A Chronic Care Management Innovation Center Is a Lousy Idea: Warning Will Robinson!

Much like the Jupiter 2 in the campy ‘60s TV series Lost In Space, the Senate Finance Committee is risking going off course into Deep Space on the topic of care management. It released a 52 page paper two days ago describing ‘policy options’ designed to ‘set forth’ ideas on ways to revise payment systems and policies in the Medicare program. It has 5 sections on 1) improving quality and promoting primary care, 2) fostering care coordination and provider collaboration, 3) health care infrastructure investments, 4) Medicare Advantage and 5) combating fraud.

The Disease Management Care Blog zeroed in on the topic of fostering care coordination. While this section also addressed bundling payments to reduce inpatient readmissions as well as transitioning from fee-for-service to ‘accountable care,’ it was a loopy option to create a ‘Chronic Care Management Innovation Center’ (‘CMIC’) that caught the DMCB’s eye. CMIC? Another acronym? Another Department in an already sprawling bureaucracy?

Recall that CMS can test potential reforms under a mechanism called ‘demonstrations’ and that there are about thirty of them currently underway. This option would enshrine perpetual demos under a permanently established Center. This CMIC would be charged with conducting a continuous quest for models of care that include patient centeredness, focusing on ‘in-person contact’ with beneficiaries, self care and teaming around primary care providers. In addition, a ‘Rapid Learning Network’ (RLN) consisting of a network of providers that would participate in these demos would be created on a competitive basis.

Ay carumba! The DMCB thinks this is a lousy idea. While demonstrations under a CMIS are one important tool that enables CMS to examine the merits of a care approach, they:

a) are inefficient and time-consuming, often resulting in the reporting of results long after continuous medical innovation has rendered the original approach obsolete

b) are unable to address the multiple social, cultural and regional dimensions of care management,

c) render opaque complex data that are prone to endless picayune interpretations that fail to disprove instead of succeeding to prove,

d) centralize the conduct of scientific investigation under a Federal entity that, despite the RLN, will be aligned with the interests of large academic institutions that stifle alternative points of view, research methods, audience needs and market demand

e) presuppose that demos are the best, if not only, route to testing chronic care models and finally

f) suggests that the patient centeredness, teaming with non-physician providers, and patient self care are still topics of research.

According to the paper, ‘the Committee is seeking input from members, CBO, and CMS on the design, score, and implementation of the options proposed in this section.’ While it is disappointed that it wasn't also asked for input, the DMCB nonetheless hopes that someone with the ear of the Committee includes the catch phrase ‘Danger, Will Robinson!’

How Well the Administration Does with H1N1 Swine Flu Has Implications for the Success of Healthcare Reform

In a prior post, the Disease Management Care Blog warmed up to the idea of unleashing the heavy hand of government in another area of public health. The topic of sugared beverages is relatively narrow and, what's more, taxation is the one thing that government does well.

Not long after the keyboard cooled off over that posting, the DCMB became aware of another proposed $1.5 billion government foray. This one is far more expansive. The H1N1 Influenza A Swine Flu emergency has prompted the White House to request an additional $1.5 billion in supplemental funding from Congress. The number is apparently based on the cost of vaccine, the purchasing of anti-viral drugs and first responder protective gear as well as supplemental funding going to the State and other local agencies.

This, thinks the DMCB, will be the defining moment for the idea of expanded Federal involvement in health care. This is big and very visible. If the Administration appears competent and does this right (or if they're lucky), momentum for reform will grow. If the government proves impotent in changing the course of this emerging epidemic (or if they're unlucky), second thoughts will emerge and public support for health reform could wane signficantly.

Good scenario: The Centers for Disease Control, in partnership with pharma, makes good progress in developing a vaccine. Enough anti-viral treatment medications are available to patients who need it. Hospitals and clinics reasonably keep up with the additional demand for services. Public health messaging has the three C's: consistentcy, calmness and correctness. If the virus turns out to have mild symptoms for a vast majority of cases and dissipates, count the Administration lucky. The public credits the Administration for a job well done.

Bad scenario: Whether deserved or not, the public perceives that an effective vaccine's arrival is being delayed. The Administration fails to 'play well' with pharma, who distrust the Democrats. What's more, finger-pointing develops over who is to blame. Reports of shortages of anti-viral drugs begin to pepper the evening news. Patients can't get appointments and there is the spectacle of people outside emergency rooms waiting to be seen. In the meantime, the more nimble local health resources (small physician offices and retail clinics for example), supported by commercial insurers, come through in providing all the necessary care without the special involvement of the Feds - who are a dollar short and a day late. The messaging confusingly varies between CDC, the White House and the States. Too many people with the virus die. Bad luck, the virus turns out to be the mean species originally seen in Mexico with the twin features of high transmissibility and higher than normal lethality.

The DMCB thinks the odds may be slightly tilted toward bad scenario. However, it thinks and hopes there will be good luck (from a prior post, here's why). Despite the best efforts of the most competent government in the world, it takes a long time to develop and test a vaccine, demand for anti-viral drugs currently in the pipeline may outstrip supply and anyone feeling unwell will clog the healthcare system no matter what the messaging is. The good luck news is that the disease so far is appearing to be relatively mild for the patients we know about, the actual number of H1N1 cases is still relatively low and may stay that way.

Put Down That Soda and Step Away Slowly? Taxing Sugared Beverages to Address Obesity.

While the Disease Management Care Blog is distrustful of big government involvement in health care, there can be little doubt about the important role it has to play in old fashioned public health. Taxpayers have gotten their money's worth in the many Federal, State and County programs of surveillance, disease prevention and health promotion. This link is a good example. While there is a resemblance to disease management, that’s a topic for a different post.

That’s because the DMCB is too busy agreeing with Drs. Brownell and Frieden in their April 30 New England Journal of Medicine Perspective on taxing sugared beverages. This is the right mix of public health, leveraging government power and, while we’re at it, getting our collective hands on some serious coin.

According to the authors, sugar-sweetened beverages may be the ‘single largest driver of the obesity epidemic.’ While food manufacturers would have you believe it’s a matter or exercise, don’t believe it. Too many studies have shown that that last can of soda you had is consistently associated with being overweight, having a poor nutritional status and being at greater risk for diabetes.

Since simply educating people about the need to reduce sugared beverage intake has limited impact, why not turn to an approach that worked to reduce consumption of tobacco? According to the authors, some locales have used taxation in the soda wars and they’ve found that every 10% increase in the price results in a drop in consumption by 7.8%.

Yes you, like the DMCB, may be leery about Big Brother nosing into another corner of our lives, but consider: 1) all that sugar consumption means more Medicare and Medicaid and less work-tax revenue, 2) manufacturers are very good at touting the faux-health benefits of their products and there is no other way to level the playing field and 3) er, hellooooo, this is one tax that many Americans might support – especially if the revenue were used to credibly support health programs.

Drs. Brownell and Frieden raise some other good points. A tax may represent a bigger burden for persons of low income. Just because everyone drinks less soda as a result of the tax won’t necessarily mean that, as a result, people will eat better. Imposing a small tax may raise revenue, but it will probably require a bigger tax (say, a penny an ounce) to meaningfully reduce consumption.

While this notion circulates around policy circles, the DMCB asks whether our hospital, clinics, retail phamacies and disease management organizations’ places of work should reconsider even selling soda in our cafeterias and vending machines. Instead of banning them, just jack the price up. Why not?

So, no need to put the soda down. Pay up instead and wonder if you can really afford it.

An Update on Healthways

Underwelmed by all the repetitive media cacophony over the dire Swine Flu news*, the Disease Management Care Blog detoured on over to the latest Healthways earnings call transcript to see what insights it could glean about the industry. As previously noted, Healthways is one of the few publically traded disease management-only companies. If it is doing well, it bodes well for the rest of the industry.

