Not Confirmed, But More Than Just A Rumor?

Check out this line up.

HHS Secretary Kathleen Sebelius
HHS Deputy Secretary Bill Corr
HHS General Counsel Bill Schultz
**CMS Administrator Don Berwick**
CMS Deputy Administrator David Cutler
FDA Commissioner Margaret Hamburg
FDA Deputy Commissioner Joshua Sharfstein

The Disease Management Care Blog says bravo!

Hat Tip HealthHombre.

Congressional Budget Office Says Disease Management May Well Be Cost Effective

On February 25 2009 CBO Director Douglas Elmendorf gave testimony before the US Senate on options for expanding health insurance coverage and controlling costs. It's an impressive 31 page document that effectively describes a host of healthcare reform policy options. The Disease Management Care Blog found some statements about - what else - disease management. The most important quotes are below.

Note that overall, CBO is still describing the industry in supportive terms.

'...disease management services can improve health and may well be cost effective - that is the value of the benefits could exceed the costs. But those efforts may still fail to generate net reductions in spending on health care because the number of people receiving the services is generally much larger than the number who would avoid expensive treatments as a result.'

The DMCB agrees that considering the merits of health care interventions based on their ability to 'save money' is less useful than assessing them on how well they deliver value. Contrast nurse-based coaching aimed at achieving an A1c of 7% (which is typically poorly covered outside of managed care settings, if at all) versus stents for persons with coronary artery disease. Both result in betterment. Both cost. One delivers far greater benefit than the other.

As for the dilution of disease management interventions over large populations, organizations in the business of population-based care management have known about this for a long time. In response, they use predictive modeling to target beneficiaries who are most likely to benefit from the interventions. For this to work, however, the Medicare program will need to consider the implications of unevenly applying a benefit to an eligible population. The DMCB has an ironic paraphrased quote to think about in these these days of expanding central government: from each according to their ability, to each according to their need.

...proposals could include specific elements designed to induce individuals to improve their own health or to encourage changes in how disease are treated. Through a combination (bolding mine) of approaches, proposals could try to change the behavior of both patients and providers by promoting healthy behavior,.... expanding...preventive care, establishing a medical home..., adopting 'disease management' programs,... funding research comparing the effectiveness of different treatment options... expanding the use of health information technology... and modifying the system for... malpractice. In many cases studies... studies do not support claims of reductions in health care spending or budgetary savings.

Not quite. Many of the studies in each of the domains above are restricted to just that domain (for example, just the medical home) or to a particular piece of the domain (for example, the use of physician order entry). There are few, if any, studies that examine the impact of any significant combination of approaches (for example, the medical home plus telephonic-based coaching that promotes the latest effectiveness research findings linked to a personal health record). The DMCB thinks combinations of these interventions will be proven to be greater than the sum of their parts. This will be the next frontier for effectiveness research in population based care, Medicare demonstrations and Medicaid waivers. In addition, this is where we'll see innovations in those pockets of the medical insurance market place left untouched by the Federal tsunami.

Will Obama's Healthcare Reform Be His Boston Tea Party?

Did you watch Obama’s speech last night? The Disease Management Care Blog did and couldn't discern just what the next steps are going to be when it comes to healthcare reform. It has, however, watched many other past local and national politicians square off on the issue with the same grim determination. The DMCB wishes our President good luck and would like, as bloggers are wont to do, offer some unsolicited and unheard advice.

In the winter of 1773, the British Crown made an eminently rational determination. Since the American Colony’s French and Indian Wars had cost the royal treasury dearly, a special tax was called for. As we all know, a citizen-group in Massachusetts disagreed and held what has been come to be known as the Boston Tea Party.

Fast forward to 2009 and check out this videotape showing a vociferous bunch of Chicago Mercantile Exchange floor traders reacting to the skeptical commentary of a CNBC broadcaster. You’d think these guys should be able to discern the rationale behind the mortgage bailout. As the DMCB understands it, the mortgage mess is torpedoing banks, locking up credit markets, depressing home values and wrecking neighborhoods. Tapping the US Treasury to fix it is also arguably fair and rational. These Chicago traders apparently disagree.

While it cannot judge the merits of the bailout, the reaction of these smart businessmen reminds the DMCB of its own past Tea Party. Yes, we thought that we had a wonderful disease management program destined to improve patient care, reduce physician workload and increase provider income. We spoke to local Chief Medical Officers and VPs and secured their input and buy-in. It was then rolled out in a series of meetings, e-mails and formal presentations. Many physician-colleagues, after listening carefully, told the DMCB to take a hike. Others said nothing, returned to their clinics and turned to both active and passive resistance.

So what’s the lesson? Even if an initiative is 1) needed, fair, rational and well designed, 2) rolled out with an abundance of marketing and education and 3) is directly tied to the self-interest of all involved, everyman Bostonians, Chicago traders and physicians are more than capable of coming up with opinions that are 180° contrary to those of the leaders and experts. Physicians who believe in the merits of one-on-one patient care, based on independent professionalism and scientific judgment may find ‘electronic records,’ ‘team based care,’ ‘populations,’ ‘pay for performance’ and ‘bundling’ to be wanting. As one very bright but oppositional physician explained to the DMCB, he didn’t need any more education. He got it. Want he wanted was to be left alone.

The DMCB also learned something else. The resistance of the physicians wasn’t a function of narrow economic self-interest, intellectual inertia, lack of knowledge or professional dysfunction. They had their own vision, paradigms, ideals, thoughts and opinions. They were being reasonable. Given the circumstances, who can be surprised that the docs concluded that it was their patriotic duty to resist?

In response, we went back to the drawing boards. We addressed some of the concerns, ignored others and set up work-arounds when physician cooperation wasn’t absolutely necessary. We then moved forward and counted on a track record of success to convince the nay-sayers. It took a lot of time and a lot of work.

Fast forward again to the promised release of the Obama Administration healthcare reform proposals. Even if the plan is expertly contrived, even if organized medicine groups’ leaders are supportive, and even if economic self-interest is at stake, the DMCB will not be surprised if a significant number of physicians resist.

The Advice? Don't let healthcare reform provoke a Boston Tea Party. The last time that happened, things really turned upside down.

The DMCB recommends that the Obama Administration recognize that many mainstream physicians will have deep concerns. It should resist ascribing it to unawareness, irrationality, selfishness, the lack of outreach or poor planning. Think King George III.

The DMCB also suggests that if the resistance is significant, the success of healthcare reform may hinge on Washington DC’s ability to adjust and adapt. Avoid being mainframe. Think the Yes We Can Campaign.

The Latest Cavalcade of Risk is Up!

Russell Hutchinson excellently hosts this week's blogmos roundup of all that deals with health risk and the financing of health risk for the latest version of - what better name could there be? - the Cavalcade of Risk. Take a look, or risk not being up on the 'best' and being some sort of knucklehead.

The Latest Population Health Management Journal Is Out!

Oh joy! Isn’t it great when you open your mailbox and find a goody like the latest issue of Population Health Management? Sure, you want to thumb through every page, ponder every word, examine every graph and review every citation but…. you don’t have time. But unlike your colleagues, you also regularly read the Disease Management Care Blog. That is your secret weapon. Scan the summaries below and then decide which needs to be read right away and which ones can wait. As an added bonus, the DMCB helps you impress your co-workers with your erudition by rustling up some key quotes. Use them to impress the boss at those upcoming conference calls and business planning meetings.

Dominick Esposite, Erin Taylor and Marsha Gold: Using qualitative and quantitative methods to evaluate small-scale disease management pilot programs.

Heard of the Medicaid Value Program? Neither did the DMCB, but this involved having 10 organizations use a variety of care interventions for Medicaid beneficiaries with multiple chronic conditions. Using a combination of qualitative and quantitative research, the authors found the implementation, competing priorities, provider buy-in and local leadership commitment to be the key ingredients associated with success. This is must reading if you’re going to use some of that Federal stimulus money to quickly rustle up a new Medicaid-based program.

Key quote you could use at an upcoming meeting “According to Esposito’s article in PHMJ, a smaller than expected number of eligible beneficiaries and lower than expected patient engagement rates are not uncommon.”

