Latest Health Wonk Review is Up!

Yikes!

Tinker Ready of Boston Health News is at your door trick or treat with a well written, extensive and illustrated version of the latest Health Wonk Review. This one is all treat.

Check it out here.

More Implications on the Suspended Animation of the Medicare Medical Home Demonstration

While most media and bloggery continue to glom incessantly over the iterations and implications of the ‘public option,’ the Disease Management Care Blog finds the suspended animation of the Medicare Medical Home Demo far more interesting.

As the astute Vince Kuraitis pointed out in this post, CMS' intentions are quite cryptic, the legal authority is opaque, plodding government demos can be outrun by the market and there’s a difference between demos (‘should we do this?’) and pilots (‘how can we do this?’). In prior posts (here and here), the DMCB also pointed out that a multi-payor collaboration offers up an important opportunity in experiential learning and could represent an important tipping point for the Medical Home.

What are other implications?

Medicare As A Continuous Learning Organization: Rigorously run demonstrations that compare one care approach versus usual care are ill-suited to finding out works in an environment of constant change and overlapping mutually supportive interventions in multiple geographies. This is CMS’ chance to realize an insight known to the population-based care community for years: when it comes to multi-dimensional care management, looking is not that same as seeing, listening is more important than hearing and knowledge pales in comparison to insight. The DMCB would like to be among the first to welcome CMS in from the oxygen-deprived academosphere.

First Among Equals: Not only are pilots broader in scope, the Vermont announcement suggests that future Medicare-owned medical home pilots will accommodate other insurers. These are typically fashioned as multi-payer ‘collaboratives’ (for example, here and here) that pool resources, share data, seek consensus and continuously adapt. How well Medicare can execute on this will depend on staffers who can be flexible and understand the difference between effectiveness and efficacy.

Government Silos: The DMCB has spoken to more than one Medicaid Medical Director who cajoled their States’ commercial insurers into participating in multi-payer medical home collaboratives. When it comes to government programs working with other payers, Medicaid’s clearly had a head start. Can Medicare and Medicaid just get along? We’ll see.

Boost to Accountable Care Organizations: Compared to Medical Homes, ACOs are far less defined, but the DMCB suspects they’ll be part of the coming health reform legislation. ACO’s will likely adopt Medical Homes along with all the other policy golden boys like electronic records, value-based purchasing arrangements and bundled payments. Look for CMS to use medical home collaboratives to ‘motivate’ multiple payers to support the embryonic ACOs until they’re able to prove their worth.

Start Building The Business Plans Now: Assuming a) multi-stakeholder pilots are flexible, b) can build on Medicaid’s as well as the commercial insurers’ positive experiences with disease management, c) care management resources can be shared among multiple primary care sites and d) many primary care sites will not want to reengineer what few nurses they have left, the future is very bright for organizations that know how to deploy trained, motivated and savvy nurses across a network. Here’s an example. More are undoubtedly on the way.

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Addendum: e-CareManagement has another post on the topic that is well worth the read. Check it out.

More on the Medicare Pilots: The Medical Home Purchasing Cartel That Includes Medicare

What percent of the revenue or the patients is enough to get a hospital's or a physician's attention? In it's prior life in not-for-profit managed care, the Disease Management Care Blog was stymied by only 'owning' a low percent of the patients in many of the provider settings. As a result, even if there were important quality initiatives backed-up by serious money or free assistance (usually in the form of care management nurses), the lack of critical mass compared to other payers hampered our ability to get anything done.

Which is why the Vermont CMS Demo i.e. pilot on involving a multi-payer collaborative in support of the medical home, is so important. By having the all the key purchasers of medical services form a medical home cartel i.e., monopsony, the providers will have to pay attention. The providers will also 'win' by having to operationally deal with single set of processes and payment mechanisms. Last but not least, Medicare (ironically) will be kept honest, because it will have to adapt some of its operations to mirror those of the other more experienced payors. Think tipping point leading to a virtuous cycle.

That's also called synergy, which is why a multi-stakeholder pilot - assuming CMS can collaborate - will be far more likely to show positive outcomes that a single Medicare demo.

Medicare Medical Home Demo Cancelled. Medicare Medical Home PILOTS Are On The Way

In a prior post, the Disease Management Care Blog broke the news that the Medicare Medical Home Demonstration had been placed on perma-hold by CMS. The announcement is now official, and you can read all about it and many of the implications at Vince Kuraitis' e-CareManagement Blog.

As pointed out in e-CareManagement, the purpose of a 'demo' is to ask 'if' a patient care intervention works, usually by comparing the outcomes of the patients in the intervention group to the outcomes of patients in a parallel control group. The Medicare Medical Home Demonstration is being effectively cancelled because the House Bill 3200 proposes a Medical Home 'Pilot' Program. The DMCB interprets the purpose of a pilot is to ask 'how' a patient intervention works. 'If' is first generation Ver. 1.0. 'How' is second generation Ver. 2.0

How could medical home 'pilots' be conducted by CMS? One big hint lies in the Green Mountain State, where the Secretary of HHS announced that Medicare will participate in a 'multi-payer' 'demo' evaluation. Don't let the word demo fool you. The bad news is that the multi-payer dimensions of this initiative will complicate any formal and traditional assessment of the impact of the medical home for fee-for-service Medicare beneficiaries. The good news is that this looks and feels like a pilot in which CMS will gain a treasure trove of experience on making the medical home 'work' in the real world.

The Guerrilla Approach to the Care Management that Underlies the Patient Centered Medical Home

At a recent webinar, the Disease Management Care Blog was asked how a regional health insurer implement a medical home if its provider network a) is dominated by small physician practices and b) there are no State-wide multi-payer-provider initiatives underway.

The DMCB at your service.

When it looks at what's been written about the core elements of the patient centered medical home, one recurring theme is the role of non-physician professionals - typically registered nurses - providing face-to-face (as well as remote telephonic) care management. The ingredients of that care management include patient engagement in the mangement of their own illness, coordinating that management with the primary care physician, acting as a primary point of contact for other members of the health care team as well as outside consultants, helping the patient to extract maximum value from the insurance benefit and maintaining and documenting an ongoing care plan.

Therefore, the guerrilla approach to creating care management to is for the insurer to establish that nursing resource for themselves.

Based on what it's heard on the non-Medicaid 'street,' the DMCB assumes that would involve a retail cost of anywhere from $20 to $50 per enrolled patient per month. Assuming that's true, it would dedicate most of that cost to the nurses' salary and benefits but take a fraction and give it to the physicians in exchange for letting the nurses into the practice. The DMCB is no business person, but a back of the envelope calculation suggests that each nurses would have to carry from 150 to more than 200 patients to cover their salary and benefits. There's some additional cost including the use of a car and laptops. The DMCB thinks the nurses would need to be distributed geographically and serve a hub of primary care sites, starting with the clinics that serve a large proportion of the insurer's patients.

Readers are probably thinking about the likelihood of getting this kind of sticker shock past the Chief Financial Officer. Yes, it IS pretty low, but you have several options: 1) argue that you'll only enroll patients that are likely to have $20-$50 in reduced claims expense thanks to the care management nurses' interventions, 2) sell the increased premium expense to customers that want a 'medical home' in their network (and that Medicare Advantage will use a bonus mechanism to cover that cost), 3) extract that cost by reducing payments for other services or 4) recognize this is a cost of doing business in an environment that demands the medical home all with or without the option of hiring a richly paid consultant (hint from the DMCB spouse).

