The States' Role in Health Reform

Interested in the States' role in health reform, the Disease Management Care Blog cracked open the latest New England Journal of Medicine on its way to the Disease Management Colloquium. Maybe it's because the DMCB is developing hyperolympicosis and is about to go on a marchmadness bender, but it concluded this article had many parallels to the biased TV announcer favoritism that too often transforms a perfectly fine sports broadcast into a migraine. Too bad the Journal doesn't have a 'mute' button that otherwise helps its readers get past the authors' unwarranted framing to, like, maybe learning about the underlying issues.

The DMCB says check this article out for yourself, but here's a minimalist summary with some other things to think about.

The reason States can't reform health care is because:

Insurance is profoundly expensive: The logic here is that States simply cannot afford to make a 'real investment in the population.' Accordingly, the only entity that come up with the money to pay for expanded Medicaid, preserve Medicare and provide premium subsidies for everyone else is the Federal government.

Think about: States have to make the tough trade-offs between affordability and health care gains. The fact that Massachusetts came up with its own reform suggests it's within reach, but that there are lessons to be learned about combining a relatively rich benefit with optimistic assumptions. That being said, what is the evidence that Washington DC can do that better or cheaper? Where is that remote.....

Practicality: This says the States are unable to stand up to health insurers' ‘price gouging and exclusion(s)’ and, what’s more, insurers will simply exit any State with an 'unappealing 'business climate.

Think about: According to this link, some State Insurance Commissioners have been doing their job with these insurers quite nicely thank you. Many not-for-profit health insurers are State-based or regional and have no where to go. Now, where's that mute button.....

The Law: ERISA shields employer-based and self-funded insurance plans from the States' reach. They are outside the States' purview, which means the Feds need to step in.

Thnk about: The DMCB recalls that ERISA was enacted in the first place because State insurance commissioners were too effective in regulating plans that extended across State borders and a law was needed to restrain the States. Need to aim carefullly.....

Reality: Last but not least, it’s argued that patients and their insurance move across State lines, resulting in adjacent States having insurance programs that “are far less generous” than their neighbors. This creates disparities, which begs the involvement of Washington DC to assure fairness.

The DMCB doesn’t understand why this is necessarily a problem when the elected representatives of a State do what they think is best for their constituents, unless the idea of a national program is to mandate a one size fits all single benefit structure for everyone everywhere.

Click!

The DMCB recognizes that this really comes down to subjective policy preferences, not the faux hard science being portrayed in the Journal. The arguments in favor of greater Federal involvement come down to its ability to control costs once it begins to effectively regulate insurance, that the markets that exist today are neither fish (heavily regulated) nor fowl (free and transparent) and need to be fixed in one direction or another, and that an enlightened legal and regulatory environment courtesy of Wasthington DC could bring the insurers and providers to heel.

Think that makes sense? You be the judge, but don't take this article's word for it.

Population Health Impact Institute Webinar on Transparency

To the chagrin of the DMCB spouse, looks like her hubby will be housebound today. Trying to be helpful, it pulled some ground meat from the freezer, explaining it's a high value protein platform that offers maximum dinnertime cost-effective savory/flexibility ratios.

Now banished to the office-nerve center of the DMCB World Headquarters, the DMCB has been alerted to another webinar that may be of interest to readers. The Population Health Impact Institute (PHII) is hosting a speaker-rich and complimentary March 11 webinar on achieving methodologic transparency when evaluating population-based outcomes. This looks like a great chance for experts and non-experts alike to bone up on comparative effectiveness, return-on-investment, comparability and communicating results. You can find out about it here, where there is a registration link.

"Reset The Etch-a-Sketch" - Observations from the Feb. 25 White House Health Reform Summit

That line from Rep. Roskam was probably the most memorable quote from today's White House health reform summit. The multi-tasking Disease Management Care Blog kept notes in between the the day-job emails, snacks, calls, caffeine and documents while streaming C-SPAN3 into the bottom right corner of it's second monitor screen while manning the DMCB World Headquarters. In case you missed it, the video is here.

What else do the DMCB notes say?

To no one's surprise, none of the participants appeared to change their minds.

The Democrats stuck to their main point: the bills are big and complex because the provisions are interdependent as well as necessary. For example, if there is no mandate to expand the risk pools, there can be no guaranteed issue, which is why premium supports are necessary which is why taxes.... You get the picture.

The Republicans stuck to their calls for a 'do over,' quoting public opinion polls and pitching their usual counter-proposals. That's what accounted for the etch-a-sketch quote above, likening the current bills before Congress to a messy squiggle resulting from too much fiddling with the knobs.

Yet, the Dems had one big rhetorical advantage: their 'liberal' (pun intended) use of telling anecdotes, including children with menintitis, farmers with sticker-shock insurance bills and middle-class restaurant-owners with chronically ill babies. The Republicans, on the other hand, countered with the unaffordability of a perfect health care system, no matter how deeply we care and no matter how deeply we want it.

Dems vs. Repubs: a tie.

The President's considerable oratorical talent was pushed aside by the preoccupation of policing all of the point/counterpoint discussions. While he occasionally responded to Republican misstatements or showboating, the loyal opposition made their case in a respectful, policy-focused and sometimes surprisingly wonky manner.

Prez vs. Repubs: a tie here means the Repubs won this round by not being led into the trap of being portrayed as the "Party of No."

Other observations:

Media, Editorialists, Bloggers and other Commentariat: even though none of the participants seemed to change their minds and it's unlikely that many health policy adepts gained new insights, the Summit video and transcript is a quotation target-rich environment. The DMCB suspects much of it will be out of context.

Reconciliation? When raised, the Dems implied that there has been no decision regarding the parliamentary path to reconciling the President's proposal and passing the House and Senate bills. Their disingenuousness - acting like they'll be the last to realize what the rest of the country already knows - suggests they're aware that filibuster-busting "reconciliation option" has a LOT of baggage. This is a big big gamble in an election year and this was a key signal that they know it.

Democracy in Action: persons living outside of the U.S. (and maybe Great Britain) will undoubtedly marvel at the willingness of our members of Congress to repeatedly interrupt and attempt to correct the Leader of the Free World. The first generation DMCB thinks the quote is apropos: "Only In America."

Wellness/Care Coordination: Maybe it's because the proceedings were televised, but participants on both sides of the aisle pointed to several things they can agree on. A prominent one was wellness and care coordination as a means to control costs. The DMCB found that to be not only very gratifying but very insightful of our elected officials.

And some surreal moments:

After the President made his opening remarks, the Republicans turned to the folksy Lamar Alexander of Tennessee to be the first out of the gate. As the cameras panned around, it really appeared as if the House Speaker and the Senate Majority Leader were pointedly looking away. Maybe the DMCB is being over-sensitive to the depths of the partisan rancor.

Representative Louise Slaughter (D-NY) had her own anecdote involving dentures and seemed to imply that they should be included in the Medicare benefit.

Sen. Rockefeller (D-WV) described all health insurers as "rapacious" "sharks," and later seemed to agree that all Americans should be obliged to buy health insurance.

Senator Harkin (D-Iowa) said segregating groups into various risk pools with the premium differentials they entail is the kind of "segregation" that is unjustly discriminatory. Now that's a new one.

Last but not least, one Representative observed that never before had he seen so many from Congress act so well for so many television cameras. That prompted some chuckles, but it also speaks to what must be going on behind the scenes. If true, our country deserves better.

