Want to Improve Diabetes Outcomes? Start a Hypertension Disease Management Program

An enduring criticism of disease management (DM) is that it is 'siloed." Contrasting it with the comprehensive care offered by primary care physicians, critics have charged that insurance sponsored DM balkanizes chronic care for patients into separate, inefficient and overlapping programs. As a result, patients with hypertension and diabetes and high cholesterol could spend all day on the phone dealing with separate hypertension, diabetes and cholesterol disease management nurses. The Disease Management Care Blog believed that was a canard, but its opinion fell short of its own evidence-based standard. Up until now, there were no peer-reviewed studies that specifically examined the silo allegation.

Until now. Check out this study from the Durham VA Medical Center and Duke University that was published in the July issue of the American Journal of Medicine, authored by Benjamin Powers, Maren Olsen, Eugen Oddone and Hayden Bosworth. The V-STICH Trial lasted 24 months and compared hypertension disease management consisting of telephonic-based nurse support versus usual care. While there was a modest effect of disease management on blood pressure control, the authors noticed that many of the participants had other chronic conditions, like diabetes and high cholesterol. This was a unique opportunity to assess the impact of the hypertension disease management program on the other conditions.

Of the 588 hypertensive volunteers that participated in the trial, 219 had diabetes and, of these, 216 had had a hemoglobin A1c checked during the course of follow-up. Baseline patient characteristics were not statistically significant among the diabetics in the two arms of the study. However, over the two years, the mean A1c went from 7.54% to 7.26% in the disease management group, while the A1c increased from a baseline of 7.20% to 7.38% in the usual care group. Comparison of the relative changes in the average A1c between the two groups reached statistical significance.

The authors were also curious about the impact on 528 persons who had had a cholesterol checked. The LDL declined in both the intervention and the usual care groups but did not achieve statistical significance.

The authors concluded that their hypertension disease management program had had an 'unintended effect' on blood sugar control among persons with diabetes. The DMCB is unsurprised. Disease management organizations (DMOs) typically instruct their nurses to trigger other engagement modules whenever another chronic condition is detected. At a contractual level that makes sense, because the DMOs often bear some risk for insurance claims expense and it's in their financial interest to help their assigned patients reduce their global risk. However, the DMCB suspect there is something more signficiant afoot: good nurses can't avoid helping patients manage other conditions.

They can't help themselves.

The DMCB witnessed this first hand when it witnessed how disease management nurses do their thing. It sat in on a patient-nurse telephone call for a client-patient and listened how the interchange quickly veered off-course. The nurse helped the patient deal with a new medical problem, offered some emotional support, served up some common sense advice and then closed wth some 'hang-in-there' cheer leading. The DMCB was very impressed but not surprised.

Critics of DM shouldn't be surprised either.

H1N1: The Obama Administration's Coming Katrina?

In a prior post, the Disease Management Care Blog noted that the Obama Administration’s health care chops would depend on its response to the H1N1 (Swine Flu) virus. So far, it’s been lucky: a serious pandemic has yet to land on U.S. shores. With the coming arrival of fall, however, luck may be running out.

According to this New England Journal of Medicine article, planning is furiously underway. It looks like the patchwork of emergency rooms, public health clinics and primary care providers are being geared up to give the vaccine. Individual clinics are anticipating the coming demand based on the Centers for Disease Control's (CDC's) emerging two shot vaccine recommendations that assign priority to the pregnant, children, young adults and adults up to age 50 years with a chronic illness.

This may look good on paper, but the DMCB worries that this public health campaign is vulnerable to one of two extremes. One is high numbers of persons refusing to be vaccinated because of the fear of side effects. The other is high numbers of persons demanding the two shots and over-running our decaying primary care network. Over the last decade, most primary care sites have reduced overhead to a minimum and have neither the personnel or the resources to take on a new crush of persons demanding the two Swine Flu shots.

For more insight on this, the DMCB turned to one of its primary care colleagues, who, unlike the apparent healthcare experts writing in the New England of Journal, has a real grip on the reality of what could happen this fall:

'I hear rumors that the government is going to pay for the vaccine but the cost of administering the shot (including storing the vaccine and covering the cost of the nurses to administer it) is supposed to be covered by private insurance. We haven’t heard if the insurance payers we deal with will provide first dollar coverage or if they’ll transfer some of that cost through a co-pay or other forms of co-insurance. We also still have no idea about the distribution channels and we don’t know how the vaccine supply will be shared with physicians’ offices, Department of Health clinics or pharmacies. Our small primary care office is terrified of the burden that will be imposed by having giving two more shots to our population with a short lead time. We already have full schedules for the fall season and will have difficulty processing the 1200+ extra contacts and associated paperwork. We are a tiny office that normaly gives 600-700 flu shots a year.'

By the way, the primary care physician had a particularly novel idea. It’s built on the common sense observation that lay people can be trained to give shots.

'My solution: Train census takers to give shots or better yet, put a shot giver on every Fed Ex and UPS truck. Those guys are the best logistical wizards on the planet. You could even get a tracking number and find out where your flu shot is!! They know where everyone lives. My UPS guy knows that if I am not a work to drop by my house. Talk about a neural network.

Readers may think this is naive, but the DMCB points out that the circumstances of the coming H1N1 pandemic may warrant out-of-the-box thinking. This is the Obama Administration's chance to show that it is different - that it is able to come up with non-FEMAoid approaches. Are there plans to involve the public schools? Why can't Visiting Nurse Associations be contracted to set up vaccine stations in our nation's post offices? Or maybe when the Administration isn't pillorying the insurance industry, it is working with it to reduce the out of pocket financial barriers that patients may be facing?

And, in case sizable numbers of persons refuse to be vaccinated for H1N1, check out this thought:

How about a variation of the Cash for Clunkers Program. I call it Shekels for Shots program. At first glance, this may sound silly, but if a voucher not only provides first dollar coverage of the shot for particularly vulnerable persons, but gives them a meaningful cash rewards, the population will be vaccinated and we’ll have another stimulus!!

The DMCB says the traditional response to H1N1 so far does not bode well for the Administration. If the story being told above is typical of many other primary care providers, H1N1 could turn out to be the Obama Presidency’s Katrina.

Synaptic Health Care and the Passing of Senator Kennedy and His Vision for Mainframe-Style Health Reform

The late Senator Kennedy will be laid to rest at Arlington VA on Saturday. His repose is a chance for all of us to reflect on his ceaseless advocacy for a just healthcare system, his appeals to all of us to help the least of us and his tireless efforts to achieve compromise over acrimony. Our nation owes him a great debt of gratitude.

The Disease Management Care Blog also wonders if his vision of government dominated health care will be laid to rest with him.

Mr. Kennedy belonged to a generation that believed in the greatness of government's role in modern society, and why not? Passage of Social Security Act of 1965 , the Civil Rights Act and other important social legislation demonstrated our collective ability to achieve new heights for modern America. Yet, something derailed Washington DC's momentum. What was started by the Great Society was slowed by the Reagan Revolution and reached its limits when Clinton's health reform failed. The DMCB believes Senator's Kennedy's passing may be marked as the beginning of the end.

An alternative world view is growing in our collective consciousness. It prefers networked over hardwired, parallel over serial, organic over static, tailored over pre-fab and synergy over reductionism. Its currency is communication, its actions are individually informed and the outcomes are fractal. It resists established business models and it certainly isn't taxable. It's face is YouTube, Blogging, Twittering, cloud computing and chaos theory while its symptoms are outsourcing, open sourcing, and multi-tasking. It can be easily mistaken for naivete, libertarianism, survivalism and conservatism. It's a wild card in our body politic; how else could Ron Paul become so..... cool? What else explains the misinterpretation of Federal payment for living wills as 'death panels?' It's not the 'web' and our 'Communication Age' only partially explains it. It's ....synaptic.

