Rhode Island's Health Insurance Commissioner and the Patient Centered Medical Home

The Disease Management Care Blog virtually attended a very interesting January 28 webinar sponsored by the Patient Centered Primary Care Collaborative. Access to this kind of learning experience is one of the advantages of PCPCC membership. (Hint -by the way, it’s free).

The topic was a fav of the DMCB, the Patient Centered Medical Home, titled ‘What is it? Why is this important to employers?’ There were two speakers, and it was the second, Christopher Koller, who really caught the DMCB’s ear.

First, some background. Chris Koller is the Health Insurance Commissioner for Rhode Island. Every State has an Insurance Commissioner, but the DMCB thinks Rhode Island is a distinct outlier because of two unique features:

First, this State has a Commissioner for just health insurance. As far as the DMCB is aware, other States don’t carve that function out, let alone put a former health insurance executive in the post.

Secondly, while State Departments of Insurance are charged with 1) protecting consumers (from unscrupulous insurers who refuse to pay up) and 2) assuring insurers’ solvency (preventing an insurer from declaring bankruptcy and walking away from its debts in the event of a bad year), this Commissioner is additionally charged with protecting providers and ‘encourag(ing) policies that improve quality and efficiency…’ and ‘encourag(ing) and direct(ing) insurers toward policies that advance the welfare of the public….’ This goes well beyond the usual role of being a simple regulator.

One of the centerpiece policies of the Rhode Island Health Insurance Commissioner? You guessed it, The Patient Centered Medical Home.

So what’s the big deal? The vast majority of other PCMH pilots underway are typically being sponsored by a single insurer or are happening on a limited regional basis. Rhode Island has one that is called the Chronic Care Sustainability Initiative, and the difference is that it’s state-wide. More importantly, all of the major commercial insurers (the Blues Plan, United and Neighborhood Health) plus the State Medicaid program plus the State Employees Benefit Plan, the Business Group on Health and other self-insured entities are participating, using a single:

a) set of criteria to accredit a physician practice as a PCMH,

b) contract (with $3 PMPM),

c) fee schedule and

d) set of quality measures.

This is not regulation, it’s intervening and jawboning. This is what many consumers want.

The DMCB wonders if the activism of a State level officer at the level of a Insurance Commissioner may emerge as a key ingredient for the success of the PCMH. Without it, insurers will not only be reluctant to cooperate with their competition but fearful of appearing to anti-competitively collude. What’s more, this gets government Medicaid and the private commercial plans on the same page. This can also act as a safe harbor for further cooperation on other future initiatives. By the way, the same approach is being used in Pennsylvania, though it isn’t the Department of Insurance. Rather, it’s the Governor’s Office of Health Care Reform that is leading (and maybe browbeating?) the multi-stakeholder parade.

Last but not least, the DMCB is very impressed with the ability of the States to execute on novel health care initiatives. By the time ObamaCare passes Congress and the first data arrive from the Medical Home Pilot years from now, Rhode Island and Pennsylvania may long have the answers we need. These State residents won’t need Washington’s Czars telling them what to do and how to do it.

Any problems here? The DMCB is aware of several. There seem to be a relatively low number of involved physicians (N=28), which may make the results hard to assess at that unit of measurement. It may also make the results less generalizable and there is no guarantee that all physicians will want to participate, even if the pilot is successful.

Secondly, the evaluation will be performed by the Harvard School of Public Health. The DMCB has high regard for HSPH, but it thinks that decisions about insurance design and affordability are fundamentally more of an actuarial than a health services exercise. Ideally, it's both.

Finally, this is a test of the PCMH only, without any later generation features such as additional remote telephonic coaching, synergistic benefit and pharmacy designs, consumerism and yes, intelligently designed information and technology registry and decision support.

The DMCB wants to keep an eye on Rhode Island. The State's Motto? Hope. The DMCB’s view? Hopeful over what one State is up to and hopeful that if the PCMH is successful, it works in a multi-payer, State-wide environment.

City State Health Care Systems and their EHRs

Dr. Lesitsky is a community-based primary care physician who practices in rural northeastern Pennsylvania. He's not only a buddy of the Disease Management Care Blog, but someone with a working knowledge of life in the trenches of primary care. When docs like him talk, the rest of us should listen.

By Neil Lesitsky, MD

I am a busy solo family physician located 25 miles from the nearest hospital but within 50 miles of at least 9 separate healthcare institutions. My patients may frequent any one of these or their ancillary branches. In addition, there are literally hundreds of providers within the same radius who are not aligned with any system.

As I see it, each one of these institutions is run as its own City-State, each of which has their own unique monarchs, deities, moats, armies and, most importantly, its own electronic health record (EHR). Each institution treats their EHR as their coin of the realm. This coinage functions well within its own borders but lacks infrastructure to be recognized or connect outside its sponsors’ sphere of influence. The information is locked away in the City-States’ treasuries and inter-treasury transfers continue to require a byzantine process.

One City-State in my area, Geisinger has published a paper demonstrating how its coin has become the gold standard in its region. It makes a compelling case from the viewpoint of that King's Court. From my vantage point, however, the other institutions in my area haven’t necessarily agreed.

Our Government has addressed this issue by suggesting that there be a common language for EHRs, so these City-State realms can communicate with a common diplomatic tongue. However this is not the same as a central treasury. This perspective has also been noted by Rick Peters of the HealthCareBlog in an excellent article noting the difference between standards and interoperability.

In my view, a major barrier to the adoption of an EHR by my primary care colleagues is the lack of a common treasury that aligns the City States in a global infrastructure. In primary care, the attraction of an EHR has more to do with data transfer and preventive care prompts than documentation of care (although my back office may disagree).

There is much more data flow into a primary care office than out of it. In my situation, until such a central treasury exists, and the city states easily transfer their deposits, it is not prudent for me to align myself with any of the monarchs.

Do Computers in Hospitals Save Lives? Reduce Costs? Make the Food Better?

Well, a hot-off-the-press article in the Archives of Internal Medicine says maybe two out of three. Is this a landmark study? Some media reports suggest that's the case.

Given how starved adherents of healthcare technology are for any news that can justify Congressional largesse to the tune of $20 billion, this little gem of a manuscript may garner additional attention in the coming days. If you’re interested in knowing whether computers in hospitals really save lives, the Disease Management Care Blog is at your service with a summary. Another bonus is that you won’t have to rely on the mainstream media to get it wrong.

Dr. Amarasingham (Parkland in Texas), Ms. Plantinga (Bloomberg Public Health), Dr. Diener-West (Bloomberg Public Health), Dr. Gaskin (Hopkins) and Dr. Powe (Bloomberg Public Health) surveyed a variety of Texas hospitals’ physicians about their hospitals’ level of ‘automation.’ The survey they used was the validated Clinical Information Technology Assessment Tool (‘CITAT), which assesses four domains of ‘record keeping, test results, order entry and decision support.’ If 5 or more surveys were completed, each hospital was assigned an average score based on the physicians’ answers. The Texas Hospital Association then provided the hospitals’ data on mortality, costs, complications and length of stay for all patients as well as those with heart attack, chronic heart failure, open heart surgery and pneumonia. A total of 41 of 72 targeted hospitals had 5 or more surveys completed and could therefore be scored and included in this study.

Did high CITAT scores correlate with death rates, cost, complications or length of stay? Well, as the CITAT score increased in each of the four domains, adjusted odds ratios of death and complications for some conditions decreased. Costs and length of stay also decreased for some conditions. Many did not change.

The curmudgeonly DMCB says 'not bad.'

