A Dose Of Nursing Home Reality

"Hello, Dr. Smith? This patient has a fever..."

Read this New England Journal Perspective by Drs. Ouslander and Berenson on Reducing Unnecessary Hospitalizations of Nursing Home Residents, and it's easy to conclude that the enlightened application of better documentation, quality assurance, payment reform, administrative policies, decision support, guidelines, appropriate downjobbing and delegation of responsibility will keep many sick and feverish nursing home residents away from the unnecessary expense of emergency rooms and hospitals.

Were that it was so simple.  Such is the unreality of many Journal authors inhabiting the oxygen-deprived academisphere.

When residents of nursing homes get sick, they require a significant amount of nursing attention.  Since busy, salaried (and sometimes understaffed) nursing home personnel aren't compensated for the additional work of documenting, monitoring and worrying about that sick patient down the hall, they have every incentive to transfer sick patients elsewhere.  No amount of macroeconomic policy making bells and whistles is likely to change that.

When physicians and other non-physician providers are alerted by the nursing home personnel that a patient is sick, they have been taught that the best approach is to evaluate the patient in person. That takes time and effort.  While they may be compensated for the additional work of a bedside evaluation, it's not enough to make up for the additional work of documenting, monitoring and worrying about that sick patient down the hall.  So, they also have every incentive to agree with the nurse and transfer the patient to a setting where a bedside evaluation is available.  At 2 AM, the answer is to move that bedside to the local emergency room.

Would the bells and whistles that Ouslander and Berensen be enough to keep the nursing homes and the doctors from sending most sick patients to the emergency room?  Based on the simple realities described above, the answer is no.

The Latest Health Wonk Review Is Up

A Jim Henson inspired Muppets Edition of the Health Wonk Review is here for your reading pleasure.  This is a compendium of recent high quality blog posts dealing with health care policy.  Miss Piggy says she can't do without it, and neither should you.

The Provider Version of a Death Spiral?

The health care commentariat are all wee-weed up over the just-released Kaiser Family Foundation survey on employer health benefits.  The report, based on telephone interviews of a representative sample of more than 2000 employers, shows that the cost of employer-provided insurance has increased by a whopping 8-9% this year. 

Supporters of Mr. Obama and Affordable Care Act argue the increases have preceded the chief provisions of the ACA and are the best evidence to date that federally-led health reform is necessary.  In the meantime, foes of Obamacare are glomming onto the increases as proof that current and anticipated federal mandates are doing nothing about the underlying causes of cost inflation and are ruining any hope of slowing it down. 

And so the debate goes on and on.

Unlike the political class, the DMCB has never found that there is any "single" culprit or simple explantion when it comes to health care cost trends.  In this instance, the 8-9% increase is likely due to variations in the underwriting cycle and a combination of insurance and provider market forces. They include new (and expensive) technology, an aging workforce, continued reliance on fee-for-service mechanisms, grabbing some additional  rate before federal oversight increases, the cost of covering all those college students and other various mandates.

But the perceptive DMCB will offer up one more cause: the provider equivalent of the insurer "death spiral."   If insurers are having a bad year thanks to increased claims, they can be forced to increase their prices.  In response, persons who don't need insurance exit, leaving only the persons who must keep the insurance because they know they are a bad risk. That leads to another bad year, another price increase and more exits until the insurer is left with a small book of business that is unaffordable.

Thanks to 1) 9% unemployment leaving persons without health insurance, 2) high "under" employment also leaving persons without insurance and 3)  high out of pocket expenses for those who do have insurance, the DMCB suspects many more persons with a choice are electing to not go to the hospital or the doctor.  That leaves fewer persons, but they're sicker, higher cost and unable to pay. Less margin, bad debt and fixed costs are forcing providers to increase their rates. 

While this a arguably a form of cost shifting, the DCMB doesn't believe that term adequately captures what is going on.  If it's right, the lower frequency of claims with a much higher severity could point to a true spiral and next year's increases will also be unexpectedly high.  In addition, once the economy improves and all that pent-up demand can be addressed, it'll get worse.

Combined with everything else going on, this doesn't bode well.

Practical Approaches to Obesity Care and Chronic Illness In Busy Clinical Settings: Three Key Ingredients

If anything is true about the population health management service providers, they are constantly looking for better ways to fit their programs into busy clinical settings.

That's why this article on New and Emerging Weight Management Strategies for Busy Ambulatory Settings, courtesy of the American Heart Association, should be "must" reading for the vendor industry.  It's chock full of practical advice on how to "engineer" the PHM-physician partnership. While the focus of the article is on a practical approach to obesity, its approach can be applied to other conditions, such as diabetes or tobacco abuse. 

Among the three key lessons that resonated with the physician Disease Management Care Blog:

1. Providers and PHM vendors should make liberal use of surveys outside of the provider-patient encounter.  The surveys should include a assessment of readiness to change and measures of baseline behaviors.  In the specific area of weight-loss, there is a short 5 item survey (go here, then Table 1 and then scroll to the 3rd of 4 lists) that assesses readiness that can then be paired with measures of diet and exercise knowledge and activity.  By the way, the paper has other references that describe other validated surveys that can used in weight management.

2.  The physician's role is important because he or she can non-judgementally endorse, encourage and even "medicalize" the patients' interest in lifestyle change  That being said however, "collaborative approaches that involve physicians, nurses, or other providers" can be first stop for the assessing the survey results and with tailored counseling and follow-up that practically matches the expertise of a physician.  In other words, the docs don't need to do it.

3. The "internet" is emerging as an important option. It works best if it offers education, enables self monitoring, provides individualized goals, builds on motivation and has peer support.  It also helps if there is a "live" person somewhere in the loop.  There are some promising handheld device "apps" too.