Iver Juster, Stephen Rosenberg, Deeptimayee Senapati and Mayur Shah: “Dial-an-ROI?” Changing basic variable impact cost trends in single population pre-post (“DMAA Type”) savings analysis.

In a prior post, the DCMB delighted in a review of chronic vs. non-chronic trends to derive what the cost of health care would have been absent a disease management program. If you think that’s simple, read this paper from a DM Jedi Master and his colleagues and find out just how complicated it can be and why, in the end, you’re going to need an actuary to ascertain whether you’re really reducing claims expense.

Key quote you could use at an upcoming meeting “According to Sensai Juster’s article in PHMJ, the length of the look-back period, the length of claims runout and the number of months of enrollment are important determinants of trend!”

Jason Cooper, Lakevia Hall, Angel Penland, Andrew Krueger and Jeanette May: Measuring medication adherence.

Read this and you’ll not only know the operational definition of medication adherence (the days supplied divided by the days prescribed) but how to handle claims runout and disenrollment when it comes to assessing whether a population is taking their meds. You’ll also get benchmark adherence rates in a commercial population (depending on the condition, mostly between 75% and 84% - bile acid sequestrants unsurprisingly are lower). Kudos to Accordant for making the data available.

Key quote you could use at an upcoming meeting “According to May’s article in the PHMJ, our medication adherence rates are already running at [insert ‘more’ or ‘less’] than what’s been reported in the literature!”

Kejian Niu, Liming Chen, Ying Liu and Herman Jenich: The relationship between chronic and non-chronic trends.

Sorry, but there’s no escaping this chronic and non-chronic trend stuff. In this paper, the authors stress-tested the DMAA methodology in a stable population without a disease management program and compared the chronic and non-chronic trends over time. It turns out the two were similar if there is satisfactory statistical adjustments and persons are annually requalified.

Key quote you could use at an upcoming meeting: “Good thing our actuarial consultants are using the DMAA methodology to assess the impact of our disease management program. According to Niu’s article in PHMJ, that approach has considerable merit!”

Thomas Kotsos, Keven Muldowney, Griselda Chapa, Eric Margin and Antonio Linares: Challenges and solutions in the evaluation of a low back pain disease management program.

This is even more evidence that the DMAA approach is taking root, since this article also relied on that methodology to assess a condition of great interest to employers. There appeared to be savings, but the subpopulation with simple mechanical low back pain apparently experienced an increase in claims expense. Everyone else experienced decreased utilization. One lesson may be to leave the simple back pain patients out of the program.

Key quote you could use at an upcoming meeting: “We’re already doing the top 5 chronic diseases, so let’s tackle a new one – like low back pain. Kostos in PHMJ showed that a telephonic nurse support intervention can make a difference!”

Al Lewis: How to measure the outcomes of chronic disease management.

Exhausted by all this high falutin actuarial stuff? The remarkably insightful father of disease management comes at the topic from another point of view by giving you 5 Important Questions that should always be asked when you are attempting to assess whether your disease management program is working.

Key quote you could use at an upcoming meeting: “You’re right of course, but how do we estimate the amount of co-morbidity reduction that has also taken place? According to Al Lewis (and everybody knows his name), that is a key question that must be addressed!”

And then there’s an editorial by … the DMCB. Called ‘Disease Management Grows Up,’ it points out that the sophistication of the literature above reflects an evaluation-science sea change underway in the disease management industry. In fact, the growing sophistication of measurement in population-based programs could well turn out to be the benchmark for other healthcare reform initiatives, including the patient centered medical home.

Key quote here: ‘Gosh, if the company I work for isn’t a member of DMAA, we should join. Not only would we get the PHMJ, we could get involved in future iterations of how to measure outcomes in population care management programs!’

Here’s a new number for you to memorize from Health Affairs: $2.4 trillion. The one that should scare you? 6.2%

***A DMCB early release***

Mr. Obama will be giving an address Congress tonight and the Disease Management Care Blog will be all ears. It hopes to learn more about the Administration’s coming plans for healthcare reform. The tone surrounding those plans may be gaining urgency thanks to a curiously timed if highly informative release of a Health Affairs web exclusive by actuaries from the Centers for Medicare and Medicaid services.

They’ve rendered up two numbers you may want to listen for tonight or in the coming days: 2.4 trillion and 6.2%. The former may make it into the speech. The latter probably won’t. The former is big and makes the stimulus package pale by comparison. The latter sounds small. Don’t let that fool you, however. 6.2% is really really scary.

The first number is the amount of money that will be spent on health care in 2008. As testimony to the huge size and strength of our economy, we can currently afford to spend that on ourselves every year. Unfortunately, we can’t afford the second number. That’s the rate of spending growth that is projected over the coming years. It contrasts with the 4.1% growth projected for the gross domestic product (GDP – or the sum of all goods and services produced in the course of a year). The mismatch means that year over year, more and more of both our individual income and taxes will be spent on our own and others’ health needs. Right now, that is about 16% of GDP. It could grow to a total of 20% in less than 10 years.

6.2% is known as ‘trend.’ While us mortals think about absolute numbers, actuaries lay awake at night worrying about the rate of growth. Successful insurers recognize that increases in the rate of health care costs are part of the business. Their job is to predict those increases and advise what the health insurance premium should be. The DMCB is no actuary, but it bets the Fed’s actuaries are telling their bosses that this kind of trend is this.

The number 1 and 2 drivers of the cost inflation is ‘medical prices’ and ‘growth in the use of services,’ which accounts for about 2/3 of the growth rate – not the aging of the population. Interestingly, the ‘administrative costs’ of private insurance are projected to continue to decline from over 13% to 12%, making it less likely that insurance company’s ‘profiteering’ can be blamed for our cost woes. And the DMCB doesn’t understand how spreading unsustainable health care costs over the uninsured is going to help either.

Right now, all we know are increased money going to the States for SCHIP/Medicaid and less money for Medicare Advantage. That’s easy. Now comes the hard part - where we see the difference between oratory and reality, bombast and bipartisanship, gimmicky delay versus the day of reckoning.

2/25/08 addendum: The Wall Street Journal points out that the numbers above were calculated without the additional spending in the current stimulus package. Yikes.

FCCCER: An Unfortunate Acronym. Hopefully, It Won't Stick

There they go again. Invective. Hyperbole. Partisanship. Un-niceness.

Read this editorial and you’d get the impression that the Feds are using health care as a Trojan horse to strip us of our freedoms. Listen to this guy and you may want to don your war paint and dump some tea into Boston’s Harbor. No… wait! It’s the other side that’s evil. They’re vicious, ignorant fear mongers who should just sit down and shut up. Because, this is Good and Righteous. It's Very Good.

And so it begins.

What’s got everyone so riled up? ‘Comparative effectiveness research’ and the ‘health council.’ Confused, the DMCB went to the original language of the stimulus bill (p. 63 of this 407 page behemoth) and found language that states $1.1 billion will go to the National Institutes of Health (NIH) and the Secretary of Health and Human Services for ‘comparative effectiveness research’ that measures ‘clinical outcomes, effectiveness and appropriateness’ of ‘items, services and procedures that are used to prevent, diagnose or treat.’ The money can also be directed to encourage the use of registries, clinical data networks and electronic health data that can be used for outcomes data. The money can be granted to ‘appropriate public and private entities.’ $1.5 million is allocated to the Institute of Medicine to decide on priorities for the research.

There will also be a ‘Federal Coordinating Council for Comparative Effectiveness Research’ (FCCCER) (page 73) which will be made up of 15 individuals who ‘foster’ coordination of the research as well as advise, assist and report. This Council will not be allowed to mandate coverage, reimbursement, or other policies for any public or private payers such as clinical guidelines for payment, coverage or treatment.

Like factcheck.org, the DMCB is not worried. But it’s not all that impressed either. Here’s why:

In its days as a managed care medical director, we were constantly scouring the peer-reviewed medical literature to help us divine insurance coverage decisions. We found no matter how carefully crafted, even the best studies leave unanswered questions and are riddled with exceptions. Recent case in point? The rigorously performed SYNTAX trial, which found open surgery bypass had better outcomes compared to the use of stents among persons with severe coronary artery disease. You’d think case closed until you read how these two experts differed in their interpretation of the findings. What they agreed most strongly on was the need for more research. More research begets more research.

