Welcome to Cavalcade of Risk, Version 81 (CoR.81)

Welcome to the Disease Management Care Blog’s hosting of Version 81 of the Cavalcade of Risk (CoR.81). In its one and a half years of blogging, the DMCB has also enjoyed thinking about health insurance risk, risk transfer, risk management, markets, carve outs, reserves, premiums and managing surplus, so it’s a special treat to share the latest insights on these and other related topics from its sister blogs.

The only remaining issue for the DMCB was finding a suitable CoR.81 theme. It considered Michael Jackson’s untimely demise (his life was so awful, the DMCB couldn’t look away), Farrah Fawcett’s death (in days past, the DMCB didn’t want to look away), Mr. Sanford’s political suicide (the Governor should have looked away) and Bernie Madoff’s sentencing (investors shouldn’t have looked away). The risk dimensions of each are not inconsequential: there are the lingering travails of concert insurance, the health insurance coverage of treatments not approved by the FDA, the downside of hitching your political star to a flawed Governor, and $1 billion in investor insurance fallout.

In the end, the DMCB decided to not run with any of these themes: they are for media-besotted amateurs. Instead, the DCMB would like to dedicate CoR.81 to Peter Bernstein (January 22, 1919-June 5, 2009). He was a truly remarkable person: economist, investor, educator and consultant who not only advanced insights about markets but explained risk so us average guys could grasp many of the underlying concepts. The DMCB thinks his best work was Against the Gods, which described the creation of one of the arguably greatest intellectual achievements of mankind: the transformation of risk into a financial engine that makes modern society possible. You can read more about this intellectual giant here. His greatest legacy is that people should - and will -continue to look to his insights for decades to come.

So armed with that inspiration, on to this Cavalcade!

Healthcare and Related Risks

‘Health Risk Assessments’ (HRAs) are surveys used by insurers, employers and even towns to gauge the health of the population, determine which prevention initiatives have the best chance of success and provide a baseline for future comparative measurements. Henry Stern over at the InsureBlog points out that, despite HRAs’ merits, the Equal Employment Opportunity Commission is worried that HRAs may enable employers to unfairly discriminate against the disabled. Is this 1) unnecessary government meddling, 2) the protection of high risk persons from the overzealous health police and/or 3) another example of the government’s right hand not knowing what the left is doing? The DMCB can’t decide on the first two, but thinks no one should be surprised by the latter.

One purpose of HRAs is to identify persons who abuse tobacco. Maybe Fiat/Chrysler should look into that for its new senior management because David Williams of the Health Business Blog warns it’s not unusual for persons from Italy to smoke – including physicians. Despite l’angoscia (anguish) from witnessing so much morte (death), those docs would do well to pay attention to their 43% chance of prematurely sharing Jacko's fate.

The DMCB always enjoys how the CATO healthcare blog combines libertarianism and health insurance. You can sample CATO’s unending skepticism about everything government by checking out Jeffrey Miron’s post on how insurers should be free to assess risk and price it accordingly. He also points out excessive government subsidization will create moral hazards, fulfill a only a minority's view of what's fair, make the market less efficient, strip us of all our liberties and force us to have to wait in line to see a government salaried health worker.

And speaking of liberty, Wenchypoo’s Mental Wastebasket cannot believe how far the U.S. House of Representatives is willing to go to protect us against ourselves from the risk of climate change. California building codes preempting those in rural Pennsylvania? Yearly home audits by the climate change police? Wenchypoo's astonishment has a link to C-Span for you to see and hear for yourself.

Information Technology Risks:

If you think you are cool because you can talk confidently about cloud computing, you may want to pause and think about its risks. This post on the topic of controlling server clouds from the Burton Group Blogs is a good lesson on how service providers may have inadequate security assurances. Short question: can they be automatically trusted? Their short answer is a red-alert ‘no.’

OK, if you can’t feel confident about cloud computing, don't you want to buff your information tech mojo by being familiar with denial of service attacks, SQL injection, cross site scripting as well as network exploits and their overlap with traditional risk management? Keep this link from the Silver Tail Blog handy so you can steal the show at your next risk meeting with those arrogant IT and/or Finance Department weenies.

Brand Risk

Like many bloggers, the DMCB imagines its posts makes the giants of the healthcare be afraid - very afraid. After all, it is a blog and everyone knows that in our interconnected world, blogs are only ignored at great peril. Not so fast says the Digital Marketing Blog, which draws lessons from one blogger’s impotent track record to point out that, under the right circumstances and armed with measures of internet traffic, companies can safely ignore them. The DMCB is so angry about this that it is threatening to post A LOT of bad things about the Digital Marketing Blog.

The Risk of Ignoring Adam Smith

Didn’t The Wealth of Nations point out the irony that water, which was so critical for sustaining life, was cheap while inert practically useless stones called diamonds can command a steep price? While the answer may have to do with marginal utility, The Healthcare Economist Blog’s Jason Shafrin is showing us how the city of San Diego would rather regulate water use than harness the invisible hand of markets. They do so at their peril, but this is California. Go figure.

Personal Risk

What’s any posting on risk without some common sense advice from the Manilla Folder on three ways to reduce your risk of identity theft? There’s even a handy link there that will take you to a web site where you can enter all your personal information so you can better protect all your personal information.

Market & Business Risks:

It’s ironic that the certainty of Death and Taxes is the risk-oriented namesake of this posting on an important dimension of the classic moral hazard involved in the Great Bailout. Not only does the unprecedented foray of the U.S. taxpayer into banking mean risk-taking behavior will become more likely, but the signals used by investors to price various financial instruments will be dampened by indifference.

Fancy yourself a savvy armchair investor? The DMCB doesn’t either, but if it did, it would appreciate this reminder from Monevator that intentional market timing is a mirage. A better approach to managing equities is to ‘drip feed’ your money in, even if things are unendingly bearish. It’s not a ‘piffling’ matter.

And speaking of protecting capital, what about the merits of buying gold? Common wisdom says this commodity is a wise hedge against the inflation that is sure to follow the expanding money supply. Maybe, maybe not says Goldbug who speculates over a number of scenarios that include the word ‘doom.’ The message here is that the complicated state of the current markets is truly unprecedented. If you think it's predictable, think again. If the folks from Treasury and the Federal Reserve tell you they have things in hand, think again and again.

So, without much hope of getting a decent return with even precious metals, maybe your money should be tasked to more being more socially minded through the use of microloans. So says the Nobel Prize Committee, but now you don’t have to send your cash overseas to poverty-ridden Africa or Asia anymore. Read about Kiva microloans in none other than San Francisco at the MortgageLoanPlaceBlog. The DMCB never heard of Kiva either but it suspects it’s legit because it was mentioned here by Associated Press. A new risk market if interest income can be garnered? Maybe.

As further testimony to how far we've come, Julie Ferguson of Workers Comp Insider takes a look back at how we've evolved by posting these vintage WWII video clips about teaching workplace safety to women. Hint: The DMCB suspects Brad's troubles are multiple.

But in the end, we can always count on the sometimes cool and often loopy Presidential candidate Ron Paul to occasionally pull at our ‘now wait a minute, he may be right….’ heartstrings. More power to the very institution that presided over the current disaster? Is putting a check on the Fed’s power that outlandish? The darkly suspicious TheTruth blog has this post on how Mr. Paul wants to audit those miscreants. Before you shake your head at silly lingering extremism over the defense of liberty, check out this related editorial on the topic.

News About the DMAA Meeting: Save Money by Registering Early and Why Not Apply for an Award?

