Population Health Must Include Social Determinants: The Approach in the Patient Centered Medical Home

Diabetes control isn't
their top concern

The Disease Management Care Blog's primary care colleagues are undoubtedly aware of how "social determinants" can undermine the best care planning. So, if you're going to rely on the Patient Centered Medical Home (PCMH) to increase health care quality and reduce costs, ignoring the impact of poverty or health literacy could lead to poor diabetes control, worsening high blood pressure or more hospital readmissions.

Arvin Garg, Brian Jack and Barry Zuckerman have written a JAMA "Viewpoint" that offers five lessons from pediatric medical homes that can mitigate harmful social determinants:

1) Include social determinants (for example, community factors, substance abuse, education, malnutrition or poverty) in the creation of national treatment guidelines.

2) Develop and implement screening programs to identify any social determinants that could impact medical treatment.

3) Colocate community resources that address social determinant in PCMHs.  Examples include housing programs, job training programs or food pantries.

4) Colocate "outside the box" social programs in PCMHs also.  This is an area ripe for piloting or researching innovative interventions

5) Integrate visiting nurse programs with the PCMH.  Think of the visiting nurses as an extension of the medical home.

As readers of the DMCB are aware, not all PCMH's can build the full suite of services that make up a medical home. Since health insurers and care management vendors are partnering with primary care physicians to build medical homes, this approach to incorporating social determinants in their programs is worth a closer look.

The Politicizing of Preventive Health Care: Whither the US Preventive Health Services Task Force?

Here comes the camel nose!

Kudos to JAMA for tackling what the Disease Management Care Blog has been saying for years: now that the Washington DC's camel nose is under the tent, there is no way health insurance coverage - and the care it pays for - isn't going to become politicized.

That's the bigger issue in this just-published article by Steven Wolf and Doug Campos-Outcalt. They're focusing on the political pressure that is being brought to bear on US Preventive Services Task Force (USPSTF). As readers may recall, the Affordable Care Act requires health insurers to fully cover screening services that are deemed effective by the USPSTF. Drs. Wolf and Campos-Outcalt point out that politics rudely intruded on the USPSTF's determination that the evidence supporting mammography for women under age 50 years was lacking. The resulting firestorm not only prompted Congress to not only waive the USPHSTF recommendation, but led some of its members to question the Task Force's integrity.

As academics writing in peer-reviewed journals are wont to do, the authors suggest that this can be remedied by another layer of bureaucracy. They want a new "firewall" committee to be inserted between the "pure" evidence-based USPHSTF and the "political" fisticuffs of the public square.  It'd be the job of this a new entity to insulate USPHSTF by reconciling the proof and the politics prior to the upload of the final recommendations to the mandarins that are running CMS.

"Another committee?" asks the dismayed DMCB. While that would end the Obamacare fiction that health reform was ever going to be truly "based on science," the real Achilles heel of the JAMA proposal is that it literally doubles the opportunity for political meddling. The smartest political operatives will see this as a target-rich environment and naturally seek to influence all of the committees with any jurisdiction over the medical-industrial complex of laboratory medicine, radiological imaging and medical devices.

The DMCB has bad news for its colleagues who thought that they could have the Washington DC "cake" of enlightened government involvement along with the "icing" of scientific independence. Uncle Sam's been given a clinical inch and now he'll take a political mile to influence clinical guidelines and define standards of care with a one-size-fits-all mentality sprinkled with a healthy dose of cronyism.  Surprise!

The DMCB has an alternative solution: CMS should tread very carefully when it comes to insurance design.  Congress needs to reengineer the preventive health part of the ACA. Instead of building new infrastructure to make up for the emerging failures of the old infrastructure, Washington should be pushing benefit design down, not up, to the local level. It can partner with commercial health insurers to assure that the USPSTF recommendations are considered, but with local committee assessments of market demand, provider opinion and community input to determine what's best for its covered population. It should do this while simultaneously promoting the use of shared decision making to help every patient ponder for themselves when testing is in their best interest.
 
Let a thousand flowers bloom.

Image from Wikipedia

Suggested Session Topics for the Next TEDMED Conference

Smarter than the best EHR

The stunning multimedia. The earnest and expert speaker. Telling anecdotes, wry observations and exciting insights. Gasps of appreciation from a fawning audience. Standing ovations. 

