Representative Stark Goes By The Numbers In An Attack On The Heath Insurers

The Disease Management Care Blog can put up with U.S. Representative Pete Stark's unrepentant progressivism. It can tolerate his embarrassing partisan bombast. It forgives him for being so easily baited into trading vulgarities with his constituents. However, the DMCB draws the line on the internet posting of monochrome text with simple raw numbers to attack health insurers. Mr. Stark's latest anti-insurer sucker punch describes "hundreds of millions" and "billions" in health insurer profit.

Last but not least, a maroon colored trim? What was the Congressman's staff thinking?

Everyone knows that compared to Congress' health care spending, hundreds of millions and billions are mere chump change. Mr. Stark's faux sticker shock fails to note that the profits only seem high because of the total amount of money under management, most of which is committed to reserves. He also conveniently fails to note that the health insurers' really have an anemic 3.8% net profit margin. Details on Wellpoint's 3.75% and Humana's 1.28% corporate "criminality" can be found here.

Compared to the profits of health information service providers (19%) and medical device manufacturers (12.5%), the real story is that the insurers are being squeezed by the Feds on one side and the provider system on the other. No wonder the newly centrist Obama Administration felt that Mr. Stark's brand of socialism was too awkward and decided to expand funding for Medicare Advantage.

Fortunately, says the DMCB, these inconvenient health care truths can be overcome by smarter web packaging. The helpful DMCB suggests using long-honored below-the-belt content like anecdotes ("until Mrs. Smith decided to buy health insurance after she got sick....") images of circa 1930's dust bowl children and hyperlinks leading to more information extolling the virtues of the Cuban health care system.

And for crying out loud, more "flash," interactivity and, most of all, colors. What are you trying to do, Mr. Stark.... mimic the boring blue-toned CMS website?

All Health Care Is Local. So Are Truly Successful Care Management Programs

If you had to make a wager on care management, would you put your money on local talent and hard work, or blaming inertia and budget shortfalls? Well, thanks to two presentations at the recent Health Canada conference it participated in, the Disease Management Care Blog's betting on the talent and work.

The first was by a physician at a regional hospital that scraped together small amounts of internal and external funding for three interrelated initiatives: 1) hiring a diabetes case management nurse who was shared by 35 primary care clinics, 2) alerting all physicians with "pink sheet" notifications about patient A1cs that are out of range and 3) creating a "standard inpatient order sheet" (an example from another institution is here) designed to combat sliding scale insulin and promote the use of basal insulin. All three led to statistically and clinically significant improvements in blood glucose control.

The second was by a registered dietitian who described how a group health center developed blanket medical "directives" (not to be confused with end-of-life "advance directives") that allowed non-physician professionals to semi-autonomously initiate changes in patients' diabetes care plans while they were interacting with patients via telephone, individually and group visits. Compared to a quasi-experimental control group, multiple measures of diabetes quality (cleverly combined into what was termed a Good Health Outcomes in Diabetes or GHOD score) showed statistically and clinically significant improvements over several years.

Both presentations demonstrated how great programs often have to start with small beginnings, usually involving nimble and dedicated visionaries who understand that good ideas and a successful track record can create its own funding streams, not vice versa. And speaking of a track record, both programs would not have gotten as far as they did without committing considerable resources to recording and analyzing their data on a prospective basis.

Want to start a a) medical home, b) disease management program, c) inpatient work flow solution or d) decision support system but blame the "administration," lack of "funding," colleagues' inertia and other resource constraints? Think you need "support" from the central government, or that you "deserve" square feet and full-time-equivalents and no one will cough it up? It may all be true, says the DMCB, but it was also true for the two presenters above, and they didn't let any of that get in their way. They boot-strapped their way up and were careful to document outcomes along the way. They just "did it."

Last but not least, the DMCB points out that the programs above were far away from the spotlight of academic approbation, policymaker awareness or government support. That is, literally far away, as in the heartland, hundreds if not thousands of miles away. In its travels, the DMCB has found the same has been true in the United States, such as Portland Maine, West Allis Wisconsin, Albany New York, and Boulder Colorado. As we continue to look for good ideas to achieve the triple aim, the Health Canada Conference served as a useful reminder that maybe all we really need to do is look no further than in our own backyards.

Insights on Diabetes Management, Courtesy of Health Canada

The Disease Management Care Blog has completed day 1 of 2 of the Health Canada conference on Diabetes Management Programs. While it certainly had much to say in its presentation, the real treat was hearing from the other speakers.

Among the many insights are:

While Canadians are patriots and are loyal to their government-dominated health care system, they readily admit that there are two problems with it: 1) politics intrude in health care policy making and 2) year-to-year clinical program planning can be hostage to year-to-year budgetary funding.

One speaker independently concluded - without having previously read the DMCB - that delivery system redesign with improved scheduling, organization and multidisciplinary teaming with non-physician providers offers the greatest hope for the care of persons with chronic illness. Health information technology and decision support, on the other hand, has little impact on patient outcomes.

One Province allows "stickers" to be placed on the back of insurance cards that are recognized as standing orders by all government labs for regular blood testing, like A1Cs or lipid testing.

While nurse-educator patient coaches are associated with increases in diabetes testing, patients from the same clinics who have not interacted with the nurses also experience increases in testing. The nurses seem to "nudge" changes in physician behavior.

Physicians, clinics or larger systems seeking to achieve outcomes should expect to spend 10% of their budget on data management, analytics and statisticians.

Which diabetes interventions are truly cost saving? You may be surprised by the contrast between how many lead to increased costs and how many actually save money. The global answer, courtesy of the Diabetes Control Priorities Project is here.

The Cost Effectiveness of Diabetes Management Programs, Courtesy of Our Neighbor to the North

The Disease Management Care Blog is broadcasting tonight from Ottawa, Canada, where it is furiously preparing for tomorrow's Health Canada sponsored conference on the cost-effectiveness of diabetes management programs.

So what will the DMCB have to say?