Psst! Want to save some serious coin and learn about the latest real world advances in care management, prevention and wellness? You may want to invest in your or your company's intellectual capital by going to what is, hands down, the premier national educational meeting on care management, 'bending' the insurance trend and reconciling clinical outcomes with reductions in claims expense. You'll get to see the industry's leaders in action, make new friendships, renew old acquaintances and obtain critical policy and competitive insights.

As you are reading this, you have only four days to not only save $400 by registering early for The Forum 09, the 11th annual meeting of the DMAA: The Care Continuum Alliance, but there is an additional $50 discount here if you do it on-line. Now THAT's a return on investment.

The Forum 09 will feature expert keynotes on health policy and trends, including Mark D. McClellan, MD, former Medicare and FDA administrator and director, Engelberg Center for Health Care Reform; Michael J. Barry, MD, director, Health Services Research Program and chief of the General Medicine Unit at the Massachusetts General Hospital and medical director, John D. Stoeckle Center for Primary Care Innovation; and David K. Nace, MD, vice president, clinical development, McKesson Health Solutions and co-chair, Patient Centered Primary Care Collaborative Center for e-Health Information Adoption and Exchange. DMAA also offers a terrific selection of educational sessions, including a new Pacesetters Policy Issues series and tracks on physicians and collaborative models, outcomes measurement, obesity and other timely topics. Last but not least, you'll get the walk up and actually meet the Disease Management Care Blog.

What's more, you have eleven days to throw you or your company's hat into the ring for a coveted DMAA annual award. You may think you can't compete against the big boys, but the DMAA has seen plenty of examples of smaller novel initiatives capture the attention of the awards committee.

DMAA will accept nominations for its annual industry awards through 8 p.m. Eastern Time, July 10, through its online nomination system here. DMAA this year expands its new Quality Awards program to three categories: Most Innovative Program Design or Delivery, Greatest Impact on Health and Greatest Impact on Satisfaction. Combined with the association's annual Leadership Awards, you have 10 awards categories from which to choose. Not only will you be featured at the Forum but the DMCB may describe your winning entry in a future post. Right after the one where it describes how the DMAA should create an 11th award category for 'best blog.'

Do You Have a 'Kindle?'

In its travels, the Disease Management Care Blog is seeing more and more people with 'kindles.' These are lightweight personal backlit electronic readers that can download just about any book and a variety of newspapers. Travelers seem to favor them because they're easier to lug around than a paper book.

That's one problem solved, but the DMCB understands another downside of travelling. You may not be able to readily access your favorite on-line blogs, including this one. Well, now you are in luck. The entrepreunerial folks at Amazon have fixed it so that for a remarkably small price, you can download the DMCB to your kindle for your reading convenience on that commuter flight between ORD and MDT.

The DMCB spouse is not impressed, however. While the revenue from this blog could potentially double as a result of this groundbreaking Amazon-DMCB alliance, her metrics are based on absolute measures of cashflow, not relative ones.

The DMCB will continue to assist the spouse in modifying her penurious sentiments.

Cost vs. Benefit in the Healthcare Reform Debate: More on Pacemakers in Centenarians

In its Obama Pacemaker post, the Disease Management Care Blog pointed out that critics would use the President’s convoluted response about the merits of a $30,000 device in a 100-year-old against him. As if on cue, the Wall Street Journal (WSJ) editorial pages mined Mr. Obama’s answer and came up with an interpretation that predicts that government rationing is around the corner.

The WSJ’s clairvoyance aside, the DMCB has some Peggy Noonan- inspired (and unsolicited) advice for reform-minded policymakers who are struggling to answer questions about cost and value: we need to reduce our wonky paragraphs down to sentences. There is a time for careful reasoning and then there is a time for conviction. If meaningful reform is to occur, now is the time for the latter.

Take disease management, for example. While it can be thought of as ‘evidence-based population-based care management initiatives that seek to achieve maximum health care value for persons with chronic illness,’ another way to explain it is ‘your nurse that’s there to help you.’ The medical home is supposed to be a ‘team-based patient centered primary care system of care that offers comprehensive personalized care coordination,’ what it really is ‘your own family doctor on steroids.’

And what was the issue that the President was trying to communicate with the pacemaker question? That we are reaching the point where we can no longer support modest individual health gains at huge taxpayer expense. No wonder he dropped his usual laser-sharp eloquence.

Consider the following graph: as health care spending for any group or population or country increases (from low to high on the horizontal axis), the overall benefit as first increases sharply (‘A,’). Then – as more money is pumped in – the incremental additional benefit begins to slow down (‘B’), stop (‘C’) and then actually declines (‘D’).

All those darlings of the health care economists – the Mayos, the Kaisers – apparently inhabit the A and B parts of the curve, while McAllen Texas has been accused of being on the C part of the curve. Open ended health insurers that pay for everything and anything are responsible for the ‘D’ part of the curve. That’s where infections happen among hospitalized patients, where mammograms in low risk women cause more biopsies than save lives, where unnecessary colonoscopies cause more bowel perforations than detect cancer and the where invasive placement of cardiac stents cause more damage than just taking pills.

The D part of the curve accounts for Medicare’s interest in stopping payment for services such as readmissions to the hospital for avoidable complications. Easy.

The DMCB thinks one attraction of comparative effectiveness research is that it can address the C part of the curve – if it is allowed to assess cost. Less easy.

The top part of the B curve is far trickier because that is where pacemakers in centenarians comes in. Very hard. There is cost (in this case, $30,000) that results in real incremental benefit (5 years of quality life and a daughter that can visit her in the home), but it’s not as much as the same pacemaker in a 60 year old (who would get 40 years of benefit, including years of taxable income and trips with grandkids to Disney World). The DMCB thinks the 100 year old got a worthwhile use of healthcare dollars. However, there are more difficult examples of higher cost with lower levels of benefit: one example includes cancer treatments that cost 6 figures and lead to an increased life-expectancy that is measure in months. Another may include the notion that everyone should have a regular physical examination, which rarely detects a problem.

Five other points while we grapple with this:

a) many policy makers think solving the C and D parts of the curve are enough to solve the health care budget crisis. The DMCB isn’t too sure about that.

b) don’t believe that money saved on the B, C and D parts of the curve necessarily means more money will be available for A. The money isn't necessarily wired that way.

c) don’t expect an individual physicians dealing with individual patients to solve this curve on a day to day basis no matter how you pay or decision support them.

d) the DMCB believes disease management and the patient centered medical home - which typically charge less than $100 per patient per month - occupy the steeper part of the B curve: the investment results in considerable increases in benefit.

e) while Mr. Obama ducked the pacemaker question with a paragraph, the day of reckoning is coming: sooner or later, we'll need to use sentences to decide what life-prolonging therapies we can afford and how we intend to afford them.

Holodeck Thinking from the New England Journal on Primary Care and It's Time for the AAMC Members to Step Up in Fixing the Primary Care Crisis

Academicians Thomas Bodenheimer, Kevin Grumback and Robert Berenson are holding forth in the latest issue of the New England Journal of Medicine in an effort to influence Washington DC healthcare reform debate. Their message is that the reform needs to include a 'three stranded' lifeline to primary care practitioners. The article is available gratis without a subscription.

Don't bother reading it; they should pay YOU to do so. The authors are recycling the same tiresome policy ingredients for an intended audience that does not include the more sophisticated real-world denizens of the Disease Management Care Blog. After all, we know better. Rather, the Journal piece is aimed at giving their allies in Congress another reprint to pass around the room from a notable paper-based journal - even if it is of fading importance - to support their ideology in the D.C. beltway policy debates.