It seems there was good news, resulting in just over a dollar or 11% increase in the share price.

What made the increase remarkable was that it occurred despite Healthways having lost money, thanks to having to settle a $40 million suit - thanks to some past sins by its predecessor company. Investors apparently forgave the total 1st quarter loss of $14.8 million because, in the background, there was real revenue growth. The number of persons Healthways serves (or 'covered lives' in health insurance parlance) reached an impressive 35.8 million (up by 3 million). It signed nine new insurer contracts and renewed or extended another 9 contracts. Excluding the legal settlement mentioned above, Healthways achieved revenue of $0.02 per share. That ain't bad, given the specter of rising unemployment and fewer people being able to afford health insurance. What's more, there were more persons participating in its Silver Sneakers programs, and it looks like there will be business in Australia and Germany. Cash flow seems healthy and Healthways is making capital investments in IT.

The insights?

Once again, while disease management and population-based care programs continue to come under intense scrutiny in Washington D.C., the debate seems to be over in the commerical helath insurance markets. They continue to see value in what companies like Healthways brings to the well-being of enrollees. Ever more insurers are buying into this.

While the earnings call mentioned the loss of the Minnesota Blue Cross Blue Shield business, note that that wasn't due to its abandonment of disease management. Rather, that insurance plan still values the concept, because the only difference is that it's been brought in-house. It will take at least a year to see how successful that strategy is, assuming Minnesota is willing to share its experience with the DMCB.

In addition, Healthways is clearly positioning itself as a one stop shop solution that crosses the spectrum of care for popultions with wellness, prevention and chronic illness programs. This ain't your old disease management stuff anymore.

Last but not least, Healthways is well aware of the Patient Centered Medical Home. Here's a telling quote from Ben Leedle during the call:

And we’ll continue to hear more and more about the medical home which I think has lots of different supporters with lots of different definitions. I think the general construct there is there needs to be a whole lot more coordination for the consumer in and around how to navigate the resources that already exist and to take advantage of new ones like what our company brings in the area of wellness and prevention. And to put those resources at the helm of the captain of the ship, which in a lot of these models is the primary care physician. We know a little something about how to help get that done.

Yup.

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

*The DMCB thinks it will only be a matter of time until someone blames the emergence of a new influenza A variant on global warming. You may want to be skeptical if it comes up.

A Primer for the Disease Management Community on Swine (H1N1) Flu

Good grief! Don your masks, don’t go out, forget about being with other people and most of all don’t even THINK about touching ANYTHING. According to dire media reports a Swine Flu Pandemic Panic of Biblical proportions is upon us.

The good news is that the Disease Management Care Blog is at your service by asking if it’s really that bad. After some research, the answer is no, but the population-care community needs to learn about this and to stay tuned. Here’s a Background, The Facts and What To Communicate primer for the DMCB readers:

Background

Viruses are non-cellular packets of genetic material (DNA or RNA) surrounded by a membrane. Each virus species is defined by their structure, typical host (bird, pigs or human are common), lineage and subtypes. For this pandemic, it’s important to know that viruses don’t necessarily have to restrict themselves to any single species. In the case of the ‘flu’ viruses (known as the influenza viruses), they target the cells of birds, pigs and other mammals in addition to humans.

Different subtypes of influenza have varying ability to bind and enter the cells of these species, which leads to infection. The severity of the infection can vary from mild to lethal depending on both the virus as well as the host.

Influenza A is one species of virus (versus other species in influenza like ‘B’ and ‘C’) that has different subtypes. Among the influenza viruses, subtypes are based on the makeup of two surface proteins called hemagglutinin and neuraminidase.

Hemagglutinin is a type of ‘glycoprotein’ (a molecule that contains both amino acids and ‘sugar’ or oligosaccharides) that sticks out from the surface of a virus. It helps the virus stick to the surface of living cells (via the ‘sialic acid receptor). Neuraminidase is a protein that sticks out from the virus that allows newly formed virus to be released from infected cells. The structure of these two molecules contributes to their ability to attack cells, i.e., their virulence as well as their ability to change species.

Scientists have found that the individual amino acids in the hemagglutinin and neuraminidase molecules among influenza type viruses can vary. There are at least 16 main types of hemagglutinin molecules (labeled H 1 through H16) and well over a hundred different types of neuraminidases, each associated with varying virulence.

While the hemagglutinin and neuraminidase viral molecules have their own purposes, they also are targeted by the human immune system. Once recognized, these key molecules are blocked by the immune system and the virus is unable to spread.

Since viruses undergo spontaneous changes in their genetic makeup, the amino acid content of the hemagglutinin and neuraminidase can correspondingly change in small but important ways, allowing them to escape from the immune system’s recognition. There are two ways to prompt that recognition by the immune system: either an infection with the new virus (the virus causes illness until the immune system ‘kicks in’ and fights back) or immunization (an injection with weakened or even inert/dead viral protein) that prompts the system to build immunity before the real virus appears. The DMCB gets a flu shot every year because it finds it to be much easier than the alternative.

Last but not least, the clinical detection of a new influenza virus relies on a curious alliance between community-based labs and the Centers for Disease Control. It’s not routine for physicians to swab the noses of persons with flu symptoms and send it off to a local microbiology lab to try to isolate any virus. When that happens and and the local lab detects a different virus, it alerts the CDC. So, the CDC is dependent on the health care providers to take samples when they are seeing patients with the flu. When it was in practice, the DMCB rarely swabbed noses, telling persons instead to go home, drink fluids and rest. In contrast, some of the DMCB’s partners got lots of swabs.

The Facts

So with that as background, a new Influenza A virus with a hemaglugglutinin type 1 and neuraminidasetype 1 that was previously restricted to pigs appeared in lab samples from Mexico in mid March, followed by April reports in California, Texas, New York City, Kansas and then recent reports in New Zealand, Hong Kong and Spain. This particular type of Influenza A was previously isolated only from pigs or had been rarely documented to be transmitted from pigs to humans. The DMCB surmises that in the pig to human cases, the humans probably got infected because they lived in close proximity to the swine and got exposed to a large amount of virus. A new H1N1 swine influenza virus has now emerged. It has changed and can now jump from human to human, leading to hundreds being infected in Mexico. While there have been reports of many deaths in that country, that’s not true in the U.S., where infections have been described as mild with sore throat, runny nose, nausea, vomiting and diarrhea.

The DMCB thinks that all influenza infections have a mortality rate. It could be that because Mexico had many more cases, so it only appeared to have excess mortality. The next few weeks should clarify that.

In addition, while it may appear that this new virus is ‘spreading,’ it may also have been out there for more than a month. While it may be spreading, the DMCB thinks recent reports are being fueled by more docs sending off more nose swabs because they are aware of this swine flu outbreak. It’s not necessarily more cases, but more docs diagnosing more cases.

It is also possible that this virus could dissipate and simply go away. That has happened before and the fact that we’re headed into the summer season – where people don’t crowd as much and person to person transmission is decreased – may help that happen. Once again, time will tell.

What To Communicate

Influenza infection generally is a bigger threat to health among persons with chronic illness (see Box 2 here). Persons with diabetes can develop worsening of their blood glucose control, persons with chronic heart failure can experience an exacerbation of their disease and persons with lung diseases such as asthma or COPD can experience bronchospasm. Preventive advice to share with persons who are reported to be in counties with H1N1 is here and don’t forget to warn against aspirin in persons less than age 18 years.

Treatment with antiviral medications is recommended for any ill person suspected to have swine influenza A (H1N1) virus infection. The drugs to use are either zanamivir alone or with a combination of oseltamivir and either amantadine or rimantadine for five days. It’s important to note that this may change as more information on the virus becomes available.

The Population Health Management Journal, for your quoting pleasure

Today was a good day for the Disease Management Care Blog. That's because any day that includes the latest copy of the Population Health Management Journal in its mail box is a reason to pause, get an extra cup of coffee, put up the feet, crack the cover and sample this buffet of learning from the peer reviewed, population-based care literature.