The DMCB suspects some physicians will simply refuse to let a nurse into their practice. Other physicians will demand to hire their own nurse in exchange for the option of collecting the entire fee of $20-$50 PMPM. Fine, says the DMCB, but it would want to see a care management job description connected to a live care manager and have the option of performing an audit of the care plans.

Last but not least, the DMCB understands there are other elements of a medical home such as decision support, an electronic record, creating policies, NCQA recognition and 'transforming' the primary care site. While those other elements bring additional value, the purpose of hiring the nurses is not to establish 'medical homes,' but to create the greatest value proposition of medical homes: nurse-led care management.

The secret sauce here is the background, skill set, attitude and personality of the nurses. They need to understand outpatient primary care, appreciate the importance of patient engagement, buy into the notion of bridging the primary care-insurer divide and be smiling and steely-nerved ambassadors.

By the way, yes, that's a picture of Flo Nightingale above after her return from the Crimean front. Take away the bullets, and the DMCB sees many similarities between her role then and the new role demanded of nurses in the battle against chronic illness.

H1N1 Vaccination: The Difference Between the Obama Administration Being At Fault and Being Responsible

The Disease Management Care Blog has pointed out twice (here and here) that the Obama Administration's health care chops will be tested by H1N1. The President can't blame a lack of any warning, the prior Republican administration, absent regulations or an unfunded infrastructure. While moving virus from eggs to humans is very complicated, this is a public health effort that risks falling short across the entire system bandwidth of health care - most visibly the part owned by the Federal government.

Of course, there is no underestimating the capacity of loonies on the left or the right and the middle to refute the same technology that conquered small pox and polio. The community-dwelling DMCB personally discovered this nuttiness is not confined to distant enclaves and AM radio. The astonished DMCB ran into one urbane and educated colleague who, over a glass of Toasted Head, serenely discounted the research on vaccines. No amount of explanation could get past his blinkered anti-science puritanism.

Whatever. Americans still have the right to make bad decisions.

What the DMCB worries about, however, is that those who correctly decide to get the vaccine won't be able to get it, those unable to get the vaccine will get ill, those who are ill won't be able to get to a physician, those unable to get to a physician will overwhelm emergency rooms, and those in the emergency rooms will overwelm the hospitals. It won't necessarily by the White House's fault, but given their leadership and visibility in this area, they will be held responsible.

Fairly or not, the risk is that opponents of health reform will use a failed vaccination campaign to impugn the Obama Administration's competence in managing the nation's health. The DMCB wonders if this could reduce the odds that legislation will be passed.

Observations About Today's Patient Centered Primary Care Collaborative Annual Summit. Most Important: The Value of Magic Nurse Stuff.

The Disease Management Care Blog spent an extremely rewarding day at the Washington DC Primary Care Patient Centered Collaborative's Annual Summit on the Patient Centered Medical Home. It caught up with colleagues, got some valuable scientific updates and got to share in the growing enthusiasm for a very compelling approach to care. It also grabbed a copy of this report that was released today, 'Proof In Practice,' that will be the topic of a future DMCB post.

Random observations from today's meeting in no particular order:

This time the PCPCC Meeting was held in a very large room in the Washington DC Convention Center. There were over 400 attendees and the crowd was very supportive. The Patient Centered Medical Home appears to have gained considerable momentum - and that's putting it mildly.

Several Congressional staffers were there along with a House Representative who gave the keynote. Based on their comments, it's pretty clear that some version of the PCMH will be in the final health reform bill. The DMCB suspects that 'pilots' will be used in lieu of 'demonstrations' in FFS Medicare. In D.C.-speak, pilots have a better open-ended political prognosis than 'demonstrations.'

One key Congressional staffer pointed out that there seem to be many iterations of the PCMH ('means different things to different people') with variable outcomes ('for example, it doesn't consistently reduce repeat hospitalizations'). While some prefer to 'lump,' Congress is leaning toward 'split' by recognizing two models of the medical home: 1) 'high intensity' and 2) 'low intensity.' Each warrant different levels of funding support. Watch for this in the final health reform bill.

One physician audience member pointed out that his Medicare Advantage (MA) Plan has been offering a version of the PCMH for years. He pointed out that if MA funding is cut, this could mean its demise. The panel responded by noting that most MA Plans have not used their allegedly high fees to support versions of the PCMH. In response, MA funding cuts are politically inevitable, but there is a chance that bonuses will be offered to MA Plans that offer care coordination. Look for this in the final health reform bill also.

Why aren't commerical insurers and self-insured employers stampeding toward the PCMH? Three reasons were offered: 1) the PCMH is very much a function of managing 'locations' in a network that depends on local physician adoption; it's easier to just manage the benefit design, 2) it's still all about a short term focus on costs, not a long term emphasis on 'value,' and 3) irrefutable and solid 'proof of concept' is still lacking.

That's not stopping the Veteran's Administration. All 820 of their primary care sites are going to be transformed to PCMHs over the next two years thanks to a combination of experiential learning collaboratives, learning colleges, consultation teams, demonstration labs and an abundance of communication. The VA's challenges are 1) promoting 'top of license' care among members of the PCMH team, 2) limited phone based care experience, 3) the usual challenges in retooling for chronic care activities, 4) limited experience in managing transitions between the hospital and the outpatient setting, 5) while the VA's EHR is robust, its decision support capabilities are minimal.

Last but not least, much of what appeared in the many panel discussions and on screen in the PowerPoints was filled with nursing concepts and terminology. To the DMCB, it's pretty clear that the core of any PCMH is high-end primary care nursing. Sure, we need physician leadership, information technology, teaming, payment reform etc, but let's face it: when it comes to assembling and managing the resources necessary to care for patients with chronic illness, physicians can best lead by getting out of the way. To us docs, it's magic nursey stuff. The good news is that it seems to work not matter what you call it and that the nursing profession is finally going to get the recognition that it deserves.

News About the Medical Home Demo

The Disease Management Care Blog understands that it has been decided that it would be impractical to clear the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot. You read it here first.

While a New England Journal of Medicine article on a poll showing high physician support for Massachusett's health insurance reforms* captured some of the news cycle, the Disease Management Care Blog was much more interested in catching up with this jewel from a week earlier on the logic underlying Medicaid's inclusion in healthcare reform.

This article by George Washington University academician Sara Rosenbaum is a very handy and well written summary. Recall that Medicaid covers a whopping 60 million Americans that generally meet three broad conditions: 1) age (children and the elderly), 2) a qualifying condition (pregnant, disabled or a caretaker of children) and 3) income (a percent of the Federal Poverty Level or FPL). The latter category threshold varies from State to State (from a low of 17% to a high of 275%). The first two conditions trump the latter. If you are a ‘nonelderly’ adult and don’t have a qualifying condition, you are out of luck when it comes to Medicaid no matter how low your income is. You probably can't afford commercial insurance either, which means you are uninsured.

That may change thanks to the bills before Congress. They bascially do two things: 1) eliminate the age/qualifying condition barriers, and 2) create a one size income standard as a percent of the FPL across all States.

Fans of the private market may wonder why health reform is turning to Medicaid. According to the article, it is more than just a matter of the Democrats’ policy preferences.

