Five Reasons Why The Ovarian Cancer Avastin Story Is Not Finished

An ovary almost completely
replaced by cancer

As regular Disease Management Care Blog readers may have predicted, the controversial anti-cancer drug Avastin went bust again in two just-published studies (here and here).  This time it wasn't for the questionable treatment of breast cancer but ovarian cancer.  Yet, while the nation's mainstream media has passed sentence on Avastin's failure, the DMCB isn't quite ready to "short" the drug.

Very briefly, one randomized prospective trial involved women with high risk or disease that had spread.  Participants were randomly assigned to standard chemotherapy plus Avastin, while the other group got just the chemotherapy.  Women in the Avastin group went 24.1 months without progression of their disease versus 22.4 months in the non-Avastin group.  Death rates are still being analyzed.

The other trial involved women with cancer that had spread.  They were randomly assigned to one of three groups: just 1) chemotherapy or 2) chemo plus either Avastin in the earlier cycles of chemotherapy or 3) Avastin with all the cycles of chemotherapy.  The just chemo group went a median of 10.3 months before there was disease progression, while the Avastin groups went 11.2 and 14.1 months, respectively.

Even with the depressing results outlined above, the DMCB has several reasons for believing that we've not seen the last of Avastin for ovarian cancer.  Much of the DMCB's obstinacy has to do with the complexities of cancer treatment and how statistics are collected and interpreted:

1.  The trials involved patients with aggressive or advanced disease. Much like the logic of using a small extinguisher on a huge house fire, that doesn't mean that persons with limited or microscopic disease wouldn't be helped by Avastin.  The only way to find out is to perform the same sorts of randomized trials involving patients with less widespread or aggressive disease. 

2.  It's possible that some of the Avastin patients may have gotten much better, but their positive results were diluted by the majority of the patients who didn't benefit. In other words, the clinical trials report the average response rate.  That does little to answer the two questions that every individual cancer patient asks: 1) are there exceptions and 2) am I one of them?

3. Assuming exceptions exist, there may be a way to identify that small minority of patients who are more likely to derive a greater benefit from Avastin. Assuming ovarian cancer is a heterogeneous disease, there may be a blood test or an additional type of biopsy that can answer the two questions above.

4. "Disease progression" is just one of several cancer outcomes.  While it's important, there are others that may have more meaning for patients and could simultaneously put Avastin in a better light.  As a reminder, death rates in one of the trials described above are still being compiled and have yet to be reported.  Stay tuned.

5. Last but not least, the most selectively generous interpretation of the data above is that Avastin helped patients go an additional 4 months before their disease started spreading again.  While that may not seem worth it, the DMCB has taken care of plenty of patients who would think it's plenty worth it.  While commercial insurers will have every reason to question payment for a horrendously expensive drug with only 4 months of benefit, patients and their doctors will argue that hope is "medically necessary."

Image from Wikipedia

Of Accountable Care Organizations, Pioneers and Potatoes

It wasn't long after the Dec. 19 CMS announcement that the Pioneer Accountable Care Organization Program had launched that the champagne health policy corks began to pop.  According to writers in the Health Affairs blog, ACOs have the "potential" to align incentives, leverage electronic health records, harmonize government and commercial insurers and improve care.  After that they'll potentially restore the polar ice caps, save the Euro and help Facebook finally realize that its users are the customers, not the product.

But in all seriousness, recall that Pioneer will run parallel to the bigger "Shared Savings Program." The purpose of Pioneer is to test the ability of already integrated health systems to function as ACOs.  From a pool of anonymous applicants, CMS' "Innovation" center chose 32 "winners."

You can read how their contracting arrangements will work here.  As the Disease Management Care Blog understands it, it'll involve an optional Chinese menu of threshold-dependent and first-dollar shared savings and/or full capitation.

It all reminds the Disease Management Care Blog of potatoes.

Why would the DMCB chose the lowly spud to make its point about ACOs, you ask?   Read on:

Align incentives?  Under shared savings, health care providers will ultimately bill less and receive a fraction of any savings in return.  If you like that business model, the DMCB would like to pay you a dollar less for any bag of potatoes you've just bought and give you 50 cents to reward you for our "shared savings."