While no one can argue that obesity is an important health issue and that primary care physicians have an important role to play, it's difficult to address it in the usual course of a doctor-patient encounter.  The good news, however, is that if you call a busy doc up and point out that assessments can be done via survey, that there are effective counseling strategies that involve other health professionals and that the internet is a resource, they'll endorse the approach.

Good news for the vendors, the docs and, most importantly, for the patients.

Designing A Smarter Congressional Staffer

"But will it change practice patterns?"

That's what the Disease Management Care Blog often hears when it's on The Hill talking health policy, resolutions and legislation with Congressional staffers.  After several visits to Congress, the DMCB discovered that this abiding interest in altering physician behavior underlies much of the current background work on provider reimbursement, liability reform, "innovative" ACOs, value-based purchasing and budget cutting.

Consider the case of staffer Kristin Smith (not her real name). She is a recently graduated lawyer who, along with her elected boss, is alarmed by how health care costs are threatening to bankrupt the U.S.. Multiple letters from the district have warned against "cutting Medicare," while the doctors want the SGR "repealed" and the hospitals are the number one employer in the district.  Cutting payment rates or changing eligibility are politically unpalatable. Given the results of the Dartmouth Atlas, wouldn't it much nicer if there were a way to get docs to order fewer tests and use less expensive technology less often?

What Kristin and her colleagues often don't realize is that changing physician behavior is notoriously difficult.  Considerable research spanning several decades has shown 1) no single intervention works all that well; it takes multiple tailored, overlapping and mutually supportive interventions, 2) once the interventions stop, physician behavior rapidly decays back toward the baseline, and 3) dedication to patients plus professional independence combined with local practice patterns and culture are a huge influence in day-to-day clinical medicine. 

In other words, doctors live by more than bread, guidelines, bonuses and payments alone.

In the opinion of the DMCB, the good news is that smaller regional organizations, such as local health plans, physician and hospital groups understand what they're up against and have amassed a track record of economic incentives, educational programs, peer support and non-physician disease management programs that make a difference. They're close to their providers and know how and when to apply that secret sauce to change physician practice.

Which is the irony for Kristin.  Despite the considerable financial resources and power of a vast Federal government, her predecessors' good ideas like "meaningful use" "pay for performance" and "value-based purchasing" are not meaningfully transforming the practice of medicine.  In fact, other supposed game changing interventions like the SGR and the RBRVS have only made things worse.  

That being said, the DMCB reports some good news: Kristin and her colleagues are listening and learning.  Many are coming to understand the limited ability of Washington's blunt-force policy and payment mechanisms to reach across culture, education and professionalism to gently tilt the doctor-patient relationship in the right direction. 

Want to design a smarter staffer who knows how to change practice patterns? It takes knowing how similar efforts have worked in the past, understanding what the science says and appreciating how local markets can be harnessed. 

Next step: designing a better member of Congress.

Scrimping On Medical Out-Of-Pocket Expenses While Splurging On Luxury Items

Is it good or bad to ask patients to pay for a portion of their health care with their own money, i.e., "out of pocket?"

If you think it's good, you probably believe that consumers need to bear some of that cost and that markets can drive wise-decision making.  You like to quote the famous RAND study. 

If you think it's bad, you probably believe cost-sharing can cause persons to withhold needed care and paradoxically can cause unwise decision making.  You probably like to quote studies like this.

Which reminds the Disease Management Care Blog of a patient named Victor (not a real name), who refused to get his yearly diabetic A1c blood test because it was going to cost him $5.  He understood the importance of the test but thought the charge was simply too much. The exasperated DMCB knew the guy had a nice car and could afford it.  It figured, given a choice between foolish luxury and good health, this patient was being shortsighted.

This behavior isn't unknown to managed care executives, who know that many of their middle class and employed enrollees come from socioeconomic backgrounds that make it very possible to pay five lousy bucks for a blood test.  While it's an issue for indigent patients, if well off and rational patients "choose" to not invest in their own health, that's not the fault of the insurer, is it?

Which is why the DMCB found this New York Times article on consumer scrimping and indulging fascinating. In response to our "new economy," Americans are cutting back on common household staples and simultaneously splurging on luxury items. When it comes to items like household cleaners, shampoo and batteries, consumers are squeezing pennies.  Yet, the sales of high-end handbags, shoes and watches are going strong.

The conclusion of the Times' article is that the wear and tear of daily sacrifice results in an occasional need to indulge. Maybe persons think they deserve an occasional reward or just get tired of doing with less, but whatever the cause, this has important lessons for the pricing of health insurance deductibles, co-insurance and co-pays:

1) enrollees use completely different standards when it comes to willingness to pay for "necessities" versus paying for "extravagance." If it's a "necessity," patients like Victor will say no if the price point is too high.

2) just because enrollees could economically "afford" a relatively small fee for a medical service doesn't mean they'll perceive that they can afford it.  For Victor, $5 was too much.

Make sense?  Maybe not to the DMCB, but that's the reality of health care consumerism. Health insurers should pay close attention and wonder if it could be their fault.

Nurse Care Managers: The Mortar Holding the Bricks of the Patient Centered Medical Home (PCMH)

It's no secret that the Disease Management Care Blog is an enthusiastic believer in nurse care managers.  In its humble opinion, it makes no difference what "bricks" are used to build a Patient Centered Medical Home, an Accountable Care Organization, a Population Health Management Program or an employer-based care support/wellness initiative, the nurses are the mortar.

Readers can read more on how this specifically works in a DMCB co-authored article titled "The Focus of Case Management Grows" in this on-line version of The Case Management Society of America's (CMSA) Case In Point magazine.

