Tuesday, January 6, 2009

The DMCB Cannot Help It: More on Medicare Health Support

While popular media tries to ascertain whether a mysterious pancreatic ‘hormone imbalance’ can be ‘nutritionally’ treated or if a media-star neurosurgeon is qualified to be U.S. Surgeon General, the Disease Management Care Blog can't help it - it's still thinking about MHS. It is marveling over how little attention is being focused on the 18 month update on the Medicare Health Support program. It didn’t show up KaiserNetwork.org and had only a brief mention in the Health Care Blog. A Google search uncovered little additional commentary. Given the new Administration's interest in the topic, you'd think there'd be more buzz. Apparently, many observers concluded long ago that disease management and fee-for-service Medicare were not to be. The DMCB hoped otherwise, because it calculated that it would take more than a year to see any meaningful outcomes. Well, a year has passed......

A more detailed review – with a promise of more to come – is over at the e-CareManagement Blog. The DMCB is especially looking forward to this, because co-blogger, colleague and epidemiologist Tom Wilson may be able to define the report’s approach to conducting t tests of mean differences using ANCOVA regression modeling.

In the meantime, the DMCB steered around the statistical gobbledygook and scrutinized the clinical quality outcomes measures. If there is supposed to be a correlation between health care quality and economic outcomes, the a) measures used in this report were disappointing and b) the degree of improvement in what was measured was small. Table 5.1 in the report displays rates of cholesterol, urinary protein, eye and A1c screening. The DMCB knows cholesterol ‘screening’ will have little impact on health care utilization in 18 months. What really counts are the use of ACE inhibitors/beta blockers in heart failure patients or the degree of glucose or blood pressure control among persons with diabetes or the promotion of flu shots or pneumovax among both types of patients. Where are these important data?

Given the disappointing lack of any reduction in emergency room visits or inpatient stays among persons with heart failure, the DMCB also wonders if the disease management organizations were unable to garner meaningful physician support. While an informal assessment of physician attitudes indicated they believed disease management was helpful to their patients, the DMCB knows that it’s one thing to teach patients to avoid the ER with daily weights and proactive calls to the PCP, another thing to have physicians say nice things about you, while it’s another thing entirely to get the PCPs to add these semi-emergently ill patients to their already overbooked schedules. Perhaps the physician owned Medical Home Demo will do better here.

The DMCB’s disappointment, however, is being tempered by a mention the Health Affairs blog. It is looking forward to the themed March 2009 issue and reading it along with Sanjay Gupta and all the Obama health advisors.

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