The insight here is that useful inpatient information technology – as defined by physicians, not technobabbly consultantspeak pseudoscience – is associated with impacts on death rates and costs. Importantly, there was a ‘dose response relationship’; as the CITAT increased, the impacts grew. Even better, the insight has greater credibility because it’s gained from real world hospitals, not disconnected academic medical centers authoring studies that are only read in other academic medical centers.

But the DMCB offers up some cautions:

Association is not the same as causality. It is possible that hospitals with the ability to invest in automation also have the ability to invest in nurses, maintain quality programs, attract the high caliber clinical/administrative leadership or leverage other unmeasured features that really account for the observed changes. The authors attempted to statistically control (neutralize) for hospital status, but this is never perfect (the same techniques were used to control for limitations in the same kinds of studies of estrogen in women, which were shown to be mistaken once a prospective randomized trial was done). The bottom line is that there is no guarantee that an install of this kind of IT in year 1 will lead to fewer deaths, decreased complications, lower cost and shorter length of stay in year 2. It might.

This is hardly a slam dunk panacea. The authors noted the swing in mortality rates was in the range of 0.5%. If you’re among those 5 in a thousand, that’s a lot. For the other 995, survivorship doesn’t change. However, those 995 are facing some other issues including never events, being adequately vaccinated, being disconnected from real doctors or being discharged safely. Swings in the amount of dollars numbered mostly in the low hundreds - when an inpatient stay costs thousands and the ambient national healthcare inflation trend rate eats hundred dollar bills for lunch. We don’t know how the savings profited the hospitals or the insurers and, what's more, we don’t know if any profit was greater than the cost of all this IT.

Sorry ye worshippers of the physician office-based electronic health record. This study tested elements of the EHR outside the physician office setting. It does not apply to your vision of a paperless physician office. You’ve still got work to do in terms of providing reasonable assurance that you really save money and reduce costs in that arena.

Multiple comparisons were performed, making the likelihood of statistical mischief greater. Many of the changes were statistically significant (seemed to be of a magnitude that were mathematically unlikely due to random chance) but barely so. To the authors’ credit, they attempted to statistically control for this also and recognized it as a limitation of their study.

The DMCB doubts a single study can answer the question, but this is an important addition to our knowledge base. Good work, authors. Finally, kudos to the Archives for making the manuscript readily available on-line.

Health Affairs Broadcast: Prevention Doesn't Save Money. Is Anyone Listening?

Now that the Obama Health Reform Dirigible is about to be launched, recall much of its ballast is predicated on the twin notions that electronic health records (EHRs) and prevention will ‘save money.’ Both fictions have been past topics of the Disease Management Care Blog, which is confident that both initiatives will add to health care costs. The DMCB doesn’t think additional cost is not necessarily a problem, so long as the end-user patients get reasonable value for their dollar. It’s just that the DMCB distrusts the ability of a huge sprawling ‘mainframe’ Federal bureaucracy to get anything right.

You don't have to take the DMCB's word for it. To learn more about the important topic of prevention, the DMCB recommends Rutgers University’s Louise Russell’s Health Affairs perspective piece. Freshly published, short, to the point, highly readable (few references to ‘QALYs’) and packed with references pointing to the original research, it points out what many health services researchers have been saying for decades: most interventions designed to prevent heart attack via blood pressure or blood lipid control or aspirin cost. Well run programs that promote lifestyle changes to prevent diabetes cost. In fact, of the hundreds of published studies on the topic of prevention, about 80% have been shown that they cost.

Too bad disease management’s legacy is so entangled in the cost ‘savings’ business proposition, especially because many vendors also offer prevention programs. In its travels, the DMCB is still running into this simplistic black and white either-there-is-or-there-isn’t-an-ROI archetype. The truth is, depending on the population, the condition and the insurance benefit, some later generation disease management programs may reduce costs and, if not, are still a great deal for the healthcare dollar. If healthcare consumers want tailored programs to achieve blood sugar control, weight reduction, lower blood pressure or better fitness, it may well cost them via higher premiums from their health insurer. Is that necessarily bad?

The DMCB has read that the HHS Secretary Designate likes to relax by thumbing through issues of Health Affairs. Hopefully he’s read Dr. Russell’s manuscript. Hopefully the new class of Health Czars is aware of the budgetary implications of promoting healthcare prevention programs. Hopefully they’ll get around to telling the American public the truth. By the way, Governor Ed Rendell (D) of Pennsylvania has amply demonstrated that taxpayers are willing to take on new costs if it’s in their interest. I’m sure he’d be willing to share some pages out of his playbook.

For more peer-reviewed truth than you’ll ever want to know about the topic, check out this link at the Tufts CEA registry. It was used by Dr. Russell in her paper. The registry reminds the DMCB of the commercial in which the hapless traveler checks into a dusty motel and is told he can access every movie ever made in every language anytime day or night. When it comes to a huge organized data base of intervention studies that reconcile the benefit versus the cost of care, the same is true here: every paper ever published in every journal anytime day or night.

What Do Professional Wrestling and Political Wrangling Over Health Insurance Have in Common?

Check out this January 21 editorial from The Hill. Apparently, while the Obama administration is playing nicey nice with all the stakeholders in his various initiatives, one group that has been left out in the cold are the health insurers. According to the editors, President Obama et al are getting ready to spill some blood. Woo hoo!

Don’t be fooled. The Disease Management Care Blog knows that health insurers are inured to being the bad guy when it comes to blame games. While the public face of health insurance is a curious mix of ‘We Care!’ platitudes and ‘You Don’t Love Me?’ dismay at public hearings and in press releases, they have a) been getting pseudo-beat up for decades and b) are continuing to use back communication channels to have very meaningful and constructive dialogues with the politicians, policymakers and regulators. While things may certainly 'change,' the likelihood of a wholesale disembowelment of the insurers is remote. They know their job is to reconcile what doctors and patients want with what the premium will cover while maintaining reserves and a surplus that are tightly - and I mean tightly - controlled by State regulators. They'll continue to do that while contributing to the shape of coming health reform...quietly.

This is more akin to the faux professional wrestling than bloody cage fighting. Every time a politician rails against those loathsome insurers, think Hulk Hogan throwing a fake forearm at the Undertaker while stomping on the mat to make a big noise. Once they’re on the bus heading to the next show, they’re sharing drinks.

Cheers!

Insurance Risk & Performance Risk: An Alternative Payment Mechanism, Compliments of the Robert Wood Johnson Foundation

While readers and the Obama Adminstration search for better ways to pay for health care, the Disease Management Care Blog remains skeptical of basic fee-for-service, capitation (or 'global fees') and pay for performance. Like the Three Little Bears, the first is too hot (it promotes overuse), the second is too cold (it’s a disincentive for care) and the third is just… unproven.

That’s why it continues to like the ‘episode of care’ (EOC) reimbursement approach of having a single fee for a medical event that covers all subsequent services over a set period of time. An example would be paying for the hip surgery, the hospitalization(s), the physical therapy and all the follow-up physician visits with a single check. Think of EOC as capitation (which is supposed to cover all unrelated medical services over a period of time, typically a month) for a single condition, not a single patient.

There’s a very understandable discussion of the topic in a Robert Wood Johnson Foundation supported report from the Network for Regional Healthcare Improvement. The DMCB likes their notion of distinguishing between ‘insurance risk” (based on the numbers and types of diseases that occur in a population) and ‘performance risk’ (based on what is done to mitigate those diseases, which is a function of the numbers and types of treatments that are applied). The folks at the Network argue that while there is overlap of performance risk with insurance risk, the performance risk still can be measured, monetized and transferred to the providers.