No, the Disease Management Management Care Blog is not describing any of its past speaking gigs, but a typical TEDMED session. Videos from the April 16-19 2013 event have been posted and the luminaries run from medical university big wigs to interpretive dance choreographers. 

"Gimme a break," thinks the covetous DMCB. While TEDMED offers a lot of brain candy, content sampling shows too many empty calories and too much artifical coloring. Bleh.

Knowing that the attendees ("delegates") at the 2014 TEDMED will demand similar edutainment for the thousands of dollars they pay for each ticket, the DMCB still wants to help and is pleased to offer a listing of suggested 2014 session titles:

The Remarkable Absence of Prehistoric Obesity: Clues from Fossilized Dino Dung

Genomic Medicine and Dysmorphic Unsightliness: It Turns Out It Is Your Fault and There Is No Cure

Buzz Lightyear Takes on "Big Data": To "Infinite Data" and Beyond!

How Losing Half My Brain to Disease Qualifies Me As a TEDMED Speaker

Hacking a Fruit Fly's Brain with Teeny Wires to Build a State-of-the-Art Electronic Medical Record

What George Jetson's Factory Job Can Tell Us About the Future of Medical Practice

Relationship Relief Is On the Way: 3D Organ Printing Him A New Brain

Image from Wikipedia

What Makes the Disease Management Care Blog Happier Than?

To the continuing disappointment of the spouse, the Disease Management Care Blog cannot resist pausing its channel surfing to watch the humorous Geico "Happier Than" insurance commercials.  Figuring that the Affordable Care Act is on the verge of being embraced by a majority of Americans any day now, the inspired DMCB is pleased to cash in on that positive brand to pitch its own "Happier Than" themes for use by any company with a product to sell:

Happier than......

.... a statistician in a care management data center.

.... a diabetes care manager in a crowded pastry shop.

.... a specialist physician at a RUC meeting.

.... a bank robber at a RAC audit.

.... a potato chip vendor outside a medicinal marijuana store

.... a lap band manufacturer at a Governor Christie news conference.

.... a vampire at a glucose meter testing lab.

.... spandex at a wellness vendor trade association meeting.

.... a bankruptcy lawyer at an Accountable Care Organization convention.

.... a CMS official watching a National Geographic Channel special on sloths.

.... a health economist at a fog-machine quality assurance testing facility.

.... a personal injury attorney reading an electronic health record.

.... an ADHD patient with a Twitter account.

and last but not least.....

.... a skeptic discovering the Disease Management Care Blog.

The DMCB invites readers to submit their own.

The Oregon Medicaid Experiment: Good Study, Bad Politics

Examining the Oregon Medicaid Study

By now, most Disease Management Care Blog readers have probably read or heard about the release of the health and costs outcomes data from the Oregon Medicaid experiment. The purpose of the study was to ascertain whether one of the arguments still being used to support the Affordable Care Act is really true, i.e. that health insurance leads to better health leads to lower health care costs.

It's not a minor argument. When the important provisions of the ACA go "live" in 2014, liberal-progressive supporters of the ACA will be tenaciously seeking to validate the merits of health care reform, while conservative critics will be looking for any excuse to strangle Obamacare in its crib.

So naturally, if a well performed study supported or contradicted the health insurance hypothesis, it would make little political difference.

How was the study done?

Unable to afford universal enrollment of approximately 30,000 eligible persons into Medicaid, Oregon figured the only fair way to administer the program was to have a lottery. Because participating individuals were allocated to one of two options (with or without Medicaid) by chance, Oregon's approach had all the makings of a prospective randomized clinical trial.

The lottery was conducted in 2008 and the health status and health care costs for the winners and losers were compared using face-to-face interviews an average of 25 months later. While the lottery was state-wide, the study itself was limited to the Portland area. The researchers planned to compare the health status of 10,405 individuals who had won the lottery to 10,340 individuals who had lost and were not enrolled in Medicaid.

Not all persons signed up for Medicaid and others couldn't be tracked down for the one-on-one interviews, leaving a final number of 6487 (62% of the eligible) lottery "winners" versus 5842 (57% of the eligible) "losers."

What were the results?

All in all, the results were disappointing for persons believing the health insurance hypothesis. Having Medicaid didn't lead to better control of high blood pressure, diabetes, blood cholesterol levels or overall cardiac risk. There was also no impact on the likelihood of being admitted to a hospital or having to go to an emergency room.

