Up and Down Side Risk Proposed In the CMS Notice of Proposed Rulemaking on Accountable Care Organizations (ACOs)

The Allure of Risk!

The Disease Management Care Blog has been culling through a variety of documents that were released today by CMS on the Accountable Care Organization "Notice of Proposed Rulemaking."  What follows is an initial reaction and "first-read" summary that focuses on the proposed payment methodologies.  The DMCB will use the wisdom of crowds in sister blogs to update and correct as necessary.   

CMS proposes to forgo the upside-only "gainshare" and offer ACOs two tracks that have upside as well as downside insurance risk on a prospectively attributed population.

Track 1: Upside gainsharing for two years with two-sided risk on the third year. ACOs that opt for this track will get 50% of the upside savings that is capped at 10% of the benchmark.

Track 2: Upside and downside risk sharing  for all three years. ACOs in this track get 60% of the upside savings, while the downside is capped at 5%, 7.5% and 10% for years 1, 2 and 3, respectively.  Payment is capped at 7.5% of the benchmark.

CMS proposes that the upside risk payment only occur when two things happen:

1) a savings threshold ("minimum savings rate") is exceeded.  ACOs in Track 2 will need to get above a 2% savings versus a calculated benchmark.  Track 1 ACOs, especially those that are smaller or in rural or underserved areas, have both good and bad news.  The good news is that their benchmark can be as low as 0% (especially if they are in underserved or rural areas) but the bad news is that may need to achieve a higher level of savings over that benchmark.  The DMCB read that level may go, depending on size, as high as 3.9%   The smaller population, the greater the statistical variation that can plague the measurement of savings; 3.9% over the benchmarks increases the statistical likelihood that the observed savings are real.

 2) a composite measure of more than 60 clinical quality performance measures is met or exceeed.  Exceeding them can earn extra shared savings: up to 2.5% for Track 1 above (adding up to a max of 52.5%) and 5% for Track 2 (adding up to a max of 65%).  Achieving these measures can also blunt the downside losses.

It appears that CMS also proposes to hedge against future downside adverse risk development by holding back 25% of any bonus.

Next stop: figure out how the benchmarks are determined and what will go into the risk adjustment.

If the DMCB has any of this wrong, please comment!

Health Wonk Review Is Up!

While all of us waiting for the ACO regulations to get released today, readers may want to check out the Healthcare Economist's Health Wonk Review - Opening Day Edition.  Just who is on first, what is on second and I dunno is in the bullpen.....?

Seven Reasons Why "Better to Best" Could Have Been Better: A Look at the PCPCC Paper on the Value Driving Elements of the Patient Centered Medical Home (PCMH) and ACOs

From Better to Belly-Up?

What happens when you assemble a roomful of academic and Washington D.C. policy experts who have already bought into a core set of assumptions about the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs)?  Toss in a tape-recording facilitator-consultant and what you'll get is a 48 page impressively titled document called Better to Best - Value-Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations.  The good news is that this is a highly readable, richly quotable and well-referenced "must-read" for ACO wannabes.  The bad news is that, while the title is certainly bodacious, the document ignores a host of critically important issues that are falling outside the participants' closed information loop.  By recycling and repackaging the same old assumptions and biases, the authors have made Better to Best necessary reading, but it is far from sufficient.  The paper was sponsored by The Commonwealth Fund, The Darmouth Institute for Health Policy and Clinical Practice and the Patient Centered Primary Care Collaborative (PCPCC). 

Don't want to deal with 48 pages?  Good thing you regularly check the Disease Management Care Blog.  Thanks to the DMCB, you don't have to read the entire document to know that it describes a set of conclusions from a choreographed, day-long and invitation-only (but the DMCB is not bitter) meeting on the role of PCMHs in ACOs.

Better to Best looks at four areas:

1) the PCMH promises to increase patient access thanks to better     off-hours, telephonic and electronic access, timely appointments, a personal relationship with a provider and reductions in health care disparities;

2) the PCMH is a key and central ingredient in the creation of a "medical neighborhood" that, in turn, leads to the high-value coordination of all those specialty, home care, pharmacy, workplace, home and community-based services.  Come to think of it, a medical neighborhood and ACO are practically synonymous;

3) the interconnections of health information technology (HIT) can optimize engagement, coordinated care and support value - assuming "critical gaps" in functionality and meaningful use criteria are overcome;

4) this is going to need money that could be packaged as some combination of fee-for-service, case management fees, payment for episodes of care or case rates and comprehensive global payments with or without bonuses at the primary care or ACO level.

As you might expect, in addition to cheerleading the merits of transformed primary care and more money, the document is replete with jargon like "policy action items...", "support federal funding..." "involve consumers....."  "create measurement sets...." "research collaboratives..." and "align payment models...."  It then closes with a set of consensus statements about 1) keeping the focus on Dr. Berwick's cherished Triple Aim, 2) measurement, 3) payment model change, 4) learning collaboratives and 5) the continuing role of health plans, providers, academics, employers, federal players, consumers and others.

So what does the DMCB think about findings of this medical home meeting, this transformational talk-fest, this sagacious summit of the select?

There were seven shortcomings:

First off, kudos to the rather contrarian leader of the discussion about interconnected HIT. McKesson's David Nace seemed to be refreshingly skeptical about electronic health records and information exchanges.  Contrary to the HIT groupies magical thinking, Dr. Nace pointed out that this technology won't transform health care, its job is to enable it.  In fact, the Better to Best document strongly implies that HIT has yet to meet its potential. Dr. Nace sensibly recommends measuring the impact of HIT using yet-to-be-defined metrics, adjusting the "meaningful use" criteria to support the PCMH and aligning the MU measures of HIT with those of the PCMH accreditation organizations.  Too bad Dr. Nace doesn't go far enough in worrying that overemphasis on HIT could distract ACOs from the real work ahead.

Speaking of magical thinking, the Best to Better participants seem to be assuming that the ACO pilots are a just a learning exercise on a success-lined path that is preordained to lead to certain adoption of the PCMH.  They may wish to reconsider their hubris.

Thirdly, aside from some standard clichés familiar to any reader of the New England Journal or Health Affairs, there was very little real-world focus on the patient.  Sure, the PCMH, medical neighborhoods and payment reform will benefit patients, but where is mention of the tailored care plans based on the patients' values and preferences that take full advantage of self care, the support of family and the nuturing of community?  Where is the shared decision making that - to paraphrase one extremist - transcends Outcomes Ver. 1.0?

Fourth, the summiteers assume that a "personal physician relationship" combined with better after-hours and remote communication will increase access, while failing to note that the published literature on the PCMH supports reductions in the standard 2200 patient physician panel size (Group Health's PCMH program reduced physician:patient ratios from 1:2327 to 1:1800, it's 1:1200 at the VA's version of the PCMH and this review quotes an average  22% panel size reduction).

Fifth, there is no recognition of the physician-hospital tension that will certainly underlie ACOs.  To be blunt, if the PCMH is the key to ACO success, the primary care docs in those PCMHs have to have a meaningful say in day-to-day-operations and be able to direct where the money goes.  If the physician-hospital relationships doesn't go well, ACOs will not go from Better to Best but from "Better to Belly-up."  'Nuff said.  The image tells it all.