1. Whoever owns the insurance risk should own the disease management (DM) program. That's because DM is ultimately a strategy to mitigate the risk of chronic illness and reduce claims expense.

2. There is an emerging body of evidence that shows DM reduces claims expense and that the savings can benefit the risk-holders' bottom line. See here, here and here.

3. While the U.S. leads the world in per capita health care costs, the rate of increase (a.k.a. "trend") year over year is remarkably high among all industrialized countries. DM is one evidence-based option among many that can blunt that trend.

4. If a nation, province, state, organization, insurer or provider group wants to sponsor or initiate DM, what should it look for? There are several ingredients that are truly universal:

~ nurses that have experience in primary care, are mobile, are credentialed, can work at "the top of their license," are change agents and ultimately enable patients to participate in shared decision making. Docs can't do it alone.

~ information systems that can identify and recruit optimum patients into DM programs. That's because modifiable risk is not evenly distributed in any population. Some persons with chronic illness are not candidates for DM because they are doing well or because they are too ill.

~ it's not enough to achieve outcomes, it's also a matter of documenting them. "Field" research is well within reach, assuming you know how to do it.

~ if you strike the right balance of keeping them in the loop, making life easier and demonstrating real value, docs often support it. Woe to you if you mess it up.

The DMCB will be keeping notes on what others have to say and report on it tomorrow.

Time To Reform Medical Education (and include instruction on population health management)

The Disease Management Care Blog hasn't had much patience for our nation's medical schools. While there are exceptions, too many of them have imperial Deans, all-powerful Chairs, bloated bureaucracies, huge palatial edifices, and a pernicious skill in overproducing specialist physicians. These medical-industrial blobs continue to be unaccountable and tax-sheltered money machines and their leadership just doesn't get it.

Of course, that isn't going to stop reasonable suggestions on medical education reform from appearing in print from time to time. Case in point is a Perspective article by Mitesh Patel, Matthew Davis and Monica Lypson appearing in the New England Journal titled "Advancing Medical Education by Teaching Health Policy." It's just appeared on line, but that's OK because you read the DMCB.

The authors are proposing that the nation's medical schools adopt a "standardized health policy curriculum." They suggest that it focus on four domains: 1) health care systems (insurance, the safety net, workforce health information technology), 2) health care quality (outcomes measurement, quality improvement, patient safety), 3) safety, value and equity (economics, decision making, comparative effectiveness, disparities) and 4) health politics and law (legislation, adverse events and medical errors).

The authors also point out there are three barriers getting in the way: 1) the canard that there is simply no more room in undergraduate education (there is research that says otherwise), 2) the faculty don't exist (er, the truth is that they haven't been hired) and 3) the best way to teach this hasn't been developed (pending research on the topic, that doesn't mean that excellence should be the enemy of the good).

The DMCB wholeheartedly agrees, but being published in the Journal doesn't mean its going to happen. Perhaps what's called for is a top-to-bottom reform of medical education akin to what happened after the publication of Carnegie Foundation's The Flexner Report in 1910 (that's a pic of Abraham Flexner, circa 1895). The Foundation is still at it and many of its current proposals dovetail nicely with Patel et al. Perhaps it's time to link funding or tax policy to "performance," not the least of which should be an increase in the number of docs pursuing primary care careers.

The DMCB will close with an interesting recommendation from the Carnegie Foundation's list of reform proposals. The parts bolded by the DMCB speak to the importance of including team and outcomes-based principles of population health improvement in the curriculum. As a result, it deserves support by the care management community.

As we move forward with health reform, hopefully medical school reform will move to the top of the list:

To cultivate a spirit of inquiry and improvement in learners and in health care teams; this spirit supports both innovations in daily practice that translate into better service to patients, system improvements and improved patient outcomes as well as the development of larger research agendas, new discoveries, and knowledge building.

Wisconsin Teachers: OK To Rank Health Plans and Physicians, But Not Us?

Raucous citizens refusing to leave public places. Political leaders implacably refusing to compromise. A President's politically crafted statements of support. Greece and Libya you ask? Yes, says the Disease Management Care Blog, but include Wisconsin and its public union travails in that list. And one particularly visible group has been the state's public school teachers, who are fighting against proposed changes in their collective bargaining rights, having to pay more for their benefits and, until recently, merit pay.

On behalf of the health insurers and doctors in the Badger State, welcome to our world, says the Disease Management Care Blog. Prior to Madison's political stand-off, Wisconsin's "Department of Employee Trust Funds" had initiated a "3 Tier" health insurance model in which health plans were ranked according to efficiency and quality. Tier 1 plans had the lowest employee premium, which was engineered to attract the largest number of state employees. The state's insurance commissioner and the Wisconsin Collaborative for Healthcare Quality (WCHQ) have also been rating the plans. Since union member enrollment means income, health plans lusting after that coveted Tier 1 status have been undoubtedly rating their physicians. The WCHQ has joined in and has been naming (practice) names.

The DMCB believes it's doubtful that the 3 tiering system and public ratings would have ever occurred without all of the unions' consent. Ironically it seems, they didn't anticipate that this swell idea would be eventually applied to their own members.

The DMCB recalls some of its physician colleagues wishing that they had a union to counter the ratings. The lesson here is that it looks like even a union ultimately isn't going to help in this fight against city hall and its grumpy voters.

Disease Management: An Important Piece of the Puzzle Lives On

An important supplement to Population Health Management is now available on line. Even better, it's all open access.

Much of the issue is devoted to the good, the bad and the ugly of the hapless Medicare Health Support program. It's good, because long-term follow-up may show evidence of a return on the government's investment in remote telephonic coaching for chronic illness, bad because modern versions of remote and targeted telephonic coaching continue to be dismissed by policymakers, academics and researchers alike, and ugly because CMS' aptitude as a research partner in MHS was sorely lacking

The Disease Management Care Blog immodestly suggests a good summary of both the supplement contents as well as the policy issues can be found here. Basically, the DMCB argues continued industry innovation, ongoing translational research and a more sophisticated understanding of the role of "disease management" has made the traditional interpretation of MHS moot. Remote telephonic coaching has since evolved to become one piece of the puzzle in caring for populations with chronic conditions.

