A President's Invite for Beer as a Metaphor for Medicare's Current Coverage of Medical Necessity (Egads)

When it comes to Medicare, beneficiaries can generally have any service that is ‘medically necessary.’

And when it comes to having a beer with the President, apparently you can have any brand you want, so long as it’s…beer. For Mr. Obama, it’ll be a Bud Light, while Dr. Gates prefers a Red Stripe and Mr. Crowley likes Blue Moon.

The ever curious Disease Management Care Blog knows what 'medically necessary' is, but wanted to better understand the definition of beer. It found out that it is a starch-based beverage that is commonly based on rice, wheat or barley that is fermented with one of several different types of yeast (commonly lager or ale), that is combined with a variety of hops (gives that bitter taste) and allowed to brew to various levels of alcohol concentration. Depending on the style, type and mix of the base ingredients plus other additives (for example, cherries or even hot peppers), the variety is truly endless. What’s more, beer can range from really cheap to really expensive.

Which makes it a good metaphor for health insurance coverage. The beers chosen by Mr. Obama’s guests fell within the standard ‘covered’ White House ‘benefit’ preferred by many beer drinking consumers. If Professor Gates or Mr. Crowley, however, had asked for a lusty mead or a tall glass of Strongbow, the President’s staff would have probably had to mimic a Medical Director and review the definition of ‘beer’ as well as the text of the President’s invitation. They would have determined that neither of the requests were grain-based starch beverages and therefore not covered by the invitation. Unless there was an appeal or grievance, case closed. But suppose either of the guests had chosen, based on the advice of their physician, a unique Bar Harbor or a pricey Chimay Ale? Just like Medicare, the beer would have to be served, right? Medically necessary is medically necessary and an invite for brewskies with the President is an invite for brewskies. Cheers!

The DMCB realizes it’s being silly and knows how rude it would be to abuse the gracious hospitality of a President. Decorum and common sense rule in such situations. Unfortunately, that is not the case in another corner of the Federal bureaucracy, where we as a nation have come treat the Medicare benefit as an open tab for every conceivable fermented beverage that meets the broad definition of medically necessary.

Too bad Mr. Obama can’t invite folks over for a beer when it comes to health reform. It’s all just too complicated.

The Latest Cavalcade of Risk is Up!

Personal risk, risk management and lots about health care reform is up in the latest Cavalcade of Risk. It's ably hosted by Nancy Germond at the Insurance Copywriter Blog. It's a link-filled feast of great posts from around the web. Check it out!

Healthcare Reform, Readmissions and the Contribution of Disease Management: The Rest of the Story

Did you know that flu shots are effective in the workplace? Or that exercise can reduce the incidence of falls among the elderly? Or that care management can reduce post-discharge rehospitalizations? All three breakthroughs were reported more than ten years ago, yet recent news reports from the Wall Street Journal (‘unusual!’) and National Public Radio (‘a third way!’) are recycling the old news about rehospitalizations with new anecdotes about clinical programs that can successfully reduce readmissions.

[Yawn] The science has been pretty clear on the topic since Michael Rich’s seminal 1996 publication. Other researchers (for example, here and here) have individually confirmed post-discharge care management works quite well, while this review of the peer reviewed literature suggests there are critical ingredients that can help this be state-of-the-art.

Given the recent renewed interest in reducing rehospitalizations since a) Stephen Jenck’s recent New England Journal article (20% readmission rate among Medicare beneficiaries along with the potential of saving a whopping $17 billion), b) the inclusion of readmission data in CMS’ Hospital Compare website, c) post discharge guarantees by an innovative integrated delivery system's health plan and, last but not least, d) proposed bundled hospital and follow-up payments as a part of health reform, the topic is certainly timely and important.

With their renewed interest, hospital administrators and policy-makers agree that these kinds of care programs haven’t taken root in day-to-day fee-for-service clinical practice and the Medicare benefit because insurers don’t ‘cover’ hospitals’ post-discharge care programs. In the meantime, current health reform proposals seem to be tilting toward penalizing hospitals with a stick of high readmission rates. The DMCB can’t tell if the proposed bundling methodology described above will adequately include 'the carrot' of covering the cost of hospital-sponsored post-discharge care coordination.

[Yawn]. Too bad the media is missing out on telling the rest of the story.

We already know that a host of commercial and employer-sponsored insurers include disease management programs. What isn’t being mentioned is that a standard contractual feature in practically all disease management programs is to provide post-discharge follow-up to patients with the key chronic conditions like heart disease and heart failure. That’s why most of the literature on post-discharge readmission avoidance programs typically refer to them as ‘disease management’ in the first place. In other words, the industry has long since developed a viable business model based on this need. It has already entered hundreds of thousands of recently discharged patients in its decade-old post-hospitalization care programs. And they can work.

While most of the reports in the literature describe research-funded ‘hospital-based programs,’ the DMCB suspects the DM organizations have not gotten around to describing their experience in the peer review literature. They're certainly not being called by the Wall Street Journal or NPR. Pity.

That being said, the key ingredients - patient engagement and coaching with monitoring, self-care and close coordination, usually performed by nurses – can be independent of the location and doesn't necessarily have to be hospital based. Until there is good research that says otherwise, the DMCB doesn’t think it makes any difference how the nurse care is funded, just so long as it’s done one way or another. It would appear the 'fit' is better with disease management because of its outpatient focus, its ability to include this with all its other programs and its successful track record. Hopefully, the Patient Centered Medical Home (PCMH) will eventually demonstrate success in this area also.

Hopefully, the architects of health care reform will recognize that when it comes to readmissions, a ten year old disease management solution is already at hand.

Musings From A Drive Home From Washington DC About Democracy and Health Care: Are They Incompatible?

The Disease Management Care Blog was on Capital Hill for the last two days. While staffers' cards are being held close to the chest, it really appears that no one has any idea if health reform will pass.

Democracy in action, especially when the nation’s health is at stake, shouldn’t be so difficult, should it? While there are real policy issues around the role of government and the use of our treasury, the process should be aided by common-sense changes involving primary care, population-based care, insurance benefit designs, premium subsidization, expansion of current programs, rigorously assessing new technology, not paying for mistakes and stopping insurance abuses. Instead, a faction of Congressional Democrats are not playing nice, the Congressional Budget Office keeps coming up with inconvenient truths, key leaders are missing in action, key supporters are being undercut by their rank and file and momentum is decreasing. Delay means opponents will have the summer recess to sink reform with bail-out fatigue, fear of Federal deficits, cap n' trade second thoughts and what's-in-it-for-me politics. The ever-wise information markets are down to a 35% chance that the U.S. will have a government run health insurance plan in place by the end of December.

And yet, that great shining light on the hill is still there: the vaunted Integrated Delivery System (IDS), where hospitals and physicians align their incentives, concoct best practices, charge less, work more, use EHRs anyway and stomp out complications in a paradise of access, efficiency, value and innovation.

It was just in such a setting years back that the Disease Management Care Blog and some of its colleagues were engaged in what can be generously described as a vigorous dialog with a nudnink of a Chairman. The clinical and revenue issues at stake were also common sense and the Chair was simply not going along with our logic. Unable to achieve consensus, the Chair concluded with the meeting with a telling observation: ‘This is not a democracy.’

