Wednesday, November 12, 2014

Rising Healthcare Costs: Delayed or Defeated?

Ready, set......
According to this just-published New England Journal article, analysts are still waiting for the twin forces of 1) an improving U.S. economy and 2) higher numbers of newly insured Americans to reignite healthcare inflation.  While the latest data from the Bureau of Economic Analysis (BEA) are conflicting, data from the early part of 2014 suggests that health costs are remaining tame.

What gives?
While many Obamacare supporters say this is more evidence of Washington's central-planning genius, author Charles Roehrig notes other factors be at play, namely:

1. The 9 million of 2014's newly insured amounts to 3% of the U.S. population. Their baseline spending was probably half of normal, so the resulting increase would expand the nation's spending by a modest additional 1.5%.  Since this group is younger, it'll likely be less than that.  Their contribution to increasing costs will be harder to detect.

2. What's more, insurance enrollments were finalized relatively late in the year, so these newly insured haven't had much of a chance to give their new benefits an early test-drive.

3. The first quarter of 2014 was an unusually cold winter. The Population Health Blog recalls how freezing temps, wind and snow made for a relaxed day at the clinic. Multiply that across millions of newly as well as long-term insured people, and it adds up.

4. Yes, stupid, it is the economy, which has a strong correlation with healthcare spending. Loss of health insurance thanks to unemployment, declining tax revenues that pressure government insurance programs to limit eligibility as well as benefits, employers' unwillingness to go along with otherwise automatic benefit increases and a general unwillingness of consumers to open their wallets in recessionary times has also added up.

5. Thanks to the expiration of some patents, prescription drug spending moderated.

Bottom line: all of the above are one-time impacts.  The economy's impact and new access to insurance are lasting fundamentals that will not go away. It's too soon to tell what is really going on.
The PHB will stay tuned.

Tuesday, November 4, 2014

Health Care Cost Insights and Capitation for the Patient Centered Medical Home (PCMH)

The Population Health Blog finally caught up with the Oct 22/29 "Price, Cost and Competition" issue of JAMA

One of the more interesting articles was a Viewpoint editorial on the Patient Centered Medical Home (PCMH). After tut-tuting fee-for-service payment as antithetical to meaningful payment reform, the author admits what the PHB has been saying all along: a global payment that covers all the medical, coordinating as well as non-physician services of the PCMH is tantamount to old fashioned "capitation." As we learned in the 1990s, capitation's unintended consequences are a) signing up too many patients, b) limiting access to primary care and c) over-referring to specialists.  To counter that, the editorial's author suggests the PCMH movement seeks "accountability." 

We'll see about that.

In the meantime, some other interesting articles:

Are "for-profit" hospitals evil?  Not necessarily.....

237 hospitals that converted from not-for-profit to for-profit anytime between 2003 and 2010 were compared to 631 hospitals that had not converted.  Converting hospitals improved their financial margins (practically all were in the red and subsequently became break-even) vs. the comparison group, and did so without increased utilization, restricting access to care, higher death rates or declines in quality for their Medicare patients. Their path to profitability may have been lined by renegotiated commercial insurance contracts, cutting costs or moving non-performing assets off the balance sheet.

Can physician groups become monopolistic? In a word, yes.

Commercial insurance preferred provider organization (PPO) charges for ten types of physician office visits in ten different specialties across 50 states were correlated with a measure of local market dominance dubbed the "Hirschman-Herfindahl Index" (more on that here).  As the HHI index increased, payments also increased, suggesting that as much as additional $3 to $12 in fees for the same services were the result of monopolistic contracting.

Monopolies aside, if docs are in charge vs. the hospitals, can they reduce health care costs?  Also yes.

This study compared average "per-patient expenditures" of physician-owned versus hospital-owned integrated medical groups and independent practice associations in California from 2009 to 2012. Among the 158 groups, 118 were owned by docs; their expenditures were over a thousand dollars less compared to hospital owned groups.  Larger physician groups had higher expenditures than the smaller ones.  More on that in a future post.

Does price transparency help patients chose to spend less?

Over 500,000 insurance plan enrollees had special on-line access to prices for medical services prior to using them.  There were over 250,000 households and of these, approximately 7500 accessed the information. Compared to households that didn't check the information, the price-shoppers seemed to choose cheaper labs (a few dollars per test) and imaging options (about a hundred dollars per test).  In looking at the data, the DMCB suspects some may have also deferred testing by choosing to use them less frequently or not at all.