First of all Medicaid is the cheaper alternative. States are required to cover part of the Medicaid budget, Medicaid has a lower fee schedule and its administrative costs are partially carried by the government. Private insurers can't match this. Ms. Rosenbaum quotes research showing comparative policies for private insurance could cost approximately $6000 while Medicaid’s cost would be less than $2000. That’s over 4000 reasons in favor of Medicaid.

Secondly, absent highly vigilant and extensive regulation, the private market could easily tilt toward ‘cherry picking’ and actively enroll a younger and healthier population. Medicaid programs, in contrast, are configured to be a fiduciary for the poor and ill without any of the enrollment or benefit gamesmanship.

Last but not least, the professionals that administer Medicaid understand the special needs of persons living at the margins of society. They understand how community health centers, public hospitals and local agencies can be used to best serve underserved persons living in inner cities or rural settings. This kind of expertise is simply unavailable in the commercial insurance market.

The article closes with three 'show me the money' recommendations:

1) Show me (the States) the money. Without credible support from the Feds, the States may be simply unable to afford their share of an expanded Medicaid program.

2) Show me (the docs) the money. Without credible support from the Feds, the States may simply squeeze their payment rates down to unsustainable levels. Spotty physician refusal to accept Medicaid patients could uptick considerably.

3) Show me (the system) the money. Medicaid needs to become more a visible player in each of the States' efforts to rationalize health care, increase quality and drive greater value.

Readers may or may not agree with the rationales described above, but they make sense from an insurance reform perspective. Unfortunately, other than reducing benefits and lowering payment levels, the DMCB sees few other options for a new and improved Medicaid to hold down costs if health care inflation continues unabated.

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*The DMCB cannot resist. Of course physicians prefer it when their patients have an ability to pay for health care services. Check out this telling article on the Brit's introduction of the National Health Service in the 1940's and politician Nye Bevan's "bribe" to win the support of the physician consultants: "I stuffed their mouths with gold."

The Latest Cavalcade of Risk is Up!

Boo!

Frightened by all the bad risk out there? Your money could evaporate, your good health could vanish, your car could crash or your employees could go absent. Learn how to think about this and more at Lynch Ryan's Cavalcade of Risk's spooky pre-Halloween edition.

The Genetic Information Nondiscrimination Act (GINA), Health Risk Assessments (HRAs) and Lawyers Run Amok

The Disease Management Care Blog received a DMAA email containing this press release today. It calls for a moratorium in "GINA regulation implementation."

What's this about you ask? The DMCB at your service.

GINA is part of the logarithmically expanding blob of Washington D.C. acronyms. This particular one refers to the 'Genetic Information Nondiscrimation Act' that was signed into law by President Bush on May 21, 2008. Its intent was to prevent discrimination based on genetic information by health insurers and employers.

In reading about the act here, it appears that the way discrimination is prevented is by prohibiting employers and health insurers from collecting any genetic information in the first place. In addition to not collecting it, insurers are also prohibited from using it for decisions about coverage or rates (by insurers) or for hiring, firing, promotions or other decisions about the terms of employment (employers).

So far so good.

So the intrepid DMCB went to the text of the law itself and found a lot of language stating that collecting and use of 'genetic information' was prohibited in health insurance 'underwriting.' The statute has very clear definitions of underwriting ('health insurance rules used to determine eligibility, computation of premiums, exclusions of pre-existing conditions and other activities related to contracting health benefits') and genetic information ('results of genetic tests of the individual or the family members and the manifestation of a disease or disorder in family members of an individual').

The DMCB is struck by the inclusion of 'family history.' Read on and you'll see why.

On Oct 7, 2009, the Departments of Labor, Treasury, HHS and the Equality Employment Opportunity Commission released proposed regulations a.k.a interim final rules that are intended to guide their interpretation and enforcement of GINA. The rules become effective on December 8, 2009.

The lawyers that crafted these regulations must have also been struck by the term 'family history,' because they've addressed it in the context of health risk assessments (HRAs).

HRAs are widely used in the population-based health care. It typically consists of questionnaire that asks a series of health related questions. The individual answers can then be summed up to determine an overall risk score in one or more health domains. This is an example of an HRA used to assess the risk from being overweight, while this HRA determines the risk of future heart attack. Note that both of these examples include family history as one factor in the overall assessment of risk.

What do the interim final rules say? They correctly point out that HRAs that include family history questions are typically distributed at the time of new or re-enrollment and are often accompanied by incentives to complete the survey. When present, these incentives consist of rewards such a premium reductions, lower deductibles and cash bonuses. Since this is money that is tied to the premium which is defined to be part of underwriting, the practice will become illegal on December 7.

What's more, if the HRA is requested prior to enrollment, even if there is no payment to the enrollee, the act of collecting the 'genetic information is also a violation of the law.

If your disease management organization, population-based care company, employees benefit plan or health insurer uses HRAs at the time of open enrollment, you have two choices:

Change how the HRA is done: No financial incentives, period. What's more, the HRA can't be distributed or collected until after enrollment,

or

Strip all the family history questions out of the HRA.

The DMCB agrees with the DMAA that the interim rules need to be put on hold until this twisted pretzel logic of lawyers run amok is straightened out.

First of all, while inquiries about family history can be intrusive to individuals completing HRAs, the cash value of the incentives are undoubtedly very welcome and are a fair value transaction.

The DMCB also did a word search of the original statute and did not find the term 'health risk assessment.' It doubts our legislators intended to sweep HRAs into the scope of this legislation.

It is also illogical to group the practice of increased payment to all enrollees with and without significant family histories with the other repugnant practices of charging more or denying benefits on the basis of genetic history. The resemblance is superficial to anyone with common sense.

In addition, in real practice, it is highly unlikely that the underwriters in any health plan would harvest the data from HRAs and mathematically price it into their premium decision-making. It is theoretically possible, but that's simply not how the business is operates.

Last but not least, the risk of harm from showing some flexibility around this topic is far less than the risk of harm from hobbling how HRAs are distributed, completed and used. Thanks to HRAs, companies are not only extending hard cash but using the information to provide a higher level of service to individuals who would benefit from it.

If the DMCB is reading things right, comments on this silliness can apparently still be submitted (E-OHPSCA.EBSA@dol.gov) through January 5, 2010. The DMCB copied the above text and simply emailed it in over its signature.

Medicare For All, i.e., the Public Option Can Cause Cost Shifting. It Is Possible.

Commercial health insurers are arguing that a government run ‘public option,’ if included in health reform, will force a take-it-or-leave-it’ low-ball fee schedule on hospitals and physicians. This, in turn, will lead the providers to recoup their losses by charging the competing private insurers correspondingly more for the same services. This phenomenon is known as ‘cost shifting.’

Various luminaries have dismissed this as pernicious (former Secretary of Labor Robert Reich) a misrepresentation (Nobel Prize winning Paul Krugman) and taxing credulity (Princeton health care economist Uwe Reinhardt). Absent any data that prove that this really happens, critics of the evil, recessioning, care-denying and robber baron health insurers charge there they go again: they’re trying to pull a fast one on the unsuspecting public.