Indeed. The DMCB cautions, based on personal experience and lots of gossip with other colleagues, that while on the outside IDS’ may appear to be enlightened institutions that use the most modern approaches to capital allocation, use of human resources and clinical program design, inside they have more than their fair share of internal strife. In fact, the past issue wasn’t important and the DMCB suspects the Chair was right. What’s important is that the Chair and other centers of power in IDS’ are always right because they don’t function as democracies.

Which may be why the well-meaning Madam Speaker is having so much difficulty. The DMCB wonders if good health care delivery, in addition to being evidence-based and market-driven with good incentives and a strong mission and all that stuff, is also something of a dictatorship. Congress’ misbehaviors, competing factions and wonky debate remind the DMCB of its dysfunctional yet halcyon IDS days. Perhaps the critical missing ingredient inside the beltway is what IDS’ possess: central command and control that can suspend the exercise of democracy.

The DMCB suspects the odds of passage may need to be rated at less than 35%.

The Liberal Conscience is Wrong on Theory and Evidence

When Nobel Prize winners blog, the Disease Management Care Blog, reads. And read is exactly what it did for Paul Krugman’s piece on ‘why markets can’t cure healthcare.’ According to Professor Krugman, emergency healthcare (like treatment for a heart attack or a broken hip) can’t be bought and sold like flat screen monitors or hotdogs. Accordingly, the financial platform we’ve invented to barter the risk of a heart attack is insurance. However, Dr. Krugman says all insurers are out to reduce the costs of those heart attacks and broken hips by denying payment of claims. That means they need to spend considerable money on infrastructure that specifically exists to concoct rationales for denials. What’s more, comparison shopping for the best heart attack care is hobbled by imperfect information.

He concludes as follows:

‘There are….no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn’t work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.’

Of course, blogging doesn’t lend itself to the kind of thoughtful analysis the topic deserves, but the DMCB respectfully disagrees with the Liberal Conscience using both theory and evidence. It turns out insurers, thanks to their claims data, are very able to discern which hospitals are offering the best value for heart attack care as well as many other big ticket emergency health care items. It’s worked so well that Medicare is adopting the practice That is the basis for many insurers recognizing Centers of Excellence, how Medicare is able to deny payment for conditions acquired in the hospital and how the researchers at Dartmouth can compare the value of services provided in Florida versus Minnesota.

As for the reputation for denying claims, the DMCB notes there are many heart breaking anecdotes of persons being really screwed by their insurer. This has given the industry a huge public relations problem. However, Professor Krugman is using an unnecessarily broad brush that uses multiple anecdotes to paint a trend. The truth is that State insurance departments are closely involved in the day-to-day monitoring of health plans, that consumers generally have access to expedited appeal mechanisms if they feel coverage is being unjustly denied and that without a credible administrative infrastructure, fraud and abuse will go to Medicare levels.

The folks at Safeway would argue markets do work if only Dr. Krugman and his allies and their would look at the real evidence and get out of their way.

Waterloo.... or "Mission Accomplished?"

The Disease Management Care Blog likes military history and has a passing familiarity with battlefield analogies. For example, there are ‘Verdun’ (a wasteful stalemate), ‘Thermopylae’ (noble defeat), ‘Gettysburg’ (the turning point), ‘the Bulge’ (holding against overwhelming odds), invading Russia (biting off too much) and ‘Waterloo’ (overreaching leading to disastrous defeat). As readers are aware, the latter term was gleefully used by a Republican U.S. Senator to describe the President’s and his fellow Democrats’ prospects over healthcare reform. Mr. Obama, in turn, has categorically rejected the notion as an example of toxic partisanship.

And so it goes.

The DMCB recalls an old military joke based on the Russia analogy. Just prior to the invasion of the Czar’s Russia, one of Napleon’s Generals was spending the night with a woman of ill repute. In the afterglow of their love making, Monsieur Le General was unable to restrain himself and shared the details of the top secret battle plans. In fact, he kept a map of Europe on him and spread it out over the bed. In hushed excited terms, he described how the French armies would sweep toward Moscow and beyond, bringing even more glory to the Republique. The woman listened in silence, thinking about the obviously different sizes of the countries on the map. When the General paused and asked her what she thought, the woman pointed to small France on the left versus the huge Russia on the right and said ‘Have you shown Napoleon this map?’

While the expanse of healthcare reform could turn out to be more Russia than Waterloo, the DMCB has a better analogy in mind: Bush’s Baghdad and ‘Mission Accomplished.’ Following a superbly executed U.S. military campaign, Iraq’s conquered capital descended into frightening chaos that cost precious American lives and treasure. Of course, Washington D.C.’s ragtag Democrats have little in common with General Schwarzkopf's staff, but passing a healthcare bill is not that dissimilar from the complexity of armoured divisions. What is important is that the Dem's army with considerable legislative firepower has its Baghdad in sight. Odds are, according to the information markets, that bill may pass.

The DMCB takes the longer view. It looks beyond Waterloo and asks what happens if Baghdad falls?

We know what happened in Iraq. While the U.S. Army ‘took’ Baghdad, establishing peaceful representative democracy in the Middle East turned out to be a far more elusive goal. Various tribes, religions, extremists turned out to have far different agendas, making a real mess of things. Will the same scenario happen in a post-Obama U.S. healthcare system? Will providers, insurers, States, regulators, big Pharma, technology manufacturers, the Unions, U.S. businesses really fall into line as predicted/agreed?

Going forward, the healthcare architects in the House, Senate and Administration would be wise to keep this more recent military analogy in mind. Just because a bill passes may not mean they can claim health care inflation has been tamed, that Americans will have credible access to care, that quality will grow, that our life spans will increase or that the mission is accomplished. After passage of a bill, our Commander in Chief may be politically tempted to take credit while standing on the tarmac next to some hospital, only to watch things not go at all according to plan.

President Obama and the Red Pill Blue Pill Discussion: The Real World Doesn't Work So Simply

In its health insurance days, the Disease Management Care Blog learned an important rule: never ever let anyone upstairs in the 'C' suites get involved in the cumbersome details of pharmaceutical coverage. That included the formulary, comparative effectiveness, pricing or making a medical necessity call on an individual patient. It wasn’t their fault, but they often messed things up with over-simplifications, lack of scientific knowledge or poor communication.

Case in point? All were amply demonstrated in last night’s President Obama’s red pill-blue pill explanation:

“If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that’s going to make you well?”

This was a rare lapse for a President with such impressive communication skills and a staff that’s been helping to keep him on message. What’s more, the euphemism blew right past our bored (‘may cause drowsiness,’ ‘lackluster,’ ‘paying defense’ and ‘small’) press corps into Americans’ living rooms, where the damage to our body politic was done. It reinforced a hopeless expectation that can never be achieved in the real world.

In the real world, the blue pill never works ‘just as well’ as the red pill.

Different pills have different molecular structures that impart different properties in how quickly they are absorbed, digested, reacted to, metabolized and cleared. In the laboratory, in individuals and in populations, there are, and sometimes there aren’t, real differences in risks, benefits and side effects.