Many don't have that luxury, but no fear. The DMCB went through each manuscript and culled what it believes you need to know and what you can quote for your corporate-jousting, revenue-enhancing, client-facing, career-laddering advantage. Just another leg up when you join the many hundreds that regularly check in with the DMCB!

Anthony Stanowski: Influencing employees' attitudes and changing behaviors: A model to improve patient satisfaction. ARAMARK Healthcare conducted a national survey of 700 nurses (68%), physicians (11% and other clinical staff (the remainder) attitudes toward clinical support service employees. What follows is a descriptive journey that finds ‘a psychographic segmentation model can form the basis of a messaging strategy to create a collaborative approach with support services and the total patient experience with the health care institution.’ Despite the graphs and the percents, the DMCB was confused by how the author got from here to there, and why the PHMJ published a lead article that seem more attuned to an inpatient care oriented audience.

Amy Wilson, Holly Rodin, Nancy Garrett, Eric Bargman, Lori Harris, Melinda Pederson and David Plocher: Comparing quality of care between a consumer-directed healthplan and a traditional plan: an analysis of HEDIS measures related to management of chornic diseases. Consumer directed health plans have been accused of being the devil’s spawn because they oblige persons to actually participate in the economics of their health care services purchasing. While this may reduce global health care costs, does it also reduce medically necessary health care costs? In this study from Blue Cross Blue Shield of Minnesota, approximately 131,000 consumer directed enrollees’ HEDIS scores in heart disease, asthma, back pain, diabetes, medication monitoring and depression were compared to the HEDIS scores from just over a million traditional health plan enrollees. Ultimately there was either no difference in most of the HEDIS measures. Consumer directed plans actually did better in three of them: back pain, diabetic eye exams and diabetic urine screening. While it’d be easy, based on these data, to conclude that consumer directed plans are not the devil’s spawn, the authors didn't appear to statistically adjust the data for the baseline differences in age or gender. They also didn’t take into account the possibility that persons who chose consumer directed plans are more savvy health care purchasers. To really decide the question, better matching of consumer directed enrollees and health plan members would be necessary. It’s highly unlikely that a prospective randomized trial will ever be done, so the likelihood that the question will be ever be settled to everyone's satisfaction is remote.

John Fortney, Jeffrey Pyne, Jeff Smith, Geoffrey Curran, Jay Otero, Mark Enderle, Skye McDougall: Steps for implementing collaborative care programs for depression. Want to establish a state of the art, evidence based, clinically effective, generalizable, diffusible, CQI-oid, Plan-Do-Study-Act formatted, organizational theory-led implementation plan for the management of depression in your institution? Look no further. Here’s a series of check-listed steps with recommendations, along with a flow chart, for you or your 'team' to follow, all based on ‘lessons learned’ in two Veterans Affairs implementations. The DMCB will leave it to the reader to decide if this approach has any hope of success outside a vertically-integrated and salaried-provider care setting without a 3 month waiting list for non-emergent patients in carve out commerical plans to see a psychiatrist in the first place.

John Knight, Jeffrey Dowden, Graham Worral, Veerabhadra Gadag, Madonna Murphy: Does higher continuity of family physician care reduce hospitalizations in elderly people with diabetes? If you think one purpose of Canada’s health care system is to remind us Americans of the poor job we’re doing, you’ll like this study from the province of Newfoundland. The family medicine physicians’ insurance claims of all persons age > 65 meeting an insurance-based definition of diabetes mellitus (N=1393) were analyzed for the presence of “continuity.” Continuity was based on the patterns of claims that suggested that there was a single family practice provider responsible for the patient’s care. The higher the continuity score, the lower the likelihood of hospitalization in this group. Interestingly, the number of visits with any family practice provider was not associated with a lower hospitalization rate.

William Cardarelli: Asthma: Are we monitoring the correct measures? The DMCB thinks the asthma HEDIS measures were chosen because they’re easier to measure, not because they have any real world correlation with disease activity. It is not alone. This latest review of the literature from Atrius Health/Harvard Vanguard points out that there are several easily administered surveys that correlate quite nicely with the asthma severity as well as patients' quality of life. The author argues that clinical assessments of asthma control should be multidimensional and be partially based on these patient self-assessments. The DMCB also notes there’s a difference between individual patient assessments of asthma activity and population-based assessments of asthma quality of care. Why not, asks the DMCB, also use these surveys to supplement the insufficient HEDIS measures?

Yiduo Zhang, Timothy Dall, Sarah Mann, Yaozhu Chen, Jaana Martin, Victoria Moore, Alan Baldwin, Viviana Reidel, William Quick: The economic costs of undiagnosed diabetes. It makes sense to think that the years prior to a formal diagnosis of diabetes is probably a time when diabetes is present but hasn’t been diagnosed yet. The folks from the Lewin Group and Ingenix/i3 compared total insurance claims for the two years (2004 and 2005) prior to a first time diagnosis of diabetes in 2006 to insurance claims from persons from the same period without diabetes. The authors found the claims expense was comparatively greater. Based on these data, the authors estimate that the annual per person cost of undiagnosed diabetes and its associated complications is $2864. When extrapolated to the United States’ population, that’s $11 billion in direct medical costs, which typically goes unmentioned in all those other estimates of the already huge cost of diabetes.

Timothy Dall, Sarah Edge Mann, Yiduo Zhang, William Quick, Rita Furst Seifert, Janna Martin, Eric Huang, Shiping Zhang: Distinguishing the economic costs associated with Type 1 and Type 2 diabetes. Did you know that it’s not until folks are greater than age 45 years that direct and indirect medical costs of Type 1 diabetes becomes greater per person compared to Type 2 diabetes? By the time Type 1 diabetes reach age 65 years, much of the individual excess costs are associated with institutional care, including year-round nursing homes. Yet, the aggregate costs of all Type 1 diabetics (because there are far fewer cases) are much lower compared to Type 2 diabetes (which comprise 94% of all the cases). The most impressive number in this manuscript is $159.5 billion in total U.S. health care costs for Type 2 diabetes, vs. $14.9 billion for Type 1. That’s a lot of money that could otherwise be spent on, say, bank bailouts.

Health Care Reform: A Readable Summary from the New England Journal of Medicine

Today's New England Journal of Medicine has a brief and readable summary that describes the status of D.C.'s health reform efforts.

As you are reading this, there are 3 House committees and 2 Senate committees that are meeting behind closed doors trying to hammer out some legislation. Each of the committees will generate similar 'harmonized' proposals within their respective areas of jurisdiction. Based on what is known about the discussions that are underway, we can already begin to discern what kind of bill will emerge this summer.

Elements include an insurance mandate (with a tax penalty for those who don't cooperate), premium subsidies for the poor, changing eligibility criteria for Medicaid, strengthening SCHIP (the Children's Health Insurance Program), bundling payments around episodes of care, promotion of 'accountable care organizations,' supporting the medical home, capping the deductability of employer-based health insurance (which would generate some money to help pay for it all), malpractice reform, pursuit of fraud, reduction of waste and creation of a public plan. This last issue is proving to be the most contentious and may prove to be the flash point between social conservatives and liberals.

The Disease Management Care Blog has previously come out in support of bundled payments as a means of promoting efficiency. It also believes that if the payment is done right, physicians and hospitals will start to become aligned without having to craft additional legislation.

As for the medical home, the DMCB notes that Phase II of the Medicare Electronic Health Records Demonstration was cancelled following passage of the American Recovery and Reinvestment Act (ARRA). Is the same fate looming for the Medicare Medical Home Demo? If Congress passes a bill that fully underwrites the Medical Home in fee for service Medicare, why would a demo be necessary?

