Wednesday, April 1, 2015

The Patient Centered Medical Home, Medicare's Comprehensive Primary Care Intiative and Cost Neutrality

Like this, but with snow
Oh my, he was really angry.

Back when the teenage Population Health Blog was living in New York, our family had a small garden tractor that was outfitted with a snowplow. After a particularly heavy snowfall, the PHB's father assigned the son the task of clearing the driveway. When the obliging PHB ran out of space to push the snow, its solution was to eschew use of a shovel and ram piles of snow outward by repeatedly backing up and accelerating forward in 4th gear. Teenage cries of "ramming speed!" seemed like a good idea at the time, but it really mangled the metal struts that held the plow to the front end of the tractor.

In economic terms, any savings the father achieved in outsourcing the snow removal was chewed up by hours of do-it-yourself blacksmithing that weekend. The driveway may have been cleared, but to the PHB father, the entire transaction ultimately ended up being a cost neutral bust.

Which brings CMS' Comprehensive Primary Care ("CPC") Initiative to mind. Thanks to the just-concluded Medical Home Summit, the PHB got to hear one of the authors of a CPC deep-dive analysis speak to the initiative's first-year findings.

 The entire report can be found here.

Very briefly, by October of 2012, CMS got Medicaid and 29 commercial health insurers to agree pay participating primary care sites a fee for Patient Centered Medical Home (PCMH) style care management.

 The rationale for this arrangement was to spare the clinics from having to offer the PCMH to only some of their patients. By imposing a "critical mass of payers" all patients had equal access to the same benefit.  That meant that practices wouldn't have to deal with the variations of different payer-dependent work flows and payment structures.

More than 500 practices (with an average of 4.4 providers) serving more than 2.5 million patients in 7 Medicare regions agreed to participate. In order to do that, the practices had to demonstrate that they had met meaningful-use criteria for their electronic health records (EHRs), had been officially recognized as a PCMH and had experience in quality improvement.

Once they were in the CPC, they were not only paid additional care management fees by CMS, but received quarterly feedback reports and technical assistance in achieving CMS mandated "milestones" (they can be found on page 84)  Over the course of the first year, practices received a median of $226,000 in care management fees.

At the end of one year, compared to propensity-matched non-CPC practices, CMS averaged $20 per beneficiary per month in care management fees.  They saved $14 per beneficiary per month in claims expense.  Compared to the non-participating sites, that $6 in additional cost did not achieve statistical significance.  Because the confidence intervals crossed $0, the conclusion was that CPC was cost neutral (the results can be found on page 120).  Some of the regions had statistically significant savings, while other regions had statistically significant losses.

The PHB's take:

Good thing the PHB father isn't in charge. 

This isn't the transformative PCMH break-through, and if CMS is looking to bend the cost curve, these one year results suggest Ms. Burwell et al are going to have to look elsewhere.

That being said, it's possible that years 2, 3 and 4 will show savings.  Even if that's true, the PHB wishes CMS and the health system "good luck" in being able to execute anything outside of fiscal year blocks of time.  We'll see.

The good news? The PHB suspects that the participating primary care sites ended up in the black.  They had already absorbed the costs of their EHRs and becoming PCMHs prior to the start of the initiative, so most of their $226,000 probably flowed right to their bottom lines.

As an aside, some of the $14 PBPM savings were attributed to a reduction in 30-day readmissions.  As the PHB understands it, CMS already has a methodology to claw that cost back from the health care system.  If that's true, the PCMH readmission savings are being double counted.

Image from Wikipedia

Thursday, March 26, 2015

Health Policy Insights from the Medical Home Summit: Wellness, ACOs

The Opening Ceremony of
The Medical Home Summit
The Population Health Blog is back home after attending the intellectually rewarding Population Health Colloquium and Medical Home Summit.  It was great to reconnect with old colleagues and make new friends.

In no particular order, here are some PHB take-aways:

One representative from household-name health insurer spoke in a lofty plenary session on the merits of keeping patients healthy. While the PHB was inspired by the videos of device-wearing joggers, it all seemed eerily reminiscent of the wacky pharmaceutical company value-propositions from years ago. That's when these companies said that they weren't selling "pills" but "cures."  It remains to be seen if Humana's transition from pooling risk to promoting fitness will lead to a similarly unprofitable ending.

More than one smart policymaker expressed skepticism on-stage about the ability of Accountable Care Organizations to reduce costs or increase quality. Wow. The PHB suspects more ACO shoes are getting ready to drop inside the beltway. If that's correct, it seems the expert-class is not only reducing their exposure to the coming stinkbombs, but is retooling to get in on The Next Big Idea gravy train.