('’)


Etch-a-sketch image from Wikipedia

The Latest Cavalcade of Risk Is Up!

Managing, transferring, categorizing and fearing risk: you can find out how to do all that and even more by checking out David Williams and his Health Business Blog's latest Cavalcade of Risk. It's safe to go in the water and it's even smarter to check it out.

J.D. Salinger, Franny and Zooey's Fat Lady, Lent and the White House Health Reform Meeting

Since the Disease Management Care Blog has repeatedly belabored J.D. Salinger's Fat Lady, familiar readers may ask why it didn't mark the author's passing on January 27.

It was waiting for the right time. This posting is dedicated to him.

Recall the 'Fat Lady' is that piercing insight achieved by the crisis-addled Franny. Thanks to the counseling of her precocious brother Zooey, her breakthrough helps her deal with a favorite theme of J.D: the modern world's self-absorbed fakery. Franny realizes that her deepest human potential will be met so long as that poor distant woman 'sitting on a porch, listening to the radio' is served - because that Fat Lady really represents something far more wonderful.

Which leads us to the confluence of two other events, one being major and the other relatively minor. One is Lent, the other is Mr. Obama's Feb. 25 go-for-broke Blair House health reform meeting. Lent is that 40-day season before Easter when believers practice self-denial, penitence and seek insight, including thinking about all the other '40's' that are embedded in the Christian calendar. That includes the Jews' 40 years of wandering about in Sinai, as well as Jesus' fasting for 40 days in the desert while being tempted by the devil.

And what temptations they were. The DMCB's amateur interpretation is that Satan's three offers appealed to our most basic human needs: turning stones to bread means freedom from hunger, the 'on-call' availability of angels after leaping off a pinnacle means being immunized against death, and having dominion over all the world's kingdoms means absolute power.

The DMCB isn't suggesting that ashes be passed around or that scripture be read at the Feb. 25 health reform confab, but the Temptation of Christ does have something to teach about the fundamental hard wiring of the human condition. Being "human" means to live by more than bread alone, by being content with some hard facts about our mortality and to being acutely aware of the hazards of concentrated political power. Otherwise, we risk falling far short of meeting our deepest human potential. In order to achieve that, something far greater is necessary.

The DMCB has little doubt that there are honorable people on both sides of the health care debate, that there are critical policy issues at stake and that social justice is in our lifeblood. While some may wonder if the DMCB has turned into some wingnut case full of the Devil Made Me Do It, it thinks the lessons of Lent and the Fat Lady should give pause about the tempting notion of being able to practically cure any threat to our mortality if only we were willing to apply the right kind of enlightened political power.

Franny was a radio entertainer, so she knew something about audiences. When she recognized the Fat Lady was out there, she got her life in order. For the Feb 25 Health Reform meeting, our elected representatives would be well advised to remember the Lenten season and that the Fat Lady is in the audience. It can only help.

The DMCB thinks J.D. would probably approve.

*Since J.D. probably wouldn't permit an unauthorized image of him to be shown, the DMCB decided to portray the prayer (this one's in original Romanian) repeatedly uttered by Franny until Zooey's rescue

About A Third Of the President's Reform Proposal is Devoted to Attacking Medicare Fraud: Will It Work?

Looking back at its career, the Disease Management Care Blog suspects at some point or another, it could have been accused of having technically committed Medicare fraud. Not intentionally of course, but the intensity of service, the documentation, the modifiers, the "incidental to's" CPTs, DRG's, ICD-9's and whatever else was used by the billing office was a thicket of coding logic that seemed to get more complex with each passing year.

That's because with each passing year, the regulations grew more complex in response to increasing levels of Medicare fraud. The DMCB recalls when the teaching hospitals got slammed, the Tenet imbroglio and HCA's expensive troubles. And it hasn't stopped there, including issues, for example, with 'professional courtesy,' enrollment rules, and lately the dreaded Recovery Audit Contractors. In fact, the DMCB stumbled across a Google function that collects web pages on the topic of Medicare fraud and they number in the hundreds. Like an arms race, the government ratchets up its anti-fraud efforts and still, the miscreants find new ways to steal.

Which is why the DMCB is turning once again to the President's Health Reform Proposal. Out of the 11 pages, there are three on attacking 'waste fraud and abuse,' and most of it is directed against the fraud part. There are items that pertain to following bad actors with a history of malfeasance (sort of like a Medicare 'no-fly list), background checks, real time as well as wider data sharing among various enforcement agencies, profiling increased penalties and greater enforcement lattitude.

We've heard this before (here and here, for example) and we're supposed to believe this time it's really really going to work. Trust me.....




Right.

And if the posture of the President's Proposal, when it comes to fraud, strikes you as borrowing concepts from the war on terrorism, then you may understand why some docs may fear being ensnared somewhere in that increasingly complicated grey zone that separates 'simple mistakes' and 'trying to take advantage of the Medicare system.'

Did Wellpoint's Rate Increase Lead the Obama Administration to Propose the Health Insurance Rate Authority ("HIRA")?

Wow. 'The President's Feb 22 Proposal' will cut health premiums, increase competition, promote accountability, eliminate pre-existing condition denials and reduce the deficit. The Disease Management Care Blog knows it is so, because that's what it says on the 1st page.

The DMCB is still chewing on this, but here are some of the more important features in store for commercial insurance reform: the individual insurance mandate is still there with financial assistance consisting of a mix of 'carrot' tax credits and direct payments to insurers. These are combined with the "stick" of "assessments" (a.k.a fees) for those who go without insurance. In addition, employers still need to provide insurance coverage (helped with tax credits for small businesses) or also face "assessments." Once those new fangled insurance exchanges kick-in in 2014, there can be no denials of coverage based on pre-existing conditions and there can be no annual or lifetime limits. As for those so called 'Cadillac' plans, the plan is to delay the excise tax and raise the premium threshold. Many of the comparative number details can be found in the Wonk Room.

There's one other key feature of commercial health insurance reform, which is quoted below:

"...creating a new Health Insurance Rate Authority to provide Federal assistance and oversight to States in conducting reviews of unreasonable rate increases and other unfair practices of insurance plans..... health insurers must submit their proposed premium increases to the State authority or Secretary for review... if a rate increase is unreasonable and unjustified, health insurers must lower premiums, provide rebates, or take other actions to make premiums affordable....(the Government will) provide needed oversight at the Federal level and help States determine how rate review will be enforced and monitor insurance market behavior" (bolding from the DMCB).

The alleged origin of all this, of course, is Wellpoint's political tone deafness when it raised its insurance rates right in the middle of a national debate over health care reform. It would appear that when Anthem's February letters went out announcing the rate increase, the White House announced that enough was enough, went on offense and came to the rescue with its proposal for increased Federal "HIRA" oversight.

The DMCB doesn't think so.

According to this article, the California Department of Insurance knew of Wellpoint's plans in mid-November. The DMCB can't believe that the White House only recently learned of the planned rate increase and was just spurred to action by shocked moral outrage. More likely, it decided weeks ago that it needed cover for its tweaked evolving health reform proposals, looked around for an insurer it could mug and naturally landed on that perennial recissioning, coverage-denying, for-profit and outrageously paid executive-led Wellpoint. Talk about a political windfall of perfect timing.

But the political DMCB doesn't mind, even if it hasn't been invited to the February 25 Health Care Summit confab. Here's why.