Sixth, speaking of which, who says sufficient numbers of docs can or, come to think of it, want to transform their practices into full PCMHs - especially when you read some of the docs comments at the bottom of this ACO article.  To wit: "another flavor of HMO"..."lower provider revenue"...."dubious ethical validity"..." pit the doctor against the interest of the patients"..."black box"... "alphabet soup"..."regional healthcare  monopoloy"..."place physicians at the mercy of the hospitals"...."ACOs are more dangerous than HMOs"...."ration care through ACOs."  It may be presumptuous to assume that all docs will buy into the notion that a PCMH-ACO is a win-win no-brainer.

Seventh, or last but not least, there is no recognition in Better to Best of the existence of a huge group of organizations with two decades of experience in patient education, promoting evidence-based medicine, extending the reach of physicians, mitigating (and accepting) insurance risk, delivering on outcomes-based (including gainshare) performance guarantees and delivering versions of the Triple Aim in commercial and government health insurance programs.  While the Best to Better conference participants have the luxury of their theoretical nostrums PowerPointed in one day meetings, the statutory fact is that ACOs will need to be launched in about nine months, while it can take "three to five years" to create a PCMH.  As noted previously, there is good evidence (here, here and here) that other care approaches that can be used to support or even backfill the work flows of ACOs without a fully functioning PCMH network.

Bottom line: the DMCB likes the synergies of the PCMH and ACOs and believes that both will be more likely to succeed with each other than alone.  That being said, this is no time for wishful thinking.  Hard work and significant challenges lie ahead to make this work for physicians AND, most importantly, for their patients.

By the way, if you're interested, here's more reading on the combination of Patient Centered Medical Home and ACOs.

Yes Or No Or It Depends To The Medical Loss Ratio (MLR)?

Does every person in imminent danger of being massacred by an oppressive regime warrant U.S. intervention?  Should every person in the U.S. own a home?  Should every teenager attend college?  Should every person buy health insurance?  Does every husband chased from a home by a knife-wielding spouse probably have something they did to deserve it?

The Disease Management Care Blog spouse agrees that the answer to almost all of those questions is "it depends."  A one-size-fits-all "yes" or "no" answer involving whole countries or millions of Americans risks the extremes of a) prolonged foreign entanglements versus isolationism, b) Fannie Mae-powered housing bubbles versus putting the hope of home ownership out of reach for millions, c) loan defaults and "for-profit" colleges, versus putting higher education out of reach for millions and, d) the twisted pretzel logic of a "penalty" designed to protect the private insurance market versus a death spiral.

Which brings the DMCB to the topic of the  Affordable Care Act's minimum medical loss ratio (MLR) rule (information from CMS here).  Readers will recall the idea was to make sure that 80 to 85% of every insurance dollar is spent on health care.  Now that the rule is kicking in, authors Jean Abraham and Pinar Karaca-Mandic, in a study published in the American Journal of Managed Care report on potential impact on the individual insurance market.  Using data from the National Association of Insurance Commissioners (NAIC), they show that about a third of the 6.7 million persons nationwide is in an insurance plan that is failing to meet the rule.  This is bad news for regulators, who may have surmised that the number of vulnerable individuals was about 3 or 4 million.

Unfortunately, our political class, working in the intrusive glare of a polarized 24 hour news cycle, tend to yield to the temptation of easy "yes" or "no" policymaking.  Unwilling to let markets sort out all the complexities and thanks to the twin toxicities of dogma and playing to a political base, the MLR rule was passed with the apparent assumption that waivers would be granted few if any times.

The AJMC authors point out that insurers can respond by reducing administrative costs, reducing profits, increasing fee schedules, reducing premiums or exiting the market.  Unfortunately, individual plans have higher administrative costs (there are fewer economies of scale), lower profits (individuals are more likely to have high claims expense) and are therefore poorer risks. That leaves the threat of market exits, which prompted CMS to grant a waiver to all of Maine's health insurers, with New Hampshire under active consideration and possibly four more states to follow.  And thanks to the insights from AJMC report, it appears the pressure on CMS to grant even more waivers is likely to grow.

Is every health insurer with a less than an 80% MLR abusing its beneficiaries, being administratively top heavy or deserving to be put out of business?  The complexity of the issue, the numbers of persons involved and the law of unintended consequences is making the answer to that question also "it depends."  The DMCB wishes the good folks at CMS a hearty "good luck" in sorting all that out.

Nurses: The Secret Sauce for Disease Management, the Patient Centered Medical Home (PCMH) and for Accountable Care Organizations (ACOs)

The Disease Management Care Blog has made no secret of its opinion that the secret sauce underlying the success of the many iterations of disease management and the patient centered medical home is nurses.  While various pundits and commentators may assert that it's some latest electronic record tweek or a novel form of provider payment, the DMCB knows better. Once you pull it all apart, there's usually a trusted nurse in there using that EHR or finally getting paid to keep patients out of the emergency room with a special nurse sauce of advice, education, expedited appointments and an unwillingness to take "no" for an answer.  Find a news report or a scientific publication claiming that "DM" or the "PCMH" increased quality or reduced costs and you'll find mention of nurses in there somewhere.  They're the mortar holding those bricks together.  

A recent case in point is this article appearing in today's Wall Street Journal that describes the multi-specialty group Atrius Health Care.  In addition to apparently having solved every known problem there is in U.S. health care, these guys purport to being the Known Universe's First Successful Accountable Care Organization (ACO).  Read through the article, though, and you'll see it - as predicted:

"Atrius Health also uses case managers, who help patients with chronic conditions coordinate care using multiple doctors and medicines"

Which brings the DMCB to three points.

1.  As far as the DMCB knows, there aren't any prospective, randomized and blinded trials that compare nurse-centered disease management or medical home with usual physician-encounter care.  As a result, it's difficult to figure out causation: are high functioning clinics, that are already destined to do well anyway, more likely to hire nurses, or are the nurses responsible for making these clinics high functioning?  The DMCB suspects its more of the latter but it's possible both are happening at the same time.

2.  Which begs the question:  is it possible that an unmeasured "nurse impact factor" is not only responsible for the early achievements of the medical home but that these professionals will turn out to be one of the key success factors  for Accountable Care Organizations?  If that is a strong possibility, should CMS carefully examine whether there is sufficient nurse-support when it finally starts reviewing ACO applications?

3.  While it's mentioned in passing in the WSJ article, the DMCB has learned from personal experience that these nurses are fundamentally unable to "flex" their commitment to patients based on the insurance benefit.  As a result, patients with insurance that doesn't "cover" diseasse managment (for example,Medicare fee-for-service) who are being cared for in clinics with a large commitment to nurse-led disease management typically end up seeing these nurses anyway.  So, while Medicare doesn't pay for disease management, the irony is that its beneficiaries in Atrius and in other health systems are still receiving disease management services in what is another example of cross subsidization of government health care by the commercial sector.  For clinics without broad multi-payer support for their nurse medical home/disease managers, the hidden cross-subsidization of other payers is the price of doing business and could hamper adoption of the patient centered medical home.

Disease Management for COPD.... Kills?

Can disease management for chronic obstructive pulmonary disease (COPD) kill?