Monday, November 3, 2014

State of the Art Obesity Management - Keep It Away from Primary Care

In the course of the Population Health Blog's last primary care encounter, a measurement of its height and weight determined that it was overweight.  On the way to the examination room, the nurse apologetically provided a patient education leaflet. The physician let the topic go unmentioned.

These health care professionals clearly were not "into" managing weight issues in their patient population.

After reading this paper, who can blame them?  A review of fifteen randomized clinical trials involving over 4500 patients showed that while primary care-based "behavior change for weight loss" results in statistically significant weight loss, the average amount was a clinically insignificant 3 lbs.

While web sites such as this provide useful pointers on engaging patients on the topic of weight loss, the U.S. Preventive Services Task Force (PSPSTF) recommends that persons with obesity be referred to a care setting that specializes in intensive multi-component behavioral interventions.

The primary care PHB agrees: these frontline clinics can screen for obesity using height and weight, but that's where their responsibility arguably ends.  Until there is research that shows otherwise, the primary care setting is no place for management of weight issues.

The PHB's care was state-of-the-art.

Sunday, October 26, 2014

President Obama Addresses the Ebola Crisis

In this weekly address, President Obama addresses the Ebola crisis.  As we've come to expect from our Chief Executives, it's a perfectly crafted speech that addresses our major concerns. But the Population Health Blog doesn't think it goes far enough.  In its continuing quest to help Mr. Obama overcome his tanking approval ratings, the PHB changed a few words and modestly offers up a slightly edited version of the address.  It believe it speaks more forcefully to the issues at hand.....

PRESIDENT OBAMA: Hi everybody, this week, we remained focused on spinning a favorable White House narrative about Ebola. In Dallas, the natural history of the disease and basic isolation procedures limited spread of the disease to only two among the dozens of health care workers who had been in close contact with the first patient. Now, those two workers are two too many, which is why I've told the CDC that their calm and distant inertia is unacceptable.  As you know, that's my job.

The two nurses who contracted the disease in West Africa were thankfully released from the hospital. I was proud to welcome one of them to the Oval Office to give her a big hug and make sure plenty of photographs were taken.

And in Africa, the countries that did not wait for our help, Senegal and Nigeria, were declared free of Ebola.  Which is probably why New York City also decided to not wait on Washington DC. Local public health personnel there moved quickly to isolate the doctor who recently returned from West Africa. While we deployed one of our new CDC rapid response teams, I wonder what they'll learn from New York City's approach. Maybe a lot. And I’ve assured Governor Cuomo and Mayor de Blasio that they’ll have all the federal support they need as they go forward.  After all, I'm from big government and I'm here to help.

More broadly, this week we've continued to step up our use of words like "efforts" "outreach," "coordinate," and "integrate" across the country. New CDC outreach is helping hospitals coordinate and integrate training. The Defense Department’s new team of doctors, nurses and trainers will outreach, coordinate and integrate if called upon to help with coordination and integration and, you know, outreach and other efforts.

Now, rather than institute an unworkable travel ban, we now have a less unworkable travel measure that directs all travelers from the three affected countries in West Africa into five U.S. airports. Starting this week, these travelers will be required to report their temperatures and any symptoms on a daily basis—for 21 days until we’re mostly hopeful that they don’t have Ebola. Here at the White House, the lawyer I've appointed to coordinate and integrate the government's response will tell the doctors what to do and how to do it. And we have been examining the protocols for protecting our brave health care workers, and, guided by the science, we’ll continue to do everything we can to embarrass the Republican nutjobs who are also using Ebola for political gain.

In closing, I want to leave you with some basic facts. First, you cannot get Ebola easily through casual contact with someone. The only way you can get this disease is by coming into direct contact with the bodily fluids of someone with symptoms. But, if you do get it, your internal organs could liquefy. That’s why health workers must wear total body condoms. That's the science. Those are the facts.

Here’s the bottom line. We can beat this disease. But we at the White House have to stay on message by repeatedly saying that we have to work together at every level—federal, state and local. And we have to give the impression that we're leading a global response, because West Africa is in a world of hurt right now along with other global hot spots like Syria and Ukraine and Hong Kong and Russia.

And we have to be guided by the science—we have to be guided by the facts, not fear. Yesterday, New Yorkers showed us the way. Despite the mainstream media's alarmist reporting, they did what they do every day—jumping on buses, riding the subway, crowding into elevators, heading into work, gathering in parks, ignoring speeches like this and wondering why the Yankees aren't in the World Series.

