Healthcare Ver 1.0 vs. Healthcare Ver. 2.0

Happily, the Disease Management Care Blog is not going to give up its day jobs for cartooning. It's too hard!

Loss of Physician Autonomy: Gimme a Break?

In its befuddlement over this post on physician autonomy, the Disease Management Care Blog circled back to its DMCB spouse muse. Compared to most Americans, she observed, the profession still lives very well, yet suffers from more than its fair share of tone-deaf entitlement, arrogance and narcissism.

She pointed out that an instructive case in point is the DMCB's not-infrequent conversation with the the living room flat screen, when it observes that it should be the one being interviewed on GMA, CNN and Fox. The DMCB retorted that it wouldn't have to say that if she did.

Exactly, replied the DMCB spouse.

Comparative Effectiveness Research: How We Could Make It Effective

Yesterday's Disease Management Care Blog post on the impact of physician professional autonomy in health reform generated some readership consternation, including some personal feedback that it must have been written after a recent excess of additional research in this topic area.

Not true, says the DMCB. But it thinks the same charge could be leveled at the authors of this utopian viewpoint on the topic Comparative Effectiveness Research (CER) that recently appeared as a Commentary in the Amercian Journal of Managed Care.

According to Dr. Sox et al, CER will usher in a new age of enlightened medicine in the United States, enabling it to join other civilized nations with the means to scientifically assess every corner of health care. Those means are two fold: 1) money printing presses that finance the research and 2) experts to assess that research and make recommendations. As a result, policy makers will be informed, uncertainties will wane and patients and physicans will choose wisely. Medical Journals that recognize this will be doing their part to make a healthier and happier world.

In order for this supposed nirvana of knowledge, this cornucopia of comprehension, this era of excellence to occur, however, the CER will need to be scientific, conducted under protocol, use representative populations, registered, peer reviewed, open accessed, published in traditional upper tier journals and be accompanied by descriptions of the research limitations and disclosures of author conflict of interest.

The problem? The DMCB notes plenty of research is already subject to protocol, representative, peer reviewed, open accessed, published and transparent. More of the same, thanks to $1.1 billion, isn't any more likely than the current system to sigificantly influence physicians. Case in point is the CER poster child ALLHAT Study (also detailed in the prior post) that met all the CER criteria favored by Cox et al and still failed after publication in JAMA to increase water pill prescribing vs. other more expensive medications for hypertension.

What CER really represents is a 10 figure gravy train for the academic-medical-publishing industrial complex courtesy of the U.S. taxpayers. There will be some benefit, thinks the DMCB, but it doubts we're going to get our money's worth.

Fortunately, the DMCB has some additional suggestions that will help increase the odds that CER could actually have an impact:

1) the research protocols should be explicitly translational. In other words, the interventions that are being tested should include features that help us understand how they can be best disseminated into mainstream care settings. For example, ALLHAT could have included a thiazide plus disease management/value-based insurance design treatment arm. It's not only important to understand what but how.

2) the outcomes should not only appear in traditional medical journal "channels," but be actively and freely disseminated in nontraditional venues used by health care professionals as well as consumers, including, but not limited to, on-line web sites, discussion boards, blogs and other social media. There should be a routine methodology to deconstruct the complex outcomes results into language that can be accessed and understood by lay persons. A good start is the Annals of Internal Medicine's patient information section.

3) speaking of lay persons, it's not enough to "open access" the summary results of CER. The individual level data itself - within the limits of current interpretations of the need to respect privacy - should be open sourced. There are plenty of lay scientists with the skill and the interest to look for and find problems that may have been missed by the authors, reviewers and editors. An example is the initially missed excess number of heart attacks among Vioxx users in this paper that was published in the New England Journal.

4) candidacy for research funding should not be limited to traditional members of the academic community with a track record, but favor initiatives that involve partnerships that include, but are not limited to, community and faith-based organizations, health insurers, purchasers, buyers and patient advocacy groups like this.

The Latest Health Wonk Review is Up!

The DMCB has used the terms 'blogmos' and 'blogiverse,' but it never occurred to it that there were plays on the word 'wonk.' That's only one small insight, however, compared to a feedbag-full of intelligence, opinions, insights and news that's been assembled for your browsing comwonkication at David Williams' Health Business Blog's Health Wonk Review.

An Under-Recognized Ingredient in the Lingering Battle Over Health Reform, the SGR and Physician Buy-In: Professional Autonomy

Physicians have plenty of reasons to be vexed and lately this is coming up. Commercial insurers and Medicare have always been squeezing payment rates. Now the Obama Administration is failing to hold up its unofficial pledge to fix the repugnant Sustainable Growth Rate formula in exchange for organized physician support for its health reform legislation. Yet, something deeper is going on here and the DMCB couldn't quite put it's finger on it....

Until it read this and viewed this.

First, the "read" of the Archives of Internal Medicine article by Randall Stafford and colleagues, titled "Impact of the ALLHAT/JNC7 Dissemination Project on Thiazide-Type Diuretic Use." Feeling pretty good about the results from a huge international study called "ALLHAT" that showed simple cheap water pills are a best option for the treatment of high blood pressure,the investigators concocted a follow-on study. They figured they'd go out to more than 18,000 physicians' offices and academically teach, persuade, market, convince and ultimately "detail" docs to use water pills among their patients with high blood pressure.

Compared to nationwide trends, the investigators found that the physician outreach was associated with a discernible increase in the prescription of thiazide-type water pills. Unfortunately, the effect was modest, with a bump in prescribing from a baseline of 38% to 47% among persons with high blood pressure. They even tracked the intensity of the teaching as a function of how many physicians per county received the intervention. Counties with relatively low numbers of physicians saw no meaningful increase in thiazide prescribing.

While the authors generously noted that their physician "detailing" had an impact, they also recognized it was blunted. An accompanying editorial suggests that the detailing was watered down (groups of physicians were approached in lieu of one-on-one) and that the data included patients who were on stable doses of medicine, making their physicians less inclined to change things if they were doing well. The DMCB adds that the detailing used by the ALLHAT investigators was "weak" compared to the traditional pharma detailing that is typically linked to considerable financial incentives.

But the DMCB thinks something else was going on.

Which makes this video worth viewing. While authored by a surgeon, the diatribe starting at about 9:40 is does a good job of describing physicians' overall eroding sense of autonomy. It's not a small issue. Loss of professional autonomy correlates highly with overall primary care physician career satisfaction. It can get in the way of pay for performance programs and could impede the successful creation of the Administration's cherished "Accountable Care Organizations" (more on that here). The DMCB also thinks this also may have gotten in the way of the ALLHAT detailing described above.

And it is probably an ingredient among the percent of physicians opposed to Obamacare.

Years ago, the DMCB was the manager of a work force of health professionals. It quickly learned that disgruntlement over "compensation" frequently belied a deeper underlying issue. While those issues often included co-worker conflicts or pressure over job duties, it frequently boiled down to disagreements over what the employer wanted and what the employee was willing to do. That spoke to autonomy, and addressing it often helped smooth things over.

Accordingly, the DMCB worries that organized medical groups like the AMA and the Obama Administration are failing to address a far more important issue than how many shekels docs get from Medicare. That's bad news, because even if the SGR gets fixed somehow, a sizable contingent of docs - who live by more than bread alone - will remain unhappy.

Which brings up a important issue for the population-based care/disease management industry. Learn how to deliver the care interventions to the patients you serve and simultaneously preserve what's left of your physicians' sense of autonomy, and you'll win.

Very difficult? Yes. Extremely important? Very.