Disease management: both the term and the concept warrant its inclusion as a viable option for the care of populations by providers, insurers, buyers and governments.

Provider versus Payer Centric Shared Decision Making Support: There's A Big Difference

By Bob Tavares

In its post “What Can A Hockey Game Tell Us About Shared Decision Making?”, the Disease Management Care Blog may have missed the important difference between physician-centric versus payer-centric models for patient decision support. While efforts to support shared decision making (SDM) have largely been driven by payers in the past, it is now possible for physicians to “prescribe” patient decision aids and track patient compliance directly from their electronic health record.

This brings up three important questions:

1) Can traditional disease management firms re-invent themselves to support provider groups (including Accountable Care Organizations) as they assume more risk? If the answer is “yes,” that will probably mean moving from 30 mega payer contracts to 300 small provider contracts - just to keep revenue flat with smaller margins.

2) Can providers who want to build shared decision making themselves really cobble together all of the pieces? The most advanced medical homes have EMRs, registries, and patient portals but many are still very crude as it relates to population health management (PHM).

3) Will a new class of population health management (PHM) firm emerge that doesn't have the baggage of the legacy firms? That's my bet. There are new PHM companies that have traditional disease management execs at the helm who are building a provider centric solution from the ground up. Business rules are being built to ensure that every patient is connected to the appropriate level of decision support across the continuum of care.

My company is working with over 100 hospitals, many of whom are embracing SDM and positioning themselves to be ACOs. We have a long way to go before SDM becomes the standard of care, but providers are further along than you may think. We estimate we’ll be providing decision support programs to approximately 1 million patients this year.

Time To Share Your Good News

Thousands of Disease Management Care Blog readers have come to recognize that it's possible to launch robust population-based care management programs and simultaneously study and manage the outcomes. That methodology also means that you can also share your results with your colleagues at scientific and industry meetings.

Case in point: the Care Continuum Alliance annual meeting called Forum11. There is still time to submit an abstract. Not only will you and your company get the recognition you so richly deserve, but it will be a great excuse to network and learn at a great meeting. You may even get to see the DMCB in person!

The Latest Heath Wonk Review Is Up

Life IS a box of chocolates, especially when you open up this latest Valentine's Edition Health Wonk Review. Sample the best and brightest of the wonky opinionating - all assembled in one place for your learning pleasure at the Colorado Long Term Care Insider blog. Enjoy!

A Tale of Two Insurers

And it befell in the days of President Obama, when he led the Administration and so reigned, that he held a mighty siege against a great alliance of health insurers. Using a great and wondrous rhetoric, he issued forth with a mighty host and wonderly portrayed health insurers as corporate rabid dogs that should slain'd by a forcefull and enlightened federalism. And a law dubbed The Affordable Care Act was passed.

And so the Disease Management Care Blog hearkens back to Anno Domini 1999, when Independence Blue Cross (IBX) in the towne of Philadelphia was locked in desperate and mortal unpleasantness with hospitals, with the force of two-way lawsuits with many accusations of unrighteous and monopolistic pricing at both small community hospitals and great premier academic centers. The DMCB tells of IBX's then CEO and Duke, Fred DiBona, by the faith he owed us and of pleasant countenance, the crying of his many consternations as a very unjust deed of arms. He personally fell passing sore into disrepute, unable to make joy at any public function without news-bards, city-royalty or clergy laying upon him to cease the ungracious slewing of hospital profitability. And the CEO and Duke DiBona retreated to his castle grievously wounded. And a consensus rose up in the land of "hospitals one, insurers zero."

And yet, while the IBX and other insurers throughout the land were put to flight, policy has made a passing change. Forced into unending jousting tourneys defending The Act unto a host of wrathful Congressional Knights, even the fearsome and noble Sebelius has become a new found believer in State autonomy and putting limits on coverage. For inconvenient political and fiscal reality has rendered onto the Administration a great many insights on the basics of health insurance.

Yet, that is not foremost in the possible undoing of Mr. Obama's carefully laid planning. For IBX has obtained a greatly ironic revenge after the passing of so many years. For now, Massachusetts Blue Cross Blue Shield in Boston is set upon smoting Partners Healthcare, while the populace of that honored land has been of unhappyness over hospitals' billion dollar capital campaigns, hand-off errors and many unsavory business tactics.

Which is why the DMCB so asks if the lay-public now holds a more favorable countenance upon the insurers and is less passing glad with their hospitals. What else can explain the continuance of the Massachusetts Blue Cross Blue Shield campaign? Health insurers are not as angels, but the field of battle now seems of more even level. For the people may be coming to see the insurers as being innocently obliged to pass through the vexsome cost increases, are often blessed with not-for profit status, are preserved by the Affordable Care Act and, of greatest consequence, are seen as - perhaps - unfairly and woefully set upon by the mighty Obama.

Think You Know Everything You Need To Know About Measuring Quality? Think Again

Fast on the heels of this recent Disease Management Care Blog post on a serious shortcoming of mainsteam quality measurement (the routine failure to account for patient preferences) comes this more far reaching and eye-opening JAMA commentary titled "Sudden Acceleration of Diabetes Quality Measures." Authored by Leonard Pogach and Avid Aron, it efficiently summarizes what’s wrong when it comes to trying to do the right thing for populations with diabetes. Thanks to checking in with the DMCB, you’ll do yourself right by familiarizing yourself with the handy summary below on the downsides of our current mainstream approach to “outcomes.”