Last but not least, the DMCB is less aware of the art of bipartisan compromise over the issue of a public plan, but it knows that the definition of a public plan may be the route to some sort of agreement. For example, it might be possible to create a public option that is funnelled through a private insurance mechanism, acts as an insurer of last resort and is backed by regulations with teeth.

And all those community meetings over the winter and the public discussions and roundtables over the spring? Thanks to all of you for your efforts, but we know those events had a far different purpose. The real decisions are now being made behind closed doors. Our job as citizens will be to wait and see what emerges - and to carefully read the fine print for all those important details.

The DMCB is looking forward to it.

The 76th Edition of the Cavalcade of Risk is Up!

If you don't take a look at the 76th edition of the Cavalcade of Risk over at the My Wealth Builder Blog, you'll be at risk of missing out on the best and the brightest of the blogmos postings on insurance, health improvement and financial well being. Check it out!

Managed Care Pharmacists and the Medical Home: The Disease Management Care Blog Examines the Prospects for Collaboration

The Disease Management Care Blog recently had the pleasure of lecturing at the annual meeting of the Academy of Managed Care Pharmacy (AMCP). As readers may imagine, this professional organization provides advocacy, outreach and education services for persons – mostly pharmacists – involved in the pharmacy plans for health insurers. The DMCB provided an AMCP educational service by offering up a session on the merits of the chronic care model and the medical home.

While most of the 80 or so pharmacists in the room knew all about disease management, few had heard of the ‘chronic care model’ or the ‘medical home.’ In its commentary, the DMCB noted that managed care pharmacists can play an important role in helping enrollees/patients be more knowledgeable participants in their own treatment plans. A post-lecture survey indicated most of the attendees agreed the concepts of the chronic care model had merit. Thanks to the DMCB, that’s 80 more health professionals who know about the medical home.

The DMCB isn’t optimistic this will make much of a difference, however. That’s because it knows that the pharmaceutical insurance plans are typically ‘shielded’ from the standard health insurance policies that they are paired with; they are sold as a ‘rider’ with their own benefit designs, underwriting, cost structure and premiums. For an example of how this works, see here.

As a result, most of the business-as-usual pharmacy leaders that were in the room have little economic incentive to coordinate their pharmacy insurance products with all that other ‘medical stuff’ going on back home. In fact, under most circumstances, they have an incentive to ‘transfer’ their pharmacy costs to the standard insurance plan. If this sounds like health care silos at their worst, you’re right.

For example, certain injectable medicines can be administered in a physician’s office (making them eligible to be covered as a medically necessary service) or at home (making them resemble any other drug that persons need to take on their own). Given a choice, the likelihood that any pharmacist would welcome these drugs' cost into the budget is inversely proportional to their price. Yet, it is the precisely the conditions treated by the high cost injectables (such as cancer or connective tissue disorders) that may benefit from close coordination with the involvement of knowledgeable pharmacists in care management services. The pharmacists’ response? Why take on the expense of taking on any of these services when that additional cost will make their insurance product less competitive and less profitable? In fact, a really good education program could attract chronically patients, further stressing the budget.

If this reminds you of the tension between physicians and managed care insurers, you’re right. Primary care physicians have also pointed out that they’re vulnerable to taking on the cost of patient education and empowerment while the financial benefit goes to the insurance company.

And that’s not all. The DMCB has generally found that the really smart pharmacists that rise to the top of their organizations do so because they understand pharmacology, pharmacoeconomics and budgeting. These are brainy hardnosed businessmen and women who have less professional affinity for the squishy business of patient education and empowerment.

The DMCB predicts as awareness of the medical home grows, managed care pharmacists will support it if they believe it can reduce their costs. If (and that is a big if) they believe it reduces their drug spend, their support will consist of:

1) agreeing that the medical home should be covered by the standard insurance benefit, since better control of disease may reduce drug consumption, and/or

2) conducting outreach activities to primary care sites that function as medical homes.

Otherwise, the DMCB thinks it will be all talk and no action.

The only wild card? Pharmacy Benefit Managers (aka PBMs). The DMCB thinks their value as intermediaries between the pharmaceutical manufacturers and the managed care plans is becoming increasingly commoditized. Their position will become even more tenuous if price controls are pursued by the Obama Administration. To maintain their market share, expect more of them to offer not only disease management services but active support for medical homes on a 'value added' basis without any expectation of lower costs.

Female Undies and Integrated Delivery Systems: The DMCB Examines the Relationship

In one of its earliest posts, the Disease Management Care Blog questioned all the fawning over integrated delivery systems (IDS’). Yet, much like the female undies at a Tom Jones concert, accolades continue to be hurled at the notion that vertical integration has useful lessons for healthcare reform.

That was on ample display at the recent World Health Care Congress, where multiple speakers used minor variations of the same canned theme over and over and over. So, as a public service, the DMCB took notes and is happy to provide future national conference speakers with this handy template, suitable for index cards, teleprompters and jumbotrons everywhere.....

As (pick one)....

a) Chief Executive Officer,
b) academic with scant face-to-face patient time,
c) someone who slept in a Holiday Inn last night,

I can confidently state that the association between integration and quality is (pick one).....

a) a no brainer,
b) taken for granted,
c) stated so often by me that I’ve come to believe it.

Y’know, when persons see a doctor, there is a 50-50 chance they’ll (pick one)

a) get evidence-based care,
b) result in a physician actually getting paid,
c) obtain a referral to an expensive specialist who actually likes to see patients.

That’s why as someone who (pick one)

a) is paid far more in a year than many of you will see in a lifetime,
b) really REALLY wants a job in the Obama Administration,
c) is wearing a pricy pair of boxers,

my (pick one)

a) evident reasoning,
b) insufferable arrogance,
c) taking others’ word for it

has led me to (pick one)

a) commend,
b) pitch,
c) worry if I can get a flight back home earlier, so I’ll repeat that

integrated delivery systems are the best hope for (pick one)

a) high quality low cost healthcare reform,
b) me getting to speak at other conferences,
c) getting mentioned in the Disease Management Care Blog.

Thankfully, there are a few contrarian souls out there. The DMCB really likes this piece written by Francois de Brantes and Lawton Burns over at the erudite Health Affairs Blog. Noting that the right kind of payment reform should drive the organization of health care systems, he argues that intelligently designed payments for ‘episodes of care’ will lead to coordination by non-physicians, physician-specific cost accounting, teaming, clinical leadership promoting cost effectiveness, supply chain management, continuous quality improvement and better, smarter billing. None of these are the exclusive province of IDS’ and all are possible in other healthcare settings.

Two other points to keep in mind:

1) Many health care policy experts constantly salute the lower-cost and higher-quality countries in Europe as source of healthcare insight for the United States. Note that they do it without IDS’.

2) The difference between ‘integration’ and ‘consolidation’ may ultimately be only cosmetic. The former suggests there is coordination of care, while the latter portends a local monopoly.

Support the Patient Centered Primary Care Collaborative

The Disease Management Care Blog has been alerted to the posting of a copy of an important letter addressed to Charlene Frizzera, CMS' Acting Administrator and Peter Orszag of the OMB expressing concern over possible changes in the upcoming Medicare Medical Home demonstration. The letter is from the folks over at the Patient Centered Primary Care Collaborative. Apparently, OMB is actively considering restricting participation in the demonstration to primary care sites that have obtained Tier III recognition in the NCQA's Patient Practice Connections/Patient Centered Medical Home (PCC-PCMH). As readers may recall, Medicare initially planned to use its own Level I and II certification process.

The letter correctly points out that, while it was going to be difficult for small physician owned practices to participate at a Level I or II, it will be far more difficult for these clinics to attain the highest NCQA Tier III level. It takes considerable resources to attain this, and the inevitable failure to do so will effectively shut out about 1/2 of all the U.S. primary care physicians from participation. As a result, we will have no idea if the the Medical Home is a viable and generalizable option in fee for service Medicare in all corners of the country.