In the end, it really doesn't make any difference if the States are presiding over health insurance premium increases or the Feds are. In the end, each line of business within an insurance portfolio needs to stand on it's own two feet: the DMCB and Ms. Sebelius know that health insurers a) have a fiduciary duty to charge actuarially sound rates that will pay the medical bills, and b) are not allowed to cross subsidize between insurance lines, no matter how profitable one or more may be. While the Washington DC's "assistance," and "oversight" are technically an intrusion on the States' Departments of Insurance, the DMCB is betting that most of the Commissioners won't mind giving up that political and regulatory headache.

Which is why the DMCB will close this posting with this piece of advice to the Republicans: even though you may discern that this is another repugnant expansion of Washington's bureaucracy, it's OK to yield on this particular issue in front of the C-SPAN cameras because it won't ultimately make that much of difference. You'll look less like the 'Party of No' if you agree and, who knows, maybe you can leverage this in exchange for a compromise over what's really important.....oh, like physician liability insurance reform, further rolling back all gun control laws or, better yet, getting an agreement from Jon Stewart to book at least five softball interviews to make up for this blunder on The Daily Show with y'all.

A Quick Summary of Arguments Against the Dartmouth Atlas and Why They May Come Up at the White House Reform Meeting

Like two large ancient armies, the Democrats and Republicans are grimly getting ready for their Feb. 25 White House Health Reform 'dialog.' Around the distant camp fires, rhetorical pikes, speaking point axes and argument maces are being distributed up and down the line, while plans and counter-plans are being prepared in the pursuit of total victory.

The Disease Management Care Blog will leave it to the far more connected commentariat to provide minute-to-minute analysis of the unfolding order of battle. However, the DMCB figures that one issue that may figure prominently in the televised verbal jousting is the issue of 'unnecessary' or 'wasteful' healthcare variation, a.k.a., the Dartmouth Atlas. This says, but for the export of the efficient care of places like the Mayo Clinic to the rest of the country, we could be saving a LOT of money. According to years of research (much of it based on Medicare beneficiaries in the last two years of life), there are considerable geographic variations in the national healthcare cost landscape that cannot be explained by quality or any other outcome variable. In fact, the Atlas data suggest the opposite: that the more money is spent, the worse the outcomes.

Regular DMCB readers, however, know that the Dartmouth Atlas has not been without controversy. The DMCB is pleased to review its prior posts and offer this efficient and linked executive summary of the reasons why the Atlas folks may not be entirely correct. In the coming televised verbal combat, look for one or more of these five arguments to be used by the reform opponents:

1. It's Local Patient Poverty: critics charge that the variation in the observed cost of care correlates with the degree of local poverty, which leads to a higher burden of (especially chronic) illness, more readmissions and longer lengths of stay with greater intensity of care. This interesting post contends that when chronic illness is backed out, white the Colorado suburbs end up looking a lot like the infamous McAllen, Texas.

2. And Hospital 'Poverty' Too: it's also been pointed out that areas of high poverty tend to have poorer hospitals that can't afford the quantity and caliber of nurses or state-of-the-art technology. They're probably getting more than their fair share of Medicaid patients, which is a notoriously poor payer. The degradation in efficiency and inability to provide additional programs also results in more readmissions with complications.

3. 'Bring Out Your Dead!': this article shows that when you look backwards at the patterns of care for Medicare patients that have died, you're excluding the patients that are still alive thanks to pricey health care resources. In contrast, looking forward reveals that higher costs and longer hospital lengths of stay can be associated with survival. This opinion piece in the New England Journal concurs, pointing out that it's important to not only examine the costs for patients that have died, but the severity of illness as well as the outcomes for all patients receiving care.

4. The Underlying Assumptions: this same opinion piece in the New England Journal points out that hospitals don't necessarity control all health care costs in the two years leading up to death.

5. It's Medicare: it's also been pointed in the Journal that the Dartmouth Atlas looks only at fee-for-service Mecdicare. A better gauge of hospital costs would be to examine all charges on all patients. What's more, the charges for FFS Medicare has poor correlation with overall hospital efficiency.

Why care about this? One cost-saving proposal in the pending legislation is to examine the possibility of using economic sticks and carrots to reward hospitals on the basis of Atlas-style efficiency. So, while there is debate about its underlying scientific merits as well as the leveraging of any argument that could upend Obamacare, there is something far more political here. Since hospitals are large employers in many Congressional districts nationwide, the DMCB predicts the Republicans will attempt to use this as a classic "wedge issue' to peel away the Dems that are from districts with allegedly high cost hospitals. Look for it on the 25th.

Important Webinar Alert

Are you flummoxed by the methodology utilized to evaluate disease management outcomes? Do you wonder why the experts utilize the word "methodology" instead of "method?" Do you wish they'd stop with the "utilize" stuff and just use the word "use?"

You're in luck because the DMAA is hosting a pair of Webinars that will help you better understand its important (and free, by the way) guide, the 'Outcomes Guidelines Report, Volume 4.' The March 4 kick-off includes faculty who really know what they are talking about: Soeren Matke of Rand and David Veroff of Health Dialog. Compared to other webinars, the pricing is quite modest, especially if you're a DMAA member.

HealthReform.Gov: Insurance Companies "Prosper," Families Suffer and CMS Gets Even Slicker With the Facts

The Disease Management Care Blog doesn't know just how it happened, but its email address has ended up on the HHS press release list. It likes to think that it's because of the DMCB's sprawling internet Wikio Top 5 readership, but more likely it's because it signed up to receive automatic alerts from CMS about its ongoing demos.

The DMCB spouse points out that it certainly isn't because anyone in charge at HHS is actually paying attention to what the DMCB has been posting (here and here). As usual, she's right: if that were the case, they wouldn't have released today's HHS FOR IMMEDIATE RELEASE 'Press Release' about this fiasco of a report.

Titled "Insurance Companies Prosper, Families Suffer: Our Broken Health Insurance System," the report is all of 1286 words. While the DMCB salutes the folks at HHS for their break with a habit of issuing text that routinely exceeds 1286 pages, this bullying demagoguery reflects poorly on the former State Insurance Commissioner with a reputation for moderation.

According to this manifesto, the White House's plans for 'reform' (i.e. what the President and the Congressional Chair-Mandarins seem so far unwilling to compromise on) will:

'Increase government oversight, enforce medical loss ratios, increase public scrutiny and leverage exchange participation.'

It could also increase red tape, lead to regulatory uncertainty and, no matter how much they bully, do little to slow down the relentless medical cost inflation or change the fact that 'billions' in insurer profit is the result of single digit returns spread over very large reserves and regulated surpluses.

'End arbitrary limits placed on coverage by insurance companies.'

Benefit packages are regulated by the states, many of which have run amok by being unable to say no to any constituency and blowing past limits on medical services that strain the definition of 'medically necessity.' Federal meddling could only make it more complicated. And here's some apostasy: caps on benefits, like it or not, are also one way to cap the cost of health insurance: why not contemplate their reasonable use, especially if costs are truly out of control and if (and that's a big if) consumers are aware of they entail?

'End denials of coverage based on health status.'

We've been through this. Without an accompanying universal insurance mandate with teeth, the only persons who will want coverage are those with poor health status. Right now, despite shifting polls, the chances of Congressional approval of a mandate looks about as good as Ms. Sebelius posting a comment on this blog that thanks the DMCB for its erudition.