Think of it in terms of automobile insurance. Insurers can sell policies that are designed to make you 'whole' if you have an accident (that’s the risk). They assess your age, gender, past driving record and zip code, which helps define much of the risk being priced. They collect your check (the premium) along with checks from thousands of others. However, they also have to pay attention to how much it would cost to fix the various cars in their book of business, such as parts and labor. In the Network world, the car insurers would collect your premium but then could cut a deal with the car repairmen and their body shops by negotiating a standard fee (which is functionally now an insurance premium that they ironically have to pay) to manage all the repairs that occur over the course of a year. Since the repairs occupy the lion’s share of the costs most of the money goes to the repairmen in the ‘network.’

Ahhh, but you correctly point out that diabetes and high blood pressure don’t work that way, because there is no end - like there is with hip surgery or a car that comes out of the repair shop. No problem, says the Network folks: there are cars out there that don’t necessarily need new fenders but burn oil, have threadbare tires, worn seats and cracked windshields. Since the drivers can’t give them up (they don’t like the alternative), their car needs lots of extra maintenance. For those cars, the insurers can still cut a global performance risk transfer deal with monthly payments that don’t end. That’s called ‘condition-specific capitation.’

The DMCB likes the concept because its ultimately rewards the services that are being provided for the condition at an EOC level. The payment is better targeted. That being said, it has several caveats to keep in mind while we think about paying providers a set monthly fee for a specific condition:

1) if the payment is to be done at a provider level, it requires a significant amount of physician/hospital/provider coordination, with good information transfer and ironclad hand offs. That is more likely to be present in smaller integrated healthcare systems but is tough to achieve in usual community settings with independent providers. Electronic health records are necessary but are not sufficient to pull this off.

2) while many physicians ‘get it’ and would do all the things necessary to mange their risk with higher levels of efficiency, using technology appropriately and keeping their costs to a minimum, many fine physicians would struggle in trying to adapt to this kind of arrangement. Between ‘here’ and ‘there,’ much work would need to be done. This is not a turnkey payment solution. A new fee schedule is necessary but not sufficient.

3) which is why performance risk transfer may be better thought of in terms of disease management. The DMCB thinks DM organizations understand risk (that's their pedigree) and can partner with providers in the absence of formally integrated networks to maximize coordination. Disease management, however, is also necessary but not sufficient to pull this off.

4) this would be a bear to administer, which makes it unsuited for large “mainframe” insurers like Medicare. Accordingly, the DMCB doesn’t expect this to see the light of day in national healthcare one-size-fits-all reform efforts. However, among the smaller innovative, nimble employer-based self-insured entities out there, the DMCB hopes to see this given a shot. Who knows, if a competing government sponsored insurance entity is created, the private insurers may be able to compete by offering novel payment systems like this.

5) finally, while the payment process described above transfers risk, it’s not ‘insurance’ from the point of the State or Federal regulators. Ultimately, only one party can be responsible for managing the total risk of health insurance for an individual policy holder who pays a single premium. In other words, if a hospital fails to meet its contractual obligation to provide timely and medically necessary care which, in turn, results in additional cost to the policy holder, the party ultimately responsible for fixing it is still the health insurer, not the provider.

The Post Inaugural Health Wonk Review Celebration Event

There is something very unique about the United States’ mix of unabashed patriotism and Hollywood showmanship during times of national celebration. Sure, other countries can assemble their own organized spectacles, but there is something exceptional about all those flags, speeches, music, salutes, color guards, banners, close ups on children’s faces, tributes to heroes past and present as well as the earnest rhetoric that makes the hardest cynic proud to be an American.

What better example of this phenomenon than the star studded We Are One pre-inaugural concert, complete with its own Washington D.C memorial building with an A-list cast of cinematic liberal luminaries and mega-rock stars? Sure, the entertainers may not know all that much about the ins and outs of our new President’s policies and yes, the music’s lyrics had nothing to with foreign affairs, health care or the federal budget, but their hearts were in the right place. It was a heluva show, even if you had to watch it on a jumbotron.

Since this is a grand participatory democracy and the Disease Management Care Blog believes no part of our nation’s body politic should be immune from having a chance to celebrate, it decided that we wonks and readers could have our own concert. ‘What?!’ you say? No stage, no sound system, no Hollywood types, no rock stars? ‘No problem’ says the DMCB. This is a virtual world, the web is our stage and the music is only a click away. And we have speeches aplenty. The DMCB knows because it has screened them all.

Ladies and gentlemen, welcome to the Post Inaugural Wonk Celebration Event, brought to you by the best and the brightest thinking of some very smart health policy blog writers. Read, learn, listen to some tunes (assuming you have speakers) and enjoy while we wish President Obama the best in his coming administration.

Taking the stage first is New Health Dialogue Blog’s Joanne Kenen, who examines a recent MedPAC recommendation that hospice care be ‘front loaded’ with higher payments at the start of the care and then “back filled” with higher payments when the end comes. MedPAC knows that when you cover a service that offers better care for a higher payment that is welcomed by hospitals, physicians, families and patients, gaming is as inevitable as death and taxes. And look, the band taking the stage is Aerosmith, singing take me to The Other Side.

Oh double look, here comes Brady Augustine of the MedicaidFrontPage blog, who has a three-fer. He looks at the status of SCHIP renewal and extension and the implications of failing to secure Republican support for the inclusion of immigrants as well as the lack of available funding at the State level. Then he reviews the recent report in the New England Journal of Medicine that operating room check-lists save lives. Most of all, DMCB likes his explanation of the curious logic behind Florida’s nursing homes’ willingness to support a tax increase to secure more Federal matching funds. Complex? Yes. Creative? Yes. Is this the kind of dysfunctional funding that distracts us from creating high performing care systems? Yes. The very opaqueness of public funding is not unlike the lyrics from Brimful of Asha by Cornershop. The DMCB doesn’t understand these words to this song either, but doesn’t care because it thinks a camera is focusing on him and the spouse while they are grooving.

For further insight about SCHIP, listen to Anthony Wright of the Health Access Blog. He points out that the Democrats not only have the Republicans to deal with, but also their more leftward leaning colleagues who are demanding a lower threshold for access of immigrant children to SCHIP. Drawing on the lessons from California’s star-crossed run at expanding access to health insurance, he notes the pursuit of bipartisanship in the defense of health care is no virtue – it’s a delay. Which is why Dierks Bently bemoans his inability to keep the Republicans and Democrats from splintering by singin’ Trying to Stop Your Leaving.

And here comes Maggie Mahar of the Health Beat Blog on the same topic of SCHIP. Yes, she says, partisanship is a messy time consuming feature of the formulation of policy, but that’s because partisanship is another word for a willingness to debate and act on social values. Ditto the role of ideology in evidence-based medicine, which she argues should be implemented using a set of beliefs. Is this a necessary evil or a vital part of our democracy? Check out Maggie’s twin posts here and here on the matter and decide for yourself. Katy Pery can’t decide, so she’s decided to croon Hot N Cold for the crowd.

The DMCB and the crowd are big fans of nurses. Overworked, underpaid, these healthcare foot soldiers probably know more than anyone about what’s good and what’s bad about the system. Which is why Annie of the Virtuous Skeptic’s recounting of the American Nurse’s Association’s Social Policy Statement would be welcome in any venue. Read and learn more than you’d otherwise hope to learn about his noble profession. Yes, they’re Unglamorous sings Lori McKenna, but they rock!

Think our neighbors to the north are convinced that their healthcare system is all that it should be? Sam Solomon is now up and points out in Canadian Medicine that that may not be the case. The physicians are debating the merits of a public vs. more private approach and it’s being played out in a contentious Canadian Medical Association election between family practitioner Dr. Tracey, who leans toward greater privatization of the system, and Dr. Turnbull who supports a publicly funded system. Read their ‘vote for me’ statements and find out that even with the dominance of public funding, there are eerily similar debates over administrative work, access, payment levels, evidence based medicine, the role of market forces and electronic records. Along with us, our Canadian friends are struggling to find a Better Way. Ben Harper is now up singing about it.