Until now, that question, thanks to this classic 2006 Canadian study that was published in Chest, would have never crossed the Disease Management Care Blog's mind. In that study, 191 recently hospitalized COPD patients were randomly assigned to either usual care or a self-management program with ongoing care management that included home visits and telephonic counseling. Using the perspective of a "health care payer," the economic analysis showed a per patient savings of $3,338 vs. an expense of $3,774. However, that was based on a caseload of 14 patients per nurse per year. The authors calculated that if that number was increased to a more real-world standard of 50-70 patients per year, the savings would exceed $2000 per patient. The DMCB likes to reference this Chest study in its publications and quote it in its lectures because it was randomized, statistically rigorous (all costs were detailed) and targeted (resources were focused on high risk and recently discharged patients).

And the DMCB was feeling even more confident about the benefits of COPD disease management thanks to this recently published American Journal of Respiratory and Critical Care Medicine study. This one was conducted at five U.S. VA hospitals involving 743 patients with a history of COPD-related hospitalization or an emergency room visit, on chronic oxygen or using systemic corticosteroids. The control group patients received usual care while the intervention group got a single education session, an "Action Plan" for self-treatment of exacerbations and monthly follow-up calls from a case manager. After 1 year, COPD-related hospitalizations and emergency visits was 0.82 per patient in usual care group versus 0.48 per patient in the disease management group. The difference was statistically significant.

While common ingredients include tobacco cessation, flu shots, giving patients basic information about COPD and teaching breathing, coughing techniques, lifestyle modifications as well as energy conservation for day-to-day activities, the DMCB thinks the secret sauce of COPD disease management is the "Action Plan." It's mentioned as an option in the Global Initiative for Chronic Obstructive Lung Disease or "GOLD" guidelines (113 pages can be downloaded here, you'll find it mentioned as "B" evidence on page 71). An Action Plan typically consists of a ready-to-go and "shoot-first-and-ask-questions-later" patient initiated package of antibiotics and glucocorticosteroids that are started if there is a sudden cold, infection, cough, shortness of breath or other disease exacerbation.  Both of the studies mentioned above included this in the intervention group.

Disease management: check.

Action plan: check.

Which is why this news is so counterintuitive (hat tip to KevinMD). According to this article, the VA's Bronchitis and Emphysema Advice and Training to Reduce Hospitalization "BREATH" COPD disease management trial, which was started in 2006, was halted early in 2009 because of higher all cause mortality rates in the intervention group.

The DMCB went to the clinicaltrials.gov website to find out more. BREATH was a two phase study. The first part was a twelve month "feasibility" study performed at six VA sites that targeted a recruitment of 180 patients, followed by a second phase expansion at 8 other sites targeting the recruitment of an additional 780 patients. In reading the protocol, the DMCB thinks the intervention group received the standard mix of disease management services, including the education, telephonic follow-up and an Action Plan.

The trial was stopped in 2009. According to news reports, a manuscript in the works and should be published in the coming months. Until the paper gets published, the DMCB can only speculate about the cause of the increased death rate in the disease management intervention arm of BREATH. If it had to guess, however, it would wonder if the Action Plan play some sort of role - perhaps the antibiotics led to microbial resistance or the steroids hampered immunity.

Stay tuned.

(late post - Google formating wouldn't work)

Submit That Report To Population Health Management: Here's Why

Have you created a novel care management program? Developed a unique approach to wellness? A groundbreaking approach to analytics? Performed a literature review with some new insights?

Have you already committed your findings to paper with tables and figures and, with some additional effort, could turn them into a real manuscript? Does the idea of sticking all that hard work on some shelf or letting it languish in the C-suite upstairs annoy you?

If you are in the C-suite, do you want to advance the career of some key employees?

If so, do you want to simultaneously advance the science of population-based care to the benefit of patients everywhere, hone your findings with rigorous and insightful peer review, contrast your evidence-based program with the take-our-word-for-it fluff of your competitors and bask in the envy of your colleagues and enemies?

If so, you may want to seriously think about submitting a paper to Population Health Management. Instructions for authors are here.

Benefits include....

• Publication in a highly respected peer-reviewed journal
  


• Rapid, high-quality peer review—average time to first decision 19 days
  


• Fast-track publication online within 4 months
  


• Global readership in 140 countries
  


• High Impact: 90,000 downloads from the journal in 2010
  


• Visibility: Publisher gives special promotion to important papers including e-promotions and press releases
  


• Author-friendly manuscript submission system
  


• Indexed in Medline, Current Contents, and all key indexing services worldwide
  


• Probably being mentioned in the Disease Management Care Blog

Will Accountable Care Organizations (ACOs) Lose Money - and Mimic Disease Management's Medicare Health Support?

Remember the much regaled "Physician Group Practice" (PGP) CMS Demo? Ten group practices (five integrated delivery systems, two free standing, two academic organizations and one hospital sponsored provider network) continued to bill Medicare on a fee-for-service but were eligible for a bonus if they reduced costs. The bonus consisted of 80% of Medicare's savings in excess of 2% - assuming they also met some quality targets. To pursue those savings, the ten groups used a varying mix of care management protocols, registries, provider education, data feedback, HIT, remote patient monitoring, team-based disease and case management programs as well as discharge and palliative care programs.

You can read more here and here but the financial bottom line is nicely summarized here. Six out of ten of the participants met the quality and expense goals. Each was rewarded with at least one bonus during one of the three years which, in all but one case, amounted to millions of dollars.

The PGP observation that providers could organize and use the mix of interventions mentioned above to save taxpayer dollars helped advance the notion of "Accountable Care Organizations" (good summary here) in the Affordable Care Act:

“….with respect to the quality performance standards established by the Secretary under subsection (b)(3), if an ACO meets the requirements under paragraph (1), a percent (as determined appropriate by the Secretary) of the difference between such estimated average per capita Medicare expenditures in a year, adjusted for beneficiary characteristics, under the ACO and such benchmark for the ACO may be paid to the ACO as shared savings and the remainder of such difference shall be retained by the program under this title.”

The prospect of being able to form regional ACOs has provoked an organizing/merger/buy-out frenzy among hospitals and physicians. While the DMCB suspects ACOs will turn out be more about physician vs. hospital control of monopolistic cartels, being able to bill fee-for-service and still get a bonus is too sweet to ignore.

Or is it? While the PGP groups were awarded millions, how much did they have to spend on all those additional care management programs?

Writing in the latest New England Journal, Trent Haywood and Keith Kosel report on a financial analysis they conducted on the Group Practice Demo. Combining data from the Demo reports, the Government Accountability Office and the HHS Report to Congress, the authors created this curve. Based on a mean investment of $737 per provider or $1.7 million per organization, a 13% and 20% margin on that investment is needed for a break-even within 5 years and 3 years, respectively. If that's not bad enough, recall that 4 out of the 10 Demo participants never received a single cent.

And remember how the Medicare Health Support Demo on the topic of disease management was partially tripped up by delays in promised beneficiary data from CMS? The authors note their analysis may be limited because:

"....the participants did not receive provider- feedback reports and bonus payments in a timely manner, which may have negatively affected their ability to perform more effectively and receive greater shared savings."

In response to their findings, the author offer up some cautions for ACO wannabes:

1) This is not about fee-for-service. Think hard about the high cost of those up-front investments in care management and be prepared for a return on investment that may not materialize for five years.