Create competition among insurers with a health insurance exchange.

While the DMCB likes 'competition,' it's the big insurers with big reserves and big surpluses that are able to survive the inevitable underwriting cycle.

Ensure value in our health care system by rewarding quality, efficiency and coordination.

The DMCB asks if that's the case, then why are the majority of these initiatives being assigned to pilots (whatever they are) and 'demos,' a political morass where good ideas go to die?

Lower premiums, based on a Congressional Budget Office report that estimates streamlining and the entry of more people in the market will lower individual costs by 14 to 20 percent.

Oh? The DMCB went to the CBO Director's Blog and found this November 30 quote about Senator Reid's proposed Patient Protection and Affordable Care Act:

"Average premiums in this (the non-group market) would be higher than under current law primarily because the typical insurance policy in this market would cover both a substantially larger share of the average enrollee’s costs for health care and a slightly wider range of benefits."

Crossing swords over what the CBO said or meant and when that happened aside, however, the fact is that projections about future health insurance are like looking at a blurry chest x-ray from an moving and uncooperative emergency room patient at 2 AM: guesses built on assumptions made up of shadows.

Last but not least, in watching the accompanying video, it really appeared to the DMCB that Ms. Sebelius spent less time addressing the points above and more time trying to portray how 1) CMS can be the watchdog agency that will bring the insurers to heel if only wearegiventhepowertodoso, and 2) righteous the President's agenda for health care reform is. Watch it and draw your own conclusions here.

+++++

Coda: Carl Mecurio has a pair of worthwhile posts on the topic with a different spin over at the Corporate Research Group (CRG) Blog. He agrees that insurers make an easy target, that the rhetoric is, well, rhetoric and that the individual market is in need of some serious work. He also provides some important insights about Pennsylvania's adultBasic. In the meantime, the DMCB isn't sure if the Administration's health reform proposals will a) just spread the underlying cost inflation over a larger pool and hide it with unsustainable deficit funding or b) jump off a political cliff by imposing an unsustainable mandate. Well worth a look.

The Latest Health Wonk Review Is Up!

There's the politics, the economics and then there's the medical dimensions of health care reform, but what about its psychology? Even so-called 'pop' psychology can give important insights into what is going on. Dr. Phil is coming to the rescue in a superbly hosted Health Wonk Review over at Brady Augustine's medicaidfirstaid. Bravo!

The Reality of Health Insurance in the Individual Market: Even State Programs Are Increasing Rates

The Disease Management Care Blog doesn't much care for drama that pits white hats against black hats. Novels, plays or movies that portray triumph and tragedy despite our very human flaws are the ones that have staying power because they give us insights about ourselves. Franny's borderline mawkishness, Hamlet's dithering and even Hans Solo's mercenary swagger are the ingredients that can distinguish the serious from the superficial plots. These are the stories that tell us about the human condition and how we deal with our grey world.

Contrast that with other vacuous fictions, like each of us has a marketable talent awaiting discovery by Idol, adolescent vampires routinely sport 6-pack abs and that stand-alone health insurers exist only make huge profits at the expense of the little guy. These simple plot-lines provide a nice fix in a culture addicted to superficial explanations, but little else. What's next, that all that's needed to be President is common sense and conservative values?

Anthem and other health insurers were pilloried ('screw its customers,' or 'defiant and unapologetic') for passing its increases in overall health care costs in a changing book of business to their individual market customers. Yet, for a grey-world reality check, take a look at this report about Pennsylvania's adultBasic program. Run by Pennsylvania's Insurance Department using funds received from the National Tobacco Settlement and through 'voluntary' contributions from the State's 'Blues' plan, it serves as the health insurance program 'of last resort' for indigent individuals unable to obtain insurance elsewhere. Currently, there are just over 40,000 enrollees who pay a subsidized premium of $35 a month, but, due to lack of funding, there is a waiting list of approximately 3500 qualified individuals who pay the full premium of about $330 a month.

Well, thanks to 'sharply rising costs,' persons on the waiting list will see their preimum double to $600 a month. For those already in the adultBasic program, their monthly premium will go up by $1 to $36, but office visit as well as emergency room co-pays are doubling and other services will now have a 10% co-insurance. The reason for these increases in a group least able to afford it isn't because this health insurance program is putting profits before patients, but because:

'...general “medical” inflation: medical appointments and procedures simply cost more than they used to. Another major reason for ... cost increases is that everyone who accesses the benefit package tends to use medical services at a level much higher than in the commercial market. Because of these factors (general medical inflation plus significantly higher usage), the rates needed to be increased substantially to allow the program to continue covering as many people as possible.'

Of course, upon further quiet reflection, smarter folks recognize that it's not the insurers' 'fault,' but a business model that even Republicans agree is broken. Yet like any good storyline, flawed fixes abound: individual mandates to increase the risk pools seem politically unpalatable and do little about the underlying rising frequency and severity of claims expense, while tax breaks and cross border sales could result in a race to the bottom for even fewer people who choose to buy insurance.

This is not easy stuff. Superficial storytelling may make for heros and villains from either end of the political spectrum, but our flaws and the greyness of reality is far different.

Unemployed Sons and Fathers: Implications for Disease Management and the Patient Centered Medical Home

Writing in the New York Times, David Brooks points out that we're entering the lean years with 8% unemployment extending out to the horizon. It's men that are turning out to be the victims of our Great Recession, with a close to 20% umployment rate for those between the ages of 25 and 54 years. For the first time, a majority of the U.S. workforce will be made up by women.

For the chronically unemployed, there are issues that go beyond the impact on health status. On a long term economic basis, there could be less upward mobility and stunted wage growth. At a more significant level, the cultural American ideal of masculinity itself may have to be redefined.

While this megatrend continues to unfold, the Disease Management Care Blog thinks there are some more immediate implications for the disease and care management industries:

While pregnancy care appropriately focuses on the mothers (for example), how will the pre and perinatal 'dyad' care be impacted (think HEDIS first trimester care) by mothers who also happen to the sole family breadwinner? What's the role of fathers in assuring timely follow-up for their newborns? When disease management and medical home care managers call the child's residence to see how things are going, will they be prepared to deal with a male voice?

At the other end of the age spectrum, until now it's been up to the daughters to deal with most of the work involved with being in the sandwich generation. The DMCB has seen them at clinic appointments and in hospital hallways. As more men assume greater responsibility for their struggling parents, how will gender issues that surround coping skills play any role in the support systems for our nation's elders? How will the disease management industry respond? Will care managers in patient centered medical homes adjust appropriately?

And finally, in the absence of a one-size-fits-all insurance mandate, there are implications for the families that primarily depend on an employed female breadwinner. The DMCB thinks women employees are not only more vulnerable to being underpaid, but being in pay-grades with more minimalist insurance or being forced to chose skinnier insurance options with a smaller pay check deduction. Navigating a family though high deductables, co-pays, co-insurance and benefit limits will be more important than ever in care management.

('’)

The Jefferson Colloquium on Population Health and Disease Management

The Disease Management Care Blog is getting prepared for travel. PowerPoint files are being updated, literature searches are being finalized, graphics are being prettied up, hotel rooms are getting reserved and planes, trains and automobiles are being arranged. It has two speaking gigs coming up and one of them is Jefferson's once-a-year Population Health and Disease Management Colloquium.