Electronic records?  If the ultimate leveraging of the EHR is to improve care coordination, the bad news is that there is still a large gap between the hard science of EHRs (here and here) and wishful jargon.  In other words, documenting they're potatoes and what you've done to them in some computer still doesn't make 'em any easier to cook.

Commercial payors?  Unencumbered by miles of regulations, statutes and political meddling, commercial ACOs are already miles ahead of CMS.  At a recent holiday meal, the DMCB spouse served traditional boiled spuds.  She also served up a creative casserole of shredded potatoes mixed with sour cream and cheese.  One was much more tasty.  One was not.  'Nuff said.

Improve care? Ten years ago, James Robinson said it best: our problems are limited resources, unlimited expectations, widespread skepticism and reduced tolerance for interference with individual  autonomy.  We have 20 lbs of potatoes.  The ACO bag is made for ten lbs.  Good luck.

Image from Wikipedia

The Latest Cavalcade of Risk Is Up!

Want to learn more about the ins and outs and the ups and downs of business-related risk?  You can learn about that and even get some insights on the risk of starting a business in the latest Cavalcade of Risk hosted by Jacob Irwin at the My Journal of Personal Finance blog.

Enjoy!

More On the Affordable Care Act's Health Insurance Mandate

Is this also some type of "mandate?"

With two prior posts under its belt ("Optics" and "Furies"), the Disease Management Care Blog continues to follow the opinionating over the constitutionality of Affordable Care Act's health insurance "mandate." The latest is this New England Journal Perspectives piece.  According to author Mr. Elhauge (who personally opposes the mandate), a federal law that uses the Commerce Clause to require persons to purchase health insurance is perfectly legal and proper at multiple levels:

Congress has repeatedly used broad interpretations of the Constitution to insert itself into the conduct of commerce, so the mandate is nothing new.  One past example is the prohibition against gender, religious or racial discrimination by private firms, while another is the ban on home grown medicinal marijuana.  Since health care is a commercial activity in the public space, the logic is that Congress can similarly require anyone who has ever received health care in the past to purchase health insurance for the future.

While prohibiting an activity (like discrimination or pot) may not be the same as requiring an activity (health insurance), readers may be interested in knowing that the first Congress not only required ship owners to buy medical insurance for merchant seamen but later required seamen to buy hospital insurance.

And what about that mortgage deduction?  If you don't buy a house, you can't take the deduction, which economically the same as a penalty for not engaging in the economic activity of home ownership.

Another favorite of mandate opponents is the argument that the Feds are on a slippery slope leading to a requirement that we all buy broccoli or General Motors cars.  The counter argument is that Medicare is a system that requires the purchase of "broccoli" at government stores.  What's more, if we were to privatize Medicare, wouldn't that also functionally be a mandate for the purchase of private insurance?

Last but not least, if personal liberty is the underlying issue, the argument is that no one would ever force anyone to eat the broccoli.  Mandating insurance is not the same as mandating health care.

Care Continuum Alliance Insights on the Population Health and Disease Management Industry Outlook for 2012

Future's so bright, gotta wear shades!

Optimism.  Enthusiasm.  Bullishness.  Who can blame the Care Continuum Alliance for describing the future as "bright" in a ebullient 2012 population health management "Industry Outlook" white paper?  Based on a survey of unnamed "industry leaders,'  the CCA found that practically every high visibility health policy initiative out there is relying on the principles of care management.

They're right.  Given growing recognition that "health care as usual" cannot continue, companies, vendors and organizations (and blogs) that offer new approaches will thrive.  Have a good idea on reducing chronic illness and improving health and the value proposition will follow.  Have a value proposition and the business model will follow.   Have the business model and an early comfortable retirement will follow. 

The report can be downloaded here.  No company or individual resource knowledge library is complete without it.  The Disease Management Care Blog also thinks that forwarding the report to colleagues, co-workers, bosses, underlings, friends and enemies will demonstrate two key traits:

1) your situational market business awareness is second to none
2) reading the DMCB is a competitive advantage

A DMCB summary review is below

ACOs and Shared Savings: the industry has a host of necessary  risk assessment, predictive modeling, information technology, analytics, patient engagement and condition management tools that can be built and tailored. Provider organizations that seek to make money from "upside gainsharing" ignore these resources at their peril.