While the manuscript focuses on the PCMH, its lessons can be applied to any corner of primary care:

1. Some patients have higher health care needs, more care gaps and greater risk.  Surveys and analyzing insurance claims and electronic health record data can find them.

2. There are cheap medical  interventions that increase quality and lower costs.  Nurses know about them and, when they're supported by physicians, can champion their use among patients with the most to gain.

3. Most patients want to meaningfully participate in their own care.  This goes to the core of patient centeredness and these nurses know how to harness that energy.

As systems confront the limitations of pay-for-performance, the disappointments of the EHR Kool-Aid, the inertia of Washington-run health care and dwindling budgets, the DMCB is confident that these nurses will finally get the recognition they deserve. What's more, patients will be better off for it.

Care Coordination: The Way Forward For The Dual Eligibles

Hot on the heals of the Disease Management Care Blog's bus tour of the problematic "dual eligibles"  comes this AHIP sponsored report from Emory health economist Kenneth Thorpe on how the Feds could save the taxpayers some serious money.   Recall that there are close to 9 million duals costing in excess of $230 billion per year and that the President's recent cost reduction proposal is curiously devoid of any mention of this group.

So what is Dr. Thorpe's recommendation?  It can be summed up in two words:

"Care coordination."  The report can be found here.

 As the DMCB previously noted, the duals are being victimized by a perfect misalignment storm of Medicare and Medicaid.  Dr. Thorpe recommends that they be automatically enrolled (on an "opt-out" basis) in State-regulated managed care plans that would finance 24-7 centralized team-based care that, in turn, would be required to offer three key evidence-based services:

1. Transitional care or comprehensive planning and follow-up as patients move from the hospital to the community, which is led by dedicated full-time nurses.

2. Coaching and education using motivational interviewing and behavior change theory that is designed to prompt changes in life-style and greater self-care.

3. Medication management under the direction of a full-time pharmacists who make sure that the right medicines are being taken at the right time.

Based on a host of papers that have examined the impact of the interventions described above, Dr. Thorpe estimates, depending on the number of opt-outs, that the savings could exceed a whopping $125 billion over ten years.

The physician-DMCB endorses Dr. Thorpe's recommendations:

While critics may charge that it gives too much power to the insurers, it thinks that the States and the Feds can ensure that there are consumer protections.  Witness the preliminary good work of the Special Needs Plans.

The report avoids drinking the "physician-centric" Kool-Aid that assumes some combination of electronic records and financial incentives will enable primary care docs to take this on.  They can't.

While the Patient Centered Medical Home (PCMH) is certainly an option, report capitalizes on the more important elements of the PCMH and discards the rest. 

Finally, it's the health plan that has the accountability - and the downside financial risk - for making this work in a high cost and particularly needy population.

Cavalcade of Risk - Terrorism, CyberWar, Floods, Bad Mortgages, Robberies, Investment Losses and Disease Edition

The Disease Management Care Blog is reconsidering the wisdom of agreeing to host the Cavalcade of Risk #140. The links below are a unpleasant reminder that disasters are lurking everywhere and that there is no escape.  Being a contrarian physician-blog that dwells on health care and insurance, your DMCB was confident that it could intellectually digest the topics below.  After writing this Cav of ubiquitous hazards, however, the DMCB now wants to digest some Xanax and PeptoBismol.

Who knew that so much could go so wrong out there?

Ever heard of the "Terrorism Risk Insurance Act" (TRIA) of 2002?  Neither has the DMCB, but readers can learn more about it at the Insurance Regulatory Law Blog's post on Quantifying the Unquantifiable: Some Perspective on Terrorism Risk.  It turns out the U.S. government is providing "reinsurance" (insurers can buy their own insurance) for a host of commercial companies that have to deal with a threat that is hugely expensive, quite rare and non-random, which is the very antithesis what the usual market needs to function well.  And by the way, TRIA is set to expire 2014 and it looks like it may not be renewed.  Seems some sort of budget issue has come up.

If being reminded about terrorism isn't enough to rattle you, how about cyberwar?  That's tackled by the Risk Management Monitor Blog in this post on how UK Infrastructure Providers 'Accept an Unexpectedly High Level of Risk' of Cyber-Threats, and the National Response Is 'Fractured and Incoherent'.  It appears, lacking a coordinated response by their government, that the Brits' businesses and banks have decided to deal with this risk on their own.  Unfortunately, they're not dealing with it very well.  Not only have some companies been slow off the mark, others have decided to accept the inevitability of an intrusion and plan on simply dealing with it then.  How many other key industries worldwide have adopted the same cavalier attitude, asks the DMCB?

Terrorism, cyber attacks.... it's enough to make the DMCB flee to the country and seek sanctuary on a farm and live simply off the land.  But wait, even that isn't safe, because Lynch Ryan's Workers Comp Insider Blog points out that the risk of getting trapped, suffocated or crushed in a grain bin is increasing.  In response, the National Grain and Feed Association has a video on one more reason why our nation's farmers deserve a lot of respect.  The DMCB thinks it deserves to flee back to the suburbs.

So it might be best to stay safe and stay at home, right?  Well, if you have a mortgage on that home, the canadianfinanceblog warns that your sneaky bank may try to to sell you "mortgage life insurance."  It turns out this may be a lousy deal, since the premium may not change even as the balance on the mortgage declines.  Better to get standard term life policy.  And when you've done that, you can scrutinize the rest of that small print in the mortgage documents that you signed for some other unpleasant surprises.