In a three-for-one bargain, the Colloquium will be collocated with the National Retail Clinic Summit and the Second National Medical Home Summit at the downtown Marriott in Philadelphia. It promises to be a premier event, what with speakers from Health Affairs, AHRQ, government, academia, physician organizations and industry. The DMCB is especially looking forward to hearing what the disease management organizations are up to and what advanced versions of care management are being assembled in conjunction with patient centered medical homes. There's also the happy prospect of seeing old friends and making new ones.

And the loquacious DMCB is looking forward to serving double duty at the conference. On the first day, the Colloquium organizers were foolish enough to cede the DMCB the last 45 minutes of the day so it can discuss 'health communication and social networking.' When THAT's over, it'll be time for celebratory beverages. On the second day, the DMCB will be part of the closing panel discussion on Innovation, Strategy and Practice.

If you can't go because your boss is a short-sighted cheapskate who doesn't want to pay for travel even though the DMCB will be there, point out that you also have the option of watching the conference via live streaming video. It'll be available on-line afterwards, making it even easier for you to liberally quote from it.

Finally, as a bonus for the thousands of regular DMCB readers, here's one preview on the topic of communication and networking: the competition for 'eyeballs' (attention) in social media is won by a) content and b) nimbleness. The former is only partially defined by accuracy and the latter is only partially defined by timeliness. What is important, however, is that neither depend all that much on formal credentials. In it's travels around the blogmos and the twitterverse, the DMCB is running into 'netizens' who, with study, hard work, passion and some luck can turn out to be just as much of a player as many of us so-called university-trained experts. This has huge implications for the transmission of health information gleaned from advances in health care, especially for research journals, health educators and the disease management industry.

See you there!

Some Common Sense Suggestions on Health Reform

In a prior post, the Disease Management Care Blog reviewed Business Week's dour report on disease management. As readers may recall, BW relied on the single anecdotal experience of a dubious General Electric medical director to portray the entire care management industry as a waste of money.

Well, that same General Electric medical director has penned a common sense editorial about health reform in the most recent on-line version of American Journal of Managed Care. It gives good insight on how a commercial non-governmental employer-insurer thinks about insurance reform.

His DMCB-abbreviated short and sweet recommendations follow:

First, everyone has to agree on four assumptions:

1) Reform is a work in progress and rapid cycle assessment of pilot programs is necessary,

2) Provider payment systems need to evolve quickly to being performance based,

3) Not only is all politics local, so is health care

4) Continued flexibility on pursuing quality and cost is important.

Assuming everyone can agree on these, then.....

CMS and the private sector will need to coordinate performance-based payment approaches. Neither alone are likely to get the docs' attention.

Beware the unintended consequence of increased provider coordination that could lead to the formation of local physician-hospital monopolies. Pricing transparency is a minimum requirement and if that fails, CMS and private insurers will need to enforce price ceilings.

That being said, the collective experience of the experimentation described above could act as a national information resource and act as a safe harbor that allows the physicians to focus on clinical quality improvement rather than payment rates.

The DMCB hopes someone points these out at the Feb. 25 White House health reform meeting.

A Report on the Electronic Record and a Report on the Patient Centered Medical Home: Good Reading

The bookish Disease Management Care Blog found two recent and interesting pieces from the medical literature for your consideration. One deals with the electronic record and the second deals with medical homes. Both are written with the physician incentives in mind and deserve to be considered by policy-makers and anyone with 'line' responsiblity for dealing with either of these two initiatives in a provider network.

The first is from David Kibbe MD, a senior advisor to the American Academy of Family Physicians. Writing in an online 'ahead of print' version of Family Practice Management, Dr. Kibbe offers up some words of caution over the latest plan (proposed rule making) by the Feds to promote the 'meaningful use' of the electronic health record (EHR). This should give pause to policy makers that think the EHR is a wonderful idea that only needs a nudge to make it become reality in every corner of every physician practice.

Basically, he says, the Feds' latest actions have raised even more uncertainty. As a result, physicians without an EHR may elect to sit tight and use paper for at least one more year or longer. According to Dr. K, here's why:

1. emerging 'meaningful use' requirements by the Feds will force EHR vendors to reconfigure their wares, which is leading to future price uncertainty. (Ditto for the docs that were brave enough to invest in EHRs, by the way).

2. health reform has been slowed, leading to additional uncertainty about future physician fee schedules, revenue and their ability to afford investment in an EHR in the first place.

3. 'modular' EHR-like components are around the corner, which will allow docs to assemble 'clinical groupware' into a functioning EHR, which raises additional uncertainties.

4. the Physician Reporting Quality Reporting Initiative (PQRI), another CMS program that promised to reimburse physicians outside of the normal fee schedule 'P4P style,' has not gone all that smoothly. Docs may doubt that the government can really deliver the goods, er, make that checks.

5. money aside, it's just a big hassle to deal with Uncle Sam

6. the meaningful use process will eventually require the on-line submission of quality outcomes data. Right now, it's not clear how CMS will handle what promises to be a huge data load, introducing even more doubt about the promise to pay physicians in a timely manner.

7. the Feds are threatening penalities down the road for physicians that don't comply with meaningful use EHRs. Many physicians may respond by planning on using paper until that date and then simply retire from practice altogether (when the economy eventually turns around and the 401k's get back)

The second article is available (subscription required beyond the abstract) at the Annals of Internal Medicine. Recall that advocates of the Patient Centered Medical Home (PCMH) suggest that physicians who offer it should be reimbursed with a monthly and risk-adjusted fee per PCMH enrollee in addition to the usual fee-for-service payments. If that sounds like 1990's style capitation, you're right. Written by Ann Mirabito and Leonard Perry of Baylor, the article presents three HMO mistakes that need to be avoided by capitated PCMHs:

1. resist the temptation to go along with any mandated patient enrollment in medical homes. If PCMH's work so well, they should have no problem attracting patients by acting as a 'trusted' guide to navigating referrals in a patient-centered and evidence-based manner.

2. early HMOs were regarded as patient friendly, but things quickly turned sour when there were too many patients and things turned impersonal. Physician practices without the capacity to truly be medical homes will need to resist the allure of signing up too many patients and grabbing all that capitation revenue.

3. simple risk-adjusted payment systems will simply reward physicians for signing patients up. Better to include meaningful dollar incentives that reward measurable quality.

The Feb. 25 Healthcare Summit: Time to Transition from 'Yes We Can' to 'Yes We Will'

It starts at 10 AM here

President Obama has invited the Congressional leadership from both political parties to a televised Feb. 25 White House 'summit' on health reform. The Republicans are leery yet confident, the Democrats are grim and determined, and the bloggers promise to be on this thicker than cardiologists on a proposed fee reduction. Like other denizens of the blogmos, the Disease Management Care Blog looks forward to viewing the video, combing through the transcript and reading the participants' body language.

This could turn out to be grand political theater at its dysfunctional finest. Yet, while the DMCB is fed up with all the Machiavellism, it thinks the Feb. 25 meeting is a necessary evil. It could turn out to be the dark before the dawn - the cloud behind the silver lining.

Here's why. In order for bipartisan health care reform to succeed, the naive DMCB thinks it will need to devolve into the boring complicated policy-over-politics process that it really is. That means having many more competent, serious and responsible meetings dealing with stuff like entitlement reform and changing how providers are paid.