It is being underestimated by and hasn't helped those in favor of health reform. It has aided but hasn't been harnessed by reform opponents. Its cultural sexiness has greater appeal than the efficiencies from central command and control and its ascendancy is eclipsing classic liberal notions of social justice and progressivism. Government may be able to preside but it cannot own this. It is too complex, nimble and amorphous.

Which is why Senator's Kennedy's demise may be symbolic of the passing of an era. Whether it's big bang or incrementalism, and whatever its merits, the sun is setting on the likelihood of buy-in over the notion of a uniform benefit package being overseen by single authority. The DMCB doesn't think it's reached a majority yet, but the tipping point is fast approaching. When it arrives, the likelihood that Kennedy's vision will be fulfilled will be gone forever. This is another reason why supporters of health reform intuit that this last chance is not only hostage to the short term election cycle but to a profound long term trend. Taking Ver 1.0 reform's place is a Ver 2.0 vision of healthcare that is more local, responsive, personal, information-based, tailored, consumerist, rich and all those other terms that have been incorrectly dismissed as jargon. A telling example* can be found here.

That doesn't mean that experts won't continue to embrace a mainframe-style single payer, top down, highly proscribed system with regulated salaried physicians and policy being set by a Health Fed - for example, such as this article appearing in the New England Journal.

Waiting in the wings are folks like those who prefer a Guaranteed Healthcare Access Plan, consisting of vouchers that support a flexible minimum benefit. There are other approaches that meet the spirit of synaptic reform. Their proponents are waiting and watching to see what happens.

*Hat tip InsureBlog

Chronic Illness Survivor?

The DMAA web site has an 'online bank' of individual patient testimonials about the virtues of care management. Including patient quotes and sometimes mentioning disease management companies by name, the stories take sterile statistics like reductions in inpatient admissions and blood glucose control and put real faces on them. The Disease Management Care Blog finds the anecdotes credible: get a good system of patient support in place, and it's amazing how well persons can do.

This made the Disease Management Care Blog want to open a separate page for reader testimonials. Something along the lines of.....

'After years of low awareness of disease management and forgoing daily updates offered through the internet, Mabel finally decided to subscribe to the DMCB, a great source of free info about population-based care management. Through regularly logging on, Mabel has become really smart, amazes her co-workers with her fund of knowledge, has helped her U.S. Senator better understand health reform, prompted a local hospital to close one wing from lack of business and has reduced the PMPM in her State by $0.03. 'This is so great,' said Mabel, 'I've forwarded the link to the rest of the folks in my Department!'

But seriously, if we're going to show how persons can get their quality of life back to normal, how about a variation of CBS' successful Survivor show? To qualify, persons would have to have a major chronic condition that is a) under control, thanks to b) having to take two or more medications on a daily basis and c) having to self-monitor/treat. The show would not only feature feats of stamina and guile, but how contestants manage the disease on a daily basis through of combination of as needed treatments, rest, nutritional adjustments and contact with a support team. The DMCB is thinking a 45 year old man with diabetes mellitus versus a 35 year old house wife on IV meds for rheumatoid arthritis versus a 55 year old office worker with paroxysmal atrial fibrillation......

Cavalcade of Risk #86 is Up!

The Political Calculations blog has used a variation of the Moody's Bond Rating system to assemble this week's postings in the Cavalcade of Risk #86. Great stuff on all things having to do with business and finance risk. It's worth a look.

The Disease Management Care Blog wondered why it didn't deserve Aa1, but then it realized that's the credit worthiness of U.S. Bonds. It likes not being in that company......

Clinical Practice? Evidence Based. Health Care Policy? Just Argument

Pity Victor Fuchs. He's a Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy at Stanford. He has all those articles in the New England Journal, JAMA and Health Affairs and his sensible suggestions are not seeing the light of day in the health reform debate. According to Kaiser Health News (KHN), he's disappointed with the President. He's just so plain wrong on:

Prevention: 'there's hundreds of studies showing you don't save money on that stuff.' The DMCB agrees, but don't take its word for it.

Electronic Health Records: "you are just throwing money away." Hear hear says the DMCB.

The Public Plan:' 'cost shifting' doesn't do anything about the real cost of health care.' The DMCB wonders if it read some of Dr. Fuch's articles in an unremembered past, leading to its current point of view.

Keeping What You Have: 'Most of these stories [Mr. Obama] tells about the way he’s going to save money don’t ring convincing to me when they are accompanied by the repeated insistence, 'If you like what you have, you can stay with what you have.' A big part of the problem of the high cost of medicine is precisely because of the system we have. If you don't contemplate changing that system, everything else is kind of a pretense.'

According to Dr. Fuchs, the system is riddled with bloated overhead (brokers, administration, marketing, bureaucracies, specialists), excess capacity and open ended financing. How he proposes to fix this was left unsaid in the KHN interview, but he likes the idea of handing out risk adjusted vouchers that cover a pre-defined benefit.

The Disease Management Care Blog is sympathetic. It's ironic that clinical practice is supposed to be evidence-based, while it's OK to simply argue past one another on healthcare policy.




There may be some good news for our democracy, however. Check out this article from the New York Times that suggests, while some raucous Town Halls have been spotlighted by the media, the a majority of them were civil and informative. Maybe some of Dr. Fuch's points have gotten through.

When Patents Become Patients (At Least When It Comes to Payment)

The Wall Street Journal (WSJ) has an interesting front page article on how lawyers' 'Billable Hour' style of reimbursement is 'under attack.' Instead of being paid an hourly rate for their lawyering, many firms are yielding to 'alternative billing arrangements.' Stressed by the economic downturn, customers are balking over the hourly 'incentive to rack up bigger bills,' with 'flat fee contracts' and, faced by declining revenues, the lawyers are acquiescing. While activities like 'anti-trust fights,'or 'tricky corporate mergers' or having the 'absolute best team of trial lawyers' will likely continue to be billed hourly, more routine work like 'patent applications' will be paid with.... capitation.

Capitation you say? That's how the Disease Management Care Blog thinks of it. Donning an insurance hat for the moment, the legal customers are transferring the risk of high work effort cost of patent management to its lawyers. If some detail in a patent plan gets thorny and requires more time, that cost is borne by the lawyer, not the payer. Without the remuneration from of fee-for-service (measured in time units), work effort that used to represent revenue now becomes a loss.

The Disease Management Care Blog feels their pain, though it points out that what is described in the WSJ may not represent a full capitation arrangement. That would involve transferring the risk of all the costs of a patent application, such as all the other fees, additional unforeseen litigation (patent infringements?), having to call in additional lawyers (referrals) or loss of income (from delays?). Rather, it's likely to be 'partial capitation' that is limited to a narrower range of services, such as just the legal legwork owned by the firm.

The DMCB asks what's next for our legal colleagues. Other unrecognized but important services may or may not need to be carved out. Customers may want phone counseling over the merits of their patents, the anxiety of dealing with them or now to market them once they are awarded. This would involve specially trained non-lawyer professionals who can work within their scope of practice. Patents probably range from simple to complex, so payment may have to be risk adjusted. Persons who are elderly or socioeconomically deprived may warrant government support: PatentCare or PatentAid. Visiting a patent office and pleading the case with the necessary follow-up correspondence (for, say... 60 days) may have to be managed with a global payment and there is no, repeat NO payment for 'mistakes.' Since there are so many patents, an electronic record of some sort could become necessary to adequately follow progess and populate a registry that can assess patent outcomes. While trial lawyers only get paid if they win (the ultimate pay for performance), some sort of reward for a patent process measure or two (time to application, time to notification) may have to be considered. They may have to be publicly reported on a vetted web site. Of course, the firms offer a spectrum of services, so coordinating them may prompt some to offer client centered legal homes.

Despite that, costs for patents may rise uncontrollably, leading to high costs that hamper our nation's ability to compete globally. We'll debate if equal access to patenting is a right or a commodity. Cherry picked and heart breaking anecdotes of loss of patents will abound. Presidents will wonder why blue ink is preferred versus red ink. Lack of iron-clad evidence that any of this works, of course, may prompt comparative effectiveness research. The government may need to step in with a single patent payer system.