Essentially, Tom's, Kevin's and Bob's three strands are:

1. More money, because primary care physicians earn less than their specialist colleauges. They say these docs should be given special dispensation from the zero sum game that has capped the global physician payments to physicians. They think a 5% to 10% increase over several years would be reasonable. In addition, they say loan forgiveness should be extended to young physicians who go into primary care. Additional sources of cash should also be extended via monthly payments for care management services for medical home activities or in the form of bundled payments, perhaps as part of 'accountable health organizations.'

2. Outpatient practice infrastructure modernization, starting with electronic records across all specialties. However, the American Recovery and Reinvestment Act (ARRA) funds should be disproportionately and urgently allocated toward the primary care docs. What's more, they should be given "technical assistance" to expedite the adoption of 'medical homes.'

3. Funding for graduate medical education should be increased and wrestled away from hospitals (where the education takes place) and channeled toward the residency programs themselves.

For another perspective, Dr. Steinbrook obliquely points out in a separate opinion piece in the same issue of the Journal that money is not the only reason why docs pursue their career paths. He's right. What is known is that gender, socioeconomic background, belief systems and rural vs. urban background also play important roles in choosing primary care over a speciality career. Once docs are in practice, income plays a role in career satisfaction, but so do autonomy, control over personal time, and administrative hassles. Not only does all that go unsaid in the Journal, but what is also lacking is any mention of the ability of US medical schools to select students that are already predisposed toward primary care.

While the point about graduate medical education is a good start, the DMCB thinks the American Association of Medical Colleges (AAMC) has been remarkably unhelpful in matching their members' undergraduate medical student recruitment, selection and financial support process to the nation's manpower needs. Given how much public money these institutions receive, the DMCB asks if it's time to ask them to stop being so self-serving and step up to the plate when it comes to doing their part on behalf of health reform.

We also still don't know how many primary care physicians in doctor-owned businesses/practices will a) embrace the kind of profound practice transformation that will lead to the creation of a medical home and/or b) readily cooperate with being pushed into relationships with local hospitals to form accountable health organizations. The authors are fancifully assuming that a model of care that has been the topic of research in physician-salaried settings, in Medicaid programs and a pending Demo will work today everywhere in every town in every State - if only Congress would throw money at it. The DMCB doubts that and so does, by the way, the Congressional Budget Office.

Last but not least, the population-based care/disease management community has an emerging track record of working in and with in wide variety of practice settings to promote better coordination of care. Funny how that evidence was skipped over in the Journal's published narrow-minded holodeck construct.

The DMCB thinks there are many primary care physician practices nationwide that already provide excellent care. They need more than money and Boston-style central planning built on wishful thinking about half-proven concepts. The Journal's readers deserve better and so do whoever is getting copies of this opinion piece.

The DMCB's advice is to step toward the holodeck door and press the reality button.

President Obama's Prescription for America Pacemaker Question

The Disease Management Care Blog just finished watching ABC News Primetime's Prescription for America. It is impressed. With all the things Presidents do plus worrying about financial reform, turmoil in Iran, missles in Korea and the split between John and Kate, Mr. Obama did a remarkable job of navigating around all the issues without any major gaffes.

However, he stumbled over the pacemaker question from Jane Sturm. Recall she's the woman with the centenarian mother who was the exception to the rule that expenses - like '$30,000' pacemakers - are needlessly wasted on persons in their last year of life. The good news for momma Sturm is that she is doing well enough to sit outside and chat with her daughter in the summer sun 5 years later, even if she is wearing a transcendentally false wig. Jane was afraid that Mr. Obama was promoting a health care system that would withhold such life saving treatment in the face of someone still having a certain spirit and a quality of life.

Mr. Obama didn't really deny it. The DMCB can't find a transcript of the encounter yet, but the President vaguely discussed the need to rationalize end of life care and specifically said that judgments based on 'spirit' would be too 'subjective.' There was also a nod to the decision-making being something best left to doctors and patients.

First, some background. A pacemaker is a battery powered device that is placed under the skin next to the collarbone. Under that area is a large vein. It is through that vein that one or more wires from the pacemaker is threaded, which follow the course of the vein toward the heart. The end of that wire is stuck into the inside of the heart muscle. An intermittent current goes from the pacemaker pack through the wire and mildly stimulates/shocks the heart muscle in a regular basis that causes it to contract. If the heart muscle is beating too slow because the normal signals that intrinsically govern the heart rhythm are disordered, the pacemaker can override the problem with the electric shocks that cause the heart to contract on a more regular basis. Pacers can also treat other types of rhythm disturbances including fibrillation (that type is pictured above). Heart rhythm problems are common among the elderly and pacemakers can make the difference between a person prone to regularly passing out, falling or being dizzy versus a person that is able to lead a normal life. There are many different types of pacemakers

It turns out that evidence-based guidelines are readily available to physicians who are considering a pacemaker. The DMCB looked at the document and cannot find any statement that supports the notion that age is a sole criterion on the decision to put in a pacemaker. In fact, there is one statement (about one type of pacer device) that says 'although survival after implantation is shorter among the elderly than among younger groups, survival is substantial, and age itself should not be the predominant consideration in the use of device-based therapy among the elderly' (italics from the DMCB). That being said, there is evidence that pacemakers can be overutilized.

The DMCB....

1. ...thinks it's difficult for a layperson, even if he is a President, to navigate around the thorny complicated medical issue of putting in this kind of hardware in the elderly. He intuitively understood that saying that all Americans should never be denied a pacer would have been silly, but he also understood that saying always withholding pricey therapy in 100 year olds was also risky. He sought out a more nuanced answer and eventually landed on the doctor-patient relationship as the final element in the decision-making process. The DMCB suspects critics on both sides of the issue will be able to use the President's answer against him.

2. ...speculates, given the circumstances, that it was a physician who declined to OK the pacemaker and that the family decided to seek out a second opinion. The insurance company (and it was probably Medicare) played no role in the decision making process. The ready availability of guidelines should make this a non-issue because medical directors and practicing physicians would rarely if ever disagree here. Unlike 'life-saving' vs. 'experimental' or 'futile' cancer therapy battles, it is unlikely a 'denied pacemaker treatment' will even spill over into the evening news involving Medicare, a commerical insurer or a even public option plan.

3. ...points out, last but not least, the 'system' worked, didn't it? The pacer was initially denied, the patient's family appealed and they eventually prevailed. Mr. Obama has pointed out that there are areas in the health care system that work well. He has repeatedly stated that he wants to keep what is right and fix what is wrong. Well, this is one area that turned out right. Mrs. Sturm need not worry about it and the President can confidently know that there is evidence that can govern this part of the healthcare system where ageism isn't an issue.

Interesting Information on the Survival Advantage from Having the Metabolic Syndrome

Check out this interesting article in JAMA by Jesse Roth about the genetic link between being fat and simultaneously being protected against tuberculosis (TB). Since readers may not have a subscription to JAMA, the Disease Management Care Blog is pleased to provide this Cliffsnotes summary about a disorder that we still have much to learn about.

One of the issues with obesity has been its link to the 'metabolic syndrome,' which is typically accompanied by increased 'background' inflammation. Experts have suspected that this in turn leads to chronic molecular 'wear and tear' that subsequently leads to chronic diseases such as diabetes, atherosclerosis and cancer. While the ability to preserve energy and store fat makes evolutionary sense for humans that have been at risk for famine, scientists have been mystified by the accompanying genetic programing that leads to ongoing cellular damage. Why would having a turbocharged immune system offer a survival benefit?

The answer may be the scourge of TB. Until antibiotics came along, this was an infection that, once established, could never be cured and frequently led to death. It's been estimated that TB has caused more than a billion deaths in the course of human history. For who survived, victims harbored the disease in a subacute or latent form for the rest of their lives. Having increased amounts of visceral fat leading to elevated levels of adipokines, tumor necrosis factor and other pro-inflammatory proteins may have given big bellied people a chance to beat or at least combat the infection.

