Thursday, December 18, 2008

CBO Issues (Positive) Report on the Option of Including Disease Management in Health Care Reform (and the Medical Home too - though not so positive)

If you’re interested in having the good, the bad, the ugly, the skinny, the inside track, the talking points, just the facts and or the lowdown when it comes to all things Federal policy health care, you may want to ‘bookmark’ or ‘favorite’ or download two just-released reports on the topic from the non-partisan Congressional Budget Office (CBO). They are briefly summarized in the CBO Director's Blog. Simplisitically stated, it's up to CBO to give evolving legislation a green light. If there is no green light, that often times means no go. This is a gateway through which all health care reform must pass.

These reports are must reading for staff, lawmakers, policy makers, regulators, academics, employers, reformers, insurers, patient advocates, consultants and bloggers. The Disease Management Care Blog, however, recommends that you resist clicking that print icon: these puppies are hundreds of pages long and that shared printer will be tied up for a long long time. Rather, don your glasses, take an NSAID, get a caffeinated beverage and go full screen…. but think about waiting until Monday and after you’ve read what the DMCB has to say.

The first is ‘Key Issues in Analyzing Major Health Insurance Proposals.' Describing its 196 pages as an exhaustive review would be an understatement, but the good news is that it’s all there: policy options for reducing the number of uninsured, altering insurance benefit design, changing the regulation of insurance, manipulating the pricing of health care services, expanding health information technology, influencing patient choices and understanding the impact on the national economy. Egads, says the DMCB, this is more like an encyclopedia, best meant for looking up your favorite topic.

And the DMCB’s favorite topic, ‘disease management' (DM), is in there. The Key Issues report recognizes that a prior CBO review and a more recent RAND review of the evidence of cost savings from DM programs was ‘inconclusive.’ It states that reasons include a) the possibility that the fees are too high, b) private plans are not in the business of sharing their results in the public domain, c) there is an economic downside/dilution of having everyone – including persons who may not benefit – participate in DM, d) it’s difficult to intervene early enough and f) conducting clinical trials in this area is very complicated. On the other hand, the report admits that just about every commercial insurer already has DM in one form or another. As a result, it predicts the U.S. impact of any future requirement ‘mandating’ DM in the commercial/private sector is likely to be blunted.

VERY interestingly, however, the CBO report goes on to indicate that ‘certain types of private-sector programs…would have a greater potential to limit federal spending,’ especially if ‘targeted…. toward the …enrollees most likely to benefit from them or most likely to generate savings….’ and if the DM programs have ‘a strong financial stake in the outcome.’ To the DMCB, this appears to suggest that the CBO is supportive of including DM as an ingredient in the reform of government-sponsored health insurance under certain circumstances: a) for some, not all chronic conditions, b) aimed at high risk enrollees and c) with DM organization risk sharing. Wow. Double wow, especially since the DMAA issued a statement applauding CBO's recognition of DM's 'potential to reduce costs.'

The medical home is also examined in Key Issues and doesn’t appear to fare as well. The report recognizes that better access to primary care and greater coordination of health care services ‘could’ translate into savings but ‘the impact of medical homes on health care spending remains unclear’ because health care utilization could paradoxically increase. Interestingly, it points out the potential for savings would be greatest if “the coordinating physician had a financial incentive to limit the use of specialty care.’ The DMCB interprets that to mean gatekeeping, which is precisely the term used in the CBO report. Ugh. It doesn’t think this is what the primary care physician advocates of the Patient Centered Medical Home (PCMH) had in mind.

Head on over to this second report on ‘Budget Options’ and you’ll find a treasure trove of 115 one to two page long summary statements that examine each and every one of the many reforms (except, curiously, disease management) currently under consideration. Option 39 deals with the Medical Home and it echoes the posture in the Key Issues discussion above: ‘CBO cannot estimate whether the net result… would be to increase or decrease spending for the Medicare program.’ The DMCB paid special attention to this write up because a paper it recently wrote for Health Affairs was referenced: CBO used it to correctly point out that many of the reports of the Medical Home’s success are not necessarily generalizable to the Medicare FFS population.

Is the notoriously dour CBO being cautiously optimistic about the potential role of disease management? The DMCB thinks the answer may be yes, but its job is to be an optimist. What do readers think?

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