In addition, the DMCB isn’t sure that the current insular medical-industrial complex is prepared to conduct the kind of comparative research we need today. We need speed, we need community-based studies, we need to simultaneously implement promising interventions and we need to ask not only ‘if’ it worked but ‘how’ and ‘why’ and for who and under what special circumstances. It’s not just the DMCB that feels that way.

What’s more, clinical effectiveness research won’t answer many important questions – even if money isn’t an issue and even if everyone in Washington DC would like to ethically advance cost effectiveness. Should hundreds of thousands of dollars be spent to prolong the life of an elderly man with advanced brain cancer? What should ICU physicians do in the face of overwhelming but not absolute odds of dying? Is State by State variation due to physicians and is it necessarily bad? Even if we know something doesn’t work, would we still pay for it?

And how about FCCCER? Assuming ‘advise’ and ‘assist’ and ‘report’ are really action verbs, does it have any hope of navigating through the hugely bloated DC bureaucracy? Note that many of its members will be from AHRQ, CMS, NIH, FDA and the VA. Think members of Congress won’t be calling them on behalf of their constituencies? Think again.

Last but not least, FCCCER is an unfortunate acronym. Quite.

Summary: It’ll take years before results appear from traditionally conducted effectiveness research. It won’t answer the important questions. Medical directors will still need to use clinical judgment in deciding coverage issues. It’s not a Trojan Horse and it’s not a panacea. Hopefully, if it has any negative impact, my medical colleagues won't use their own FCCCER-like action verbs to describe its performance.

A Tale of Two Reports. Commonwealth Fund and Milliman.

Want to think some more about reducing healthcare costs? Neither does the Disease Management Care Blog but, nonetheless, two reports deserve your attention. One is a retread of some unproven policy notions swirling about Washington DC. The other makes for a refreshing read from an actuarially sound point of view.

The Commonwealth Fund report on a High Performance U.S. Health System would naively spread the costs of an out of control healthcare system over a larger payer base. By forcing more persons to join, the average cost of the insurance premium may drop but overall costs will continue to grow. The DMCB also continues to be amazed over the faux certainty that the medical home, health information technology or patient-centered-care will measurably increase quality or reduce claims expense. The DMCB also doesn’t understand the difference between The Commonwealth Fund’s support for capped premiums and Nixonian price controls, or if either are reasonable in a real world risk-transfer environment. That being said, there are some other meritorious ideas, including bundled payments. Look it over for yourself and decide.

In contrast, check out this report from the 100% actuary guys at Milliman. While less likely to attract the attention of the policy elites or the blogmos, the DMCB likes this because it tackles healthcare cost inflation in lieu of recycling policy fluff. Bruce Pyenson et al present a series of options that, while politically challenging, are meaningful long-term goals that will fit into any future payment system, public or private or both.

According to these guys, reducing the rate of healthcare inflation from 16% of GDP to 12% (a 25% decrease) can be achieved by exporting the best practices that are already active in many areas of the United States to the rest of the country. This will shift utilization, without having to change the reimbursement (i.e., cost cutting) per unit of service.

Here's a shortened summary of Milliman's excellent recommendations. The DMCB thinks they make for good benchmarks next time you hear or read others' ideas on how to get health care costs under control as part of our reform efforts:

Reduce overall utilization and variation to levels being achieved at Intermountain Healthcare and Mayo (maybe venture capital is warranted at finding successful ways to align independent health care entities at a regional level?)

Make hospital-based health care services available 7 days a week (don't let a weekend get in the way of performing needed testing and treatment)

Put hospitalists in control of inpatient stays and make specialists readily available for consultations (the DMCB is convinced that hospitalists make for more efficient inpatient stays)

Implement inpatient pathways, order sets, computerized order entry (these are the inpatient parts of the electronic record that have been shown to improve efficiency and reduce complications)

Reduce medically unnecessary admissions from the ER to the inpatient setting (once an ill patient crosses the ER threshold, it's very hard to return them home. It's far easier to admit and move onto the next patient)

Optimize discharge planning (the weeks after discharge from a hospital is a time of great vulnerability. Patients are still sick and may not know what to do to cope)

Routinely get family involved (back in the day, the DMCB asked family to come in and learn how to care for Mom. The nurses were more than happy to help teach. Anecdotally, it works)

For patients already in nursing homes, manage their needs as much as possible there rather than transferring to a hospital (physicians will recognize that nursing homes are a rich source of transfers to the emergency room and that most get admitted to the hospital).

Promote commoditized generic medications, durable medical equipment, outsourced (overseas) radiology interpretation, drug importations and medical tourism (it's called price competition).

Expedite FDA approval process,

Enhance the financial transparency behind drug purchasing (this is a morass of contracting arrangements where everybody wins except the consumer)

Promote skin in the game for patients' medication adherence and persistence,

Capitlize on personalized medicine to target prescribing for maximum outcomes

Allow nurse practitioners to prescribe.

Give up on the notion that health care is local (while the DMCB is uncomfortable with the notion that once size fits all, standards of care can be combined with expected patterning so that a less than 100% fulfillment rate is not only accepted, but expected)

Standardize protocols surrounding patients who are in end-of-life care including promoting home-based care, following advance directives, doing comparative effectiveness research on high tech care options, using hospice as the control arm and focus on comparative effectiveness studies (end of life care is where there are huge cost opportunities).

The Milliman report is also interesting for what it doesn't include, like disease management. It correctly notes that it's role in reducing costs to a significant degree - compared to inpatient care or pharmacy - is limited and still subject to some study.

An Instructive Study Gets Published in the American Journal of Managed Care

Regular readers of the Disease Management Care Blog are already aware that the DMAA took the lead in developing a ‘real world’ approach to evaluating the economic impact of population-based care management programs. Since prospective, randomized clinical trials are not reasonable in business settings and parallel control cohorts may not be available, the ‘DMAA approach’ allows for a pre-post design, including the cost trend of a ‘non-chronic’ population to predict what the cost would have been absent the intervention. It also recommends that the costs measured pre and post be generally based on persons who are ‘requalified.’

Confused? You don't have to be:

The ‘trend of the non-chronic population’ is based on the observation that, from year to year, there is a baseline rate of health care cost inflation. If health care costs among persons without chronic illness climbs 10% per year, then a 9% cost increase in the disease management population from year 1 (pre) to year 2 (post) implies you saved 1%. It may be counterintuitive (versus relying on the trend among persons with chronic illness), but a lot of background work has shown this is a conservative and better approach.

The term ‘pre and post be based on persons who are requalified’ is also counterintuitive. In any insured population, there are persons in the pre or baseline year with one or more insurance claims for chronic illness care and then there are persons in the post or follow-up year with one or more claims for chronic illness care. The 'requalified approach' says that you are only allowed to include the costs of persons with active claims in the year of measurement. So, if a person with a claim for diabetes in year 1 (pre) turns out to not have a claim for diabetes in year 2 (post), that person’s costs are not used to measure cost in year 2. They are taken out.

Which is why a paper by DMCB colleague Soeren Mattke and colleagues (Seth Serxner, Sarah Zakowski, Arvind Jain and Daniel Bold) appearing in the latest issue of the American Journal of Managed Care should be of great interest. It not only is another carefully conducted study of the impact of disease management but it’s a good exercise in what you should look for when you read studies like this. As an aside, it was Dr. Mattke who was responsible for this oft-quoted paper, so when he writes it, the DMCB reads it.

The authors used insurance claims data to assess the cost impact of unnamed vendor-owned case management, disease management, medical advice telephone line and wellness programs sponsored by two large unnamed employers. The DMCB thinks the employers were probably self-insured and that the program designs were of the usual type, including HRAs and predictive modeling. Two year baseline costs 'pre' were compared to costs one year 'post' baseline and the programs' own predictive modeling was used to statistically adjust for other factors that could have influenced the numbers.