While readers may believe that only nincompoops and ne'er-do-wells would dare to second guess the National Committee for Quality Assurance’s (NCQA) and Leapfrog Group’s approach to quality for diabetes mellitus, Drs. Pogach and Aron assure us that’s not the case. The Diabetes Quality Improvement Project (DQIP) and its successor, the National Quality Improvement Alliance (mentioned in this AHRQ summary) also reviewed the science of diabetes control and concluded there was insufficient evidence to warrant recommend an A1c of 7% or a blood pressure of less than 130/80. In the years that followed, they may have turned out to be correct. The ACCORD study showed that an A1c of 6.4% resulted in an increased death rate (here) and a blood pressure of 119 systolic was ultimately no better (here) than a blood pressure of 133 systolic.

So, how did the NCQA get it wrong? According to the authors, measuring quality in populations demands a more nuanced, conservative and go-slow approach. To wit, what is needed is a measurement methodology that:

is continuous - right now, most measures are "binary" i.e., measures are boiled down to meeting a single measurement threshold. Since benefit and risk are non-linearly associated with diabetes control, quality assessment should recognize that there is a difference, for example, between an A1c of 7% versus 8% versus 9% and higher.

accounts for selection bias - not all populations that selected for measurement are the same, so comparisons of quality between groups may be prone to bias.

is amenable to case-mix adjustment - if any known sources of bias are present, they should be statistically accounted for.

accommodates patient preferences - take the DMCB's word for it, a significant number of highly informed dabetes patients do not want a low A1c or blood pressure if it means taking more pills.

minimizes measurement variability - blood pressure measurement is very operator dependent and even blood tests can also vary.

is not used until potential harms like hypoglycemia (low blood sugar reactions) and polypharmacy (too many pills) are fully accounted for.

The authors recommend that the Agency for Healthcare Research and Quality take things over. They're more likely to be accountable, take other viewpoints into account, be fully transparent and would probably agree to have everything televised before any quality measure is formalized for widespread use.

The DMCB isn't sure that it necessarily agrees with blowing things up and starting over, especially if it involves a government agency. While it thinks this through, one common sense suggestion may be for the science of quality improvement to adopt the principles above for the NEW measures that are coming out. Hopefully, the NCQA is paying attention.

Capitatation, a.k.a. Bundled Payments a.k.a Monthly Coordination Fees: So...Why Are They Such A Good Idea?

The Disease Management Care Blog's world is filled with unanswerable mysteries. Is Lady Gaga an eggample of musicianship or has she become some type of bad yolk that's no longer funny? Do modern presidents never dye or do they just gray away? Are bundled payments really the answer to the physicians' income needs?

Lady G and the President resist analysis, but the DMCB thinks of bundling as a version of capitation, where providers are paid with a fixed periodic global payment (per "caput" or head or person) on a periodic (usually monthly) basis. Its purpose is to reimburse the doctor for a packaged suite of medical services. Under "full" capitation, docs are obliged to rely on the payment for practically all services such as office visits or check-ups. While capitation results in a steady cash flow whether patients are seen or not, the downside risk is that the patients' costs may exceed the monthly payments. As a result, physicians may have an economic incentive to withhold services.

More modern versions of primary care provider payment are trending toward a mix of fee-for-service (FFS) and capitation. In other words, physicians are free to bill the patient (or the insurance company) for each face-to-face encounter (where a fee is generated for each service). But over and beyond the FFS, physicians can get an additional per person payment that covers the cost of a suite of additional services, such as other communication (like emails), patient education and coordination of care. This hybrid payment model isn't referring to it as "capitation" but euphemistically describes it as a "monthly care coordination payment" or a "bundled care coordination fee."

What seems to really get the DMCB's physician colleagues excited is the prospect of "risk adjusted" monthly payments. It's complicated, but the idea is to shift more capitated dollars toward patients who require more services based on characteristics such as advanced age or the presence of co-morbid conditions. So, while the monthly payments can range between $5 and $30 per patient per month (PMPM) it makes sense to remit the higher payments for older patients with conditions like diabetes or, for example, those who have been in and out of hospitals with heart failure.

Sounds good, right? Docs can have their FFS cake and eat the capitation too!

The DMCB doesn't think it quite works out so simply because:

1. Insurers rarely find "new money" in its premium dollars. A common approach is to take any scheduled premium increases and use them to pay the PMPM fees instead of increasing the fee-for-service payments. In the end, the physician community isn't really being paid any more. Some are being paid more (thanks to risk adjustment) but that mathematically means others are being paid less.

2. Risk adjustment is a notoriously inaccurate both inside and outside of primary care. As the DMCB understands it, much of risk adjustment is mathematically based on "binary" functions (for example, there is diabetes or there isn't; it fails to account for poorly controlled vs. well controlled disease) and doesn't to account for other conditions that aren't easily detectable that may also drive utilization. As a result, only a fraction of utilization is accounted for, leaving the physicians to deal with the rest.

3. Last but not least, risk adjustment is subject to the same downward pressures that are being applied to all those other good ideas making up the payment systems such as DRGs, RVU conversions, the SGR and even the notorious fee-for-service payments. The DMCB suspects that the bundled payments may seem like a bonanza now, but just wait. The money will dry up faster than Dr. Berwick's admiration for the British health care system. Physicians will be squeezed between trying to make a profit by withholding care or depleting their inadequate capitated fees by providing substandard care.

So why are bundled fees and partial capitation payments systems such a good idea? The DMCB will continue to go ova this this but it isn't expecting to make much headway.

What Can A Hockey Game Tell Us About Shared Decision Making?

The Disease Management Care Blog attended a professional hockey game this weekend and it must say it was quite the spectacle. While the athleticism on the ice was quite remarkable, the real wonderment involved the hometown fans. Questionable referee calls prompted thousands of all ages to chant phrases that the DMCB has not recently read in any medical journals, while the willingness of grown men to display, in stereo fashion, obscene gestures was only last witnessed by the DMCB during an early morning ER shift.