A Summary of the Latest Population Health Management Journal

It's that time again. The Population Health Management Journal (PHMJ) has arrived and it's full of your competitors' published findings on wellness, prevention and care and case management. Good thing you read the Disease Management Care Blog. It's saving you time with this handy PHMJ summary so that you can quickly and efficiently scan the contents over your low fat, weight controlling lunchtime yogurt and fruit snack. You'll know which articles deserve closer attention. The result will be better market awareness, enhancement of your professional development, heightened competitiveness for your company, advancement of the science of population care management, fewer Americans with chronic illness and reduction of the national debt. And that's just for starters.

Without further ado:

Impact of Online Primary Care Visits on Standard Costs: A Pilot Study by James Rohrer, Kurt Angstman, Steven Adamson, Matthew Bernard, John Bachman and Mark Morgan

Do “on-line” visits save money? It depends on your definition of saving money. These researchers from the Mayo Clinic pulled the records of 391 patients who were “served online via a secure patient portal” and compared them to 376 consecutive patients who were seen at a “same day clinic at a downtown location,” all of whom were served/seen during a six month period in 2008. The online visit used branching logic to solicit the patients’ history and then forwarded it to a physician for his/her review and reply. In order to use the online option, patients had to have a Minnesota primary care provider and be willing to pay the $35 if their insurer didn’t cover it. “Outlier status,” defined as being outside the 75% national percentile of total costs ($219) over the next 6 months, was used to assess cost savings. 28% of the "same-day clinic" patients met outlier status versus 21% of the "on-line" patients; median costs for both groups were $131 and $87, respectively. Both differences in median costs and outlier status held up as statistically significant even after controlling for baseline utilization. The DMCB thinks that much of this depends on the portal software (“Medfusion”), so we don’t know how generalizable this is. That being said, the DMCB is intrigued by the novel definition of cost savings that is based on an "outlier status." The DMCB also wonders if the next and even more cost-saving step is to have non-physicians handle much of the on line review and reply, oh wait, that is already being done in many population-based care management programs....

Disease Management to Promote Blood Pressure Control Among African Americans by Troyen Brennan, Claire Spettell, Victor Villagra, Elizabth Ofili, Cheryl McMahil-Walraven, Elizabeth Lowy, Pamela Daniels, Alexander Quarshie and Robert Mayberry

In this study, primary care physicians and their patients with an Aetna insurance claims history were randomly assigned to either 1) a high intensity, multi-modal and culturally competent nurse-support program with blood pressure monitors and instructions on how to use the monitors or 2) a “light support” program that included just the instructions and the monitors. 5932 persons were approached for participation and 320 were eventually assigned to the high intensity group while 318 were assigned to the light group. Patients were telephoned to self-assess and report their baseline and 6 month follow-up blood pressures. Mean baseline pressures were not different between the two groups at the start of the study, but at 6 months the high intensity group’s mean systolic pressure was 124, while the light group was 127. While an approximate 3 point difference may seem small, this is what is typically seen in the science of successful blood pressure control. What’s more, the difference was statistically significant. The DMCB likes this study because it’s directed at a population that suffers from disparities in access to care and it shows that additional patient support trumps skinnied-down home blood pressure monitoring. Kudos to Aetna for supporting this study.

Do Case Management Programs Save Money? by Donald Fetterolf, Albert Holt, Travis Tucker and Nazmul Khan.

After reading this article that describes how Alere thinks about it, you may still not know the answer. The good news is that you’ll have a better appreciation for the highly variable nature of patients that are typically entered into case management and how their care is prone to overuse, underuse, misuse and abuse. You’ll also learn that the cost and utilization patterns in this group speak to the problem of health system variation. While this is consistent with the policy message of the Dartmouth Atlas, the broad baseline confidence intervals also can get in the way of statistically proving that case management “works”; the authors used a standard power calculation for a typical cohort of case management patients’ cost patterns and found that more than 30,000 patients would be needed to conduct a research study on return on investment (ROI). Their common sense suggestions to assess the impact of case management include 1) assess and infer from other process, operational and clinical outcomes, 2) look at other pertinent markers of utilization, such as nursing home days per thousand, 3) apply known savings that have been demonstrated in clinical trials to the smaller population of interest and 4) measure quality of life, patient and physician satisfaction and use self-reported anecdotes. Unfortunately, grumpy purchasers may not appreciate how difficult this is and insist on other measures such as 1) estimates from the case managers on individual client savings that are, in turn rolled up (but fail to capture other costs), 2) propensity matching (but also prone to no achieving statistical significance) 3) a “book of business” approach that’s described in the DMAA Guidelines III Document. After all that, the best business approach to case management is to 1) document methodology, case mix, the impact of variation on “ROI,” 2) educate clients about the limitations, 3) agree on directional estimates in lieu of point values, 4) use “performance corridors,” 5) limit only small amount of any performance guarantee on “ROI” and 6) plan for the likelihood that any calculation of program savings may show a loss. The DMCB says this is "must" reading if you're in the case management business.

Wellness, Hard to Define, Reduces Trend up to 4 Percent by Cyndy Nayer, Jan Berger and Jack Mahoney.

This is a title that says it all. The authors conducted a series of open ended and multiple choice surveys of a group of companies that had been selected by the “Center for Health Value Innovation” as particularly innovative and dedicated to wellness among their employees. Innovative respondents 1) seemed to have broader and more inclusive definitions of just what comprised "wellness" and 2) reported that they believe their cost trend was only 4%, compared to national trend of 8 to 10%. The DMCB agrees there is an association between wellness and trend but it still struggling to ascertain whether this is causal and if so how much. If it is, does being blessed with a low trend enable companies to be squishy over wellness?

Comparring Diverse Health Promotion Programs Using Overall Self-Rated Health as a Common Metric by James Rohrer, James Naessens, Juliette Liesinger and William Litchy.

In this study, employees who completed a health risk assessment (HRA) and had four or more “risks” identified were assigned to one of four telephonic coaching programs aimed at weight, exercise, stress or nutrition. Over six months, participants were asked about eating patterns, weight, levels of exercise and degrees of stress, as well as an additional single question: in general would you say your overall health is excellent, very good, good, fair or poor. Of the approximate 48,000 who took the HRA, about 16,000 agreed to participate in coaching, 10,500 were eligible and 2855 enrolled. Drop outs were significant, with 1.5% to 26.7% completing the six months. Improvement in the single question about overall health appeared to correlate with weight loss (an average of 4 lbs.) and exercise levels (increased by an average of 43 minutes a week). The single question did not correlate with stress management practices or healthy eating. The authors suggest that weight loss and exercise programs may have an beneficial impact on the perception of overall health compared to stress management and nutritional interventions. If this holds up, the DMCB wonders if weight loss and exercise programs can reduce overhead by limiting their data collection to a single question. Alternatively, the single question approach may not be adequate enough to detect well-being among stress and nutrition program participants.

Improved Blood Pressure Control Among School Bus Drivers with Hypertension by Joseph Dozy, Tina Severance-Fonte, Elizabeth Morandi-Matricara, Jenifer Wogen, Feride Frech-Tamas.

There is no reason to believe that commercial driver’s license (CDL) holders should be any less prone to hypertension. The pharma-company developers of the “BP Downshift” program don’t think so either, so they created a tailored program made up of multiple educational mailings and a website, BP kiosks that were available in employee areas, free dietitian advice and free gym memberships. The developers showed up at an unnamed school district’s annual orientation for their CDL-holding school bus drivers. 208 entered the study by undergoing a blood pressure screening. 120 had a follow-up blood pressure screening at the close of the school year. At follow-up, systolic and diastolic pressures decreased by 9 and 4 points respectively. Among those that completed surveys, there also appeared to be an increase in health behaviors, and personal health perception. Bravo to the authors for recognizing in the discussion that their study was limited by a lack of a satisfactory control group, lack of generalizability, possible selection bias, the possibility of regression to the mean and temporal factors leading to bias. The DMCB doesn’t think the authors – or the school district – were out to win a Nobel Prize here; rather may be better suited to being thought of as a feasibility study. The next step is to perform a more vigorous study to see if the school district and its taxpayers are getting their money’s worth.