One compelling speaker suggested that truly "patient-centric" primary care medical homes should offer timely access, the ability to talk to the doctor by phone at any time and attentiveness to the social dimensions of their patients' needs while richly rewarding docs to provide high-value care to fewer patients.  When the PHB mused out loud that may be what precisely what Concierge/Direct Primary Care practices are doing, the reaction of the audience prompted momentary concern that it might get lynched. 

The looming repeal of the SGR was mentioned only in passing, suggesting that few believe that this latest legislative fix portends a renewed commitment to health care reform.  As the PHB understands it, the current proposal commits Medicare to a .5% increase in physician fees per year over the next five years. This reminds the PHB of a compromise it made when the Spouse countered that a loaded SUV was a better option than a loaded sedan.  We got the loaded SUV.

And the EHR wasn't mentioned at all, which kept the PHB from offering its novel twist on Ms. Clinton's Emailgate tempest. It's clear that the Secretary reasonably concluded that her State Department's email system was unable to meet her personal workflow electronic communication and documentation needs. Our nation's EHR-using physicians feel her pain and salute her for her approach to finding a workable solution. After the American Medical Association gives her a suitable award, they should ask her if they can expect that same commitment to innovative health information technology solutions when she wins the White House.

Image from Wikipedia

Thursday, March 12, 2015

The Latest Health Wonk Review Is Up

The latest Health Wonk Review is being hosted by Brad Wright and the cleverly named Wright On Health Blog.  This is a review of some of the better health policy blogs from about the web.  You Won't Go Rong by checking it out.


Tuesday, March 10, 2015

A Health Care Clerisy?

We're here and we've figured it out
The Population Health Blog is reading Joel Kotkin's "The New Class Conflict." While it hasn't gotten through all of it, the central premise is a refreshingly alternative explanation for our
national malaise. 

It's less a matter of conservative vs. liberal ideologies that are leveraging class warfare. Rather, it's us vs. an unholy alliance of the new internet-media Oligarchs and their fawning expert clerisy.

"The New Class Conflict" doesn't dive into the implications for health reform. That naturally prompted the PHB to apply Mr. Kokin's lens to our healthcare expert class. 

Let the readers decide if this shoe fits. It may be paranoid, but it sure is fun to think about.

A quick word on the Oligarchs: these are the fabulously wealthy who dominate Silicon Valley.  They truly believe their template for success can change society for the better. They are very willing to deploy their new-found billions to promote their progressive, technological and green mindset.  The fact that their solutions are enormously self-serving makes them no different than the industrial barons of the 1930s.
Enter their health reform "clerisy" allies. They are made up of a growing academic, media, not-for-profit and government-worker technocratic class.  Armed with their science-based insights, they are advocating, lobbying, funding and regulating away an old health care order previously dominated by church, lay-business and volunteer organizations. Markets and ownership are being replaced by the priestly wisdom of an unelected elite presiding over a regulated utility. And they are being cheered on by their liberal-progressive and highly creative allies who dominate the old and new social media.

Opposing views are not only unwelcome but drowned out by a self-reinforcing echo chamber of this clerisy's group-think. Unapproved thoughts on, for example, the old-fashioned ability of health insurers to pool risks, the virtues of fee for service to incent access and the merits of small physician-owned private practices are tut-tutted as sadly misinformed. The few who rise above the noise are labeled as in the pockets of fat cats or being right-wing ideologues. 
And who should be surprised that the oligarch's interest in information technology dominates their health care agenda? Electronic records will save health care from itself, decision support will usher in a new clinical wisdom and big data today will lead to miracles tomorrow.  And by the way, if that leads to additional billions flowing to the oligarchs, all the better.  All that remains is figuring out which city they should buy an estate in so that they can run for elected office and legislate a single payer system modeled after Microsoft and powered by Google.

Their hardest job?  Persuading consumers as well as front-line health care workers to "work against their material interests or traditional beliefs." Think about paying more for energy, giving up control of education  and letting the NSA troll Facebook's data for bad behavior. In the healthcare space, patients must agree to consume less health care with health insurance they don't want while letting more of their personal data be used. Front line providers have to do more with less income, less control and less prestige.

Oh, and the clerisy and their oligarchs remain personally insulated against the very policies that they promote for everyone else. If they need health insurance, it won't be a Bronze plan from an Exchange any more than they'll give up their big cars, private schools and internet privacy.

It's the 1% alright, but they're hiding in plain sight.

Frightening thoughts.