Red pill-blue thinking is often applied to stomach acid, cholesterol lowering and anti-depressant medications. Some examples of how complicated this can become:

Esomeprazole (Nexium) is the active stereoisomer of the active ingredient omeprazole (Prilosec). According to this paper, it reduces stomach acid for a longer period of time. Many well meaning lay persons and some physicians could scientifically conclude Nexium is a better drug. That doesn’t mean there will be necessarily improved clinical outcomes. Should Nexium be the red or the blue pill?

It is well known that cholesterol drugs differ in ‘potency.’ Many well meaning lay persons and physicians could conclude that a high dose of a potent statin is a better strategy. This observational and real world study, however, found that a change involving atrovastin (Pfizer’s potent Lipitor) did not lead to a significant decline in the study population’s cholesterol levels. If a doctor is convinced that the potency is important for the patient, should Lipitor be the red or the blue pill?

The success of antidepressant medications are known to vary, depending on the symptoms, concurrent medications, side effects, medication response history, tolerance and patient preferences. Yet, there is consensus is that there is an ‘equivalence of therapeutic effect,’ which is shared by primary care physician leaders. Which symptoms, concurrent medications, side effects etc. should be used to decide which should be the antidepressant red pills and which should be the blue ones?

Which brings up a deeper problem in the President’s words. Reconciling red versus blue pills is what doctors do. Unfortunately, they don’t necessarily do a good job. Saying that we’re going to insist on blue pills while simultaneously respecting the independence of the doctor-patient relationship is an exercise in cognitive dissonance.

If pressed about covering medications, health insurance C-suite execs and Presidents should stick to saying they are doing their best to make sure that the right drug reaches the right patient for the right reasons. They should also admit that that process for making this happen is imperfect and that we have ways to make it less cumbersome and more precise.

Last but not least, the DMCB wonders if the red pill –blue pill discussion may be more than a Presidential misstep. If it is representative of sophistication of the policy-making going on inside the White House, maybe it’s not such a bad idea that things slow down.

The Latest Health Wonk Review is Up!

The Disease Management Care Blog invites you something as delish as cotton candy, as brain building as guessing what happened to the penny, as challenging as punching out the star with a BB gun and as rewarding as getting the brass ring. If it sounds like a wonk filled carnival of the best and the brightest health policy blogs, you're correct!

Head on over the Paul Testa's version of the latest and bestest Health Wonk Review, 'All's Fair in Love and Health Reform' at the New Health Dialog Blog.

A Call To Action For Physicians.... From a Brit (and an endorsement of disease management)

Baron Darzi of Denham, Ara Warkes Darzi, KBE, FMedSci, HonFREng, FRCS, FRCSI, FRCSed, FRCPSG, FACS, FCGI, FRCPE has a Perspective appearing in the July 22 New England Journal of Medicine (NEJM). It's available as a free download, and it's worth a look by anyone interested in how all those academic initials can make someone smart enough to intelligently comment on health reform. It also has some good points that warrant the attention of the disease management community.

Dr. Darzi is an eminent surgeon from the Imperial College of London who was instrumental in a recent effort to change Great Britain's ailing National Health Service (NHS). While the problems were different than those facing the Yanks today, Dr. Darzi believes there are commonalities in the two countries' efforts at health reform. There are three lessons, says he, that worked for Her Majesty's Government and they may work here.

They all focus on the physicians:

1. It's up to the physicians to help keep the debate focused on the patients and the outcomes that count. That's the key to providing a 'strong common purpose.'

2. Physicians need to get involved in linking the amount of funding and the amount of care in a model that meets American values.

3. They need to educate policy makers and politicians about the value of different levels of care. It's not robotics or bigger hospitals, but primary care access, 'innovations in public health and lessons from the emerging discipline of behavioral economics' [bolding mine].

The Disease Management Care Blog realizes that it's easy to dismiss this as idealistic nonsense, but it says not so fast. Individual physicians need to join organized medicine (options are here and here; there are others between the two extremes) and/or write to their elected representatives. They need to email the politicians, write letters to the editors and speak in church basements about the non-linear link between the spend and outcomes and how to humanely limit healthcare inflation. They need to help cool the allure of technology and talk about access not only to primary care physicians but other under appreciated entry-level care options. The quality and quantity of their input needs to save our well meaning President Obama from his repetitive nostrums and allowing bad legislation to be passed.

This is the flip side of a prior posting by the DMCB that described the Brits' herulean efforts at reaching out to the physicians. They recognized that they needed to solicit the docs' input. This was not only to get their buy in, but because their support turned out to be a critical success factor.

Which brings up two points about the disease management industry:

1) They've had some hard lessons on the need to solicit physician input. The industry needs to continue to use what they've learned to find common ground with the providers in the three areas described above. There is strength in numbers.

2) Those of us that have been working in disease management should be very pleased at the NEJM-level endorsement of our 'innovations in public health' and the business models developed (examples here and here and here and many others) that leverage precisely the 'behavioral economics' that can make a big difference in addressing chronic illness. That is what the industry is all about. It is why it remains a crucial ingredient in any health care reform that has any hope of meaningful success.

Community Care of North Carolina, Association vs. Causality and How Insurers vs. Physicians Think

Shiites vs. Sunnis. Lycans vs. vampires. Liberal musicians vs. Republicans. Insurers and health providers. The Disease Management Care Blog wonders about the basis of all the antipathy. Is it how they were raised? Is it the DNA? Perhaps exposure to an environmental toxin in utero? While the DMCB continues to ponder this, it was struck again by how differently insurers and physicians interpret Community Care of North Carolina and what it means for the adoption of the Patient Centered Medical Home.

As readers may recall, CCNC has been credited by physicians with using the Medical Home Model to save the State hundreds of millions of dollars in claims expense while simultaneously paying primary care physicians additional PMPM fees. Even though this was all Medicaid all the time, advocates of the patient centered medical home (PCMH) point to apparent success of CCNC as evidence that this care approach should be implemented by all insurers all the time and the sooner the better. In contrast, commercial insurers have taken a more cautious approach, opting instead to test the medical home with 'pilot' programs. No doubt PCMH devotees are also disappointed by the U.S. House of Representatives’ Tri-Committee proposal to also limit the funding of the PCMH to a pilot.

Which is why the DMCB recommends an insightful article appearing in this month’s Medical Home News (subscription required & a disclosure: the DMCB is a non-compensated member of the Editorial Advisory Board). While a blog summary here won’t do it justice, the very experienced Michael Cousins, PhD walks the no-man’s land between insurers and providers to distill the opposing points of view.

Dr. Cousins points out that the actuaries who authored the CCNC reports used a classic insurance-based paradigm. These were ‘observational’ descriptions of what happened, not explanations about the underlying causes. Actuarial reports can get closer an understanding of the causes if the analysis mathematically neutralizes or adjusts for variables such as patient/physician self selection, cost/service inflation, reimbursement changes or other flaws in the study design. Dr. Cousins read the CCNC reports closely and found they didn't do that and, what's more, that they steered clear of addressing the issue of causality by carefully relying on words such as ‘associated’ and ‘correlated.’ The reports never used the 'C' word and without it, the utility of the CNCC reports, according to Dr. Cousins, is ‘limited.’