While we’re on the topic of Canada (hey, if an Irish band can rock the pre-inaugural concert, international stuff is fair game) check out The Lucidicus Project’s Jared Rhoads’ assertion that Canada is really all about pseudoscientific global budgeting that really relies on patient queues and the questionable substitution of cheaper services to make up the difference when the yearly allotment runs short. The DMCB has heard this argument over and over but some Canadians apparently believe it. Why else would they Drive South asks John Hiatt?

It’s David Williams of the Health Business Blog’s turn and he’s here to discuss the Ingenix settlement. As the DMCB understands it, Ingenix was a business hatched by the managed care industry that in turn sold information about prevailing fee schedules to the managed care industry. The allegation from the New York Attorney General is that it artificially lowered the published fee schedules so that insurers could pay less when their patients went out of network. While many reports would have you believe that the AG helped the little guy here, this contrarian post by David points out that many fee schedules are inflated, opaque and highly variable. He doesn’t think the terms of the settlement is all that. This reminds the DMCB of just another chapter in the financial arms race between insurers and providers. Figuring out how to understand just how insurers pay providers? Donovan from this black and white vintage link tells the jumbotron viewers that we might as well try to Catch the Wind .

Not satisfied and want to hear even more about claims payments? Then pay attention to this other post from the Health Access Blog. In a fit of unusual clarity, the California Supreme Court has ruled that individual patients should not be put into the middle of a payment dispute between a big institutional hospital emergency room and a big institutional insurer HMO over the adequacy of payment for treatment. If the ER feels they are not being paid enough, the California Supremes say there are plenty of mechanisms that allow them to appeal. Emergency rooms balance billing patients? Outrageous sings Paul Simon. The crowd loves it.

But wait, there’s more on the Ingenix matter. Richard Eskow of The Sentinel Effect is telling the revelers about the Ingenix settlement from the perspective of someone who personally got stiffed to the tune of an extra thousand bucks – and he’s an industry insider. While he thinks the terms of the settlement are good, he has his doubts about its overall impact because consumers still won’t understand the pricing, won’t be able to negotiate the charges or avoid being billed for extraneous services. Beware, he says, the settlement is only a piece of the puzzle: it won’t have a big effect. Del Amitri agrees and is now singing that patients are always the Last to Know.

Henry Stern of InsureBlog helps the concert-goers be among the first to know about a study on Consumer Driven Health Plans released by UnitedHealthCare. They found there were considerable savings and that the bulk of them come from changes in health care utilization, not cost shifting. The DMCB wants to learn more but, along with the rest of the crowd, needs to move onto the next act. You can find the post and the link to this report by clicking here. You can hear Joe Walsh sing about this Happy Way of insuring folks by clicking here.

Joe Paduda of Managed Care Matters entertains by donning the swami hat and helps our virtual concert-goers prepare for What Is Coming for Health Plans. The ‘shun’ keywords are consolidation (and he names names), their response to coming legislation (a mix), regulation, physician collaboration (‘Why can’t we be friends?’), expansion of Medicaid, contraction (thanks to loss of jobs and fewer member months) and stagnation. Find out the details while Patty Griffin commiserates with the health plan audience members out there by singing We Don’t Need No Bad News.

Nancy Miller of ultrasound technician schools blog frets that open computer terminals laying about hospitals are making it too easy for n’er do wells and evil doers to blow past the nominal HIPAA safeguards and steal your identity. It must change, she is telling the crowd – hospitals are obliged to take appropriate action. And here comes Green Day, emphasizing her worries by singing Warning.

Tom Wilson and Vince Kuraitis of the e-CareManagementblog give the throng eight takeaways from the Medicare Health Support on how to build better bridges toward better population health care. This is a must read if you want to know where the disease management industry is going. While you’re at it, you can enjoy his updated picture. And now up, appropriately enough, are the Pretenders telling the disease management vendors to Stop Your Sobbing.

Few people on the Mall would agree that’s there’s nothing necessarily wrong with making some money, unless of course, you are a for-profit health insurer and have a reputation for sticking it consumers. Not so fast, says forenamed Louise of the Colorado Health Insurance Insider, who went insurance shopping and found the premium amounts for a comparable policy from for-profit and not-for-profit insurers were pretty much the same out in her section of the country. Since the health insurance market is driven by price, price and price, concert goers would think that the non-profits would be able to use their favorable tax status and lack of any need to pay shareholders to reward consumers with lower costs. Not so, and that’s why the Mavericks are on stage singing Crying Shame.

Speaking of making money at a company level, how about making money at an individual level? Roy Poses of the Health Care Renewal Blog discusses one allegedly underhanded way of doing it in this post about a $1 Million CEO. Is this greed? Is this failure of Board governance? Conflicts of interest? Just another sad example of how disjointed things have become when it comes to performance vs. compensation? Roy has his opinion and this is your chance to develop one on your own. Whatever we do, however, the most important thing is that we don’t Shut Your Eyes to the matter. That’s what Snow Patrol is singing.

The DMCB suspects there are some partiers on the mall. Alas, allowing alcohol and drug abuse to wreck your personal and professional life is a terrible waste and a huge toll for our nation’s health care system. A standard approach is to refer such persons for counseling and treatment. But does it really work? That is the question raised to the crowd by Glenn Laffel of Pizaazz. This is not an insignificant issue. In these days of evidence-based healthcare, Glenn asks about that evidence and furthermore, points out that without it, it’s difficult to credential drug and alcohol rehab programs. MGMT asks if this means it’s Time to Pretend that we really know what we’re doing.

Think those wall sized jumbotrons are technology writ large? Well, healthcare is also moving so fast that its disruptive technology is being disrupted by the disruptiveness of even newer technology. Case in point brought to the audience thanks to David Harlow of the HealthBlawg: American Well, which consists of a virtual online and telephone consultation service with access to a wide range of physicians that are available for 10 minute appointments that cost about $10 (a co-pay with insurance) to $45 (no insurance). Madonna agrees about the pace of change while she sings Ray of Light.

Michael Cannon of CatoAtLibertyBlog takes on the prospect of the Obama administration pulling the rug out from under the ENTIRE 9 million member strong Medicare Advantage Program. Michael reminds listeners that this contrasts conspicuously with candidate Obama’s promise to maintain choice when it comes to insurance options. He thought that Plan A of those darn liberals was to starve Medicare Advantage by slowly reducing payments but this frontal assault via outright cancellation could mean the end of a huge batch of innovation, cost savings, quality improvements, provider incentives and care coordination in a successful part of the Federal insurance program. Has the Obama Administration already Missed the Boat? Modest Mouse sings about it.

Robert Aurbach of Workers’ Comp Insider is next up and looks at how workman’s compensation payments that have already been arranged for injured workers can be held hostage by Chapter 11 bankruptcies. Patients are ill prepared when their payments suddenly stop, are unequipped to deal with the cross-state legal issues and are being shortchanged by underfunded so-called guaranty funds he warns. Even Joe the Plumber, for all his bombast, could be left holding the bag as a ‘least worthy creditor,’ not a human being who was counting on that monthly check to make ends meet. And even though Ted Nugent would probably rather sing for Michael Cannon, he rocks on over this by calling it an unnecessary Stranglehold.

And here’s a new term to reward you for attending this concert all the way to the end! Neil Versel of the Healthcare IT Blog finds that the definition of ‘academic bulimia’ has reached enough of a critical mass to be applicable to the error-dense environment of the teaching hospitals that don’t have adequate information technology (IT) decision support. Wake up hospital administrators, he says: When it comes to IT support, the choice should be Easy. The Barenaked Ladies are on stage saying so.