2) Think really hard about doing this if you are a small provider organization with limited access to capital, a short time horizon or an inability to tolerate a 40% chance of this being a complete bust.

The DMCB offers up this third consideration: think hard about taking that money and investing in a broadly diversified mutual fund.

There are also some policymaker recommendations:

1) Limit ACO participation to provider organizations with sufficient financial strength

2) Change the bonus from being based on demonstrations of annual savings to cumulative savings.

The DMCB offers up this additional thought: If there is a chance that ACOs will end up like Medicare Health Support, the good folks at CMS may want to reconsider. The poor design, inadequate data support and the lack of a cumulative time frame was not part of CMS's calculus when they shut down the disease management demo. Here's a Healthways study that shows it was a mistake that set care management back years. It'd be unfortunate ACOs failed not on their merits, but on poor planning and execution by CMS.

Happy Anniversary Affordable Care Act

About one year ago, the Disease Management Care Blog was watching health reform unfold in all of its toxic splendor. Deconstructing those complex events will happily occupy pundits, pollsters, editorialists historians and bloggers for years to come. The DMCB likewise hasn't been immune from reflecting on some of the ingredients that were mashed into the dreadful sausage-making that ultimately made up the Affordable Care Act. To wit:

~ an emboldened Democratic Congressional leadership determined to govern from the left of their rank and file;

~ the staking of a U.S. Presidency on a huge roll of the political dice - that could still come up snake eyes;

~ speculative projections from health care economists able and willing to portray any scenario based on assumptions built on theories derived from wishful thinking, which still continues today;

~ organized medicine groups being politically boxed in by a) their prior position statements, b) an bum deal over the SGR and c) fear of being thrown under the bus;

~ the astonishing misuse of 'health insurers" as a political piñata for garnering support, deflecting criticism and changing the subject;

~ equating any lack of support for health reform as a lack of education about health reform.

And how do things stand today? For the best example of how topsy turvy things are, check out the disparate perspectives of some Kaiser report "players and experts."

~ State governments are simultaneously opposing and implementing the ACA;

~ Maybe providers and insurers didn't really need federal legislation to cooperate all along;

~ It's not a majority or any broad political coalitions - which remain stubbornly split - but the small "independent" voter block that may hold the key to the long term survival of national health care reform.

~ The private sector still remains the best hope for innovation.

~ It's in the regulations outside of the legislative process where important battles over the MLR, insurance exchanges, essential benefits packages and worksite wellness programs will be won or lost.

~ The direction of national health reform will be decided by nine lawyers - and probably one in particular.

One question continues to perplex the DMCB: Why is the Administration so reluctant to endorse the eponymous flattery and historical legacy of the term "Obamacare?"

Image from Wikipedia

Crossing Over From Medical Home Land: Lessons For The Patient Centered Medical Home (PCMH)

Think Chinese culture is inscrutable? That the laws in Saudi Arabia are alien? That Lutheran Norwegians at a dinner table are weird? That, once you leave the familiar safety of home, life unpredictably becomes more opaque, dizzying and unfamiliar?

Such appears to be the reaction of some of the Disease Management Care Blog's colleagues once they venture outside the borders of "Medical Home Land." Case in point is this essay by Bob Doherty and this heartfelt "I second that emotion" by Dr. Bob at the aptly named Medical Rants Blog.

Inside Medical Home Land, transformed primary care always increases health care quality, reduces cost, increases patient access, attracts medical students, increases patient satisfaction and increases wellness. Inside that protective bubble, the medical home has admiration of PhDs, unquestioning acceptance by fawning medical journal editors and keynote status from pricey conference promoters. It is a nice place to be.

Unfortunately, Medical Home Land is missing one absolutely necessary natural resource. No, it's not statistical significance for measures of claims expense reduction (for example, p=.08 at Group Health, p=.21 at Geisinger and not even mentioned at HealthPartners). Rather, what's missing is money. To get their hands on that, Medical Home Land denizens have to step outside its borders and deal with insurance market skepticism, physician "transformation" inertia and patient-voter apathy.

As the DMCB has previously described, the likelihood that anyone is going to just hand over fistfuls of money to something that is a good idea is nil. Saying the Medical Home is the right thing to do is not enough. But be of good cheer, says the DMCB. While stepping outside of self-reinforcing closed information loops can be traumatic, dealing with reality has its benefits. The Medical Home is still a work in progress. Learning to joust with hard nosed actuaries, insurance execs and CFOs will ultimately help it be a leaner and more effective approach to patient care.

To help the Medical Homeites successfully adapt to being strangers in a strange land, the DMCB offers up some lessons learned by others that have also had to deal with the trauma of crossing over:

1. Once the disease management industry was confronted by data that it wasn't really saving money, it changed. It used its experience in wellness to contract with self insured employers to develop worksite-based prevention programs. It also honed its protocols to target the patients most likely to benefit. The point is that that industry figured out what the naysayers wanted and jettisoned the rest.

2. The electronic health record vendors worked for decades in the shadows of the health system before they finally achieved enough of a critical mass to catch the attention of a U.S. President. Yes, the EHR vendors continue to spout unrealistic bromides, but they were very patient. So should supporters of the medical home.

3. The DMCB learned the hard way that simply publishing positive results seldom achieves stakeholder buy-in or generates change from front-line providers. Recall how slowly physicians adopt any evidence-based medicine? Quoting it may be necessary but that alone will get medical home advocates about as far as quoting a Berwick paper to a Republican US Senator.

4. The pharmaceutical industry figured out how to trump branding for its me-too products. It's not that pill, its being able to ride motorcycles with your chums, blow rose petals at your daughter's wedding and lounge in twin bathtubs with the spouse. The ex-medical director DMCB has had to deal with countless enrollees demanding coverage of me-too lipid lowering agents at $80 a month. It's time for Medical Home Land to figured out how to harness that energy and the cash that goes with it. Which would patients rather have: a "patient centered medical home" or a "concierge?" Figure that out and commercial insurers and Medicare will follow.

5. Think being invited to the White House means anything? Not only does that environment also suffer from its own brand of health care unreality, you'll be asked to take a seat between the Thoracic Surgeons and the the National Association of School Nurses. Good luck with that.

The DMCB says be of good cheer, medical home supporters. Listen to the naysayers and adapt, hang in there for the long haul, figure out how to create patient demand and put publications and the support of fickle politicians into perspective. Good ideas always win out in the end.

Telephonic Disease Management "Opportunity for Savings" in Body of the Article, "Does Not Save Money" in the Title?

Readers of the Disease Management Care Blog may have missed this provocatively titled article, "Telephone-Based Disease Management: Why It Does Not Save Money" that was published in January 2011 the American Journal of Managed Care. The DMCB not only didn't miss article, it quietly wrote a Letter to the Editor. It was only a few weeks ago that it learned that it had been scooped by a better letter.

The DMCB decided to bide its time.

In the original AJMC article, former Healthways researcher Dr. Motheral reviewed the early promise of telephonic disease management (borrowing from programs aimed at reducing readmissions) and the bitter disappointment that followed once the industry matured and underwent greater scrutiny. Reasons for the stumble, according to the author, were 1) numerous econometric studies that showed most preventive treatments do not reduce costs, 2) numerous econometric studies that showed most specific chronic illness care interventions do not reduce costs, 3) dawning awareness that the financial impact of increased utilization (for example, pharmacy) can exceed other program savings and 4) the non-generalizability of published positive studies versus the real world, where program content or the measured outcomes were often modified.