It was long observed that persons with poor nutritional status seemed to be more prone to TB and were more likely to die from the disease. That's because starvation generally impairs immunity to the point where more persons succumb from just about any infection than from the weight loss itself. In contrast, persons with excess weight have heightened immunity with inflammation. While the link between the two conditions is still being unraveled, Dr. Roth speculates overweight allowed individuals to have the kind of heightened immune response that made them more likely to survive an encounter with TB. As a result, big people had a survival advantage.

Interestingly, high amounts of LDL are also involved in the immune response. Little wonder, then, that physicians in the pre-antibiotic era prescribed sedentary behavior in their sanatoriums with high calorie diets.

Individuals of Indian or Japanese heritage appear to develop the metabolic syndrome at lower levels of obesity. The Inuits, on the other hand, have historically low rates of obesity and seem to be especially prone to TB. This suggests the genetic trigger for inflammation may vary from gene pool to gene pool. These observations are leading scientists to look for the genetic and metabolic triggers for the inflammation that may be modifiable with yet-to-be-discovered medications.

Now that TB is largely absent in the U.S. and much of the West, the metabolic advantage that served us so well for tens of thousands of years is causing chronic illness.

Blogs vs. Traditional Journals in Health Care Policy Making: McAllen Texas as an Example (and the possibility that it's not an outlier)

Atul Gawande’s New Yorker McAllen Texas article is the policy zombie that refuses to die. The big news is that while this still-walking undead has generated some vigorous debate, it's prompted a fascinating insight about the growing role of non-traditional media in driving health reform.

First off, there’s a lengthy Health Affairs academic, contrasting policy and business-oriented roundabout on McAllen from the learned Elliott Fisher, Gail Wilensky, Robert Berenson and Robert Galvin. Don’t want to read all 16 pages? Neither did the Disease Management Care Blog, who was reminded of an exchange by its spawn years back. The daughter was talking about something extremely remarkable to the utter boredom of her brother. Seeing her enthusiasm wasn’t being shared by the lout, she stopped and asked him what was wrong. He laconically replied the topic was interesting enough, but she was ‘using too many words.’

Thanks to some Argentinean Torrentes and grilled salmon, the wordiness became tolerable and can be summarized for your quoting pleasure as follows:

Fisher: Being from the outfit that brought out the Dartmouth Atlas, he finds Gawande’s lay person style to be an accurate portrayal of the science of variation. Given the public’s interest in health reform, the article's timing was perfect. Dr. Fisher is against slashing prices in an effort to cap McAllen’s expenses and prefers the use of positive incentives, bundled payments and better integration of primary care and specialist physicians.

Wilensky: This former Medicare and Medicaid administrator is concerned that the article may have been too simplistic and missed some other explanations, other than dysfunctional incentives, for McAllen’s outlier status. That being said, she thinks the phenomenon is real and physicians need to be better aware of it. It’d be nice to fashion some turbocharged demos to attack variation, but in the meantime, she doubts physicians are ready to walk away from old fashioned fee-for-service (FFS).

Berenson: He spotted McAllen back in 2003 but no one paid attention. Medicare might want to investigate for fraud and abuse and, if none is present, he’ll chalk it up to the community’s practice style. Speaking of which, Boston, Chicago and Atlanta have much to be desired in their practice styles also. He likes accountable care organizations (ACOs) because they don’t have to take on insurance risk and accurate risk adjusted payments are within reach. If it’s done right, physicians might even be willing to give up on FFS. He also warns that bundled payments don’t necessarily mean that a population will have better outcomes or that hospitals won’t come to dominate the health care scene.

Galvin: This General Electric medical director was also struck by how unaware the McAllen physicians were about their outlier status. He isn’t sure that (ACOs) are a proven answer to the problem of variation and, what’s more, they could become local monopolies. He prefers comparative effectiveness research linked to yet-to-be-developed payment models.

As pointed out in another post, the DMCB agrees there is variation but points out that outliers are a) randomly inevitable in any large market and b) don’t necessarily hold any lessons that can’t be learned by studying the average. The trick is to tell the difference between randomness and causality, which was conspicuously absent in Gawande's article.

But hold on. Maybe McAllen isn’t even an outlier if Medicare enrollment, socioeconomic status and disease burden are properly accounted for. Check out this very important analysis that was posted by health services researcher Daniel Gilden on the Health Care Blog. He concludes that McAllen’s utilization patterns are high, but if careful and standard statistical methods are used to neutralize the cost drivers outside of the physicians’ control, McAllen is decidedly close to the average. In contrast to the Health Affairs posting, every word on this very important article has huge implications for the argument that physicians have run amok with unwarranted practice styles.

So here’s the real lesson: Classic journals like Health Affairs and the New England Journal and their go-to authors still have a role to play in policy discussions but alternative media, like the blogs, are becoming remarkably nimble in ‘posting’ insights that seem to be out of reach of these traditional information venues. While policy giants went on and on and on in the staid Health Affairs, Mr. Gilden chose the non-traditional but widely read THCB to post an important and provocative analysis that will undoubtedly garner significant attention. It's deja vu all over again for the DMCB and its spawn.

That’s why the DMCB hasn’t submitted many manuscripts lately to any journals. Sure, keeping a blog is fun and just as remunerative as assigning eternal copyright to the publisher for free, but the emerging potential of the web as the most important source of health policy information is truly remarkable.

Education....Engagement....Marketing

What are the limits of ‘education’ when it comes to changing human behavior? The Disease Management Care Blog asked itself that question when National Public Radio reported that as many as 1 million television owners crossed the analog-digital switch deadline without a converter box. While some persons were undoubtedly confused, the DMCB wonders if a number of persons – despite some considerable advertising about the subsidized converter box - elected to procrastinate and just deal with things after the change. Come to think of it, consumer choice was also a factor in the mortgage meltdown. While there was bad policy and predatory lending, conscious decision-making by home buyers in the subprime market also played an important role.

Healthcare isn’t immune from this dynamic either. For example, according to this article in the New England Journal of Medicine, vaccination refusals, mostly over fear of harm, range as high as 26% in some counties in the U.S. Handguns cause more accidental killings and injury than those occurring in self-defense, yet many homeowners still keep such a weapon in their house. While the science heavily favors screening colonoscopies, approximately half of those eligible have not had the test; while the cost and insurance status undoubtedly are factors, many persons simply refuse to go through with it.

For better or worse, persons in the United States not only have the right to make choices, they have a right to make bad choices. While the Feds and the banks have been blamed for the failure to protect TV viewers and homeowners from themselves, there is obviously a limit to what education can accomplish in overcoming bad decision-making.

For those of us in population-based care and disease management for chronic illness, we’ve known this for a long time. Our answer is patient engagement. ‘Education’ generally refers to the transmittal of information to a recipient-learner, while engagement refers to a deeper attachment that can be harnessed to create brand loyalty or, in the world of disease management, promote optimum self management. Accordingly, the logic goes, all we need is an effective engagement program and persons will bend over and get their shots, willingly turn over their handguns and stand in line for colo’s.

It’s not that easy. While care management has a better track record in changing patient behavior than simple education, it has its limits too. The DMCB thinks the next step will the kind of marketing that uses the same sophistication of direct to consumer pharmaceutical advertising that leverages the appeal of cleverly constructed ads that promote colonoscopies as well as statins and vaccinations as well as E.D. drugs.