The DMCB thinks this is emblematic of one gulf between insurers and docs. The latter think association, while the latter worry about cause. It's 'what' vs. 'why' and 'how.'

‘’What happened?’’ Insurers are in the business of risk transfer. The DMCB wonders if trading risk for money doesn’t necessary require a deep understanding of causality: the observation that characteristic “A” (drivers less than age 18) is associated with “B” (more car accidents) is what is important. The State of North Carolina got an actuarial report that said “A” (paying providers a PMPM fee and pairing it with nurse care management) was associated with “B” (a drop in claims expense). The actuarial 'what' for this version of the Medical Home was amply demonstrated for the State, which continued the CCNC program. Case closed. (There are other equally simple answers when it comes to risk transfer that are more painful, but the DMCB digresses.)

‘’And did it cause savings?’’ In contrast, in order to provide care, physicians need to know the underlying reasons on why and how good and bad things happen to their patients. For example, they’ll ask why adolescent drivers are so vulnerable to risk-taking? The utility of knowing this is what leads providers to constantly search for cures. That is the business of moving from association to causality. And if there is a direct causal link, all stakeholders - insurers, physicians and patients - can be more confident that it will work outside of North Carolina Medicaid.

Unfortunately, understanding causality is a far more difficult exercise and the process is more prone, as has been demonstrated plenty of times, to mistaken assumptions. When circumstances warrant, the best way to address causality is with clinical trials involving a good comparator. Dr. Cousins agrees and points out that concluding there is a causal link between the medical home and lower costs could be a mistake.

The DMCB goes one step further. Since insurers only need ‘what’ in their business decisions, observing a decline in claims expense in their local pilots will be good enough for them. That’s also why private insurers continue to support their local disease management programs: they are also associated with savings. It's an endorsement, but a very shallow one obtained one network at a time.

Doctors, however, continue to look for answers to the questions how and why. They think they’ve found the answers for the Patient Centered Medical Home that will work in all settings.

No wonder the insurers and docs are talking past each other on the topic.

40th Lunar Walk Anniversary Inspired Quotes for Health Care Reform

Who can forget the 40th anniversary of the Apollo 11 Mission that put a man on the moon? Certainly not the President, and neither can the Disease Management Care Blog. And what a great quote when Neil Armstrong jumped off the ladder onto that magnificent desolation:

“That's one small step for man; one giant leap for mankind”

Sure, years later, Jack Kennedy and Walter Cronkite have been replaced by the likes of Harry Reid and Glenn Beck, while lunar walks have been supplanted by searches for errant Shuttle tiles, but no matter. The heroism of those intrepid spacemen still inspires the DMCB.

To wit: some health reform quotes fashioned over those legendary first interplanetary words:

The President: That’s one health reform plan in trouble: one giant all Obama all the time

Congressional Democrats: That’s one large budget hole; one giant chunk of Americans’ incomes and that's just for starters.

Congressional Republicans: That’s one large market for Americans; one giant doubt that many are insurable at any price.

The Blue Dogs: That’s one large cost of government; one giant ‘no-way!’ for Nancy Pelosi.

The Congressional Budget Office: That’s one nice try from Congress; one giant ‘no’ to budget neutrality.

Health Care Costs: That’s one huge trend line for inflation; one giant failure to contain the beast.

The AMA: That’s one we’ll support anything if it means the SGR formula goes away, make it go away, dammit.

The For-Profit Disease Management Organizations: That’s one attractive budget; one giant push to get disease management more explicitly covered in the amendments and the reconciliation anyway.

The Patient Centered Medical Home: That’s one big pilot; one great hope it actually saves money as advertised.

The DMAA, the Care Continuum Alliance: That’s one not-small annual meeting; one giant please help us meet budget and go to it

The DMCB: That’s one large meeting of bloggers, one great missing DMCB blog

The DMCB Spouse: That’s one more added RSS blog subscriber; one giant ‘so what?’ for the hubby

Planet Doctor Rules Say Professor Reinhardt Is Only Partly Correct on a 'Just' Physician's Income

The Disease Management Care Blog spent over 25 earth-years on Planet Doctor. Located in Earth orbit on the other side of our sun, it is oxygen starved and the surface temperature can vary from absolute zero to blistering. Only when you know the serpentine thinking of its kooky inhabitants, can you survive. Armed with this expertise, the DMCB would like to share some truth about primary care physicians (PCP), courtesy of Planet Doctor logic.

PCP numbers in the North American continent are decreasing and, as a result, a cadre of Significant Earth Leader (SELs) is giving them considerable attention. These SELs have observed in their pronouncements to their underlings that, compared to other specialties, the PCPs’ average income is considerably lower. Using the linear input-output logic typical of this class of human species, the SELs have calculated that income -> incents medical students to -> select more remunerative specialties which will -> lead to a shortage of generalists. To correct this trend, the ELs have decided to increase the income of PCPs.

We of Planet Doctor ask you to consider the following ‘thought experiment,’ of Robert Frank. He stole his counterfeit invention from us when he visited us via spaceship decades ago. While the relative income and lifestyle of our denizens compared to your Earth is indeed higher, the relative status of PCPs, compared to specialists, is at the low end of our world's socioeconomic scale. It is hard for Earthlings to comprehend this, what with incomes > $100K, but it is true.

This is why Professor Reinhardt’s assessment of a just physician’s income focuses on the wrong earthbound standard. While PCPs certainly appreciate the status conferred on them by Earth society and their patients, the rules of Planet Doctor are what really count. For example, your RBRVS system was really invented here and beamed to your CMS headquarters by our satellite radar array. That and specialist physicians’ words and deeds reinforce the second class citizenship status of PCPs (see p. 5) on a daily basis. Even patients, even if they savvy about health care policy, still want to see a specialist instead of relying on the training and judgment of their PCP.

Silly Earthlings. You think money and percentiles are what is important to PCPs? Whether you consider it in relative or absolute terms vs. other professions or society at large, income and status are insufficient windows on the many dimensions of professional status and the impact on the number of PCPs. The truth is far more complicated. More money courtesy of SELs is not the fix and simplistic economic notions of status fall short of the real truth.

Accountable Care Organizations (ACOs): A 'Blue Ocean' for the Disease Management Industry?

The Disease Management Care Blog eschews business gobbledygook. Many readers know this stultifying corporate-speak when they see it: jargonesque paragraphs that proclaim fresh enhancements, novel strategic directions, commitments to the value chain, stunning leadership redesigns, solutioning, portfolios, alignments and other such enigmatic nonsense from wannabe corporate titans that actually impair communication for their workers and customers alike.

That doesn’t mean that there aren’t important concepts behind the wordage, which is why the DMCB will apologetically cross the line and use one overused expression for a classic business concept: the ‘Blue Ocean Strategy.’ While those mots remain a darling of faux-visionary business people and consultants everywhere, it’s still an important concept: there may be markets that can be made tomorrow that do not exist today.

A new market opportunity may be opening up for the disease management organizations (DMOs), thanks to the U.S. House of Representatives. The DMCB went back to the ‘America’s Affordable Health Choices Act' and looked at what it had to say about ‘accountable care organizations (ACOs). The DMCB defines these as one or more hospitals and the physicians who work within and around them who are formally organized to manage quality and cost for the local populations they serve.