There is also an editorial by Chris Behling named "The Ghosts of Disease Management Past." He laments the persistent haunting of population-based care management by the threefold perception 1) that disease management is all about five chronic diseases, 2) is really all about telephonic coaching and 3) that it's disconnected from primary care. He dispatches each specter with some compelling arguments and recommends the industry leverage it's corporate infrastructure, measure measure measure and "extend and enhance the reach of physicians while filling the gaps that exist in the current delivery of care. Hear hear, says the DMCB.

Modular Approaches to Our Post-Industrial Biologic Age

In a fav Disease Management Care Blog movie Bladerunner, Harrison Ford portrays a futuristic cop who tracks down genetically engineered humanoid "replicants" that have gone rogue. Too bad their emotions and free will get in the way of accepting their assigned tasks, like combat (the menacingly friendly Roy Batty), dangerous work (Zhora and her artificial snake ooo la la) or serving as a "pleasure model" (Goth-like Pris, ably played by sexy-no-more Darryl Hannah).

While there's plenty of theme to go around (so, just what is the definition of "human?"), it's the "modular" portrayal of biology that has caught the imagination of the DMCB. In contrast to the standard sci-fi plot of simply growing bodies, Bladerunner implies the creatures are assembled, Frankenstein-like, from parts manufactured in outsourced mini-labs.

Pretty good soothsaying for a 1982 film. Fast forward to May 2010 and the announcement that that Gibson and colleagues have inserted a new set of chromosomes into the bacterium Mycoplasma mycoides, creating a form of life that is without an ancestor. According to this article in The Economist, Craig Venter and colleagues assembled and combined the necessary blocks ("cassettes") of DNA and then used a virus to insert a newly completed genome into a DNA-free cell host. It started to divide and, well, Life Was Created, sort of.

So what does this have to do with disease management, you ask? The DMCB thinks the imagery of successful 'swapping" of the components of complex organic systems is having a far greater impact on our culture than we realize. At the height of Industrial Revolution, society reflected that Age's principles of scientific rationalism and standardization. Schools were one-size-fits all, soldiers and tanks assembled in huge symmetric formations and everyone lined up for their immunizations.

Since our transition to a post-industrial Information Age, the paradigm has now become more "biologic." DNA can be tasked to computing, complex organizations are referred to as living and Hollywood even portrays entire planets as animated with an interconnected network of life. And in the middle of all that are stem cell infusions, telomere manipulation, immune modulators and solid organ as well as facial transplants. Is it any accident that education is often based in experiential learning guerrilla war has become organic, and population-based health care is based on interdependent care interventions (value based insurance design, physician payment reform, shared decision making, medical homes, disease management and the like?)

The DMCB is out on a limb here, but it's not sure if cultural form follows function or vice versa. But in our age of organic, flexible, interdependent and plug n' play approaches to education, health care (and unfortunately war), it seems scientists, administrators, policymakers and provider organizations that use the same approach to the problems of our modern age are the ones poised to come up with the Next Big Advances. Like creating living cells or, which is just as exciting, reducing the burden of chronic disease.

Hypertension, In-Home BP Monitoring, Web-Based Reporting, Phamacists and Press Releases: Read the Studies for Yourself

Sometimes the Disease Management Care Blog fancies itself as a virtual "journal club" that simultaneously combines updates on medical research with healthy levels of skepticism about the underlying science. It's a useful way to think through much of the spin that can clutter breaking news about medical advances. Given our mainstream media's spotty track record when it comes to reporting and interpreting medical news, wary journal club approaches are needed more than ever when it comes to uncovering the facts and only the facts.

Case in point? Check out this Kaiser - Microsoft press release touting a "50%" improvement in blood pressure control thanks to "in-home BP monitors and web-based reporting tools that connect clinicians and patients via the internet." The study of "348 patients" was presented at an American Heart Association meeting.

It goes on to say:

At the start of the study, the average systolic blood pressure was 149 mm Hg in the home monitoring group and 145 mm Hg in the usual care group. At six months, patients in the home monitoring group were 50 percent more likely to have their blood pressure controlled to healthy levels compared to the usual care group. Similarly, a significantly greater decrease in systolic blood pressure at six months occurred in the home monitoring group (-21 mm Hg) versus the usual care group (-9 mm Hg).

The DMCB thought this sounded quite impressive, so it pulled the AHA meeting abstracts and went to page 82. According to the report, "A Pharmacist-led, AHA Heart 360 supported Home Blood Pressure Monitoring Program Improves Blood Control in Patients with Uncontrolled Hypertension," the experiment involved a total of 353 (not 348) hypertensive patients who agreed to be randomly assigned to usual care (N=174) or an intervention group (N=179). The intervention really involved a pharmacist-led program that adjusted the patients' medications in response to home BP readings that were uploaded into a personal health record HealthVault.

Six months later, data was available on 125 of the usual care patients and 120 of the intervention patients. 47 of the 125 patients, or 38%, in the usual care group vs. 69 of 120, or 58%, of the intervention patients reached target blood pressure levels. This difference turned out to be statistically significant. After some statistical adjustment, the 20% absolute advantage (58% minus 38%), works out to represent an approximate "50%" relative advantage. In other words, if a Kaiser pharmacist is adjusting your blood pressure pills, you're 1.5 times more likely to get your blood pressure under control compared to usual care.

Or does it? The trial started out with 353 patients but ended with only 245 - which is about a 30% drop out rate. A more conservative calculation would include the drop outs and assume none of them got their blood pressure under control. Accordingly, 47 of 174 or 27% of the usual care group achieved blood pressure control while 69 of the 179 or 38% of the pharmacist led group did so. That's a more modest absolute improvement of 11% or a 1.4 relative likelihood of control. The DMCB went to this web site to do a quick chi square and thinks the results had a more modest yet still statistically significant p value of .03.

So what does the DMCB think?

Never take a press release's word for it: always go to the original report and read it for yourself. In this instance, there were two important features that were not stressed in the press release:

1. The secret sauce behind study was really being "pharmacist led" (the title of the study), not home based monitoring and web-based reporting. In that context, this isn't really all that new: it's abundantly clear that non physicians can improve care quality. To sort out the added value of the Kaiser-Microsoft alliance, we'd need a trial that compares pharmacist-directed care using the old fashioned telephone vs. pharmacists using a web-based personal health record.

2. Learn to look at the numbers: in this instance, a casual read uncovered a 30% drop out rate. By focusing only on the patients that remained in the study at 6 months, the authors cast a more favorable light on their success rates. In addition the "1.5" relative likelihood of improvement is technically correct but of less use to doctors, who have to worry about the patients who may not keep appointments. They're more interested in the 11% absolute improvement rate.

Medical Loss Ratios & Health Insurance: Are You A "Constructionist" or an "Activist?"

As readers may recall from a prior Disease Management Care Blog posting on the topic of medical loss ratios (MLR), the ratio of health insurer medical costs to total costs is conceptually simple, yet administratively complicated. One reason is because providers of medical services - such as hospitals and physicians - are accepting various forms of risk transfer such as capitation, gain sharing and risk contracting that behave like insurance. Health insurers, in turn, have been taking on clinical roles that look and feel like traditional provider services. Examples of the latter include quality assurance, patient reminders and wellness initiatives.