Call for Abstracts!! Do You Have a Good Story to Tell About the Care of Populations?

If so, you should strongly consider submitting an abstract for the DMAA Forum '09 Meeting. You or your colleagues may be put off by the prospect of assembling a presentation and having to present it in a mini-lecture format, but keep in mind that its a heluva lot easier than you may suspect. The abstract reviewers from DMAA are not only interested in a sufficient degree of methodologic rigor but they are more interested in new and meaningful approaches to employee, insured, uninsured or community-level populations. Folks in the audience are supportive and enthusiastic. They'll be counting on the same level of support from you when they make their presentation.

How does the Disease Management Care Blog know this? Because it has served as an abstract reviewer. It likes new program descriptions from newcomers. That's where all the innovation is.

Ask yourself:

Thanks to your novel program, did people lose weight or exercise more often? Stop using tobacco? Have better control of their chronic illness?

After your unique intervention, did enrollees see their primary care physicians more frequently? Stay away from emergency rooms? Have lower claims expense?

Once you were done, did persons express greater confidence in dealing with their chronic illness? Did they like their relationship with your health coaches?

While your excellent initiative was being launched, did the physicians change their approach? Were they willing to participate? What feedback did you get?

And let's not forget the Patient Centered Medical Homes. This is a perfect setting to share preliminary results about the many pilots underway and share notes with others at the Forum who are undoubtedly going to be talking about the same topic.

There are many reasons to submit. It's not only a reason to go to sunny San Diego, it's a chance to gauge the reactions of other experts in the field and solicit their input. It may help you spot changes that could be made to further improve your program going forward. You may be approached by the media for a quote. Various peer review journals representatives may ask you to submit a manuscript for possible publication. You may get an award for best presentation. You'll be labeled an expert. You can put this on your CV. Once you break the ice, you'll be even better at submitting for Forum '10. DMAA is a good place to trial run your abstract prior to submitting it to another meeting. This is a good way to not have to think about the prospect of how badly healthcare reform will be messed up in D.C. The DMAA 'Faculty' name badge makes a great fashion accessory and memento to show your relatives. Finally, you'll also get to meet the most excellent DMAA staff and their indefatigable leader, Tracey Moorhead.

Face it: when you and your colleagues launch a population-based care program, you probably have a pretty good idea of what the baseline is like and you probably have at least a good idea of what you'd like to see happen. By performing at least partially complete measurements and having an adequate comparison group, you have the ingredients necessary to submit your abstract along with all the big boys.

Go ahead.... the Disease Management Care Blog dares ya. You have until 8 PM EST Feb. 20 to pull it together. Mark your calendar, close down your web browser and hammer out a preliminary Word document. You thought about it last year, this year is your chance to actually do it.

Another Top 100 List for the Disease Management Care Blog

While the Disease Managment Care Blog reels from all the excellent submissions for the upcoming Health Wonk Review, it takes comfort (and some pride) from knowing that it's been named in another top 100 list. If you're reading this and learning something, you're not alone.

HWR deadline tomorrow!

Healthways Crawls Back

As regular readers know, the Disease Management Care Blog likes to keep an eye on Healthways' financials. Because it's a publically traded disease management organization, the DMCB thinks its rising and falling fortunes are a bellwether for the rest of industry, particularly the privately held companies (an example might be LifeMasters) and the entities that are subsidiaries in in larger companies (an example might be McKesson).

It took a while for the DMCB to catch up with the latest report that was released on January 8. Briefly, it looks like 'top line' revenue for the three months ending November 30 is up compared to a year earlier by almost $10 million. By the time all this money trickled though the organization, there was a net of $12.6 million, which was also up compared to last year by over a million. The number of covered lives in the U.S. and internationally is up, internal costs are being pared, there has been 'continued improvement in result from the Hedicare Health Support pilot (comment: does that mean losses and/or foregone fees are not as steep as anticipated?) and Silver Sneakers is expanding. Debt is down but so is their cash on hand (from about $35 million to just over $4 million).

Not bad. Healthways may be crawling back. And it would appear the street agrees. The image below may be blurry but check out the slight upward trend in the stock price waayyyy over on the right. There's also an analysis from that crazy guy Cramer here. That's pretty good for a company in today's markets.

As discussed many times, the DCMB is generally bullish on the disease management industry. More companies are seeking self-insured arrangements (that include disease management), disease management organizations can scale telephonic coaching with maximum efficiency better than anyone else, the DMCB doesn't think most health insurers ultimately want to own clinical care programs and last but not least, health care reform is tilting in the direction of care management for chronic illness.

The disease management industry is also tied to the health insurance business cycle. Such are the fortunes of a maturing industry with good years and bad. In the short term, the DMCB expects growth to be blunted as a) unemployment continues to climb and persons lose the insurance that's paying for their disease management and b) insurers push back on price. Healthways is also dealing with a potentially expensive lawsuit that could theoretically result in ' treble damages plus up to $11,000 per false claim .' Yikes

In the long term, however, prospects for the core business of helping healthcare consumers manage their chronic illness remain good. P/E ratio still around 8 and the stock may be on a rebound. Draw your own conclusions.

The DMCB does not knowingly invest in the disease management industry and, like many amateurs trying to build a retirement fund, relies on a professional financial manager to help it lose its money.

JAMA Commentary on Consumer Driven Health Care: It's Time to Give Healthcare Consumers a Chance

In the latest (January 21 and not on line yet) issue of JAMA, physicians Robert Berensen (of the Urban Institute) and Christine Cassel (of the American Board of Internal Medicine) argue that consumer driven health care may not be what patients need. Briefly, they argue that this kind of approach – in which consumers have full access to information on price, quality and services and get to choose accordingly – places patients at a huge disadvantage. It also discounts the proven and long standing value of physician professionalism. According to Drs. Berensen and Cassel, the knowledge needed by the consumer is too complicated, the relationship with the health care system too asymmetric and patients are too vulnerable to making bad choices. Compared to your physician healthcare system tour-guide where your doctor can act as an advisor, fiduciary and advocate, the medical marketplace is a lousy option.

The Disease Management Care Blog doesn’t entirely buy this at several levels.

While physician professionalism is an ideal, physicians are also:

Humans who carry their own bias and agenda into their patient encounters.

Vulnerable to economic factors when framing patient options.

Even when salaried and even when in premier academic settings, may belong in organizations that are monopolistic, predatory and not acting in their patients’ interests.

Drs. Berensen and Cassel also fail to distinguish between preference sensitive and insensitive care. The former involves healthcare services that are subject to patient choice (for example, a total knee replacement for progressive osteoarthritis), while the latter involves services are not readily optional (for example, a total hip replacement following a fracture). The DMCB accepts the notion that women in labor, men with heart attacks and grandmothers with hip fractures generally cannot exercise the usual laws of economics in a medical marketplace.

However, persons with chronic illness – such as osteoarthritis, prostatism, diabetes, high blood pressure and coronary artery disease – generally do have the ability and the time to get involved in determining much of the content of their care. This includes the outcomes they want from treatment and the amount of money and effort they are willing to expend to get there. There is plenty of great commentary and reviews that show that consumerism is an untapped force in healthcare.

The DMCB has lived through decades of physician professionalism and isn’t all that impressed. While it’s a great notion, relying on its routine applicability to day-to-day medical practice, while attractive, is at best naïve and at worst the last refuge of the status quo. It's what the doctor ordered, not what patients need.

We can work on expanding and improving the profesionalism but it’s time to give the consumers a chance when it comes to health care choices for chronic illness.