Like the Medicare medical home pilot, the House bill has a similar trial program for Medicare to test the ACO. The DMCB interprets the House legi-speak to define its version of an ACO as, among other things, a physician-based a) legal structure for the receipt and distribution of incentive payments, that b) has sufficient numbers of primary care physicians, c) can collect quality measures and other data for public reporting and d) prominently uses care management planning for patients. It’s up the Secretary of HHS to set performance targets and, if they’re met, the ACO can receive payments that are, in turn, distributed to the docs. ACOs are also allowed to create similar contracts with other payers. The pilot is to start at the latest by January 1, 2012.

Just like the medical home pilot, there is language aimed at getting smaller physician-owned groups to participate. In this instance participation by high cost patients can be limited, which also decreases variability and increases the likelihood of success. To the DMCB, that makes sense.

Extension of the pilot is possible for the ACOs if they are meeting targets and have qualified for at least one incentive payment. The incentives can also be flexed and expanded. Last but not least, just like the medical home pilot, the CMS’ Chief actuary has to certify that any expansion is budget neutral.

While ACOs have yet to appear in any number, parallel examples of them exist in the Medicare Coordinated Care Demonstration that was described in JAMA this year. They involved disease management organizations (DMOs), many broke even and some even made a profit. In prior posts, the DMCB doubted they had much of a real business model or had much attraction for physicians. Depending on the details of this Pilot, however, that could conceivably change.

And the House's public plan option? The Secretary of HHS is also allowed to include ACOs in its design.

Up until now, typical DMOs have contracted with commercial insurance plans and self-insured employers. While the DMCB thinks that part of the business is still healthy (though threatened by a hardening insurance market, declining insurance rolls and carve-ins), the advent of Medical Homes has presented a number of challenges for the DMOs. Two important ones are a) how to integrate their telephonic programs with team-based primary care management, and b) dealing one-at-a-time with all those clinics across a network.

Along comes ACOs. They not only aggregate primary care sites into a single administrative entity but their funding is contingent on the kind of care planning and management that is very compatible with classic disease management. The DMCB thinks that if the concept survives the legislative process, newly spawned ACOs will face the same buy or build dilemma for the many facets of population-based care management. Since telephonic care is one part of that, many smart ACOs could choose to buy, using part of the check sent to them every month courtesy of Secretary Sebelius. Who knows, they may also turn to DMOs for assistance with more intense care management programs, like case management.

That’s not gobbledygook. If this survives and the DMOs start planning now, that’s Blue Ocean.

(There's lots more on Accountable Care Organizations here)

Chronic Disease Management and Building Medical Homes Without Having to Transform Primary Care Practice in the Senate HELP Committee Reform Bill

Hot on the heels of the unveiling of the health reform bill in the U.S. House of Representatives yesterday, the Senate's Health Education and Labor and Pensions (HELP) Committee passed the 'Affordable Health Choices Act.' Readers can look at the summary here, or if you’re so inclined, review the complete 615 page bill here.

If the Disease Management Care Blog is reading both bills right, the Senate's HELP bill - in contrast to what's in the House - is requiring health insurers to reimburse 'high quality care that improves health outcomes through activities that shall include... chronic disease management, medication and care compliance initiatives, including through the use of the medical home model' (bolding and italics mine).

While the DMCB is slightly confused by the language 'including through,' the specific mention of 'chronic disease management' in legislative language would appear to be good news for disease management organizations. Note that Sen. Chris Dodd (D-CT), the acting Chair of HELP, represents the home State for CIGNA and Aetna, both of which have invested heavily in population-based care and disease management programs. In addition, the ailing Senator Kennedy (D-MA) represents a State that is home to Health Dialog. Readers are free to draw their own conclusions.

In addition to this, the Senate bill importantly provides for 'grants' that will support 'health teams' that, in turn, can contractually support primary care physicians in the creation of medial homes.

The DMCB is discerning a significant pattern here. As readers may recall, the House bill has a provision that funds a 'pilot' designed to test 'Community' based not-for-profit entities that can associate with primary care providers in the creation of medical homes. It would appear the Senate bill is doing the same thing, but isn't insisting on a non-profit or State sponsored status. Both approaches recognize that not all primary care providers necessarily want to build their own medical homes, but may want to associate with entities external to their practice that enables them to do the same thing. Given the considerable expense and work of 'transforming' a medical practice into a medical home, providing this option makes sense not only to the DMCB, but also maybe to the Dr. Pectors and the rest of her colleagues that inhabit the real world.

On another note, the Senate HELP bill also trumps the U.S Preventative Health Services Task Force (USPHSTF). In addition to the disease management requirement above, the bill states insurers 'will not be allowed to impose more than minimal cost sharing for certain preventive services endorsed by the USPHSTF as clinically and cost effective...' It may surprise some readers to know what the USPHSTF does NOT endorse. If readers are interested, they can check the links to services that insurers presumably could impose significant cost sharing for:

Pap smears for healthy women over age 65 years - answer
Chest x-rays to screen for lung cancer - answer
Prostate cancer screening - answer
Routine stress tests - answer
Screening for ovarian cancer - answer
Testing for the presence of diabetes in adults - answer
Counseling to promote weight loss among the overweight - answer
Counseling to promote exercise - answer

Cavalcade of Risk Is Up!

Yes, the 82nd Cav is up over at the Colorado Health Insurance Insider. In addition to the risk dimensions of health reform, this is the reader's chance to think about Supreme Court Justices' health problems, disability, reinsurance, the role of trust and even how your social security number is vulnerable to decision-logic based hacking. No week of pondering risk is complete without checking it out!

Foes of the Public Plan Option Will Need to Do Better Than This

National Public Radio’s ‘Morning Edition’ interviewed Wellpoint’s Dr. Sam Nussbaum today about the option of a federally sponsored public plan. Wellpoint is a publically traded and for-profit health insurer with 35 million enrollees and yearly revenues exceeding $60 billion. While those facts are impressive enough, readers may be more familiar with Wellpoint because of its reputation for rescissions.

The Disease Management Care Blog admits to being something of a fan of Dr. Nussbaum. Years ago, we both served on the Board of Directors of DMAA and the DMCB was mightily impressed with his energy, judgment and kindness. This is not a doc who puts profits before patients or dollars before doctors.

Dr. Nussbuam, however, is a doc that puts private insurers before public ones. His point in the interview was that the private sector is more ‘efficient’ and a public plan is simply not needed. He gave the example of ‘advanced’ imaging (pricey CAT and MRI scans are an example). Noting that up to 30% of such tests are not necessary, Wellpoint’s subsidiaries instituted a program (the DMCB suspects it involved precertification for ‘medical necessity’) that resulted in a 0-5% radiology cost trend. Dr. Nussbaum noted that in contrast, Medicare’s trend for these tests have been 15-20% per year.

Which begged the question: if the private plans are so efficient, why can’t they compete against the seemingly inefficient public option? Dr. Nussbaum’s answer was that the competition wouldn’t be on a level playing field. What they lack in efficiency would be made up take-it-or-leave-it low-ball fee schedules. As a result, providers would turn to the private insurers to make up the difference, resulting effectively in ‘cost shifting’ or a ‘hidden tax.'