That spirit—that determination to carry on—is part of what makes New York one of the great cities in the world. And that’s the spirit all of us can draw upon, as Americans, as we meet this challenge together.

Thursday, October 16, 2014

Health Worker Nonchalance About Ebola?

The Ebola virus
Recent reports of two nurses becoming infected with Ebola begs the question of whether they were lax in following infection-control protocols. Even if that's true (and it may not be) the bigger mystery is healthcare community's apparent nonchalance. TV's talking heads are generally not alarmed. NBC medical correspondent Nancy Snyderman reportedly snuck out to get some take-out food. Experts at the CDC apparently okayed one mildly feverish nurse's request that she be allowed to travel.

What gives?

First off, how does Ebola spread?

 Ebola is "filovirus" (so named because it has a uniquely filamentous appearance) that, once introduced into the body, can attach to and invade numerous types of human cells. Getting into the human body occurs from the injection of infected blood (such as a inadvertent needle stick from a person with Ebola) or hand-borne "self-inoculation" of a patient's body fluids into the mucus membranes. That's typically the mouth, nose or eyes. 

"Self-inoculation" of a virus by rubbing the eyes or touching the nose/mouth has been a long-known means of spreading infection. Because humans unconsciously touch their facial mucous membranes frequently during the course of a day, eye goggles and facemasks are not only a barrier to airborne virus (such as regular cold viruses), but also act as a reminder to keep your fingers away from your face and eyes (which is more important with the Ebola virus, which is not airborne). 

After the inoculation and during the initial stages of invasion and replication, there aren't enough viral particles to pose a significant person-to-person transmission risk. It's only when the infection becomes overwhelming (which is heralded by a fever) that the virus makes its appearance in body fluids, including blood, tears, saliva, sweat, diarrhea and vomit. Healthcare workers cannot avoid handling the sick patient or their bedclothes, and that's when accidental needle sticks and unconscious touching of their face - i.e. mucus membranes - leads to transmission of the virus to a new victim.

What are healthcare workers' attitudes about infections?

Getting health care workers to pay attention to the inadvertent spread of infection in the course of patient care has been a topic of research for decades.  It's not like they don't know how viruses move from person to person.  Rather, failure to act on that knowledge is a result of poor adherence, insufficient resources, staffing problems, lack of culture change, no impetus to change, and issues related to staff and patient education.  Even with intense education, attitudes may shift by a only a few percentage points. It's not uncommon for up to a quarter of health care workers to not follow basic infection control protocols after a teaching intervention.

How well do health care workers educate lay-persons?

Even when patients are in contact isolation for other reasons, healthcare workers do a bad job of dealing with the concerns of family members or educating their patients about its importance. And it doesn't help that nurse "burnout" can be an independent risk factor for the inadvertent transmission of infection to patients.

While reports like this portray the importance of public education, it's fair to say that the gap between the "stay calm" Ebola expertise of organizations like the CDC and the growing alarm of the lay public is significant.

The Population Health Blog's take?

Healthcare providers have cared for patients with other serious infectious diseases, and their attitudes to dealing with Ebola are not new. While the PHB is unaware of the details of how the two nurses described above contracted the disease, it was just a matter of time until someone got infected. 

If more primary Ebola cases occur in the U.S., we can expect more healthcare workers to contract the disease. A nonchalance toward infectious disease has been a part of the medical landscape for decades.  While the risks associated with Ebola are higher (a purported mortality rate as high as 70%), this is another virus bumping into decades-long patterns of imperfect human behaviors.

While the public is extremely concerned about the specter of Ebola, expert infectious disease talking-heads are well-acquainted with the above data.  They are not surprised that nurses are coming down with Ebola.  Unfortunately, that unsurprised expertise combined with a legacy of poor lay-public education is coming across as incompetence. That's especially true when clinical judgment about a fever leads to a plane-load of passengers being exposed to a sick patient's body fluids. The public deserves better.

Wednesday, October 15, 2014

Associations. Correlations. Inferences. Signals. Yes, That's Big Data

America's corporate Directors
celebrate big data
The Population Health Blog's recent travels recently included a speaking gig at the just concluded National Association of Corporate Directors ("NACD") annual conference meeting.  It was part of a panel discussion focusing on health care innovation that was ably moderated by tech guru John Hotta.

The PHB's educational mission was to enable the persons who serve on Boards of Directors understand how "big data" is going to change health care.  After giving its standard definition (the use of large, disparate and unrelated data sets to find correlations and draw inferences that are actionable at the individual level), it turned to the following example:

"Imagine standing at the top of the Empire State Building and analyzing the noise from below to find out what's most likely happening down on Fifth Avenue."