You read it here first.

The National Public Radio (NPR) Interview on Health Reform: Dr. Howard Dean, You Need to Regularly Read This Blog

When interviewed last Friday on National Public Radio's All Things Considered, Howard Dean explained the polls showing declining support for health reform by saying:

'And we do know from polling - because I've seen some polling about messaging - is that when you talk about health care reform, a lot of people disapprove of it. When you explain the president's health care reform views and his bill, then people support it overwhelmingly.' [bolding from the DMCB]

Aha! So the concerns out there are the result of an information gap.

Readers may recall that Howard Dean is not only a former Vermont Governor and former Chair of the Democratic National Committee but is an academically trained general internist. And in the quote above, he demonstrated a classic sign of the syndrome of Chronic Unremitting Insufferable Physician-Centric Generalinternistitis (CUIPCGI). This is an abiding belief that education is the single ingredient that transforms patient non-compliance into compliance. Its dysfunction becomes extreme when this delusion intrudes in other aspects of living, such as national politics or changing a spouse's mind about the merits of letting the porch go uncleaned. The Disease Management Care Blog is also similarly trained internist physician and has observed that CUIPCGI frequently among members of its specialty, in much of the academic peer reviewed literature and among many of the Brahmins advising the Obama Administration.

For the longest time, patient care was built on the notion that the transmittal of facts from Those-In-Possession-of-Knowledge to Those-Not-In-Possession-of-Knowledge was suffuciently transformative. We believed it made the dumb smart, the lazy energetic and the disinterested inspired. Accordingly, the uncontrolled diabetics would become controlled, hypertensives would become normotensive and the obese would become thin.

Unfortunately, victims of this disorder soon suffer severe consequences: 1) the subjects of their belief system often discern they are incorrectly being labelled dumb, lasy and disinterested, 2) persons with chronic conditions don't make much progress in disease control and 3) stymied by a lack of buy-in, these unfortunates paradoxically inflate their confidence in the merits of education and compensate by framing the same facts with accelerating degrees of bias.

Fortunately, for the many otherwise excellent professionals who are afflicted, there is a cure. It involves humility and paradoxically applying the same educational standard to oneself, starting by reading some of the vast amount of peer reviewed scientific literature from the last ten years that has revolutionized the science of patient behavior change. It has amply demonstrated that recounting of 'facts' are only the beginning. 'Expalining' the facts is necessary but not close to being sufficient when it comes to getting patient buy-in and behavior change. The literature on this is not hard to find and examples include this, this, this and this. There is a good review of the topic at AHRQ and the Population Health Journal has this thoroughly researched description of various approaches to behavior change. Last but not least, regularly surfing, RSSing and Twittering the modest DMCB is also a good way to keep up on care management. Regular readers know the bottom line is that when state-of-the-art patient engagement is applied, variations of shared decision making centered on the patients' knowledge and values results in a mutually acceptable care-plan.

Viewed through the prism of population-based health care, therefore, the August recess Town Halls are one stop in the process of a sort of shared decision making that could lead to a national 'care-plan' consensus on healing our broken health care system. While rancorous and sometimes loopy disagreement has slowed reform's momentum, responding by smugly 'explaining' the President's views to the opponents is insufficient, implies they are lacking in knowledge, is disparaging and damaging to our national dialog.

The DMCB is unaware of Dr. Dean's readiness to change, but if the DMCB was using motivational interviewing to help him, it would reflectively listen and offer up the option of reading this blog as one way to be a more constructive force in getting to meaningful health reform.

A less clinical way of saying the same thing is to bluntly point out that our national discourse and the listeners to NPR deserve better.

The Latest Health Wonk Review is Up!

David Williams of the Health Business Blog wastes no time in an efficient series of almost Twitter-like descriptions of the latest and greatest wonky bloggery. Alas, while many are shouting at Town Halls, the health wonk reviewers are thoughtfully writing about everything they like and don't like about health reform. David has a masterful summary of quite a large number of posts - there's something here for everyone!

The DMCB was also remiss in alerting readers that the Cavalcade of Risk Downunder was posted days back. Chatswood Consulting has a series of links to posts that deal with the management of risk, be it be it life, health, disability or business risks. Also well worth your time.

Accountable Care Organizations: The Good, the Bad and the Better Thanks to Health Affairs

In a prior post, the Disease Management Care Blog not only explained, but got all mushy over the notion of ‘Accountable Care Organizations” (ACOs). The DMCB felt that ACOs could provide the endoskeleton over which a mix of carve-in and carve-out population-based systems of care - including commercial disease management - could be assembled.

ACOs may be a healthcare policy golden-boy, but the Health Affairs Blog has a posting authored by Jeff Goldsmith that argues the concept is simply not ready for prime time.

The Bad: Jeff Goldsmith notes the ACO concept was born when policy makers realized that many community physicians are loosely organized around hospitals anyway. So, the thinking went, it shouldn’t be too hard to devise risk-based incentive payment mechanisms to nudge these nascent ACOs into coordinating care. Dr. Goldsmith disagrees. He says we saw this bad movie before back in the 1990s when hospitals snapped up physician practices like brides grabbing gowns at Filene’s. Payers didn’t like their closed networks, their internal controls were atrocious, they couldn’t manage risk contracting and the administrators knew about as much about running ambulatory-based clinics as Barney Frank’s dining room table. What’s more, Dr. Goldsmith charges, once they failed, single-specialty physician groups had learned to integrate, leading to local monopolies that are still present in many U.S. cities. Even though things are different ten years later, physicians are still unlikely to play nice across specialties, the proceduralists have cherry-picked the remunerative patients for their own surgi-centers and the Generation X physicians are more likely to trump kayaking over the after-hours call it would take to make ACOs a success.

Aaron McKethan and the famous Mark McClellan have a different take in separate post.

The Good: They like ACOs and think they have a decent shot at success thanks to a wider range of more sophisticated payment options such as upside risk or quality-based payments. What’s more, since ACOs are just starting out, it should be possible to experiment and to see what works best. As for Dr. Goldsmith’s criticisms, ACOs may be just the ticket to bridge the physician-physician and physician-hospital divides, there are physician leaders that can make this work and today's information technology is much better compared to the 1990s. Indeed, they point out that there are some anecdotal reports of success emerging from the ‘ACO Learning Network,’ (hm... the DMCB Googled that one but found very little), various State-level reform efforts and, last but not least, the Medicare Demos. Last but not least, if the ACOs can also figure out how to motivate their patients toward better self-care, it won’t be a rerun, it could be a hit movie.

The Better: The DMCB points out that the consolidation of specialty physician groups could actually work in favor of ACOs; rather than deal with multiple small physician groups, getting buy-in from the big cardiology group would not only be administratively simpler, they’d be less likely to feel victimized by take-it-or-leave-it contracting. What’s more, if organized correctly, ACOs are more, not less likely, to help Gen X physicians stick to their precious 35 hour work week. The DMCB likes the point about role of physician leadership and thinks there are a whole new generation of MD-MBA-MHSAs that are up to the task.

Last but not least, when it comes to patient support services, savvy ACOs will be far less likely to insist on a 100% ‘own’ strategy if they can buy a better product at lower cost. That and the experimentation mentioned above will lead to exciting new models of care that incorporate the best of HIT, decision support, registries, disease management and the medical home.

The only downside? ACOs control of the local hospital(s) and physicians could tempt them to act like a regional monopoly. While the DMCB can be suspicious about government regulation, much work remains on crafting the kind of checks and balances that assure that ACOs translate their efficiencies into competitive and not predatory pricing.