Yet, Dr. Motheral points to four lessons learned since then: 1) applying disease management to vulnerable patients "may provide opportunity for cost savings," 2) some commercial disease management programs work better than others, 3) face-to-face interactions are more potent than telephonic ones and 4) transparent peer reviewed studies trump enthusiastic marketing gimmickry.

The letter mentioned above has recently appeared on-line and was authored by former LifeMasters CEO and current ZOLO Consultant Christobel Selecky. In it, she points out that disease management has evolved in response to Dr. Motheral's criticisms, uses many of the approaches that have also been shown to reduce readmissions and that it's not its fault that the market is demanding costly preventive and care interventions. She also asks why no other sector of the health care industry (like physicians) has been asked stop providing services because it doesn't "save money." Rather, she argues, the future of disease management, and, by the way, health care in general, lies in generating value and continuing to build on what has been shown to work.

The AJMC Editors gave Dr. Motheral an opportunity to reply (same letter link). She notes that assessing value generally means politically thorny and intellectually complex cost effectiveness studies and that the industry, with one exception, has been remiss in showing that it can reduce readmissions. Finally, she asks, if the industry is evolving, why are employers still paying for millions of persons to get questionably effective phone calls?

Ouch.

So does this tempest in a disease management teacup diminish the disease management industry? The DMCB doesn't think so. Such is the nature of medical publishing, where authors vigorously debate competing approaches to care, heap scorn, score points and draw blood. In the end, issues are clarified, new areas of investigation are opened up, medical science is more precise and patients are better off.

As for the eternal debate over "saving money," it not only makes for interesting reading but great bloggery. Over its history, readers will recall that the DMCB has practically made and addressed all of Dr. Motheral's concerns, including the disconnect between prevention and savings (also by linking this article many times), the dubious value of some diabetes interventions, why disease management can work despite cost-effectiveness naysaying, the complicated nature of pharmacy in disease management, the difference between efficacy and effectiveness, the benefits from targeting vulnerable patients, combining disease management with face-to-face care, the limits of cost-effectiveness studies and the need for the industry to invest in peer-reviewed research.

As for the observation that some disease management programs work better than others, isn't that the point in a competitive marketplace? By the way, isn't that also a lesson for our faith in clunky government run demos and health care programs?

When it wrote its letter to the AJMC, the DMCB saluted Dr. Motheral for an insightful review but questioned why the editors allowed the author to use such a contentious title. After all, the body of the paper suggests costs savings are well within reach and expertly describes what the industry can do to "bend the curve."

As we know, the DMCB letter was not accepted for publication, but the question remains: why not a title worthy of a fine, balanced and supportive review, like...

"Telephone-Based Disease Management: Why It Will Save Money" or....

"Telephone-Based Disease Management: Why Cost Savings Are In Reach" or...

A DMCB favorite: "Telephone-Based Disease Management: Why The Disease Management Care Blog Has Been Correct About An Approach to Care That Can Save Tons of Money."

Are Primary Care Bundled Payments for Chronic Illness Really An Answer?

In this enlightened era of "evidence-based" medicine, you'd think that the progressive academics, viziers, and mandarins who are cluttering the policy making commentariat would pay more attention to what was tried before. That should be doubly true if those lessons come from that health care nirvana called Europe, where enlightened central bureaucracies wisely allocate health care for its caffè sipping, plaza strolling and beret adorned citizenry.

Case in point is "bundled payment," which has been underway for several years in the Netherlands. Thanks to this timely New England Journal Perspective from Jeroen Struijs and Caroline Baan, readers can get some insight about what is and isn't known about the topic.

By way of background, the Dutch require citizens to buy subsidized private health insurance for "short-term level" services, such as outpatient care and acute hospitalizations; prolonged care and durable medical equipment is covered by public insurance. Their reliance on private insurance has been held up as a role model for the United States.

According to Drs. Struijs and Baan, starting in 2007, private insurers began offering global payments to legally defined physician "care groups" who, in turn, accept the up and downside risk for persons with a chronic condition, such as diabetes, COPD or vascular disease. The single payment is negotiable for a defined bundle of services related to the condition itself. The care groups are typically made up of primary care doctors. They, in turn, provide and arrange for all the necessary care services and, when necessary, contract with other non-hospital providers (for example, labs) or other services. Patients with services falling within the bundle coverage provisions have no out of pocket expenses.

So what happened?

1. Variability persisted. Bundled payments turned out to vary from group to group and cannot be explained by patients' burden of illness or the intensity of services. Other factors that probably played a role were differences in how the bundled coverage terms were interpreted and, thinks the DMCB, the negotiating leverage of the various care groups.

2. Integration grew. Providers became organized with greater attention to coordination, protocols and consultations. There was a greater emphasis on use of the EHR. In surveys, physicians reported that they believed they are providing better care.

3. Transparency increased. Providers were obligated to document and report performance against established benchmarks.

but....

4. Outcomes, you ask? According to authors, "...it is still too early to draw conclusions about the quality of care or the effects on the overall cost of care." There has been no observed impact on glucose control (A1c), lipids, patient satisfaction or cost. So far.

5. Market power increased? Some subcontractors reported that they are being squeezed by the care groups' local market power. What's more, patients' freedom of choice in the selection of subcontractors may have been curtailed.

6. Bundle "boundaries?" The Dutch are still working to define just what services are covered by the chronic care bundle. That's important, because the care groups have an incentive to cost shift.

Most U.S. observers seem to agree that the fee-for-service system is broken. Drs. Struijs and Baan are reminding us that replacing it, despite policy savoir faire of many U.S. europhiles, isn't necessarily going to reduce costs, increase quality or not introduce its own set of unintended consequences.

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Thank You

The Disease Management Care Blog typically doesn't toot its own blogging horn, but it will take an end-of-the-week moment to reflect on the State of the Union in its small corner of social media. This pause has been prompted by the DMCB YouTube "Setting Up An Accountable Care Organization" video crossing the 10,000 view mark. The DMCB hasn't found much in the way of reliable statistics, but it suspects that puts it in the top 5th percentile. It's also the 2nd most frequently viewed YouTube video on the topic of ACOs. This is probably because viewers appreciate its humor while making some important points.

As for the DMCB site, it estimates, using Google Analytics, that it has had over 16,000 returning visitors over the past year. Among these, it loosely calculates that there are about about 5500 readers that return more than once a month. Based their ISPs, many are from care management organizations, consulting groups, government and academia - a high quality group!

As further testimony to the DMCB's web footprint, there also are approximately "RSS" 400 subscribers, several attempts a day to plant spam in its "comments" sections and it finally hit $100 in Google Ad revenue.

And why does it blog? Because it makes the DMCB think - sometimes correctly, sometimes not - about an important health care issue five days a week 365 days a year. Since it started years ago, there are over a 1000 posts. Until it finds a better way to accomplish that or do something more important, it's going to keep it up.

In the meantime, readers, thank you for giving the DMCB your precious time.

The Latest Health Wonk Review Is Up!