There are three ingredients that will help that happen:

1) the Republicans need to be 'win-win' kept at the table over the long term with the goal of giving everyone credit. They've demonstrated an ability to derail things and their cooperation has moved from optional to necessary.

2) with the usual exceptions, ongoing C-SPAN video style transparency is needed to keep posturing to a minimum. While the common wisdom is that public scrutiny could derail delicate negotiations, the DMCB is confident that the mainstream media will move on in its search for the salacious, leaving behind a committed viewership. Sure, it won't be pretty, but it'll be better than the big government reformists being trapped in a closed information loop.

3) our elected representatives are given free reign to behave badly at this kick-off meeting. To quote the Godfather's Clemenza, some opening-bell rancor will 'help to get rid of the bad blood.' The DMCB says it's OK if the Feb. 25 meeting serves as an opportunity to photo-op for each party's base. After that, it's time to roll up the sleeves and get to work.



So, watch the Feb. 25 meeting. If there are no plans to a) continue meetings b) in a televised manner, the DMCB will fear that health reform will truly remain in disarray. If there are plans for additional meetings and they fall off the news-cycle radar screen, we may have a chance at actually accomplishing something. This is how we'll know if the Obama Administration is stuck in campaign mode or is really interested in serious policy accomplishments.


It's time. Less Yes We Can and more Yes We Will.

The Latest Cavalcade of Risk is Up!

John Leppard describes it as the best risk-based writing on the web. The DMCB says it cannot disagree and that this is stuff you won't see anywhere else. Check out HealthCare Manumission and all the provocative posts that range from weed to workers comp to health care to investing!

Ms. Sebelius and Wellpoint's Rate Increases: Doesn't HHS Have Enough to Worry About?

Egads, doesn't Ms. Sebelius have enough to worry about?

Our HHS Secretary faxed a letter to California-based Anthem Blue Cross, expressing how 'disturbed' she was by 'unaffordable' rate increases 'as much as 39%' in the face of 'soar'ing $2.7 billion profits. She calls for greater transparency on the ratio of medical vs. overhead costs and urges Anthem to 'cooperate fully' with California's Insurance Commissioner, because [gulp!] she will be 'closely monitoring the situation.'

While the Disease Management Care Blog appreciates this latest example of perma-campaign mode political grandstanding, it would like to remind the HHS leadership that there is no national health insurance comissioner with jurisdication over state regulated plans. Ms. Sebelius' considerable administrative and political skills would be better spent addressing the government's 10.4% trend rate, relentless growth to the point of accounting for 50% of all health care costs, a budget increase in 2011 in excess of $80 million with close to 3000 additional FTEs, not having anyone at the helm at CMS, and a looming deficit that has perilous national security implications.

The DMCB hopes that Ms. Sebelius' puffery wasn't completely orchestrated by the White House's Four Horsmen and that she actually took the took the time to personally look at Wellpoint's 2009 financials. If she did, she'd know the company lost 1.4 milion members, mostly from its small group business. Operating revenue went down compared to 2008, the cost trend was high at 8.9% thanks to rising provider costs and investment income was lower. The DMCB suspects it all adds up to a toxic brew of premium increases due to a combination of higher medical costs and unfavorable underwriting: in the current economy, healthy persons that can do without insurance drop it, leaving behind relatively more sick persons with high health care costs. The DMCB wonders why no one has pointed out that a rate increase was the responsible thing to do in the face of relentless health system cost increases - unless, of course, you're willing to trample on State's rights, fudge entitlements, print money and borrow from the Chinese.

Ms. Sebelius can fuss all she wants. The there are only so many premium dollars to cover the cost, the State of California is in charge, and the Obama Administration's time would be better spent on dealing with bigger problems that it can actually do something about.

Current and future Medicare beneficiaries deserve better.

++++++++

Addendum:

For an update on how things can snowball (no pun intended for those of us living in the Mid-Atlantic), check out the investigative spleen venting in the Health Access WeBlog. The veteran Bob Laszewski has more middle-of-the-road perspective here at the Health Care Policy and Marketplace Review Blog.

The DMCB is going to double down and predict that, once the news cycle moves on, Anthem will quietly provide all its pricing information to all the various Committee Chairs, Senators, Commissioners, Commissars and Potentates. After a requisite amount of nit-picking and face-saving adjustments, the bulk of the premium increases will stand. That's because, in this particular instance, health care inflation and the political process are the real problems, not the health insurance industry.

Compare and Contrast CIGNA's and General Electric's Approach to Disease Management. What's the Difference... Really?

After reading the latest CIGNA earnings call transcript, the Disease Management Care Blog couldn't help thinking some more about the Business Week (BW) faux exposé of the disease management (DM) industry.

CIGNA seems to have had a very good year thanks to a total income of $1.1 billion or earnings of $3.98 of per share. This represents an impressive 16% increase compared to last year. Not only have their capital levels been clawing their way back to healthy levels, but the insurer has also been tackling overhead, including a reduction of $100 million in its healthcare operations, while simultaneously providing a 24/7 service model with 'a broad portfolio of capabilities to achieve health improvement, including risk identification, lifestyle and wellness programs, incentives, coaching, and engagement services.' Armed with a motto of 'Go Deep, Go Global, Go Individual,' the company said that '(t)here is no question (that), regardless of what happens with US healthcare reform, there will be more individual accountability for health and healthcare. So "Go individual" is a fundamental philosophy as well as part of our growth strategy.'

Critics of DM would probably say that CIGNA's commitment to the principles of DM described above isn't based on proof, but to unsophisticated market demand. Yet, there is still a telling contrast between CIGNA's many 'believing' customers versus the experience of General Electric that was described in BW. If many pilots and trials of DM are conducted in multiple settings, a distribution of outcomes is pretty much guaranteed. Is the one company's experience with DM described by BW typical, or a statistical outlier? The DMCB can't tell, but has learned to distrust the media's ability to distinguish between the two.

The faultfinding BW article ends with a description of a curious decision by GE:

This spring, GE will start an outreach service that shares some elements with traditional disease management. Nurses will use claims data to identify gaps in care, such as unfilled prescriptions or missed checkups. But rather than just contacting patients, the nurses will also call the treating physicians, if patients agree....

What about the company's pronouncement that its experience with DM was a failure? It's more likely that, much like the rest of the DM industry, there is ongoing innovation, building on the lessons of what has worked and what doesn't work. Much like CIGNA, it appears GE appears to have a commitment to population-based care management that includes remote nurse coaching. Does that include what BW portrays as foolish DM? You be the judge.

In the meantime, good for CIGNA, good for GE, good for the DM industry and most of all, good for the moms, dads, grandparents and all the American workers and dependents that are lucky enough to be insured by CIGNA or to be working in companies like GE.

Let the evolution continue.

Business Week and Disease Management: A Closer Look

The Feb. 4 Business Week has an article on disease management provocatively titled ‘Take Your Meds, Exercise – and Spend Billions.’ The accompanying graphic displays a circa 1950’s nurse pointing to a Rube Goldberg contraption that ends in cash being shredded.

Ouch.