So, now that you know about the outlines of ‘non-chronic trend’ and the ‘requalification’ method, you probably want to know about that too. The DMCB notes the non-chronic trend was not explicitly mentioned by Mattke et al; rather they used a ‘nonpurchased trend.’ It also appears that there was not a requalification but an ‘intention to treat’ approach that probably means all persons eligible in year 1 were included in the year 2 cost analysis.

Bottom line? The programs in aggregate were associated with a non-statistically significant $13.75 increase in the per member per month (PMPM) claims expense over what was expected, based on (the 'non-purchased') trend. Case management dropped costs by $1.35, disease management increased them by $8.63, the advice line increased them by $21.71 and wellness increased them by $20.14; only wellness was statistically significant and it went in the wrong direction. Ouch.

The DMCB thinks this is a first-rate study for the following reasons:

1. This probably started out as a standard inquiry into the performance of a disease management vendor for a purchaser. It was disciplined, methodologically rigorous and turned out to be not that far from being good enough for peer-review publication. It marries the real world and evaluation science. Bravo. The disease management industry has come a long way.

2. It offers up a template that could be used by purchasers to economically assess the impact of their wellness, nurse-advice lines, disease management and care management programs. Yes, we can debate the merits of the trend that was used and whether the lack of a requalification was important (and it probably is), but the DMCB thinks that can be swapped in or out depending on the preferences of the purchaser and its actuaries. Dr. Mattke and colleagues have given purchasers a public-domain benchmark on how these analyses could be conducted.

Think you don't have the time/resources to bother with publication? The DMCB says that if you perform an adequate evaluation, you should be 90% there. The other 10% is the cost of doing business.

3. Think we'll ever get to a standard methodology to assess disease management programs? Think again. As testimony to this, Mattke et al strengthened their paper by conducting other analyses that had their own merits (and didn't really change the overall conclusions).

4. The DMCB is reluctant to generalize the findings from this single study to the entire industry. Other purchasers are discovering savings, or they wouldn't be buying into these programs. The conclusion is not that disease management doesn't work, but more DMAA members need to publish their findings. And by the way, in addition to quibbling over the methodology, we don’t know enough about the employee population or their insurance benefit design or about the disease management programs.

5. It would appear that the package of interventions purchased by these unnamed employers did not give them their money’s worth. The DMCB says fire the disease management vendor and issue a new RFP – including the warning that another analysis based on the methodology above will be used to assess their performance next year.

Hopefully, that will be shared in a peer-reviewed setting.

The Latest Health Wonk Review is Up!

The Disease Management Care Blog can't get that Monty Python tune out of its head....'wonderful spam... wonderful spam!' and it's not just because more Americans will to be turning to it in the coming months. It's also because Henry Stern of InsureBlog has cooked up a delicious recipe of Health Wonk Review submissions for your simultaneous gustatory and intellectual pleasure. Learn about cheese balls, comparative effectiveness, mexican extravaganza, COBRA and much more here. You'll also get to use a new term on your colleagues and assocates: 'spendulus.'

Where's the Gas When You Need It?

The Disease Management Care Blog confesses that it wasn’t easy learning the differences between an EMR (electronic medical record), an EHR (electronic health record) and a PHR (personal health record). While medicine is certainly riddled with its own complexities and acronyms, health information technology (HIT) seems to have taken it to a whole new level.

There may be one less acronym, however, to worry about. If (and that is a big if) this post from the Health Care Renewal Blog has any basis, there may allegedly be little reason to distinguish HIMSS (a membership organization) from CCHIT (involved in certification of electronic records). Is the DMCB’s buddy Scott Silverman an HIT voice crying in the wilderness? Time will tell but the DMCB will be harkening.

The disease management community, in contrast, seems to have had its act together from the very beginning. The DMCB was there in the early days when several disease management companies earnestly set out to define what set them apart. That’s when they came up with this. Realizing that a distinct brand was emerging, they sought a process that would accredit reputable full-service disease management companies – similar to the track record of hospitals and managed care organizations. They correctly reasoned that the more distant they were from owning the accreditation process, the more credible it would become. Not to mention that their lawyers pointed out that anything less could result in the improper appearance of collusion. It was good business sense and it was also the right thing to do.

It paid off. The highly regarded National Committee for Quality Assurance (NCQA) and URAC have both developed independent programs that are distinctly free of any allegations or even the appearance of conflicts of interest.

++++++++++++++++++++++++++++++++++

And a now for a non-sequitur: It’s bad enough having to see a dentist, but having him remind you of the striking difference between medicine and dentistry makes the drilling seem comparatively blissful. Grinning through his mask and goggle-glasses, he asked his physician-patient today what he thought of the newly inked ‘stimulus bill.’ By this time the DCMB was immobilized thanks to having to simultaneously guess where half of its face was while French-kissing a latex dome with a mouthful of gruesome metal objects. Not caring to translate my gurgling, he went on, ‘Looks like the government wants to tell you guys how to practice.’ After a pause, he added, ‘And they’re going to get away with it.’

Where’s the gas when you need it?

The Medicare Coordinated Care Demonstration (MCCD) Didn't Work: Conclusion? That the Medical Home Will Work.

You may have seen some dispirited reports (here, here, and here) about the published summary from Mathematica (Deborah Peikes, Arnold Chen, Jennifer Schore, Randall Brown: Effects of care coordination on hospitalization, quality of care and health care expenditures among medical beneficiaries) appearing in JAMA (2009;301(6):603-618) on the federally funded Medicare Coordinated Care Demonstration (MCCD). This involved a total of 15 participating healthcare entities (5 disease management organizations, 3 community hospitals, 3 academic medical centeres, 1 integrated delivery system, 1 hospice, 1 long-term facility and 1 retirement community) serving fee-for-service (FFS) Medicare beneficiaries with one of several chronic conditions. Each of the 15 entities ran their own randomized clinical trial with varying inclusion criteria and risk factors. Patients were randomly assigned to usual care vs. being assigned a care coordinator who, depending on the program, used different types of behaviorally-based patient education programs that were ultimately aimed at increasing self care. Final fees ranged from $60 to $270 per member per month (PMPM).

The Medicare beneficiaries entered into these programs were sick and therefore expensive at baseline, averaging just over $1535 per member per month (PMPM). One program had to drop out because of low enrollment. Of the 14 that were remaining, only one program reduced hospitalizations in a statistically significant manner. Two programs had a significant change in costs, but in the wrong direction: both went up. Two programs had non-statistically significant reductions in cost; if outlier costs were deleted from the analysis, one of the two programs turned statistically significant. Bottom line: Medicare funded care coordination programs for FFS beneficiaries, based on this research, will not reduce healthcare costs.

Those are the facts. But the authors of the report then went on to offer up some subjective impressions, presumably based on their close working relationship with each of the MCCD entities. The Disease Management Care Blog forgives them for going on a speculative bender - but only up to a limit.

Those subjective impressions? The care coordination programs that came close to saving money were:

a) High Touch - care coordination personnel seemed to have more face-to-face time with the patients, even if that meant travelling out to the doctors' offices to meet them. Relying exclusively on the telephone seem to have less success.

b) Not Too Hot, Not Too Cold - patients who had a low burden of disease and patients that were extremely ill continued to use little or high amounts of care, respectively, no matter what intervention was used. Programs that aimed their interventions at the 'just right' patients seemed to do best.

c) Aimed At the Pills As Well As the Ills: helping patients understand why and how they need to take their medicines seemed to be helpful, and

d) All About the Fundamentals: Keying on 1) patients when they got out of the hospital and 2) assigning care coordinators by physician (and not by the patient) kept patients out of the hospital and kept physicians from having to deal with too many nurses.

So where did the authors cross the line? You guessed it: by force-fitting their subjective impressions into an editorializing closing paragraph about the supposed virtues of the Medical Home:

'...the medical home model may be able to replicate or exceed the success of the most effective MCCD programs.'

