Go To the Annual PCPCC Annual Summit. Even If You Can't, Here Are Some Links So You Can Learn More About the Patient Centered Medical Home (PCMH)

Want to be an expert on the latest news about the Patient Centered Medical Home? Well, in addition to regularly reading the Disease Management Care Blog, you could be the U.S. President or one of his health care advisors and simply ask the folks from the Patient-Centered Primary Care Collaborative (PCPCC) to stop by and provide their insights. Or better yet, you could plan on going to the October 22 PCPCC Annual Summit: All Eyes On the PCMH that will be at the Washington Convention Center from 8:00 - 4:30. You can register here. The Agenda is packed with informative experts, Washington DC is a beautiful city in the Fall and what's more, you can say hi to the DMCB, which will be sitting in the back and taking notes.

This is an exciting time for the PCMH. News from the many commercial insurer pilots should start arriving soon. What's more, CMS's Medical Home Demo is going to be getting underway in the not too distant future. Last but not least, PCMH pilots are highly likely to survive intact in the current versions health reform legislation.

Even if you're not a Presidential advisor and cannot make it to D.C. three weeks from now, thanks to the DMCB and the PCPCC, you now have access to their list of peer reviewed publications or analyses, which are below with links to what you'll need and more. Thanks to keeping the DMCB on your reading list, you can now access and review the same established evidence base that was shared with the White House.

The folks at PCPCC were kind to provide these to the DMCB - which is greatly appreciated.....

Group Health Cooperative of Puget Sound - Reid R, Fishman P, Yu O et al: A patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71-e87. Reviewed previously by the DMCB, this twelve month study comparing a PCMH clinic with control clinics found an additional cost of $16 per patient per year was associated with offsetting cost reductions, with the net result being no overall increase in total costs with a reduction in inpatient and emergency room costs with climbs in HEDIS-defined quality. (Link)

Community Care of North Carolina - Steiner, B.D et al: Community Care of North Carolina: Improving care through community health networks. Ann Fam Med 2008;6:361-367. Community Care of North Carolina found that circuit-riding nurses and compensating primary care offices for PCMH-based care coordination was associated with savings totalling $135 million for TANF-linked populations and $400 million for the aged, blind and disabled population. Likewise examined by the DMCB here, here, and here. (Link)

Health Partners uses "BestCare" practices to improve care and outcomes, reduce costs. It must be true if the Institute for Healthcare Improvement says Health Partner's medical homes had a 39% decrease in emergency room visits, a 24% decrease in admissions and a 20% decrease in inpatient costs for behavioral health patients. Diabetes care measures increased and clinic waiting times decreased. (Link)

Geisinger Health System and ProvenHealth Navigator. As far as the DMCB is aware, it's not been published in any formal or peer review setting, but at a recent DMAA Forum 09 meeting, their powerpoint quoted a 7% reduction in overall costs, a 25% reduction in readmissions, a 15% reduction in admissions accompanied by quality increases in diabetes, coronary artery disease, preventive care and member satisfaction. It hears a publication is in the works somewhere. (Link)

Johns Hopkins Guided Care PCMH Model - Leff B, Reider L, Frick K et al: Guided care and the cost of complex health care: a preliminary report. Am J Managed Care 2009; 15:555-559. The folks at Hopkins call this version of the PCMH 'Guided Care.' Primary care clinics owned by Hopkins and Kaiser had 'pods' consisting of 2-5 primary care physicians and 7 were randomized to an intervention consisting of a care manager nurse while 7 others served as controls. Based on 8 months of data involving 485 patients in the PCMH pods versus the 415 patients in the usual care pods, the intervention patients had a 24% reduction in total hospital inpatient days and a 15% fewer ER visits. Based on a Medicare fee schedule, that's an annual savings of $1364 per patient. (Link)

Genesee Health Plan. In another report from the Institute for Healthcare Improvement, the Genesys Health System started the Genesee Health Plan to serve 25,000 previously uninsured adults in Michigan. The insurance benefit emphasized the PCMH and, compared to competing health plans, Genesee had a 10% to 25% lower cost, declining ER utilization and increased enrollee healthy behaviors. (Link)

Colorado Medical Home. The State's Medicaid program enrolled 88,000 Medicaid and 62,000 CHP+ children in medical homes as of March 1, 2009. Since then, ER visits and hospitalizations were lower with annual costs being $785 for PCMH children compared with $1,000 for children being cared for outside of a PCMH. In an evaluation specifically examining children in Denver with chronic conditions, PCMH children had lower median costs ($2,275) than those not enrolled in a PCMH practice ($3,404). More children also had well child visits. (Link)

Intermountain Healthcare Medical Group Care Management Plus PCMH Model - Dorr DA, Wilcox AB, Brunker CP, et al: The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008;56(12):2195-202. Intermountain instituted a multidisease care management program called 'Care Management Plus' relying on dedicated nurses in seven clinics. Their outcomes were compared to those in six control clinics. In the 1144 intervention patients versus the 2,288 control patients, mortality was lower at 1 year (6.2%, vs 10.6% for controls) and at 2 years (12.9% vs 18.2%). The hospitalization rate was lower (21.0%, vs. 24.2% for controls) at 1 year and substantially more so at the 2-year follow-up. Hypothesized savings from decreased hospitalizations was $17,384 to $70,349, but access to the abstract and not the full article doesn't allow the DMCB to compare the savings to the costs of the program. (Link)

Rosenthal, T. C., M. E. Horwitz, et al: Medicaid Primary Care Services in New York State: Partial Capitation vs Full Capitation. J Fam Practice 1996;42(4):362-368. According to a write up by the folks in the PCPCC, during the 1990s, Erie County in New York State implemented a primary care medical home program for dual eligible Medicaid-Medicare beneficiaries. The abstract itself says claims data was used by the New York State Department of Social Services to compare the costs for matched cohorts enrolled in partial capitation programs, in which the primary care physician is paid an ambulatory primary care monthly fee for its assigned Medicaid recipients. This partial capitation program worked as well as full capitation and saved the state 38% compared with a matched control group enrolled in traditional, fee-for-service settings. The PCPCC also says quality measures and patient satisfaction for partial and full capitation programs were equivalent and there were savings of $1 million for every 1000 enrollees (No Link Available at the Journal of Family Practice but a reproduced abstract is here).

Geriatric Resources for Assessment and Care of Elders (GRACE) Model - Counsell SR, Callahan CM, Clark DO, et al: Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;12;298(22):2623-33. Researchers at the Indiana University Center for Aging Research and Regenstrief recruited medically indigent outpatients aged more than 65 years from six community-based health centers affiliated with Wishard Health Services, a university-affiliated urban health care system in Indianapolis, Indiana, between January 2002 and August 2004. Over 900 patients were randomly assigned to usual care versus the GRACE intervention. This involved an advanced practice nurse and social worker who worked in close collaboration with the primary care physician and a geriatrician-led geriatrics interdisciplinary team. The cumulative 2-year ED visit rate per 1000 was statistically significantly lower in the intervention group (1445 vs 1748), but hospital admission rates were not significantly different. However, in a predefined group at high risk of hospitalization (comprising 112 GRACE and 114 usual-care patients), ED visit and hospital admission rates were lower for the GRACE patients in the second year (848 vs. 1314 and 396 vs. 705, respectively). (Link)

Finally: Your Tax Dollars At Work for Something Worthwhile in Health Information Technology: The VA and Its CCR Registry

Suppose the Disease Management Care Blog asked you for a summary about the number and types of documents and emails excluding PDFs that are on your computer’s hard drive containing the words ‘diabetes’ or ‘hypertension’ that were created or modified on or after January 2, 2008 with a font size of 10 or greater? The DMCB guesses finding out would be a struggle for most of us. Yet, if you use that same computer open any individual file meeting any of the attributes described above, you’d be able to marshall state of the art information technology to manage all of the features of that file and more.