Which leads to the DMCB’s prediction for the changing role of the disease management industry. While the techniques of coach-based patient engagement will always be important, the art and science of getting consumers to make the ‘right’ choices will increasingly incorporate the kind of marketing that sells statins, soap and automobiles. The disease management company that adds this to its repertoire of services will have a market advantage.

Two final thoughts:

It’s not going to be just TV commercials either. Think cell phone aps and twitter.

Want physicians to become engaged? They have a special reputation for looking at the evidence and making their own judgments. For example, just ‘educating’ them about the merits of the electronic record probably won’t get very far. Believe financial incentives will work? Think again. Far more will be necessary.

A Peek at the U.S. Senate Committee's Health Reform Proposal

An expository (and exclusive) on-line summary of the U.S. Senate’s Finance Committee’s health reform proposal is available via the levorotatory Ezra Klein’s Washington Post column that the Disease Management Care Blog discovered thanks to the mulish Matthew Holt over at the hortatory Health Care Blog. The fact that he is accusing the Dems of pusillanimity suggests the proposal is practicable. But, we share an admiration for HotForWords, which makes Matthew’s point of view exculpable. But don’t take the DMCB’s 'word' for it, check it out the summary for yourself.

Hope vs. Optimism for Healthcare Reform

Today, the Disease Management Care Blog listened in on Michel Martin's Tell Me More, which featured an interview with three physicians (Dr. David Ellington of Lexington VA, Dr. Hector Flores of Los Angeles and Dr. Carolyn Barley Britton of the National Medical Association) who have special expertise in the care of low income patients. None of their points of view over the public option, payment reform and the role of primary care were particularly suprising. Toward the end of the interview, each were asked about their level of optimism over the prospects for health reform. 'Very optimistic,' said one, for at least incremental reform, 'stars are aligned,' said another, while the third said the ball 'will move down the field... we're going to do it.'

The DMCB hopes there is health reform if it's done right. As for being optimistic, well.........



Hatp tip: HealthHombre

Cavalcade of Risk is Up!

The latest collection of blog writings about 'risk' await you here. With inspiration from Bubba's soliloquy on the many different types of shrimp in the movie Forrest Gump, we have healthcare risk, wordplace risk, insurance risk, financial risk, miscellaneous risk and spam risk. That - that's about it.

Learn all about it at Supporing Safer Healthcare at the Number 80 edition.

CBO Rains More On the Health Reform Parade - The Letter to Senator Conrad

Egads.

First the Congressional Budget Office (CBO) letter sucking the life essence out of the Senate HELP Committee’s 'Affordable Health Choices Act,' and now this. Much like a college fraternity president going to the house-mom about the merits of establishing a 24-7 open beer tap in the living room, Senator Kent Conrad (D - North Dakota) asked the Congressional Budget Office (CBO) to weigh in on many of the favorite elements of Congress’ big plans for health reform. The June 16 reply is a far ranging and mostly qualitative assessment of the many reform ideas making the rounds and does an insightful job of discussing how extensive the need for change is.

Normally the Disease Management Care Blog would try to summarize and interpret Director Elmendorf’s letter to Senator Conrad, but the quotes directed at all those oft-cited and 'cost-saving' darlings of government-run healthcare are just too juicy to not share word for word. What’s more, the tone of the letter makes the DMCB wonder if the CBO staff has been reading its blog. Why not? They read its published papers.

On the Dartmouth Atlas:

‘Some studies have expressed skepticism about the Dartmouth researchers’ estimate. CBO’s own informal comparison of per capita Medicare spending in metropolitan areas controlling for both the health status of individuals and the prices of health care inputs, implies that the savings from turning medium- and high-spending areas into low-spending areas might be roughly half of the estimate by the Dartmouth researchers.' (The DMCB pointed this out back in December)

On Integrated Delivery Systems:

‘Examples of efficient care certainly exist today, with many individual health care providers and groups of providers offering both high quality and relatively low cost. Yet applying the methods of those efficient providers throughout the health care system cannot be accomplished through fiat or good intentions.’ (The DMCB has had its doubts about IDS' all along)

On pay for performance (P4P), bundled payments, no-pay for mistakes, gain sharing, cost sharing and decision support:

'Unfortunately, little reliable evidence exists about exactly how to implement those types of changes—especially at the level of specificity required for legislation.' (Er, we could also use some better evidence on why to implement many of these changes. An example is here)

On the Letter from AdvaMed, the AMA, AHA, AHIP, PhRMA and SEIU:

'Those stakeholders see increased efficiency as a critical goal of their organizations, and they agree that significant savings can be obtained. At the same time, many of the group’s proposals offer little detail about the specific changes necessary to achieve those objectives or the obstacles to their making the changes.' (So said the DMCB here)

On Accountable Health Care Organizations:

'(Based on results from the Physician Group Practice Demo)… the evidence for cost savings is mixed. Moreover, expanding this approach to physicians who are not already in an integrated system and may be reluctant to join one raises further issues. For example, challenges arise when trying to design programs that are voluntary for both enrollees and physicians, because both parties would generally need to expect some gain in order to participate—often at the government’s expense.' (Hear hear!)

On Comparative Effectiveness Research

'Merely conducting and disseminating additional research is unlikely to have major effects on patterns of clinical practice or health care spending, however. For new research to have a significant impact, providers’ financial incentives would need to be aligned with the results…… Further challenges in reaping net savings from comparative effectiveness research arise from the cost of the research itself and from the lags in getting research under way, developing results (particularly if they depend on new clinical trials) and disseminating the findings.' (Indeed!)

On Prevention:

'Several factors make preventive care less broadly effective at reducing health care spending than might be expected. For some preventive services, clinical evidence on effectiveness is lacking: In its 2006 review of such evidence, the U.S. Preventive Services Task Force was neutral toward—neither recommending nor discouraging the use of—approximately 40 percent of the services it reviewed because of a lack of evidence.' (The DMCB tackled the topic here, but wasn't aware of the extent of the USPSTF's skepticism).

On More Primary Care Providers:

'One study of the relationship between Medicare spending and the composition of the workforce of physicians found that, with the total number of physicians held constant, states with more general practitioners had lower spending. Achieving that outcome, however, involves reducing the number of specialists in line with increasing the number of primary care physicians, and the mechanism for accomplishing that change (for example, the appropriate adjustments in payment policies) is unclear. Savings would be less likely if the number of specialists remained the same while the number of primary care physicians increased.' (DMCB never considered this possibility. Wow)

On Health Information Technology:

'Some experts maintain that increased use of information technology and a new focus on efficiency will yield substantial productivity gains in the health sector. Some of those gains may appear as reductions in the quantity of services and thus yield savings automatically for the government. However, most of the gains are likely to take the form of reduced costs per service, which would cut government spending only if the government cut the prices it pays (and otherwise would end up boosting providers’ profit margins).' (The DMCB has been a refugee from the EHR, but kept a sense of humor about it. But this is a great point by CBO: essentially, any efficiency gains are unlikely to be passed back to the payers).

Maybe in addition to reading some blogs, CBO's been getting its inspiration from watching youtube:

The Senate HELP Committee's Affordable Health Choices Act: A Summary and a Recommendation for a Consumer Friendly 'Nutrition Facts Label'

Readers may have already learned that one of the two major Senate Committees that are drafting health reform legislation has finally come up with a long awaited product of the political process called a "bill." While this particular piece of legislation is still a work in progress, Senator Kennedy's Health, Education, Labor and Pensions (‘HELP’) Committee’s bill has already made some progress: it has been preliminarily ‘scored’ by the Congressional Budget Office (CBO).

CBO's analysis makes for very interesting reading. What is helpful about the CBO report is that it gives a readable summary of this ‘Affordable Health Choices Act’ (AHCA), saving the Disease Management Care Blog from having to don its oxygen apparatus and blow tanks for a dive into the original legislative language. CBO then tells us how well this will work and how much this is going to cost. It ain't pretty.