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

Medicare: A Mainframe Using Levers. Why Health Reform Is So Complicated

Drive through Hartford Connecticut on Route I-84 and you cannot miss Aetna's huge corporate headquarters. Or how about visiting Indianapolis and running into Wellpoint’s headquarters? That’s a big impressive building too. The Disease Management Care Blog had seen both of these insurance behemoths, but it can assure you that they’re pipsqueaks compared to what’s at 7500 Security Boulevard in Baltimore.

The DMCB recently visited our Centers for Medicare and Medicaid Services and was blown away by the size of the place. The buildings are not only colossal, the parking lot is probably visible from space. Two words occurred to the DMCB on its way out of the complex: mainframe and leverage.

The word mainframe, coined by former HHS Secretary Leavitt, probably doesn’t do it justice, because CMS is obviously far more, well.... organic like the DNA controlled machines in the movie District 9. Armed with a unique combination of information technology and human resources, this nation-state has a budget that exceeds most countries’ GDP. It somehow manages to move hundreds of billions of dollars around in an opaquely complex system of policies, regulations, claims processing and provider billing. It probably uses more processing power and full time equivalents than what was used to put men into space and describe Britney Spears' behavior combined.

It’s the money that also prompted the DMCB to think about one of the earliest and simplest tools known to mankind: the lever. Since CMS is a payer, its administrators understand that economic incentives can be used to incent or disincent the provision of health care services. While CMS’ influence is far more complicated, a bottom line is that its machinery is increasingly being used to manipulate provider and patient behavior.

Why is this important? Aside from the observation that big bureaucracies with imperfect levers seek to become even bigger bureaucracies with more levers:

1. The ability of so vast an enterprise to fine tune its leverage across an even more complicated U.S. health care landscape can be questioned. For example, DRG-based prospective payment reform was successful in decreasing hospital lengths of stay, leading to earlier discharges. The line that separates early from premature discharges is thin, however, especially when good discharge planning is lacking and patients get readmitted. CMS is now piloting paying for the former and increasingly not paying for the latter. Think hospitals won't respond by doing everything they can to not re-admit patients, even if that would be in their best medical interest? Can the mainframe develop a new lever to address this, or will there be even more unintended consequences? How will this work in downtown LA, in Peoria and in Boise?

2. Man lives by more than bread alone. The rich web of relationships that exist between doctors and patients are driven by far more than money, but when all you have is a lever, all the world looks like a moveable object. Leaving aside the conflict of interest in a health insurer trying to promote living wills, the DMCB doubts CMS’ paying for living will counseling will meaningfully increase their use. It’s already easy for physician to ‘bill’ CMS for patient encounters that include such discussions, but it’s not happening. The reasons for this lapse are multiple (and maybe the topic of a future posting) and most are not a function of an undersupply of shekels from CMS.

3. Which leads to the combination of mainframe reforms and new levers appearing in the health reform bills before Congress. Critics complain they are too complicated. The DMCB says visit CMS outside of Baltimore and you'll understand why.

Heart Failure: JAMA Helps Us Understand Counting Measures and Measuring What Counts. Implications for CMS and Disease Management

Most population-based care afficionados will recognize these: measuring left sided heart function if there is a diagnosis of heart failure, using angiotensin converting enzyme inhibitors (ACEi) drugs among patients with low left-sided heart function, providing complete diagnosis-specific patient discharge instructions and giving tobacco cessation counseling when needed. That's right, these are the four state-of-the-art performance measures used by Medicare and the Joint Commission (thanks to recommendations from the National Quality Forum or NQF) to assess the quality of care for recently discharged patients with chronic heart failure.

JAMA has published (Aug 19, 2007;302(7):792) an important article on lingering quality-improvement disconnect between what is measured and what matters. Titled 'Heart failure performance measures and outcomes. Real or illusory gains' Drs. Gregg Fonarow and Eric Peterson of UCLA and Duke, respectively, point to the persistent gap between the gains in all four of the areas mentioned above versus the stubborn and persistently flat U.S. heart failure 30-day rehospitalization (about 20%) and one year mortality rates (close to 40%) over the last five years.

What is going on? The authors point out that the patients themselves may have changed: better care may have led to a relatively higher percent of sicker patients being left among those who make up the statistics in the latter part of the measure periods. Alternatively, the hospitals that are reporting these statistics may simply be doing a better job of documenting care that was really being given all along. Finally, the processes themselves may have limited impact. After all, only ACEi's have been definitively shown to slow the progression of heart failure.

It turns out that CMS is already looking at measures that matter, like readmission and mortality rates. Drs. Fonarow and Peterson point out that's a step in the right direction, but also suggest that future quality metrics should be linked to 'outcomes of interest' like tobacco cessation rates (not counseling), better statistical risk adjustment, developing registries that go beyond simple administrative claims and working with independent physicians and hospitals to create better buy-in.

This has implications for CMS' recent self-congratulations over the updated results from the MCMP and PGP demonstrations. The DMCB notes the demos included additional measures that could have accounted for the improvements, such as flu shots and use of beta blockers. On the other hand, much of what CMS is up to is still heavily laden with process instead of outcome measures. What's more, how well CMS can translate their promising successes among voluntary organized systems into the mainstream of its FFS payment environment remains to be seen.

Finally, there are important implications for other stakeholders in population-based management. The physicians from UCLA and Duke should know better and think about the track record of disease management in managing heart failure, including its endorsement by the American College of Cardiology/American Heart Association (check out p. e448) and its wide use by the participants in the very demos named above. Furthermore, they need to consider the emerging role of the medical home in better coordinating care once patients get discharged. These two (and soon to be one says the DMCB) systems of care may be just the ticket that pulls together all the resources it takes to reduce re-hospitalizations and decrease mortality rates. They can credibly apply their information technology, EHRs, registries and richer data bases to measure the progress really matters.

The DMCB thinks the population-based care approaches have a much better chance of success than a bureaucracy like CMS, no matter how much they read JAMA or try to follow the author's well-intentioned recommendations.

5 Ways to Improve Health Reform, Beating Germs, Health Co-Ops and the DMCB is on Twitter

So many things going on, so little blog. So, in the perfunctory style of KevinMD:

Can the Health Reform Legislation Currently Before Congress Do An Even Better Job With Chronic Illness?

The answer is yes, but by the time the Disease Management Care Blog began to think this through, the Partnership to Fight Chronic Disease was already on the case with this highly readable report. It's only seven pages, but important reading for anyone interested in advancing population-based care. Even if health reform gets scaled back to more modest levels, these five recommendations from the PFCD are worthy of urgent consideration at both the Federal and State levels:

1. Phase in evidence-based next generation care coordination models over the next three years. Emphasis on next generation. In other words, reducing re-admissions, piloting medical homes and experimenting with medication management programs are insufficient; no wonder that the CBO is unimpressed. More fruitful areas include increasing patient adherence and reducing barriers to chronic illness treatment options.

2. Expand on pay for value. Patient adherence to treatment recommendations needs to become a key outcome measure in any assessment of quality. And while we're at it, let's move the cost of care management and disease management programs out of the numerator of the health insurers' administrative cost ratios and recognize them for what the are. There are medical costs.

3. How about preventing chronic disease? That includes the work-place and the community with the right incentives, partnerships, community-based teaming, expansion of the public health infrastructure and getting the schools involved.

4. Reduce patients' out of pocket expenses for the prevention and treatment of chronic disease. It doesn't make any sense to charge a co-pay for the many services needed to manage chronic illness. The insurance benefit can be tweeked to reduce barriers and incent patients to do the right thing. Use co-pays when you want to reduce utilization, like in the case of multiple MRIs.

5. Better health information technology that includes telehealth, expecially in physician shortage areas. This includes remote monitoring, telephony and self-management support.

It's spelled 'a-m-e-n-d-m-e-n-t-s.'

Singing Happy Birthday Beats Germs?