The other example he gave was the cluster of insurance plans that are available to federal employees. Dr. Nussbaum noted that the same highly regarded ‘kind of health insurance Members of Congress get for themselves’ really consists of private sector plans that are purchased by the government.

Hmmm. The DMCB gets it, but with further reflection, isn’t sure the average voter is all that concerned about the cost shifting in a bloated medical-industrial complex. They’re more likely to be concerned that their CAT scan will be denied. In addition, health insurance is 1) arcane (?risk pooling?), 2) frightfully expensive (the middle class DMCB writes a check that exceeds $1000 a month) and 3) a commodity (consumers will change insurers in a heartbeat over price). Since other parties buy private insurance for most individuals (including the Federal government), there is little brand loyalty - especially when consumers and Senators are grumpy over rescissions. Accordingly, the average voter is unlikely to be concerned over the threat to Wellpoint’s economics, especially when that 0-5% trend doesn’t translate into meaningfully lower premiums.

If this is the best that the private insurers can do to muster support, the DMCB fears the public plan has a decent chance of passage.

The Medical Home and the U.S. House of Reprentatives' "America's Affordable Health Choices Act of 2009"

A 1018 page behemoth of a health reform bill was released today in the U.S. House of Representatives. While it will take days for editorialists, columnists and bloggists to digest this, let alone try to reconcile it with what's going on in the U.S. Senate, you can get a good sense of the early liberal perspective by reading Ezra Klein's reaction here. The Disease Management Care Blog didn't find a conservative reaction yet, but it suspects it will mostly be something like this.

The DMCB donned its miners' helmet, broke out its hydraulic word search excavator and looked for 'disease management' (precious little), but hit a huge vein of Patient Centered Medical Home (PCMH) ore. It thinks, except for one detail, PCMH advocates should be well pleased.

A quick time out for one caveat. While the DMCB can get through the six point font "materials and methods' sections of dullest health research manuscripts, it's on thin ice when it's reading legislative stuff like '426 U.S.C. 1395b–1 note, as amended by section 133(a)(2) 7.' Accordingly, it will be very happy to accept any clarifications and corrections from readers.

Here's what the DMCB found:

In the 'Public Health Insurance Option' (a.k.a. the public plan), the benefit design 'may' include a version of the PCMH. The bills says the Secretary of Health and Human Services 'may utilize innovative payment mechanisms' for the medical home (and other 'care management 'payments' and accountable care organizations'). The DMCB thinks that will be welcomed by its primary care physician colleagues and may be enough to elicit their support for a public plan.

There's also language that supports payment to certain hospitals (the Disproportional Share Payment Hospitals) to cover the work of 'assigning' medical homes to vulnerable patients. 'Funding.... shall be used by targeted hospitals (that receive disproportional share payments) for transitional care activities designed to address the patient patient noncompliance issues that result in higher than normal readmission rates such as... assigning discharged individuals to a medical home.' This makes sense, since readmissions are frequently the result of fractured disjointed care immediately after discharge.

But it's Medicare that is the most significant. It has a five year $1.6 billion 'Medical Home Pilot Program' (MHPP).

Establishing and certifying the specific medical home criteria to be used in MHPP will be up to the Secretary, but the guiding legislative language pretty much reflects its now classic definition and will be aimed at the usual 'high need' beneficiaires. What's really different is that two types of Medical Homes are envisioned: 'Independent' (the usual physician or nurse-practitioner directed) and 'Community.' The latter consist of nonprofit community-based or State-based organizations that are under the 'supervision of' or 'collaborates with' a primary care physician and employs community health workers. Both are to be paid with monthly fees that are adjusted on the basis of a) the patient's risk and b) the scale of services and resources offered by the medical home. The pilot is supposed to specifically target small physician owned practices, is to start within six months (Independent) or two years (Community) of passage of the bill and last for five years. $6 million for each of the 5 years is dedicated to the design, implementation and evaluation of the pilot. $200 million/year for the Independent and $125 million/year for the Community are allocated to pay for patient care services. There is also a process for States to apply to create their own pilots within Medicaid that are also based on the above framework. Last but not least, the Medicare Medical Home Demo would specifically be repealed.

If the Medicare pilot results in improvements in quality, reductions in disparities, fewer hospitalizations, readmissions, emergency room visits, improvements in satisfaction, higher outcomes, fewer duplicative services 'and reductions in health care expenditures,' the program can be expanded 'on a permanent basis.'

Here's that one detail. Unless CMS' Chief Actuary certifies that expansion of the pilot 'would result in estimated spending .... that would be no more than the level of spending that.... would otherwise be spent in the absence of such [an] expansion,' the permanent program is no-go. In other words, it sounds like MHPP has to break even.

If this section of the bill survives, the DMCB thinks that the CMS certification of budget neutrality will be a significant hurdle. As noted in prior posts too numerous to mention as well as the published literature, there is a surprising lack of good evidence that the medical home consistently lowers health care costs, especially outside of community centers or in Medicaid programs. While robust primary care is certainly associated with lower health care costs, a) we don't know if the association is truly causal or just observational, b) if the medical home is truly better than the robust primary care that is associated with lower health care costs, and c) if expanding primary care services in areas with high baseline utilization will lower health care costs. Last but not least, the DMCB is skeptical that Medicare - even with $6 million a year - is optimally configured to conduct the kind of complicated study is needed to address the research question.

The Importance of Community Partnered Participatory Research in Disease Management

No less than three editorials in the latest issue (July 15 2009; no link available yet) of JAMA warrant the attention of the disease management community. All are remarkable for the academic authors' astonishing blindness about the impact of population health programs in the Medicaid sector, but at least one of them has a good idea.

First, the good idea.

Kenneth Wells and Loretta Jones of UCLA and the Charles R Drew University of Medicine, respectively, give us a new acronmym: 'CPPR.' This stands for community-partnered participatory research. They point out that the 'R' ('research') word is an otherwise 'loaded' term for vulnerable underserved communities because it denotes manipulative exploitation and experimentation. The good news is that they believe research is more than possible in these settings if it is jointly and transparently developed, addresses one or more community needs and is tasked to seeking out new solutions. The key words are that the research needs to be conducted 'with' the community, not 'for' it and that there needs to be 'humility' tempered by being open to diverse perspectives, especially in the interpretation of the study results.

The Disease Management Care Blog thinks this is a great reminder that studies on the effectiveness of population-based programs in Medicaid (which is an important window into the underserved) as well as other vulnerable populations should include the input of not only the sponsors, statisticians, regulators, consultants, actuaries, researchers and line management, but the local community leaders, representatives and advocates. It's our job to seek out those centers and church offices staffed by savvy street-wise workers and preachers who can give invaluable input into the formulation of the research questions, the study design and the meaningfulness of the data. These JAMA authors remind us that its a good idea for academics and disease management organizations (DMOs) alike to routinely seek out this support when we conduct even quasi-experimental designs to determine what worked best and why.

Now for the blindness.