According to CBO, AHCA would either mandate or impose ‘play or pay’ health insurance coverage, provide States grants to establish Massachusetts-style ‘exchanges’ that enable insurance purchasing and subsidize that purchasing on a sliding scale from 150% to 500% of the Federal Poverty Level. The bill assumes that individuals below 150% would qualify for Medicaid.

Because AHCA doesn’t mention it, there is no mention by CBO on the impact of a ‘public insurance option’ or the expansion of Medicaid. Another possibility being considered in Congress is allowing children to be covered as dependents until age 27 years, which could also change things. In addition, administrative costs are unknown and some language in AHCA needs to be clarified. As a result, CBO’s assessment is technically incomplete - which was not only pointed out in their report, but on the Director's Blog.

So with the ‘incomplete’ caveat, CBO projects that, absent any legislation, the number of persons who are less than age 65 years with insurance will go from the current level of 217 million to 228 million over the next ten years. At the same time, the number of persons without insurance will go from the current level of 50 million to 54 million - or 19% of the U.S population.

If the HELP AHCA legislation, as currently written, passes Congress, the number of persons without insurance will decrease to 36 million - or 13% of the U.S. population. About a third of these uninsured would be undocumented aliens or Medicaid eligible individuals who haven’t been signed up. What’s more, the report predicts the number of persons with employer based insurance will decline from 162 million (if things are unchanged) to 147 million.

Cost? The total cost of the sliding scale insurance subsidies is $1.28 trillion, averaging $5000 per individual. $60 billion is needed to set up the insurance exchanges. These costs would be offset by taxes on more employers presumably paying higher wages if they’re not paying for health insurance ($257 billion) plus fewer people using Medicaid and SCHIP ($38 billion) plus ‘pay’ penalties from individuals who refuse to ‘play.’ Bottom line? A whopping $1.042 trillion over ten years.

Wait a minute, says the DMCB: 36 million uninsured? OK, 24 million if we exclude illegals. 13% of the U.S. population? $1 trillion? Fewer persons with employer-based insurance? That sounds like there will still be plenty of uninsureds in 2019, which even ardent liberals find shocking. Heart breaking tales of bankruptcy and lack of access will continue to pepper the health policy landscape and we’ll have 36 million reasons to move to a single payer system.

The DMCB doesn't think it's just about the money. Americans are generally willing to give the government more money if they believe the expense is worthwhile. This is not about the eye-popping sum of $1 trillion, this is about getting $1 trillion of value for the taxpayer.

Unless the DMCB is naively misreading the CBO report, $1 trillion in exchange for ‘only’ 36 million uninsured would not seem to pass muster. The DMCB hasn't done the math, but it suspects that the Federal outlays necessary to reach higher percentages of the uninsured are not a "linear" process. Much like the "last mile" of broadband connectivity, the cost will spiral up on a logarithmic scale. Good intentions, the DMCB would like to introduce you to fiscal reality.

And don't let the notion that the report is 'incomplete' fool you. Here's a quote:

“Although this analysis reflects the proposal’s major provisions, taking all of its provisions into account could change our assessment of the proposal’s effects on the budget and insurance coverage rates—though probably not by substantial amounts relative to the net costs already identified. Public plan and expansion of Medicaid would mean additional costs.”

Given the consternation over the cost of AHCA, the DMCB would like to borrow from the ubiquitous FDA's 'Nutriton Facts Label' that is designed to help consumers quickly navigate through the ingredients and the value of pre-packaged food. A similar label is necessary for AHCA bill, so that consumers can quickly and efficiently understand what they are getting for their hard earned money. If you think about it, the only difference is that the HELP Committee is giving us a pre-packaged health reform solution. If that's a box on the DMCB's fiscial breakfast table, it recommends that the label should look like this:

The Lead Investigator Responds

In a prior post, the Disease Management Care Blog raised some questions about a wonderful study about 'PAM' conducted in two LifeMasters call centers.

As readers may recognize, comments in the Google system are buried away from the main blog page: the post itself needs to be accessed and the comments will only then appear at the bottom.

In this instance, the DMCB heard directly from the principal author of the study. Her timely and helpful response deserves greater visibility. It is reproduced in it's entirety here:

Thank you for your review of our recent study. As the lead investigator on the study, I am happy answer the questions you raised about the methodology. You asked if hospitalization risk was part of the propensity score risk adjustment we used to equalize the two study groups. Yes, the risk severity score, based on claims data, was part of the risk adjustment approach. You also asked about the differences in hospitalization rates between the two groups. The analytic approach we used assessed the trajectory of change and examined whether this trajectory was different for the intervention group as compared to the control group. This analytic approach reduced the need to control for multiple factors, because most of the characteristics of the individuals remained fixed and changes that were observed could be attributed to the intervention. However, because there were some key differences at baseline (including their baseline utilization rates), we constructed the propensity weights to equalize the 2 groups. That is to say, after controlling for other differences, the statistical significance in the utilization tables indicates that the trajectory of change significantly differed for the intervention group as compared to the control group. In the case of Emergency Department use, the control group’s trajectory was up, while the intervention group was down. In the case of hospitalizations, the control group trajectory was flat, while the intervention group went down.Finally you asked about a possible Hawthorne effect, with the nurses who were responding to this “observation” rather than the PAM intervention. This is a very unlikely explanation, as both the intervention nurses and the control group nurses knew they were in a study and were being observed, thus the effect of “observation,” would have been the same for both groups of nurses.

President Obama's Speech to the AMA: Masterful, Necessary and Insufficient

The Disease Management Care Blog tuned into online C-Span and watched a part of President Obama's 56 minute speech to the American Medical Association's Chicago House of Delegates' meeting. It was quite the tour du force for a politician espousing greater government involvement in health care to an organization that has always been hostile to the idea. Unable to believe that the AMA interrupted the speech repeatedly with occasionally robust applause (though there was one episode of booing), the DMCB went back and listened again.

It's heard all these arguments before, but found how they were packaged was simply masterful.

What is the template for such a speech? The DMCB kept notes and has outlined them for you below, just in case you're ever called upon to enter a room full of doctors that are reluctant to go along with your brilliant plans. As a medical director, the DMCB has been down that road and wishes it had President Obama's rhetorical skills in past encounters, when the physicians, after listening closely with sketpical frowns and crossed arms, told it to get lost:

Open with vague descriptions of a better future rising out of the ashes of the current adversity. Bond listeners to you by noting their assistance is needed. Be a supplicant: modesty looks good and builds rapport.

Quote some telling and heart breaking anedotes: patients with cancer, doctors with hassles, small businesses with layoffs. Reach for big anecdotes if you can: automobile bankruptcies, the national debt and, what the heck, global warming if you can get away with it.

Call your listeners to action by saying that doing nothing is not an option. Costs will spiral upward, taxes will go up, budgets will be cut. The Huns are almost on the beaches of Dunkirk, now is the time to man the ramparts.

Recognize the fear and challenge listeners to take action under your confident leadership. Give examples of that leadership and take credit for anything you can. Anything.

Repeatedly commend the audience for their courage, good will and intelligence. Disarm them by thanking them for being so smart.

Remind listeners that, while big change is coming, their core issues will not have to be compromised. You're only fixing what needs to be fixed. It's OK to use terms like "hundreds of thousands" or "tens of billions" here.

Leverage the idea that, aside from a few Luddites, "everyone" agrees with your points of view. Cast your perspectives in the most reasonable way possible. Look affably mainstream.