Welcome to the contrast between an electronic health record (EHR) and a registry. The EHR is configured to help the user manage the patient’s dedicated file. In a registry, the user is interested in managing all the patients meeting predefined criteria. The former is all about individuals while the latter is all about populations. Just because your PC’s operating system enables you to handle that single item open your desk top doesn’t necessarily mean you’ll be able to get a detailed snapshot of a piece of your hard drive containing all the files of interest.

Which is, until you think about it, very counterintuitive, especially to us clinicians. You’d think that in this era of terabytes, servers, and Googling, it shouldn’t be so hard to find out how many patients with chronic hepatitis C infection who live in Illinois and have Blue Cross Blue Shield insurance and received peginterferon between the ages of 45 and 55 years had a relapse of their disease within one year. You'd think that using that informaion to assess the quality of care among physicians and hospitals should be a few clicks away. Alas, just like your PC's operating system, it ain’t so easy.

But it is not impossible. Which is why anyone interested in learning more about the topic should check out the article by Lisa Buckus et al in an August 28 Journal of the American Medical Informatics Association (JAMIA) ‘PrePrint’ titled ‘Clinical Case Registries: Simultaneous Local and National Disease Registries for Population Quality Management.’ It describes the implementation of theVeteran Administration’s (VA) Clinical Case Registries (CCR) that was developed to stand alongside its much admired VistA EHR.

Interesting takeaways:

This is not easy. The software took five years and it’s still being expanded, not only because new data bases are being added but because VistA is also evolving. A change in VistA means a change in CCR.

The description of CCR involved a jargony informaticisms, but to the DMCB it seems that the CCR “crawls’ the VistA system much like Google web crawler bots.

CCR is updated nationally every 24 hours. There are tens of thousands of patient records.

Big emphasis on privacy.

While CCR reports and makes research possible on a national basis, it also enables local users to extract local registry information. ‘Canned’ reports are available but users have the ability to customize. They’re being exploited: over 2000 local reports are generated each month.

National level summary reports – good or bad – will be available on the internet.

While the identification of candidate patients for placement in the various registries by automated programming has high sensitivity and specificity, a live and specially trained person at 128 VA facilities is necessary to manually review and confirm some patients’ information prior to inclusion in any registry.

Positive or negative labs that determine the presence or absence of a disease state is read off a free text field, not via any direct data interfaces. The DMCB has heard that this is not usual: clinical laboratories are not formatting their data in ways that can be used at a population-based level. It suspects the same is true for imaging studies, like echocardiography, cardiac catheterizations and CAT/MRI scans.

A telling anecdote: a new drug-drug interaction was announced by the FDA and the VA was able to use CCR to quickly identify the patients at risk.

The DMCB rates this as a must read. So much of what we as a nation want to do in assessment of quality, cost effectiveness, comparative effectiveness research, leveraging information technology will be dependent on the creation of useful registries. The lessons from the VA in this article are important for physicians, policy makers and anyone interested in population-based health improvement.

The Imperfect Expert Class: Another Risk of Health Care Reform

The Disease Management Care Blog has seen these kinds of folks in action. Astonishingly bright, widely published, exquisitely educated and supremely confident, they never fail to dazzle and amaze those of us with lesser pedigree. Sure, you can try parrying with a quote from an obscure study or last month’s conference, but your pitiful verbal swordsmanship will be bested. You are an amateur. These folks are professionals, hardened by years of having yokels like you for breakfast.

So when Rhodes Scolar and Harvard Law graduate Nancy-Ann Min DeParle, Director of the White House Office of Health Reform speaks, it’s only natural we shush and listen respectfully. And when they and their colleagues are rolled out by the Administration armed by charts and wotnot, even U.S. Senators will listen.

The Disease Management Care Blog admits to also being repeatedly smitten by smart-person-in-the-room eye over its 25 year health care career. Yet, once The Über Expert recedes from view, the DMCB recalls similar mesmerizings often being dashed by cold hard reality. RBRVS, HMOs, predictions of physician oversupply, physician risk contracting, certificate of need and physician profiling are all examples of failed past divinations by brainiacs armed with faux special insights about just how to manipulate the levers necessary to create health care wonderfulness.

Sure, you say, the DMCB is being a cynical weenie-wagging curmudgeon. For the record, the DMCB denies being cynical, but can't help it that its experience has taught it to doubt the experts. Despite their serene assuredness, their prognostications on how the latest suite of reform ideas are likely to play out in the coming years may be wrong. Really wrong.

But don’t take this blog’s word for it, check out the this interesting article by the also vastly intelligent Henry Aaron and Paul Ginsberg.

Two telling quotes:

‘Exactly why Americans spend so much on health care is not well understood’

and

‘The unsurprising verdict is that several factors contribute to excessive spending and to unduly rapid growth, but that devising ways to correct both problems in ways that promote welfare is politically challenging and technically difficult.’

It’s remarkable because the authors, whether they realize it or not, point out how little is known about the underlying basis of the United States’ high health care costs. We really don’t know if high technology is necessarily accompanied by inefficiency or if our market is targeting dollars toward the treatment of disability instead of death avoidance. We don’t understand the impact of our unique complex mix of competition and regulation or the lessons from areas of medicine where increased spending does result in higher quality. If we don't know the basis of our problems, how confident can we be that the solutions out there are really.....solutions?

The DMCB understands modesty, temperance and hedging is unlikely to score points in the current political climate. But it also knows that one understated risk of health care reform is the unforeseen consequences of good ideas developed by a repeatedly imperfect expert class.

A Worse Case Scenario For Deficit Spending - Even If It's Worthwhile

The latest issue of The Economist has a telling article about Britain's need to downsize to a ' leaner and fitter state.' According to this 'Briefing,' persistent deficit spending, lower tax receipts, and 'permanent loss of (economic) capacity means something has got to give. The first sign would be a downgrade by the rating agencies, in turn forcing Britain's borrowing to yield higher interest rates. Since there is little appetite among elected officials to make the leaner and fitter hard choices vs. continuing the welfare state, a tempting way out will be to permit inflation to melt the deficit away. Unfortunately, that'll also melt away the value of everything else, like pensions and savings - and interest rates will only zoom higher.

This may sound familiar to those of us in the U.S., where we have also opened up breathtaking deficit spending, even if it is in the name of the public good. While extreme times call for extreme measures, the amount of debt we're assuming to support our lifestyle is truly remarkable.

And the latest guest to the U.S.' deficit spending banquet? While health care reform is being touted as 'deficit neutral' i.e., not adding to the deficit thanks to a combination of cost controls and taxes, the Disease Management Care Blog isn't too sure about that. While the President's promise sounds good, the DMCB thinks the critics have two good points:

1. Past is Prologue: Washington D.C.'s track record in controlling costs in its Federal healthcare programs to date have been insufficient. The rhetoric around fraud and abuse, electronic health records, comparative effectiveness research and prevention may have some basis in reality, but is any of that really up to the task of countering our appetite for technology and the aging of the Boomers?

2. The Healthcare Bubble: Bubbles occur when too much money is chasing a product or service. The high tech stock boom was an example of irrational exuberance in the private markets, while the housing bubble was at least partially driven by Uncle Sam's policies promoting home ownership. When millions get a relatively complete insurance benefit that continues to insulate them from the real cost of healthcare, they'll use it. Combined with our collective inability to restrain costs, the injection of new money will throw gas on the fire.

So where will this lead? You may think it's only funny money, other people's money or justified money, but the expanding deficit is going to have to be fixed one way or another. While we're pondering this, it may make sense to think long and hard about the worse case scenario. Marc Faber of the widely read Gloom Doom and Boom Report connects the numerous spending dots out to its most wicked end. In this video, he predicts either a) standards of living will precipitiously decline once the current stimulus runs out of steam (around 2018 plus or minus) or b) governments will turn to war as a means of hitting the 'reset' button the financial system, or c) both.

Likely? The DMCB doesn't know. Worth thinking about? Definitely.

Telemedicine: A Good Trojan Horse?