After you read all that fine print and discover what you've unwittingly agreed to, you may want to think about property losses from hurricanes, floods, tornadoes and earthquakes. Yes, you can buy a specific insurance policy for each of those possibilities, says the Free From Broke Blog.  On the other hand, given how uncommon hurricanes, tornadoes and earthquakes are, it may make more sense to invest in a sump pump and simply stash away an emergency fund.  The DMCB followed that game plan during the recent flooding from Tropical Storm Lee and now needs a basement mold mitigation fund and a get-rid-of-wet-carpets fund.

Plus, you may want to get "home insurance" against the possibility of a loss from a robbery.  Unfortunately, says the My Personal Finance Journal Blog, the cousins across The Pond are grappling with a daily toll of more than $3.5 million in home insurance fraud.  As a result, the DMCB calculates that honest home owners there are unnecessarily having to add a hidden tax of $1 for every $3 in insurance.

While you're putting bars on your home windows and barricading the doors, it may be smart to take that money out from under that mattress and seek some investment income, right?  If that's your plan, you may want to check out this "101" posting on the fundamentals of investment risks posted at The Financial Literates Blog.  How many things can go wrong, you ask?  "Fifteen" says the FLB!

Or if you want to avoid those 15 dreaded errors, how about an "annuity?"  This lengthy post by the Free Money Finance Blog on Why Do We All Hate Annuities explains that the fine print is perplexing, the sellers are a shady lot, their fees are high, the company (like AIG) could go belly-up, you lose control of your money and they're still a big gamble.  One option is "laddering."  Another option, says the DMCB, is digging a hole and stashing away some precious metals.

While being attacked, hacked, crushed, ripped off or making a bad investment bet is a possibility, at least we Americans have an enlightened government that is helping us buy health insurance, right?  Think again, says Louise of the Colorado Health Insurance Insider.  She points out the fed's online "healthcaredotgov" web site can be misleading.  It appears that the site reports blunt pricing underwriting statistics that fail to capture what is really going on.  While Louise makes the point that brokers can help customers navigate this complicated marketplace, the DMCB thinks that the healthcaredotgov website is a telling reflection of the unsophistication of Washington DC's health insurance bureaucrats.  Good grief, and these amateurs actually want to be in charge.

Maybe you should take charge, then, and confront the risk that you may come down with a debilitating, crippling and non-curable condition and need long term insurance.  The curiously named High Yield Savings Accounts Blog  offers up a check list of what to look for in such a policy, such as excluded services, maximum lifetime benefit terms, riders and renewable guarantees.

While we're struggling with hazards, perils, dangers, disasters, terrorism and disease, Hank Stern over at the Insure Blog suggests there is a way out from all this danger, at least for the fairer sex. Women may want to have a mid-day tipple because another observational study has shown that there is an association between imbibing and well being.  To that, the DMCB says "Cheers!" and points out if you end up in the hospital anyway, your physicians will know what to do.

"Gulp!" says the DMCB.  While it likes the idea of imbibing to support the DMCB spouse's continuing good health, it thinks it should also look into buying an electric generator, firearms and a year's stash of fresh water and vacuum-packed ready-to-eat meals.  While it's doing that, it'll be looking forward to Jay Norris of Insurance Shoppers hosting the next edition of the Cav.

The Budget Battle and the Dual Eligibles

$315 billion?

While it digests the details behind the Prez's $320 billion health care budget-cutting proposal, the Disease Management Care Blog toured an unfamiliar corner the health care universe called the "dual eligibles" a.k.a. "duals."

Two good up-to-the-minute summaries are here and here.  For a program that is so poorly run and an Administration that is so willing to spend money, the DMCB is surprised the duals haven't garnered more attention.

According to the Kaiser Family Foundation, there are 8.9 million disabled young persons (40%) or low income elderly (60%) who are "dually" enrolled in both Medicare and Medicaid.  Under this system, Medicare is the primary payer, while Medicaid is "secondary." Depending on the beneficiary's income level, Medicaid can be limited to paying for the duals' Medicare Part B premiums, cost sharing deductibles and co-pays (about a third of the duals), or it can cover other services that are not otherwise covered by Medicare (two thirds of the duals).  Two examples of services that are picked up by Medicaid is long-term care in a skilled nursing facility and home-based services. 

Duals had combined Medicare and Medicaid spending of almost $200 billion in 2005 and it's projected to go to a whopping $315 billion in 2011.  While this population on average accounts for only 15% of a state's Medicaid beneficiaries, these patients account for almost 40% of a state's Medicaid budget, mostly for long term care services.

The DMCB learned that these patients are the canaries in the health care coal mine.  They are vulnerable, the sickest of the sick, low income, have multiple conditions and are notorious users of hospitals, emergency rooms and nursing homes.  While some benefit from being in managed care style "special needs plans," 80% of the duals are stuck in a patchwork of overlapping state and federal fee-for-service programs, financing and rules that result in haphazard and poorly organized care.  What's more, since Medicare is the primary payer, any efforts by states to reduce the health care costs of their duals go to the fed's bottom line. 

That's why the Affordable Care Act established a "Duals Office" that is providing grants to states to develop proposals based on either 1) capitated payments to plans that achieve savings for both Medicare and Medicaid or 2) state-run 'managed fee for service" options like "ACOs" or "health homes" that allow states to gainshare in any savings.  The Office will also be monitoring consumer protections, such as preserving choice, maintaining an adequate provider network and ensuring that some of the savings are directed toward care management, coordination and community-based services.  It's too early to tell if they've had any meaningful successes.

In looking at President Obama's latest proposal, the DMCB can't quite discern what the budget cuts will do to the duals.  Cost shifting to the states won't help, but in the long run, the DMCB believes the states are better positioned - despite some bumps in the road - to rely on well-run special needs plans to serve this population with expanded population health and care management programs.

Stay tuned!