Repeatedly remind the audience of how your plans will make life better for them.

Describe your plans with opening softballs (EHRs, prevention, Dartmouth Atlas) that you already know they agree with and lead them slowly to your more controversial points of view.

Repeatedly commend the audience for their selflessness, dedication and sacrifice. Disarm them by thanking them for being so unselfish. In fact, you'll eventually be able to say that their higher calling obviously makes them willing to forgo any economic rewards - and they won't boo at that.

Open your more controversial proposals with the options that are most likely to be supported thanks to your audiences' economic self interests. Yes, it may be more work but more work means more compensation.

Your audience is now ready: hit them with the items that they may not cooperate with. Now is not the time to let up! Sprinkle in more anecdotes that demonstrate why your ideas warrant their support.

Repeatedly recognize your audience wants to do what's right and that they have great expertise. Disarm them by recognizing that they are the trustworthy experts.

There is always something your audience wants. Don't give it to them (and expect the boos now), but now is the time to give something close to it in exchange for their support. Explain why your compromise bauble is a) is still worth having and b) is better than nothing at all.

Repeatedly commend the audience for their helpfulness and assistance. Disarm them by thanking them for their help. Admit that we're all in this together.

Point out that you recognize the core values of your audience.

By now, close to 40 minutes have elapsed. Attention is waning. Now is a good time to raise additional controversial recommendations.

Recast any disagreement as 'healthy debate' and 'legitimate concerns' that you 'welcome.' If there were prior mistakes, point out that you're not responsible... for any of them. Now is a good time to good-cop-bad-cop: mention that you're shielding your audience from others that are more radical than you are.

Identify a common enemy. Take sides with your audience against that enemy. Be firm. Look resolute.

Bring up the example, if you have one, of a family member or close friend, that would have done better if your ideas had been adopted years ago.

Your audience is more tired now. You can quote any economic statistics you like at this point. They are more likely to be believed.

Wrap up: unless you agree NOW this deal with disappear faster than primary care physicians taking Medicare.

No doubt the President will get good grades for this speech. However, the DMCB has a caution for the Administration. With time, it learned, on its own with lots of trial and error, to use many of the approaches mentioned above. As a result, it often also achieved the verbal support of its audiences. Weeks or months later, that support often waned unless there was continuous dialogue, feedback, reaching out and more face-to-face visits.

Mr. Obama has given a necessary speech, but he and his advisors need to know that it was far from sufficient. There is still some way to go.

So, What Is a Health Insurance 'Cooperative?' and Five Reasons Why Senator Conrad's Idea is a Realistic Option for Health Care Reform

If you've been following developments in Washington's attempts at health care reform, you may have read how the concept of an 'insurance co-op' was "pitched" by Senator Conrad (D - N.D.). See him describe it here. It's a compromise offered to bridge the disagreement over just how the Feds should sponsor a public option.

Senator Baucus (D-Mont.): “I am inclined, and I think the committee is inclined, toward a co-op”

Senator Grassley (R - Iowa): "there was a thing suggested that would be kind of a private-sector option along the lines of co-ops."

Senator Rockefeller (D - W. Va) is "dubious."

Senator Hatch (R - Utah) "I'm totally opposed"

When the Disease Management Care saw the term 'insurance cooperative' bubble up in its news feeds, it was confused but, unlike our Senators, didn't offer up any snap judgments. Instead, it did its homework. At first, it thought a 'co-op' was a large carbon footprint air-conditioned store filled with baguette-laden wicker baskets where boomer earth mothers and natural-foodies drive their hybrids to buy over-priced asparagus. That plus high end Chardonnay. Thanks to some web-enabled detective work, the DMCB found out they don't necessarily involve hybrid automobiles and that the concept of a co-op can be applied to the purchase of health insurance.

So, exactly what is this thingie called an 'insurance cooperative' and what is its potential for meaningful health reform? Because you regularly read the DMCB, you'll find the answer to this question well before you can finish that lunch you've been eating at your desk.

According to this Commonwealth Fund Issue Brief, an insurance co-op exists when small employers 'band together' on a regional basis to form a purchasing block that can negotiate better deals with the local commerical health insurers. This efficiently consolidates the decision making, billing and servicing under one roof and often allows for choice among several competing plans. It also allows all the participants to 'pool' their insurance risk, which, in turn, should lead to lower and more predictable premiums. Unfortunately, the track record of co-ops has been spotty, apparently because member businesses are constantly on the look-out for better deals and may exit the co-op, leaving the higher-health risk businesses behind in the equivalent of a death spiral. If they don't keep and maintain a large market share, they can't go toe-to-toe with the commerical insurers.

For a more complete review, this paper from Health Affairs teaches us about a number of pooled purchasing arrangments including the 'co-op.' It seems this has been around for a long time. They typically operate at the state- level, are not for profit, are run by employers, don't have to accept all insurers, carve out the administrative/back office functions to an insurer for an administrative fee, leave it to employees to choose the insurance they want from a list, and, thanks to ERISA, may not be subject to all State regulations.

And if you're wondering if the famous Group Health Cooperative has anything to do with this, the answer is yes. Back in 1947, a multi-member community-based group decided to buy its own clinic to offer health care for its employees. The rest is history.

How would the co-op fit in healthcare reform? According to this link, the legislative outline currently under consideration would require them to be State-by-State or regional, non-profit, provide a coverage option for individuals and small businesses with as few as 2 employees, be subject to State laws and have 'governance standards' that would presumably trump a consumer focus in the Boards of Directors.

The naive DMCB thinks the co-op idea may develop legs:

1. As noted previously on the DMCB, as debate on the public plan option matures and stakeholders realize it's not synonymous with 'Medicare for All,' the focus will shift toward other more politically nimble options that also offer credible health insurance. The co-op is such an option.

2. According to the Commonwealth Brief and Health Affairs articles described above, commercial health insurers don't like co-ops because they force them to compete on price instead of benefit design. The fact that insurers have historically been hostile to the co-ops is telling and could be reason enough for many Democrats to support the idea.

3. Without a government-run public plan, employers will have less of an incentive to drop health insurance for their employees.

4. The very term 'co-op' has the kind of fuzzy appeal - like ''pesticide-free' or 'consumer directed' - that the Democratic majority can spin while it seeks to counter partisan Republican attacks.

5. While the the DMCB has seen little evidence of input from the NAIC anywhere in the healthcare reform debate, it suspects the nation's insurance commisioners would support the co-op as a reasonable compromise between the State and Federal governments over what is a looming intrusion by Washington DC into their space - which, by the way, they think they've done a good job regulating. Recall that Ms. Sebelius is a Past President of the NAIC, so she'd probably understand how her fellow Commisioners could shepherd the State by State co-ops into position.

The articles above are somewhat skeptical about the ability of co-ops' to control costs. While that is a fair assessment of their track records, some of the examples cited occurred during the 1990s, when health care costs were on their way down and employers were disinterested. That's not the case now, so the DMCB thinks their prospects are better. That being said, If the co-op idea moves forward, look to Congress ponder regulations that keep (as in 'mandate') small employers and individuals in the co-op risk pool and keep insurers from poaching away low risk business with side deals.

LifeMasters & Tailoring Disease Management to Degree of Patient Activation. A Summary & a Good Example of How "Applied" Real World Research Can Work

Check out this study appearing in the American Journal of Managed Care by Judith Hibbard, Jessica Green and Martin Tusler. In it, LifeMasters tested the use of a 'Patient Activation Measure' (PAM) by nurses on call duration, the usual clinical measures (A1c, blood pressure, LDL cholesterol, flu shots, aspirin, statins, beta blockers and ACE use) as well as admissions, emergency room visits and outpatient office visits.