What are they thinking?

You're welcome to sign onto the letter to express your concern. Readers can contact Relja Ugrinic, at rugrinic@pcpcc.net, directly by COB Tuesday, April 21st, to add your name to the letter.

The Latest Health Wonk Review is Up!

The Disease Management Care Blog likes the irony of going round and not ending up where you started. To quote a modern bard:

Come gather 'round people

Wherever you roam

And admit that the waters

Around you have grown

And accept it that soon

You'll be drenched to the bone.

If your time to you

Is worth savin'

Then you better start swimmin'

Or you'll sink like a stone

For the times they are a-changin'.

See how you can go round and round and end up where no body knows by riding the best of the carosel blog ponies at the latest Health Wonk Review over at Glenn Laffel's Pizaazz. You may be dizzy, but it'll be a good dizzy.

Random Reports from the Field at the World Health Care Congress

The Disease Management Care Blog is in Orlando tonight, getting ready for tomorrow’s presentation at the Academy of Managed Care Pharmacy annual meeting. Its message: that pharmacists have a role to play in population-based care programs, including the medical home. More on that in a later post.

In the meantime, the flight from Reagan was an opportunity to pull out various notes made at various times while sitting in the audience at the World Health Care Congress. What a great meeting.

In unrelated and random order, here they are:

While the speakers knew of which they spoke, the moderators ranged from superb to hopeless. Just because you carry a byline in some household-name news organization doesn’t mean you can spot when the speakers are hiding behind their vague nostrums. The DMCB came away with a better understanding of the divide between the complicated business of health policy and the ability of the media to understand it, let alone translate it.

Attendance? Around 1400 persons, which was not only high for the WHCC, but contrasts with other meetings in the non-health care fields, where attendance (according to a meeting planner) is down by 25% or more. During the ride to the Orlando Hotel, the driver told the DMCB that he was thankful that there was a cardiology meeting coming up, 'otherwise we'd be out of business!' Strange? Unexpected? You be the judge.

Karen Davis of the Commonwealth Fund saluted Germany’s healthcare system for providing the nurses that staff the doctors’ clinics for care management services. It seems to the DMCB that that is closer to the ‘disease management’ model (externally supported nurse coaching) than the medical home model (in which the primary care site is responsible for staffing a team). As noted before, the DMCB thinks a combined model is best and looks forward to when Dr. Davis can salute the U.S. system for being better than Europe's.

George Halvorson of Kaiser blithly dismissed malpractice costs as a driver in health care inflation. He can afford to do so because of MICRA. Is this another reason why California's integrated delivery system may be less of a role model for healthcare reform than anyone thinks, or is he just plain wrong? And is the DMCB crazy, or is the resemblance to Orson Wells more than just skin deep?

In addition to founding a social-missioned bank in Bangladesh, Nobel Prize winner Muhammad Yunus also started a Bangladeshi insurance company with a premium of $2 a year. Interestingly, the benefit involves co-insurance, otherwise ‘people would see the doctor for anything, like being dizzy in the head.’ The DMCB asked him about the all important cost ‘trend’ in his insurance company. He noted it was low, not only because of the out of pocket consumer brakes on utilization, but 1) because when people in Bangladesh get ‘sick,’ that means they are physically unable to get out of bed. ‘If they can get out of bed, they are not sick’ and do not need any health care services, 2) his insurance covers wellness services such as non-physician-based prenatal care in all the villages, and 3) use of the internet for specialist physician consultations – ‘we don’t bring the doctors to the villages, we bring the villages to the doctors.’

Peter Salgo MD, host of Second Opinion announced that ‘evidence-based medicine’ (EBM) is far less available than anyone believes. Rather, most of what passes for EBM is really high probability medicine (how the DMCB interpreted Dr. Salgo's remarks), characterized by the best guess at what works for average persons within the bounds of statistical probability. The moderator and other guests on the dais were horrified.

Dr. Jeffrey Kang, the Chief Medical Officer of CIGNA, pointed out that comparative effectiveness research (CER) could be used for one of two purposes: coverage or reimbursement. In the former, only treatments that pass CER muster will be “covered” by an insurer. In the latter, treatments that don’t pass muster will either be reimbursed with a comparatively lower fee or, alternatively, the patient- consumer will be responsible for a higher out of pocket payment. He thinks the reimbursement approach will be far more palatable to the American public.

Is the classic server-web-clinic based electronic medical-health-personal record already obsolete? The DMCB wonders if that’s the case. It ran into two vendors that rely on the cell phone as the primary platform for e-medical record management. Think of an icon on your IPhone or Blackberry that retrieves your history, sorts your medications, stores your lab results, remind you to take your pills, texts your providers and who knows, even pulls up your x-ray images. If you LOSE your phone, the vendors will signal the absconded phone with a signal that will wipe it clean. More on this in a future post.

Finally, an historical insight from Newt Gingrich. While the Poles were overthrowing their Communist government, one of their slogans was ‘2+2 = 4.’ The point was that the government had been telling them that ‘2 + 2 = 5’ and it was time to face reality, not slogans. Newt felt the last ten years in the U.S. were filled with ‘2 + 2 = 5’ economics (quote: ‘a strange detour in the American journey’), in which we failed to recognize that ‘when you can’t afford a house….. you can’t afford a house.’ He’s afraid the next ten years will be one of ‘if you can’t afford all the health care you want….. you can’t afford all the health care you want.’

The Bad and the Ugly of Disease Management ROI and How Al Lewis of the Disease Management Purchasing Consortium Wants to Fix It

Al Lewis is a colleague of the Disease Management Care Blog. It’s always a treat running into a founder of the DMAA and the head of the Disease Management Purchasing Consortium (DPMC). That’s doubly true when he’s taking no prisoners. At today’s World Health Care Congress, Al threw down the population measurement gauntlet for all vendors, actuaries, benefits consultants, health plans and anyone else of dubious analytic pedigree. In fact, Al named names and dared audience prove him wrong or sue him. Neither happened. When Al was done, there was a long line of persons who wanted to give him their business cards so that they could get an email copy of his presentation and Excel spread sheets.

As opening testimony to his vexation, he quoted directly from one actuarial analysis:

'….cannot state which trend assumptions reveal the true program effect. The choice of trend has a large impact on estimates of financial savings.' (bolding from the DMCB)

Al Lewis argues this ‘choice’ is a canard: savings are or they aren’t. He believes the business-as-usual disease management pre-post analyses being foisted on unsuspecting purchasers miserably fail to account for the persons with chronic illness that are missing in the baseline. Missing claims can be due to any number of problems, including not having any encounters but having disease, or having too few claims, or not having the right 'kind' of insurance claims. In Al’s experience, both of the competing approaches of a) 'prospective' identification (once chronic, always chronic and counted over the entire period of observation) and b) 'annual' identification (must be requalified with relevant claims every year) are vulnerable to this shortcoming. After showing some simplified examples in which both approaches led to inflated savings because of missed claims and regression to the mean, Al argued that the better method is to assess total event rates over time across a population while comparing them to valid national sample.

Al’s dyspepsia reached its zenith when he examined the issue of ‘innumeracy.’ He had examples of huge savings being touted with little understanding of the usual or reasonable baseline measures typical among persons with chronic illness, or the role of cost drivers like hospitalizations. Using coronary artery disease management programs as an example, Al bascially recommended that you keep it simple: measure the baseline heart attack rate over several years and compare it to a simultaneous national mean. If the DM program is successful, heart attack rates should comparatively decline over time.

Co-presenter Roberta Herman MD of Harvard Pilgrim Health Care agreed with Al. Sharing numbers from HPHC's disease management programs, she showed there was gratifying drop in asthma ER/hospital rates over the last 7 years. However, the DMPC method demonstrated that the program was far less effective when it was compared to national baseline. In contrast, while diabetes appeared to flatline, there was a concurrent decline in heart attack rates that bettered national statistics and seemed to contribute to Harvard Pilgrim’s NCQA success.