In other words, its the use of computational analytics to separate the noise from the signals, and using those signals to ascertain a probability.

An informed guess.  Or, a probabilistic choice.

Folks in the audience seemed to get it, especially when the PHB noted that insurance (ICD-9 250), electronic record ("diabetes") pharmacy (insulin), public health (obesity prevalence data by zip code), survey ("have you ever been told you have diabetes?"), government (car registration; overweight persons prefer minivans), web-usage (recent interest in low calorie foods?) and purchasing (grocery purchases) data could be marshalled to assign a risk that diabetes is present, and if it's present, the risk of complications, and if there is a high risk, whether it's actionable.

The value proposition? 

By understanding the risk and being able to array it from high to low, precious health care resources can be scaled to the burden of illness in the population.  So, instead of "carpet bombing" all persons with a diagnosis of diabetes with one-size-fits-all reminders to see their doctor along with mass mailings of educational materials, personalized outreach can be targeted on those persons most likely to be hospitalized (and there are big data signals that can predict it) in the next year.

Bottom line: it can save money by rationalizing health care.

The PHB wanted to point out some other need-to-knows, which it did with variable success:

1. Quantum jumps in processing power and server capacity have put this within reach of desk-top personal computers.  As an added bonus, you don't need an army of mathematicians.

2. "Actionable" also means that the information is meaningfully available at the point of care, i.e. in the doctor's office where 80% of the decisions that drive health care spending occur.

3. Big data can also point to way toward more accurate diagnoses (imagine if all the risk factors for an Ebola infection had been rolled up into a single score in that Texas ER) as well as treatment (deciding on the "best" cancer treatment program after knowing the relative influences of genetics, lifestyle and past medical history).

Wednesday, October 8, 2014

Version 1 Care Management to Prevent Hospital Readmission Fails (Unsurprisingly)

Does this high profile randomized study "prove" that telephone follow-up of recently discharged inpatients fails to prevent readmissions? 

Should hospital leaders reconsider care management programs aimed at reducing readmissions?

Hardly, says the Population Health Blog.

Here's how the study was designed:

To be eligible, patients had to be aged 55 or older and without mental illness or serious cancer. They also had to be able to use a telephone. If the patient and their doctor agreed, patients were then randomly assigned to either:

1) "usual" care that consisted of a pre-discharge review of medications, follow up and other instructions plus a 10 day medication supply, or

2) "intervention" care that was comprised of pre-discharge disease-specific education using motivational interviewing, personalized notification of the primary care physician for follow-up, a medication schedule, an in-person follow-up by a registered nurse within 24 hours and follow-up telephone calls on days 1-3 and 6-10 after discharge.

Over 6300 patients were reviewed, 1781 patients were considered and 700 were enrolled in the study. 679 patients completed 30 days, 581 patients completed 90 days and 561 patients completed 180 days of follow-up.  The mean age of the study population was 66 years, 56% had mild cognitive impairment, 33% had visited an emergency room in the prior six months and 62% used English as their primary language. 

In the intervention group, nurses managed to complete their two phone calls 83% of the time.


"There were no statistically significant differences in the number of ED visits or readmissions between the intervention and usual care groups at 30 days (0.33 vs. 0.26 per person-month; 112 vs. 89 events), 90 days (0.23 vs. 0.20 per person-month; 238 vs. 203 events), or 180 days (0.20 vs. 0.18 per person-month; 392 vs. 370 events)." 

There was also no different in the number of primary care visits between the two groups.


The authors speculate that this patient population already had a high level of support from primary care providers and good access to medications.  In addition, a high prevalence of cognitive impairment may have blunted the nurse interventions.  Last but not least, the authors state that further reductions in ED visits or readmissions may require more in-person home visits in lieu of just telephone calls.

The Population Health Blog offers another thought:  the study was doomed from the start.

Years ago, the Ver. 1.0 "disease management" vendors learned the hard way that aggressively "calling" every patient with did not reduce complications, costs or health care utilization

The study described above was a reprise of that long discredited approach. Calling every person being discharged from a hospital may help some patients, but not all

Since that time, "population health" vendors have discovered risk stratification. By restricting their in-person and telephonic follow-up to patients discovered to be at greatest risk by advances in"big data" analytics, resources can be better focused on the patients who are most likely to benefit and the likelihood of a return on investment is accordingly increased.