So said HHS Secretary Sebelius on the Sunday news show This Week when she was not only ratcheting down the Administration's cleaving to the public plan option, but helping the public steel itself against the coming H1N1 epidemic:

'Because this virus spreads quickly child to child. Schools are taking preparation to get ready with hand sanitizers and frequent hand-washing, teaching your children to wash their hands, singing "Happy Birthday" to themselves as they wash their hands is good strategy.'

Oh?

The DMCB tried to look that one up and ironically could find no comparative effectiveness research in the peer-review literature to back that assertion. It appears that the CDC's Clean Hands Save Lives! 'Happy Birthday' approach was developed as a timer. Singing the song twice through while soaping up makes the wash last at least 15-20 seconds. Fifteen seconds is at the limits of what health care workers will tolerate when it comes to hand-washing, even though going for 30 seconds reduces bacterial skin counts even further. If you decide to include this tactic in the battle against H1N1, this video is quite instructional.

Unfortunately, disease management organizations may decide that this doesn't quite meet evidence-based muster.

A Member of the U.S. House of Representatives That Doesn't Know What a Health Care Cooperative Is?

Representative Phil Gingrey (R-GA) appeared on today's MSNBC 'Hardball' to be interviewed about health reform and, now that the public option is on ropes, was asked about health insurance cooperatives. His disingenuous reply was that he didn't know what a cooperative exactly is. The DMCB hopes he just being cagey, but if he really doesn't know, he or his staff can simply 'Google' health insurance cooperative and look for the number one listing that has been used by thousands: that's right, the DMCB is at your service with an unbaised literature-based discussion of the topic.

and finally.....

The Disease Management Care Blog Is On Twitter?

Good news! Yes, even if the DMCB doesn't really understand Twitter either. Gosh darn it all, it decided it was going to find out. If you Twitter and are into Tweets, you can look for the DisMgtCareBlog and follow or whatever is done to twitterers. More to follow in this interesting journey.

Health Reform Needs Villains: Here Are Three

Egads, promoting health reform is really hard work, especially for a U.S. President. Not only do you have to become expert in health economics, contend with others’ imperfect decision-making and settle for less than what you'd prefer, your family vacations have to be cut short. Since letting others do the heavy lifting isn't working out so well, Mr. Obama has turned to old-fashioned political rhetoric and generalities to garner support. Unfortunately, even that tried and true method is wearing thin.

But there is another approach that oten works: pin the blame on a villain. Yet, unbelievably, Mr. Obama gave up using that approach when, reproached by an insurance broker at a Town Hall, he answered:

'First of all, you are absolutely right that the insurance companies, in some cases, have been constructive. So I'll give you a particular example. Aetna has been trying to work with us in dealing with some of this preexisting conditions stuff. And that's absolutely true. And there are other companies who have done the same. Now... in some cases what we've seen is also funding in opposition by some other insurance companies to any kind of reform proposals. So my intent is not to vilify insurance companies. If I was vilifying them, what we would be doing would be to say that private insurance has no place in the health care market, and some people believe that.' (bolding from the DMCB).

Talk about a political blunder. Thanks to a deal with big pharma, a separate deal with the hospitals and breaking bread with the AMA, the only villain left standing was the health insurance industry. Now that’s gone.

The Disease Management Care Blog understands that finding someone to blame is a long-standing tradition in today’s ends-justify-the-means politics of partisan elbow throwing. What's more, half of the August recess is gone and big-bang health reform is in trouble. Knowing that it’s do or die time for the Administration, the DMCB is pleased to come to its rescue with three ready-made villains that are available to kick-start the health reform debate on the President's terms:

Global Warming: Can anyone doubt that the simultaneous warming of the planet and skyrocketing health care costs are more than just a coincidence? Their co-occurrence is not only clear proof than one is causing the other but fixing one will fix the other. The DMCB is thinking both ways: not only will cooling the planet preserve precious farmland (nutritious veggies) and halt the spread of bugs (like malaria and spiders), but vice versa: controlling health care costs will reduce our carbon footprint. Think smaller hospitals using less power, less use of internal combustion engines to access physicians thanks to the greater use of blue pills in lieu of red pills, fewer pacemakers and better preservation of both legs so that folks can bicycle to the organic Farmers' Market and the next Town Hall.

The Taliban: These enigmatic bad boys are behind a host of things that are wrong with our world, so why not toss in health care. Sure, they’re half a world away and their threat to the homeland is questionable, but that hasn’t stopped a prior President from successfully rallying the country to defeat these evil-doers. Time to dust off this template and say it out loud: unless health care reform passes, the terrorists will win.

Aliens: Why not leverage our country’s fascination with nefarious space beings. Case in point? How about the eerie resemblance between the wacky Sarah Palin and the space beings of Area 51? Is her bouffant hiding an unacceptably large head cavity? Are her spectacles making her eye sockets appear smaller than they really are? Can her behavior only be explained by orders beamed by some orbiting craft? While the DMCB wonders about this, it also thinks that implying that only a not-of-this-world entity could equate death panels with advance directives will resonate with a huge swath of gullible Democrats and Republicans. This will rally naysayers faster than managed care CEOs to an insurance mandate.

Advance Directives: An Achilles Heel to Health Reform

How about former Vice Presidential candidate Sarah Palin and her 'rationing' by 'death panels?' She's on the topic thicker than the carpet in a hospital lead administrator's office.

Which is why the Disease Management Care Blog is taking this opportunity to categorically deny that it advised the Republican opposition that the topic of advance directives was an Achilles heel for health reform. It knew this early in the debate because of its experience with the Patient Self Determination Act (PSDA). This 1990 law required a number of health care entities - including HMOs - to provide information to patients about end-of-life care. This was something the DMCB knows about and, back in the day, the DMCB's managed care boss asked it to help make sure our HMO was in compliance.

The DMCB ultimately advised that we become minimally compliant. The more we wrestled with the topic, the more creepy it appeared. We felt uncomfortable with the specter of a health insurance company promoting living wills. Even though 1) the intent was honorable and 2) living wills do not equal choosing to die, we thought the appearance of a conflict of interest to the average enrollee was too risky.

The DMCB understands the current version of the House bill only authorizes payment to providers for the the work effort of discussing living wills with patients and requires the Secretary to create a measurement system to see how well this is working. However, it also knows that much of the Miami-to-Minnesota variation in health care observed by the folks in the Dartmouth Atlas really is based on data on the cost and outcomes in the time prior to death. This undoubtedly informed Congress' thinking on the subject.

Imagine what it would be like to have your homeowner's insurance company contact you on the merits of foreclosure. Or making your car insurance company send you paperwork on cash for clunkers. Or making sure beneficiary of a life insurance policy - like the DMCB spouse - brings up the topic of a living will after any life insurance upgrade.

A Summary Primer on What Americans Think About Health Reform

The Disease Management Care Blog is flummoxed by the polls and counter polls that say Americans are for and against healthcare reform. Good thing the New England Journal of Medicine has published a summary of the various polls to paint a complete picture of what the public thinks.

Generally, most Americans feel the ‘system’ is broken but are simultaneously satisfied with their own personal health care and their insurance status. However, they are also worried that the quality of their care could decline and that the cost of their insurance will go up. Accordingly, they are in broad favor of change. That includes a national health insurance program.

And the hot button issues? Requiring insurance coverage of people with preexisting conditions, taxing people with higher incomes, and requiring employers to provide insurance seem to have widespread support. Persons are opposed to taxing employer-sponsored health insurance and increasing the Federal deficit. Persons like the idea of a public plan but aren’t sure how it would function. Persons are divided about the individual mandate and increased government influence. Finally, Americans seem resigned to the likelihood of increased taxes and little change in their own health care status.

The DMCB agrees with the Journal that these results, combined with a high personal approval rating for the President, may bode well for the passage of reform bill. This is especially true if Americans come to believe this bill will result in the coverage of more Americans and lead to lower costs and higher quality. On the other hand, if Americans believe more coverage also requires higher deficits and no change in quality, support could continue to erode.

Yes, continue. The DMCB checked out another type of survery. This information market says the likelihood of passage by December '09 is just above 35%.