There is no denying Americans' fascination with gadgets. Those electronic and single purpose doodads are supposed to make life easier, but let's face it: do we really need devices dedicated to creating the perfect cucumber slice or illuminating martinis for proper mixing or capturing solar energy to power miniature helicopters?

The Disease Management Care Blog is convinced our affinity for things technologic is part of the business case for telemedicine. Whether it's a USB compatible peak flow meter, Bluetooth enabled glucose meters or weight scales connected via modem, their electronic beeping, digital interfaces and diode lights can be the irresistable luster that tips the precontemplative to the active. Call it 'telemedicine,' and even a marketing piece will be run by the Washington Post.

The Disease Management Care Blog doesn't think that's necessarily a bad thing. Medical gadgets are often linked up with human case management. As a result, the DMCB thinks gadgets can be the 'sizzle' that gets the less sexy yet important care management into the boomers' homes.

Think of it as a Trojan Horse: the attractive shell that gets wheeled into the city so that the soldiers can do their thing.

A DMCB prediction for the future: population-based care management programs that are aligned with monitoring devices will be favored by the market. While the devices will 'lead,' the real heavy lifting on the back-end will be the care managementblocking and tackling. Devices will be the channel used by disease management to provide value that leads to the economic return. What's more, device value will be defined by a low price point backed by high service.

Latest Cavalcade of Risk is Up!

The incomparable Wenchypoo's Mental Wastebasket hosts the latest Cavalcade of Risk #88. It seems you can always count on this blog for a unique take on economics, the role of government and the management of risk. She doesn't disappoint, especially with her take on the role of nurse coaches...... Obey, or else!

Random Observations On the Disease Management Industry Thanks to the DMAA Forum 09

The Disease Management Care Blog used the DMAA’s Forum ’09 exhibit booths as a window looking into the state of the industry. It came away with several impressions.

The first is that while the salespersons are infected with ebullient enthusiasm, there was a lot of optimism in that exhibit hall over the future of the disease management/population health industry. The DMCB discerned two reasons:

1) Tally ho! The exhibit hall denizens said there has been no decline in the overall number of commercial sector RFP’s. Despite the dour skepticism of the inside-the-beltway CBO and their academic friends, the customers still like what the industry is offering, and

2) Blue Ocean. Whatever shape health reform takes, it will include dumptrucks of money for wellness, prevention and chronic condition management. That means new customers and new markets with new opportunities.

Over and beyond the industry’s derring-do, the DMCB detected a considerable willingness to engage in modular multi-party partnerships that involve two or more companies plus whatever components that are kept in-house by their customers. Thus, while individual companies are offering a broadening suite of health information support, telephonic care management, wellness interventions, surveys, analytics and the like, they are paradoxically more than happy to offer their wares cafeteria style. What’s more, being able to share data, integrate work flows and play nice with other companies is emerging as a competitive advantage. The DMCB thinks this has implications for the advocates of the Patient Centered Medical Home, who will need to figure out how it can flexibly plug into evolving spectrum of care management services.

The DMCB is also disappointed to report that the excess of superlatives continues to infect the science of disease management more stubbornly than a MRSA outbreak at a humid fitness center. Examples include 'robust!,' 'unmatched!,' 'outstanding!,' 'rigorous!,' 'award-winning!,' 'innovative!,' 'proprietary!,' 'unique!,' 'cost-saving!,' 'proven!,' 'exceptional!' and on and on and on. The DMCB lessened its pain by increasing its bar-based beverage intake. Duly fortified, it then soldiered on through the silliness, wondering when these industry mouseketeers will stop being so tone deaf to the difference between evidence and proof. Now that policy makers, scientists, physicians and masters-prepared Congressional staffers are just as much an audience as all those naïve human resource directors, the DMCB suggests it’s time to reign in the vendoring run amok. The marketing may taste great, but it’s perpetuating the industry’s lightweight less-filling branding.

Outside of the Display hall atmospherics, the DMCB never expects to be so famous and busy that it will have to send a video of itself in lieu of speaking in person at a national conference. In the case of Dr. Clancy, the miracle of this substitutive technology ended up making her look almost alive.

Thanks to a DMAA Forum session, the DMCB is now aware of one more instance in which a State Medicaid Medical Director, along with some friendly jawboning from other State departments, has gotten multiple commercial insurers within the borders to cooperate in population-based care programs, including data sharing and pooling support for primary care. Perhaps the Medical Directors’ job descriptions need to be broadened to include words like convener, trusted intermediary, networking, and innovator. The States’ impressive work in this area seems largely under-recognized in the health care reform debate, and it’s only just been recognized by CMS. As usual, Medicare is late to the party.

Finally, a Harvard researcher provided an interesting plenary session on the topic of bias-free and evidence-based patient education that harnesses the patient’s ability to decide on whether or not to have a test or a treatment. The DMCB has been aware of the supporting peer review literature for quite some time, which convincingly shows that when patients receive this kind of state-of-the-art education, they are better able to discuss the risks, benefits and alternatives with their physicians. What's more, many, compared with usual care, will elect to not undergo preference-sensitive and unnecessary procedures. As a result, patients may appropriately elect to avoid controversial prostate cancer screening, decline an invasive heart procedure and refuse inappropriately extensive breast surgery. The DMCB asked what this means for a HEDIS measures, where patients may also elect to not have a mammogram or a flu shot. Maybe the denominators need to be changed.

HAPHIE

The best part of today's DMAA Forum '09 meeting was the plenary session address by the Chair of its Board of Directors, Gordon Norman, MD. He tackled the important issue of how to combine the various interventions that are being promoted by the various stakeholder groups, including the patient centered medical home, patient monitoring technology, the electronic medical record, data exchange, physician payment reform, classic disease management, wellness, prevention and consumerism.

The Disease Management Care Blog agrees with Dr. Norman: it's no longer a matter of measuring the return on investment or the impact on quality for the still evolving iterations of each of these individual interventions, it's now a matter of figuring out how to fit these all together into a integrated whole.

He called the concept 'High quality, Affordable, Personal Health Improvement for Everyone' a.k.a. HAPHIE. His point was that we already have all the tools and all the information and all the science we need to provide mass customization for individual health care consumers. There is already plenty of money in the system to provide personalized care on a population-based scale. The challenge is to fit all the pieces together in an overlapping, mutually self-supportive and synergistic whole.

The DMAA Forum '09: Volume IV Recommendation on Assessment of Disease Management Outcomes Is Out

If you have been struggling with the topic of how to evaluate your latest population health program, things got a little bit easier today. The Disease Management Care Blog sat in on a DMAA Forum '09 session on the release of Volume IV Recommendations for Measurement of Outcomes. It builds on all the prior Volumes but (and here's the good news) this latest edition will contain all the previous published recommendations and be available without charge for download from the DMAA website.

The DMAA deserves a LOT of credit for making this available gratis. The DMCB thinks the recommendations are not only valuable for assessing disease management, but could be of use for stakeholders interested in the evaluation of other population-based programs, including the patient centered medical home. Sure: a randomized clinical trial is the gold standard for any program evaluation, the fact is that it's not always feasible to do that. Volume IV offers a way out.

The latest release has some other important additions, including:

How to measure and report medication adherence (for example, a minimum to two claims for a specific drug class must be incurred to include a member).

Which baseline to use for long term programs (i.e., those that have been underway for 3 or more years: do you use the first year or the last year?).

A consensus definition of 'Population Health Management' (and a diagram to go with it): 'strives to address health care needs at all points along the continuum of health and well being through the participation of, engagement with, and targeted interventions for the population.'

How to assess the impact of wellness programs (it depends).

The report at the time of this writing is not available on the DMAA web site. The DMCB will keep an eye out for it.

Other noteworthy happenings at the DMAA Forum:

The frightfully bright Mark McClellan MD PhD, former administrator of CMS, gave the day's keynote speech and noted that the considerable consensus over the need for insurance reform means a bill will pass one way or another. He stated that care management - even though it's not viewed favorably by the Congressional Budget Office - has wide bipartisan support. He was very optimistic about the disease management industry's prospects in the coming legislation.