Will the Patient Protection and Affordable Care Act's (PPACA) 80% to 85% MLR requirement make this mash-up "better?"

Opinions seem to fall into two camps:

1) The MLR requirement limits administrative costs and maximizes the spend on health care services and is evidence of an enlightened civilization at work that, by the way, is also providing a target rich environment for health policy bloggers

2) The MLR floor is a clumsy, ill-fated, if well meaning, intrusion into the business operations of insurers that will assure the perpetual employment of a host of health lawyer-regulators which, by the way, provides a target rich environment for bloggers.

The DMCB really thinks that the two points of view above embody a much bigger debate about the role of health insurance in reform between the

1. Constructionists, who view insurance as a means of monetizing and pooling risk in a way that enables the payment of needed health care services, or ...

2) Activists, who favor using the monetizing and pooling of risk to enable the betterment of needed health care services.

Interestingly, despite Senator Rockefeller's apparent constuctionism, the PPACA seems to favor activism. While the DMCB finds the legislative language as murky as a Gulf of Mexico oil plume, it appears to require that health insurers improve health care quality including "effective case management, care coordination, chronic disease management and medication and care compliance initiatives including through use of the medical home model.... activities to prevent hospital readmissions... including patient centered education ...(and).... activities to improve patient safety and reduce medical errors." By the way, the activist view of Medicare may underlie the nomination of Dr. Berwick to lead the Agency.

Unfortunately, since the law is flawed by being both ambiguous and ambivalent, we're in for an interesting time on this issue. Stay tuned.

The Latest Cavalcade of Risk Is Up!

Are academic sociologists really that depressing? The Disease Management Care Blog doesn't think so, after seeing the number of excellent risk related posts at Nancy Germond's Trainwreck Edition. Check it out and enjoy!

Political Nostrums About Controlling Health Care Costs: A Case Study

Oh, those wacky politicians. Blessed with a charismatic ability to spin half-truths into yummy sound-bites, the more successful ones float into our field of view like oversized blimps and mesmerize us mere mortals with astonishing chutzpah and plausible fibbery.

Look no further than the Health Affairs blog for an example of this kind of spectacle, courtesy of none other than the Keystone State's Governor Edward Rendell. His approval ratings are lower than Obama low, budget crisis impasses are routine, taxes and spending are out of control and he still has time to share his half-baked health policy opinions. They make for an, ahem, interesting read.

It's easy, says the Disease Management Care Blog's Governor, to reduce health care costs. It's just a matter of....

"...not paying for medical errors (1); decreasing the number of hospital-acquired infections by requiring hospitals to report the rate of such infections and penalizing hospitals that do not make progress in limiting them (2); fostering the development of “medical homes” in practices across the state (3); and expanding the scope of practice of nonphysician medical providers (4), thus promoting the growth of after-hours clinics staffed by nurse practitioners and other providers and thereby cutting the number of unnecessary emergency department visits by people unable to access their physicians on nights and weekends (5)."

1. What Mr. Rendell is probably referring to is the adoption of Medicare's 'no pay' policy for hospital acquired conditions (HACs). While many HACs are avoidable, their overall frequency is much lower than the salacious media would have us believe. In this Health Affairs study, the future economic impact of the policy is estimated to be negligible.

2. Check out this study report looking at the statistics behind dreaded "Staph" infections among patients discharged nationwide: 0.8% of patients.

3. Oh? Other than a few studies in Medicaid or integrated delivery system settings, the DMCB can find no conclusive evidence that the medical home reduces costs in community care settings. Isn't the fact that this is all still rather experimental why they're calling them "pilots?"

4. Mr. Rendell may have special biases about the role of non-physicians as primary care providers thanks to his spouse, but this isn't a slam dunk solution thanks to a similar shortage of nurse practitioners as well as lingering economic dysfunctions.

5. That's a commonly held perception, but this review of the literature fails to support the contention that uninsured persons using the ER do so for lack of primary care access or for the sake of convenience. While primary care access undoubtedly plays a role in patients' willingness to use an ER, that's still less than 3% of the nation's health care bill.

It'll take more than these overused platitudes to control health care costs. The DMCB ultimately admires Mr. Rendell and knows he's a lot smarter than this. Pennsylvanians and readers of the Health Affairs blog deserve better.

Image from Wikipedia

The Evidence for Texting As "mHealth": Another Tool For Population-Based Care, Medical Homes and Disease Management

Did you know that in some countries, the number of cell phones in circulation exceeds the number of persons? That in the U.S., 58% of persons have sent text messages, 89% of teens use text messaging regularly and that 30% of teens do so daily? That the widespread of texting has already prompted a number of highly innovative researchers to investigate the role of texting in improving health? That there is a really really cool term that you can use to bedazzle your colleagues, impress your boss, stymie your competitors and bore your spouse called "mHealth?"

The Disease Management Care Blog didn't know any of this either until it stumbled across this highly informative article by Heather Cole-Lewis and Trace Kershaw in the medical science journal Epidemiologic Reviews titled "Text Messaging as a Tool for Behavior Change in Disease Prevention and Management."

The DMCB managed to get its hands on the full manuscript and found a well-written and up-to-date scientific review of the literature on "mHealth" (short for "Mobile Health"). To be included, studies had to be randomized or quasi-experimental and focus on text messaging as an independent variable. After winnowing some publications over quality issues and others that were duplicative, the authors settled on a total of 5 studies on disease prevention (vitamin pill adherence, physical activity, smoking cessation and two on weight loss) and seven on disease management (six on diabetes mellitus and one on asthma). The oldest was from 2005, only two were from the U.S., most were prospective and all assessed a variety of behavioral and clinical outcomes in age groups ranging from 15 to 45 years.

Frequency of text messaging varied from once a week to five times a day. One study used automated texting, while the reminder were written by health professionals. Much of the texting was also two-way and highly tailored, using nicknames, commonly including personal goals, culture, gender, age and health status along with informal language. Three studies allowed the participants to dictate the frequency of their messaging. Supplementary email, internet links and other self-management tools were not unusual. Three gave the patients cell phones.

Results you ask? Three studies (on vitamin pill adherence, physical activity and peak flow in asthma) showed no statistically significant effects but were also "underpowered" to detect small but significant differences. Of the remaining nine studies, eight showed a beneficial effect compared to controls, including short term tobacco cessation, weight loss and, among persons with diabetes, increased blood glucose monitoring/reporting as well as lower A1c levels; one of the diabetes studies failed to show a difference in the A1c. While it was difficult to pool the results, the outcomes benefited adolescents and adults, minorities and non-minorities and all nationalities.

The authors correctly point out, given the widespread use of cell phones across the globe, how surprising it is that few studies have been performed in developing countries. In addition, other than a single inconclusive vitamin study, there don't appear to be any good studies on medication adherence. Last but not least, there are a variety of adult learning theory constructs that were largely unmentioned and probably neglected in these studies which, if used, could have probably improved the impact of texting.

According to the authors, texting has the advantage of being inexpensive, personalized, efficient, widely accessible, consumerist and 'asynchronous.' The bad news is that it can medically marginalize persons without access to cell phones or who are unable to read. They point out that more studies are needed and have some important suggestions on how this can be done, including adapting texting to behavior change theory, considering the ethics mHealth and including cost-benefit analyses.

What does the DMCB think?

It suspects some innovative U.S. care management companies are already using texting and, given the paucity of research findings, they have an opportunity if not responsibility to deploy transparent, efficient and cost-effective research methodologies to study their impact. They owe it to themselves, their customers and the medical community to advance the science of mHealth.