Given their apparent fondness for calorie dense foods and various carbonated beverages, it was also clear to to the DMCB that wellness, prevention and chronic illness management was not at the top of most the hockey fans' agenda. Since there is a ready availability of high quality health care providers surrounding the hockey venue, the DMCB suspects most if not all of the gluttons on display were well aware of their downsides of their risky lifestyle.

So, is that their doctors' fault?

While the DMCB was at the American Medical Association's National Advocacy Conference, it was repeatedly reminded that the preferred physician answer is "hell no." While the DMCB's colleagues recognize the key to control of chronic illness is patient education, the sense of powerlessness over this issue was telling. Doctors talk, patients listen and, when the next visit rolls around, nothing has changed.

Enter "patient centeredness." This has been defined by the Institute of Medicine's Crossing the Quality Chasm report as any care that is “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." So, if a physician provides whole person care, comprehensive communication, coordination, support, empowerment and access on Friday afternoon and the patient washes three jumbo dogs and a plateful of nachos down with a pair of brewski's that Saturday night, is that a breakdown in a physician-owned care process?

Common sense says no, but our systems for quality improvement have yet to catch up with this reality. Ultimately, says the DMCB, patients should be able to fully participate in shared decision making and decide for themselves whether an ideal body weight, an A1c less than 7% or taking extra blood pressure pills is worth it. Assuming they've been apprised of all the risks, benefits and alternatives, that should be their decision to make. Given their behavior at the hockey game, patients certainly enjoy making full use of their right to make bad decisions.

Which leads the DMCB to three recommendations:

1. In addition to measuring "process," and "clinical," "economic," and "other" outcome measures, perhaps its time for the health care system to start learning how to measure "shared decision making" outcomes including counting the number of times patients at risk (the "denominator") participated in a state-of-the-art risk reducing, engagement seeking educational session (the "numerator"). The DMCB has little doubt that when this is done right, variation will diminish and the quality curve will shift toward the better. Physician buy-in will also increase.

2. Physicians should be free to assume personal responsibility for the task of seeking patient engagement during all the free time they have (not) during their face-to-face patient encounters. A more reasonable alternative may be to outsource this, either to the other team members in a patient centered medical home or to a companies (like this) that can scale this from one to thousands of patients.

3. Finally, hockey fans should recognize that persons unengaged in personal health improvement or risk reduction who also have no redeeming physical characteristics are not helped in their appearance by wearing a foam replica of an oversized hockey puck on their head.

The Affordable Care Act Mandate: It Comes Down to Optics

Early in the course of the Disease Management Care Blog marriage, the spouse would target an important non-optional purchase for the DMCB spawn and tell her husband to hand over the cash. Provoked by a loss of control and a spike in circulating blood testosterone levels, the annoyed DMCB would resist. After listening to its sputtering claims that it was better suited to evaluating the merits of said purchase, the shrewd spouse relented.

After listening to very smart dueling lawyers (Simon Lazarus of the National Senior Citizens Law Center and Ilya Shapiro of CATO) at the AMA National Advocacy Conference, the DMCB decided that a key part of the debate over the individual mandate is the tangled DMCB-spouse-spawn purchasing relationship writ large.

The debate over the mandate (which, by the way, has been supported by the AMA for years) comes down to the "optics" on whether there is a difference between:

a) the spouse (government) collecting the 'hand-overed cash' (taxes) to make a purchase necessary for DMCB spawn upkeep (health care insurance),

versus

b) the DMCB (a citizen) being obliged (mandated) to spend its own cash to make the necessary spawn-upkeep purchase (health care insurance).

Supporters of the mandate point out that the Feds can use payroll taxes to force us to purchase Social Security. It can also use its taxation powers to purchase Medicare Advantage on our behalf. The only difference in the mandate scenario is that the Feds-spouse are taking themselves out of the middle. In the end, it's the same outcome.

Opponents of the mandate make an important distinction between it and taxes. While taxes are as certain as death and can be used by the spouse-government to buy anything on our behalf - examples include Fannie Mae (mortgages), GM (cars) and AIG (insurance) - it shouldn't necessarily be able to oblige DMCB-citizens to buy the stock of Fannie Mae, GM or AIG, even though that's what is happening anyway. It also can't require citizens to buy their mortgages, cars or insurance products either.

Supporters say a key distinction is that health care is unlike mortgages, cars or insurance because it's not optional. Opponents retort neither is food and shelter.

And so it goes.

The DMCB has previously examined the Affordable Care Act's (ACA) "individual responsibility" and "penalty" language (as an aside, to its knowledge, the word "mandate" never appears in the Act itself). It recalls a craven Congress wanted to avoid the political atmospherics of a "tax" while simultaneously supporting a private health insurance market. It turns out that the legislative cure may have been worse than the disease.

As an aside, during Q&A, the DMCB asked about fast-tracking the ACA-mandate legal challenges to the Supreme Court. The panel pointed out that the appeals process will allow both sides to sharpen their legal arguments, enable a better review by the Supremes and, ironically, prompt Congress to start thinking about "Plan B." Good points but, then again, they're lawyers.

By the way, as the years have passed, the DMCB just hands over the money.

A Hearty "Good Luck" To Two Victims of the Affordable Care Act

While the health reform hand-to-hand combat continues, the Disease Management Care Blog had a chance to see two features of the Affordable Care Act (ACA) up close and personal.

The first was courtesy of the AcademyHealth National Health Policy Conference, where there was a breakout session on how employers will have to cope. It wasn't pretty. The speakers, who were experts on the ACA's wording and the likely supporting regulations, described an emerging horrid thicket of employer and employee tax credits, penalties, fines, benefit design rules, assumptions, subsidies, gaming, audits, reporting requirements and what-if calculations. The DMCB figures that companies that want to buy health insurance for its employees will eventually need to hire a small army of tax and benefit consultants and, despite trying to do the right thing, will still risk being in violation of some rule some where. It's so complicated, the DMCB predicts that it won't be the "money" but the indirect costs, administrative burdens and hassles that will lead to businesses bailing out, paying the fines and pushing their hourly employees into the individual market health exchanges. The DMCB heard that the ACA's architects ultimately wanted employer-sponsored insurance to waste away, and it looks like they'll get their wish. Despite this, however, the message was that the employers liked some features of the ACA and were patriotically planning to comply.