Tracey Moorhead, the President and CEO of DMAA pointed out in her short speech that peer review studies of disease management and its outcomes are critically important going forward. All eyes are on care management, and policy makers as well as legislators will continue to be very interested in knowing more about it. The DMCB agrees: performing rigorous assessments of outcomes and reporting them in the public domain under the scrutiny of peer revew is becoming a cost of doing business for health care in general including disease management organizations including 'carve-ins.' It is our duty and it's good business to understand what works and how much it costs.

Also of note: attendance at the Forum seems high enough to fill meeting rooms, cause crowded escalators and lead to queues at the reception bars. It appears the number of paying attendees is about the same as previous years' meetings but there are also fewer numbers of people manning the display booths.

Can Non-Nurse Professionals Coach Patients With Depression?

The Disease Management Care Blog is in San Diego on the eve of the annual DMAA Forum. What better way to prepare for all the learning that is going to happen tomorrow than to briefly share an important and recently published study on disease management for depression?

The article 'Case management for depression by health care assistants in small primary care practices' by Gensichen et al is in the latest Annals of Internal Medicine. You need a subscription to get to the entire manuscript, but the DMCB is ready to summarize the more important insights for you. The bottom line is that telephonic care management for depression may not require reliance on nurses.

This was a two year ‘pragmatic’ cluster randomized trial involving 74 small and often rural German primary care practices. The clinics, not the patients, were randomly assigned to having depression care for patients supplemented by specially trained ‘health care assistants’ (who were trained for a total of 17 hours) versus usual physician-only depression care. To be eligible for the trial, patients had to be referred into the study by their physician (presumably for suspected depression) and score high on a depression survey (the 27 point PHQ-9; ten points or higher suggests depression). 3051 patients were referred and 1671 scored high enough on the survey. For a variety of reasons (including withholding consent) 555 patients made it into the trial.

The health care assistants were non-physician non-nurse office ‘assistants’ who were described as first contact care workers who 'need not be college graduates.' They contacted patients twice a week for the first month and then once a month for the remaining year. Not only did they formally monitor the depression, but they monitored medication adherence, ‘encouraged self management activities’ and provided patient information back to the physician.

Twelve months later, the intervention group scored better on the follow-up PHQ-9 by 1.4 points (10.7 vs. 12.3) and had greater medication adherence according to a ‘Morisky Score.’ Over the year, both groups averaged about 6 visits with their primary care doctor and about 2 visits with psychiatrists.

The DMCB likes this study because it showed that success can be achieved with non-nurses. It always wondered if any caring and educated voice at the other end of the line was enough to shift patient behavior and medication adherence in the right direction. It suspects the same is true when it comes to other chronic illnesses. Ideally such a system in the U.S. would rely on nurse back-up and the right kind of attention to the U.S.' scope of practice laws and regulations.

Some other points to keep in mind:

The effect size was small (1.5 points on a 27 point scale and the means were still in the depressed range of greater than 9). We still have a long way to go.

Presumably, physicians only chose patients they thought were good candidates for the trial. We don't know if this would work on all patients with depression. Plus, if you run a disease management program and are stymied by poor recruitment and high drop out rates, welcome to the club. Even in a well run research program, patient leakage can be very high.

This study occurred in Germany. Differences in culture and how health care is regulated should be kept in mind while generalizing this to the U.S.

One problem among persons with depression is the occurence of suicidality. It's not clear how this was managed in this study, but imagine how thorny things can get if a patent expresses an intent to harm themselves over the phone.

There was no discussion of costs.

While the DMCB likes the study, it doesn't like how the authors 'framed' their manuscript and how the editors of the Annals let them get away with it. In fact, there is an accompanying editorial 'Progress on primary care management of depression' by Allen J. Dietrich of Dartmouth (which also needs a subscription). According to the authors and the editorialist, this use of non-nurse care management is further evidence of the merits of The Patient Centered Medical Home.

While the intervention did involve personnel that were physically located in the doctor's offices, the reason this worked is because someone was telephoning the patients. The DMCB doesn't understand why that function necessarily has to be physically located in each doctor's office; in fact, consolidating it may be more efficient. There is nothing in the manuscript that describes the linkages between the health care assistants and their assigned physicians, or why those linkages would better than those found in typical disease management programs.

The authors also conveniently and totally ignore the similarity of their intervention with traditional telephonic, disease management-based and insurer-sponsored patient coaching. The success of their non-physician supportive approach has been matched in the U.S. for years and in many respects, this Annals lead article is old news. In fact, the DMCB believes telephonic-based coaching and follow-up of patients with depression should be considered standard operating procedure.

Rather than compare their approach with usual care, the real question is whether non-nurses can perform as well as nurses in reducing depression symptoms and increasing medication compliance. Perhaps this should be a topic of investigation in comparative effectiveness research.

Deng Xiaoping, a former leader in Communist China, famously signalled his country's economic flexibility with the observation that it doesn't matter if a cat is black or white so long as it catches mice. The same may true when it comes to nurses vs. non-nurses and this part of reducing the burden of depression.

Learn From Docs in the Trenches About the Patient Centered Medical Home: A Dispatch from the Front

The Disease Management Care Blog attended a masterful presentation on the Patient Centered Medical Home tonight. It was one of several sessions designed to increase physician awareness, enlist support and prepare for its eventual implementation across the State.

This was about as close to the trenches as you can get. All 30 or so family docs in the room were full time, private practice and seeing more than 30 patients a day in relatively small physician-owned clinics. The are overworked, they are cynical and they worry every minute of every day about quality and cash flow. Most had heard about the PCMH and none had implemented it. They came to listen.

The DMCB also listened and approached this like a 'focus group.' It came away with some important lessons:

1. Despite its academic merits, don't assume the PCMH is a self-evident slam dunk. These guys have seen other silver bullet solutions (like RVUs and capitation) that were also touted as transforming primary care for the better. They are skeptical and you need to posture the 'pitch' accordingly.

2. Be prepared for 'showboating.' Anybody who has been to a lot of physician meetings will recognize the phenomenon: a passionate physician in the back of the room who is loudly doubtful, asks rhetorical questions and dominates the agenda. The presenter loved him to death with upbeat answers that helped win over the rest of the crowd.

3. The presenter needs to have personally implemented a PCMH in his or her practice and report not only what the academic literature has to say, but what his/her own experience was like including the downsides. The best way to portray the PCMH is a balance of advantages and disadvantages, with the former outweighing the latter. In other words, be realistic.

4. In a variation of number 3 above, the presenter will need to not only speak to the standard principles that define the implementation of the PCMH, but be comfortable with the many local factors that influence the implementation. Examples include the lack of any RNs in many offices, a shortage of adequate square footage and the fact that electronic records typically do not include registries. Be genuine.

5. Like it or not, there is no way the PCMH can be separated from physician payment reform. The docs made it absolutely clear that this is not about getting additional payment for the PCMH, this is about a complete reorganization of payment for all services including the PCMH.

6. There are physicians out there who have done some pretty amazing things on their own. Their worry is how to retrofit what they've done into the PCMH. The presenter's job is to respond to that and agree that the implementation needs to accomodate that.

7. Finally recognize that Rome was not built in a day. The DMCB took a decidedly unscientic pre-post poll of some of the physicians and the best that could be said was that many docs moved from being skeptical to less skeptical. Winning these guys over for good is going to take a lot of work.

Other telling quotes:

Think the docs are not aware that there's something wrong? 'Thanks to the PCMH, if a patient's diabetes doesn't come under control, I'll know it's not my fault.'

On delegating: 'Tasks for the staff, decisions for physicians.'

And finally, a credible insight on the physician shortage: 'We all know docs that were going to retire, but, thanks to the markets, they can't. They have to work a few more years.'