Impressions from the DMCB:

Maybe the fancy actuarially-focused disease management trend reconciliations are too complicated for a lot of folks in the disease management industry. Al’s method clearly resonated with the audience, who were skeptical about the vendors’ conflict of interest in running a disease management program and being simultaneously responsible for assessing the return on investment.

Roberta Hughes also pointed out that C suite leaders also need the mumbo-jumbo free simplicity of overall vs. national rates, especially if the skeptical actuaries over in the CFO's office are telling them that the disease management programs are having no impact on overall trend.

When asked, Al doesn’t have an issue with the impact of disease management programs. Rather, he thinks the DMPC measurement methodology is a better way to assess the degree of the benefit. The DMCB asked him about the option of using multiple measurement methodologies to “triangulate” on the return on investment from several vantage points. He agreed that the DPMC approach could complement other analyses – assuming they’re all in the same ball park.

News From the World Health Care Congress

In the opening day of the World Health Care Congress, the Disease Management Care Blog didn’t really hear anything new, but there were a few interesting and random wrinkles. It seemed like everyone is simply repeating themselves, apparently hoping that by saying the same thing over and over, the Congress and the Administration include will include them the design of the upcoming health reform package.

Here are some of the wrinkles that caught the DMCB eye:

The gracious Dr. Dora Hughes laid out the principles that the Obama Administration will be seeking while it works with Congress to craft mutually acceptable healthcare reform legislation. Those principles are protecting families, promoting affordability, including prevention, increasing quality, having more portability, preserving provider choice, ending the use of preexisting conditions to deny coverage and reducing the upward cost trend. All well and good, but Dr. Hughes spoke in careful generalities, giving the impression that she had been carefully coached. She remained very loyal to parroting the administration line. The DMCB has witnessed this with speakers from the last administration. Plus la change…..

How about the controversy of a federally supported public plan? Dr. Hughes said the Administration didn’t care if the principles above remain intact. Bruce Bodaken of Blue Shield of California didn’t surprise anyone when he argued that the right kind of regulatory oversight of the private market could readily lead to access, fairness, universality and affordability without the downside of government intrusion. But it was John Kingsdale of Massachusetts‘ Commonwealth Health Insurance Connector that pointed to a middle way. His State does not use a classically defined public plan. Rather, he noted they rely on government subsidized Medicaid managed care organizations with Medicare-style fee schedules that act like a public plan. The point: if Republicans and Democrats change the definition of a public plan and blur the distinction between private and public options, they may be able to find a (insurer of last resort on steroids?) compromise that keeps everyone happy.

Mr. Kingsdale made some other interesting points about cost control, which can be paraphrased as follows: The road to cost control goes through health insurance reform. Access to health insurance is the moral high ground that can next be protected by controlling health care costs. The country can’t let cost control hold the uninsured hostage. While the DMCB isn't sure it agrees with the logic, the man has a point.

Mr. Kingsdale also pointed out Massachusetts isn’t necessarily a model for national health care reform because 1) since health insurance and health care are really local, States rely on a level of ‘intimacy’ in creating consensus over things like benefit packages and networks. It takes a lot of work and even when there is agreement, the work has only just begun. Maintaining consensus and building on the initial success takes time – which is unlikely in Washington DC. A speaker from Minnesota echoed the same refrain. Both hope that Federal health reform gives the States breathing room. The DMCB finds it ironic that these liberals are arguing on behalf of States' rights.

New Gingrich weighed in briefly on health information technology by pointing out that the biggest danger is creating a system that not only will be obsolete but locked in and therefore too big to change. As you may suspect, he distrusts large government solutions.

Practically everyone - and the DMCB means EVERYONE - repeated over and over how important care management is. All population-based programs, including disease management, were included. If you work in that industry, the future seems bright indeed.

Over the next two days, the DMCB will continue to scour the WHCC for more nuggets.

Listen Up Federal Coordinating Council on Clinical Effectiveness Research: Here's Some Advice From the Disease Management Care Blog

Darn it.

The Disease Management Care Blog spent the day traveling to D.C. for the World Health Care Congress and missed the deadline to submit commentary to the Federal Coordinating Council on Clinical Effectiveness Research (FCCCER). Looks like it will miss the April 14 listening session too, since it'll be listening to other wisemen in some audience somewhere in the bowels of the Wardman Park Marriott. The listening sessions starts at 2 PM and you can link in here.

Undaunted, the DMCB assumes, hopes and aspires to the notion that many on or associated with FCCCER regularly read this blog and that they're really into listening and not pandering. So for better or worse, here's some tardy advice for the CER crowd:

Comparative effectiveness research (CER) is a style of scientific medical inquiry that compares a new proposed treatment to the state of the art treatment. Up until now, much of previous research on new advances in care has pitted new treatments against placebo or against one or more weak approaches that are predestined to fall short. Often engineered that way on purpose, the result has been a mash of care options that flummox physicians, cause escalading variation and force insurers to pay for everything.

Unfortunately, proponents of CER assume using state-of-the-art comparators will enlighten physicians and reduce costs. That’s unlikely unless CER addresses other far more serious shortcomings that have gone largely under-examined in the CER debate. Unless these shortcomings are also managed, physician inattention will continue, clinical research will be marginalized, variation will linger and cost will continue to spiral upward.

These shortcomings are three fold:

Most of the medical research published today is typically focused on a limited number of variables among the many obscure interrelated details of disease, laced with picayune caveats and weighted down with dense methodologic jargon. As a result, many reductionist peer review publications are opaque data blobs remarkably lacking in the kind of insight needed by today’s modern physician. Many become dated by the time they appear in print anyway. They can be ignored with little risk to most patients most of the time week after week. Why should we expect CER to be any different?

What’s more, published research is too often only partially about the patients. The granting agencies, the research scientists, the medical schools and the medical journals – while well meaning - don’t necessarily exist for the benefit of patients, but for the benefit of more grants, bigger medical schools, higher academic promotion and the luster that comes with appearing in print. As we know more and more about less and less, why should we expect CER to be any different?

Last but not least, typical medical research often resembles a successful operation on a patient that died: it too often falls short in answering the bigger questions. These unanswered questions often include: what combination of approaches works best for typical patients given a particular set of cultural and economic circumstances? When and by how much do they improve patients’ well being, extend life, save money and cause physicians to go out of business? Since decades of traditional research, with a few exceptions, has repeatedly failed to ask the right questions while substituting statistical significance for real world consequence, why should we expect CER to be any different?

Until we know if the current medical-industrial complex is a) up to the task of asking the right questions, b) creating the right protocols, c) accessing the right research settings, d) getting meaningful data, e) extracting useful information and f) easily and efficiently transmitting the insights in a manner that is useful to docs who take care of patients day in and day out, CER will mostly likely stand as the newest testimony to the futility of other uni-dimensional big-bang central solutions, like capitation, new and improved CME, RVUs, P4P and EHRs.

Here's four suggestions on how to make CER different:

Target funding for CER at researchers with a track record in meaningful effectiveness research performed in community settings untouched by ivory tower academia.

Efficiently test multiple mutually supporting interventions designed to create breakthroughs and reward success unencumbered by the Priesthood of the Shrine of 0.05 and the pyramid system of academic promotion.

All results, both positive and negative, need to be divorced from the hidebound paper-based review process and routinely fast-tracked through multiple channels in the expanding medical information system (including on-line publishing, open access data and dare we mention blogs?).

The Fat Lady, Attending a House of Worship, Disease Management Engagement Rates and the Little Things That Count

The Fat Lady reminds the Disease Management Care Blog that everyone should regularly attend a house of worship. Aside from matters of faith, it’s a good way to regularly put things into perspective while taking a break from worrying about tomorrow’s meetings and deadlines. More importantly, you’ll gain insights about the human condition that are generally ignored by popular culture. Heavy stuff indeed.