The good news was that having Medicaid seemed to lessen the likelihood of battling untreated clinical depression and, if pap smears and prostate specific antigen tests are markers for access to primary care services, Medicaid increased that also. Last but not least, Medicaid participants were less likely to have catastrophic medical expenses or be in debt to cover medical bills.

Was the study perfect?

Nope. The study's generalizability was limited by being restricted to persons age 19-65 years in Medicaid and in an urban environment. Two years may not be long enough to truly gauge the benefits of having insurance. Many persons were lost to follow-up. Statistics limited the ability of the researchers to spot smaller improvements in health status.

And how did supporters and detractors of Obamacare react?

As expected. If bloggers are a window into the soul of the body politic, this KHN article amply demonstrates that no one's mind has been changed. Between inflating or minimizing the study's imperfections, cherry picking the outcomes and spinning them, we are no closer to achieving any consensus.

The Disease Management Care Blog's take:

Studies like the Oregon Medicaid study are not only rare, they're as good as we're going to get. Since no study is perfect, the likelihood that Washington DC will be able to use any nuanced research insights to inform the next steps in pursuit of the Triple Aim is not good.

The battle lines have hardened.

Big Data Analytics Salesmanship: A Free Public Service for the Data Management Vendors

Data analytics for sale!

While the Disease Management Care Blog continues to delight in the clever electronic health record humor of the Extormity web site, little did it know that the same over-promising jargon typical of the EHR hucksters would be adopted by the "Big Data" health care analytics vendors.

Sensing that the hard-sell carpet bombing of the provider community from these outfits is only going to increase, the Disease Management Care Blog is pleased to offer the emerging community of data analytics vendors some cut n' paste bombast suitable for their press releases, web sites, trade show presentations and glossy collaterals:

(Insert name of your company here)'s business intelligence and work-flow solutions offer best-in-breed data analytics that both monetizes and obfuscates open-source programming.  As end-utilizers utilize any Windows 8-based interface to satisfy myriad and shifting passkey screens to eventually tap our physician-led and lawyer-vetted intelligence applications, a robust informatics ecosystem awaits, all in a series of hosted legally immunized informatics platforms located in India or Kuala Lumpur and Vladivostok.

Providers, administrators and auditors can then utilize (company name's) propriety specifications developed by dozens of PhDs to assess trending, risks, outcomes, costs, spending, incurred-but-not-reported, billed-but-not-paid, correlations, odds ratios, attributable risk, Z statistics and regressions for pre-packaged insurance claims-based definitions of diabetes mellitus, migraine, gout, dropsy, lumbago, and conkus of the bonkus.

(Insert name of company) can also access Centers for Medicare and Medicaid Services claims data and use benchmark advances to apply truly artificial intelligence to derive predictive assessments that can also predict your health system's business planning needs. Claims data from some commercial carriers are also suitable to import and derivation thanks to the availability of an upgrade plug-in Ver 2.3.1.1 licensing option.

"Our company's approach to analytics is truly unique," said CEO Vera Patented, adding "We seek a long-term relationship with our partners and aspire to leverage our proprietary technology to assure that's precisely happens."

"Our technology is compliant with all known, anticipated and over-interpreted federal statutes and regulations," added Chief Legal Officer Doan Suemoi.  "Our ironclad hold harmless contracts guarantees our protection from allegations related to HIPAA, HITECH, the ACA, the GNA, the FDA, the FAA and the NRA," she added.

Remarked customer and Chief Imagination Officer Dr. Mustafa Raturn, "As an early adopter of this technology, I was impressed by this product's ability to arbitrarily assign risk scores to two decimal places for populations using a methodology backed up by years of research. This functionality was paired with a cut-and-pace interface with bar graphs and pie charts configured to impress my hospital's Board of Trustees." 

About the company:

(Name of company) is a wholly owned subsidiary of Triple Aim Fail Ventures, a company that offers innovative, integrated and illusionary services designed to meet the full spectrum of analytic, management, consulting and predatory health care business needs.

Prospective Payment Good, Fee For Service Bad, Right? Unless You're a Patient That Is.....

Applying the brake in the name of patient care?