Antipsychotic Agents, Suddent Death, the New England Journal and Implications for Research and Disease Management

There have been a flurry of mainstream media reports (here and here and here, for example) about a study published in the New England Journal of Medicine (NEJM) that showed there was an increased risk of ‘sudden death’ among persons who use antipsychotic agent drugs.

The Disease Management Care Blog at your service. Unlike many in the media who quote from other’s press releases, it looked at the original study for numbers behind the media facts.

Briefly, the authors pulled 15 years’ worth of insurance claims data from Tennessee’s Medicaid program for persons with an average age of about 45 years who were using thioridazine (Mellaril is one brand name), haloperidol (Haldol is one brand name), clozapine (Clozaril is one brand name), quetiapine (Seroquel is one brand name), olanzapine (Zyprexa is one brand name) and respirdone (Resperdal is one brand name). These persons' sudden death rates were compared to matched persons with a similar insurance-medical profile who were not taking these drugs. That’s possible because every insurance claim indicates a diagnosis or a treatment and can be linked to age and gender.

What’s sudden death? Just what it sounds like. It’s a death that occurs within an hour of the onset of symptoms, though it’s usually thought of as simply keeling over. It’s usually but not always caused by a heart problem/coronary artery disease. It happens, but it’s rare, compared to other types of death, especially in this age group.

Antipsychotic agents block the action of dopamine in the brain and are widely prescribed for serious mental illness including psychosis. Because they also commonly have a ‘calming’ effect on users without causing sedation, they are also used by physicians for other mental illness when it is complicated by agitation such as Alzheimer’s Disease.

These drugs have been known for a long time to have side effects. They include weight gain (up to approximately ten lbs), the development of diabetes (it may go as high as 10%), higher blood pressure (more than 10 points systolic or the top number) and alterations (acquired long QT) in how electrical impulses are routed through the heart (which accounts for the electrocardiogram or ECG) in the course of normal beating (up to 3%).

The increase in weight, blood sugar and blood pressure could lead to an increased death rate from heart attacks. The alteration in the ECG could also lead to electrical instability in otherwise normal hearts. Whatever the cause, physicians have been long aware that patients who take antipsychotic agents have a higher risk of cardiac related death and/or sudden death. This risk appears to be particularly high when the newer antipsychotic agents (clozapine, quetiapine, olanzapine and respirdone) are used in elderly persons with Alzheimers Disease: the death rate can go from a baseline of 2.6% (remember, these are elderly persons) to 4.5% (in other words, the risk is increased by 1.9%) over three to four months. That's like a whopping 18% a year.

Based on the old information that there are heart problems associated with these drugs, is the information in the NEJM all that momentous? Decide for yourself: the authors found there were 895 deaths among ‘624,591 person-years’ (perhaps mathematically best thought of as 624,591 persons followed for one year) or a risk of 895 divided by 624,591 or 0.14 percent (just over a tenth of a percent) per year in the group of persons NOT taking antipsychotic drugs. Persons taking the drugs, on the other hand, experienced 223 deaths among 79,589 person-years or 0.29% per year. This overall death rate changed slightly depending on the types of drugs used, but the excess rate held up across all categories.

For comparison’s sake, check out the causes of death and their frequency in this population here. Therefore, while the risk of sudden seems very low for any single individual (3 in a thousand over a year), it’s a significant number from a population perspective (hundreds of Tennessee's citizens).

What can students of population-based health learn from this little gem of a study?

1. Once again, we’re witnessing the rise of rigorous insurance claims-based population studies that have an adequate comparison (control group) without having to rely on stodgy, time consuming expensive randomized prospective controlled clinical trials (RCTs). In fact, studies like this are more powerful than RCTs because they can draw on thousands of patients over many years and find important and statistically significant differences in the range of tenths of a percent. Disease management organizations also preside over huge data bases in their information systems and should draw a lesson from this study. They can and should also be doing this kind of research.

2. Disease management organizations that offer mental health programs have an additional reason to be vigilant about the use of antipsychotic agents in their patients. Since antipsychotic agents can mean the difference in being able to function for persons with chronic psychosis, the low risk of sudden death, when these drugs are truly needed, is outweighed by their benefit. On the other hand, use of these drugs in children or the elderly for their calming effect is dangerous (and promotion on that basis by pharmaceutical companies is illegal and expensive), especially when other approaches work just as well and are safer. Disease management organizations have a role to play (or perhaps a market opportunity?) in keeping that to a minimum through patient coaching and provider feedback.

Disease Management and the Necessary Qualifications to Be Surgeon General of the United States

After much reflection, the Disease Management Care Blog concurs with the spouse that it is not qualified to be the next Surgeon General of the United States. It’s not like it can’t handle the duties or won’t look dashing in a uniform. It can’t “pack.” If that wasn’t enough, the DMCB takes pause because of an insight that shared by our last Surgeon General, Dr. Richard Carmona about taking this inside-the-beltway job.

In an immensely informative speech, Dr. Carmona warned that President Truman advised persons in Washington DC to “get a dog” if they wanted any friends. During his tour of service, Dr. Carmona found out that it’s better to get two dogs. That’s because you’ll need the second when the first one turns and tries to bite you.

Given the spouse’s derision as well as the high likelihood that even the most bipartisan lovefesting will turn eventually devolve into partisan rancor, the DMCB is happy to endorse Dr. Sanjay Gupta’s ascent to the post. While his familiarity with all things media is certainly a plus, the DMCB principally supports the nomination because it’ll mean there will be far less of Dr. Gupta when CNN is on. In fact, the DMCB wonders if there is room for an Assistant U.S. Surgeon General and nominates Fox News’ Dr. Manny for the same reason.

But seriously, who should be Surgeon General? While the DMCB is a fan of ‘disease management’ and has many doctor friends in the industry, those aren’t the only reasons why it believes any of the senior physician executives in any of the national level disease management organizations are far more qualified than many in or out of government, media or policy circles would give them credit for. Check out those “Duties of the Surgeon General” and you’ll see terms like ‘educating the public,’ ‘advocating for effective disease prevention and health promotion programs,’ ‘articulating scientifically based health policy analysis,’ ‘promoting …health initiatives e.g., tobacco and HIV prevention,’ and ‘elevat[ing] the quality of public health practice.’ Sounds a lot like the latest approach to population health, doesn’t it?

The DMCB understands the job also involves administering the U.S. Public Health Service Commissioned Corps, advising the President and interacting with a host of governmental entities, but the disease management executives represent a pool of persons with considerable acumen in the art and science of improving quality, optimizing cost and navigating large organizations around competing stakeholders.

Call the it naïve, but to the DMCB, it sounds like the Surgeon General is the Chief Medical Officer of the United States government. The government is currently very interested in lessening the burden of chronic illness. What that insight, just who is best qualified to take the job?

The Fickle Sine Wave of Provider Payments and Implications for the Patient Centered Medical Home

The Disease Management Care Blog has been thinking about the Patient Centered Medical Home. In yesterday’s post, it reviewed a New England Journal of Medicine piece that noted one of the virtues of the PCMH is that it will be paid for by a ‘set fee.’

While it was a medical director in the not too distant past, the Disease Management Care Blog was once told by a veteran health insurer executive that hospitals always seem to pine for one of two contrasting payment methodologies: either ‘per diem’ or ‘DRG.’ The former is ‘per day’ or a payment for each inpatient day. The latter is a global payment, based on a diagnosis (or 'Diagnosis Related Grouping'), for the entire patient stay regardless of how long the patient is there. Under the per diem approach, the longer the patient is in the hospital, the greater the money. Under the DRG approach, the less time the patient stays in the hospital, the greater the money.