Really? This is lecturing based on what data? The DMCB believes the statistics showed that care coordination programs failed to achieve statistically significant reductions in healthcare costs. Statistical significance was only achieved in one program when high costs were censured out of the data, which is a luxury that the real world Medicare program does not have. Finally, while the authors' impressions of successful program characteristics made sense, they selectively focused on the one that fit their unfounded admiration for a yet unproven - if promising - care strategy. As an aside, an accompanying editorial by John Ayanian of Harvard didn't do much better.

Message for the disease management organizations? Based on this article, none of this should be any surprise to you. Many in policy circles may not know it yet, but you should keep doing in the market what you've already learned to do, thanks to an ever-growing knowledge base that relies on far more than a hidebound research paradigm: for the right patient, it continues to make sense to rely on nurses that are available for in-person coaching, to use your predictive modeling algorithms to identify patients that are ''high impact,' to pursue medication adherence and persistence,to do everything possible to find and help patients that are recently discharged and to build close relationships with the primary care physicians.

Oh... as for waiting for Medicare to catch up? The DMCB isn't too sure about that. We'll see.

A Kaiser Foundation Misstep on Employer-Based Coverage for Cancer Care

How unfair. But it works.

Want to attack any process with a track record that is pretty good, considering the circumstances and alternatives? Look for individual instances of shortcomings and vaguely generalize them, making it appear that things are far worse than they really are. Given the complexity of insurance benefit designs and cancer coverage, the topic is perfect for this type of gamesmanship. And this is exactly what the Kaiser Family Foundation and the American Cancer Society (ACS) did here. By lining up 20 cancer victims who got tangled up in insurance benefit designs, the unsuspecting reader would conclude that when it comes to cancer, commercial insurance companies are either hopelessly broken (‘individuals may not be protected from high out-of-pocket costs’) or evil (force patients to ‘incur debt in order to pay for care…. or forgo or delay lifesaving treatment’).

The Disease Management Care Blog is not saying that each breakdown isn’t heart breaking or an opportunity to learn from mistakes. While this makes for a good narrative, this is not how to make good policy about the interlocking roles of deductables, cost sharing, out of network tiering, annual limits, lifetime limits and minimal coverage designs in the evolution of healthcare reform.

The truth is that faced with unrestrained medical costs, the vast majority of employers are successfully coming up with creative and functional health insurance designs. Without such creativity, there is either no health insurance for their employees or no staying in business for their customers. While the insurance may thin out, the fact is that for every example described in this Kaiser Foundation report, there are many other unseen examples of individuals who were able to use perfectly adequate insurance to access cancer screening and treatment. That piece of good news went decidedly unmentioned.

Instead, Kaiser and the ACS used anecdotes in combinations of highly unusual and lethal diseases requiring highly unusual treatments under highly unusual insurance designs. Toss in overpriced screening tests, docs cancelling their insurance contracts and rare employer stupidity, and you have biased report tilted away from locally controlled State-regulated or HIPAA protected employer-based insurance. That’s not necessarily bad, says the DMCB, but us citizens can’t rely on biased reports like this one to make an informed decision about the alternatives of a) greater State or Federal regulation, b) developing a tax-payer supported Federal insurance plan with first dollar coverage, no deductables, no coinsurance and no lifetime limits or c) a single payer system.

A rare Kaiser Foundation misstep.

Well, the DMCB to the rescue. It suggests you read the report, but keep in mind the inconvenient truths that follow below. You’ll be closer to getting your head wrapped around the high cost of cancer and how to insure against it.

Pre-existing condition exclusions cause treatment postponement. Many patients with pre-existing conditions preferentially seek insurance after the fact. Forcing coverage under such circumstances would drive up the cost of the premium, forcing even more individuals to forgo insurance.

The individual market screws patients by refusing coverage to persons with a cancer diagnosis. If the individual market were forced to cover individuals with a past history of cancer, all persons buying insurance in the individual market would be forced into higher premiums to pool that added risk.

Out of network doctors lead to medical debt: Many doctors choose to be out of network because they refuse to accept the insurers’ fee schedules, putting patients in the middle.

Annual benefit limits lead to debt: Benefit limits of $2500 to $20,000 to $100,000 are the exception and not the rule. $1 million is common, but when it is exceeded, what is the right limit that Americans are willing to pay for?

Patients need to continue working while getting chemo: In the example provided, the patient’s employer worked with the patient to maintain her employee status. Most do.

Separate deductables lead to debt: Deductables are a standard approach to making insurance affordable. What’s more, in the example provided, the patient was contesting a PET scan’s medical necessity, not the deductable.

COBRA sucks: COBRA was conceived, written and passed by the U.S. government and insurers are following the regulations. To the letter. Which is why the Feds have stepped in with another fix. Whether we can count on government over the long run to continue its support is a question mark because of the next item.

High Risk Pools suck: As the DMCB reads it, it’s the government that is underfunding them, which should make one wonder about the government's ability to manage any of this over the long run.

The Perfect Academic Health Policy Maker Girlfriend

The Disease Management Care Blog sympathizes with its colleagues in the industry, who are constantly striving to engage hostile academic policy makers and skeptical administrative staffers in a constructive dialogue over the role of disease management in healthcare reform. It is such an uphill battle, isn't it? Being shot down, calls not being returned, being rejected.....

While the effort continues, however, the DMCB found, thanks to a tip from a progeny, the dream date for y'all. Her paraphrased comments are below the video window.......

"I like disease management programs who have a little bit shareholders... a little bit profits. I like programs who like to tell me they have good outcomes and charge a LOT of money. This is good thing. If I know there are no savings, I'm not like, oh poor taxpayers, there's no value. This is so silly. I know sometimes they go to, the ehhh... Congress, but that is okay.... I'm not jealous. They can do whateverrrr they want. I mean, I don't care."

Medicare and Applied Health Services Research. It's Time.

The Disease Management Care Blog found two suggestions from its buddy, Sandra Foote, to be interesting options as the U.S. continues to think about healthcare reform. While we know what works, there is a lot we don't know. The evidence-based medical literature only helps us with approximately 30% of clinical practice. While we continue to struggle with financing and shaping the other 70%, Sandy recommends that Medicare develop "a powerful continuous innovation strategy" that draws on the lessons of the private sector. The idea would be to develop "goals, leadership, organizational structures, incentives and processes" that would constantly test innovations. The DMCB thinks of this as "demos" but multiplied on a log scale and placed on steroids.

Paired with this idea is a mandate that's been given to MedPAC to "conduct a study of the feasibility.... of establishing a Medicare Chronic Care Practice Research Network." Sandy reports this would involve creating a standing network of providers that test new approaches to care.

The DMCB thinks of this as "tithing," i.e., giving a portion of your income for service to a greater good. All healthcare organizations, from individual physicians up to large integrated delivery systems have an obligation to assess the content of the care they are providing. The DMCB thinks that in order to do this right, it generally takes about 10% of the operating budget: that's how much time it devoted to data management and reporting in its former life as a medical director.

Think that sounds like a lot? The DMCB argues that one reason the Federal Government is creating a national center for effectiveness research is because mainstream healthcare - outside of academic medicine - has not stepped up to this plate. The good news is that other healthcare organizations, including disease management providers, are also beginning to embrace the value of "applied" health services research. They'd welcome Medicare to this party. Hopefully, Medicare would be prepared to commit sufficient resources to doing this right.

Heads up: the DMCB will have a print editorial on the topic appearing in the not too distant future.

Paying Smokers to Quit: A Report from the New England Journal of Medicine

Should employers give their employees hard cash to stop using tobacco? The Disease Management Care Blog doesn’t know the answer to that either, but it’s a little closer to understanding the numbers thanks to this publication by Volpp and colleagues appearing in the latest issue of the New England Journal of Medicine. Of approximately 1900 smoker-employees of an unnamed company with multiple worksites, about 800 agreed to be randomly assigned to ‘community based tobacco cessation resources’ within 20 miles of each of the work site (442 persons) or being assigned to the community resource plus being paid $100 if the program was completed, $250 if there was tobacco cessation within 6 months of study enrollment and another $400 if still off tobacco 6 months later (436 persons). Participants were not required to actually use the community resource; it looks like they could quit on their own if they so chose. Cessation was confirmed with a highly accurate test for the presence of cotinine in the urine or saliva.