And Here's Another Skeptical Paper On Accountable Care Organizations (ACOs)

Adding to a continuing drumbeat of skepticism about Accountable Care Organizations (ACOs), Gail Wilenksy offers a "sobering" Perspective in the New England Journal about their underlying business model.  She draws on the lessons of the Physician Group Practice Demonstration, where - despite "glowing" press releases - the financial savings were decidedly elusive.  Summarizing things nicely, Ms. Wilensky points out that only 2 out of the 10 Demo participants were able to achieve savings in the first year of operation and that only half of the group had savings after three years.

Why did this happen?  She agrees with many of the criticisms noted by your Disease Management Care Blog: there were some important "design" issues involving the comparator groups (the use of "rural" settings may have set the baseline too low), CMS struggled with providing timely claims data and the risk adjustment methodologies may have fallen short (for example, the Demo participants had high-cost specialty services which may have inflated their cost). 

While Ms. Wilensky previously served in a Republican administration, the Disease Management Care Blog has always found her to be a reasonable pundit.  That's why it's telling that she concludes her paper with a damning observation candy-wrapped in bureaucrat-speak: as currently envisioned, she says, the proposals "seem inconsistent with the hopes that have been pinned to ACOs as a viable alternative to both traditional Medicare and traditional managed care."

The Latest Health Wonk Review Is Up

There is something for everyone at the latest Health Wonk Review hosted by David Williams of the Health Business Blog:  Obamacare will grow more popular, the Super Committee will utterly fail, it's Obamney crap, shadowly right wingers are afoot, ACOs are a perfect prescription, the mainsteam media will never get it right etc etc etc,  Check it out and you're guaranteed to find something to agree with, further evidence of the nuttiness out there and why it's not only fun but endlessly interesting to pay attention to what the bloggers have to say.

Affordable Care Act Clean-Up Bills Are An Uphill Battle

The Disease Management Care Blog spent the day navigating the halls of Congress.  The DMCB discerned a preference for black-toned suits and dresses among many of the staffers, making it think in was either in a "Men In Black" movie or that the depths of D.C.'s doldrums worse than even it imagined.

As further evidence of the dysfunction, the DMCB was told that the "clean-up" bills that typically follow every major piece of legislation are unlikely to get anywhere anytime soon.  The inevitable additions, deletions and clarifications that are usually necessary to align any newly minted U.S. law with its original legislative intent are typically tackled over the following years, but not for the Affordable Care Act.  Cleaning up the ACA is being stymied by the Republicans, whose only solution to any problem in the law is to repeal it, as well as the Democrats, who are reluctant to introduce any bill that could open a Pandora's Box of crippling reforms.  That 'no-go' approach has also spilled onto other unrelated health care legislation.

And speaking of no-go, it also took the DMCB twice as long to get out of downtown DC thanks to traffic that was stuck somewhere between paralyzed and gridlock. 

Funeral garb. Legislative brainlock.  Automotive immobility. Merely a coincidence?  You be the judge.

Image from Wikipedia

Never Mind Regulating Insurance Rates, What About Hospital Fees? A Look At Maryland's Health Services Cost Review Commission

Do believe that government should regulate health insurance premium rates?

If so, then why not agree with the government's regulation of hospital fee rates?

This article in JAMA explains how largely Democratic Maryland is using its "Health Services Cost Review Commission, or "HSCRC" to do precisely that to its 51 hospitals.  Its independent 7 member Board of Commissioners is appointed by the governor for four year terms.  Only 3 can be hospital administrators, hospital board members or hospital staff physicians.  Its budget of 7 million is paid for by a fee assessed on hospitals and much of it is used to collecting and publicly reporting cost and quality data.  The HSCRC uses patient risk adjustments, uncompensated care adjustments and other statistical factors to determine a "charge per case" which all insurers in the state are required to follow.  Medicare and Medicaid follows suit through a waiver system.

After the system was instituted in 1976, the rate of hospital cost inflation plummeted, making Maryland the lowest hospital charges of any state in the Union.  And by the way, the HSCRC is also incorporating pay-for-performance and a no-pay for certain complications in its fee schedule.

While the DMCB tends to be pro"market" and anti-regulation, that's not going to stop it from congratulating Maryland for taking a health care bull by the horns.  It thinks this is another example of a state that is stepping up with its own local version of health reform without having to necessarily wait for the federal government.  While the DMCB doubts that other states could pull this off, the HSCRC works in Maryland and the voters seem to like it.  That's quite a contrast when it's compared to  the Affordable Care Act.

U.S. Government Launches a Population Health Improvement Initiative Called "Million Hearts"

The Department of Health and Human Services (HHS) has launched a "Million Hearts" campaign that is designed to prevent a million heart attacks and strokes in the next 5 years.  You can read about it in the New England Journal here or in Circulation here.  There is also more detail here at the HHS gov web site.

The campaign is crafted to address the "ABCS" a.k.a. aspirin, blood pressure control, cholesterol control and smoking in the U.S. population. The Feds propose to 1) consolidate just how ABCS will be specifically measured in any population, 2) remind and help manufacturers as well as users of EHRs that they can be tasked to addressing ABCS, 3) initiate a "pharmacist-led campaign.... (to) facilitate counseling about hypertension control," 4) launch an anti-tobacco marketing and community-based campaign, 5) push for food labeling in restaurants and 6) increase the measurement of sodium and fat consumption.  Details are in this table.

"Bravo!" says the DMCB.  When it reads about Million Hearts, it's clear that the Feds are identifying population-based strategies, basing their interventions on demonstrated needs, increasing awareness of health risks, using patient-friendly education, helping consumers make the right choices and figuring out how to assess outcomes on an ongoing basis with a feedback loop.