In its past life in the managed care industry, the Disease Management Care Blog remembers hospital administrators repeatedly arguing that they needed the commercial insurers to pay their institutions higher rates than Medicare to remain in business. Since Robert, Paul and Uwe suggest this was just a negotiating ploy, the DMCB did what it usually does when it’s confused. It looked at some peer-reviewed literature.

It didn’t take much to find three articles in a health policy journal named Health Affairs that is not known for excess partisanship or biased authors.

This 2003 article by Lee and colleagues points out that when Medicare’s DRG payment system ‘gets it right,’ by correctly paying hospitals, there is no need for hospitals to cost shift. The authors seem to imply that when Medicare underpays hospitals, they turn to cost shifting to make up the difference.

In this 2003 article, Paul Ginsburg argues that there is a lack of evidence of the phenomenon but, on theoretical grounds, it is quite possible to assemble a ‘conceptual basis’ for cost shifting. He shows it can certainly happen in geographic areas where one health care provider has market dominance and the health insurers have no choice but to agree to their terms. In the DMCB’s experience, this monopolistic behavior is common in rural areas where there is only one hospital per county, or anywhere when a medical specialty’s services (like high end cardiology) are otherwise not available.

In this 2006 article Jack Zwanziger and Anil Bamezai examined the relationship between Medicare and Medicaid rates versus private insurance rates in California and found an inverse financial correlation in rates to the tune of a 0.17% increase for every 1% decrease by Medicare. While the relationship is not necessarily causal, the association suggests that the phenomenon of cost shifting is real. It's not dollar for dollar, but the 'signal' was out there.

The DMCB concludes that cost shifting is quite possible under the public option. It also wonders if it is missing something and why such smart people are so dismissive of any likelihood that it could happen.

Comparing and Contrasting Population Health/Disease Management and the Patient Centered Medical Home

The Disease Management Care Blog has given a number of grand rounds, webinars and presentations and, like many speakers, has a core set of PowerPoint slides that seem to make it into every occasion. In thinking about it's last few engagements, one slide in particular keeps cropping up. It's a fav that compares and contrasts six key domains of the population health née disease management and the patient centered medical home.

Who: In population health (PH), it's the nurse-coach manager who is engaging the patient. In the PCMH, that role belongs to the primary care site-based team that includes a nurse-care manager.

What: In PH, the 'what' is an enabled, confident patient who is better able to participate in decision making. In the PCMH, it's all about the patient ideally becoming a member of the health care team in mutual decision making.

Where: In PH, it's remote and virtual. In the PCMH, it's local and based on the 'bricks and mortar' of the primary care site.

When: i.e., when do I see my money? In PH, the money is based on a year-end reconciliation of the observed vs. the expected costs i.e., savings. In the PCMH, there may be some upside gain sharing and/or P4P at the end of the year, but the real money is paid every month on a risk adjusted basis for every person that is enrolled, i.e., revenue.

Why: The lingering success of the disease management organizations makes the DMCB think that why is a function of the market still demanding PH. In contrast (pending data on the ROI from the PCMH pilots), the why is a function of policy making and the belief that it will play an important role in the resurrection of primary care.

How: In PH, change is accomplished by activating and engaging patients, who are then empowered to deal with the health care system based on their own goals and values. In the PMCH, change is accomplished by fundamentally altering the practice of primary care.

The DMCB agrees that the PH-PCMH overlap is far greater than any real differences.

The DMCB would be happy to share the slide. Just email 'n ask.

The Sauce vs. Soufflé Approach to Care Management: Implications for Health Reform

Thanks to all those cooking shows, the Disease Management Care Blog fancies kitchen metaphors. In thinking more about yesterday’s post on ‘care management,’ one allegory came to mind: the making of sauces versus soufflés. It occurred to the DMCB that care management, despite all the scientific trappings, is best thought of as a sauce. How well health reform can swallow that remains to be seen.

When the DMCB makes spaghetti sauce, it knows the red stuff basically involves tomatoes. Once that basic ingredient is fulfilled, the rest is a creative mix of spices, maybe some wine, chopped sweet peppers, mushrooms, onions, garlic, other stuff and what-the-heck whatever-this-is-from-the-fridge and then drinking some wine. Think The Godfather’s Peter Clemenza and his famous going to the mattresses recipe for 20 guys.

Then there are soufflés. The closest the DMCB ever got to that level of culinary expertise was when it tried to make crème brûlée. What unfolded early the next morning wasn’t pretty. The point is that the DMCB appreciates that soufflés require an extraordinary level of cookery. The ingredients have to be apportioned in exact amounts, their mixing has to be precise and the oven temperature and bake time must be unerring or the result will be a stone. In medicine, think the operating suite and making sure the same check list is completed all the time every time.

When guests sit down to the DMCB’s sauce n’ pasta, they know what it is and it usually does the job. In the world of case management, the red stuff (otherwise known as the key core ingredient) is the generalist registered nurses referred to in Dr. Bodenheimer’s New England Journal article on care management. The rest is based on nursing science, lots of opinion, local culture, available resources and what’s in the fridge.

Check out the peer-reviewed literature used by Dr. Bodenheimer to make the case for care management. There is one reference on advance practice nurses and the role they play in helping patients discharged from six city hospitals, another on ‘trained nurses’ using a Care Transitions protocol for recently discharged patients in Colorado and primary care-based registered nurses in Baltimore who had completed a course in ‘Guided Care Nursing .’ There are other examples used in the article, including a geriatrician-led high risk clinic doing home visits, a roving geriatric physician-two nurse team managing 300 patients and the CMS capitated benefit plan called PACE. All are unique, yet all share the key ingredient of nurses doing nursing stuff that help patients move from point A to point B. It’s what does the job.

In the DMCB’s recent American Journal of Managed Care editorial, it argued that population-based programs for the care of patients with chronic illness are necessarily varied. The core ingredient makes it recognizable but around it there is considerable creativity and flexibility. Dr. Bodenheimer’s article didn’t necessary address the non-uniformity of care management, but the references he used certainly speak to that dimension.

As a result, it will be very challenging for accreditation agencies, recognition programs, managed care and accountable care organizations as well as Federal health reform and all the necessary regulations that follow to accommodate all those excellent cooks and their wonderful savory creations in the delivery of care management. Hopefully, the powers-that-be will recognize the need for flexibility in this area.

Hopefully, they'll be less about soufflés and more about sauces.

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Post script: The closest Dr. Bodenheimer has come to endorsing disease management is also in this New England Journal article:

'Telephonic care management has been effective when combined with face-to-face visits but has not worked by itself.'

Welcome to the club, Dr. B. The DMAA's been pointing this out for over a year and regular readers of the DMCB have long been familiar with the concept.

The Latest Health Wonk Review Is Up

That's right, the latest and the bestest from the health care-related blogs, giving insights unavailable anywhere else is up at Hank Stern's Lean Mean and Clean summary. He calls it like he sees it, has nice things to say about the DMCB and as an extra bonus, throws in a pun. This prose by any other name smells as tweet!

The Definition of 'Care Management' Courtesy of the New England Journal

The Disease Management Care Blog appreciates it when a useful definition appears in the peer-review literature. It helps everyone in the population-health care business to agree on terms, concepts and principles. The definition of 'care management' has now appeared in an article* by Thomas Bodenheimer and Rachel Berry-Millett in the Sept. 30 New England Journal of Medicine. This quote and the reference can be used by population health warriors everywhere who are dealing with those upcoming responses to RFPs, business plans, presentations, learning sessions, staff meetings, PowerPoints, professional development classes and care initiatives:

Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services.