For those U.S. care management companies that aren't using texting in their outreach and engagement strategies, it would appear that there are a sufficient number studies to justify its use. How well it compares to other traditional communication interventions remains to be seen, but the more channels the better. The DMCB suspects this will get complicated, especially as we discover that different individuals have different communication preferences.

By the way, the same is true for Patient Centered Medical Homes.

In the meantime, our government's unwieldy approach to meaningful use, comparative effectiveness research, disseminating advances in care as well as relying on vanilla forms of consumer support and persistently failing to accomodate older forms of telemedicine suggests texting could emerge in commercial care settings long before the ink is dry on health reform. Despite the best of intentions, D.C.'s inertia could lead to a digital texting divide.

Last but not least, updates on unique news like this is a good reason to regularly check in with the DMCB. Stay tuned, because it has a manuscript on social media and population-based care management that will be published shortly.

('’)

Group Health Medical Home "Savings" At Year Two Fails To Achieve Statistical Significance

When the Disease Management Care Blog saw the flurry of news reports (for example, not to mention a YouTube video) about the Patient Centered Medical Home (PCMH) "saving money," it couldn't wait for the full print version of Health Affairs to arrive at the DMCB World Headquarters. The DMCB had previously reviewed Group Health's negative "no statistically significant.... cost differences" one year study and was looking forward to seeing researchers Robert Reid et al's reportedly positive two year follow-up.

Here's what the DMCB found out when it lifted the abstract gown and examined the patient-manuscript itself:

The authors reported the outcomes of a single clinic with a "stable workforce, strong leadership and history of successful quality improvement" that cared for about 9200 patients and which was selected to pilot a "prototype" medical home. This clinic's results were compared to 19 other Group Health primary care clinics without a medical home approach to patient care. Investing in the medical home was not cheap, because the prototype clinic had to hire additional physicians, medical assistants, licensed practical nurses, physician assistants, nurse practitioners, registered nurses and pharmacists. It also appears that the clinic "downsized" its primary care patient panels to reduce physician workloads.

Using vigorous statistical methods to neutralize baseline differences, the authors compared over 200,000 usual care patients to the medical home's 7,000 continuously enrolled patients. The medical home was associated with fewer emergency room visits and inpatient admissions with greater numbers of specialty physician visits. When the costs were added up, this is what the authors found:

"When costs are totaled across all types of care and adjusted for case-mix and baseline costs, we estimate a total savings of approximately $10.30 per member per month, a result that approaches statistical significance, p=.08, meaning that the difference could still be due to chance." (bolding from DMCB)

In other words, the savings failed to meet the conventional threshold for statistical significance.

Despite the negative finding, the authors forged on and added up the cost of the program and compared it to the savings:

"...we can estimate return on investment associated with the prototype at 21 months at 1:51"

In addition to its failure to achieve statistical significance (let alone mention that in the abstract), there are several possible weaknesses with the study that went unmentioned in the "Lessons Learned" and Policy Implications" sections of Reid et al's Health Affairs publication: 1) the authors chose their strongest clinic (making its generalizability to other Group Health clinics suspect), 2) it's not clear which patients were dropped from the panel prior to institution of the PCMH, 3) despite statistical attempts to neutralize any known sources of bias, this was a non-randomized study and could have been influenced by unknown or unreported factors, and 4) what works at Group Health - an integrated delivery system in the Northwest - isn't necessarily going to work in any primary care clinic in Dade Country Florida, McAllen Texas or Mobile Alabama.

The DMCB wonders why its friends in policy circles and academia continue give the PCMH a pass. Based on these data, the PCMH is still not ready for prime time and should be confined to pilot testing. The DMCB is not the only curmudgeon that feels that way: check out this thorough review of the possible sources of bias and the testy response of the study's lead author.

Speaking of pilots, check out what Rhode Island Blue Cross Blue Shield is up to. The insurer is directly paying for the salaries of nurses that are being dropped into network primary care physicians' offices. While the Group Health article preaches about investing in primary care, clinical leadership, change management, electronic records, transformation, educational reform and the like, the folks in Ocean State have come up an approach that is a quadruple threat: it's 1) generalizable (could work in multiple settings), 2) adaptive (care management nurses are a supremely flexible species) 3) probably cheaper than "redesigning" primary care sites and 4) preserves the core value of non-physician coaches dedicated to engaging patients in their own care. That used to be called disease management, but it's really become a hybrid "2.0" version of the medical home that, if it works, may also deserve the attention of Health Affairs.

Vermont's Foray Into Accountable Care Organizations: An Update From The Commonwealth Fund

The Disease Management Care Blog used to make grape wine. Its stand of Foch vines was well suited to the northeast U.S. climate and reliably yielded an adequate if unrefined extract. It was great fun to dump juice, crushed skins, stems and leaves into a large bin every August, measure specific gravity with a hydrometer, guesstimate additional amounts of water and sugar, add the yeast and stand back. Once the foamy fementation began, it filled the DMCB's house with a sweet thick odor. The smell was disquieting, but the DMCB calmed the spouse by reminding her that the scent was evidence of God's angels at work. What else could account for miracle of trading carbon dioxide for ethanol?

The same approach of mixing, patience and reliance on divine intervention may be in store for Vermont's Accountable Care Organization Pilots. According to this Commonwealth Fund (CWF) report, the three provider organizations are hard at work with preparations in an initiative that, unlike any other multi-payer ACO and/or PCMH pilot anywhere, involves Medicare.

This CWF update is worth a read. Since readers may not have the time or patience to do that, the DMCB, armed with a Sunday afternoon Pinot, is at your service by cutting through the admino-speak with this handy if vinophilic summary of what these Green Mountain State ACO-wannabe provider organizations are planning. DMCB editorializing is italicized.

The Grapes: The main ingredient is lots of primary care 'exemplified by the patient centered medical home' (PCMH). Reading between the lines, the DMCB suspects the pilots may not be able to insist that every participating PCP meets criteria for a PCMH.

How will ACOs help primary care physicians not rely on emergency rooms and specialists to off-load the work of complex patients? Foch grapes do not a Chardonnay make.

The Sugar: This consists of 'shared savings' pools with the necessary legal cover to distribute payments to the providers. The term 'shared savings' is repeatedly used, making the DMCB think that reduced claims expense is the underlying business model.

In reading the report, the paranoid DMCB gets the distinct impression that the "shared savings" are really intended to build a better - and bigger - health care delivery system. Yet, if the PCMH does its job, the ACOs will need smaller hospitals and fewer specialists. If money doesn't get taken out of the system, how will the ACO business model succeed?

Water: This is a patient population of 'sufficient size' from multiple payers, including Medicare, to support performance measurement and stability of expenditure projections. The authors suggest an ACO needs 70% of patients in a shared savings pool to make this work.

That's newsworthy and should be noted by other ACO wannabes. Yet, if this key ingredient is contaminated by an unwieldy, inflexible and erratic Medicare program, the result will be vinegar.

Hydrometer: Measurement coupled with information technology with "process improvement capabilities" to improve performance and achieve financial and quality goals.

The DMCB can't tell how the planners intend to format and reconcile claims data from multiple payers and then mix it in with clinical data from pharmacy and clinical electronic records. More to follow.......

Yeast: leadership involving physicians and hospital CEOs.

This is a good point, but the DMCB cautions that being a physician leader or CEO may not automatically qualify anyone for running a risk-bearing ACO. For that, an ACO may need an insurance executive or someone from the disease management industry.