Thursday, March 5, 2015

The Iron Triangle of mHealth Apps Due Diligence: What CEOs and Boards Need to Know

As the Population Health Blog's medSolis CMO expertise in mHealth expands, it can't help but admire the infectious "can-do" optimism of its "app" programmer-developer colleagues and competitors. Even if healthcare is a morass of dreary economics, regulatory meddling and dysfunctional politics, these entrepreneurs really do believe that "there is an app for that!"

And neither are leaders in hospitals, clinics, provider systems, insurance companies, medical device manufacturing and population health immune from the developers' enthusiasm. "Apps" are being built or bought with the belief that they'll lower costs, create profits, increase quality, promote satisfaction, build brand, secure customer loyalty and generate invitations to White House conferences.

The PHB agrees. Apps can certainly achieve many of these outcomes, and it is looking forward to seeing the Roosevelt Room for itself in the not-too-distant future.

But that doesn't mean that CEOs, Boards and investors shouldn't be wary of how the healthcare "Iron Triangle" should factor into their "app" due diligence.

Old fashioned management experts will recognize the concept. They know that any project involves trade-offs between cost, quality and access. Improve any single dimension and the other two will suffer.  Improving two means having to compromise on the third. 

In other words, there are inevitable trade-offs.

Population health service providers are well acquainted with this. For example, launching a diabetes initiative means balancing the costs of the program, the intensity with which the enrollees will be managed (quality) and outreach with a span of services as well as associated risks that will be addressed (access). Accepting a lower fee per patient may lead to compromises in quality. Insisting on a greater span of managed risks could lead to higher costs or cut-backs in the level of patient counseling.

Which brings the PHB to mHealth. To the PHB, the three iron sides to configuring an app are the same:

Cost: This is not only a function of the nuts and bolts of programming, hosting and updating the app, but includes the additional economic burden of maintaining up-to-date security for the users' personal health information. There's also the added cost of updates.

Quality: This includes dimensions such as symptom control, condition management, promoting patient safety, reducing identifiable risks and measuring outcomes for quality improvement as well as research.

Access: The interface has to be speedy and intuitive, meeting consumerist expectations for ease-of use. That includes connectivity, screen loading, minimal manual inputting and efficient asynchronous communication.

How should CEOs and Boards think about apps? 

They should think about cost, quality and access and understand the inevitable trade offs that underlie the sweet spot of a successful app.

Costs will never go away. But smart app developers are using off-the-shelf, open-source as well as modular programming with (secure and encrypted) web-based hosting. Shortchanging IT support or security risks not only crashes and hacking, but could limit the end-users' ability to manage the continuum of health risks (quality) in a user-friendly and speedy manner (access).

Quality is important but judgment is necessary in understanding the secret sauce that links quality, behavior change and risk. It's possible to "overdo" condition management with a glut of care options, unnecessary attention to every risk, over-engineered branching logic and over dependence on human inputs. 

Access will be what the end-user cares the most about, including ease of use in a pleasing interface. Streamlining this too much, however, could lead to shortcuts that compromise optimum condition management or require additional costly information technology.

Bottom line?

If a company's senior leadership or Board of Directors is grappling with an app-based product launch, they need to understand the inevitable cost-quality-access trade-offs that were made in the course of its design.  If the cost is low compared to benchmarks, ask about the compromises in quality or access that were made.  If the developers claim that the condition management is the highest quality, scrutinize development costs and how access could suffer. 

Accordingly, the best apps on the market will be those that strike the right balance between cost, quality and access.

Thursday, February 26, 2015

The Latest Health Wonk Review Is Up!

Happy Anniversary to the Health Business Blog. And what better way to celebrate the occasion than by hosting the Health Wonk Review.  David Williams' linked summary has the best of brainy health policy wonkery from around the web.


Monday, February 23, 2015

The Third Wave, Informatics, Quantum Mechanics and Health Care Reform

Schrödinger's cat
While the Population Health Blog continues to mull the promise vs. reality of Alvin Toffler's book on The Third Wave "Information" Age, it's been struck by the observation that any Wave's ideals are often applied to institutions.

It's a classic chicken vs. egg self-reinforcing feedback loop. For example, during the Second Wave, the industrial mindset gave rise to bureaucracies

Which prompts the PHB to wonder if the electronic health record (EHR) was the inevitable result of the Third Information Wave, or its intrusive invention?

Whither Biology in Health Care's Third Information Wave?

Yet, at the same time, the physician PHB has been struck by the emergence of biology-laced health reform jargon.  It's not unusual to read or hear that care delivery should have "organic" features (e.g., here and here) and resemble "ecosystems" (here and here).  Indeed, the intellectual underpinnings for integration is eerily close to complex 'living" entity, with a whole that is more than the sum of its semi-autonomous parts.  Think more organism than organization.