If you agree on the DMCB's assessment of what the Feds are up to, you also agree that they've they have launched a huge population health improvement (PHI) initiative.  The DMCB isn't making that up: if you compare the Care Continuum Alliance description of PHI here with the fundamentals of Million Hearts, you'll see that the overlap is almost 100%.

What's different is that the Feds are also using Million Hearts to 1) further justify the Affordable Care Act and the EHR meaningful use initiative, 2) leverage some potent government entities like AHRQ, CDC, CMS and the FDA, 3) distribute hundreds of millions in community grant money, 4) create a coalition that includes The Y, AHA, Walgreens, some professional pharmacy associations and AHIP, and 5) say some nice stuff about Mrs. Obama's childhood obesity program.  

All that makes perfect sense from a governmental as well as political process, but it's still PHI.

"A hearty welcome to the fold!" says the DMCB.  HHS has finally decided to give millions of Americans access to PHI that combats atherosclerotic heart disease.  Better late than never, but based on what we know about the science of PHI in multiple other settings and assuming the government can pull this off, the DMCB is confident that a million lives being saved is within reach.  

The Latest Cavalcade of Risk Is Up

Better late than never, says the Disease Management Care Blog, but go figure, the spouse insists we deal with the carnage of a flooded basement first.  Emily Holbrook is currently hosting the latest Cavalcade of Risk, a compendium of business-risk bloggery that has floated to the top of the list.  Enjoy!

and no, no flood insurance.

11 Insights for the Disease Management Community From Dr. Lundberg

The Disease Management Care Blog couldn't have said it better.  It's not often that the DMCB "reflects" web-based content from elsewhere, but this deserves an exception.

Writing for the MedPage web site, former JAMA Editor-in-Chief George Lundberg describes 11 "false assumptions, practice failures, clinical errors and things amiss" in health care today. 

If these defects were corrected, the DMCB guarantees that U.S. medical quality and cost would improve.  The list also speaks to the difficulty of relying on laws, economists, budgets, Rose Garden announcements, regulations, policy-making, hearings, benefit design tweaks and politicians to have any meaningful impact on the real underlying problems in health care today. 

The good news, however, is that disease management offers some solutions to the 11 points.  That's why practically every health insurer in the U.S, with the exception of Medicare, offers some form of population health and care management.

To wit:

1. "Physician persuasion is powerful": in other words, patients need to actively participate in calling the shots.  That's called shared decision making, which is a bedrock principle of the population health management service provider industry.

2.  "Medical tests can lie":  when physicians intuitively disregard "positive" tests, low pre-test odds can make that the right decision.  Smart and experienced care management nurses understand that and can support the physician's decision in care planning.

3. "Disease onset can be gradual" and persons in the earliest stages of chronic illness may not meet the definition of even having a "disease" - yet:  That's why active disease management is best suited for later stage conditions and offers prevention and wellness programs for the rest.

4. "Preventive public health deserves more credit": part of disease management's success lies in its value proposition of applied public health.

5. "There is an overreliance on the indirectly obtained information of labs and imaging" and testing begets more testing as well as avoidable treatments that are the hidden part of health care cost iceberg:  Disease management can help patients understand that they don't need another MRI.

6. "Long term outcomes data for many age/gender groups are lacking": this is why disease management approaches long-term risk contracts cautiously and why the industry can help keep ACOs from jumping off a 3 year cliff.

7. "It's not all in their heads": care management coaching understands the false allure of the mind body dichotomy.

8. "There is what is known and then what is believed": reliance on still evolving evidence-based research that taps a variety of investigative methodologies is not only the best long-term approach, it's becoming the bricks and mortar of disease management.

9. Some conditions cannot be treated: and some patients should be discharged from disease management programs.

10. There is a difference between "biology" and "medicine":  this is why seasoned nurses make the best care managers

11. There is no test that distinguishes the well from the sick: seasoned care management coaches don't necessarily assume their clients are "patients" who are "sick."  They assume their clients want a say on getting from their current health status to a desired health status and strive to help them get there.

Does Telemonitoring For Chronic Illness Work? The Emerging Body of Literature Says Yes.

That's the question that the Disease Management Care Blog asked itself after comparing this new study published in Health Affairs with this negative study that had been published in December 2010 in the New England Journal and reviewed by the DMCB.

Briefly, the new study, "Integrated Telehealth and Care Management Program for Medicare Beneficiaries with Chornic Disease Linked to Savings," involved patients with diabetes, heart failure or COPD cared for at the Wenatchee Valley Medical Center and the Bend Memorial Clinic in Washington and Oregon, respectively. 

It used “Health Buddy,” which is a handheld device with four buttons and a screen that is telephonically linked to a care management provider service.  The device asks a menu of condition-specific questions, and patient answers are aggregated by computer for subsequent review by the care management nurses.  If the answers are consistent with any deterioration, the patient is telephoned. 

Health Buddy was originally examined as a CMS Demo (the report is here).  This new Health Affairs study was a reanalysis of the data paid for by the owners of Health Buddy.

Briefly, in this new study, Medicare beneficiaries with diabetes, heart failure or COPD who appeared to be high risk and high cost were chosen by CMS.  Two batches of patients were chosen at different times: 763 were selected in early 2006 and, because of attrition and death, another 1056 were chose one year later.  37% of the candidates ultimately agreed to participate and use the Health Buddy device. There was no charge for using the device.  This was an "intent to treat" study, so even patients that declined participation were included in the analysis.

What was different in this analysis was that two control groups similar to the intervention groups were abstracted out of CMS' databases, using counties of residence elsewhere in the U.S. with similar degrees of urbanization, demographics and local care delivery systems. Claims and other data were then used in propensity matching to finalize a group of patients that resembled the intervention patients. 