The Disease Management Care Blog poses a simple question: knowing that, despite the best of care, things can occasionally go wrong following surgery (for example, inpatient MRSA infections can still happen and readmission rates will never go to zero), do you really want your doctor or hospital to not be paid for the additional care that you may require?

Go to the websites of organizations like Robert Wood Johnson or The Brookings Institution and you'll find impressive expert papers that extol a variety of "payment reforms" designed to "align incentives," "reduce waste" and "achieve cost savings."  Dig into these reforms and readers will encounter admiration for payment approaches like "prospective payment," case-based," "bundling," and "shared savings."  You'll also find a deep disdain for "fee-for-service" (FFS). 

Prospective good, FFS bad, right? 

"Not always," replies the DMCB. It depends on your point of view. Like, if you're a patient.

The DMCB explains.

The DMCB learned long ago to simplistically think of provider payments in terms of "gas" and "brake" pedals.  FFS applies gas and accelerates provider services; that's because each time a "service" is provided it subsequently generates a "fee." 

In contrast to FFS, case payment, bundling and capitation apply the brakes, because providers receive the payments up-front. Since the money is in hand, providers have an economic incentive to preserve it and withhold services.  The DMCB thinks of "shared savings" in terms of brakes because the up-front payment is essentially held in escrow until the savings (versus a targeted level of utilization) are achieved.

The simplest example of how this can be applied is to hospitalization.  If hospitals are paid for each day that the patient is in a hospital, that's FFS (otherwise known in the industry as "per diem"). 

Instead of per diems, most hospitals are paid with a different payment mechanism based on "diagnosis related groups" (DRGs). Every time a patient is admitted, that generates a payment (similar to FFS).  That payment, however, is not pegged to the number of days the patient stays in the hospital. Instead, the payment is bundled to pay for the entire hospitalization.  That's why hospitals are always willing to admit patients (the gas) and then in a hurry to discharge them (the brakes).

Under the payment reforms championed by Robert Wood Johnson or The Brookings Institution, the inpatient payment bundling would be expanded to pay for the entire case after discharge from the hospital.  Under this system, if the case had to be readmitted, the hospital and providers are SOL.  After all, why should they be rewarded for shoddy care?

Unless, of course, you're the patient.  The DMCB worries that a one-size-fits all approach to payment policy could have unintended consequences. Patients battling unanticipated outcomes would likely prefer that their providers be incented to give additional care.  They want to be back in the hospital.

The payment policy may be good from the point of view of health reform, but it can be bad for patient care. 

The DMCB asks if we are on the verge of another round of unintended health care consequences.

We'll know soon enough when anecdotes of patients being inappropriately denied readmission begin to appear.

AHIP Steps Up With Their Version of Health Reform

While HHS Secretary Sebelius reassures the House Republicans that the Fed's health insurance exchanges are on track, that the implementation of the Affordable Care Act will not be a "train wreck" and flies around the country touting Obamacare, Disease Management Care Blog readers may want to check out this 3 page article by the notorious anti-Sebelius a.k.a. AHIP's CEO Karen Ignagni.  In it, she mounts a vigorous defense of her trade association's commercial insurer members.

She points out:

1) Commercial insurers' versions of accountable care organizations include a variety of prospective payment approaches that are tailored to the provider's willingness to take on insurance risk.  What's more, commercial insurers can "calibrate" the benefit so that consumers', physicians' and hospitals' economic incentives are all aligned.

2) Health plans are quite able to share data and analytics support that translates into early identification of trends, accurate payment designs and the targeting of programs at patients who are at greatest risk.

3) AHIP's members are routinely providing health risk assessment tools, predictive modeling, medication compliance programs and care management services.

4) AHIP is well aware of the difference between true cost savings versus mere cost shifting.  As a result, they are asking for greater transparency on commercial and government fee schedules so that the potential impact of cost shifting can be better understood.

5) While Washington DC deserves a lot of credit for promoting a quality agenda, it could do a better job of working with all insurers to come up with a set of universally used quality measures.

6) While commercial plans are required to use uniform billing systems, providers are under no obligation to submit their claims electronically.  While this certainly helps physicians over the short term, the long term inefficiencies are not cheap.

7) Commercial insurers would rather cover treatments that have been shown to work. The "Patient-Centered Outcomes Research Institute" is not mentioned by name, but you get the idea.