The Latest Health Wonk Review Is Up!

Rich Elmore has assembled the latest wonky health reform bloggery at Healthcare Technology News. All for your reading, learning and quoting pleasure!

Use Enterprise Risk Management in Your Dealings with the Feds: A Lesson From LifeMasters

The Disease Management Care Blog has been thinking some more about the LifeMasters bankruptcy debacle.

There will be some additional fall out but in the meantime the the DMCB thinks there are some important lessons for the future:

The Government Can Be a Fickle Business Partner: One classic example is the Medicare Advantage (and let's not forget Medicare+Choice) program. Like it or not, that Federal program has been a roller coaster of commitments made and unmade. While you may not feel sorry for the contracting insurers, there's still something unfair about midstream and unilateral funding cuts ultimately based on shifting politics and budget shortfalls. It's a heluva way for a government to treat its citizens, especially when it comes to insurance.

And now we have LifeMasters. As the DMCB understands it, the disease management organizations (DMOs) that participated in the Medicare Health Support (MHS) Demo are dealing with the specter of having to remit their fees minus the savings back to CMS. The DMCB hasn't been privvy to the contracting terms, but it suspects there is room for interpretation and negotiating. The fact that one of the DMOs had to resort to bankruptcy suggests that the flexible, mutually beneficial, inquiry-driven partnerships that have characterized the MHS pilot has been replaced by lawyering. How much of the government’s hardball interpretation of the pilot's terms is a function of the CMS’ legitimate fiduciary responsibility versus a change in President, the lack of a strong full time CMS administrator and budget shortfall? Are the other DMOs involved in the MHS pilot going to have to litigate their way out of this?

Beware Rosy Actuarial Projections: The DMCB remembers those heady days back in the 1990s when those of us in traditional disease management thought we could conquer the world. While there were some preliminary studies that suggested increased quality and lower costs, our enthusiasm made us generalize preliminary findings involving an underdeveloped uni-dimensional care approach to any population in any setting. The fact that we were so naïve is OK, but let's face it. The calcuations underlying CMS' and LifeMaster’s assumptions on the fees and savings were about as accurate as all the other predictions about Medicare costs. It won’t be the last time.

There is a relatively new and admittedly imperfect business tool called 'enterprise risk management.' The DMCB suggests sponsors of the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) and Co-Ops that are so anxious to do business with the Feds aggresively use their ERM to pause and think really long and really hard about all the worse case scenarios that could happen when getting into the projected savings business with CMS. Think hard about changes in the administration, funding levels, the tax code, insurance support, costs vs. upside risk, data availability, shifting regulators and the threat of litigation. It's not only good corporate governance, but when it comes to the goverment, it may be all that stands between you and bankruptcy.

Physicians and Health Reform: Heal Thyselves

The Disease Management Care Blog is a member of the American Medical Association, it's State Society and the County Medical Society. It's also a member of the specialty organization for internists, the American College of Physicians.

The DMCB may be something of an exception. Depending on the practice type, many physicians may not belong to any of the usual organized medicine groups. There are other professional organizations, however, that address the needs of specialist physicians such as gastroenterologists or orthopedic surgeons. Each individual group probably has an idea of it's 'market penetration,' but the DMCB doubts it's 100%.

This is important because despite the wide number of professional associations out there, there are a significant number physicians in clinical practice who are 'disengaged.' These groups not only serve educational and professional needs, but they also provide advocacy on behalf of its members and the patients they serve. Not participating in any association, organization or society means not having any input during what is arguably one of the most tumultuous times in the history of American medicine.

The DMCB has two suggestions:

1) To its physician colleagues who haven't joined at least one professional group, you are doing your patients a disservice by letting your opinions go unheard. You owe it to yourself to join up with at least one organization that comes close to what you believe. That may mean the AMA or it may mean PNHP or it may mean a specialty society. If either of these groups are too 'left' or 'right,' it may be because you're not participating. If they haven't succeeded in getting anything done, it may be because you're not participating. Dues can cost less than a large flat screen T.V., but that's not the point: you ultimately can't afford to not join.

As an aside the DMCB points out that the local preachers in its home town don't care which church the local neighbors go to, just so long as they go to a church every Sunday. Organized medicine groups should take a page out of that playbook and promote the idea of professional membership somewhere. Physicians would be better off for it.

2) To policy makers, the DMCB recommends that efforts to promote greater integration among physicians, such as the creation of 'Accountable Care Organizations,' include an assessment of how many physicians are involved in a professional organization that promotes education, establishes professional standards and is involved in advocacy efforts. It wouldn't be all that difficult to create language that establishes the standards. The point is that ACOs and their patients would be better off it were populated by physicians who gave a damn.

LifeMasters Declares Bankruptcy

You can read one of the typical press releases here. Rather than battle the Feds over who owes what to who for its star-crossed foray into accepting risk (i.e., the claw back of fees that were unmatched by savings) in Medicare Health Support, privately held LifeMasters is seeking the safe harbor of bankruptcy protection.

The BEST summary can be found at Vince Kuraitis' excellently written review of the history, the balance sheets and all that is known and unknown over at e-CareManagement.

The Irony of Adapting to Local Care Resources to Reduce Variation and Increase Quality

Writing in the American Journal of Managed Care, the Disease Management Care Blog points out that another looming danger of Health-Reform-As-We-Know-It is the lack of flexibility over local care patterns.

What, you say, isn't that precisely the problem?

Yes and no says the DMCB. It is a problem when variations in the rates of flu shots, diabetes blood glucose control and high blood pressure treatment occur across adjacent counties and from State to State. And the good news is that there are 'remedies' including provider feedback, information infrastructure, right-sizing the delivery system, economic incentives and shared decision making. However, in AJMC editorial, the DMCB points out that key ingredient of just how a network of providers implements the mutually supportive feedback, IT, system capacity, profit sharing and the other countless details involved in delivering flu shots and diabetes care is very much a local phenomenon. It describes the M-CARE system in Michigan that launched a successful and adapting diabetes care management program that evolved over time, shifting its resources in response to a changing population.

Nowhere is this phenomenon more obvious than in disease management. Talk to any of the leaders in the industry and you'll find that their success has been built on accomodating the local biases, cultures, resources, insurance types and numerous other quirks to drive care management standards in rural Florida, inner city Boston and the suburbs of Philadelphia.

Can the type of health care reform being contemplated in Congress be nimble and flexible enough to accomodate the success of the M-CAREs of this world and account for the key ingredient of locality? The DMCB has read a lot about the bills currently before Congress and hasn't seen it.

It hopes it is wrong.

The Senate Finance Committee's Bipartisan (Gang) of Six Framwork for Reform: Complicated is Only the Beginning

The Disease Management Care Blog had a chance to look over the Senate Finance Committee ‘Bipartisan Six’s’ ‘framework’ for comprehensive healthcare reform. Recall this is the one Congressional Committee that has a reputation for bipartisan compromise and is the missing link in crafting a bill that will ultimately make it to the President's desk.

The 18 pages do not make for easy reading and builds on the array of federal programs, regulations, financing, incentives and tax code that are already intercalated in our national health care quilt. If reform advocates are looking for the breakthough-remake that simplifies access for our soccer moms, NASCAR men and the Millennials, they'll be disappointed. The framework is a thicket of current public program eligibility standards, income thresholds, tax credits, premium credits, cost sharing and penalties that are ultimately designed to ‘path’ consumers into doing the right thing. Since the combinations and permutations are so complex, the DMCB doubts any actuary will be able to project costs or savings, especially since the knobs and dials known and unknown are going to be legislatively` twiddled. While the DMCB has an abiding respect for economists, actuaries and oracles, it predicts their soothsaying will mimic that of a near-sighted and over-cautious radiologist’s interpretation of a fuzzy total body CAT scan: caveats and assumptions based on invisible electromagnetic shadows assembled in a very dark room. Accept it at your peril.