The Optimum Medical Home Or Whatever You Call It: Patients First With Physician Access, E-Care or Phone Care

The Disease Management Care Blog welcomes Chuck Kilo M.D. Dr. Kilo is CEO of GreenField Health, an innovative research and development focused medical group providing comprehensive primary care services. He is also executive director of The Trust for Healthcare Excellence, a not-for-profit organization promoting the collective efforts and conditions necessary for health and healthcare excellence. From 1995 to 2000, Dr. Kilo was a vice president at the Institute for Healthcare Improvement. In 1998 he started the Idealized Design for Clinical Office Practices, which helped create a design foundation for comprehensive primary care services and subsequently what has become known as the Patient-Centered Medical Home. He is on the board of directors for TransforMED and the Foundation for Medical Excellence.

When he writes about the medical home, the DMCB pays close attention.

Comprehensive primary care is about meeting patients' needs when and how they need them to be met. That means offering a spectrum of services, including traditional physician visits as well as e-care or phone care. Thanks to the increasing availability of sophisticated technology, physicians are finding that both the e-care or phone care options are completely feasible today. Since many insurers treat these services as 'non-covered,' getting payment for these services remains a key issue. My clinic provides them for a small annual fee, while other physicians charge patients a direct fee for that service,

This provides ample evidence that when primary care is robust, patients will see it as the preferred location of care and will be willing to personally pay for it. In our experience, patients not only feel very comfortable with a menu of face-to-face visits, e-visits and phone care, but they welcome it. Different people want different levels of these services and our job - no matter what you call it, including a 'medical home, chronic care model or patient centeredness - is to meet those needs.

I advise our primary care colleagues to be less focused on total number of face-to-face visits as a measure of productivity. Rather, physicians need to address the total cost of patient care. If we need to interact with patients more frequently as a mechanism of reducing reliance on more expensive locations of care (such as ERs, urgent care clinics and specialists), then that is appropriate. Even though we obviously don't have direct control over all health care spending, there is good evidence that it can be managed by building strong, trust-based relationships, sending clear messages to patients about how we want and expect them to interact with the healthcare system and making ourselves very available using the technologies described above. What's more, patients can partner with their physicians to financially support this.

Most of the current definitions of "medical homes" have fallen short of this idea. They are limited by a financing system that is focused on the cost or volume of e-care and phone care, not its cost saving potential or patient interest. Fix this and the actual definition of the medical home will fade in importance and health care costs may actually improve.

The Patient-Centered Medical Home & the Accountable Care Organization: Two Sides of the Coin

The Disease Management Care Blog is happy to welcome Paul Grundy M.D. Dr. Grundy is President of the Patient-Centered Primary Care Collaborative (PCPCC) and IBM’s Director of Healthcare, Technology and Strategic Initiatives for IBM Global Wellbeing Services and Health Benefits.

by Paul Grundy

Increasing access to health care for all Americans is necessary, but not enough for meaningful health reform in this country. We must also re-design our delivery system to achieve accessible, high quality, affordable health care.

Two complementary models of delivery system re-design hold great promise for achieving these goals: the Patient-Centered Medical Home (PCMH) and the Accountable Care Organization (ACO). The PCMH emphasizes primary care that is patient-centered and delivered in practice settings with 21st century infrastructure using evidence-based processes.

The ACO is a larger provider organization that is willing to provide or manage the full continuum of care and be accountable for the overall costs and quality of care for their population. ACOs provide an organizational structure to allow providers to contract with payers to align financial incentives with the goal of improving clinical performance and slowing the growth in spending.

There's a debate about the relationship between PCMH and ACO, and how the two can co-exist. It is my point of view as the president of the Patient Centered Primary Care Collaborative that PCMH and ACO concepts are in effect a different view of the same solution. One does not work without the other. An ACO will not work without a foundation of primary care, and high performing primary care is critical to the success of an ACO.

The PCMH is the view from the doctor/patient relationship, and the ACO is the view from those who pay the bill. The PCMH is the "home," and the ACO is the "house" with supporting plumbing and wiring. The PCMH is what the patient sees, it is their home, centered on their needs, where their care is coordinated and integrated the players are on their team.

Not only are they complementary and mutually-reinforcing: they are part of the same model.

And a PCMH (as we have always said from day one) is only the primary care foundation to build a healthcare system of value. You can, if you wish, call that healthcare system of value an ACO, similar to what exists in Denmark.

When I communicate to my employees, I talk about a PCMH -- access, relationship, a team, safety, and tools like email that are available to them in a place where the doctor and the patients team know their name. When I talk to my CFO, I talk about ACO -- accountable care, a structure that supports the adult supervision we are looking for.

So how does a small practice become and PCMH/ACO? Well, very easily. They need the Internet with the right tools, like a registry or a portal. This can all be done virtually today. The primary care doctor has the relationship with the patient, plus he has is the quarterback, the point where care is integrated and coordinated at the relationship level.


From the view of the patient, all his providers are part of the PCMH team. However, from my point of view, as the payer of the bills, they are all part of an PCMH/ACO if this all works in the way that makes any sense.

Primary care organizations around the country have agreed that the future of primary care is agreed on as the joint principles of the PCMH. But equally important is the fact that an overwhelming coalition of purchasers and payers, and the exemplary integrated delivery systems (Kaiser, Geisinger and others) that recognize the value of primary care in the context of larger organizational structures, have also endorsed the PCMH as an important political paradigm and key element of delivery system reform.

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

Another Reason Why the Health Reform Town Halls Are Not Failing to Disappoint

The Fat Lady points out that the historical and religious tension between population based care versus one-on-one care may be one ingredient in the health reform Town Hall brouhahas.

Recall it was the ‘Old’ Testament that proscribed certain dietary practices and contact with persons with communicable disease. While the basis of these laws are myriad and include public health as well as holiness, they strike the Disease Management Care Blog as being among the earliest examples of population based care: the care shown by God for a chosen people blessed by a special covenant.

Contrast this community-based hygiene with the 'New' Covenant of Jesus’ ministry in the New Testament. While He certainly personally followed Jewish law, His controversial appeal to his past and present followers seems to have less to do with the collective fate of peoples and more to do with the personal salvation of individuals. To the DMCB’s knowledge, Jesus didn’t come up with a means to diminish the prevalence of leprosy, schizophrenia, blindness or paralytic syndromes. Instead, He cured individuals one at a time. How inefficient. And how wonderful.

Say what you like about the role of the Bible in modern society, the Fat Lady thinks it continues to give great insight into today’s human condition. The insight here is that when it comes to illness, persons don’t want to have the likelihood of future complications from their chronic conditions to be diminished, they want to be cured. That was the health care gold standard uncovered approximately 2000 years ago - and it remains with us today.

Which may be part of the problem underlying the August health reform doldrums and the Town Halls discussed in yesterday’s DMCB posting. After being thoroughly pressured cooked by the dense Boston-based academosphere of D.C. health policy, our elected representatives have emerged from the Capital building spouting opaquely dense terms like ‘access’ and ‘primary care provider’ and ‘bending the curve’ and “preventative.’ They want the public to buy into quality assurance, comparative effectiveness and actuarial predictions.

The Fat Lady says good luck.

Part of the Town Hall dynamic may certainly include political grandstanding, unreasonableness, partisanship, manipulation and public inattention. However, the DMCB also thinks many persons want to hear how the electronic health record, how comparative effectiveness research, how the public plan option, red pills-blue pills, better attention to living wills and subsidies for health insurance will help cure people. Anything less just won’t do, especially if it’s going to cost $1,000,000,000,000.

As an aside, even the Fat Lady understands the difference between miracles and medicine. That being said, one allure of today’s medical-industrial complex is its promise of miraculously ‘curing’ diseases like cancer, heart disease and obesity. In fact, she wonders if the continuing business success of the disease management industry is due to its recognition of the U.S. health care system’s core appeal. They quickly changed course on marketing themselves as the best approach to chronic conditions in the 1990s to re-emphasizing their role as a supportive care strategy in the 2000s.