A total of 52 patients were excluded because of problems with propensity matching, so the total analysis was based on 1767 intervention patients and 1767 (propensity-matched) controls.

Armed with a different control group, what did the authors find?

While death rates were slightly lower for the intervention group (10.5%) vs. control (10/7%)  in the first year, it was 2.5% lower in the second year (9.7% vs. 12.3%). 

At baseline,quarterly spending was $4048 for the intervention group vs. $4093 in the controls.  One year mean quarterly spending dropped to $3508 vs. $4107.  In the second year it was $3568 (intervention) vs. $4051 (controls).  Depending on which quarters were used, the authors estimated that total savings was $450 per quarter.  After the usual statistical adjustments to control for any observed variations and the ironic possibility that death may have result in savings to the Medicare program, the savings held up as statistically significant.  The statistical significance also persisted for each of the three disease groups; it was greatest for heart failure and lowest for diabetes.

How does the DMCB reconcile all this?

In contrast to the New England Journal study, where the results were forwarded to the patients' docs, Health Buddy had a nurse in the loop who called the patient at the first sign of any deterioration.  The DMCB believes that pairing dedicated staff to the telemonitoring made the difference; busy physicians are just not able to cope with additional information like this in typical day-to-day outpatient clinic workflows.

As mentioned above, this study was originally a CMS demo.  The original analysis of Health Buddy for CMS did not use propensity matching and, while costs went down, it did not achieve statistical significance.  The DMCB also thinks that the more analyses are conducted, the more disparate findings will emerge, but it also finds propensity matching to be a widely used and acceptable statistical approach.

All in all, the DMCB still thinks this is another study in an emerging body of science that supports the use of telemonitoring as one option in population health management and further evidence that disease management works.

Mayhem and Downside Risk in Accountable Care Organizations

The channel-surfing Disease Management Care Blog routinely stops whenever its remote comes across any of the AllState "mayhem" commercials.  Humor aside, they're a smart portrayal of the unexpected downside of risk that can cruelly strike property owners anytime and from anywhere.

Refusing to be boxed into mundane homeowner or car insurance, the DMCB took media flight and applied the the idea of mayhem to Accountable Care Organizations.  Assuming most readers are familiar with the commercial, the DMCB suggests that the volume be turned down when the "play" icon is activated.  The paraphrased ACO dialogue is below.... 



I’m a raccoon and the Mayhem I represent is all the things that can go wrong for your Accountable Care Organization. I'll make this the worst fiscal year of your organization's life.

This fluffy stuff is all your carefully laid plans to make a lot of money. Oops, more inpatient admissions than you planned for! Four quality measures are already in the dumpster. Think all that wiring means you can get any useful utilization data out of your network?  Check out this hole in the roof where your return on investment with Medicare will disappear. And you will be paying for this yourself even if you don't get any shared savings.

So get real about easily saving money and think about Mayhem.... like me.

And lest we forget about what can happen if rank and file physician input is ignored by ACO leadership when they're making their big plans......

The Prognosis for a Budget Compromise on Medicare Under the Budget Control Act of 2011: Not Good

It sounds reasonable enough.  Across-the-board cuts for Medicare and national defense is such an anathema that the "The 12" Super Committee politicians from both extremes of the ideological spectrum will find some way to reach common ground, right?

Think again. 

That's the message from an eye-opening editorial from a D.C. insider who is laying odds on no agreement and that the automatic cuts will happen.

By way of background, the Disease Management Care Blog checked out this handy Kaiser Family Foundation Brief on the Budget Control Act of 2011.  Briefly, The 12 must present a $1.2 trillion 9 year plan (going from 2013-2021) by November 23.  It must be voted on by December 23 and it must be signed into law by the following January 15.  If no plan makes it past that finish line, the Office of Management and Budget will have to "sequester" (claw-back) already budgeted money equally over each of the 9 years. Half of the cuts will have to come from defense and the rest will have to come from non-defense areas. 

Even if defense and other parts of the budget are reduced by The 12, the math says Medicare (except for Part B and D premiums, beneficiary cost sharing and Part A revenues) would still have to be addressed one way or another. The maximum that could be cut from that entitlement is 2% per year; that would mean a reduction in payment rates.  

That's when providers would go bonkers, health care advocates' blood would boil, hospitals would threaten lay-offs, doomsday attack ads would distract from Dancing With The Stars and someone's grandma will die.  Would our already reviled political class even dare to toy with such Kryptonite this close to a Presidential election?

Former Clinton Advisor Christopher Jennings (who held his own crossing swords with Gail Wilensky on a past PBS NewsHour) writing in the New England Journal, basically says the prognosis for agreement is grim and that's exactly what is going to happen because:

1. All health care stakeholders and advocates already understand what would happen with an across-the-board 2% Medicare cut.  On the other hand, they have no idea what mischief could happen if The 12 dive into the weeds of how the entitlements currently function.  Strangely enough, therefore, they seem to prefer the former,

2. It's very possible that the Republicans could successfully insist on more than 2% in some parts of the program and that the Obama Administration would throw Medicare under the bus agree - if it means getting concessions on the President's yet-to-be-announced jobs plan, and

3. Medicaid is exempted from the process.  An agreement by The 12 would be almost certain to tack on reductions in Medicaid, which could bust a lot of state budgets.

Think a reasoned bipartisan compromise will emerge, based on a Congress that wants to avoid a replay that led to a downgrade and do what's best for the Republic?  Based on the ingredients above, you may be wrong.

Do Electronic Records "Cause" Better Diabetes Care? Who Cares?