There have been other definitions (for example, here and here) and they more or less support the same concepts, but this may turn out to be the oft-cited reference because:

a) let's face it, it's in the New England Journal. It looks good when you quote it.

b) the authors explicitly point out that care management is generally provided by a 'registered nurse.' The DMCB heartily agrees because it is a big fan of nurses and has witnessed repeatedly how their common sense and familiarity with the 'system' are invaluable to docs and patients alike. What's more, the article points out the value of non-specialty trained nurses, which makes sense: this is a role that often calls for generalism and a working knowledge of primary care.

c) the authors also point out that care management should not be applied 'to patients who are too sick to benefit.' While there is no citation for this particular assertion, the DMCB likewise not only agrees with that, but points out that regular DMCB readers are already long-familiar with the supporting peer review literature. The DMCB recalls numerous instances in which its health plan senior leaders insisted that care management nurses 'do something' about the catastrophically ill patients that had had numerous inpatient stays, required many specialty physician visits and used some very expensive medications. Experienced care management leaders already know that care management is best 'aimed' at patients that are in the sweet middle: not too well that their risk of an exacerbation is low, but not too sick that nothing could be done.

Now, in addition to quoting the oft Googled, widely read, sometimes quoted and always useful if humble DMCB about care management, you can also quote Dr. Bodenheimer and the Journal.

Here's the citation for your copying and pasting pleasure:

*Bodenheimer T, Berry-Millett R: Follow the money - Controlling expenditures by improving care for patients needing costly services. New Engl J Med 2009;361(16):1521-1523

And here's the pdf for printing or forwarding to your colleagues.

The Bush Doctrine of Health Care Reform and One Anecdote About What's Right About Regional Not For Profit Health Insurers

Oh my. Reading the news and bloggery about the AHIP-sponsored study by PricewaterhouseCoopers, it’d be easy to conclude that the Forces of Dark have finally been confronted by The Angelic Host. Using terms like ‘dishonest,’ threatening,’ ‘ self-serving and ingenuous’ as well as the mother of all invectives (‘tobacco industry!’), it’s become clear to reform supporters that anyone opposed to the health bills before Congress is Satan’s Spawn. It’s almost like an ironic version of the Bush Doctrine that rationalizes preemptive overwhelming attack on any entity that could give aid to evil-doers.

The Disease Management Care Blog has a different take and thinks the PWC report provides is useful. It thinks there are too many unknowns in reform to confidently predict the future and appreciates the insights from this worst case scenario analysis.

It’s too bad that the entire health insurance industry is being painted with such a broad brush of loathing. While shrillness makes for good website traffic, it can make the rest of us lose sight of the more subtle issues that are a far better gauge of what’s good about health care in the United States.

Take this local story about the unlucky employees at a company called Turbine Airfoil Designs (TAD), whose company went completely bankrupt months after failing to pay their workers’ health insurance premiums to Capital Blue Cross Blue Shield (CapBSBS). No one outside the leadership of the company apparently knew about the lapse and a number of the workers and their family members, assuming they had insurance, generated some significant health care bills. It was after they got the bad news about being unemployed that they also found that their health insurance hadn’t been in place and they were personally liable. What’s more, some tone deaf hospitals billed their full rate for services (instead of the discounted Cap BCBS rate they had agreed to accept in the first place) and. to add insult to injury, some patients were referred to collection agencies.

What developed what a circle of mutual non-culpability. Thanks to the bankruptcy, the outstanding health care debts got in line with the rest of the company’s creditors. CapBCBS couldn’t have been expected to notify these patients that they didn’t have insurance and arguably shouldn’t use their paying customers’ premium dollars to pay for nonpaying customers. The hospitals argued that they can’t afford to give services away for free. And some proud working class Americans unsurprisingly refused to turn to charity.

So what happened? The Chief Executive Officer of CapBCBS announced that it was going to fix the problem. The rationale that used was:

'Capital BlueCross is a business -- but we also are a nonprofit organization with a 70-year community mission. And this is one of those instances where mission should prevail.'

First of all, The DMCB says bravo to CapBCBS. But don’t be too surprised, because countless regional not-for-profit insurance companies with a local sense of mission and community mindedness would have done the same thing.

Secondly, it doubts very much that the close-minded Forces of Light described above will pay this anecdote any heed.

The Transmogrifying of Fee-For-Service Medicare into Managed Care

In one episode of the long retired comic strip Calvin and Hobbes, the highly imaginative and socially dysfunctional Calvin invents the Transmogrifier. The answer to all both large and small boys’ fondest wishes, this upside down cardboard box is controlled by a large dial that can change its passenger into any shape. Its settings include tiger, bug, eel and dinosaur. The Disease Management Care Blog would really like to have one of those and include ‘motorcycle owner’ on the dial, but, alas, the DMCB spouse will have none of it.

Outside of the DMCB's imagination, however, a very real version of the Transmogrifier lives on thanks to the Congressional plans for Medicare. How else can Medicare dial in ‘value based purchasing,’ ‘quality and efficiency,’ ‘accountability,’ and taxpayer savings’ without the use of an imaginary cardboard box and even more imaginary money?

Yet, our imaginative and dysfunctional legislators have left one key setting off of the dial, and that’s ‘managed care.’ They should put it on because that's exactly what the Transmogrifier is going to accomplish for Medicare when they get done.

Here's why.

Other than Medicare Advantage, most versions of Medicare so beloved by the Democrats and many of our seniors is a fee-for-service indemnity plan. This means it insures the beneficiary against a financial debt (or 'indemnity') incurred as a result of medical treatment for an illness. While Medicare has the advantage of fee setting, its role in the clinical decision-making in the doctor-patient relationship has been historically quite small.

Contrast the coming legislative proposals for Medicare with managed care insurance. According to this link, 'managed care' is any health insurance that uses of a variety of methods of financing and organizing the delivery of health care in which an attempt is made to control costs by controlling the provision of services. These methods (according to this link) can include 1) contracting with selected physicians and hospitals usually for a predetermined monthly premium 2) utilization and quality controls that contracting providers agree to accept, 3) financial incentives for patients to use the provider and facilities associated with the plan and 4) the assumption of some financial risk by doctors, thus fundamentally altering their role from serving as agent for the patient's welfare to balancing the patient's needs against the need for cost control.

Armed with these key insights about just what defines managed care, DMCB compared some key features of the U.S. Senate Finance Committee’s Framework to see if ‘managed care’ belongs on the dial. It may:

Selective Contracting: Under value based purchasing, only hospitals that meet yet-to-be-determined quality thresholds will receive favorable payment rates..

Predetermined Monthly Premiums: While unmentioned in the Framework, the payment mechanism for patients assigned to Medical Home pilots is likely to be a monthly fee. This is otherwise known as partial capitation, which is a common approach in managed care networks.

Utilization and Quality Controls: Physicians that exceed, compared to their peers, ordering high cost imaging services will be penalized. The only difference here is that physicians won’t have much of an opportunity to not agree.

Financial Incentives: That ‘I’ word is used to encourage Medicare beneficiaries to participate in healthy lifestyle programs that meet yet to be determined criteria.