Presidents are a good illustration of this. Both Kennedy and Reagan, for example, reached for inspiration from the shining city upon a hill. Abraham Lincoln famously pointed out a house divided against itself cannot stand. Even President Obama has told us it is time to set aside childish things.

Well, the DMCB isn’t immune either. It reached into the Easter Service grab-bag for two insights about its little corner of healthcare.

First off, purchasers of disease management programs have long gnashed their teeth over low contact and engagement levels of all persons in their eligible populations. In its business dealings, the DMCB has tried to point out that increasing recruitment drives up costs, enrolls progressively more disinterested patients and counter-intuitively reduces the return on investment. Perhaps it should also point out that that it was recognized long ago that a message far more important than A1c levels, asthma medication compliance or blood pressure control has also been stymied by ears that do not hear. 100% of all eligible patients will never cooperate with disease management, engage with their patient-centered-medical-home team, log onto their electronic health record, buy health care insurance, take their medicines or see a physician. Since less than 100% engagement was described in important literature well over 2000 years ago, the population-base care industry should work on describing what engagement rates are possible, not ideal.

Secondly, the Gospel of John has an interesting detail about the Tomb and the Resurrection:

“and a linen, that was about his head, not lying with the linen clothes, but wrapped together in a place by itself.”

The DMCB isn’t too sure about the significance of the folded cloth separate from the rest of the rumpled burial linens. It was told by a Methodist preacher that the ancient carpenters used this to signal that their job was done. Even if that is not true, the Fat Lady still likes the special touch in this behemoth of a population-based (and soul saving) intervention. The lesson here is that the little things nurse coaches do to inspire, nudge and motivate their patients are as important as any exquisitely constructed, decision-supported, evidence-based protocol. While we think about populations and billions of dollars we’re preparing to spend on chronic illness, we need to remember that the small details also count in ways measured and unknowable.

The New Cavalcade of Risk is Up!

Are you a fan of Risky Business? So is the Disease Management Care Blog. You'll be an even bigger fan once you check out John Leppard's posting of the best and the brightest writings on the topic over at Healthcare Manumission.

The DMCB couldn't help itself:

"My name is Joel Goodson. I deal in human fulfillment. I grossed over eight thousand dollars in one night. Time of your life, huh kid?"

"You've done a lot of solid work here, but it's just not Ivy League, now is it?"

"Looks like the University of Illinois!"

Will Health Insurers Become 'Too Big To Fail?'

If a federally supported public plan is launched without careful planning, the answer is they could become that way.

Here's why:

We’ve all heard how the life insurers are in trouble. While Prudential’s, The Harford’s and Lincoln’s investments were more conservative and heavily regulated than those in the shadow banking system, the life insurers were not immune to the carnage in their residential and commercial real estate-backed holdings. Undercapitalized, their variable annuities products (which guarantee minimum returns) are now stressing their balance sheets. Seeing a bail out on the horizon, many life insurers bought banks, which made them technically eligible for the Troubled Assets Relief Program (TARP).

On the face of it, TARP isn't a bad idea. Life insurers own a whopping 18% of the corporate bonds that undergirds a big part of the credit markets. If they can’t buy bonds, these markets’ short term prognosis will remain grim.

Which made the Disease Management Care Blog ask: why aren’t health insurers also in trouble? Well, they are. Rising unemployment is leading fewer persons buying employer-based insurance, which, in turn, is resulting in decreased earnings. Furthermore, many of the commercial health insurers are being battered by problems involving their parent company.

Yet, despite the AM Best downgrades, they’re holding their own. Health insurers are aggressively fighting back by cutting their workforces and reducing their budgets. The DMCB wonders if they were aided by being less inclined to seek big returns by investing in real estate. It could also be argued their bailout has partially arrived in the form of COBRA subsidies. What’s more, the prospect of the Feds mandating coverage for all with means tested subsidies should help. It looks like the insurers are going to weather this storm intact.

But the DMCB thinks there may be a bigger reason for the health insurers’ relative well being: they’re aggressively regulated by Departments of Insurance at the State level. This has functionally forced health insurers to uncouple their business into regional entities with separate P&L statements, separate ‘Yellow Books’ and separate regulations. This is not only true for many of the 'Blues' and other not-for-profit insurers, but even the giants Aetna and Cigna are made up of regional subsidiaries defined largely State by State with oversight by 50 different Insurance Commissioners. While it’s true that all insurers are regulated at the State level, the DMCB thinks health insurers receive more than their fair share of scrutiny. The result has been a crazy quilt complexity that is further scrambled by the different features of the large group, small group and individual markets. No wonder that relief from State regulation has been sought for years. And no wonder that the economic contagion couldn't spread through the health insurers as easily.

In light of this, what are the implications of healthcare reform? As previously discussed in a prior post, the DMCB believes community rating, guaranteed issue and having to compete against a public plan will increase health insurer mergers and acquisitions. As a result, small insurers will evaporate and the remaining health insurers will get even bigger, arguing they need the economies of scale and access to capital that comes with size. If healthcare reform doesn’t include 'single standard' Federal regulations, the DMCB expects the insurers (the ones that are left standing) to seek them, which will in turn allow them to centralize their operations outside of State oversight.

And once that happens, they’ll be too big to fail.

Which is why the DMCB is still a big fan of Nassim Taleb, the author of the highly readable The Black Swan, who recently penned this interesting editorial in the Financial Times. His ten recommendations for ‘Capitalism 2.0’ deserve consideration while policy makers and regulators struggle to minimize the future risk of rare catastrophic financial upheavals. They are listed below, followed by the implications for health insurance reform from your trusty DMCB:

Nothing should become too big to fail – The last thing we need is one or more AIG-like health insurance entities with a critical mass of beneficiaries and providers vulnerable to unpaid bills.

No socialization of losses and privatization of gains – It’s not unusual for insurers to contribute to State-regulated ‘insurance for insurers’ risk pools. In light of recent events, do we know if they are adequate? Who will be responsible for this once health insurance goes truly national?

It is foolish to trust the very experts that got us into this mess – Hear hear! Says the DMCB; health insurance executives should know that failure to fulfill their fiduciary responsibility means they will be banished from the business for life. Will Timothy Geithners of Washington DC really be interested in protecting us from a future health care insurance 'Black Swan?' Do they even know how?

Do not let bonuses hide hidden risks and tie them to downside risk – While health insurers have an underwriting cycle with good and bad years, it’s not just revenue. It’s those ratios on the balance sheets that denote capital adquacy and clinical quality in their dashboards. Bonuses need to be aligned with what is important.

Keep it simple – If readers of this blog cannot understand the fundamentals of their health insurance plan, something is wrong. Ditto legislators, policy makers, regulators and community-based watch dogs. Ditto when the insurers go national.

Ban complex financial products – The DMCB thinks the health insurers’ balance sheets were relatively untouched by this pollution. If that’s not the case, it needs to be fixed and kept that way.

It is not the role of government to restore confidence – It is the role of health insurers to maintain confidence now and in the future.

Leverage is the problem, not the solution. Health insurers are just as vulnerable to the temptation to assume debt in their operations and acquisitions. Regulators at the State or Federal level will need to maintain their vigilance and be given the adequate staff and resources to do so.

Definancialize economic well being – The integrity of a health insurance policy needs to depend less on interest income and more on old fashioned risk pooling.

Blow it up and start over again with Capitalism 2.0 – And don’t spare the health insurers.

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

Will you be going to the World Health Care Congress? The DMCB agrees this is one of the premier meetings on health care reform and is very much looking forward to what everyone has to say. If you can't make it, think about that nifty video portal. And, whether you go or not, check in with the DMCB and at the WHCC blog for exclusive updates.