While the DMCB's use of the wine allegory is a little forced, it's not the first time. The point, however, is that while the ingredients are pretty standard, the DMCB learned through trial and error that the outcome of wine-making is far from certain.

The same can be said of ACOs.

Acountable Care Organizations: Links and Peer Review Literature

The Disease Management Care Blog has several posts devoted to the topic of Accountable Care Organizations (ACOs). Not only has there been significant web traffic aimed at the topic, but there isn't a hospital administrator, academic chairman, VP of medical affairs, consultant, medical director, policymaker, practice manager, regulator, consultant, venture capitalist, medical blogger, masters degree student or health news writer that doesn't realize that ACOs are the Obama Administration's best hope for putting Integrated Delivery Systems into mainstream health care.

Is it more-of-the-same and inside-the-beltway-hype or Obamaesque hope? Here are the all the links you need to help you decide:

Accountable Care Organizations: Here's a Manuscript That Helps Us Move From the PPACA Legislation to Actually Making It Happen reviews and links a Journal of the American Medical Association publication on a three tiered approach to regulating ACOs.

Accountable Care Organizations & Criteria For Piloting Them in the House Reconciliation Bill: Include Disease Management & the PCMH discusses the House's health reform bill's original language on ACOs and the prospects for disease management and the patient centered medical home.

A Marriage Made in Heaven? Accountable Care Organizations, Patient Centered Medical Homes and the New England Journal. The DMCB Says Not So examines and links a NEJM article on the topic and adds some additional recommendations: 1) more research, 2) survey community-based physicians about the PCMH, 3) link payment and quality and 4) explore combined disease management-PCMH models.

Accountable Care Organizations: The Good, the Bad and the Better Thanks to Health Affairs looks at pro and a con postings on ACOs on the Health Affairs Blog web site.

The Patient-Centered Medical Home & the Accountable Care Organization: Two Sides of the Coin is a posting by none other than IBM's Paul Grundy on the synergies of ACOs and the PCMH.

Accountable Care Organizations (ACOs): A 'Blue Ocean' for the Disease Management Industry? looks at the important business opportunities for disease management organizations within ACOs.

Fragmented Systems Don't Mean Fragmented Care: What Accountable Care Organizations Can Learn From Employer-Purchasers checks out a newsletter from the Commonwealth Fund on how self-employed insurers can coordinate the pieces of population-based care. The same is true, by the way, for ACOs.

Specialist Physicians and Patient Centered Medical Homes: Here's How To Make It Work looks at the issue of specialist clinics acting as 'medical homes' and asks if, thanks to 'transorganizational support,' that could work inside ACOs.

The Decline of Small Physician Owned Practices Explained.... and a Prediction That Private Practice Will Hang In There looks at the phenomenon of large consolidated independent practices and how, in an ACO "scramble," they will interact with multiple hospitals.

Would You Want To Do Business With Medicare Under These Two Scenarios? Looks at the Medicare Coordinated Care Demo's data and asks if ACOs could turn out to have a Feds-we-win, provider-you-lose outcome.

Vermont's Foray Into Accountable Care Organizations: An Update From The Commonwealth Fund Discusses an article on the Commonwealth Fund website that has an update about Vermont's ACO pilot - this is the one that involves FFS Medicare.

Moving From Volume-Driven Medicine Toward Accountable Care is a pro-ACO Health Affairs Blog posting by former CMS Administrator Mark McClellan. Jeff Goldsmith posts a contrarian companion piece titled The Accountable Care Organization: Not Ready for Prime Time.

(New!) Ten Inconvenient Possible Downsides to Accountable Care Organizations: Details, details outlines ten obstacles between here on the long road to ACO-dom.

(New!) The DMCB examines an article by uber economist Robert Berenson that offers three suggestions to reduce the perception that ACOs are an upside-risk-only lottery.

Links to the peer reviewed literature on the topic:

Shortell SM, Casalino LP: Implementing Qualifications Criteria and Technical Assistance for Accountable Care Organizations. JAMA 2010;303(17):1747-1748

Fisher ES, Staiger DO, Bynum JPW and Gottlieb DJ: Creating Accountable Care Organizations: The Extended Hospital Medical Staff. Health Affairs 2007;26 (1):w44-w57

Casalino LP, Rittenhouse DR, Gillies RR, Shortell: Specialist Physician Practices as Patient-Centered Medical Homes. New Engl J Med 2010;362(17):1555-1558

Rittenhouse DR, Shortell SM, Fisher ES: Primary care and accountable care - two essential elements of delivery-system reform. New Engl J Med 2009;361:2301-2303

Luft, HS: Becoming accountable - Opporunities and obstacles for ACOs. New Engl J Med;2010: 363:1389-1391

(New!) Berenson RA: hared Savings Program for Accountable Care Organizations: A Bridge to Nowhere? Am J of Managed Care 2010;16:721-726

Other health reform links:

AMEDNews: Accountable care organizations: A new idea for managing Medicare

The Patient Protection and Affordable Care Act

The Latest Health Wonk Review Is Up!

A 'mission driven' Health Wonk Review awaits you at Hank Stern's Insure Blog. Titled "The Founding Purpose Edition," it has only those postings that made the cut. Policy, funding, insurance, infrastructure, IT trends and economics await your wonky learning here. Enjoy and see if "That Does Not Compute!"

Big Oil and Health Insurers: Double Standard? You Decide

Dear Mr. President:

As a members of the oil industry, we're writing to express our pleasant surprise at not being actively compared to health insurers by your Administration. We agree with you and your colleagues that, compared to those greedy sharks, we are a beacon of ethical business practice.

As you know, the U.S. Senate has unveiled its long awaited version of the energy bill. We look forward to an informed and vigorous debate on carbon caps, renewable energy, nuclear power and how we can moderate our national addiction to fossil fuels. We anxiously await the creation of a coherent policy in a manner that meets your call for civility and respect and which, in contrast to the wreckage of the health reform debate, brings credit to our Republic.

Yet, Mr. President, we're spooked. There are some eerie parallels between health and energy reform that could unleash your populist Furies:

1) Both industries have experienced serious catastrophes. In health reform, it's been the death spiral of the moribund individual market, while in energy reform it's been an occasional oil slick.

2) Both have seen price run-ups that have harmed our economy and threatened our national security. Yet, we are pleased to note that despite $1200 a month premiums and $2.85/gal gas, our citizens can still afford $4 for a cup of premium coffee.

3) Both have been whipsawed by heart breaking anecdotes. There are the infamous rescissions of cancer patients and the needless death of some dolphins and many oysters.

4) Last but not least, both health care and energy have more than their fair share of tone deaf executives who look conspicuously guilty when pilloried by your Democratic colleagues in Congress. Unlike the health insurance industry, however, we can blame our subcontractors, stretch the legal suits out over a decades and, like the Exxon Valdez, take it all the way to the Supreme Court.

Your advisers have been undoubtedly tempted to break out the highly successful health reform playbook to help pass energy reform. They probably want to arrange town hall speeches where you can rail against "greedy" oil companies. They think members of your Administration should ambush our industry with second guesses about decisions we made months ago with all the necessary Federal and State regulatory approvals. They're probably asking that you tilt the political debate in your favor by mentioning the victims by name at every opportunity, condemning multi-millionaire executives and making vague and untrue generalities. Your advisers count on the Democratic majority in Congress to muscle something through.

While that would further energize your base and maybe minimize the coming carnage in the November elections, you've obviously decided that would be a mistake. Not because that would end up creating bad policy that ignores the underlying cost drivers. Not because you'd have to continue to burn up political capital by continuing to defend a reform long after a bill has passed. Not because you'd add taxes and costs as far as the eye could see.