Financial Risk: Under accountable care organizations, providers would be able to keep half of any savings they achieve for the Medicare program. While there are safeguards to promote quality, the fact is that the physicians will be under pressure to balance the patient’s needs against the need for cost control.

If it looks like managed care, and if it walks like managed care .....

Finally, while our political elite fault our seniors for their ‘inexcusable’ cognitive dissonance by 'wanting government out of Medicare,' this may be less evidence of flyover state ignorance than an awareness that their passive indemnity insurance is morphing into growing government activism in the doc-patient relationship. It seems to the DMCB that their concerns deserve more than sympathy or disdainful annoyance. This is a real policy direction that deserves closer scrutiny.

In the meantime, the DMCB plots its nefarious revenge on its wannabe Susan Derkins DMCB spouse.

Centralized Planning vs. Creativity for Fitness Promotion

In this NewsHour with Jim Lehrer report, reporter Ray Suarez flies to the Netherlands to examine their health insurance system. While the reporting makes those silly wooden-shoed Europeans look like geniuses when it comes to managing private insurance, one thing that was left unmentioned in the interviews was the number of persons bicycling everywhere in the background.

Do not be alarmed that the U.S. may have fallen behind the rest of the world in figuring out that there may be a negative correlation between physical activity and illness. We have a solution in hand: we're going to perform comparative effectiveness research on the topic and, if need be, hold more Congressional hearings while we also figure out how to make gasoline cheaper and add to our transportation infrastructure.

In contrast, Disease Management Care Blog salutes the Swedes for this novel inventive and fun approach to promoting exercise. Developed by Volkswagen under the banner of Fun Theory, it even has a Prize up for grabs for other ideas on how to change behavior for the better. Note that they even measured the outcomes.

Struggling With the CBO Score on the Senate Finance Committee Health Reform Bill

The Disease Management Care Blog checked out the Congressional Budget Office Director’s Blog for the skinny on the the scoring of the U.S. Senate Finance Committee’s health reform bill. According to media reports, over ten years it will simultaneously cost of $829 billion but ultimately save $81 billion.

Huh?

Confused and armed with nothing but a virtual calculator, the DMCB read not only the Director's blog but headed on over to the CBO report. Here's the bottom line as best can be interpreted:

There would be $345 billion in additional outlays to the States for Medicaid and the Children’s Health Insurance Program (CHIP), $461 billion in commercial insurance subsidies and $23 billion in employer tax credits. That adds up to $829 billion.

Then, the government would see revenue in the form of $201 billion for the tax on the ‘Cadillac plans,’ $27 billion in ‘penalty payments’ from employers and persons without health insurance and '83 billion due to other effects on tax revenues and outlays.’ That reduces the cost to $518 billion.

Then, there’d be savings of $404 billion thanks to permanent reductions in the annual Medicare updates (excluding physicians), reductions in payments to Medicare Advantage Plans, decreases in the hospital disproportionate share payments and fee schedule recommendations ($22 billion) by the newly created and powerful ‘Medicare Commission.’

By the DMCB’s reckoning, that would leave a cost of $114 billion. ‘Other provisions’ would increase federal revenues by $196 billion taking the total revenues minus costs to that $82 (the DMCB thinks it’s a rounding error, really $81 billion).

The DMCB’s take:

Death and Taxes: the government giveth coverage subsidies of $829 billion, taketh direct taxes of $311 billion, reduces outlays to the tune of $404 billion and gets apparently gets some indirect benefits of $196 billion. This is not efficiency, but a transfer of wealth. It will be up the voters to decide if that is worth it.

One of Five Bills: the remaining four health reform bills (three in the House and one in the Senate) all increase the deficit. When these bills are reconciled and eventually passed in a single piece of legislation, there is a good chance that the reduction in the deficit will evaporate.

Cover: the CBO’s scoring of this bill is the ballast needed by the four other budget-busting bills currently before Congress. If one out of five reduce the deficit and increase the numbers of persons with health insurance, the inattentive will assume they all do. Looks like the probability of a health reform bill making it to Mr. Obama's desk has increased dramatically.

Uncertainty: the costs are known but the projected savings are far less assured thanks to the likelihood of continued Congressional meddling, the specter of continued underlying cost inflation, the actuarial uncertainty and Black Swans.

Squishiness: the non financial expert DMCB doesn’t understand how the Medicare Commission can make $22 billion appear if all is going to according to plan or just what is the the source of the $196 billion of additional revenues. It’s going unmentioned in all the sister blogs, but deserves better attention.

More Squishiness: The CBO says the scoring is preliminary because the Finance Committee has yet to generate the precise legislative language. That’s the stuff that most members of Congress don’t read. When will the CBO get a chance to read it and issue a more final report?

And Finally A Prediction: The title of the final bill voted on by Congress will include the name 'Kennedy.'

Machine Learning and Clinical Outcomes in Health Information Technology

The Disease Management Care Blog is guilty of not paying that much attention to the flow of news about information internet techie killer ap stuff. It’s hard to keep it all straight, much of it seems either impermanent or futuristic, plus the 2.0 jargon is opaque. But when the New York Times Business Section and the Wall Street Journal Health Blog both mention a new healthcare computer thingy, the DMCB perks up.

Welcome to Keas (pronounced KEE’_ahs). As the DMCB understands it, this is a web site (or to the cognoscenti, an ‘application’) in which you can record your medical and family history and input other medical information, including labs from Quest. The site’s ‘machine learning’ (MLing) can apparently fashion a health profile, interpret (‘red,’ ‘yellow,’ or ‘green’) lab test results, generate a personalized care plan (based on input from Healthwise or anyone of a number of high powered academics), issue prompts or offer specific suggestions (and even quizzes) that help the user-patient improve their health or manage conditions such as diabetes, high blood cholesterol or being overweight.

The DMCB views ‘MLing’ as a learning opportunity, so it dove right in. Keas’ co-founder Adam Bosworth is of Google-engineer pedigree and he specifically mentioned the concept in his blog. Assuming that’s what makes up Keas’ insides, MLing is computers that deploy algorithms to search for and ‘learn’ known and unknown patterns and make associations. Presumably this technology can tap into what is known about patient data and various diseases, much like credit card companies can spot unusual transactions and issue fraud alerts or Amazon can prompt customers with purchase recommendations.

What luster hm? This is part cool, part patient empowerment, part information tech, part meaningful EHR use and part venture capital.

Then the DMCB dug a little deeper. While a response from Keas to an email inquiry and a phone call is still pending at the time of this posting, the DMCB did what it always does when its curiosity is piqued. It took a look at some of the pertinent medical literature, favoring randomized prospective trials from reputable peer review journals. From a clinical standpoint that was curiously missing in the New York Times, two well done studies may lend some insight as to what Keas can, and cannot, do:

Check out this Annals of Internal Medicine study on self management in asthma in which the authors compared the outcomes of a group of patients randomly assigned to an ‘internet-based self management program’ with monitoring, advice, education and web-based communication versus usual care. Instead of MLing, a questionnaire was used to discern how patients were doing and, if things got bad, a live nurse intervened. At twelve months, the internet group had modestly better improvement in their quality of life and measures of lung function but there were not differences in severe asthma attacks.