Do you like watching or thinking about baseball? Neither does the Disease Management Care Blog, but it may have to change its mind after taking look at the latest Health Wonk Review. Brainy Glenn Laffel (he is an internist, after all) has assembled the latest high quality health policy bloggery in a marvelously crafted "Spring Training Edition" over at his Pizaazz Blog. Pull up a bleacher and enjoy.

Quotes, Insights and Impressions From The Population Health & Care Coordination Colloquium: Health Reform, "Broken" FFS, Retail Clinics & The Truth

The Disease Management Care Blog scribbled notes while it was at the just concluded Population Health and Care Management Colloquium in Philadelphia. Some are paraphrased quotes, others are insights and others are opinionated impressions. With that caveat, here are some of the better ones in no particular order:

Attendance was high (enough to fill a large hotel ball room), jargon ("engaged patients!" "accountable care!") abounded and enthusiasm was high (makes no difference if health reform is upended by the Supreme Court or an implacably opposed Republican party, there is no going back).

While many speakers prized the intimacy of a primary care doctor-patient relationship, they had little problem with the intrusion of other non-physician "team" members at the local clinic level. While they seemed to think its purpose is to "help" PCPs, the DMCB suspects many of its primary care physician colleagues have a different perspective. They secretly welcome the prospect of the involvement of non-physicians so that they can "outsource" that intimacy. That means that they'll be able to focus on the more interesting complicated medical stuff.

Think retail, convenient care walk-in and strip mall style nurse-run clinics are going to take off? Maybe, but three veterans from different corners of the country all agreed that they're only profitable when a) their services are covered by an insurance benefit (this is not a cash business) and b) they're closely aligned with a provider network and can refer patients. Otherwise, they're a loss leader. Primary care physicians seem to have little to fear from these bad boys.

Other speakers tut-tutted a "broken" fee-for-service system that "pays" for medical errors. What's wrong with that says the DMCB? When it buys a defective consumer product, it generally pays for a repair unless there is a guarantee (and that's built into the purchase price) or buys up to a warranty that's available for an extra fee.

Business owners are skeptical that health reform will work. The promises are old and there's no new money. Maybe that's because some of them read the DMCB.

Long term "central" intravenous access has been the subject of considerable research. Ask women who've been through it, however, and many will tell you that a major patient concern is its annoying proximity to their bra straps. The problem is that they haven't been asked. What else haven't we asked, and why not?

Speaking of which, one speaker from a national quality standards setting organization agreed with the DMCB that classic "evidence-based" medicine is just one of many windows onto the "truth." Others include observational data bases, effectiveness studies and qualitative patient surveys. Just like "disease management," or the "medical home" or the "electronic health record are not individually "the" solution to achieving high value health care.

Apple products have a high penetration among patients, but a downside is that it also doesn't use Adobe "flash" to support on-line movie viewing. One consumer health education company described how hundreds of Mac and "i"patients under contract were unable to access an interactive patient education video.

Talk to the average doc about the active participation of patients in developing their care plans, and they'll think this is all about "informed consent," in which patients sign all the necessary forms giving permission for surgery. They don't know there's a difference between informed consent and informed choice.

Those repugnant "death panel" scares may have prompted some patients to question the big deal over Dartmouth Atlas-style health care variation. They believe "more" is truly "better."

It is possible to roll publicly available demographic, health and income data up by zip code and assign a local "needs" score that can assist in population-based care planning. The DMCB has always been tempted to define "disease management" as "applied public health." Maybe that is more accurate than it appreciated.

A Summary Of the Population Health Management Journal

The Disease Management Care Blog's travels have been taking it back and forth to the Population Health and Care Coordination Colloquium. It's been taking copious notes at that meeting (more on that in a future post), but the travel-down time has been a DMCB opportunity to curl up and take notes on the articles in the latest issue of the Population Health Management Journal.

Brief article summaries posted below.

Yi Zhou, Robert Unitan, Jian Wang, Terhilda Garrido, Homer Chin, Marianne Turley, Linda Radler: Improving Population Care with an Integrated Electronic Panel Support Tool

In this study, the authors set out to study the impact of an electronic health record “integrated technology application” called the "Panel Support Tool" at Kaiser Northwest in Oregon and Washington state. The “PST” provided on screen point-of-care reminders, supported a patient registry and generated performance feedback using individual patient screen shots and practice panel summaries. Physicians were subjected to lab, medication and screening “care gap” reminders based on national guidelines, HEDIS measures and organizational priorities. To perform the study, the authors measured a series of cross sectional “care performance percentages” that consisted of the number of completed care recommendations (the numerator) divided by the number of indications for a total of 13 quality measures. These were obtained every 4 months for 20 months for 207 practice teams that collectively cared for over 263,000 patients. At baseline, the roll-up measure was 72.9% and it gradually increased to 80% at 20 months. During the study, there were no other "care gap" interventions, so even though this is pre-post, the authors believe the PST was responsible for the 7% improvement. Hardly a breakthrough, says the DMCB. But then again, nothing is.

Dahlia Remler, Jeanne Teresi, Ruth Weinstock, Mildred Ramirez, Joseph Eimicke, Stephanie Silver Steven Shea. Health Care Utilization and Self-Care Behaviors of Medicare Beneficiaries with Diabetes: Comparison of National and Ethnically Diverse Underserved Populations.

The authors used the "IDEATel" telephone survey to compare urban versus rural diabetes care for persons living in two medically underserved areas. 755 respondents (75% and 28% self identified themselves as black or latino) from northern Manhattan or the Bronx were compared to 867 respondents in rural upstate New York (35% and 17% reported black or latino). To be included, respondents had to be Medicare beneficiaries, be age greater than 55 years, diagnosed with diabetes and live in a “federally designated medically underserved” or a “federally designated health professional shortage area” in New York State. The survey was conducted from December 2000 to April 2003 and took respondents approximately ½ hour to complete. Compared to the rural group, the urban group had worse general health (11.6% vs. 5.1% self-rated their health as “poor”), more inpatient days (a mean of 3.48 vs. 1.53), more ER visits and more difficulty with a variety of self-care activities. The DMCB finds it difficult to generalize these data to the rest of the U.S. and wonders if the urban vs. rural differences were the result of other sources of unidentified bias.

Donald Fetterolf: Long-Term Results Evaluation in Medical Management Programs.

Here’s a solid review paper that tells you everything you need to know about the evaluation of the long term impact of disease management programs. This includes “bending the trend,” the phenomenon of a therapeutic “plateau” once any interventions have reached a steady state and the occurrence of a “step function,” which signals the impact of a one-times savings impact. While you may think savings between programs should be easy to calculate, that’s not the case, thanks to a lack of standard methods, groups not being comparable, a lack of control groups, evolving practice standards and shifting program content. In addition, cost is not the only consideration. There is clinical impact, quality of life, future risk pool effects, branding and employee retention. Once a program has plateaued, it’s tempting to turn it off, risking an upward “rebound” in cost trending. Once again, Dr. Fetterolf takes a complicated topic and puts it within reach of us mere mortals.

Patricia Harrison, Pamela Hara, James Pope, Michelle Young, Elizabeth Rula: The Impact of Postdischarge Telephonic Follow-up on Hospital Readmissions.