The article opens with a description of General Electric’s disease management (DM) misadventure and contrasts that with the seemingly inexplicable $2.5 billion commitment of 75% of the nation’s large employers to the DM industry. Even more mysterious to authors Chad Terhune and Arlene Weintraub is the success of ‘industry lobbyists’ in convincing the Obama Administration and Congress to include some version of DM in health reform. They credit a vast lobbying operation, fanciful marketing, exaggeration, lack of scrutiny and the dissemination of biased insider studies. And what unfriendly news article on DM would be complete without dredging up the hapless Medicare Health Support study. Alas, says the expert-critics that are quoted in this piece, tobacco cessation and exercise promotion have no return on investment, it's all waste, it's all money down the drain!

To the reporters’ credit, they did take the time to interview industry veterans who recycle many of the Ver. 1.0 arguments in favor of disease management: 1) the fact that employers and Medicaid programs continue to support the concept year after year cannot be ascribed to naivety, there’s gotta be something to this, 2) studies in the public domain are old studies with crude methodologies examining relatively primitive programs, while newer studies or newer programs are in-house, involve state-of-the-art consumer/physician oureach and not readily available to dubious reporters, and 3) enough with Medicare Health Support already, it was stillborn thanks to sicker patients tilting the intervention groups and Medicare strangling things by not providing timely information.

The Disease Management Care Blog offers up some additional Ver. 2.0 observations not addressed in Business Week:

1. While measures used to gauge DM, such as claims expense and hospitalizations are relatively crude, the DM industry has only just begun to coalesce around a common assessment methodology. Future reports on DM’s programs will a) hopefully use it and b) submit their findings to peer review. Pending that.....

2. No proof that DM works is not the same as proof that DM doesn’t work. And if the lack of proof is the standard by which we should judge the merits of medical care in general, what proof is there that the patient centered medical home, pay for performance or the electronic health record really saves money? Or for that matter, has anyone subjected primary care to a prospective randomized clinical trial? Before readers shake their heads at such apostasy, consider an important question: would the introduction of a primary care network into Dade Country result in lower per capita health care costs?

3. While the lack of proof is a result of the lack of positive peer reviewed research, but maybe it’s peer reviewed research's reliance on randomized clinical trials that is lacking. To quote Don Berwick in JAMA:

'...multicomponent intervention (is) essentially a process of social change. The effectiveness of these systems is sensitive to an array of influences: leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.'

4. As for the MHS demo, the DMCB doesn't believe any DM results from FFS Medicare is generalizable to the commerical employed populations. It's a different kind of population with a different kind of insurance benefit. What's more, the DMCB thinks it's notoriously difficult to demonstrate any savings in a FFS Medicare setting. Even the allegedly successful Medicare Coordinated Care Demo would have been a complete bust if it weren't for some statistical legerdemain that barely squeezed 1 success out of 15 times at bat. The DMCB thinks that there is too much ‘noise’ in the health care utilization of an elderly 'free-range' population with access to every health care option known to man. Modern clinical trial methodology just may not be up to the task to detect differences in an environment with a relentless 10% trend.

5. Finally, the DMCB says the real value of DM is not necessarily a function of how much it can reduce costs. Rather, its value is based on what offers for the cost. While the Business Week article alleges it adds up to billions, the cost at an individual level per member per month is comparatively modest and the benefit to the consumer is relatively high. Compared to the majority of high-cost low-value services typically covered by U.S. health insurance, DM is a bargain. The coin of the realm is NOT saving money but giving consumers their money’s worth.

(Welcome Cav of Risk Readers! There's more on this topic here)

The Latest Health Wonk Review Is Up!

So what's the real skinny on health reform? What are the good ideas that haven't been thought of and what's problematic with the ideas that everyone seems to take for granted? You can find this out and more when you check out the latest Health Wonk Review, ably hosted by Joe Paduda over at Managed Care Review. Check it out.

When Nurses Speak, the DMCB Listens. This Time the Topic is Hospice & Palliative Chemotherapy: Why Can't They Co-Exist?

The Disease Management Care Blog has always appreciated the special insights that nurses have, whether it be how to treat a sick patient at 3 AM or how to tackle a particularly thorny health policy issue. When a close colleague offered to describe her travails with hospice for her dying father, the DMCB could not say no.

I am a nurse with experience in direct hands-on patient care, Medicaid, commercial health insurance and medical informatics. I also have a father that is dying from advanced cancer. The good news is that he is a Medicare enrollee and has access to hospice. That bad news is that he and probably thousands of other patients like him are being economically shut out of an important treatment option called “palliative chemotherapy.”

Hospice is generally interpreted to mean that persons have given up on futile medical treatments that are life-saving or life-prolonging. For most persons with cancer in who are in hospice, therefore, additional chemo or radiation therapy would be inappropriate. Some individuals, however, are candidates for chemotherapy that can provide immediate symptom relief, such as decreased shortness of breath or less pain. This is known as palliative chemotherapy. Medicare does allow for coverage of palliative chemo as part of hospice (you can look it up in hospice manual 40.2.4) but it has to be provided within the $150.00 day hospice per diem. My brief research found ten hospice providers in my home state of Pennsylvania that refuse to include palliative chemotherapy in any treatment plan. Most Medicare Advantage plans also won't cover palliative chemotherapy beyond the hospice payment once hospice is chosen. Last but not least, most Medigap policies don't cover it either. I made a quick call to my own insurer found that they won't cover chemo once hospice is elected.

The research is plentiful on the medical necessity of palliative chemo to reduce the burden of tumors without a goal of curing the patient. So those who elect hospice coverage are essentially being forced into foregoing this comfort option in the name of economic benefit limits of $150 per day.

How do families and patients cope with this? Although this can difficult for the patient, frustrating for family and burdensome for physicians, there appears to a unintended administrative work-around. Medicare allows individuals to elect to discontinue hospice for any reason at any time and then re-enter hospice coverage at any point in time. My read of the rules indicates it is unclear on how often someone can do this. It appears it's theoretically possible for someone to elect to discontinue the hospice benefit the day before chemo is scheduled and to elect it again the day after.

I've spoken to hospice staff about the Medicare option of dropping in and out of hospice. They stuttered and stammered, telling me I couldn't do that. They muttered about how they'd have to keep redoing the service/treatment plan, a new/updated intake assessment, and a rewrite of the physician orders each time. I suspect they and many other hospice providers don't have a written policy and procedure to follow for patients who would elect to do this. The means the staff would need to make the situation fit existing polices, which means starting all over again with each re-enrollment. The system doesn't encourage much out-of-the-box thinking.

My sister (who is also a nurse) and I know my father's prognosis is terminal and know the chemotherapy that we’ve arranged is not going to save him; however, he's had 2 sessions 3 weeks apart. Since starting this treatment, he is visibly breathing easier, has enough energy to remain awake and engaged for most of the day, his appetite picked up and he's gained some weight, is steadier on his feet, and other than some minor nausea hasn't had any significant side effects. If he wasn't doing well, we wouldn't consider continuing this. If the symptoms progress beyond being relievable or if he stops doing well we are prepared to stop the treatment.

Of course, this means my father doesn’t have access to the excellent respite care services and end of life counseling/support that are offered under hospice. Fortunately, his family has access to two nurses who can step in. Sadly, most families struggling with end-of-life care don't have this and are therefore being forced to choose between a limited hospice benefit or palliative chemotherapy.

It’s time to change this.

For more information, the DMCB found a good review article (subscription required) in JAMA here.