And how can you predict which payment system a typical hospital will prefer, asked my mentor? Simple, he said, it’s the one they’re not under. Under the per diem arrangements, hospitals are generally subjected to ‘concurrent review’ or getting regular phone calls from the insurer asking about the status of the patient; if the patient isn’t acutely ill, concurrent review can lead to a lower per diem payment or even a decision to deny coverage (and it works). In addition, hospitals generally feel the per diem payment is not high enough. Under DRG payments, there is no concurrent review, but hospitals have a large incentive to discharge the patient, since the longer they stay, the greater the financial loss. In addition, hospitals generally feel the DRG payment is not high enough.

If per diem reminds you of fee-for service (payment for each service instead of each day), it should. Ditto capitation and DRGs: the former pays for a patient’s care over a month regardless of how complicated the patient’s care is.

The DMCB has been thinking about this because it believes physicians are not unlike the hospitals when it comes to the grass-being-greener-on-the-other-side approach to reimbursement. During the 1990’s, many primary care physicians welcomed capitation because fees were otherwise being denied and they weren’t high enough compared to what could be made under a capitated fee schedule. And capitation did well at first but, as readers will recall, it had many problems including its built-in incentive to undertreat. The backlash led to the return of fee for service.

Guess what: while most descriptions of the proposed payment mechanism for the PCMH don’t call it ‘capitation,’ that’s exactly what it is. And while the PCMH is good and righteous and has many redeeming features, the DMCB has to wonder if part of its attraction for physicians has less to do with its clinical advantages and more with it simply being an alternative to the tiresome nickel and diming of fee-for-service with denials, prior authorizations and underpayment.

And so the cycle goes. The DMCB predicts, assuming the PCMH has legs, that physicians will eventually seek ways to unbundle the services of the medical home so that they can get paid “fairly” for all of the individual work elements involved in coordinating care. Until, that is, they’ll want to be given a global payment.

And so the cycle goes.

The New England Journal, Physician Compensation and the Medical Home

Gasp! Physicians are being pressured to make money! Health care is a business! Woe.

This is the doom and gloom insight of Drs. Hartzband and Groopman in a perspective published the latest January 8 New England Journal of Medicine.

The outcome of this bleak state of affairs you ask? Well, according to these authors, doctors may not freely share their medical opinions with colleagues, expecting instead to be paid. Communality will evaporate in a pernicious web of market-driven bartering. Lacking a sufficient reward, providers will regress to the lowest ratio of effort to reward and, if it's not worth while, go home and watch Oprah or, better yet, learn ophthalmology. No wonder primary care physicians are opening concierge practices. And thank goodness the 'patient centered medical home' (PCMH) has been invented. It emphasizes a 'social exchange that exists in a family,' is a "compassionate partnership," and is expected to yield up 'substantial cost savings.' Be warned policymakers: there's a difference between reimbursement and money. The former fosters physician collegiality, cooperation and teamwork. The latter promotes meanness, evil doing and being naughty.

After reading that article and reaching for the Compazine, the Disease Management Care Blog awards these two Boston academics the Arnold Relman Physicians Should Be Salaried Award. While they’re basking in that recognition, they should also know that the economics of their practice environment make for great preaching but have little basis in the other realities of mainstream clinical practice. What’s more fee-for-service isn’t all that bad. Paying physicians per ‘service’ is not all that dissimilar from paying physicians for performance which, despite some DMCB doubts, would probably be welcome even in Boston.

The DMCB heard an anecdote and it believes it. It was told by a salaried physician at a very large group practice that the most dangerous place in the city was that group’s doctors’ parking lot at 5 PM. As patient access and physician productivity declined, the administration stepped in with ‘variable pay’ with incentives. Once the docs felt the link between their salary and how hard they worked, the spectacle of physicians rushing out of their clinics at the end of a 9-5 workday ceased.

Let’s face it. Physician compensation will be a mix of fee-for-service and capitation for the foreseeable future. The former increases utilization while the latter blunts it. The DMCB predicts this ‘gas pedal and brake’ approach will probably be fine tuned to promote and/or blunt underused and overused services, respectively. The good news is that both systems of payment have the potential to reward docs fairly and richly – assuming it’s done right.

Last but not least, the DMCB wonders what the PCMH has to do with fixing physician compensation. The notion of a medical home has merit but is it really going to turn primary care into the paradise described in this article?

Really?

Population Health Management Journal Summary For Your Perusing Pleasure

It's that time again! The December 2008 issue of Population Health Management, that journal formerly known as Disease Management is about to land on your desk. But you're busy. Those e-mails are overwelming your in-box. The December '08 let-it-wait-till-January-'09 management decisions are looming. Do you crack the cover of that journal and if so, which articles are of interest to you? More importantly, is there one you can quote or comment on at that staff meeting tomorrow to the amazement of your colleagues and boss?

The Disease Management Care Blog at your service! Plenty of stuff here across the employer, program, behavioral and actuarial settings........

Ron Loeppke, Sean Nicholson, Michael Taitel, Matthew Sweeney, Vince Haufle, Ronald Kessler: The impact of an integrated population health enhancement and disease management program on employee health risk, health conditions and productivity.

Is the company you work at self insured? You’re in luck because your employer can be like DIRECTV. They distributed an employee health risk assessment in April of 2003 with a $15 gift certificate incentive for completion followed by a $300 credit for their health insurance if a) low risk or b) moderate or high risk and willing to participate in up to 6 lifestyle-health improvement programs. The programs included in-person as well as remote coaching. $15 was enough to get a 60% baseline participation rate. There was a follow up survey in 2005. This report focuses on 543 persons that completed both surveys. As expected there was ‘risk’ shifting over time among the low, medium and high risk populations, but the downhill flow of persons from high to medium and from medium to low exceeded the uphill flow. A reduction in risk was associated with a reduction of 3.5 absences per year versus a comparison group. Unfortunately there is little information on the penetration of this program into the entire DIRECTV workforce: is 543 employees enough to make a difference for an entire company? What’s more frustrating, the authors state we need to wait for another publication to find out if health care insurance claims expense was reduced.

Roger Mazze, Margaret Powers, Harry Wetzler, Cori Ofstead: Partners in advancing care and education solutions study: Impact on processes and outcomes of diabetes care.

The International Diabetes Center at Park Nicollet has developed a ‘Partners in Advancing Care and Education Solutions’ (PACES) program based on their Staged Diabetes Management approach to diabetes care combined with an educational curriculum. 40 medical centers were invited to compete for inclusion in a pilot and 10 were eventually selected. Using the NCQA’s Diabetes Physician Recognition Program and the ADA Education Recognition Program criteria at baseline and at follow-up, there was a broad improvement in most of the diabetes quality measures pre-post. In addition, all participating centers ended up being certified by the NCQA and the ADA. The DMCB wonders if the authors chose the centers that were performing at a low level and/or had the highest interest in succeeding. If so, the generalizability of this study may be limited. On the other hand, if you want to turbocharge your institution’s likelihood of getting ADA or NCQA recognition, these guys may be the ones to call.

Ramsey Farah, Kyahn Kamali, Jeffrey Harner, Ian Duncan, Thomas Messer: Random fluctuations and validity in measuring disease management effectiveness for small populations.

Want to know if your disease management program saved money? Well, if the number of persons in the program is small, the ability to spot any meaningful savings is decreased and gets worse as the number of participants goes down. As a result, you may need to a) hire an actuary or b) read this paper or c) do both. If you read this paper, you’ll be better able to understand using 1 vs. 2 standard deviations, 1 or 2 sided testing, admission based savings calculations, truncation at a $100,000 stop loss limit and various external populations for non-chronic trending. After reading this paper, the DMCB thinks you'll need to hire an actuary anyway.