The DMCB wishes our nation's employers good luck.

The second was at a separate conference a few blocks away, where Acting Medicare Administrator Donald Berwick spoke. The good news is that Dr. Berwick's comments amply demonstrated his smarts, credibility and passion. He genuinely believes in the merits of health system change involving electronic records, self-directed care, team-based coordination, dissemination of best practices and paying for value. He supports the ACA "after thinking about it," avoided any gratuitous comments about his boss and brought a roomful of physicians to their feet in a standing ovation. The bad news is that he naively thinks aggressive Federal activism is a good thing for patients and doctors everywhere, that there is broad political support simply because the Angels of Light are on his side and that the huge expanded Medicare bureaucracy is up to the task of leading and executing on centralized health system reform. Dr. Berwick is a good man, but his challenges are practically insurmountable.

The DMCB wishes Administrator Berwick good luck.

The Disease Management Care Blog Proudly Presents the 124th Cavalcade of Risk

Welcome to the Disease Management Care Blog's hosting of the 124th Cavalcade of Risk. Every few weeks, writers like the DMCB get to submit their on-line posts for inclusion in the CoR. Bloggers take turns hosting the CoR by selecting the best, summarizing the posts and providing links back to the original post for further review. Think of this as a virtual convention of writers who blog about risk and want to share our best recent work for your reading pleasure.

The DMCB likes to regularly write about health care, primary care, insurance, health reform and disease management. As a result, it often strays into the topics of measuring, monetizing, moving and mitigating risk. As a result, it couldn't resist a chance to host this CoR.

The DMCB has divided this Cavalcade of bloggery into two categories. The former are of the very high quality "thinking" persuasion that critically examine some new aspect of policy, regulation or the business. The latter are peripherally associated with risk but spill over into money management, employment, credit, value and personal security. They are more "informational" in nature.

Thinking Contributions

Louise of the Colorado Health Insurance Insider quotes the President of a state medical society about comparative effectiveness research (CER) and likes what she hears. Doctors need to be confident about which treatment option among many offers their patients the greatest value, says she. If every doc follows Colorado's example, maybe we'll be on the way to achieving real health reform, not just health insurance reform. The DMCB wonders if anyone has done research comparing health care quality among physicians who believe in CER versus those who don't.

If we're going to have a mandate for health insurance, why not the same for mishaps related to gun ownership? Nina Kallen of the Insurance Coverage Law in Massachusetts blog points out that insurance generally only works for unintentional accidents. She thinks it's a lousy idea. Most shootings are intentional, so it'd be difficult to price and regulate. Yet, thinks the DMCB, health insurance covers intentional injuries and what about the person who knowingly continues with a lifestyle that is harmful.....? Maybe that's why we should have a tax and not a mandate. Maybe that's why health insurance is broken. You can think about this knotty issue here.

Auto accidents, falls, skin injury, being impaled, electrocution, amputations, being trapped in a building, exhaustion, dehydration, heart attacks, lumbago and being gassed are all risks that share one key characteristic. Want to know what that is? Then head on over to Julie Ferguson of the Workers' Comp Insider Blog, who succumbs to the blogtemptation of an informative "Top Ten" (in this case "12") List (Speaking of "cold," the DMCB spouse would have little problem with her husband heading off into space if she were recovering from a gunshot wound to the head. It's his coming back that she'd have the problem with).

Have you heard about the Obamacare "mandate" and "risk pooling," but never quite grasped it? Jason Sharfrin of the Healthcare Economist provides a remarkably clear explanation while dismissing Florida Judge Vinson's controversial decision. The DMCB worries, however, that in both scenarios, the total cost is approximately the same, it's just spread around more people and is less visible. Unfortunately, for Mr. Obama, it appears U.S. health care costs are being spread around and are more visible. Not to worry, however, since lawyers on the Supreme Court will have the answer.

Somewhere in the Affordable Care Act is something called the "Community Living Assistance Services and Supports (CLASS) provisions. This is a voluntary, tax-qualified long-term care assistance program that is administered by the federal government. Henry Stern of the InsureBlog has been closely looking at this from a "nuts and bolts" insurance perspective and doesn't like what he sees. After reading it and checking out its links, you may not either. That was certainly true for the DMCB.

Russell Hutchinson of Chatswood Consulting examines the insurance concepts of the "booster benefit" here and benefit exclusions here. The former is mysterious and the latter is pernicious. Both appear to be situations where it may really pay to have a broker on your side who can explain all this to you. Lacking a broker, another option is to regularly read the Cavalcade of Risk as well as the Colorado Health Insurance Insider, Insurance Law in Massachusetts, Workers' Comp Insider, Healthcare Economist, InsureBlog, Chatswood Consulting and DMCB (via Twitter, Facebook and RSS) every once in a while.

Last and least, the DMCB offers up another public service, informational and humorous video portraying a fictional conversation between an enthusiastic Accountable Care Organization administrator and a skeptical health care consumer. While ACOs are the darling child of President Obama's health reform efforts, there may be less to these details than meets the eye.

Informational contributions:

Indexed annuities. Their complexity is part of their fascination.... and risk.

Parachuting. Here's why you shouldn't.

Think you can beat the markets when it comes to investing? Meet your competition.

Income not keeping up with your job responsibilities? Here's what to do.

If you think $10 is not a lot of money, here's 9 good (along with one bad) reasons to think again.

Lending money to family and friends calls for some tough discipline.

Mixing your 401K and a cash advance loan is risky. If you must.

If you are considering opening or managing your own IRA, here's some facts.

Inflation is lurking out there, so you may consider some hedging strategies.

You: road warrior. Your device: iPhone. Your need: travel apps. Lots.

Credit cards can get you into credit trouble. Ironically, they can also get you out.