Electronic and Mobile Health: remote physiologic monitoring, 'app' based coaching and "pull" style  social media engagement are all reaching a tipping point.  Or rather, are all eReaching an eTipping ePoint. The Disease Management Care Blog, sharing in the eEnthusiasm, has initiated a remote "eSpouse" offering. More on the ePerils of that eBusiness model in a future ePost.

Reducing Readmissions: Come Oct. 1 2012, outlier hospitals with more than their fair share of heart failure, heart attack and pneumonia readmissions can look forward to a painful revenue cut.  "Pay us now or pay later," says the industry, with too numerous-to-count proven care management strategies that have been described at the Care Continuum's annual meetings for years.

Medicare Advantage Bonus: That's right, MA plans will be eligible for bonuses from CMS based on HEDIS inspired commercial insurance outcomes that have been the bread and butter of the care management service providers since the beginning of time.

Dual Eligibles:  This highly vulnerable population has been trapped in a twilight zone of overlapping and uncoordinated benefit plans thanks to a well-meaning but typical Washington-style mishmash of Medicare and Medicaid.  The good news is that the Feds have finally woken up to this and are interested in funding many of the coordination strategies that the population health industry stands ready to offer.

Prevention and Wellness: The Feds have money to put into this and employers are increasingly willing to invest in it.  Medicare covers annual wellness visits and covers obesity counseling.  The controversial ham-fisted involvement of HHS in calculating the MLR has thankfully correctly slotted the cost of wellness programs.  Wellness and prevention are one of the ten essential benefits.  The industry is poised and ready to go.

And what about "build" versus "buy" and the notion that providers already know how to do all this stuff?   The DMCB points to the sine wave of on-again off-again in and outsourcing that has been the norm for the commercial insurer-disease management vendor relationship for years.  The DMCB suspects the same will occur for providers, hospitals, delivery systems and ACOs that have to operationalize complex programs that achieve measurable accountability.  The difference is that, up until now, they haven't had to do that at all.  Based on a mix of in-house competencies, interest, speed to market needs and cost comparisons, many will buy. 

The population health industry's outlook is very bright indeed.

Image from Wikipedia

The Latest Health Wonk Review Is Up

Gary Schwitzer offers up a holiday-styled Health Wonk review with presents/links that delight, amaze and educate.  Tis the season at the Health News Watchdog.

Enjoy!

The "Doc-Fix" Debacle and Why Medicare Access Is In Jeopardy In Both Salaried and Physician Owned Settings

Don't underestimate the physician dismay over the looming "Doc Fix" debacle. Unless some budget compromise gets hammered out, Medicare is about to stick it to a lot of docs.

Ever since the passage of the Balanced Budget Act of 1997, Congress has been repeatedly delaying a yearly mandated cut in Medicare's physician fees. That statutory reduction has been slowly accumulating through no fault of the physician community and is now estimated to be more than 27%.  Assuming most physicians' practices are made up by a majority of Medicare beneficiaries, that represents a huge hit to their cash flow. KHN has a good summary of the partisan mutual assured destruction that has led us to this crisis here.

The docs are not happy:

From the AMA ("shameful"):

"Congress has again failed to fulfill its responsibilities. It is shameful that patients and physicians are the collateral damage; the citizens of this country deserve better. Congress had the entire year to repeal the broken physician payment formula and provide stability for the millions of seniors...who rely on Medicare... but has failed to act. It is long past time for members of Congress to act decisively and protect access to care for seniors..."

From the American Academy of Family Physicians ("outraged"):

“The American Academy of Family Physicians is outraged that Congress failed to prevent the 27.4 percent Medicare physician pay cut mandated by current law. That failure has presented their elderly and disabled constituents a bitter holiday gift — uncertainty whether their physicians will be able to provide the services they need."

A family physician blogger ("very upset"):

"I have talked some of my colleagues and some of my patients, and all of us are very upset about this. Some of my physician friends are really thinking this time about completing the necessary paperwork to stop accepting Medicare patients. How can any business (except government) run with such uncertainty as not finding a permanent fix to the broken current Medicare system. Patients will be unable to see their physicians, resulting in delayed care, increased hospitalization, and illness."