Advice on How to Run a Town Hall from the Disease Management Care Blog

The Disease Management Care Blog sympathizes with the AARP staffers and volunteers. Been there done that.

It recalls an incident when it was in student government in medical school decades ago. Our Council worked closely with the Aministration on plans to establish a local chapter of a national honor society. Once the details were all wrapped up, the DMCB stood before its class in a town hall style meeting to present the plan and get some feedback on what we thought was a no-brainer proposal. That's when the DMCB painfully learned in a large lecture hall with over 100 angry medical students that smart persons have a remarkable ability to use the same facts to come up with different conclusions. That honor society chapter did not see the light of day while the Class of 1981 was still paying tuition.

The DMCB used this experience much later in its career in subsequent meetings with hostile physicians and grumpy HMO enrollees. Even though the DMCB's medical school and professional experience was Little League compared to these Town Hall meetings, this is a blog and bloggers are in the business of offering up unsolicited advice.

So, thinking of being a town haller? Want to use an open forum to convince a group that pending legislation or some other initiative that is going to change health care is a good idea? Ignore these DMCB insights at your peril:

1) It's too easy to have your decision-making succumb to an information bubble that's insulated from important constituencies with different perspectives. The self reinforcing feedback from like minded people can be extremely seductive. Knowing this is your weakness is half the battle.

2) It's also too easy to confuse 'opposition' with an 'oppositional disorder' or conclude this is the product of some evil conspiracy. Yes, the behaviors are uncooperative, defiant, negativistic, irritable, and annoying but it's a Town Hall and it's everyone's job to listen. That includes you.

3) Deep seated disagreement from a room full of people should signal that something is seriously wrong. Makes no difference if they're a numerical minority, you still need to pause and think. It may be that the idea is wrong. It may be your underlying assumptions are wrong. It may be the message is unclear. It may be that there is misinformation. It may be that your idea will be voted down. All those possibilities need to be addressed and ruled out before concluding that this is just a bunch who 'wish to make trouble' (the quote is at the 2 minute mark).

The DMCB has some ideas on why these folks are disagreeing. More on that tomorrow.

What 'Cash for Clunkers' Teaches Us About Health Club Sponsorship for Wellness by Employers or Government

The Disease Management Care Blog, like Casablanca's Captain Renault, was shocked, SHOCKED (not) to hear on NPR's All Things Considered that there are some economists who doubt whether the United States' 'cash for clunkers' program is a wise investment. These must be the same guys that told the DMCB years back that insurer or employer-based incentives for fitness club memberships was also a silly idea.

How can this nattering naysaying be possible given the widespread belief in the promotion of healthier lifestyles? What about the luster of financial incentives that can transform indolence to healthiness? What gives these self-appointed oracles an insight that's been missed by almost a third of the U.S. corporate employers that financially sponsor club memberships?

The arguments are simple and convincing. While financially supporting fitness clubs is associated with superficially gratifying uptakes in membership, there are two problems:

1) many of the persons qualifying for financial support would probably join a fitness club anyway; all you're doing is using precious premium to unnecessarily subsidize it. This was the same argument on today's NPR broadcast: there are probably many car owners with an old set of wheels that are destined for a trade-in anyway. Cash for clunkers merely helps make it happen sooner at an additional cost of up to $4500 to the U.S. Treasury, er, make that to us taxpayers.

2) many of the persons qualifying for financial support may not necessarily need to join a fitness club; the joiners are far less likely to find exercise a distasteful chore and are already active. In the meantime, the persons who could really use some exercise are unlikely to be motivated by any financial incentive. The same may be true in the 'clunkers' program: the cars being destroyed arguably still have some value, and many have acceptable if not optimal mileage. In the meantime, many other persons will have plenty of reasons - like not taking on the debt of new car payments - to keep enough really bad clunkers on the road for years to come, not help Detroit's doldrums and not reduce their carbon footprint.

The DMCB did a literature search to disprove either of these arguments. It was unable to find any.

And then there is the inevitable gaming that can go on. Persons may 'join' a fitness club, not go and keep the money, requiring the insurer to impose requirements with or without monitoring to make sure the letter and spirit of the initiative is being met. That may be one key difference vis-à-vis a Federally-run program: the 'clunkers' program seems to be quite game-able.

Cash for clunkers... meet cash for slackers.

Welcome to the August Recess Edition of Health Wonk Review

Welcome to the August Recess edition of Health Wonk Review. The Disease Management Care Blog is happy to be your tour guide to this bloggy thinking-persons’ exercise in participatory democracy.

Ha! ‘Recess’ you say? The tens of thousands of DMCB readers know this is only a faux time-out. Citizens, provocateurs, experts, naysayers, legislators, personalities and progressives are all jostling to shape health reform. With all this tumult, there is no way us bloggers aren't going to get even more.... wonky. Indeed, given the number of HWR submissions, the health policy blogs are very engaged. While each posting is individually convincing, this lengthy HWR demonstrates the thorny mix of opinions and options facing our elected representatives.

Is there a middle way of common sense mainstream solutions in all of this? It is up to you, the HWR readers, to decide.

Enter the Health Affairs blog, which is on health reform like hospital administrators are on new MRI machines. There’s a report describing a roundtable discussion about how some showcase communities lowered health care costs (ingredients included enlightened data management and a not-for-profit mission), a Uwe Reinhardt post on using relative value units (RVUs) to transparently level the pricing of health care services across multiple disparate settings and Paul Ginsberg’s preference for a Maryland-style rate setting Board that regulates prices.

Over in the real world, however, a physician office visit may cost a $100. A CAT scan may cost a $1000. Who can blame the physicians for wanting to own the CAT scanner and snagging all $1,100? Well, Tom Emswiler of the New Health Dialog Blog has read the Washington Post story about the allegedly renegade urologists who had the temerity to not read Health Affairs and figured out how to get that $1100 over and over and over again. Tom is not only willing to assign blame but points out there are ways for insurers to collectively fight back, including bundled payments or developing a radiology-specific sustainable growth rate (SGR) formula.

While brawls on divvying up the revenue continue, the Medicaid community is busy divvying up the costs. At the Health Access Blog, Anthony Wright dissects a recent letter from Governor Schwarzenegger addressed to members of Congress about health reform. Go there to get great insight into the tug of war between the States and the Feds over paying for and controlling Medicaid. While the States’ Governors are suffering from sticker shock, Anthony asks if asking States to meet a Medicaid mandate is all that dissimilar from an insurance mandate for individuals. The DMCB thinks this may be one of the few areas where reform doubters would actually agree with Anthony.

Like Bob Vineyard of InsureBlog, who notes the Federal funding for Medicaid has been on chronic ‘life support,’ and that State Medicaid programs have had to resort to onerous methods of funding like putting liens on nursing home resident’s estates. He wonders where any additional money is going to come from, unless the use of liens is expanded whenever any beneficiary uses any Medicaid benefit.

It’s only money though. Yet, the only group working harder than the health insurers to get more of it are the State and Federal governments. Merrill Goozner of GoozNews Blog provides an insightful discussion on the pros and pros of intelligently taxing our way to broad health insurance coverage. He finds lots of money in options such as taxing high end health insurance plans and/or increasing the Medicare payroll tax with a 1% increase and/or taxing sacrosanct ‘non-wage income’ that is disproportionately earned by high-income citizens.

Brady Augustine seconds that latter motion at the refurbished MedicaidFirstAid blog. While he worries about the inverse relationship between overall tax revenue and higher taxes on capital gains, he believes it can be fashioned so that the impact in minimized. In fact, Brady’s got a detailed proposal: a 1.45% percent employee contribution on non-wage income, which would leave the rate of 16.45% still significantly less than the rate that existed during our best two periods of capital gains tax revenue.