Dr. Wells' and Ms. Jones fail to recognize how prevalent disease management programs are in the populations that are ostensibly served by the nation's academic medical centers. Not only have they missed the many reports of successful Medicaid-DMO collaborations, but neglected to ask their own UCLA colleagues about a report on a successful Florida Medicaid disease management program. In fact, the number of population-based care management programs currently underway in many States is astonishing. These programs were instituted precisely to address many of the disparities still rampant in many underserved communities today. All are have been or are being evaluated for impact, and the authors failed to note the importance of their suggestions in making these evaluations more meaningful to the populations being served.

It doesn't stop there. In the same issue of JAMA there are two other editorials that commit the same sin of looking but not seeing. Janet Collins PhD and Jeffrey Koplan MD of the Centers for Disease Control and Emory University, respectively, say it's time to institute 'health impact assessments' (HIAs) for all policies, programs and projects involving not only health care but transportation, housing, employment and agriculture. After extolling several successful HIAs (for example, its input was instrumental in the passage of the San Francisco living wage ordinance), these research scientists fail to take the next step and recognize the potential contribution of disease management methodologies in assessing health outcomes and impact on costs.

Turn the page and you'll find Jonathan Fielding MD and Steven Teutsch of the LA County Department of Public Health and UCLA (Dr. Fielding) salute the a) US Preventive Service Task Force Guide to Clinical Preventive Services and b) the Community Preventive Services Task Force Guide to Community Preventive Services. Yet, while the recomendations in both these guides are evidence based, they note with some dismay that the track record for fulfilling them in the Medicaid populations is dismal. They advocate for more effective involvement of health systems, clinical practices, employers, payers, community based groups, government and public agencies. Any mention of how disease management programs have partnered with Medicaid agencies for years in addressing precisely these shortcomings? None. The additional support from DMOs in advancing quality in these populations went completely unmentioned

If the DMCB is going to assign blame, it probably belongs to the Editors of JAMA, who failed to recognize just how narrow minded these six authors were being. JAMA is an important journal and they owe it to their readers to help authors to encompass all the pertinent medical literature in their commentaries. Given the pressing nature of health reform and the role of population based care in addressing chronic illness in underserved and Medicaid populations, the Editors of JAMA let these authors - and their readers - down.

Maybe next time.

Good thing blogs are around to keep them 'Obamaesquely' honest.

The DMCB Enters the Health Care Affordability Model Debate (and ponders the role of health insurance in controlling costs)

There's been considerable bloggery over Robert Laszewski’s post on how to control health care costs with a ‘Health Care Affordability Model’ (HCAM). While the Disease Management Care Blog likes to imagine the inhabitants of Greater Blogistan's postings really do actually influence national policy, the DMCB thinks the bigger lesson here is what the reactions of the commentariat (here and here and here and here and here) teach us about how health insurers are generally viewed.

Briefly, Mr Laszewski would make health insurers responsible for controlling healthcare cost inflation under the threat of losing their federal tax qualification. Health plans would be obliged to meet actuarially predetermined cost targets that are based on the growth of the gross domestic product (GDP). Targets would be established by a ‘Health Care Actuarial Certification Board’ within the Department of Commerce. What’s more, there would be State ‘sub-Boards.’ He believes this can be part of any health reform legislation currently before Congress. Mr. Laszewski would like to phase this in over three years.

The DMCB agrees with the politically astute prognosis from Dr. Millenson: the likelihood that this will be included in the legislative sausage-making process is about the same as a U.S. Senator ever having to remit a co-pay for a medical service. What's important however, is that Mr. Laszewski et al's proposal is based on the idea that health plans are not only responsible for spiraling health care costs but they also somehow have control over them.

They mostly aren't and they really don’t.

Commercial health plans’ benefits, premiums, capital requirements, enrollee communications, provider networks and ultimately surpluses are all already tightly regulated by State Departments of Insurance. Most well run employer sponsored plans are run as if they are tightly regulated. While they can command large discounts from hospitals and doctors, the yeild from that strategy was used up long ago. Instead, insurers are ultimately just a means to pool risk. The price of that risk is increasing, not because of the insurers, but because of external cost drivers that include (but are not limited to) pricier technology, dysfunctional fee for service incentives and an increasing burden of chronic illness. In other words, they collect actuarially defined premiums, pay the bills and pass all the costs plus a small margin (that varies from year to year in the underwriting cycle) to the consumer.

When the DMCB says they mostly aren't responsible, that doesn't mean insurers don't have a role to play in defining a benefit that promotes quality and fulfilling a fiduciary duty to their enrollees. All that, however, is at the margins. The truth is that the managed care backlash defanged the insurers over a decade ago.

If they were given their fangs back, they’d probably turn to leveraging a selective network of high efficiency providers (tiered networks including the option of excluding hospitals and physicians that cost too much), denying payments on the basis of suspect medical necessity (for example, low risk prostate cancer, coronary stents for angina or treatments for colorectal cancer and that’s just for starters) and ‘steering’ patients toward the cheapest alternative when all else is equal (for example, medications for diabetes mellitus). Health plans can't do this today because elected representatives, regulators and the public don't trust them to do this right. We still have the Sicko hangover and insurers behaving badly. It's less a matter of comparative effectiveness research (CER) and more a matter of policy.

By the way, the DMCB thinks there are many health plans that could, in aggregate, do this right. They're generally smaller, not-for-profit with effective Boards and meaningful consumer input. They're generally not centrally-controlled public and behemoth plans. Some entity somewhere is going to have to start using the terms 'no,' 'not covered' and 'denied' in earnest. Whether it's based on CER (we 'know' drugs and exercise beat invasive heart procedures) or common sense (whoa, how much for a cancer treatment designed to extend life by 4 months?) it's going to need to happen sooner or later.

The DMCB likes to imagine Congress will get health reform right. It daydreams about the income potential of its blog. HCAM without the means to back it up shares in the same level of unreality.

For the Disease Management Road Warriors

The Disease Management Care Blog understands the travails of the disease management consultant, sales, speaking and other-duties-as-assigned road warriors. It recalls an early posting on hotel water glasses, but now we know to not pack our guitars.....

A Summary of a Summary of a Book. Dr. Porter's New England Journal Piece on High Value Healthcare Systems

Another ‘Perspective’ piece in the New England Journal of Medicine caught the eye of the Disease Management Care Blog. Written by a father of bundled payments, Michael Porter, it outlines the elements necessary to get to a ‘value-based’ healthcare system.

This time something in the NEJM is actually worth knowing about. What's more, if you take the time to read the article, you won’t have to read Dr. Porter's important, if lengthy, book “Redefining Health Care.” The DMCB thinks this NEJM piece is really one of those executive book summaries that busy captains of industry read in airport lounges. The only downside is that you’ll miss the part in the book where Dr. Porter references an article written by the DMCB and colleagues.

No matter. The expectation-exceeding DMCB is pleased to offer up a two paragraph outline of Dr. Porter’s NEJM health reform outline. No lounge for you: you can dispatch this at your desk with a few bites of lunch and be all the smarter for it. Then you can click on through to your other favorite blogs so you can get back to your job (or - hint - forward the link to your colleagues). After all, it's Friday and it's time to wrap things up. You don't want to be cornered at the end of the day with a pile of unfinished business.....