Or how about this Archives of Internal Medicine study on the use of a ‘practice linked online personal health record’ for patients with diabetes. Once again, patients were randomly assigned to usual care versus a web application that listed medications, asked questions about the diabetes and other labs and then generated a care plan. At the end of one year, the intervention group had experienced greater changes in their medications, but there were no meaningful differences in blood sugar control, blood pressure and blood cholesterol levels.

Based on this information, the DMCB suspects that organizations that may consider paying for this service on behalf of their enrollees may be skeptical about the ability of Keas to lower claims expense enough to justify the investment. However, as pointed out before, Keas-like applications' greatest potential is when it's combined with other population based care interventions that synergistically add up to more than the sum of their parts.

Since the literature above may prompt some skepticism, Keas’ may wish to conduct some of its own studies to better define what it can and cannot do and how it best fits with the patient centered medical home, disease management, benefit-based insurance incentives, physician patient reform, accountable care organizations, registries and traditional electronic records.

Addendum: In looking around the web site, the DMCB also found these terms of service (bolding from the DMCB) that speak for themselves:

'The Content and Services may link you to other web sites or information, software, data, or other contents on or off the Internet, including linked click-through or other advertising, or through featured or sponsored sites. We have not reviewed the contents that may be reached by such links and we are not responsible for such content. Your linking to any other pages on other sites is at your own risk. The information, software, data, or other contents (including opinions, claims, comments) contained in linked references are those of the companies responsible for such sites and should not be attributed to us. We have not attempted to verify the truth or accuracy of any such opinion, claim, or comment, nor do we endorse or support them. We do not warrant, nor are we in any way responsible for, information, software, data, privacy policies, or other content that is outside of our control.'

The Latest Cavalcade of Risk is Up!

A great risk at this point is not heading over to David Williams' Health Business Blog and checking out the 89th Edition of the Cavalcade. This is an excellent summary of the best of the recent bloggery on the topic of.....risk!

Disruptive Innovations in Health Care From JAMA: Worthy of Consideration in Future Health Care Reform?

Much like the non-excitement over the winners of the Academy Awards' 'Performance by an Actor in a Supporting Role,' the Disease Management Care Blog's interest over the current bevvy of health reform legislation that will need to be reconciled in Congress is rapidly dissipating. While following the ups and downs of the various Senate and House bills makes for great bloggery, who really cares? It's all entering that opaque arena of legislating that Ronald Reagan described as the combining of an apple and an orange to make a pear. The DMCB will wait to see what unpredictable fruit of Best Picture ultimately emerges.

Yet, whatever happens, it is delighted by the NY Times' columnist David Brooks' analogy of Mr. Bentham vs. Mr. Hume and agrees the former will prevail in the final legislation, even if the latter is ultimately right.

When the DMCB isn't reading the Times, it would rather think about the future, especially because additional reforms are certainly going to be unavoidable. So, check out this commentary piece in the latest issue of JAMA titled 'Disruption and Innovation in Health Care' by RAND scientist Robert Brook (no relationship to David). He makes even Clayton Christensen look behind the times.

Here are eight important disruptions that Dr. Brook believes are within reach, are not being adequately addressed in Congress by either Mr. Bentham or Mr. Hume and could save us a ton of money.

1. The Carbon Footprint: Assessing the carbon dioxide load being emitted by the health care industrial complex is just as important a dimension of overall value as measuring cost, savings and quality.

2. Social Impacts: Where you live and what your race is is turning out to be more important that your cholesterol level or how much you exercise. A child's report card is no less vital to well being than screening for scoliosis or annual check ups. It's time to think about the role of physicians in increasing social determinants of health and whether the current pay for performance for narrowly defined health care measures is giving us our money's worth.

3. Competency, not Training: Nurse midwives, physician assistants, nurses may buy into the notion, but why stop there when it comes to down-jobbing? New training programs combined with the right kind of support may enable even high school grads to safely read mammograms, perform colonoscopies or inject botox.

4. Inefficient Use of Capital: Why build another MRI when the existing one is down six out of 24 hours a day. 24-7 health care would be a better use of existing pricey resources like physician offices, outpatient surgi-centers than building new physician offices or oupatient surgi-centers. If persons can't get a vaccine on a timely basis, why not enable it in the name of public health so that consumers can get it as easily as some motrin at an all-night pharmacy?

5. Waste Reduction: Every other business outside of government relentlessly roots out waste. What will it take to make health care CEOs and their Boards worry about this before, during and after their quarterly meetings?

6. Globalization: High quality and low cost care is turning out to be a plane ride away. If the U.S. can't create a market, maybe the globe can.

7. 'Applied' Public Health as a Skill: Medical schools, post-graduate training programs, medical certification and professional organizations will grow increasingly attentive to promoting the skills necessary to manage quality and cost on a population basis. Bravo! says the DMCB and it's sure the DMAA Care Continuum Alliance not only concurs but is doing its share to make that a reality.

8. Rights and/vs. Responsibilities: Sure, citizens have a right to smoke, forego screening tests or not see a physician. Physicians have just as much a responsbility to remind patients to not smoke, to get tested and to come in and get an appointment. Patients also have the right to have this done at their convenience. Patients who take advantage of the testing may also have a right to be moved to the front of the line if they come down with cancer anyway. That's all debatable, but it may be time to have that debate.

Of Nobels and Telomeres: The Disease Management Care Blog Explains

The 2009 Nobel Prize in Medicine has been awarded to Drs. Blackburn, Greider and Szostak for their work in ‘telomeres and the enzyme telomerase.’ According to the cluttered news web sites CNN and MSNBC, telomeres guard chromosomes and telomerase protects telomeres which is important in diseases like cancer. Unfortunately for the main stream media, this news is competing with the swine flu scare, Kate minus Jon Plus Eight, Mr. Letterman’s foibles and the death of Gourmet Magazine.

The Disease Management Care Blog to your rescue with a brief analysis.

Chromosomes contain DNA, which is literally the computer used by cells to run the machinery of life. ‘Telomeres’ are pieces of inert or inactive DNA that are present at the ends of all chromosomes. They protect the rest of the interior and important functional genetic material from being degraded by other normal cellular enzymes that clean up unneeded or leftover molecules, including DNA. If there are no telomeres to protect the DNA, valuable genes on the inside are damaged, leading to cell malfunction and an inability to replicate.

Telomerases are proteins that build telomeres. No telomerase means no telomeres means early cell death. Lots of telomerase means lots of telomeres means cells can theoretically live forever.

Many types of cancer cells seem to have an abnormal ability to increase telomerase, which may explain how those cells continue to live, divide and invade normal tissues. If that can be turned off, it may offer a tool to fight cancer. In addition, there are some diseases of premature aging like Werner’s Syndrome which seem to be caused by accelerated telomere shortening. While rare, they speak to the role of telomeres in normal aging.

It has been observed that as humans age, their telomeres seem to progressively shorten. This ‘exhaustion’ has been known about for decades. With each cell division (called ‘mitosis’) in our bone marrow, gastrointestinal tract, skin and other tissues, our telomeres appear to grow shorter. As a result of this 'mitotic clock,' over the course of aging, we are left with DNA that is increasingly vulnerable, fractured, malfunctioning and unable to maintain normal health. In other words, our life span may be a function of our telomerase.

If we can determine how to 'up-regulate' telomerases in our normal tissues, we may not only be able to battle diseases like arteriosclerosis but to lengthen time of fertility, engineer tissues for transplantation and possibly significantly increase our human life span beyond the accepted maximum of approximately 120 years.

