Tuesday, May 12, 2009

When Actuaries Talk, the DMCB Listens.

The Disease Management Care Blog reviewed the latest Milliman Research Report titled 'Imagining 16% to 12%.' As actuaries are wont to do, they have looked at the healthcare cost trend numbers and do not like what they see. However, they also know where us providers 'bury the bodies' literally and figuratively. Armed with this knowledge, Bruce Pyensen, Kate Fitch and Sara Goldberg know where to squeeze out the cost savings. That can enable us to simultaneously cover the uninsured and reduce the total amount the nation spends on healthcare from 16% to 12% of GDP.

Their proposals have a lot of merit and the report is worth a read for anyone interested in getting serious about controlling The Trend That Will Eat Us All. When actuaries talk, we should humbly listen - or else!

While the devil is always in the details, the (bolded) suggestions from Milliman below make a lot of sense (to the DMCB, which follows up in parentheses).

Hospitals work on a seven day a week schedule with the full compliment of services.

(Comment: The DMCB recalls imaging studies and procedures were simply not available when it was on call on Saturdays and Sundays. If it could wait until Monday, we waited. That's SOP everywhere).

Hospitalists manage the inpatient episode of care. No part timers, no amateurs.

(There are good data that indicate hospitalists result in shorter lengths of stay for inpatients. The DMCB thinks they also do a better job of chasing down all the loose ends typical among patients with other chronic illnesses).

Computerized order entry, standard order sets, pathways and decision support on every hospitalization. Healthcare is NOT local.

(Unlike other parts of the electronic health record, inpatient CPOE and a menu of routinized orders has been shown to promote higher safety thanks to a credible reduction in medication errors).

Help the emergency rooms to NOT admit every sick patient by making alternative care options readily available. Right now, ER physicians are overworked and find it much easier to simply arrange an admission for patients.

(It's 1 AM. She had chest pain hours ago. She's stable, EKG is normal, labs indicate no heart damage and the history suggests the likelihood of a heart problem is very low. Does she really need to be admitted? The answer is often yes because it's 1 AM).

Effective discharge planning with comprehensive follow-up on every discharge.

(Depending on the numbers, 5-10% of inpatients need to be readmitted and many of those readmissions are avoidable. While it will never be zero percent, we can do better).

Bring the family into the care plan at the time of admission, during the hospital stay and when the patient is discharged.

(The DMCB and its team have shown countless spouses and children how to help get grandpa out of bed, how to give shots and what symptoms to look for. It works).

Help skilled nursing facilities (i.e., nursing homes) to reasonably keep patients if there is an acute decline in health status.

(Patients can get ill while in the County Home, and the strain on nurses in giving those patients a higher level of attention is considerable. The DMCB doens't blame them for routinely calling the physician and getting authorization to have the patient transported to the local emergency room).

Commoditize the process that gets drugs from the manufacturer to the consumer.

(Mark-up anyone? Wal-Mart has shown us that it's possible to manage this better).

Align payment mechanisms for drugs with one purpose in mind: medication compliance.

(The DMCB does not clinically understand why persons with chronic illness are rewarded by signficant high out of pocket costs and co-pays when they take medications that control their disease. It understands the pooled risk insurance and policy principle that everyone should have access to the same benefit. If the Feds want to pass a law or two about healthcare, this area might be a good place to start).

Evidence-based prescribing of drugs.

(This can be thorny, but there is a lot of merit behind the notion of simple generics being a first line treatment option for persons with chronic illness in lieu of all those heavily promoted brand name drugs that really are no better. While Comparative Effectiveness Research can help, we already have a lot of information that can help us increase the use of effective generics).

Allow non-physicians to prescribe medications.

(Well, the DMCB didn't say any of this would be politically easy. That being said, there are medications that aren't that hard to prescribe, decision support can add another layer of safety and physicians can be in the loop. With compromise, the DMCB thinks something should be do-able here).

As an aside, this report doesn't support the notion that disease management reduces health care costs. The DMCB thinks the answer is far more complicated (hence, this blog), but let's also recognize that more modern disease management programs haven't really been tested as well as reported in the public domain and that the literature does show that they deliver great quality for the healthcare dollar. The DMCB forgives Milliman for being so orthodox. Afterall, they are actuaries.

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