8) AHIP supports letting non-physicians practice "to the top of their license."

9) State-based "laboratories of democracy" are a useful way to try out a variety of health reforms before they are adopted by Washington.

The DMCB's take?

AHIP and Karen Ignagni have been mostly out of the public eye.  Could this be a sign that they're less wary of the Administration's anti-insurer bluster?

While Medicare's Innovation Center continues to get high marks, the commercial insurers appear to be advantaged by having more leeway to test new payment and care management strategies.

AHIP's members are aware that many providers could fold if they mismanage the risk that underlies prospective payment systems.  Unike Washington's one-size fits all approach, they seem prepared to adapt their contracting accordingly.

Care and disease management programs?  The commercial insurers have rolled this into standard operating procedure.

Three Models of Primary Care Teaming (TL, CC and ET): An Unexplored Feature of the Medical Home

What defines optimal outpatient primary care "teaming?"

The Disease Management Care Blog just assumed that if it took equal scoops of adaptable physicians, dedicated nurses and supportive culture and baked with a dollop of accountability, "teaming" would just.... happen.

It turns out that what may come out of that clinical practice oven is a lot more complicated than that. 

Which is why medical home advocates should pay attention to this article by George Washington University's Debra Goetz Goldberg and colleagues.  Interested in finding out more about primary care "teaming," they interviewed, reviewed and observed three different Virginia clinics that had embarked on transformative quality improvement programs.

Each clinic came up with a different version of "teaming":

1."Top of License" - nurses interviewed the patients, presented the problems to the docs and then documented the care plan.  They were also responsible for the patient education.  Thanks to using this model, the physicians almost doubled the number of patients they were seeing per day.

2. "Care Coordinator" - nurses focused on helping patients undergoing care "transitions" (typically out of the hospital) and provided self-management and health education to high-risk, high complexity patients.  Interestingly, unsatisfactory reimbursement levels forced the practice to cut back, but they still doubled mammography and blood pressure control rates among persons with diabetes mellitus.

3. "Enhanced Traditional" - the physicians still performed the bulk of the patient care but the researchers observed that the other clinic personnel benefited from increased trust, communication and hand-offs that translated into patient centered care, shared responsibility and heightened volunteerism.  The practice was unable to measure any outcomes.

"Very interesting!" says the DMCB. Authoritative web-sites like this or this and peer-reviewed articles like this refer to "teaming," but fail to precisely define it.  Assuming the three categories described by Goetz-Goldberg (in shorthand, "TL," "CC" and "ET") hold up in future studies, the DMCB looks forward to learning which approach results in the greatest quality or cost-savings.

Coda: As a reader bonus, the authors offer up a definition of "team-based care" that seems to span all three models and can be used for the DMCB readers' quoting pleasure:

"A group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients."

Bullying Health Insurance Actuaries

"Gotcha!"

Years ago, the Disease Management Care Blog proudly showed the consulting health insurance actuaries published data like these and these. It naively expected the actuaries to agree that disease management had resulted in cost reductions and that the programs should be favorably factored into the managed care insurance plan's premium pricing for the coming year.

The response of the actuaries was "no."

Disease management not only did not factor into their trend analysis, they decreed that the programs' costs needed to be loaded as an additional administrative cost. The worst part of dealing with their obstreperous math was that the health insurance plan was actually paying them to deliver this bad news.

Which is why the DMCB believes that anyone who believes that actuaries' relationships with health insurers are riddled with conflicts of interest is amateurishly misinformed.  To wit, Senator Franken (D-MN) recently scored a political "gotcha"against the Society of Actuaries when they had the temerity to predict that health insurance costs in the individual market could go up by 32%. While it is true that their consulting services generate fees that are paid by their insurers, their hard-nosed recommendations are hardly ever welcome in the industry, their fees are not linked to health plan profitability, states have regulated actuarial consulting input for decades and, to add insult to injury, customers like the DMCB have to pay their fees for unwanted news.

At one level, the DMCB welcomes members of the U.S. Congress to its world.  The job of the independent actuaries is to present inconvenient truths about future health care trends and premium pricing.  At another level, the DMCB is concerned that Frankenesque-style bluster and bullying could force health insurance actuaries to underprice insurance and destabilize the market just when Obamacare is getting out of the blocks.  We deserve better.