Speaking of money, does exempting small businesses, defined as having a payroll of less than $500,000, from an employer mandate makes sense? Simple question and Jason Shafrin of Healthcare Economist has a characteristically simple answer: yes it does. After all, if he had a complicated answer, he’d be an actuary. Jason cuts to the chase by noting that small employers have a higher cost per employee and are at risk, without the exemption, of being at a huge competitive disadvantage versus the big companies. Beware of unintended consequences, however, since a company with a payroll of $499,999.99 or less would have a significant incentive to put an indefinite freeze on hiring, putting the kibosh on the small business engine that accounts for a lot of employment in the United States.

Would small employers and the rest of us be hurt by the monopsony of large regional insurers? The Incidental Economist isn’t so sure about that because there is plenty of literature that also isn’t too sure about this. TIE does a great job of summarizing that literature and examining the underlying issues. He also provocatively suggests that provider consolidation is more of a threat when it comes to the optimal pricing of health care services. Great links.

Louise of the Colorado Health Insurance Insider reminds us that individuals sure are being hurt by not being able to get a tax break when they purchase insurance outside the employer market. She hopes there will be plenty of changes in the coming decade. So does the DMCB.

Naomi Freundlich of Maggie Mahar’s HealthBeatBlog argues that legal (repeat legal, i.e., the kind with green cards) immigrants should be included in any health reform that includes covering the uninsured. It seems Massachusetts’ health reform journey is veering to the right on this issue thanks to overblown anecdotes from penny-wise pound-foolish conservative reactionaries. Naomi reminds them that legal immigrants not only pay their fair share of taxes, they’re a low insurance risk. What’s more, if they use health care services that aren’t covered, we’re all going to end up paying for it anyway. Except for the politics, Ms. Freundlich says this is a no-brainer.

Alas, ‘except for the politics’ sighs the DMCB. On the right, there’s ‘‘JD’s’’ take on a recent contentious town hall on health reform involving HHS Secretary Sebelius and Senator Arlen Specter (D-PA). JD appears to share many a Philadelphian’s skepticism about this health reform thingy. Maybe they’re confused by their Senator’s recent switch to the Democratic Party. Or maybe it’s because London’s Big Ben was switched for Philly’s City Hall. On the left, folks like the Health Plans Plus blog are not confused. The politics are easy. Mix facts. Bake. Serve up single payer system to JD’s Philly curmudgeons and they’ll be sure to change their mind and write to their Congressman.

No wait, maybe not if they watch TV. An ad is being run that features the Canadian woman who claims she would have been dead thanks to a ‘government run’ health care system. You can read all about Ms. Shona Holmes at Sam Solomon’s Canadian Medicine. See if you agree that her story and its use by partisan foes to demonize the Canadian health system may be enough to upend President Obama’s health reform efforts. In the meantime, the DMCB wonders why the Holmes ad includes a CAT scan of the abdomen, unless she was being cared for by American urologists who should read Health Affairs.

Joseph Paduda of Managed Care Matters has the most interesting take on the politics of the anti-reformists. It appears they are well organized and well funded by the usual cast of suspects. That must mean that they are really terrified that health reform could happen this time. Their horror is cause for your celebration if you want to see those health insurers and medical device manufacturers get their comeuppance.

Maybe it isn’t money or being mentioned by the media, reported in journals or included in some politician’s speech. Maybe it’s a matter of local grit, determination and pioneering by locals that have decided enough is enough. You’ll see what Joanne Kenen means by this in her post back at the New Health Dialogue Blog that describes creating a picture of health(y) for the nation’s capital.

But Wright on Health says sorry, it is the money. He has done some nifty analytics using public domain data and found there has been an alarming increase in the percent of funds devoted to lobbying by the usual physician, hospital, pharmaceutical and insurer groups and that there are jumps in the money being thrown about whenever major health care legislation has a chance of passage. What seems to inhibit the lobbying is when Congress and the Administration are tied up in partisan knots. The DMCB wonders if this may be a good reason to look forward to the 2010 elections. Check out Brad Wright’s excellent posting here and encourage him to keep digging into the data.

Or maybe it’s humor we need to get everyone to compromise: Good thing Mad Kane is the blogger, who is for Repubs a sharp flogger, no mercy she gives, with limericks she ribs, opponents are poetry fodder. What’s more, the DMCB is aloof, always wanting to see enough proof.... that it isn’t belief, that we need for relief, or the treasury will certainly go ‘poof!’

But seriously, to make things even more complex, us wonkers are concerned about far more than just revenue, costs, tax policy or politics. We care about other stuff.

Like employers gone bad. Really bad. Case in point is the story of Chong-mun Chae at Lynch Ryan’s Workers Comp Insider. Mr Chae has been convicted of taking double advantage of the asbestos abatement business by using cheap untrained and now poisoned labor and not paying any workers’ compensation insurance. The DMCB wonders once again about the effectiveness of our regulatory bureaucracy.

Like information technology. David Kibbe and Brian Klepper are very excited about the Office of the National Coordinator's Health Information Technology Policy Committee’s recent recommendations on how to certify components of the electronic health record. Not only do David and Brian believe the recommendations are common sensical, but stand in stark contrast to the self-serving features promoted by the old guard legacy EHR vendors. Read it and see if you agree that this latest effort at EHR functionality deserves terms like ‘monumental,’ ‘bold’ and ‘forward thinking.’ You can check it out here in the granddaddy of blogs, The Health Care Blog (THCB).

Like information technology Part 2. Here’s a new concept for you to quote the next time there’s an HIT-related meeting: the “Penguin Problem,” or how the inertia of individuals’ self interests can inhibit a perfectly rational collective action, like diving in after some tasty small fish or adopting electronic health records. Vince Kuraitis of the e-CareManagement Blog is also very optimistic that the Fed’s recent actions on defining the “meaningful use” of EHRs and certification criteria EHRs will finally prompt everyone to jump in. The DMCB is right behind Vince on this one. But, if they’re not jumping in, there is a formula with lots of options for at least getting them engaged in a roll-out, says Elyse who muses about the topic over at Anticlue.

Like information technology Part 3. Think personal health records by definition enable patients to be virtually mobile health care information consumer/managers? Think again, because your personal bank’s willingness to help you bank on-line for free is really a plot to prevent you from transferring your account elsewhere by having to start over again. Ken Terry over at BNET Healthcare points out that employers are wise to this gamesmanship and are working with a few enlightened insurers/health systems to overcome this.

Like the advantages of automation. For example, we can automate toll booths and paying for groceries. Heck, some evil-doers have even figured out how to automate the submission of blog spam to the Health Wonk Review website. Why not automate the dispensing of medication to patients? Less room for error when a machine does it says Carla Corkern of Talyst, who is interviewed by David Williams of the Health Business Blog.

Like the use of social media and healthcare communications. David Harlow of the HealthBlawg provides a detailed list of considerations that need to be addressed by medical organizations that want to jump into this field. In the spirit of our age, go ahead, David says Yes We Can and, what’s more, the lawyers won’t always say no you can't.

And most importantly, by conflicts of interest. It appears even us bloggers can be ensnared by being inattentive to not-for-profit organizations’ corporate sponsors. Blogs are edgy, provocative, trendy and widely read, which is making our ability to drive web traffic attractive prey to marketing firms. Be afraid, says Roy Poses of the Health Care Renewal Blog, be very afraid.

Because if we’re not afraid, we could end up being used like some unbelievably tone deaf physicians. These are highly paid willing participants in the pharmaceutical industry’s questionable marketing campaigns, who have been lambasted in the national press and scrutinized by U.S. Senators. Their response? Form an organization that promotes physician participation in the pharmaceutical industry’s marketing campaigns. You can read about this medical anti-universe here in Tinker Ready’s Boston Health News Blog.

OK. You’ve read all this HWR stuff. You’re smarter for it. Now look at this video and figure out what to do next.