Speaking of credit cards, AmEx will extend product warranties with the usual exclusions.

Risk is known, knowable and unknowable. Know why here.

If you are tired of paying too much for routine care maintenance, pop this hood.

The Medicaid Wave is Coming: Will the Healthcare System be Ready?

By Carol Sardinha

There were some stark realities shared by the experts at the recent 2nd Annual Medicaid Innovations Forum in Washington that will be of interest to Disease Management Care Blog readers:

• It’s estimated that about 15 million new individuals will qualify for and enroll in Medicaid between now and 2019 if health reform goes through as currently written. Some estimates run as high as 30 million new people coming into the Medicaid ranks. That’s a lot of new people.

• Individuals with one or more type of serious mental illness will make up the largest segment of people entering Medicaid for the first time, stated Brian Wheelan, VP of Corporate Development and Strategy at Beacon Health Strategies, which specializes in behavioral health (BH) management. These individuals have much higher mental health costs and utilization rates than the typical commercially-insured population, about three to 10 times more. Individuals with serious BH issues also have much higher incidences of co-morbidities and higher medical costs than the general population.

• In the meantime, state budgets keep getting tighter, putting more restraints on Medicaid spending.

• There is a shortage of physicians willing to treat Medicaid patients. The Medicaid Health Plans of America (MHPA) is working to address scope of practice laws so more non-physician providers, such as nurse practitioners, can be tapped to treat Medicaid patients, according to MHPA President and CEO Thomas Johnson.

• The HHS Office of Integration wants to move more dual-eligibles into managed care systems, a move supported by MHPA but opposed by the American Health Care Association (AHCA) which represents long-term care facilities. Johnson says the two associations will be having discussions on the issue.

• Medicaid eligibility enrollment systems are antiquated and cumbersome and will have to undergo massive restructuring to accommodate the influx of new beneficiaries.

This is just a small sampling of the challenges ahead. Yet even as we wait for final CMS regulations on ACOs, innovation and reform is occurring at the local and health plan level. Network Health, a Medicaid plan in Massachusetts, along with its partner delivery system, Cambridge Health Alliance has already embraced developed an operational ACO delivery model, although metrics are not in yet. MHPA’s Johnson, meanwhile, says his organization has a subsidiary devoted to best practices and a work group charged with identifying ACO models that would work best for the Medicaid population.

Still, I can’t help but worry when I hear some of these numbers and think about the difficulties of building and operationalizing truly integrated and coordinated systems devoted to caring for some of the sickest and most difficult to manage patients. Will states, providers, payers, and other entities at risk for caring for these most vulnerable patients just continue to seek to shift the risks elsewhere as they have historically? Or will they find ways to effectively manage the care of these patients so that they become collectively responsible for that care within the system?

There were many bright, dedicated people at the Conference who are devoted to making this concept work. I hope they are successful. But the clock is ticking.

Watch for a future blog post citing some of the innovations mentioned at the conference that are being used to improve care delivery and manage costs in the Medicaid population.

Carol Sardinha is a healthcare industry career specialist and strategist with expertise in managed care, Medicare, Medicaid, pharmacy benefits, and other areas. A former healthcare business and healthcare policy journalist, she most recently served as Marketing Channel Lead, Mature Markets, at Healthways. Carol is currently supporting a number of independent healthcare business and writing projects. She can be reached at: casardinhaATgmailDOTcom

So Many News Events, So Little Blog

Why Not Fast Track the ACA to the Supreme Court?

The Disease Management Care Blog asked the same question as Senator Nelson in this quixotic post weeks ago. The real news is that as a lawyer, the Senator has shown there is an exception to every algorithm.

Career Management 101

The DMCB understands the best time to exit any position is while your reputation is high and before things start going bad. That may be the intentional or unintentional thinking behind Dr. Blumenthal's decision to exit, but that doesn't make it any less true. As studies begin to show that the EHR stampede is not leading to higher quality or lower costs, explaining that sorry news will become the duty of a third HIT Czar.

A Vice President for Patient Centered Medical Homes

All well and good, says the DMCB, but the PCMH will not have truly achieved the pinnacle of corporate medical-industrial success that it so richly deserves until a major health system identifies a Chief PCMH Officer, or CPCMHO for short.

This Is How We Make a Health Law Better?

There's the cost of the ACA and then there is the revenue necessary to fund it. Repealing the 1099 provision addresses only half of the problem. The DMCB fears having Congress oversee the fiscal integrity of the ACA is like having Charlie Sheen emcee a spring break party.

1000 Posts!

Last week, the DMCB broke the 1000 post barrier. Really.

No Correlation Between Physician Supply and Patient Perception of Quality and Access (including primary care)

The Disease Management Care Blog suspects that a large fraction of its many regular readers work in or with medical settings. On the other side of that door, in the floor above or below you, in the building across the street or at the other end of that phone call, there are patients and doctors doing... well, the doctor-patient... thing. Since the patients and doctors use this "thing" a lot , patients would suffer if it wasn't there, right? If the hospital, or clinic, or system or or network closed its doors, disappeared or was swallowed up by the earth, dissatisfaction, illness, death and other consternation would follow, right?

Well, maybe not. At least, if you asked the patients. That's exactly what David Nyweide (of CMS), Denise Anthony, Chiang-Hua Chang and David Goodman (all of Dartmouth) did. 4,000 randomly selected, nationally representative, elderly and independently living Medicare beneficiaries were surveyed with 12 questions about access to and satisfaction with health care. Those data were correlated with the physician supply in their Medicare-defined "hospital service area" (the DMCB learned there are 3,067 of them). The physician supply in each service area was based on the data from the AMA Physician Masterfile.

2,515 completed the survey with a respectable response rate of 65%. After adjusting for age, gender, race, health status and local income (based on outside data sorted by zip code), there was no association between the local density of physicians and patient perceptions of access, being able to get a test, being able to see a specialist, being satisfied with their care, feeling that they had enough time to talk to the doctor or having a primary care provider. There was also no association between the local supply of primary care and local perceptions of care. There was only a weak association between the local supply of primary care physicians and having one.