What does the framework have to say about wellness and prevention? Medicare will ‘cover’ health risk assessments and the creation of an individualized health improvement plan. Medicare’s cost sharing’ would be removed when it comes to the relatively conservative U.S. Preventive Health Services Task Force recommendations. A ‘five year initiative to explore consumer incentives’ would be launched. In Medicaid, States would also receive a variety of carrots and sticks to reduce consumer cost sharing and enhance incentives. Unlike Medicare, Medicaid programs would also be encouraged to develop a new ‘state plan option’ based on the Medical Home.

There are also provisions for creation of a Federal ‘national quality strategy,’ accountable care organizations (with upside gain shares), a $10 billion CMS ‘innovation center’ (to test new payment models), ‘pilots’ for payment bundling and penalties for readmissions and hospital acquired infections.

There was no specific mention of any promotion or support of other population-based care management programs. However, the DMCB thinks there are myriad opportunities for the industry. As the detail evolves, it will learn more.

And a few interesting nuggets:

Wonder why the American Medical Association leadership is gritting its teeth and not opposing huge increases in the Federal government’s role in medicine? It comes down to one sentence in the framework that is remarkable for its unusual clarity: ‘The scheduled 21% reduction in Medicare physician payment rates would be replaced with a 0.5% increase.’ The DMCB guesses that an average doc’s patient population is 50% Medicare. Even though Medicare is not necessarily the best payer, a back-of-the-envelope guesstimate is that this is all about the threat of a 10% pay cut.

And speaking of CAT scans, Houston, we have a problem with what the framework refers to as 'high cost imaging.' These include those very pricey MRIs and other remunerative pictures beloved by patients and physicians alike. Buried in the language on ‘Physician Value-Based Purchasing’ is the ‘requirement’ of establishing ‘incentives’ for physicians to ‘appropriately order’ high cost imaging with ‘feedback' and ‘penalizing physicians who use significantly more resources than their peers.' Care to guess if the 'incentives' will be positive or negative, how ‘appropriately’ will be defined and whether ‘significantly’ will be based on clinical, statistical or financial methodologies?

The DMCB pays over $1200 a month for its community rated (read no underwriting) health insurance. This is hardly a rich plan ($50 co-pays) and the DMCB knows for a fact that the insurer is not raking in lots of dough. If the DMCB is reading this right, the framework would tax premiums over $8000 for a single person and $21,000 for family, presumably to incent the choice of more modest plans and, more importantly, help pay for Obamacare. Yet, depending on how well its accountant gets up to speed on the thicket mentioned above, the DMCB’s small business could ironically end up paying more once the health reform dust settles. So why is this good?

Rhetoric for Show, Policy for Dough

The Disease Management Care Blog is still digesting President Obama's healthcare speech to the joint session of Congress last night. The recipe included sufficient rhetoric, a nice helping of eloquence, the right amount of rejoinders, some hardy swipes at the critics, comfort for the electorate, openings at compromise, a pull at the heartstrings and a surprising dash of heckling. Imagining itself as one of those haughty celebrity judges in a televised cooking contest, the DMCB awards 5 out of 5 points for plate presentation, 4 out of 5 points for originality but on taste, alas, points were lost. It thinks it needs more of the salty key ingredient of hard policy proposals. It tasted OK, but it suffered from a certain blandness.

That still may be OK. The DMCB is drawing on two political stories from its past.

The first was related by a medical school dean, who recalled being flayed at a local State Senate committee meeting by a powerful Chair, who criticized the way the institution was being funded with taxpayer dollars. When they were alone afterwards, the Chair told him to not worry about it and assured him the funding would be increased. It was all for show.

The second involved a State Medical Society President who was publicly attacked by a sitting State Governor. The Medical Society leadership was portrayed to the press in the room as obstructionist and shortsighted. Once again, once they were alone, the Governor warmed up and they worked things out. This too was all for show.

The DMCB hopes our former Senator and now U.S. President will take a page out of the playbook from the only past President that accomplished anything when it came to health reform: Lyndon Johnson. Like Mr. Obama, LBJ was a former Senator, He used the art of politics, not rhetoric, to get things done. Last night's speech, whether the President knows it not was all for show.

Now for the work of getting something that not only looks good but actually tastes good.

The Latest Edition of the Population Health Management Journal: Summarized for Your Reading Pleasure

While you were watching the President’s speech, the Disease Management Care Blog was tens of thousands of feet in the air in an aluminum tube courtesy of United Airlines. It used its unhappy cramped confinement in coach to huddle over the latest issue of the Population Health Management Journal.

That’s right, once again the DMCB knows that your fresh issue of PHMJ is languishing on your to-do list, laying in your in-box and going unread in your must-read list. But you also know you can count on the DMCB to give you a handy summary of the contents so you can a) pick and choose which articles warrant greater scrutiny over lunch or while dealing with some other biological need and b) quote confidently from even the articles that don’t deserve your attention to the amazement of your jealous colleagues.

Sarah Beaton, Scott Robinson Ann Von Worley, Herbert Davis, Audra Boscoe, Rami Ben-Joseph, and Lynn Okamoto: Cardiometabolic risk and health care utilization and cost for Hispanic and non-Hispanic women. The Lovelace Foundation, with help from United Biosource and Sanofi-Aventis, mined their 4211-person osteoporosis data base because the weight and height information obtained in the course of DEXA scanning enabled a calculation of body mass index (BMI). They then went on to combine the BMI with the available lab and blood pressure data (winnowing the number down to 2578 persons) to assess the cardiometabolic risk (CMR) of continuously enrolled Caucasians and Hispanic women. Even if six different definitions of elevated CMR were used, a statistically significant 66% of the Hispanics versus 52% of the Caucasians fulfilled criteria. Having elevated CMR was also associated with increased healthcare utilization and cost. Yet, being Hispanic was also associated with lower utilization and cost. Nothing new here: cultural and socioeconomic factors have been long known to drive Hispanics toward obesity and impede access to healthcare. While this was a convenience sample and may not be generalizable, however, the 2/3 prevalence rate in this population speaks once again to the pressing need to address a crushing public health crisis in a vulnerable group of citizens. Kudos also for showing how claims and registry data can be used by health plans on behalf of science and public health.

Joseph Couto, Martha Romney, Harry Leider, Smiriti Sharma and Neil Goldfarb: High rates of inappropriate drug use in the chronic pain population. Ameritox is a company that deals with a lot of pee. Like, 938,000 samples’ worth. And they used every single one of them to test for the presence of prescribed opiates as well as other illicit substances. These were urine drug tests ordered by physicians in the course of follow-up for patients being treated for chronic pain. 11% test positive for illegal drugs, 29% tested positive for a non-prescribed medication, 38% did not have detectable prescribed drug (indicating they could be diverting the drug to friends or for sale) and 15% had lower than expected levels of their medication. While these categories were non-exclusive, the bottom line is that a whopping 75% had one or more problems. Even if this speaks to a population with special needs, the DMCB is not that surprised. The authors point out correctly note that docs only order urine tests when they suspect something is wrong, so maybe the real news is that they’re wrong 25% of the time. The DMCB is also unsure of the positive and negative predictive value of Ameritox’s testing, because their testing algorithms are proprietary and not reported. Conservatively assuming that a typical urine submission is maybe 3 ccs, that’s about 2.8 million ccs of pee or 2820 liters or about 700 gallons of the stuff. Now that is dedication to science.

Alex Harris, Thomas Bowe, John Finney and Keith Humphreys: HEDIS initiation and engagement quality measures of substance use disorder care: Impact of setting and health care specialty. The VA really likes HEDIS because they spend a lot of time thinking about it and they’re good at it. This is amply on display in this paper from the Palo Alto Center for Health Care Evaluation in their examination of the HEDIS metrics for ‘initiation’ and ‘engagement’ measures for over 320,000 vets meeting criteria for substance abuse disorder. How and where (for example, inpatient setting vs. a specialty clinic vs. a primary care setting) vets got treated made a big difference on whether HEDIS defined quality was met, but the DMCB was overwhelmed by the permutations of how patients flowed through the system. Even worse, the authors then applied a Markov model to game how greater substance-abuse specialty involvement can increase the VA’s HEDIS rates. No tables but there are two mind-numbing flow diagrams. Avoid this one unless you like to also think how HEDIS defines the denominator population or believe the VA really has any lessons for the rest of the world, especially when it comes to the management of substance abuse.