This is a study involving 30,272 Medicare Advantage plan members who were automatically enrolled in a chronic disease management program and who had a hospital admission for any reason in calendar year 2008. Any members who were discharged from a hospital were subjected to a “Hospital Discharge Campaign” that notified the provider of discharge, called the patient with 14 days of discharge, reviewed the orders to delete any duplicated or contraindicated prescriptions and made sure the patient understood “proper steps to take,” like participating in a timely PCP follow-up visit. The intervention study group numbered 6773 patients. 23,499 patients who were re-admitted prior to getting the call or who did not get the telephone call comprised the convenience comparison group. In general, being older, male and having an increased length of stay was associated with a 30 day readmission. Admissions were highest 2-3 days after discharge; a third of all admissions occurred within 7 days. While patients who got the call were 23% less likely to be readmitted, the DMCB is concerned about the use of a control group that may not be a good comparator. The observed difference could be due to factors other than the phone call. This is a good start, but better and more research is needed.

Ron Cantrell, Julie Priest, Christopher Cook, Jack Fincham Steven Burch: Adherence to Treatment Guidelines and Therapeutic Regimens: A US Claims-Based Benchmark of a Commercial Population.

This was a “cross sectional and retrospective” study of HEDIS-like and national guidelines-based quality of care measures using pooled commercial insurer claims from the Ingenix Impact National Managed Care Benchmark Database. This contains information from a whopping 45 managed care organizations with 65 million enrollees. The authors focused on 2007 claims with persons who had identifying claims in 2006 (except for new depression) or 2007 consistent with asthma, COPD, CAD, depression, diabetes, heart failure, hyperlipidemia or hypertension. Based on the sample of approximately 5.5 million people with an index condition who had at least 6 months of enrollment the authors discovered most people with asthma don’t refill their inhalers, 3% of persons with COPD will have an exacerbation, the majority of persons with new depression fail to refill their antidepressants, and 44% and 48% of persons with diabetes don’t have an A1c or lipid test, respectively. There is lots of other information here, including tables of the average number of hospitalizations, ER visits and mean claims expense. Shortcomings of the study were listed by the authors and included the limited accuracy of claims, the lack of risk adjustment between MCOs and the potential non-generalizability of the time span that was used. The DMCB didn’t find anything that was surprising, but this paper could serve as a useful benchmark for comparison purposes.

Julie Priest, Ron Cantrell, Jack Fincham, Christopher Cook, Steven Burch: Quality of Care Associated with Common Chronic Disease in a 9 State Medicaid Population Utilizing Claims Data: An Evaluation of Medication and Health Care Use and Costs.

This is the Medicaid companion to the commercial study mentioned above. It too was a “cross sectional and retrospective” study, but this time it used pooled fee-for-service Medicaid claims from nine states using the Thomson Reuters Market Scan Multi-State Medicaid data base for asthma, COPD, coronary artery disease, depression diabetes, heart failure, hyperlipidemia and hypertension. Once again, the authors examined 2007 claims on persons identified with the index condition in 2006 or 2007; dual eligible and persons older than age 65 were excluded. HEDIS-like and national guidelines-based quality of care metrics were used. There were 2.8 million individuals with an average age of about 16 years. Only 23% regularly refilled their prescriptions on time and only about a third of newly diagnosed depression patients filled any prescriptions for an antidepressant. 70% and 63%, respectively, of persons with diabetes had A1c and LDL testing. There is other information, including hospitalizations, ER visits and means claims expense. Once again there was nothing surprising, but the numerous tables could serve as a benchmark.

Image from Wikipedia

Nuclear Power Plant Explosions Explained and the Public Health Risk

When Three Mile Island happened, the Disease Management Care Blog was attending medical school in the next town over. It not only remembers the contrast between the national ("worst accident in U.S. history") and local ("it's contained") news reports, but recalls the willingness of one hospital radiation physicist to wait out the accident on top of one of the cooling towers. His message: be of good cheer, students, the risk is very low.

While the experience may have biased the DMCB, its research has determined that the stricken Japanese reactors are of the circulating "light water" type. These use regular water (in contrast to heavy water, which has the added property of being able to also buffer radiation) to regulate the temperature of the radioactive rods at the core of a reactor. While the nuclear plants were apparently engineered to withstand the quake, the tsunami was a different matter. The water completely knocked out the circulating water pumps, permitting the temperature inside the reactors to climb to very high temperatures.

Enter "zirconium," a metal prized for its ability to inertly coat radioactive rods without interfering with the radiation that, in turn, creates the thermal heat that drives the steam turbines. With the loss of cool water, the contents of the superheated core partially melted, putting very hot zirconium in contact with standing water. At high temperatures, that metal chemically "strips" the oxygen out of the standing trapped steam/water leaving (remember "H2O?) hydrogen. That's the same highly flammable gas that was used to hold up the infamous Hindenburg airship and lifts the Space Shuttle into space. Given the combustible temperature inside the core, a hydrogen explosion was unavoidable.

Is this another "Chernobyl?" The DMCB learned there are two important differences: 1) that star-crossed nuclear plant used graphite (the same form of carbon that is inside pencils) in lieu of more expensive heavy water to buffer the radiation. When that core exploded, it was the graphite that caught fire, which burned uncontrollably, and 2) the location, which allowed the radioactive plume of smoke to spread over Europe. As noted above, the Japanese plants use water, so there is negligible "smoke." Until now, it's been radioactive steam and the prevailing winds are carrying it out to sea.

Is the radiation leak a threat to public health? Apparently the total amount of detectable radiation that's been released so far at the time of this writing has been very negligible. In an abundance of caution, iodide tablets have been distributed in some evacuation centers to prevent the eventual occurrence of thyroid cancer. While the amount of radioactive iodine in nuclear rods is small, release into the environment can allow children to ingest enough where it is concentrated in the thyroid gland. The iodide tablets saturate the thyroid with normal iodine, preventing uptake of the radioactive version. As for the risk of other types of cancer and malformations, the data are far less clear. It will take years to sort that out.

What is clear is that the news media seems to be again exaggerating the risk of a meltdown. Compared to the loss of life from the tsunami, the race to extract any survivors out of the rubble, the pressing need to restore basic services and the impact on Japan's and the world's economy, those crippled power plants are a relative side show.

Last but not least, it's not clear to the DMCB that, even with this latest catastrophe, that the health risk from nuclear power is that much worse than the respiratory illness and cancer associated with fossil fuels. The difference is that one happens in huge ugly spectacles, while the other kills one person at a time.

Neither of which is reason to be of good cheer.

March 15 Update: The New York Times is reporting that one of the plants has caught fire, which is now producing radioactive smoke, not steam. Since the plume is made up of particulate matter laced with radioactivity, concern has appropriately grown. Fortunately, prevailing winds appear to be heading east, toward the Pacific Ocean.

Memory and Disease Management: Moonwalking With Chronic Illness

The Disease Management Care Blog has just finished reading Joshua Foer's Moonwalking With Einstein. In it, Mr. Foer describes his journey from being a freelance news writer hanging with a group of memory contestants to becoming a world-class "memory athlete." Unable to remember any family birthdays or his social security number, Mr. Foer "trained" to the point where he was able to memorize decks of cards, pages of numbers and lines of poetry within minutes.