The bottom line quit rate at 9-12 months was 14.7% in the group that was incented vs. 5.0% in the group that had no incentive. There were only two urine or saliva samples that were positive for cotinine.

The DMCB counted 47 persons completed the community resource (at $100 each or $4700), 91 had cotinine confirmed abstinence within 6 months (at $250 each or $22,750) and 64 remained abstinent at about 12 months ($400 each or $25,600), yielding a total outlay of $53,050 or $828 per smoker who quit.

So if an employer has a thousand employees, and about 15% or 150 smoke (a not unusual prevalence rate) and approximately half agree to participate (75) and the quit rate is about 15%, that means that 11 persons would quit at a total cost to the company of about $9000. The authors quote a study that contrasts the $828 figure with a report from the Centers for Disease Control that states that active smokers experience $1,760 in lost productivity and $1,623 in excess medical expenditures per year.

Take away lessons from the Disease Management Care Blog:

Quit rates based in physician offices that are supplemented with the use of pharmacotherapy typically range from 11% to 30% at one year. The quit rate of about 15% in this program seems comparatively low. However, it has the advantage of offering more persons access to a tobacco program with a respectable outcome. As a result, while the relative number of quitters is lower, the absolute number is probably higher than what can be obtained in the traditional health care system.

While the number of persons trying to game the system seemed to be low (apparently saying they stopped and submitting a sample), that may have been helped by the sentinel effect of urine or saliva testing. This would seem to be an important part of any company-sponsored tobacco cessation program that involves cash incentives.

The cost of $9000 described in the scenario above is the direct cost to the company. Other costs, such as cotinine testing, physician services or drug use (for example, nicotine replacement therapy) represent other costs, especially in a self-insured company.

Last but not least, this appears to be another business opportunity for disease management organizations. This is not the first program to use incentives, but we now have a better idea on the role of cash in incenting persons to quit. DMOs can help recruit smokers, arrange for the community-based referrals, arrange the cotinine testing and adjudicate payment.

Cavalcade of Risk is Up!

The Cavalcade of Risk is up! This is a collection by Lynch Ryan of scintillating blog posts on the topic of insurance risk. Think that's complicated? Give it a look over and you'll find posts that claify, educate and satisfy.

Read In Airports and on Planes......

From 'Disease management for chronically ill beneficiaries in traditional medicare' by David Bott, Mary Kapp, Lorraine Johnson and Linda Magno, appearing in Health Affairs 2009; 28(1): 86-98.

Numerous CMS demonstrations - including, but not limited to, Medicare Health Support - have shed an unhappy light on the following premises about disease management for elderly, fee-for-service Medicare beneficiaries:

Acute exacerbations of chronic conditions could be avoided by better day-to-day self-management. This has been difficult to demonstrate and in retrospect, the evidence that exists is based on relatively small studies from academic settings.

High costs associated with chronic conditions stem from ED visits and inpatient hospital admissions for acute exacerbations. Yet, the majority of all hospital admissions have turned out to be for reasons other than the index condition.

Patients with chronic conditions are motivated and able to engage in improved self-management. There is little systematic evidence that this is true. Many patients apparently simply adjust to their condition and fail to see the benefit of additional change.

Periodic contact improves self-management and early recognition of symptoms will avoid hospitalization. Many programs turned out to have a poor rate of contact and there was little correlation between the contact frequency and outcomes anyway.

There is a health care provider who is prepared to respond to alerts by scheduling an urgent visit or coming to the telephone. Not so,unless there were standing orders or protocols. Docs won't come to the phone.

And this paraphrased quote from "Who Killed Health Care" by Harvard academic Regina Herzinger:

There are two 'distinctly differing approaches for reforming our health care system. Those who distrust markets and consumers prefer a single-payer system in which the federal government's excellent, centralized management would wring savings from billions now wasted on the hapless, competitive provate sector health insurance firms and inefficient doctors and use the savings to provide coverage for the uninsured. They would restrict insurance choices, much like an automobile market offering identical cars designed by a technocratic elite. Those who believe in consumers and entrpreneurs opt instead for private sector solutions. This small-is-beautiful camp would open insurance and health delivery market to innovators, ....where doctors are emowered to design better, cheaper care.....'

By the way, O'Hare was pretty empty for a weekday. The economy is definitely not doing well.

A Contrarian Nominee Suggestion for the Secretary of Health and Human Services

The DMCB feels sorry for its fellow bloggers who boned up for Czar Dashcle’s reign by memorizing his blueprint or forwarding the minutes from those holiday home-based healthcare confabs. While y’all were getting ‘engaged,’ the DCMB was involved in other far more rewarding holiday pursuits. The silliness is not done, however, thanks to the speculation fever over the identity of the Obama Administration’s ‘Plan B’ HHS nominee. Examples are here, here and here.

Not wanting to miss all the fun, the ever contrarian Disease Management Care Blog would like to present its own favorite candidate:

Gloria James.

NBA sports fans may recognize the name of the mother of the Cleveland Cavs’ superstar forward LeBron James. She’s something else. She had LeBron at the age of 16 and as a single mom moved from one menial job to another while keeping a roof over her head and her son from disappearing into the street violence of Akron, Ohio’s streets. This is a woman of grit, determination and hard work.

So, why is she qualified you ask? Well, says the DMCB, consider the following:

It's not just her mettle, she’s a mom. That is a huge advantage, not only because of her gender (which remains underrepresented in DC) but because of what the Fat Lady teaches us in this story from the 15th Chapter of Matthew: ‘Have mercy on me,’ said this anonymous mother to Jesus, ‘my daughter is grievously vexed with a devil.’ When rebuffed, she repeated her plea, saying ‘Lord, help me.’

Curious, isn’t it? The child is ill but it is the mom that is personally suffering and is begging for mercy and help for herself. The DMCB finds this story once again demonstrates the Bible’s special insights about the human condition: mothers feel their children’s pain. What’s more, they understand other moms’ pain and they’ll (and in this example, literally) move heaven and earth to fix it. The DMCB asks: wouldn’t this special skill of selflessness for others’ suffering be a refreshing ingredient inside the beltway? Go to ANY home and school association meeting, any school sports game or Sunday school and you’ll find qualified candidates for the job. You’ll find Ms. James.

Speaking of moving heaven and earth, Ms. James would be a tireless and energetic advocate. There is no better demonstration of this than this clip of Ms. James rigorously debating the finer points of NBA officiating with a referee during a Boston-Cleveland game. The DMCB thinks our President and his team of rivals would benefit from having a person like this who won’t be afraid to tell the Big Man the way it is. By the way, Mr. Obama’s love of basketball will only further cement their mutual respect.

Last but not least, Ms. James has allegedly amply demonstrated her preference to not to take advantage of limo rides at the taxpayers’ expense, expressed by kicking out car a window, if necessary, to make her point. No last minute tax issue surprises here: with Ms. James, what you see is what you get.

But she has no background in healthcare policy you reply? Well, it’s not just the DMCB that thinks it’s possible to have too many economist/PhD experts cluttering up the White House. What’s more, just because you are one doesn’t mean you’ll be very successful. Secretary Ms. James can surround herself with her own team of rivals. What’s more, if common sense and hard work don’t allow her to understand what’s being proposed, I think we can count on her to keep our healthcare laws regulations from being gummed up by even more gobbledygook.

But she has no chance you think? Well, she has about as much of a chance of being named as this guy does.

You GO Ms. James!

Lawmakers Gone Wild: HIPAA, The Stimulus Bill and the Prospect of Making Things Worse for Disease Management and Medical Home Care Management

You’d think the current stimulus bill before Congress would be generally welcomed by the disease management community. There is money to expand the States’ Medicaid programs, help the newly unemployed pay for COBRA-related health insurance and fund the perpetual employment needs of electronic health record consultants everywhere.