No, Mr. President, you know that the fossil fuel industry is largely global and therefore less vulnerable to U.S. political straw man and ad hominem attacks. Compared to health insurers, we also have a much larger financial base that cannot be easily morphed into a regulated utility. While insurers can bluster about leaving a market, we really mean it and don't care if that means Americans will have to drive weenie econoboxes to unheated homes lit by single small compact fluorescent bulb. China appreciates us.

Thank you Mr. President, we really appreciate the political double standard.

Sincerely yours,

The Oil Industry

Why Linking Quality & Process Is So Difficult: Do Primary Care Physicians Have a Point About Elements of the Patient Centered Medical Home?

Who can blame the primary care physicians for their discontent?

They are loved by their patients, but their patients with heart problems or cancer love their cardiologists or oncologists more. They work hard for their patients, but not as hard as emergency room docs and general surgeons. They command respect, but not as much as nurses. They make decent amounts of money, but not as much as their ex-college roommates. They take good care of their patients, but not as much as insurers, government, academics and policymakers say they should.

No wonder they’re cranky. Some policymakers believe this vexation could explain some of the PCPs' reluctance to adopt information technology (IT) or the patient centered medical home (PCMH). The Disease Management Care Blog disagrees: PCPs are unhappy but they're also hardened realists.

This paper in the latest issue of Health Affairs helps explain why. Eric Holmboe, Gerald Arnold, Weifeng Weng and Rebecca Lipner, all of the American Board of Internal Medicine (ABIM), did a deep dive into the practices of a representative sample of 202 primary care internists’ practices. Physicians completed a “Physician Practice Connections Readiness Survey” that assessed their use of Chronic Care Model (CCM), which in turn forms much of the basis of the PCMH. In addition, trained abstracters used the “Comprehensive Care Practice Improvement Module” to review a year’s worth of representative medical records.

The composite practice CCM survey score averaged 48 points on a scale of 0-100. Average clinical performance scores on chart review ranged from 45% to 59%. Like the DMCB, readers may be unfamiliar with the details of the survey and the module scoring. The DMCB isn’t surprised, however, that the ABIM would use a difficult set of measures resulting in less than 100% scores. But that’s not what’s important about this paper.

Since the authors didn’t use the “Lake Wobegon” approach, there was useful a “spread” of physician and patient measures. This allowed the authors to assess whether higher physician CCM-based survey scores should lead to better chart review outcomes, right?

That's not what was found.

The only characteristic that seemed to correlate with improved patient outcomes was the use of “reminders” that prompt doctors to use evidence-based care. For other CCM-based processes such as quality improvement, a registry, teaming, patient centeredness, enhanced access and clinical information systems, there was no correlation with patient outcomes.

The authors speculated that many of their CCM survey measures were too dependent on information technology that missed the impact of patient-physician relationships or local physician leadership. They also pointed out that their sample size may have been inadequate to detect small yet important changes, that they could have missed aggregate improvements at a practice or group level and that their results could have been biased by an overreliance on self-reported physician measures.

Keeping those weaknesses in mind, this is still another study that shows that processes of care may not be associated with better patient outcomes. But this paper is important at a more fundamental level: it reminds the DMCB that the ability to link process and outcomes at an individual physician level is very very difficult. While having registries, teaming, patient centeredness, enhanced patient access and clinical information systems may make a difference on a group, regional or national basis, the difference is difficult to detect in the average physician’s office.

This means that insurers, government, academics and policymakers may not be able to expect local process improvements to lead to observable local quality improvements. Thinking that practice by practice, physician by physician redesign will add up to population-based improvement may make sense, but it won’t be detectable at the individual clinic level.

The next time physicians say they don’t “get” the link between the push to redesign the delivery of primary care practice and what it means for their patients, maybe they’re not being obstructionist. They're being realists. They're not seeing it.

Fragmented Systems Don't Mean Fragmented Care: What Accountable Care Organizations Can Learn From Employer-Purchasers

When the Commonwealth Fund has nice things to say about "disease management," the Disease Management Care Blog pays attention. Check out this Purchasing High Performance newsletter interview with Jerry Burgess of an employer-based health care coalition called Healthcare 21 and Chris McSwain of Whirlpool Corporation.

Burgess and McSwain agree that it's possible for an insurer/employer to have multiple vendors including disease management firms in a well functioning coordinated mix of health care services.

The DMCB likes this article, not only because it speaks to the merits of the Unified Field Theory approach to care management, but because it also describes a template for leaders of budding Accountable Care Organizations to consider. Like employer-purchasers described in this Commonwealth Fund article, ACOs are also going to find that having a hospital and a physician network are not enough. They'll need the help of service vendors to help manage their populations' clinical outcomes and costs.

Here's how to do it:

1) Get the principals in a room once a year to make sure everyone understands the need to work with each other (patient referrals, data transfer are two examples),

2) Manage the vendors like a "supply chain" that exists to improve health and productivity,

3) Don't get too cozy with the vendors,

4) Demand objective measurement and reward good performance in outcomes based contracting,

5) Find vendors that can be in it for the long term; three year contracts should not be unusual.

As an aside, the DMCB will point out that disease management organizations (DMOs) have a track record of performance when it comes to coordinating services with other entities, working in supply chain mode, being all business, emphasizing measurement and contracting over multiple years. They'll get it. The challenge for ACOs will be to get the other providers, hospitals, behavioral health suppliers and pharmacy managers to work together.

In fact, the DMCB wonders if helping ACOs to coordinate the other vendors may turn out to be a future role of DMOs. We'll see.

Hat Tip to a certain Maven for the alert about this article. You Know Who You Are.

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

Are Wellness & Prevention the Solution to the High Cost of Health Care?

The laconic Disease Management Care Blog attended a business leader meeting over the weekend. There were a series of presentations (this guy truly rocked), but it wasn't until a panel discussion on the promise of genetic medicine that the curmudgeonly DMCB was unable to resist raising its hand. Noting that insurance claims expense from genetic testing can run into thousands of dollars per patient, it asked the panelists to reconcile the cost of their enthusiasm with runaway health care inflation.

The panel gave the right answers, but that isn't why the DMCB is posting this tale. During the subsequent coffee hour, it was approached by a print media executive and was asked a simple question: isn't the purpose of covering wellness and prevention in the first place to fix things so that we can afford everything else - like genetic medicine - in health care?

The DMCB was aghast. It recovered its game face, however, and answered the question "no."

There are three good reasons for the uncoupling of wellness/prevention from sickness care which, in turn, helps explain how health insurers approach issues like genetic medicine.

1. Even if $2 to $4 are saved for every dollar spent on wellness activities, the total number of dollars revolving around wellness and prevention for the average health insurer or employer pale in comparison to the short term and unbelievable amounts of money being spent on, for example, testing and treatment for cancer.

2. Even if there is an eventual long term wellness and prevention "dividend" for diseases like cancer and heart disease (which is doubtful), we have a cost trend problem in 2010 with no end in sight.

3. Last but not least, a former editor of the New England Journal of Medicine pointed out to the young DMCB that money saved in one sector of health care doesn't mean that the savings get transferred to other sectors. He was right: actuaries and CFOs don't manage insurance that way.

The DMCB doesn't necessarily agree with the Carter-esque view that the Tooth Fairy is dead. American genius will make genetic testing - and all the other good things in our future - affordable. In the meantime, the belief that we can use wellness to "save money" and use that to pay for whatever we want today regardless of cost is a pipe dream.

The Medical Loss Ratio MLR and Disease Management: Can the Notes Be Cut?