According to this 2006 article in the New England Journal of Medicine, our newest Nobel Prize Laureates' research 30 years ago on how telomerase inactivation led to telomere shortening and eventual senescence in yeast laid the foundation for our current understanding about telemeres.

The DMCB adds its hearty congratulations to Drs. Elizabeth Blackburn, Carol Greider, and Jack Szostak.

Coda: While thinking about the content of today's blog, the DMCB went for a walk with the DMCB spouse. Unable to restrain it's telomeric excitment, it opened a conversation by asking if she knew what the latest Nobel Prize had been awarded for. Feigning lachrymose disappointment, she exclaimed 'What!? Did they skip you again?'

Post Pending Health Care Reform Legislation Online and Tap the Wisdom of Crowds: A DMCB Top Ten

The Disease Management Care Blog understands but respectfully disagrees with Senator Carper’s (D-Del) reluctance to a) personally read or b) post on-line the legislative language of the final health reform bill that will emerge from the Senate Finance Committee.

He cautions that it’s full of confusing, arcane and incomprehensible gibberish that it's so obtuse that even fulltime professional legislators like him need to have it deciphered into plain English. As a result, he believes posting the beast online for 72 hours prior to a vote is an exercise in futility. He argues that America's citizenry don’t have access to staffers who can wade through all the gobbledygook and they will therefore be unable to fully digest its contents. He thinks it’s simply beyond the ability of any amateur voter to understand it all. Instead, the Finance Committee has elected to be helpful by making a ‘conceptual’ summary available to the populace.

The Senator is undoubtedly correct about the obtuseness of the legislative language. The DMCB also appreciates his self-portrayal as a regular guy who is one of us. He should also get credit for telling it like it is, even if he’s giving the viewer the mistaken impression of being amateurish, lazy or lacking the core skill set one would expect of a professional lawmaker. Unfortunately for the Senator and the rest of his colleagues, he’s also giving us voters the impression that our legislators are being purposefully obtuse. After all, it’s those last minute insertions of an 'or' in place of an 'and' in a section defining coverage or payment that can make all the difference down the road for the special interests and their lawyers.

The DMCB is not beimg naïve, however. Legislative language is a necessary evil because there is no other way to be precise. What's more, U.S. Senators want to do the right thing, correct?

There’s a bigger problem.

The problem is that the Senator and his colleagues don’t recognize the huge potential of the wisdom of crowds when it comes to illuminating legislative contents. This phenomenon's been harnessed for complex issues like U.S – Iranian relations, derivatives, computer programming and consumer products. The DMCB is very confident that the world's (and it means that literally) interested, decentralized and distributed reader-interpreters with collective backgrounds in law, medicine, policy-making and public health are quite up the task of combing through the legislative language and coming up with insights unavailable anywhere else. In fact, Senator Carper should use P&G’s business approach and ask for insights on the bill that won't otherwise be apparent to him or his expert staff. He'd be a better Senator for it.

So, with apologies to Mr. Letterman and his disappointed fan base, the DMCB is happy to offer up this Top Ten List of why the Finance Committee's legislation should be posted on line in its entirety:

10. If posting it won’t help, it certainly shouldn’t hurt for the same reasons.

9. When reporters ask if you’ve read the bill and you haven't, you can look Senatorial by saying you’ve 'posted it online.'

8. When Republicans ask if you’ve read the bill and you haven't, you can duck the question by rhetorically asking if they’ve posted an on-line version that they haven't read either.

7. It’ll give the impression of democracy in action, even if you know the details are really under the control of a secret cabal of over-lawyered staffers.

6. Everyone knows that links to pending legislation are an exciting way to liven up any web site (the DMCB spouse can barely contain herself when this happens).

5. You won’t have to say things like ‘I’m glad you asked that!’ or ‘That’s a very good question!’ while being interviewed about having read pending legislation.

4. Posting legislation on-line may actually help you read some of it, like when you’re on a train between D.C. and Wilmington with nothing else to do.

3. By posting it with an error, you can play ‘Find the Typo!’ with your constituents.

2. On-line: hip, connected, savvy, modern and re-elected. Off-line: old, paper based, slow uncool and earning a living with the likes of former Senator Daschle.

1. The Wisdom of Crowds will give you insights unavailable anywhere else.

Who Will Flash Mob the Public Option Like Whole Food Markets? Or How?

The Disease Management Care Blog watched the news about a pro-health reform ‘flash mob action’ that materialized on Sept 29 at the Oakland Whole Food Markets with considerable interest. Disgruntled over that company's CEO John Mackey’s August 11 editorial in the Wall Street Journal, members of the Northern California based and culturally ‘Left’ Brass Liberation Orchestra (BLO) wanted to noisily make known their disagreement. As their bullhorned leader exclaimed in the back aisle, health care is a right and Mr. Mackey is an extremist right-wing hypocrite.

The DMCB recalls reading that editorial. It wasn’t all THAT exciting. It was similar to many of the other just-say-no-to-government-involvement-in health-care opinion pieces that have been appearing almost daily in that newspaper over the last two months. Mr. Mackey, like many CEOs who want to cover health insurance for their employees, was in favor of a) promoting availability of high deductable plans as well as health savings accounts, b) allowing cross-State border health insurer competition, c) repealing benefit mandates that favor special interests, d) enacting tort reform, e) increasing cost transparency, f) reforming Medicare and (and this was a new one) g) using tax forms to enable voluntary donations to help persons without insurance.

What provoked the BLO’s ire was the legal and market basis of his arguments in a paragraph about halfway through. After a careful read of the Declaration of Independence and the U.S. Constutition, Mr. Mackey noted he was unable to find any mention of food and shelter as ‘rights.’ He interprets this to mean that Americans decided long ago that these are really needed ‘services’ that are ‘best provided through voluntary and mutually beneficial market exchanges.’ He argues the same logic applies to health care.

The BLO and its action allies obviously beg to differ. What’s more, they argued that Whole Foods Market’s high nutritional-value products, like good health care, are also being priced out of reach by the same cold market-based logic.

Well done, says the DMCB. What is America without the ability of the BLOs of this world to vex the powerful and make uncomfortable the rich? It’s quite cool that this was done with a horn section and without the kind of bile we witnessed at the infamous August Town Halls. In the end, shopper-bystanders were grinning. Point made.

More importantly, if government dominated health care ever does come to pass, the DMCB is confident that the BLOs of this world will be needed more than ever. Given Medicare’s track record, for example, of denying coverage for potential lifesaving services like virtual colonoscopies, not fully paying for wheelchairs and oxygen, or driving contracting entities into bankuptcy, there little reason to believe that the public option won’t be just as capricious.

But it won’t be so easy. As anyone who has visited the Hubert H. Humphrey Building in Washington DC or CMS’ Headquarters in Baltimore knows, there are security guards posted at all the doors with metal detectors. What’s more, in Baltimore, you need to be on a preapproved list and your car will be get-out, open the hood, open the trunk and open your luggage searched. Unlike just walking in the front door at Whole Foods for a flash mob with instruments in hand, it’ll be hard to get that tuba through, let alone explaining what you’re up to to a Federal Officer.

And don’t even THINK about pulling any stunts at the Jefferson Memorial.