Biology: Not Incompatible but Synergistic

And before you assume that the healthcare paradigm of binary silicon-based electronics is  incompatible with complex carbon-based life forms, recall that DNA has been recast as a computer, and life has been defined as a DNA software system. Is networked machine intelligence in a large regional delivery system all that different than the chromosomes and enzymes that enable me to type this blog?

It seems that the "biology" of information technology" is not cognitive dissonance, but a perfect, if ironic, window into where health care is headed.

Enter Statistics

And since software is ultimately about information, "medical informatics" has - by definition - moved front and center. Assuming it is patient-centric," success in our Third Information Age is less about collecting patient anecdotes than their associated data: assembling and using of means, standard deviations, p < .05 significance, associations, predictors, regressions, known-unknowns, unknown-unknown Black Swans, artificial intelligence and "big data" inputs. Little wonder, then, that the informatics underpinnings of "population health" are increasingly being used by policymakers and has captured the attention of the entities such as the Institute of Medicine, and The White House.

Statistics on Steroids: Quantum Mechanics and What We Don't Know

Quantum mechanics is bubbling up into popular media (from photography to leadership). Health care - from the atomic level  of molecular biology to the societal level of public health - has not been immune.

Mix quantum mechanics with some Triple Aim, and Heisenberg's "Uncertainty" over position vs. momentum tells us that the more intense the statistical measurement of health care quality and cost, the greater the complexity, impreciseness and chaos. 

If so, it may be that the best that health system architects will ever be able to do is define the range of probabilities, risk and uncertainty that underlie cost, quality and care. 

Which leads the PHB to......

Risk as the Coin of the Healthcare Realm

Insurers are masters at measuring and monetizing (and, when necessary, avoiding) health risks. They understand the inherent uncertainties of health care. In the PHB's estimation, the quantum sophistication of the Information Age is going to lead the next level: managing uncertainty.

The Bottom Line: Outcomes vs. Risk Management

As health informatics and analytics grow, health care's imprecision will become better defined. We'll understand that not every patient with diabetes will be known to have diabetes, not every patient known to have diabetes will have a test for diabetes and collecting all individual tests for diabetes will never tell us what's really going on for the universe of diabetes.  The idea that we can use the health system to attain 100% measurement or perfection is about as real as the quantum state of Schrödinger's cat.

OK, What About the Real World?

While quantum mechanics already has some real world applications, it's too early to predict how risk, uncertainties and probabilities will factor into the future of health reform.  But the PHB confidently predicts that patient outcomes will be less a function of diabetes control, rehospitalization rates, medication compliance or satisfaction. 

Instead, it will be about understanding the determinants of a lower risk of diabetes complications, a lower chance of rehospitalization, a greater likelihood of medication compliance and a higher probability of satisfaction.  Quantum mechanics tells us that when measurement causes these well-managed probabilities to "collapse" out of their "quantum" state, the measurements will look better.

All that remains is determining the best combination of buyers, payers, insurers, providers and government necessary to achieve that.

It starts with the risk.  Complex health systems that adapt to that fundamental paradigm shift will win.

Image from Wikipedia

Monday, February 16, 2015

mHealth Apps to Monitor Recently Discharged Patients

After knee surgery: how do you
monitor this patient at home?
The "this paper" link in the original post directed readers to the wrong web site.  It's been corrected and the PHB apologizes for the error)

While the Population Health Blog is tantalized by the prospect of healthcare consumers using mHealth apps to lower costs, increase quality and improve care, it wanted to better understand their real-world value propositions. 

Are app-empowered patients less likely to use the emergency room?

Do they have a higher survival rate? 

Do they have higher levels of satisfaction?

In other words, where's the beef?

That's when this paper caught the PHB's search engine eye. It's a report on using an app to monitor post-operative patients at home.

This was a "feasibility study" involving a Canadian cohort of home-based post-operative patients who had gone through either reconstructive breast or knee (anterior cruciate repair) surgery. In order to qualify, patients had to be between age 18 years and 75 years, not using tobacco and able to speak English.  Once the app was activated, patient were asked about pain, their recovery and satisfaction (using a 1 to 4 scale).  They also used the app to take pictures of the surgical site. 

To maintain confidentiality, there were no patient identifiers linked to any images and a "locked down" subscriber identify module (SIM) was used. Data was encrypted on the server and the device.

Three surgeons participated and were responsible for reviewing their patients' data on a daily basis.  The app flagged any measure that was unexpectedly out of range for expedited review.

Instruction on use of the app took between 30 and 45 minutes. Patients were loaned a smartphone or a tablet, along with an instructional booklet.  At the end of the 30 day period, the smartphone or tablet had to be returned.