Commercial health insurers need to compete on the basis of delivering value for their enrollees. Employers who buy that insurance have a stake in their employees’ health. If we can increase the value offered by insurers, we can help keep employers from abandoning their workforce to the individual market or, worse, becoming under or uninsured. Persons without access to employer-based insurance should a) have access to the same deductable tax treatment employers enjoy and b) should be able get the volume discounts and other advantages of joining in large regional pools. We should require everyone to have health insurance and couple that to subsidies for persons that otherwise wouldn’t be able to afford it.

Once everyone has health insurance, Dr. Porter says the next steps are to increase value. Start out by measuring and reporting meaningful consumer-friendly outcomes on every provider, doctor and hospital. Wellness and prevention should be covered, preferably as a bundled package of services. Services should be organized around ‘conditions,’ (e.g., heart attack) not around location (e.g., the hospital) and payments should be bundled in a manner that pays for the condition ‘episode.’ Providers that achieve high quality and low cost for their conditions should be rewarded with more business, but not to the point where they achieve monopolies. The electronic health record will support reform, not drive it. In contrast, enabling patients to be better participants in their own care is a critically important part of health reform. New organizations in D.C. will be necessary to regulate all of this.

(The DMCB has always been partial to the notion of bundled payments, especially because there's a good fit for population-based care management/disease management and dovetails with accountable care organizations. Yet, they stand in distinct contrast to the 'medical home' policy option of having the primary care provider be a leading 'coordinator' of services in exchange for a separate care management fee.

In addition, while Dr. Porter is all about outcomes, the DMCB isn't too sure that insurers can be necessarily blamed for trumping the denominator function of 'value' [defined as 'outcome/price'] because purchasers want the lowest premium possible. Unfortunately, that can mean coverage denials, cherry picking and consumer cost sharing -- and not being enlightened, having open season enrollment and accepting a high medical loss ratio.

The DMCB also doubts the usefulness of measuring performance at the individual provider level, where low numbers of patients with conditions of interest may mathematically result in 'unstable' measures: all it takes is one very high A1c to blow the group average.

Dr. Porter seems to think of insurers as large utilities or intermediaries that package and deliver services, when what they're all about is transferring risk. That's a definitional problem, not a show stopper.

The DMCB really likes Dr. Porter's recognition that patient-consumers need to become active in managing their own conditions. To celebrate, it had seconds on its lunchtime soup).

The Latest Health Wonk Review is Up....

... and it's a really good one! Ken Terry of BNET Healthcare has posted a masterful summary of the best recent blog postings on health reform. As things heat up in Washington DC, this is your chance to find insights not available anywhere else.

Prognostications on the Future of Disease & Population-Base Care Management - From a BrightTALK Webinar

Today the Disease Management Care Blog gave a BrightTALK webcast on 'The Future of Disease and Care Management for the Chronically Ill.' While the 45 minute PowerPoint presentation and audio are available on line, your DMCB is delighted to provide a short summary of the DMCB's admittedly optimistic prognostications. They may come true, assuming coming U.S. health reform doesn't completely gut the industry's passion for 'Skunk Works' style innovation.

Outside of the commercial markets, an alternative way to think of these hunches are as domains to assess the real sophistication of the various coming health reform proposals. Cover the medical home? (Yawn). Promote use of electronic records (Tsk tsk). Insure everyone? (Easy, if all you have is money and little imagination). If the wunderkids among the Congressional staffers and White House war room denizens are able to accomodate these following concepts as they hammer out their health reform proposals, then we'll be really getting somewhere:

Convergence of Disease Management & the Medical Home: While there are significant historical, economic and cultural barriers to this, advocates of both approaches have much more in common than is widely appreciated. While that alone may not be enough to combine sophisticated remote telephony with high touch primary care-based care management, the DMCB is an optimist. While this didn't come up during the webcast, it thinks that health reform that promotes versions of accountable care organizations or ACOs (which has challenges) may be the perfect venue for DM and MH collaboration - if it also gets engineered into the legislative language.

Emphasis on Demand Management: Other terms for this include consumerism and patient centered medical care, but the bottom line that that the core of any population-based care management program will consist of behavioral interventions that enable and assist greater self-care. This means the core will not be the electronic record, physician payment reform or any other number of policy notions. Rather, these and all the other elements will need to play a supportive role to meaningful, industrial-level health consumer engagement.

It's a Soup, not a Soufflé: Who says cookbook medicine is bad? It isn't if there is room for the kind of creativity that is allowed by cooking up some soup. Wrapping all the ingredients around demand management will require considerable flexibility based on local patient culture as well as the type and availability of other local care resources. The difference between Buloxi and the Bronx will stymie one-size-fits-all policy and reimbursement models, and Federal inflexibility represents the greatest threat to meaningful population-based healthcare.

The 'Build or Buy' Sine Wave Will Continue: Those of us with backgrounds in health insurance eventually learn to live with the routine: initiate an in-house program to deal with some challenge in the enrolled population, determine years later that it can be done more effectively as a carve out, then, with a change in leadership or a problem in the medical loss ratio, determine that it can be better dealt with by initiating an in-house program...... That isn't necessarily bad, but it does speak to the need for local systems to contract then construct then contract then construct care programs based on shifting circumstances.

Single Platform: The growing availability of truly robust and modular informatics solutions means that computerized systems that undergird underwriting, disease management, utilization management, case management and the electronic/personal health record will enable insurers/systems to have a single 'view' of their patient population. What's more, knowing how to promote wellness among persons with chronic illness to manage utilization (for example) will be a growing competitive advantage. There will no longer be an excuse to not tie it all together.

The Rise of Nimble Research: By the time the Comparative Effectiveness Research academics begin to submit their manuscripts to journals that few read and even fewer care about, the care management industry will increasingly use quasi-experimental inquiry designs that answer the important questions with reasonable assurance. It remains to be seen whether they'll bother with the academic journals or rely on some other venue to share their findings (like blogs).

MORE Chronic Conditions: That's right: migraine, chronic pain conditions and metabolic syndrome are some of the current leading candidates. Plus, an off topic comment: the idea that 'disease management' companies are limited by nurse coaches that 'only' deal with 'one' condition at a time, leading to the inefficient balkanization of care, is a tiresome canard. Expect the same nurses to be cross trained in new conditions. What's more, expect screening for conditions (like migraine) start with the 'captive' patients in the old disease management populations. One other point: pharmacy benefit managers are starting to find patients for disease management programs.

Automation, automation, automation: The rise of scalable and fully automated remote monitoring systems with branching logic, computer controlled speech and integration with electronic records is reaching the tipping point. This will drive down the cost of disease management programs, because fewer full time equivalents will be needed. The DMCB does not expect a wholesale reduction in force over this, because it thinks successful DM remains ultimately a high-touch value proposition.

Say Hello to the Cell Phone: If you think persons are going to be managing their chronic conditions with some lap top or home desk top on some password protected website, think again. The cell phone can hold lots of the necessary information (medication list) and access the rest (electronic versions of all past imaging studies, like x-rays) from some cloud server somewhere. Care management organizations that learn to integrate their information systems with the DMCB's Blackberry will win.

Coda: This isn't the first time the DMCB has been soothsaying. So far, it looks like the first batch of predictions is holding up.