerns about administrative burdens and problems fitting the bundles into some of the existing capitated contracts.

It all boiled down to:

1) Details: it turns out that an episode of care is complex and intertwined, making it difficult to establish consensus over what should - and should not - be covered in a bundle payment.  Insurers naturally favored inclusion of as much as possible while providers favored preserving separate fees for as many related services as possible.

2) Distrust: each of the participants had different motivations. Insurers wanted the overall volume of orthopedic procedures to drop. Hospitals wanted their implementation costs covered. Insurers wanted to price the bundle using a roll-up of fee-for-service minus a discount, while the hospitals demanded a higher aggregate payment plus higher volumes of referrals from the insurers. Insurers wanted to transfer risk, while the hospitals wanted a stop-less provision.

3) Information technology: the legacy systems of both the hospitals and insurers were unable to process the bundles. Attempts to switch to a manual system only increased inefficiencies.

4) Whither the physicians: Not only was it complex figuring out how to compensate doctors for their services within a bundle, California has a prohibition against the "corporate practice of medicine" by hospitals.  Other regulatory concerns over managed care contracts made things worse.

5) Critical mass: the absolute volume of orthopedic procedures was less than anticipated.  This diminished the financial as well as educational return on investment.

The introduction to the article sums up the Population Health Blog's takeway:

"Evidence is lacking on the effectiveness of bundled payment in terms of improving the quality of care, reducing its costs or both.  Existing evidence about bundled payment programs mostly comes from bundled payment designed with more limited scope that have little generalizability to current programs."

This real world attempt shows that "bundled payments" are not a health reform slam-dunk.

Thursday, July 31, 2014

Yuppies vs. Millenials: Health Policy Implications

In this post, the Population Health Blog distinguished between yuppies' desires and the millennials' expectations.

To further help its savvy health policy savant-readers distinguish between the two, the PHB is happy to provide examples in the table below:

Health Care Topic               Yuppies                     Millennials

Preferred Encounter:         Appointment              Text message

Appointment
Opener:               "Thank you for seeing me"  "Thank me for seeing me"

Preferred
Encounter Outcome:    Specialist referral          Complimentary latte

Likes:                                   Pills                              Pixels

Long Term
Health Goal:                      Live forever               Live well forever

Plans to Live
Well Involve....                  Testosterone                  iPhone

Opinion on
MD vs. RN
vs. NP vs. PA                    Very important               "What?"

Remote Care
Management                      Know more                   No brainer