Sandra Adams, Albert Crawford, Rajiv Rimal, Joyce Lee, Laura Janneck, Christopher Sciamanna: The effects of a computer-tailored message on secondary prevention in type 2 diabetes: A randomized trial. Think sending targeted computer generated message-reminders to persons with diabetes just before a doc appointment is a neat slam dunk? You may need to think about that again after reading this assiduously conducted randomized clinical trial from Jefferson, Miriam Hospital, Brown University, Hopkins and last but not least Penn State (Class of ’81 - Go Joe!) involving 203 persons with type 2 diabetes mellitus. Depending on a baseline assessment of blood pressure, lipids or blood glucose control, participants got either nothing, a positive message (lower you blood pressure and protect your eyes), or a negative message (you could go blind). Interviews following the physician appointment by research assistants unaware of the group assignment showed no difference in medication changes or needed testing. Of course, there may have been too few patients to yield up a statistically significant difference, but even then, it would have been small. The authors correctly wonder if the intervention itself was weak (it only happened once), suffered from not being personalized to each patient’s special circumstances and relied too much on patient self-report. The DMCB also thinks that single interventions are less effective unless they’re combined with other interventions, i.e., 'synergy.' Would this work if integrated with nurse-based care management or a medical home?

Jared Puterman and David Alter: The application of disease management to clinical trial designs. Be of good cheer disease management-ites! These researchers from York University and the University of Toronto read every big cardiology randomized clinical trial from the New England Journal of Medicine, JAMA and The Lancet and over three years, over time from year to year, the intervention and control groups had greater degrees of disease management present. The DMCB interprets this to mean that if you’re going to assess the impact of a new drug or device, you need to gauge it in an environment of population-based care support. In other words, this is becoming the standard of care. Another way of thinking about this: if a drug or device has benefit, it may mean that that benefit depends on the presence of disease management support. The only problem is that the authors used the unfamiliar “American Heart Association taxonomy” to define disease management and only small minority (3.4%) had all “eight elements.” 11% had four. The good news here is that even the academicians are recognizing the importance of disease management, even if they aren’t aware of it and are being slow-pokes about it.

Ronald Deprez, Amy Kinner, Peter Millard, LeeAnn Baggott, Jean Mellet and Jia Ling Loo: Improving quality of care for patients with chronic obstructive pulmonary disease. This is a pre-post study involving 18 inland Maine primary care clinics that agreed to go through a 3 year collaborative-style intervention aimed at helping docs do a better job of managing patients with COPD. In addition to attending three workshops, the participants were given flow sheets to better help them document various processes of care. Charts were reviewed at baseline (N=584) and afterwards (N=626). As you might predict, spirometry rates, tobacco use documentation, vaccinations, counseling and referrals all went up. The authors correctly point out this study has all the problems associated with a pre-post design, including regression to the mean or bias from other factors that could have influenced the observed results. In addition, the authors pointed out that they didn’t know if their outcomes were thanks to the docs doing a better job of documenting what was happening anyway. Maybe they were itching to use that brand new spirometry machine. Last but not least, the DMCB agrees with the authors that it’s possible that once the collaborative is over, the docs may go back to their old patterns of care. This is a good article to learn about the severe limitations of a pre-post study.

Plus, there's a editorial 'Health Is Not Enough' from Ben Leedle of Healthways about their Gallup-Healthways Well-Being Index. He argues that it gives additional insights about the health status of populations that are not captured by the usual metrics.

Why Not a Televised Speech To Persons in the Nation's Physicians' Waiting Rooms?

Not without some controversy, President Obama gave an welcoming first day address to school students in Arlington Virginia that was broadcast to the rest of the nation's schools. He stressed hard work and personal responsibility while drawing on his own past and the success of others who made it against the odds. This is where rhetoric can count. One of the viewers is probably a future President.

Which is why the Disease Management Care Blog humbly offers up a similar text that the President can use to record a speech that can be televised to persons sitting in physician waiting rooms. It's paraphrased from the prepared text of the school address and also stresses the same themes of hard work and personal responsibility. While comparative effectiveness research would be needed to assess its impact versus placebo (like Ms. Pelosi's views on health care), it beats having to read outdated magazines or staring at the institutionally beige walls and fake potted plants:

I know for many of you, you haven’t seen a doctor for a long time. It’s understandable if you’re a little nervous. You’re probably wishing you were somewhere else. I know that feeling. When my mom wasn’t teaching me at 4:30 in the morning in Indonesia, I could have come down with diphtheria or beriberi. And these Town Halls have been no picnic for me. And sitting in that waiting room now is no picnic for you.

But seriously. I’ve given a lot of speeches about healthcare. Sometimes I’ve made sense too., when I’m not talking blue and red pills. But I haven’t talked much about responsibility. I’ve talked to your doctors. They’re tired of hearing from me. Sometimes they even boo.

I know you’re still adjusting to having to see the doctor. But I’m here today because I have something important to discuss with you. I’m here because I want to talk with you about your health care and what’s expected of you. It’s time to talk responsibility.

Yes, there’s responsibility of the docs. Of the hospitals. Of government. Of insurers. But at the end of the day, we can have the best docs, hospitals, government and insurers and none of it will matter unless you fulfill your responsibility. You owe it to yourself.

Every one of you has something you can do to improve your health. Maybe you can start using the stairs. Going outside to walk, even if it’s down the driveway and back. Maybe it’s changing from 3 large meals to 5 smaller meals a day, or eating more fruit. It may be less salt. Or not using tobacco. Or drinking less alcohol. Or wearing a seatbelt. Or watching less TV, especially those silly morning shows and their ridiculous health care advice.

Plus, you’ll need knowledge and problem solving skills, use new technologies, develop new insights and gain critical skills to fight your chances of getting a chronic disease. The health care system has created new options that can help you gain creativity and ingenuity to develop a lifestyle that is right for you. It's becoming more and more available. It's on the way.

You need to develop your health care talents, skills and intellect so that YOU can solve your most difficult health care problems. If you don’t do that, no amount of money spent by a government that is wiling to bankrupt itself will save you.

Maybe you don’t have the kind of insurance you need. Maybe you lost your job and are on COBRA. Maybe there’s no money to go around. That’s no excuse for doing something, for not taking care of yourself as much as you can, for not trying. Because here in America, your health status is largely what you make of it. You make your own future.

Like a patient from the Disease Management Care Blog’s past. By the way, I LIKE to read the DMCB. I never follow its policy advice, but that may change. But Bill the patient kept going to the emergency room. He hated it. It was all paid for, he had great insurance. But he didn’t know about diet and exercise and the right medicines to keep his symptoms under control. He said enough was enough and with the help of a nurse – not a doctor, but a nurse – found the key of knowledge to better control things.

That’s why today, I’m calling on each of you to set your own goals to improve your health and do everything you can do to meet them.

Whatever you resolve to do, I want you to commit to it. I want you to really work at it.

But the truth is, being responsible for your health is hard. You won’t love learning about it. There’s a lot you won’t understand. Not every thing you do will seem that relevant with everything else going on in your life. And you won’t necessarily succeed at everything the first time you try. I’ve tried to stop smoking and I don’t let failures define me.

Your doctors, your hospitals, and your government are doing everything we can to make sure you have the healthcare you need. I’m working hard to fix up your insurance and get you the medicines, primary care and information access you need to learn. But you’ve got to do your part too. So I expect you to get serious this year. I expect you to put your best effort into everything you do on behalf of your own health. I expect great things from each of you. So don’t let us down – don’t let your family or your country or yourself down. I know you can do it.