Persons with diabetes should look for this?

High functioning primary care sites are more likely to purchase an EHR. 

That's the contrarian conclusion of the Disease Management Care Blog after reading this New England Journal article by Randall Cebul and colleagues titled "Electronic Health Records and Quality of Diabetes Care."

Briefly, this was a study of persons with diabetes who were being served by the primary care sites of seven health care organizations in Cleveland and surrounding Cuyahoga County in Ohio.  There were 21 primary care sites in a not-for-profit system, 12 owned by a safety-net hospital, 1 in a university hospital and the remainder were federally qualified health centers.  The sample was made up of 27,207 patients cared for by 569 primary care physicians in 46 practices.  13 practices with 53 providers used paper, the remainder used EHRs. 

The impressive results can be found here.  Basically, if you had diabetes and was cared-for in a clinic with an EHR, you were more likely to have your HbA1c tested, kidney disease addressed, eyes evaluated for retinopathy and be immunized against pneumonia.  You'd also have better control of your blood glucose, blood pressure, cholesterol, weight and be less likely to use tobacco.  For most of the measures, the differences were in the double digit range, and, except for glucose control and blood pressure control, remained significant after statistical adjustment.

So why is the DMCB being a nattering nabob of negative nitpickiness? 

This is an observational study involving physicians who independently chose whether to purchase an EHR.  It is quite possible that high functioning and financially successful clinics that were already taking good care of their patients with diabetes committed to an EHR, which was otherwise an innocent bystander.  That's called "confounding" or "selection bias" and cannot be ruled out.  We cannot say for certain that if the paper-using clinics were forced to purchase an EHR that their numbers would have improved.

That being said, the DMCB doesn't really care.  If the EHR caused better diabetes care or is merely associated with better diabetes care, the "signal" is the same: having computer screens in a clinic means higher quality.

The policy implications:

1.  Based on this study, we still don't know for sure if the EHR causes better care, but

2. It makes sense to "steer" patients with diabetes toward clinics that have EHRs.

Health Information Technology and Meaningful Use Without The Personal Computer?

The Disease Management Care Blog had a great three-day weekend, thanks in part to being visited by a nephew and his lovely wife.  In addition to being impressed by their verve and elan, the DMCB also benefited from an insight: practically all of their internet "connectedness" is managed via their cell phones.

In the meantime, check out this Wall Street Journal opinion piece penned by Michael Malone on the death of the personal computer.  Hewlett-Packard's exit from the PC market has not only been driven by relentless commoditization, but by the rise of alternative "platforms" including" the cloud" and the advent of the nephew's hand-held devices.

And lest we credit this to youthful techie coolness, Lucy Hood, in a separate article, opines that smartphones are now bridging the digital divide. These multi-functional devices have finally reached a price point and a degree of usability that is enabling the nephew - and millions of other persons dealing with today's economy - to readily and cheaply access the web for browsing, information and entertainment - without having to own a PC.

It's too early to assess the implications of this generational shift away from the PC for the Feds' efforts to digitalize the practice of medicine.  The provider community is still coming to grips with information technology and meaningful use" (MU). Hopefully EHRs won't share the fate of "shovel ready" and clean energy loan guarantees.

Upon review, the MU criteria may still ultimately apply, but the shift away from PCs may require some changes in how they are implemented.  Can they be adapted for example, to pharmacy data stored on "the cloud," making clinical information as instantly understandable as a city subway system, fitting visit summaries on a cell-phone screen as readily as a restaurant reservation, tapping social media to send reminders, and accommodating individualized "apps" tailored for specific conditions?

Stay tuned.

Image from Wikipedia

Bundled Payments

The Disease Management Care Blog's critical review of a NEJM article on the topic can be found over at KevinMD .

The Latest Health Wonk Review Is Up!

The latest Health Wonk Review is up.  This one is hosted by Avik Roy of The Apothecary Blog over at Forbes.  Don your foul weather gear for a blustery examination of the best and brightest of the recent health policy blogi'canes.  Enjoy!

Health Literacy and the Potential Impact on Health Insurance Exchanges

While the Disease Management Care Blog has occasionally been a snarky critic of the Affordable Care Act, it really likes uncovering policy insights and then coating them with the sweet chocolate of physician-laced cynicism.

For example, the DMCB pointed out that health insurance exchanges are surprisingly complicated and, as a result, it's very possible that Uncle Sam and the states will fail to meet their 2014 deadline.  It's in that spirit that, thanks to this recent JAMA Commentary, that the DMCB is warning that another problem could gum up insurance enrollment through the exchanges. 

Underestimated levels of poor health literacy may stand between millions of U.S. citizens and exchange-enabled access to the ACA's publicly funded and subsidized insurance plans.

Writing in the August 24/31 JAMA issue, RAND scientists Laurie Martin and Ruth Parker point out that health literacy can be defined as "the degree to which individuals have the capacity to obtain, process, communicate and understand health information and services needed to to make appropriate health decisions.  According to the IOM, a stunning 90 million Americans lack this standard of health literacy and more than half of those currently without insurance have borderline or insufficient skills to navigate health care decision making - which includes understanding eligibility criteria for insurance or subsidies, completing forms, providing documentation, discerning the differences between various out-of-pocket expense options and how exclusions of coverage may work.  Little wonder that millions of persons eligible for Medicaid fail to take advantage of it.  As a result, building an insurance exchange does not mean that they will come.

The DMCB read that Massachusetts' lawmakers realized that there might be a problem and set up consumer-friendly mechanisms to aid consumers with the tedious details of on-line form completions and decision making. 

Hopefully other states and the federal government will figure out ways to do this also.

Otherwise, exchanges will be the party ... and no one will come.