38 breast patients were approached at 33 agreed to participate.  40 orthopedic patients were approached and 32 agreed to participate.


The mean number of log-ins over the 30 days ranged from 19 to 24, with greater use in the first half of the month. Over 2000 photos were generated. Based on the pain and recovery scales, two early infections were identified and one was treated over the phone with antibiotics with subsequent improvement. On a 1 to 4 scale, the overall level of satisfaction was 2.7 to 3.9.

The PHB's take?

It would appear that the science on using apps to address specific outcomes in narrowly defined populations is still in its infancy.  While the Triple-Aim potential of mHealth is high, we're just beginning to understand how an app would work in the real world, say.... monitoring the outpatient status of recently discharged surgery patients.

That's why this particular study was interesting. It would appear handhelds or tablets can be used in the post-operative setting, that patient satisfaction is high and that, with symptom monitoring and imaging, an early wound infection can be identified and managed early.

Naturally, it'll take a study involving a control group to better understand the true value of an app like this.  Based on this feasibility study, the PHB is looking forward to reading about it in the not too distant future.

Image from Wikipedia

Thursday, February 12, 2015

The Latest Health Wonk Review Is Up

Peggy Salvatore at the Health System Ed blog hosts the latest version that's been aptly titled the Valentine Edition of the Health Wonk Review: For Health Policy Lovers Everywhere. The aw shucks PHB is there with other blogging luminaries who are embracing topics that run from the cells of women to health-worker strikes.

Tuesday, February 10, 2015

The End of Power Health Care?

Corporate titans enjoying
the good old days.
While Moses Naim's The End of Power devotes only a few pages to medicine, it's still provocative and worthwhile reading for anyone involved in the delivery of health care.

As the Population Health Blog understands it, the book's central thesis is that traditional "power" is being disrupted by the three modern trends of "more," "mobility" and "mentality."

We live in an unprecedented era of more (relative) widespread wealth, have an astonishing ability to move goods, services, information and ourselves around the globe (mobility) and are far less likely to adopt the cultural and intellectual assumptions and norms of established society (mentality).

Despite the depressing narrative of the "elite 1%," the irony is that governments and corporations have far less ability to command and control the 99%. This has big implications for world affairs, democracy and U.S. power.


Big themes like this naturally prompt the excitable Population Health Blog to speculate about the implications of Naim's more-mobility-mentality for health reform in the United States.

It should be no wonder that policymakers, politicians, academics and regulators are promoting a large and concentrated i.e. powerful version of healthcare delivery.  These cognoscenti argue that huge integrated delivery systems, accountable care organizations and regional providers can "rationalize" health care with standardized protocols, less variation, efficient service lines, alignmment of incentives, optimum capital deployment and assumption of insurance risk.

Mr. Naim cautions that the power-play may not succeed. The PHB extrapolates:

1. While pundits can argue whether the Affordable Care Act's insurance options are as good as they should be, we're devoting a lot of wealth toward health care. More individuals have higher levels of resources to put into their care than they've ever had before. And they know it.

2. While that wealth is being tempered by out-of-pocket expenses, network exclusions, service limitations and other trade-offs, consumers still have relatively abundant choices on not only when, but where to see that doctor, have that surgery or take that pill.  By the way, information is not only cheaper (thanks to the internet) but no longer monopolized by the health professions. 

3. Whether it's a one-on-one recommendation to have a procedure or a proposal to build a new hospital wing, gone are the days when a professional expert's opinion was automatically accepted. Stakeholders are demanding evidence, seeking justification, asking for alternatives and are relishing the "gotcha" moments.

Where do these healthcare versions of more-mobility-mentality take us? Greater access to resources means higher expectations. Mobility means consumers will use exercise choice to cross country, state or even national borders to access care when they choose to do so.  And mentality translates into higher levels of individual consumerism.

Instead of protocols with less variation, patients will want the care to be personalized. Service lines will be judged less on efficiency than on local notions of value. Provider incentives based on "outcomes" and "upside risk" will have zero value proposition for their wealthy, mobile and skeptical customers.  Capital won't necessarily flow toward non-performing assets and year-end savings won't materialize just because policymakers wish it so.

Accountable care organizations and integrated delivery systems will still have huge competitive advantages. That being said, their chances competing successly against smaller competitors and access to capital will be increased if

1) their protocols are flexible,

2) variation is not only welcome but warranted,

3) patients have a good reason to choose their service lines,

4) incentives are broadened, and

5) this new and different level of complicated risk is realistically priced.

And that's assuming that the health provider policymakers, politicians, academics, regulators and CEOs realize that they're not quite in charge anymore.