The President Says Politicans Shouldn't Read This Blog

This quote from President Obama today to Democratic Senators on how divine the what voters really want in today's media landscape:

“If we could just — excuse the press — turn off the cameras, turn off your CNN, your Fox, your MSNBC, your blogs, turn off this echo chamber … where the topic is politics. … We’ve got to get out of the echo chamber. That was a mistake I made last year — not getting out of here [Washington].”

Er, 'exsqueeze me,' but the Disease Management Care Blog humbly submits the White House and Congress would have done better with health reform if more of them had regularly checked in with this blog. It also objects to being included with the likes of CNN, Fox and MSNBC.

The DMCB is heartbroken. There is only one thing to do at times like this, and that's break into song.

The lyrics from The Maverick's Oh What A Crying Shame perfectly describe the bloggers' lament:

Mr. President, wasn't (we) good to you, didn't (we) show it....... and if we ever hurt you, we didn't know it.

Enjoy.

The Tea Baggers Just May Have a Point About Health Care.....

Back in the 1960s, the Twilight Zone regaled television viewers with fantastic stories from a place between 'science and superstition,' that lay 'between the pit of man's fears and the summit of his knowledge.' Approximately thirty years later, popular culture was introduced to an even more surreal place in the 1979 film The Black Hole. Disney's state-of-the-art special effects portrayed a space environment dominated by a distant, visually compelling and vaguely sinister hyper-gravitational spinning black hole. As testimony to their commercial success, the terms 'twilight zone' and 'black hole' remain instantaneously recognizable today, describing situations where the usual laws of gravity, time and common sense are unpredictably and variably suspended.

Since thirty years have passed, it may be time to recognize another fantastical environment, described in this Health Affairs web exclusive, titled 'Prices Don’t Drive Regional Medicare Spending Variations,' by Daniel Gottlieb, Weiping Zhou, Yunjie Song, Kathryn Gilman Andrews, Jonathan Skinner and Jason M. Sutherland.

Basically, the authors examined critical three factors in the regional variation of Medicare's per capita health spending: 1) the additional money allocated for teaching hospitals, 2) the additional money allocated for the care of the socioeconomically disadvantaged and 3) local differences in the cost of living, which influences pricing of medical services. The bottom line is that when these elements are mathematically 'backed out,' per capita variation in health care spending is only dampened sightly and is still all over the board.

How can this be?

While it's still up to readers to decide if some of the variation can be explained by local poverty and its effect on hospital quality, the Disease Management Care Blog is still struck by Medicare's surreal distortion of the time-space fabric of the health care market universe and how easily the viewer can be sucked into this logic-defying time-space of contractors, DRGs, RVUs, ineffective cost controls, inefficient mainframe-style central planning, political zg zagging, cumbersome denials, attacking the inevitable outliers, provider gaming and a sprawling $911 billion bureaucracy.

There is plenty of blame to go around for this dysfunction and, let's face it, Medicare and Medicaid have led to unparalleled health benefits for the poor and elderly. Yet, persons looking into the distorted market of two to threefold cost differentials with no discernible impact on quality must be puzzled by how the black hole can bend a line of reasoning toward greater government involvement.

The DMCB not suggesting the CMS be cancelled, any more than it can cancel black holes: both are embedded in our time-space continuum.

But it also cautions against tut-tutting those wacky cranky Tea Baggers and their common sense look at 'government style health care.' The cognitive dissonance of 'getting government out of Medicare' belies a deeper reality: once you step outside the Twilight Zone and away from the Black Hole, it's pretty obvious that government's management of the program is not of this earth.

A Top Ten List of Medical Uses for the iPad: An Alternate Point of View

The Disease Management Care Blog is not surprised by the fawning adulation of the health information technology (HIT) minions over the illusory potential of Apple's iPad to 'transform' clinical practice. For example, this CIO posting examines its potential to 'revolutionize' healthcare, while this one says it can become the 'No. 1 tablet.' Toss in jargon like 'point of care tool' and 'personal health device' and add some lusty excitment over applications both real and imagined, and it's easy to succumb to the seduction of touching screens instead of patients, managing data instead of diagnoses and being digital instead of doctors. Never mind that a consistent link between electronic record use and health care quality remains as elusive as the CFO-like DMCB spouse's willingness to approve the expense of a dinner in the Circular Dining Room. It's still cool! It's still neat!

Of course, the iPad hoopla (including the Moses themed cover of The Economist) has only fueled that favorite of internet-media-bloggy punditry, the 'Top 10' list. For example, the Top 10 What You Need to Know and... well the list goes on, including a Top 10 list of Top 10 lists. Within the healthcare arena, the readers of KevinMD's blog were subjected to a dose of unreferenced and wholly speculative Top 10 healthcare iPadmania.

Not to be outdone, the DMCB - based on past experience with electronic records, their starry-eyed administrative support teams, questionable outcomes and the cold hard reality of actually taking care of patients - is pleased to offer its own Top 10 list of potential iPad uses in typical practice involving busy doctors and sick patients in a place unknown to many of the electronic record nobility. That place is called 'the real world':

1. Hot Beverage Insulator: The DMCB used to perch a prescription pad on top of its coffee cup to help retain heat between seeing patients. The disadvantage is that, as a result, the liquid often tasted from cardboard. The iPad case promises to be far more inert.

2. Instrument Tray: Office assistants can lay out scapels, scissors, swabs and other doo-dads on the screen for easy access. Compared to the price of medical equipment such as trays etc. in general, the DMCB suspects the iPad will be quite cost competitive.

3. Lunch! The DMCB learned from a wise colleague that no matter where you are in the day, lunch is always on the way. The iPad will be a boon to any physician who needs to place a lunch order during the tedium of patient care.

4. Tricorder: Remember Star Trek's Dr. McCoy and his multi-purpose diagnostic tricorder? If physicians are confident nothing is wrong with the otherwise dubious patient, point the iPad (or better yet, hold it up against the patient's body), peer intently at the screen and announce there is 'NOTHING WRONG.' Your patients will thank you!

5. Light Source: Surely the iPad's screen can be made to go white. When it does, aim that puppy at the patient and no mole, no body fold and no body cavity will not be amply and completely illuminated. All that's needed is a way to affix it to the doctor's forehead a.k.a. 'hands free mode.'

6. Timer: Most physicians and their administrators understand down to the second just how much time should be allocated to each patient to maximize practice income. The iPad will calculate current billings, cash flows, visit intensity and room-to-room pace to optimize maximum physician efficiency. When 30 seconds are left for that Level 4 visit, count on your iPad to buzz annoyingly.

7. Meaningful Use Standards: Like you, the DMCB doesn't really grasp CMS' Meaningful Use Standards' that will be linked to physician payment for EHR use either, but it thinks having an iPad will magically make it happen. Turn that baby on and wait for a check from Uncle Sam

8. Door Stop: Nothing annoys patients more than being put into a room ahead of time and being left to languish while the doctor is behind schedule. Not a problem, the iPad can be used to prop the door open so that patients can see out into the hallway.

9. Pass Time: Or, if patients prefer, they can leave the door closed and curl up with the iPad edu-tainment device, accessing functions like soothing music or really gross pictures of patients afflicted with weird medical diseases.

10. Cool and Cheap (relatively at least): OK, let's assume patients think you should use an electronic record, but you don't want to shell out the tens of thousands of dollars. Pretend to use an iPad during your patient encounters and you will give the appearance of being cool, connected and networked, even though what you're really doing is surfing and checking the Disease Management Care Blog.

('’)