Leave it to Congress, however, to let other unrelated interests - that have absolutely nothing to do with the stimulus or anyone's economic hardship - to intrude. For a good example, look to what the Disease Management Care Blog found after noticing this little blurb on the Feb. 4 KaiserNetwork Daily reports:

Sen. Amy Klobuchar (D-Minn.) might propose an amendment that would exempt "quality initiatives," such as disease management and care coordination, from a provision that would require the HHS secretary to issue new health care operations rules. Health care providers have raised concerns that the rules would limit their ability to share information.

‘Huh?’ said the DMCB? ‘New health operations rules?’ So, your intrepid DMCB went to this web site that has all 431 pages of Senate Bill that was before the Senate and searched for the provision. This slightly reworded quote is for your reading pleasure:

Section 13405(d): Not later than 18 months after the date of enactment, the Secretary of HHS shall promulgate regulations to eliminate from the definition of health care operations those activities that can reasonably and efficiently be conducted through the use of information that is deidentified or that should require a valid authorization for use or disclosure. The secretary may choose to narrow or clarify activities that the Secretary chooses to retain in the definition of health care operations.

Confused? So is the DMCB after reading this several times, but think of ‘health care operations ’ as a safe harbor that allows the sharing of detailed patient data between collaborating health insurers, disease management companies, physicians, hospitals and medical homes. The DMCB thinks the language above significantly ‘tilts’ the threshold toward making it harder for patient information sharing in the name of population health activities, favoring the use of ‘deidentified data’ (for example, no birth or service dates or geographic location other than State) or requiring the patient’s personal active permission each and everytime the data moves from one entity to another.

A recent New York Times editorial says increased safeguards are needed to better assure the privacy of medical records. While there have been some examples of egregious breaches of electronic health records, the DCMB, however, is unaware of any resulting from quality improvement activities, predictive modeling, disease management business practices or medical home-based care. Disease management’s colleagues over in the research community have weighed in on the matter, stating HIPAA already adds uncertainty, cost and delay. Tilting things will make it far worse.

While readers may think they should be assured that the legislation leaves it up to the yet-to-be named/confirmed Secretary to be 'reasonable,' the DMCB suspects he or she will instead promulgate wide ranging, confusing, complex, over-lawyered, healthcare-unfriendly, litigation-prone, unrealistic, burdensome and silly regulations that make it all but inefficient or even unreasonably impossible for disease management organizations or patient centered medical homes to assess the health care needs or their populations. Want to know if you should expand your operations into some adjoining counties? Thinking about promoting flu shots but don’t have prevalence data for those over age 65 years? Want to conduct an outreach campaign based on predictive modeling? Well, based on these and other scenarios, thinks the DMCB, you better have two things if this bill passes unchanged: 1) a phalanx of lawyers who are prepared to do more than just tell you what you can’t do, and 2) lots of cash or insurance on hand to deal with a greater likelihood of legal actions or suits.

Egads. The DMCB understands Senator Klobuchar has submitted the amendment. Let’s hope it survives the sausage making.

Community Care of North Carolina: The Disease Management Care Blog Isn't Going to Quote It Without a Big Caveat

It’s impossible it seems to read anything about the Patient Centered Medical Home (PCMH) and not run into Community Care of North Carolina (CCNC) as the ‘The PCMH Saves Money’ poster child. No power point presentation on the topic is complete without its mention, no Meeting Agenda is full if it’s not there, if you’re going to testify on the PCMH’s benefits before Congress, you should bring it up, the Commonwealth Fund is working hard to replicate it and it’s even embedded in Medical Home Wikipedia.

Does the Disease Management Care Blog mind? Not at all. Its only problem is that it doesn’t understand how the savings calculations for CCNC were done. It’s not alone either. It thinks most persons who quote from, bring up, embrace, salute, disseminate and write about the CCNC have no idea either.

But first, as the DMCB understands it, CCNC is a statewide Medicaid waiver program that operates through multiple, geographically defined, physician, hospital, health and social service organization 'networks.' Each network not only provides the usual fee-for-service care, but the primary care physicians also collect a $2.50 per member per month (PMPM) ‘case management fee,’ while the networks collect $3 PMPM for its local disease management programs (including asthma, diabetes and heart failure). A chronic care management program has been added for the Aged, Blind and Disabled Medicaid population with an additional $2.50 for the primary care providers and an additional $3 PMPM for the network. About 80% of the eligible beneficiaries are in a network.

“Mercer Human Resources Consulting Group” has performed a series of analyses that have been posted on the CCNC web site (click on 'Program Impact'). They conclude that a whopping $60 million, $124 million, $81 million and $161 million were saved in fiscal years ’03, ‘04, ‘05 and ‘06, respectively. You can read one typical report here, including how Mercer ‘excluded non-covered categories of aid,’ ‘adjusted’ data sets ‘when appropriate’ with ‘completion factors’ using an ‘historical benchmark.’

In addition to the web link above, there is this publication in the July/August ’08 Annals of Family Medicine. It’s also been referenced frequently as definitive evidence of CCNC’s economic effectiveness. Close reading of this seven page manuscript, however, reveals that it’s really a narrative description of the program with a one paragraph mention of the ‘outside assessment’ of savings by Mercer.

Contrast this with a publication from the February 2009 issue of Medical Care involving Medicaid also, but in Indiana. It describes the 'Indiana Chronic Disease Management Program' (ICDMP), which involved a regional roll-out of State sponsored nurse care management (coaching), telephonic management (from ‘non-clinical care coordinators’) and an electronic information system. The roll-out was staggered, which meant that while there were persons enrolled in ICDMP in some parts of the State, there was a window of time when patients were receiving usual care in other parts. This gave the statisticians at Indiana University a chance to perform an analysis based on a “repeated cohort design.” This enables a 'refresh' of the study population on a quarterly basis, which blunts the likelihood of ‘regression to the mean’ that is typical of a pre-post study around a single point in time. What’s more, 100% of the eligible Medicaid population was included, negating any bias from a non-representative subgroup analysis.

But did ICDMP save money? What the authors report is a big impact on claims trend, going from consistently positive (about 3% per quarter) before the regional program started and then turning flat (less than 1% per quarter) after the program was launched. Take it from the DCMB, for populations with hundreds if not thousands of dollars in PMPM claims expense, blunting an annual 12% trend adds up to millions of dollars.

So is the purpose of the DMCB to pit the North Carolina Tarheels' ‘medical home’ vs. the Indiana Hoosiers' ‘disease management program?’ Actually, they weren’t all THAT different (b-ball excluded, of course), but that’s not the point.

The point is that CCNC’s ‘proof’ of explicit multi-million dollar savings is based on a non-peer reviewed actuarial analysis posted on a web site, while ICDMP’s results are far more nuanced and spelled out in a journal using health services research-based statistics that were peer reviewed . The former is probably accurate but the DMCB has no way of assessing the veracity of an actuarial exercise. The latter is reasonably accurate and, thanks to the excruciating detail and the methods being referenced, the DMCB finds the assertion of savings far more credible.

As for the DMCB's colleagues that love to quote complicated opaque conclusions of others, it’d like to paraphrase advice from Scarecrow in the Wizard of Oz: 'If you’re not sure just how you are going to get there, any road will get you there.'

The Latest Health Wonk Review is Up!

How cool to have all this wonkish learning at your fingertips.

The best of the health policy blogging is just a click away at David Williams' Health Business Blog.

Enjoy!

There They Go Again on the Medical Home

Kevin Grumbach has a Part 1 and Part 2 opinion post on the Health Affairs Blog site on what the Feds can do now to resuscitate primary care. He obviously knows of what he speaks and, when he speaks, the Disease Management Care Blog listens. It suspects Dr. G’s colleagues in the Obama Administration are also listening.

Part 1 is a short, well written if pro forma retread of all the multiple bad diagnoses afflicting this corner of the medical profession. It reminds the DMCB of many patient encounters in its past: sorry, Mrs. Ruhoh, it’s not just a heart blockage. We’ve found you have diabetes, an aneurysm, a spot on your lung and that pigmented thingy on your back don’t look too good either. Well, primary care doctors, Dr. Grumbach confirms your panels are packed tighter than EHR supporters on a stimulus bill, medical students are crossing the street when they see you coming, reimbursements are so low, even Medicaid is beginning to look good and what’s more, practice improvement investments are so out of reach, you’d have better luck getting a repeat MRI approved by private commercial carrier.