Cynthia Hartsfield, Eli Korner, Jennifer Ellis, Marsha Raebel, John Merenich and Nancy Brandenburg: Painful diabetic peripheral neuropathy in a managed care setting: patient identification, prevalence estimates and pharmacy utilization patterns.

Using claims submitted by physicians to insurance companies to indentify populations with a condition of interest is very much an art and a science. Claims can both “overcall” a diagnosis (be falsely positive) or miss a diagnosis (falsely negative). Thanks to a grant from a manufacturer of a drug meant to treat diabetic neuropathy, the folks at Kaiser used the gold standard of chart audits to fine-tune a claims-based algorithm that had a so-so false positive rate (of about 50%) and a low false negative rate (about 1%) for this condition. They estimate that among persons with diabetes, the prevalence of neuropathy, depending on the criteria used, is between 11-21%. Furthermore, treatment of diabetic neuropathy is very difficult: nothing works very well. As expected, medication claims in this population is highly variable in both the numbers of persons receiving treatment and the types of drugs being used. This is a good paper because the authors provided the ICD-9 codes and the reader gets to think about the good and the bad about using insurance claims instead of chart reviews; many of the lessons here apply to other conditions.

Karen Fitzner, Deborah Greenwood, Hildegarde Payne, John Thomson, Lana Vukovljak, Amber McCulloch and James Specker: An assessment of patient education and self management in diabetes disease management – two case studies.

The wonderful folks at the American Association of Diabetes Educators are pointing out in this review of the literature that there is some evidence that Certified Diabetes Educators (CDEs) can be a valuable asset in diabetes disease management. Yes, there are registered nurses and case managers, but the CDEs can provide an extra level of expertise to patients that need it. They even provide two case studies – one from an integrated delivery system and the other from a for-profit disease management organization – that spell it out in greater detail. The DMCB knows CDEs are an important option in disease management and is glad to finally see a paper that confirms its suspicions.

Thomas Blakely and Gregory Dziadosz: The chronic care model for behavioral health care.

This is a report from an outfit called ‘Touchstone innovare’ who implemented a behavioral version of the chronic care model in their Michigan mental health agency. Frankly, this is a difficult paper to read because there’s no description of the workings of the agency or the disease burden in the population. There was a control group but they were contaminated by being the same agency. That being said, a pre-post analysis showed an improvement in multiple measures of psychological well being and an astounding 39% reduction in inpatient days. This is a good start, but much work needs to be done before we really know how the chronic care model will work in outpatient behavioral medicine.

The Latest Health Wonk Review is Up!

Healthcare reform. Costs. Managing care. Regulations and governmental management. Bad behavior. Health IT. It's all in that big blender called the latest Health Wonk Review hosted by the Health Care Blog and written up by the smart Brain Klepper. Head on over and have a policy smoothie your brain will love!

Physician Outliers and Their Role in Health Outcomes Variation

The shortness of breath was returning. She suspected her long standing asthma was responsible, but the inhalers were to no avail. See finally saw the doctor, expecting another short course of glucocorticosteroids. The doctor examined her and arranged for an echocardiogram. It showed a dilated cardiomyopathy, i.e., chronic heart failure.

In addition to chronic obstructive pulmonary disease, high blood pressure and having had a stroke, he had had a cardiac pacemaker placed. He felt best when his blood pressure remained high at 170/90. His regular doctor didn’t change a thing.

Even family wondered why the doctors could never really find anything to help her myriad complaints that included dizziness, chest pains and intestinal complaints. As the years went by, she eventually developed diabetes mellitus. Her doctor, a fan of disease management, told her to not answer the nurses when they phoned her.

As regular readers may have discerned, the Disease Management Care Blog is delighting in Malcom Gladewell’s bestselling book Outliers. In it, he shows that human accomplishment is not just a function of innate ability but timing, social support and practice. When it comes to developing world class expertise in intellectually difficult tasks, that level of necessary practice is prodigious: 10,000 hours. That translates to three to fours a day for approximately ten years.

What does this have to do with the care of populations with chronic illness? In yesterday’s post, the DMCB pointed out that supporting ‘patient centered medical care’ (where the patient is ultimately responsible for selecting a course of treatment) can result in variations in clinical outcomes that are arguably ‘good.’ In today’s post, it argues that high physician expertise can also lead to variation.

Patients and healthcare professionals are well aware of the physician who can glance at the x-ray and spot the tumor that no one else will see, the other physician who can spend minutes with a patient and immediately discern the diagnosis or the surgeon who can perform an extraordinarily difficult procedure and cure the problem. The DMCB thinks medical school, post-graduate training and the additional years in practice easily exceed 10,000 hours. For the right individuals under the right circumstances, that level of practice results in far more than ‘art’ or ‘science,’ but Gladwellesque expertise. That’s the kind of ‘outlier’ ability that innately knows a patient’s shortness of breath is not run-of-the-mill asthma, that persons with pacemaker syndrome may ‘need’ high blood pressure and that a somatoform disorder is one area where the less that is said about disease, the better. Because they are outliers, they find outliers. Outliers are statistical anomalies. It's not art, it's not science, it's exceptionalism. As physicians, they find exceptions. They lead to variation.

True, the national guidelines that tout treatment of asthma, heart failure, hypertension and diabetes always caution they are no substitute for a physician’s judgment. It is also true that most of the problem with docs' inability to adequately recognize or treat asthma, heart failure, hypertension and diabetes can result from less than 10,000 hours of training or failure to use their 10,000 hours to maximum effect. As a result, too many patients fail to receive a sufficient level of quality care.

However, for those world-class level experts who understand the guidelines, the DMCB doubts they’ll achieve 100% compliance with nationally recognized guideline-based standards. There’s no science or peer review literature on this, but more likely they’ll be achieving 80-90% compliance because somewhere between 1 to 20% [?] of patients have an outlier reason to not receive standard treatment. The DMCB asks: which would YOU rather have: a doc with 100% compliance or a doc with 90% compliance?

Given the importance of 10,000 hours of 'practice,' perhaps being called a ‘practitioner’ is not such a bad thing after all.

Patient Centered Medical Care and Disease Management

The Disease Management Care Blog is ashamed to admit that 'Patient-Centered Medical Care' (PCMC) has been treated by it as something of an afterthought. What is this concept and what are the implications for disease management?

It turns out that the famous Crossing the Quality Chasm report has included ‘patient centeredness’ as one of the six pillars for the reform of healthcare. In order to achieve this, health care delivery should be customized based on the patient’s values, have open sharing of information, be evidence based and placed under the ultimate control of the patient. There is a good review on the topic here.

This has several important implications:

1) health care delivery will need to be far more flexible and accommodate a range of patient preferences, including doing nothing to being highly aggressive.

2) variation, that bane of the Dartmouth Atlas, the NCQA and quality improvement weenies everywhere could turn out to be a good thing if it is the result of truly empowered patients using their own values and preferences.

3) measurement of 'quality' will be a heluva lot more difficult, since the ‘denominator’ will need to be based on what a reasonable fully informed patient would have chosen for treatment of their back pain, management of their diabetes or use of the ICU with life threatening illness at the age of 90. That reasonableness includes getting an MRI anyway, opting for an A1c of 7.2 and having everything done even if the chance of survival is less than 1%.

4) insurers should embrace it because, in balance, when reasonable patients are fully informed about the risks, benefits and alternatives to various treatment options, proportionately more opt for less invasive (and therefore less expensive and possibly higher value) treatment.

5) once again, disease management should have a huge role to play because it has the resources and institutional intelligence to pull off fully informed patient empowerment. In fact, the DMCB believes disease management organizations should not only emphasize 'PCMC' as part of its suite of services and embrace it as part of its policy advocacy.

PCMC is not an afterthought. It's what disease management has been doing all along.