In the movie Amadeus, Emperor Joseph II criticizes young Wolfgang's "quality" music with the observation that "....there are simply too many notes, that's all. Just cut a few and it will be perfect!"

The same kind of logic has been applied by the same kind political class to the health insurers' medical loss ratio or "MLR." According to the Patient Protection and Affordability Care Act (PPACA), "standard" health plans must now, depending on the type of business line, have a MLR of at least 80% or 85%. This is interpreted to mean that of every dollar in insurance premiums collected by insurers, at least 80 or 85 cents has to be spent on medical care. The remainder (15 to 20 cents) goes to insurance functions, such as marketing, investing, actuarial activities, underwriting, claims processing, associated overhead and profit or surplus. A low MLR could suggest skimping on medical services, bloated administrative overhead or excessive shareholder returns. Therefore, a high MLR is good, right?

Not exactly. Check out this still timely and well written piece on the MLR by James Robinson appearing in a 1997 issue of Health Affairs. He points out that the line that separates money spent for medical services from the money spent for insurance services is very blurred. Insurers are increasingly using premium to administratively promote efficient and high quality medical care, while providers are assuming varieties of insurance-like risk-based arrangements such as capitation, upside shared savings and pay for performance.

Accordingly, says Dr. Robinson, it's easy for a MLR to become "skewed." Being in a market with small number of providers, a large amount of capitated arrangements, a limited number of insurance products, a lot of large customers or government contracts and little attention to quality all require less administrative support and will therefore have a higher MLR. On the other hand, health insurers with large networks that insure significant numbers individuals and small businesses, pay claims on a fee for service basis and have NCQA accreditation are likely to have a lower MLR.

What's more, the MLR is not necessarily a good gauge of insurer efficiency. The MLR was originally developed to help regulators and investors assess health insurer solvency, creditworthiness and profitability. That's because a rising MLR could herald a looming inability of an insurer to pay its debt obligations. The converse assumption - that the MLR measures health plan quality or waste - is more uncertain. In addition, there are no studies that have shown that there is a correlation between the MLR and a) the health status of or b) the total administrative expense per managed care enrollee.

These inconvenient truths haven't stopped a hostile Congress from piling on insurers even after PPACA was passed. Much like Emperor Joseph, Senator Rockefeller prefers that health insurers not have "too many notes" in their administrative expenses and simply solve the problem by eliminating some of them. The good news is that PPACA requires that the National Association of Insurance Commissioners (NAIC) figure out just what "notes" belong among the legitimate administrative expenses of a health insurer and which ones can be assigned to the MLR.

It won't be an easy task. For example, the U.S. Senate report linked above decries the expensing of nurse "hotlines, health and wellness, including disease management and medical management and clinical health policy” in the MLR and cites them as examples of insurer shenanigans aimed at putting profits over patients. Fortunately, the DMAA The Care Continuum Alliance has come out with a more common sense position that reflects the realities described in the Robinson paper linked above.

The DMCB recalls that it helped lead a disease management program that was, in an abundance of regulatory caution, 'expensed' as an health plan administrative cost. The nurses took care of patients. We worried about blood glucose control among persons with diabetes, made sure asthmatics used their inhalers properly and worked hard to keep patients with heart failure from being unnecessarily admitted to the hospital. Based on Robinson's insights about the MLR and a common sense interpretation of what's going on in the trenches of disease management, it's silly to categorize population-based care as an "administrative" function.

Back then, the expensing of population-based care was a local and minor issue. Thanks to this now being the subject of an inflexible, clumsy and one-size-fits-all act of Congress, it's become far more important. The DMCB hopes that the NAIC will recognize that disease management makes beautiful music and that notes cannot be simply cut.

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

Accountable Care Organizations: Here's a Manuscript That Helps Us Move From the PPACA Legislation to Actually Making It Happen

After cracking open the latest May 5 copy of JAMA, the Disease Management Care Blog was going to read this article that showed a correlation between hospital readmissions and the number of days from discharge to outpatient physician follow-up. It was stymied, however, by a methodology that relied on 'hospital-level rates of early follow-up as medians with interquartile ranges.' 'Bleh!' said the DMCB, especially because the admission rates only differed by about 2%. This appears to be a good research idea gummed up by needlessly complicated statistics.

So instead, the DMCB moved on and turned its attention to this commentary in the same issue of JAMA by Stephen Shortell (Berkley) and Lawrence Casalino (Cornell) titled "Implementing Qualifications Criteria and Technical Assistance for Accountable Care Organizations." Don't worry if you can't get to the full manuscript, because the DMCB is here to summarize and commentize for you.

Recall that ACOs are the golden boy of D.C. policy makers, who view these entities as the next best thing to integrated delivery systems. The Patient Protection and Affordable Care Act (PPACA) says (on page 277) that the Secretary of HHS has until January 1, 2012 to establish a Medicare "shared savings" "program" (which sounds more permanent than a "pilot" or a "demonstration") involving ACOs that have a "legal" and "administrative" structure, can be accountable for cost and care over three years, have enough primary care providers, care for at least 5000 beneficiaries, have "patient centered care" and other quality "processes" in place and can provide timely and properly formatted "information" to the HHS Secretary. Examples of ACOs named in the legislation include provider group practices, individual practice networks, hospital-provider joint ventures and hospitals that employ providers.

"Shared savings," generally means that ACOs can expect to receive a fraction of Medicare's reduced claims expense that would occur thanks to their improved efficiency and quality of care.

If you're thinking 'uh oh,' you're not alone. Physicians and hospitals thinking of throwing an ACO hat in the "program" ring will need to ponder the a) up front costs necessary to create a truly high performing and cost reducing organization, b) reduced cash flows thanks to (for example) fewer hospitalizations and less testing, c) downside of a risk arrangement where costs could go up instead of down and d) track record of a fickle and cumbersome Federal bureaucracy.

Despite the risks, there will probably be no shortage of physician groups and hospitals that want to form ACOs and join the "program." Shortell and Casalino have some advice for the Feds on how to deal with them.

First, divide them into three categories:

Level I: these organizations meet the minimal criteria described above and get to share in upside savings, but little else

Level II: these organizations, as determined by a tighter and more comprehensive data reporting ability can not only share in upside savings, but also agree to take some downside risk.

Level III: these organizations have it all, can report everything and as a result get paid through partial or full capitation, laced with performance bonuses.

Secondly, provide technical assistance.

Such assistance would include help creating "organizations, legal, financial and budgeting relationships" as well as redesigning practices, implementing process improvement, fostering teamwork, getting an electronic health record up and running, scheduling patients for timely access, using e-mail and group visits and developing "patient self management support programs." To fund all this, the authors suggest that some of the money being targeted at implementation of EHRs could also be used to support ACO development.

And so it goes. The DMCB expects policymakers will think about this framework while they're writing up the regulations that define exactly how the HHS Secretary will run the "program." They don't have long to do so, since the deadline is about 1½ years away.

In the meantime, the DMCB also thinks

1) this manuscript is a good and necessary next step in the journey from legislation to actually making this happen. If your organization is thinking about pursuing an ACO, this should be in your knowledge library.

2) While the DMCB agrees that ACO assistance will be necessary (the disease management industry is particularly savvy about risk and has the scars to prove it), we shouldn't kid ourselves: no one has experience in setting up one of these newfangled ACOs. What's more, the money saving track record of many of the redesign elements described above is shaky at best.

3) that it will be interesting to see how willing newly formed ACOs will be to enter into relationships with the Feds that involve downside risk. As the regulations get written, policymakers will need to think about the wisdom of letting organizations put their endowments or brick and mortar up as collateral.

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