And it's not like this is rocket science.  Surveys and clinical algorithms like this and this respectively can help identify recently discharged patients at high risk of readmission. 

If the study above had incorporated this approach and only enrolled the high risk patients, they might have had a positive study. 

That's the real lesson for hospital leaders and their care management programs.

Image from Wikipedia

Thursday, October 2, 2014

Two Additional Reasons Why Health App Adoption is Bound to Grow

The Population Health Blog is avidly learning about health apps for patients

As described here, half of U.S adults now own a smartphone, half of them use them to obtain health information and approximately a fifth have at least one health app loaded on their device. 

Regular PHB readers are well aware of the potential for health apps, including lay-person education, the promotion of consumer behavior change, increased consumer-provider connectivity with greater access to care, better medication compliance as well as medication reconciliation, increased self-care, greater quality and lower costs.

But as the PHB's e-health experience grows, it's encountered two under-recognized features of apps that - in its opinion -  are sure to also drive their adoption:

1. The Provider App Arms Race:  As  competition for loyal patients grows, health systems, care organizations, insurers, buyers and provider networks are going to expect their apps to create greater consumer "stickiness."  For example, offering a tablet with a pre-configured app may enable hospitals to not only reduce readmissions, but enhance their brand recognition.

2. The App Is the Outcome: It will take years for science to prove that apps cause better outcomes. While lingering skepticism will prove to be another bonanza for outfits like this, the luster of smart-device gadgetry will be too much to resist. As a result, it's only a matter of time until Boards and their CEOs pressure their management teams to launch their own app.  While the electronic record and big data are important advances, let's face it: they're in the background. There's nothing like a patient-facing app to remind customers, families and providers of the organization's health tech chops.

Image from Wikipedia

Tuesday, September 30, 2014

The Most Interesting Man In the World Teaches the PHB about the Medical Home

The Population Health Blog isn't sure why its Twitter account was targeted by the Dos Equis ads about the exploits of "the world's most interesting man." Tweets on how "His grandmother uses his family recipes!" and "Fish fight for his bait!" tempted the PHB succumb to Twitter followership.

Which naturally prompted the debonair PHB to ponder the exploits of the Patient Centered Medical Home (PCMH).

To wit:

The White House wants to throw the bus under the PCMH.

Health insurers like it when the PCMH loses money.

The PCMH sues malpractice attorneys.

Ezekiel Emanuel wants be enrolled in a PCMH after he turns 75.

Biker pediatricians have tattoos that say "PCMH."

When they encounter a PCMH, actuaries stop counting.

PCMH jargon about smart device apps has led to the creation of a PMCH jargon app.

"PCMH" is how "ACO" is successfully spelled.

The most interesting man in the world is enrolled in a PCMH

The PHB invites other exploits.

Stay healthy, my friends.

Thursday, September 25, 2014

Dr. Emanuel Hopes He Dies Before He Gets Old

Poor judgment.

The Population Health Blog can't discern another explanation for Ezekiel Emanuel's Why I Hope to Die at 75 article in The Atlantic.  Since leaving Washington DC, Dr. Emanuel has become safely ensconced at the University of Pennsylvania, where he can disclose what he was really thinking while he was helping to stand up the Affordable Care Act.

The Population Health Blog appreciates Dr. Emanuel's recycled nostrums on the quality vs. quantity of elder-years, Americans' unrealistic yearnings for immortality and medical over-testing. And, if the essay prompts patients and families talk to their doctors about end-of-life care, even better.

But those good points are far outweighed by four intellectual blunders:

1) The watershed age of "75" that is used by Dr. Emanuel is an averageMany individual patients suffer declines in quality of living and life expectancy before as well as after that particular age. The PHB has been privileged to care for healthy persons aged 85 who have been correctly looking forward to additional years of rich and rewarding activity.

2) The "value" of a "poor quality" life is in the eye of the beholder. The PHB has also been privileged to care for very unhealthy persons over the age of 75 who remarkably treasure every day they are alive. Who is Dr. Emanuel to disagree with their decision-making?

3) While The Atlantic piece is about the writer's very personal views, they're not only arguably ageist, they're confirming the worst fears of the "death-panel" loonies.

4) Last but not least, real doctors know that healthcare preferences can change. That's especially true for end-of-life care, where yesterday's kitchen-table decisions routinely fail to account for today's emergency room realities. While Dr. Emanuel may hope he dies before he gets old, he should think on how the lyricists behind My Generation continue to rock decades later. He may live to regret his words.