While Mr. Foer's descriptions of marshaling spatial memory and storing facts in "memory palaces" are fascinating (and, after a brief test drive, really worked), it was Mr. Foer's insight about modern society's "outsourcing" of memory that really caught the DMCB's imagination. Until relatively recently, the mark of a learned person was the ability to store facts away in the brain. While the printing press started to change that, it is the advent of limitless electronic media that has enabled humans to store everything they need to know in an external information cloud.

Foer argues that the retention and recitation of "facts" are not sufficient for true actionable insights to occur, but they are necessary. This has implications for disease management, where naive health professionals may be tempted to assume that patients will simply internalize the basic information they need for chronic illness management, such as a target blood pressure of "140," what "LDL" actually stands for and what the why "protein" in the urine is bad. Without being able to easily mentally"access" these facts, patients could drift in a fog of disconnected lab tests and treatment options. Think the average high schooler unable to connect a U.S. President with the abolition of slavery or why a "9" earthquake is ten times as bad as an "8."

As a result, care management programs may need to assume nothing and commit more resources toward helping participants "remember" key facts about their condition. In addition, they may need to make these facts easily and "externally" retrievable and reviewable using whatever media best suit the participants' needs.

Variability 3.0

In yesterday's post, the Disease Management Care Blog pointed out that heath care variability is not only unavoidable but ultimately welcome. While amateur futurists point to "personalized genomic medicine" as the ultimate driver of variation, the DMCB respectively disagrees. It believes the promise of genomic medicine exceeds reality. In contrast, there are other cultural forces outside of medicine that will profoundly alter patients' expectations and change health care delivery in the coming years.

Say hello to Variability 3.0

One of the points of Alvin Toffler's Third Wave is that society tends to organize itself along the lines of assumptions that characterize ages, i.e., the the "industrial age" and the "information age." In past industrial society, schools, city planners and politicians prized uniformity and standardization. That's since been blown away. Apple's business model is not only based on ease-of-use, but uniquely customized music lists and personalized "apps." It's possible to go on line and order tailored clothes manufacturing. Amazon knows what the DMCB likes before it's even aware of it.

The fact is that consumers rapidly are becoming acclimated to "mass personalization."

For further insight of where this is going, check out this interesting article in the Feb 12-18 issue of the Economist on "The printed world." It describes how industrial and consumer manufacturing is moving toward "three dimensional printing" that creates items such as "medical implants, jewelry, boots, lampshades, care parts, batteries and phones." Consumers will eventually be able to apply this to any consumer good by pulling up a design using a computer, customizing the specifications and then "printing" a violin or a car or a kitchen using combinations of plastics, binders, powders and filaments and fibers. Not only will these products be personalized, but the approach uses far less raw materials and, even better, economies of scale don't matter. Uniquely fitted shoes for your feet, car seats contoured to minimize that back ache and a cell phone that fits your hand and ear are coming in a futureworld of computerized mass customization.

In the meantime, the clunky faux-modern approach to health care is antithetically attacking variation with one-size fits all clinical guidelines (hydrochlorothiazide first!), decision support tools (age 50 plus female look back 12 months = mammogram no exceptions), medication formularies (one or two drugs in each therapeutic category, all others denied because they're "not medically necessary") and quality improvement programs that impose the silly expectation that an operating room and primary care clinic should stamp out gall bladders and strep throats like aircraft engines. It's possible to use guidelines, decision support, formularies and QI to stomp out all that variation, but the DMCB predicts that that expertise will peak just as consumer expectations begin to reach a post-industrial tipping point. That point is defined by expecting an alternate approach of uniquely tailored treatments based on the their individual health status, preferences and values.

The future buyers, employers, health insurers, heath providers and government policymakers that figure out how to make this health care Variability 3.0 work will win. Everyone else will be behind the curve.

You read it here first.

Image from a Wikipedia article on 3D printing.

The Latest Cavalcade of Risk Is Up!

The latest Cavalcade of Risk is up for your reading pleasure. This time it's Jay over at the Colorado Life Insurance Insider who is your able, witty, organizing, summarizing, linking and commenting host on a series of bloggy business risk topics. Well worth a visit.

Variability 2.0

The Disease Management Care Blog's travels frequently takes it down a Pennsylvania interstate. One exit off that interstate forces the DMCB to merge into a left passing lane of a roadway that is in close proximity to another left sided exit ramp. As on-coming vehicles slow, accelerate, weave and jockey for position, the DMCB's predilection for maximum courtesy often fails. Over time, despite the best of intentions, it occasionally cuts some drivers off. Their reactions vary from politely yielding to tailgating to veering in front of the DMCB to one memorably obscene gesture of an elderly bespeckled woman with an ample supply of chutzpah and a visibly bad case of arthritis in the third digit of her right hand.

Driver variability not only brings unwanted adventure to motoring, but speaks to the spectrum of human skills, intelligence, emotions at all levels of society. This is no secret to physicians, who know their "art" of medicine is to accommodate each patient's unique mix of individual traits. While the underlying disease - cancer, high blood pressure, diabetes or migraine - may have a narrow scientific basis, the treatment always has a wide social basis. Some patients meekly accept a doc's recommendations, most want some input and occasionally others get obscenely angry.

Which brings the DMCB to the topic of the Dartmouth Atlas. Its groundbreaking work amply demonstrates that much of the highly variable frequency and accompanying expense of health care appears to be unrelated to patient factors. Thanks to the DA's multi-colored maps, its easy to wonder why hip replacements and diabetes testing seems to be more related to where patients live and how close they are to certain health care services. Unfortunately, one result of the Atlas is that medical "variability" in general - no matter what the cause - as gotten a bad rap among naive policy makers and politicians.

Given that patients also vary considerably, the DMCB is waiting for a discussion and consensus on "Variability 2.0," where we recognize that some cancer victims don't want to sign living wills, where some hypertensives don't want to take pills, where some diabetics don't mind having an A1c of 7.5% and some migraineurs want another unnecessary head scan.

In other words, once we minimize the variation in the supply side, how will we accommodate the considerable variation in the demand side? Sooner or later, in the opinion of the DMCB, we'll need to tackle this.

Discussion topics in Variability 2.0:

What are the drivers of patient variability, how can they be quantified and should attempts be made to modify them? Genetics? Education? Social supports? Are persons with diabetes, after being made fully aware of every treatment option, allowed to choose pills over insulin even if it means having an A1c that is not optimal? Can women refuse to have mammograms? How many?

How do we measure and report an optimum average rate as well as the "spread" of performance around that average rate? For example, what percent of persons with diabetes with an A1c more than 7.5% is acceptable given a certain average rate of say, 7.1%?

How do we risk adjust quality measures - and physician pay for performance - based on patient variability?

How much technology (and expense) are we willing to accommodate in the pursuit of patient variability? For example, some patients with cancer will benefit from a highly toxic and pricey course of chemotherapy. Should all patients therefore be offered that treatment?

Is "disruptive" and less expensive technology a pipe dream when it comes to health care? While cheaper innovations occur (for example, convenient care clinics), the dawning of customized treatments (for example, genomic medicine) that accommodate patient variability promises to be more, not less expensive.

To what degree is patient variability contributing to overlapping, redundant and incompatible technologies? Sometimes CAT scans miss subtle brain tumors, so is the approach to have everyone with a headache get a CAT scan first and those with normal scans then get more expensive MRI scans? Is there a better way?

More on this in a post tomorrow - it's called Variability 3.0.