Part 2 is a short, well written, more interesting if thinly referenced discussion (but hey, it's a blog posting) of the Federal treatment options available to this troubled patient. Think Mrs. Ruhoh being placed on aspirin, beta blockers and a cholesterol drug, but also starting insulin, getting scheduled for regular ultrasound examinations as well as having additional lung imaging and being referred for a wide skin excision. In similar fashion, Dr. Grumbach review the merits of a multi-track treatment plan that includes not waiting for further evidence on the medical home and expediting its payment policy now in Medicare and the Federal Employee Health Benefit as well as making federal matching for Medicaid contingent on its coverage. In addition, primary care should either be shielded completely from the SGR formula or at least being held accountable for its minor role in the overall health care cost inflation rate. What’s more the Feds could kick off a county-based ‘Primary Care Cooperative Extension Service’ (that's an interesting thought), fixing the physician training pipeline and redirecting research funding toward whole-person community-based interventions.

The DMCB recommends the Obama Administration do what CBO did and also listen to what this article has to say. Based on the traditional evidence-based standards, a reasonable interpretation of the literature doesn’t necessarily support wholesale coverage of the medical home. Period. What’s more, there is little evidence that the medical home will increase primary care access, attract medical students or generate enough income to make it worthwhile for the average doc. The DMCB finds it ironic that its friends in academia are willing to suspend the usual rules when it comes to rigorously assessing the merits of the medical home, especially on a Health Affairs web site.

That being said, the DMCB is warm to the medical home and is looking forward to getting some data from the numerous pilots underway to help shape healthcare reform. Just like disease management, we need to better understand what works for the medical home and under what circumstances. Dr. Grumbach and the DCMB agree on what, not on how.

That’s why the DMCB offers this Obama Inaugural-style closing benediction for this post: we look forward to that day when disease management is in the Medicare benefit, when clunky EHRs don’t get very far, when primary care physician fees see release and when someone throws the medical home a bone.

The Interview with Tracey Moorhead. Insights About the State of Disease Management

Tracey Moorhead, President and CEO of DMAA was interviewed by none other than the Health Care Blog’s, Matthew Holt. Is the Disease Management Care Blog jealous? Even if it was, it wouldn’t mention it here, but it and the DMCB spouse do look forward to the day when it achieves the HCB’s level of sophistication, gravitas, readership and ad revenue. But it digresses…..

The podcast is well worth a listen, if for no other reason than to hear the repartee between the skeptical Mr. Holt and the optimistic and confident Ms. Moorehead. Realizing that not everyone has 34 minutes to spare (and may not be willing to put up with the periodic buzzing in the recording), here is a brief summary of the better learning points. The DMCB will keep these in its intellectual tool box and keep handy to thwart doubters, stymie naysayers and verbally smote nattering nabobs. You can also, because you read it here:

Remember that CBO report that said disease management doesn’t save money? Mr. Holt sure did, but Ms. Moorhead coolly responded by pointing out that much of the research used in that report was outdated. In response, the DMAA has opened and maintained a regular dialogue with CBO that includes a regular feed of up-to-date literature along with face-to-face meetings. As a result, CBO is better able to stay current with the rapidly changing science of population management, which may have, in turn, helped them craft this later report. The DMCB summarized it here.

And how about that Medicare Health Support? Out of date also, rejoined Ms. Moorhead. Those one-size-fits-all mass recruiting call center programs have gone the way of pneumoencephalogram and doctors' awareness of Pott’s Disease quicker than you can say ‘Tom Daschle’s history.’ In contrast, other successful public sector programs have not been hampered by MHS-style delays or an inability to update their clinical operations, which should tell you something. In addition, a gauge of MHS’ success is not just savings, it’s satisfaction and clinical outcomes, both of which have shown improvements. Keep in mind that the original law that launched MHS did not intend for it to achieve savings, only be budget neutral. Last but not least, stay tuned. A final report has yet to be issued and additional analyses may show that some subpopulations did benefit from reduced claims expense.

What about the future? Well, Ms. Moorhead says it is so bright, she’s gotta wear shades. Medicare was originally designed for an acute care model and everyone, and she means everyone, understands it needs to be changed to support a long term care model. She is optimistic that there will be a convergence of other care models such as the medical home. She is also very confident that the DMAA’s members are committed to the centrality of the physician and believe disease management is one resource that can help them. In fact, some vendors are already partnering and successfuly collaborating with some physician practices.

Finally, said Ms. Moorhead, there is a growing body of evidence that shows population-based care coordination works, especially if the emphasis is about quality of health care, not the return on investment savings. And don’t just listen to her say that, because there are champions of disease management on the Hill and in the Administration.

For LifeMasters, Nothing Succeeds Like Success.

Here’s an update to a prior post about LifeMasters’ ongoing telephonically-based 11 county Florida disease management pilot program for dually eligible Medicaid beneficiaries with heart failure alone or with coronary artery disease and diabetes. As readers may recall, compared to a control group, there were enough savings to warrant CMS continuing the program. The bottom line intervention vs. control per member per month (PMPM) difference has not been reported yet, but we do know that most of the savings to date appeared to be associated with patients that were successfully engaged by the coach-nurses. As a result, LifeMasters has redoubled its efforts to reach even more patients and enroll enroll enroll. If successful, LifeMasters will deserve credit credit credit and CMS will undoubtedly look to expand the program.

According to a January 29 press release, the push to enroll now includes a ‘Health Network One’ (HN1) physician bounty or a ‘per-member per-month fee for each patient engaged in the program with incremental increases the longer the participant remains in the program.’ HN1 is described here as a Florida company that maintains provider networks for the insurance industry; the Disease Management Care Blog suspects these are private physician practices that rely on HN1 to handle the myriad details behind contracting and credentialing with health insurers. Getting some coin from LifeMasters is one of those details. This is classic win-win: the docs get income and greater buy-in with an otherwise distant vendor, while LifeMasters knows each enrolled patient – thanks to a physician referral - increases the likelihood of success for an already successful program.

The DMCB thinks this is important because of its prediction that disease management, the medical home, pay for performance, insurance benefit design and information technology will continue to evolve to a mutually supportive interlocking Unified Field (or maybe a Teilard de Chardin-esque ‘Omega Point’) of population-based care that collectively make up for the weaknesses of the individual components. We’re already witnessing interest in combined disease management – patient centered medical home approaches, benefit designs that lower barriers to self-care and the use of P4P to support the purchase of EHRs. This is one more example of this trend by a nimble disease management organization taking advantage of the synergies with other population-based care initiatives.

The DMCB suspects the next stage (unless it’s already arrived) will be three-way combinations, such as disease management organizations using P4P to support the medical home or consumer directed health plans that have first dollar coverage of services arranged by medical homes using an electronic record. Then will come 4 and then 5. Interested in knowing which will be the leading disease management vendor in the coming years? One way to do this is look for the program that successfully incorporates all of these concepts.

While LifeMasters and CMS deserve credit, this is ultimately research that is testing an model that is already underway in other settings. That being said, it's clear to most population program architects that, in an open-range, fee-for-service setting, it’s important to get the physicians involved. This is an attractive way to do that, especially if it’s combined with additional IT initiatives like this one and if the physician compensation is tiered and additive. The DMCB knows this because LifeMasters was kind enough to answer an email question about that from the DCMB.

One lingering question remains however: what happens to all that that pay? In an ideal setting, it should be plowed back into the office practice to support even better systems that result in even better performance for even greater pay leading to a virtuous cycle of escalating outcomes. The DMCB suspects that in large salaried physician practices, not all the money makes it to the docs' paychecks. Yet, instead of hiring more personnel or hardware to help garner better performance, the temptation is to use the performance-based revenue for something with an even better ROI - like an ultrasound machine or something. Not that the alternative of diverting all of the money directly to the physicians' pocket is any better. That could happen in an HN1 type of network.

We'll see. In the meantime, the DMCB recommends that disease management programs that get into the P4P arena follow the money.... carefully.