Sunday, September 26, 2010

a Summary of the Latest Population Health Management Journal

Like you, the Disease Management Care Blog has been busy. Yet, it finally managed to find some time to crack the latest issue of the Population Health Management Journal. What's more, the DMCB kept some notes for your quoting pleasure. Check it out and if any of the articles catch your interest, you can access the abstracts here.

Michael French, Jenny Homer, Shay Klevay, Edward Goldman, Steven Ullmann and Barbara Kahn: Is the United States Ready to Embrace Concierge Medicine?

This is a very detailed review of an emerging kind of primary care where, “in exchange for a retainer or membership fee, patients receive same day or next day appointments for non-urgent care, access 24 hours a day and preventive medical services not usually offered through health insurance.” Here are some facts that caught the DMCB eye: concierge medicine started in 1996, up to an estimated 5000 physicians are CM docs and the retainer fee is typically not covered by insurance. The practice has spawned its own not-for profit trade/advocacy association ( While you might think the phenomenon is limited to small physician-owned clinics, there are companies that employ physicians in concierge practices. The retainer fees range from $1500-$3600 per patient. Docs typically have just under 500 patients in their panel, allow about 10 visits per day and enjoy incomes as high as $800,000. The authors suggest this could crowd out regular primary care and further strain access. There is precious little research on quality or outcomes Last but not least, Medicare specifically prohibits billing beneficiaries for services that it already covers, which could lead to some physicians becoming ensnared in accusations of double billing. In light of all the attention concierge practices have received, the DMCB is surprised at the low numbers and the emergence of concierge "chains." It asks if and when there will be tipping point and wonders if the SGR will play a role.

Iftekhar Kalsekar, Samantha Record, Karly Nesnidal and Bruce Hancock: National Estimates of Enrollment in Disease Management programs in the United States: An Analysis of the National Ambulatory Medical Care Survey (NAMCS) Data.

The authors used data from the NAMCS to estimate the level of participation in disease management (DM) programs. Their bottom line estimate is that 21.3% of eligible patients are enrolled in DM. While the DMCB would have guessed that chronic heart failure is the chronic condition that the highest penetrance, the answer is that it's chronic renal failure at 40%. The other usual conditions range between 16 and 29%. In reading the methodology for this article, the DMCB couldn’t quite understand how the authors got at the DM enrollment information. Since it trusts PHM’s peer review process and the authors quote other studies that have similar figures, the DMCB finds the numbers credible. Assuming they are correct, they point to the considerable upside growth potential of the disease/care/population health management industry.

Richard Feifer, Laurie Greenberg, Sandra Rosenberg-Brandi Ellen Franzblau-Isaac: Pharmacist Counseling at the Start of Therapy: Patient Receptivity to Offers of In-Person and Subsequent Telephonic Clinical Support

100 consecutive patients who had just started a new medication for a chronic condition were contacted for disease management. Prior to the counseling, the authors used a short survey to ask these patients about their experience when they first picked up their prescription at their community pharmacy. 58% didn’t recall being offered counseling, 11% refused it and 12% couldn’t recall getting useful advice. While it’s difficult to generalize from such a small survey involving a small number of patients, it confirms the DMCB skepticism about the notion that retail pharmacy windows can be retrofitted to deliver disease management. The DMCB also better understands why its own personal chain pharmacy gets its sign-off on a mechanized offer of counseling - which it never gets and doesn't want.

Justin Schaneman, Amy Kagey, Stephen Soltesz, Julie Stone: The Role of Comprehensive Eye Exams in the Early Detection of Diabetes and Other Chronic Diseases in an Employed Population

The research database of Human Capital Management Services contains a vast amount of demographic, employment, compensation, medical claims, pharmacy claims, disability, workman’s comp and work absence information on millions of employees from across the United States – including, maybe, you. Do not, however, be paranoid, because the authors looked at persons with either specific check-box notification of, or, a claim consistent with a screening eye exam that was subsequently followed by the appearance of new claims for diabetes (N=620), hypertension (N=1558) or high cholesterol (2824). When that happened (eye exam, followed by insurance claims), the authors assumed that the eye examination discovered the condition, which then led to a referral for care. These persons were compared to 2,668 persons who also had new claims for diabetes (2668), high blood pressure (17,112) or high cholesterol (12,059) but without the preceding eye exam. . The authors found the eye exam group, compared to those without the exams, appeared to have a less costly course of care. What’s more, the eye exam was associated with less disability and lower workman’s comp claims and a lower likelihood of being terminated. It all added up to more than $4.5 million in possible savings. The authors correctly point out that there may be unidentified sources of bias that could account for the differences and that this may also be a classic example of lead-time bias. The DMCB also points out that association doesn’t mean causality.

Jeanne Clark, Hsien–Yen Chang, Shari Bolen, Andrew Shore, Suzanne Goodwin, and Jonathan Weiner: Development of a Claims-Based Risk Score to Identify Obese Individuals

These Johns Hopkins researchers had concurrent access to the self-reported height and weight data from health risk assessments (HRAs) as well as insurance demographic and claims data from seven Blues plans of over 71,000 individuals. Logistic regression was used to determine which kinds of insurance claims data could be used to predict the presence of obesity in the absence of an HRA. Armed with such an “obesity risk score” tool, commercial plans could presumably use this to recruit patients that appear to have obesity into disease management programs. While the sensitivity and specificity of the modeling was far from perfect (the area under the ROC curve ranged from .67 to .73), this study shows, once again, how health plans can infer important conclusions about their enrollees based on claims data. It should be no surprise that the regression equation it self with the weights were not reported, presumably because that will only be available if you pay for it.

Manjiri Pawaskar, Steven Burch, Eric Seiber, Milap Nahata, Ala Iaconi and Rajesh Balkrishnan: Medicaid Payment Mechanisms: Impact on Medication Adherence and Health Care Service Utilization in Type 2 Diabetes Enrollees

According to the Kaiser Foundation, about 45% of Medicaid recipients nationwide are enrolled in “capitated” Medicaid plans. Are taxpayers getting their money’s worth and are these patients being care for properly? To find out, the authors looked at the claims data from between 1999 and 2005 of 8581 adults age 18 to 64 years with diabetes who were newly started on an oral anti-diabetic medication from 8 unnamed Medicaid managed care plans. 3763 patients were enrolled in “capitated” plans (where most medical services were paid for on a capitated basis) and 4818 were in fee-for-service plans. Logistic regression demonstrated that being in a capitated plan was statistically significantly associated with a greater likelihood of hospitalization and a lower frequency of outpatient visits and a lower likelihood of getting prescriptions filled. Hm, says the DMCB: maybe Medicaid plans should use disease management to make up for these shortfalls.

Nasiya N. Ahmed and Shannon Pearce: Acute Care for the Elderly: A Literature Review

Ever hear of Acute Care for the Elderly (ACE) Units? These are small 10-20 bed inpatient settings that are specially configured for the special needs of elderly persons with acute illness. It involves specialized geriatric care and interdisciplinary teaming all configured to maximize the likelihood of returning the patient to independent living. The authors summarized all the published literature on the topic and conclude that the clinical trials that do exist seem to show that ACEs, compared to usual care, generally lead to a shorter length of stay, have a lower likelihood of readmissions, end up with fewer transfers to a nursing home for longer term care, result in less functional decline, have a lower risk of delirium, reduce the chance of polypharmacy and experience lower cost. The authors caution the literature, while promising, is relatively limited and more research is necessary.

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