Thank you, God bless you, and God bless America


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Sausage Making: The Art and the Science

The Disease Management Care Blog is a physician. Like most physicians, it thinks that health care policy should be implemented using the same science-based process that forms the basis of medical decision-making for individual patients. It naively wishes the President would stand up Grand Rounds style, state the case for his version of health reform and let reasoned evidence and logic win the day.

Right.

It remains mystified by all the political factors that influence elected and appointed officials. It struggles to understand our legal and regulatory system of outside authority, conflict resolution, the relative importance of procedure and substance, the nature and significance of risk, and the legitimacy of politics as a method of solving problems.

That’s why it’s looking forward to Mr. Obama’s Wednesday night speech. Sure, there may be some new insights about healthcare and then there is the drama surrounding the President's legacy, but the DMCB will use special address to Congress to observe, listen and learn how the sausage-making of politics can trump policy.

It will be on the look-out for four key ingedients:

1) The Casings, made up of suspense, secrecy and timed unveilings: after all, if this was a legitimate open dialogue over policy, there wouldn’t be any silence. By keeping things in the dark until Wednesday night, the President can seize the rhetorical high ground at a time of his choosing without having his opponents preempt him with partisan criticisms.

2) The Meat, consisting of politically timed shifts to the center: Movement away from the loyal base can be done too slowly or quickly. The DMCB will be closely watching to see how Mr. Obama navigates to the Clintonesque center, perhaps by defusing the contentious public option with an endorsement of the trigger mechanism ascribed to Senator Snowe of Maine.

3) The Spices, a.k.a., governing by campaigning: sure, there’s a difference between governance and running for office, but the science of modern politics calls for mobilizing supporters. It’s not winning the ballot box exactly, but the process calls for the same networking, rhetoric, advertising, emails, texting, marketing, focus groups, calls, petitions, demonstrations and getting network news time.

4) Water to fold things together i.e, a kick off – The President’s speech will only be the beginning. As you are reading this, the DMCB suspects coordinated marching orders, talking points and morning news show appointments are being issued to members of the Obama administration and other officials to follow up. Expect additional enforcing appearances, editorials, conference calls, testimony, leaks and interviews.

Will this be enough to kick start the Dem's stalled healthcare initiative? The DMCB has no idea, but this should be a fascinating lesson in the art of modern bill making.

The Latest Health Wonk Review is Up!

The latest Health Wonk Review is up at Jared Rhoads' unabashedly capitalistic Lucidicus Project. Don't let its mission fool you, however, because it describes and links a host of health care posts from the left, the right the middle from all around the blogmos. Read and enjoy while you plan on getting out of work a little bit early today. Happy Labor Day weekend.

What Karen Ignagni Said, Meant & Should Have Said in the New England Journal of Medicine

Karen Ignagni of America’s Health Insurance Plans (AHIP) has an article-editorial in the latest New England Journal of Medicine. AHIP is the trade organization that represents the U.S health insurers.

There isn’t much that is new here. In fact, it's so boilerplate, the Disease Management Care Blog wonders if one of her staffers wrote this for her.

She argues the nation’s insurers want to build on the strengths of the current system. AHIP's members are prepared to cover all Americans based on the guaranteed issue of a standard transparent benefit without medical underwriting. AHIP wants clinical as well as cost-effectiveness data to inform decision making. Government subsidies may be necessary to make sure no one falls through the cracks. They really don’t want a public plan to happen because of cost-shifting.

The DMCB thinks she really means that the members of her organization would be happy to have everyone in the U.S. mandated to buy insurance from their members, even if it means that the benefit package and its price will be heavily regulated. Anything and everything that blunts cost inflation would also be very welcome. Government subsidies would be very very welcome. They really really don’t want a public plan to happen because of cost-shifting.

What she should have said is that the United States has a choice to make. It’s going to insure its working citizens with either: a) a regulated public-utility style commercial system that controls costs through a combination of provider negotiating and relying on evidence-based and cheaper alternatives or b) a government system that squeezes costs through imposing price controls. AHIP members don’t want a public plan because only the top tier of Americans will be able to afford private health insurance and the rest of us will eventually end up being in the equivalent of a Medicaid plan.

Group Health Cooperative Study Says the Patient Centered Medical Home (PCMH) Did Not Reduce Healthcare Costs

If Group Health Cooperative (GHC) can’t do it, nobody can.

The following is a quote from a published study on the Patient Centered Medical Home (PCMH) that just appeared in the American Journal of Managed Care:

‘Totaling costs across all components of care, we found no statistically significant overall cost differences between the PCMH and other clinics.’

That’s right. In this 12 month prospective, comparative, pre-post study that compared economic, clinic and other outcomes from a single PCMH clinic versus 19 control clinics, the PCMH did not save any money.

The study quite instructive on how extensive a PCMH redesign of a primary care clinic can be. A single metropolitan Seattle primary care practice was converted to a PCMH by a) reducing the physician panel from an average of 2327 to 1800 patients, b) expanding appointment times from 20 to 30 minutes, c) increasing physician support staffing, d) starting team huddles, e) instituting pre-visit outreach and chart reviews, f) issuing patient-centered quality deficiency reports, g) starting e-mail and telephone encounters (as an alternative or complement to in-person visits) and h) using on team-based rapid process improvement. Participating physicians were exempted from RVU-based adjustments. Last but not least, the most dreaded of interventions known to healthcare providers was also used: workshops. Whats' more, there were two of them.

After going through all that trouble, did the PCMH save money? The answer is no.

One year later, per member per year (PMPY) costs for the PCMH clinic was $6089 versus $6107 in the control clinics. While there was a $17 difference, it wasn’t statistically significant.

Emergency room costs were statistically significantly lower for the PCMH ($238 vs. $292), but primary care costs were statistically significantly higher for PCMH ($582 vs. $566). Specialty care costs were higher too, but failed to achieve statistical significance.

A host of other outcomes including visit types and numbers, patient and provider satisfaction (continuity for the patients and ‘burnout’ for the provider staff) and composite HEDIS measures were also studied. The detail is mind-numbing but can be summarized by saying that the PCMH performed better when it came to quality.

The Disease Management Care Blog isn't convinced that this is enough to push the DMCB into the mainstream of patient primary care or elevate it as a candidate for healthcare reform. That's because of questionable:

Generalizability: Not only was this Group Health Cooperative, but GHC chose its best clinic. If the best of the best couldn't save money, how likely is it that any of the other pilots will save money? How likely is it that GHC's experience could be replicated in other settings?

Quality: While health care quality is an important factor in the healthcare debate, it remains to be seen how the benefits described in this paper will 'play' in the market place. If there is no change in health care costs, some purchasers may ask: 'why bother?' Doctors having to go through the redesign (and those awful workshops) may also ask: why bother?'

Cost savings: While ER costs declined, there was no meaningful reduction in speciality health care costs and primary care costs increased.

Given the relentless increase in cost inflation, the DMCB doubts stakeholders, the Congressional Budget Office or reform advocates will be favorably impressed.

Mmm Mmm Health Care (With Apologies to the Crash Test Dummies)

Once there was this Prez, who
Didn’t like the health care costs, and promised to re-tool
But when he did some Town Halls
His polls had turned from great into awful
He said that all those details
That small print’s sooooo haarrrdddd

Mmm Mmm Mmm Mmm

Once there was this Speaker who
Wouldn’t go and deal with any Blue Dog in the cloak rooms
But when they finally made her…
They saw spending out of control
She’s very good at explain’in it
‘The silly voters don’t care’

Mmm Mmm Mmm Mmm

But both Speaker and Prez were glad
‘Cause one pol had it worse than that…..

‘Cause then there was this Senator
Held all those secret meetings hidden from the press pool
And with opinion research
They looked n’ saw polls lurched down a big craphole
The voters had explained it
Don’t ever EVER go….. there

Mmm Mmm Mmm Mmm......