The study is limited by being "observational" and only reporting associations. In order to better understand if more primary care causes a change in Medicare beneficiary perceptions, a prospective trail would be required. The study is also silent on the local quality of primary care, access to other health professionals, the limitations of sorting physician supply based on service area (versus more granular counties or zip codes) and the lack of input from managed care Medicare. Last but not least, there may be an association between the local supply of primary care and "hard" measures of health care quality, versus this study that used consumer perceptions.

Despite the limitations, the study should give pause to policymakers, regulators and politicians who think that increasing the physician supply or increasing the primary care physician supply is going to make a difference in voter-beneficiary-patient attitudes about local access or quality of care. It turns out that physician demand vs. supply may be more elastic than anyone considered. This should make persons wonder if pumping more physicians into a community is the "solution" we think it is.

And the DMCB asks why stop there? The NCQA and NQF should take note. Local hospitals argue that they and their physicians' social mission warrants not-for-profit status and being exempt from local taxes. Perhaps one gauge of how well that mission is being fulfilled should be perceptions of access and quality versus a national norm or a historical baseline. Since "Accountable Care Organizations" will be responsible for cost as well as quality, perhaps consumer perceptions like this should be part of the yet-to-be-defined measurement mix. Last but not least, perhaps all those suspect "Top One Hundred" surveys should consider using a variation of this.

Image source

The Latest Health Wonk Review Is Up

Lynch Ryan of the Worker's Comp Insider Blog hosts the latest health wonk review, aptly using a "stormy weather" theme to describe what the bloggers have to say about health reform. You can check out the bluster, chill and biting wit here. Enjoy!

Ten Predictions for 2011

The Disease Management Care Blog was interviewed today on blogradio by Gregg Masters of ACOWatch. If you missed it, the podcast is linked below. The audio can be accessed by clicking the "play" arrow button toward the left side of the badge. Think of it as informative background talk complimenting that extra cup of caffeine as you clean out your email inbox.

In the podcast, the DMCB makes a brazen prediction:

1. CMS will delay the targeted January 1, 2012 start date for Accountable Care Organizations. Note that none of the proposed enabling regulations have been released as of this writing. The DMCB calculates that the a) time required by CMS to solicit, digest and respond to the follow-on public commentary to the proposed rules, plus b) the the inability of most ACO wannabes to plan and organize in the time remaining, makes the current ten month window a daunting proposition. Toss in hostile Congressional meddling as well as growing uncertainty over the fate of the ACA and the deadline has now become practically impossible.

While it is at it, the prescient DMCB has some other audacious predictions for 2011:

2. While healthcare-based social media will continue to expand, its full potential as a catalyst of personalized patient behavior change will be hampered not only by the uncertainty imposed by the privacy restrictions of HIPAA, but "no you can't" Homeland Security concerns over Twitter encryption.

3. Donald Berwick will be confirmed by the U.S. Senate as Administrator for CMS. Republicans will use Dr. Berwick as the poster boy for their newfound - if cynically opportunistic - bipartisanship because a) it's just a matter of time until the Administrator's independent streak begins to vex the Obama Administration, b) the shrewdly targeted use of CMS' grants will curry favor with key individual Senators and c) health care reform is enough of a target rich environment without picking on Dr. Berwick.

4. Reality will not only continue to intrude into the naive enthusiasm over the electronic health record but rear its ugly head in the emerging evaluations of the Patient Centered Medical Home. Both will disappoint when stakeholders seek "proof" of increased quality and lower costs.

5. Speaking of health care costs, they will continue to go up a rate that exceeds the general rate of inflation. That's because, despite health reform, the twin inconvenient truths of our advancing age and voracious appetite for technology refuse to go away. That being said, opportunists will continue to blame the health insurance industry.

6. The population health management (PHM) née disease management industry will continue to hold its own thanks to the grudging acceptance of nurse-based care management as part of the suite of services required to manage insurance risk. Vendors will also have the advantage of being able to couple or decouple PHM with other sophisticated wellness, prevention and health promotion programs.

7. The term "disease management", despite the DMCB's vast supportive readership, will not be resurrected in policy parlance. It will, however, also refuse to die.

8. A political stalemate will prevail as socially-minded progressives and market-minded conservatives battle for the hearts and minds of the body politic. Conflicting public opinion surveys, a divided government and the slow march of the ACA through the appeals process will not lead to any winners or losers. Deciding that will have to wait until 2012.

9. Ours is a time of "Black Swans." Despite our scientific modernism, our worldwide interconnectedness has ironically made us ever more vulnerable to unknown unknowns like pandemics (H1N1), economic dislocations (mortgage meltdowns) and political revolutions (Egypt). Compounding our budgetary travails, another **Big Event** is going to further distract the Administration and Congress from taking constructive action on health reform.

10. The Disease Management Care Blog will not achieve the popularity or the revenue potential of the Huffington Post, leading to further DMCB spousal skepticism over the merits of this whole blogging thingy. She will be unimpressed by the hundreds of thousands of hits, the thousands of return readers, the growing number of links to media outlets such as New York Times, The Washington Post and the Wall Street Journal and vast blogging income amounting to the tens of dollars.

Listen to internet radio with ACOwatch on Blog Talk Radio

The Disease Management Care Blog Speaks!

You've read it but rarely heard it. That tragic lapse can be partially repaired today at 2 PM EST when the Disease Management Care Blog will ride some internet technology onto Blog Radio. It will be featured in a Med-Week Review interview by Gregg Masters of ACOWatch.

Unless the DMCB goes off on some intellectual bender, the interview will mostly focus on the role of independent physicians in this emerging care model.

Details here.

An Accountable Care Organization Administrator Explains Why This Is A Good Idea to a Skeptical Patient

Oh you silly attributed ACO enrollee.....