See you there.

Should Patients with Heart Failure Receive Exercise Therapy? Implications for Disease Management Organizations with Heart Failure Programs

O’Conner and colleagues asked that question in an April 8 JAMA article titled “Efficacy and safety of exercise training in patients with chronic heart failure.’ You’d think exercise is good, because it increases stamina, promotes well being and should decrease the likelihood of the heart getting worse.

Maybe, maybe not.

The Disease Management Care Blog is going to share its four conclusions first. Readers who find them interesting may want to read the rest of this lengthy post. Even if you don’t want to read all of this, the conclusions alone should enable you to confidently quote from JAMA on an important issue in disease management - to the amazement of your colleagues and boss. That's because you regularly read the DMCB:

1. Among this ambulatory population with chronic heart failure, the overall event rate was striking: over the 30 months, there was a 15% mortality rate and about 2/3 ended up dying or being hospitalized. Chronic heart failure is a bad disease.

2. If a population of patients with a mean age of 59 years and on maximal medical therapy is assigned exercise, a simple assessment of utilization (hospitalizations, ER visits and the like) won’t show any impact. Your fees will be at risk.

3. This paper suggests baseline exercise tolerance, the level of heart function, mood, history of atrial rhythm problems and the cause of heart failure can have an impact on outcomes. Predictive modeling keying on these factors may be necessary to identify patients with a clinical profile that suggests exercise therapy is helpful. Good luck trying to convince your customers after the fact that these clinical factors helped or hindered your results. Adjusting for co-variates after the fact is a luxury for the academics, not you.

4. Even if the disease management organization does everything right in the promotion of exercise for persons with heart failure, the impact won’t be seen for about 2 years. A single year reconciliation may miss the impact of exercise in this population.

Recall ‘chronic heart failure’ typically describes a condition in which the heart muscle is weak and the heart chambers dilate. Interestingly, ‘forward’ (or downstream) flow (into the arteries of the body) is preserved. It’s ‘behind’ (or upstream) where the blood flow dams up. This leads to fluid retention (swollen legs) and shortness of breath (from fluid buildup in the lungs). Think of that sump pump downstairs: as that begins to fail, the hose leading outside still has lots of flow. It’s the basement that’s filling up with water.

This 82 site study randomized 2331 patients with weakened hearts to either 1) usual care with advice to exercise or 2) three supervised 15-35 minute group sessions of walking, treadmill or stationary cycling per week for a total of 36 sessions (over 3 months) aimed at getting to 70% of maximum heart rate. The duration was increased over the next 4-6 months and then slightly decreased with an ultimate target of continuing to exercise for a total of 120 minutes per week. The average age was 59 years, 40% were non-white and the median ejection fraction (a test of just how flabby the heart is) was 25% (compared to the normal measure of more than 50%, that’s low).

Key results?

All cause mortality 17% (usual care or EC) vs. 16% (exercise group or EG). Not statistically significantly different (NS).

All cause mortality or being hospitalized 68% (UC) vs. 65% (EG), not significant (NS).

All cause mortality or being hospitalized or having an emergency room visit or urgent clinic visit for heart failure problems 77% (UC) vs. 76% (EG), not significant (NS).

Cardiovascular mortality of hospitalization: 58% (UC) vs. 55% (EG), not significant (NS)

The Disease Management Care Blog was ready to conclude that heart failure exercise was destined for the comparative effectiveness research dumpster. Then it ran into this statement:

“Four baseline characteristics (duration of the… [baseline] exercise test, ventricular ejection fraction, Beck Depression… score and history of atrial fibrillation or flutter) were identified as highly prognostic. After adjusting for these covariates and heart failure etiology, exercise training was found to reduce the incidence of all-cause mortality or hospitalization by 11%.”

This 11% effect (by looking at the figures) was not readily apparent for about two years.

Huh? The DMCB recalls that this study involved randomization. That’s supposed to assure that all the conditions that might favor one group over the other are evenly distributed. If the baseline prevalence of exercise tolerance, heart function, mood, atrial rhythm disturbances and heart failure cause were the same in both groups (and it looks like they were), why would the authors make this statement?

The answer is because adjusting for covariates in randomized trials is not unusual . The ‘adjustment’ is a statistical approach that helps neutralize the persistent impact of these factors once the trial is concluded. As their impact was dampened, the difference in all cause mortality and hospitalization became more apparent.

An Antiques Roadshow Transcript From the Future

The Disease Management Care Blog really enjoys watching PBS' Antiques Roadshow. Who would have thought such obscure items could command such big bucks? And the owners are so, garwsh, surprised at the appraisals, while the appraisers seem so familiar with the intimate historical details of each piece.

With apologies to A.R, the DMCB visits a show from the future...

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

Appraiser: Can you tell me about this piece?

Guest: Well, Bernie’s grandfather and namesake was a physician back in the days of the Obama Presidency. Ol’ Dr. Bernie wouldn’t throw nothing out. We found this case buried under a pile of unpaid bills, government correspondence and booklets on the practice of bariatric medicine and how to start a tattoo removal business. We found this metal case in the back of his office. We plugged it in and turned it on, but all it did was make blinky light and noises.

Appraiser: This is a desktop personal computer outfitted with other electronics that were designed to create what back then was called an ‘electronic health record.’ Were there a lot of wires coming out of the back?

Guest: There sure were a lot of wires laying around.

Appraiser: That’s a pity. It’s rare to find these boxes still attached to the wiring. It was common for physicians or their office staff to yank the computer cases away from the wall, rupturing the connections. See those dents here and here?

Guest: We were hoping you wouldn’t notice.

Appraiser: Those dents are actually quite common. In addition to pulling the cases out and throwing them about their offices, it was not uncommon for physicians to kick, punch or lash them with an exceedingly rare device nowadays called a ‘stethoscope.’ If you were a physician back in the early 2000’s, you were encouraged by the government to invest in these devices based on a widespread belief that they saved money and made physicians better. Notice the engraving on the back here? This was used by the government auditors during their visits to all the clinics to make sure the devices were ‘certified.’ Also, take note of the large size of the hard drive, which, for back then, handled a huge amount of information - such as instructions on how to bill the patient, suggestions on how to treat the patient, when to refer the patient and how to contact the government with additional questions on how to bill, treat or refer the patient.

Guest: So, like, how much money can we get for this?

Appraiser: To answer that question, some history may be in order. Once these boxes made it into all these doctors’ offices, the government also developed a public health insurance option based on assignment to a type of provider called ‘primary care.’ Coverage was based on what was then labeled comparative effectiveness research (‘CER’). It didn’t work too well. Patients continued to demand total body imaging studies and stomach banding. Physicians interpreted CER studies to support the stenting of every known artery for every known condition. Costs ballooned, quality stalled and, thanks to the leadership of Treasury Secretary Geithner, China's government had to bail out some hospitals. In response the government’s Social Central Repository of Health Excellence Decision Making (SCRHEDM, pronounced ‘screwed-m’) issued more approval algorithms, regulations, guidelines, emails, web-links and directives that bloated hard drives and spammed in-boxes. Doctors abandoned medicine, leading to the specialty of 'allopathic cosmesis.'

Guest: So, like, how much money can we get for this? I'm in a hurry and have to see my nurse for a check up.

Appraiser: Unfortunately, not much. When you consider how much the doctors and government spent on these devices and how much you can get for this antique, its only value is that it's a reminder of one of the largest evaporations of government capital in history – only exceeded, of course, by General Motor’s ill-fated development of the plastic ‘GreenGo’ Car. That was created during the Pelosi Presidency and designed to be powered by wind, solar and chardonnay rated less than 92 points. I estimate you can get about a thousand yuan.

Guest: Well, I'm out of here. Thank goodness President Meghan McCain got elected.

Appraiser: Indeed!