Two separate LifeMasters call centers were involved. Both administered the 13 item PAM survey that was designed to assess patient 'activiation,' on a 1-4 scale. The Disease Management Care Blog thinks of this as interest and willingness to participate in their own health care, where 1 is low (think of Bea Wilderd who works in the Finance Office downstairs and is baffled by the thought of actually finding out how all those pills work) and 4 is high (think Chip Ind, the IT guy upstairs who 'bings' the name of his pills to be on the look out for side effects). Both centers telephoned patients with chronic illness on behalf of payers to 'coach' behaviors designed to increase quality and lower cost. The difference was that the nurses in one center were specifically trained on how to tailor their messaging according to the PAM, while the nurses in the other center acted as a control.

The analysis was done at the University of Oregon and "Decision Research," also located in Oregon. It appears the PAM survey is owned and/or marketed by an entity called 'Insignia Health.' One author has investments in that company, and another author has been a paid consultant.

There was a one year baseline period and six months of follow-up. The study was hobbled by considerable amounts of drop outs, spotty access to insurance claims data and ad hoc additions of patient data to serve as controls. Ultimately, the two comparison groups seemed similar enough at baseline and, after statistical adjustments, there were greater changes in in the 'PAM" patients in all the clinical measures listed above with the exception of systolic blood pressure and A1c (which were reported in weird units that ranged from "692.3" to "764.6." Perhaps they meant 6.9 or 7.6?). What's more, there were statistically and financially significant reductions in admissions and emergency room use in the "PAM" patients that were extrapolated to a decrease in the per member per month (PMPM) of $145 and $11, respectively. PAM seemed to be responsible because nurse call times shifted: Bea (Level 1) spent more time on the phone if she was with a PAM-trained nurse vs. a control nurse.

The DMCB congratulates LifeMasters at several levels. Yes, this is another study demonstrating the benefit of remote patient coaching and there appears to be something to this 'PAM' approach to telephony. But what the DMCB likes most of all is LifeMasters' ability to simultaneously run a business and perform studies that not only serve their investors' and customers interests but to perform those studies with a sufficient degree of rigor that is good enough to pass muster with peer review and make it to the public domain. This is not a perfect study and, with admirable but necessary honesty, the authors point out the various weaknesses of their study design in the manucript. That being said, the DMCB (and plenty of others for example) has found that perfect studies often don't answer questions that address real world needs. Read the traditional big name medical journals and you are guaranteed to learn a lot about a little. Read studies like this about PAM and you often learn enough about a lot.

Anxious customers may tut-tut that they shouldn't pay for the direct and indirect costs of a PAM trial. Actually, they probably didn't. Pointy headed Chief Financial Officers may tut-tut that their business model shouldn't support research. Actually, that's only bulls***: a) without innovation, the industry will die and b) the Feds' granting agencies and the academic community have no idea how to perform this kind of inquiry. The DMCB speculates that customers and CFOs can find comfort in knowing that LifeMasters was unable to train all nurses in all call centers at once over the use of PAM. Since the roll-out had to be one center at a time, this gave them a perfect opportunity to perform a 'quasi-experimental' study because a 'control' comparator group was readily available. This study is a role model for all sectors of health care.

Limitations? the DMCB may be all wet, but wonders about two issues not mentioned in the manuscript.

While 'propensity matching' was used to compare and statistically adjust the two groups of patients, it's not clear from the manuscript if the propensity score included some assessment of hospitalization risk. The DMCB is concerned about this because the control group hospitalization rate went from ".04" hospitalizations per month to ".04" (ie, no change) while the intervention or PAM group went from ".06" to ".04" hospitalizations per month. Did the intervention group start out with a higher baseline and simply fall to level of the control group, or did they really do better?

The DMCB was also confused by blinding. If the nurses in both centers knew they were being compared in a study, the Hawthorne effect may have played a role in the behavior of the nurses, not PAM training.

And a small insight: want to know how much time a typical disease management nurse spends on the phone with patients in a commerical setting? According to this paper, 16-18 minutes.

Last but not least, while the PAM nurses beat the control group nurses, this was not a study comparing a superiorly tailored disease management program vs. usual care. This was one type of disease management versus another type of disease management. We are no closer to answering that Big Burning Question: does disease management work? If you read the press release, it's clear that LifeMasters believes this gives them a leg up versus their DM competition, not a reason for Federal health reform to include disease management.

The Latest Health Wonk Review Is Up!

This is simply the best summary ever of the latest wonky insights about the ongoing developments in national healthcare reform. The pros and cons of the public plan option? Affordability? The impact on providers? The Massachesetts model? The politics? Look no further for insights and perspectives on these topics that you'll never see in the mainstream news media at Joe Paduda's Managed Care Matters with a special edition on the why's of health reform. There's even some commentary from a U.S. Senator.

The Disease Management Care Blog got a nice comment too. Liking the DMCB puts readers in good company. 'Google' the very broad term 'disease management' and there will be more than 47 million results. However, the 'disease management care blog' now appears on first page. Ditto Microsoft's new search engine 'www.bing.com' Yahoo.... well, the DMCB never uses it anyway.

They like us blogs, they really like us!

Physicians: Paradise Awaits in 'Achieving Health Care Reform' from the New England Journal of Medicine - not.

Physicians, are you feeling demoralized? Are you angy over the decay of your professionalism? Do you think public and private insurance plans have commoditized your expertise?

If you're not a physician, do you need some simple nostrums that you can quote on behalf of wholesale health reform?

Well, look no further than the latest issue of the New England Journal of Medicine, which has the temerity to hector its physician readers on why and how they must support the health reform proposals that are coming before Congress in this legislative session.

Much like Dante gazing upon the concentric spheres of Heaven described in the Divine Comedy, the ivory tower academicians Elliott Fisher, Donald Berwick and Karen Davis behold four levels of progressive delight that await a compliant physician community. The first consists of a tripartite world aimed at increased safety, better health and lower costs. The second is made up of 'clinical microsystems' that are made wonderful thanks to quality improvement activities. The third is made up of large accountable high performing health care systems that mimic integrated delivery systems, complete with electronic health records and care management programs. The fourth is the wonderful alignment of all payment, regulatory, legal and educational systems that includes universal insurance. Ahh, say the authors, if only physicians would embrace these 'win-win' virtuous visions, rancorous debate over a public insurance plan would fade away and budgetary watchdogs would be muzzled. What's more, a reassortment of the money would lead to doctor's having greater take-home pay and a decrease in health care costs - even if it means reducing future Medicare payment rates. The celestial path? Simply agree to a 1.5% savings in exchange for universal health insurance and reform that promotes accountable health orgizations, gain-shares, bundled payments, pay for performance and the subsidization of electronic health records.

The Disease Management Care Blog thinks physicians have already bought into the need for safety, increased health and lower cost. They also know all about quality improvement. However, many practice in independent physician-owned settings and are unlikely to willingly link up with the local hospital systems in accountable organizations for the reasons that have already been described in Eliott Fisher's Health Affairs article on the topic: physicians are successfully competing with hospitals to offer cheaper and better services, their culture is one of cultural autonomy, hospital-physician gainshare arrangements could be viewed as monopolistic and the local politics would be thorny. The DMCB also doubts its colleagues a) would support any Medicare fee schedule reduction, b) would find universal insurance to be a panacea, c) believe gain shares, bundled payments or other reforms mentioned above are as proven as many policy makers would have you believe and d) agree with the Congressional Budget Office that the costs of such an approach would not be matched by the savings.

So, what would engender physician buy-in? The DMCB would be happy to write a Perspective for the New England Journal and awaits the invitation. It won't hold it's breath.