 From an email that was forwarded to the Disease Management Care Blog:

"Who can help us? 28% cut are you kidding me, some of us cannot sustain the disruption of cash flow.
I had a great home equity line on my house, but it was closed (not just frozen) because my bank just got taken over by the feds."

Observers may believe that the fallout will be limited to the small-business physician-owned practices and that the larger systems with salaried physicians will be able to carry on.  That would be a mistake.

Within each large provider systems, clinical "work units" are still responsible for meeting revenue expectations which, in turn, are tied to physician salaries and non-physician support staff.  A fee schedule cut courtesy of Medicare will be just as much of a problem for them too.

How will both the physician-owned and salaried practices respond?  The DMCB predicts that most will conclude that seeing more Medicare patients (volume) will not make up for the reduction in fees.  As has been noted by persons far wiser than the DMCB, "if you're losing 25 cents on every watermelon you sell, you can't make up for it by selling more watermelons."

As a result, both physician-owned and salaried practices will limit access by Medicare patients. Most will probably continue to see their active and established Medicare patients, but they will functionally "deactivate" their other Medicare patients and decline to take on new ones.  They'll then "backfill" those open appointment slots with patients who have better insurance.  Here's how it's done.

The DMCB will close with three additional thoughts:

1. If rates go down by 27%, there may be increased merit to the notion of "balance billing."

2. "Concierge practices," thanks to this stand-off, just got a lot more attractive to thousands of physicians.

3. Now would be an opportune time for the population health management community to close ranks and communicate with their legislators on behalf of their physician partners.

HHS Blinks On The Affordable Care Act's Essential Health Benefit

Remember that Affordable Care Act (ACA) "essential health benefit (EHB)?" 

While Disease Management Care Blog doesn't want to be reminded about it either, the topic bubbled into the health policy news cycle thanks to this sleeper bulletin recently released by HHS. Recall, despite the ACA requiring an approach based on a "typical" insurance plan covering ten categories of services, that the law set the stage for a requirement that every U.S. health insurer would have to potentially cover an expansive, complicated, expensive and controversial suite of services in each and every health insurance policy.  Any insurance plan not meeting the EHB would be excluded from the exchanges.

While the DMCB feared the unable-to-say-no amateurs in HHS would stumble their way into an unaffordable and one-size-fits-all package, it appears they've blinked.  That's because they've discovered that the ACA misread things: while insurance policies typically cover a core set of services, they vary in coverage of other services.  That includes dental care, acupuncture, bariatirc surgery, hearing aids, tobacco cessation, in-vitro fertilization, certain autism services, a variety of mental health and substance use disorders and habilitative (yes, that was a new one for the DMCB too) services.

How does HHS intend to reconcile this?

"We intend to propose that EHB be defined by a benchmark plan selected by each State."  

Whoa.

In other words, there would be 50 EHBs.  As the DMCB understands it, each would be calculated using an intra-state combination of the largest small group plan, any of the largest thee state employee plans, any of the large three national FEHBP plans and the largest commercial plan.  If a state doesn't calculate the benefit, the Feds intend to use the one used by the largest small group insurance plan.  If the calculation doesn't include sufficient coverage in all the ten categories, the ultimate default is using whatever is in the state's largest FEHBP plan.

Business groups and state leadership will probably find the local state-based approach a more palatable alternative, while some professional (for example) and patient advocacy (for example) may be disappointed.

The Wyden-Ryan Plan: Medicare Advantage Ver. 2.0 With Vouchers and Competitive Bidding

Simultaneous conservative praise and liberal support for something called the "Wyden-Ryan Plan" prompted the inquisitive Disease Management Care Blog to look up the document. 

Could this be **THE** template for a grand bipartisan compromise reform of Medicare?  Thanks to this consolidated DMCB summary, readers will not only get to ponder that question, but contrast their health market and business acumen with non-DMCB coworkers and colleagues with self-serving and career-advancing questions like:

"So Barry, do you foresee any business opportunities related to the annual risk review audit envisioned in the Wyden Ryan plan?"

Without further ado, here are the facts:

Persons who are currently age 55, i.e. become Medicare eligible on or after January 2, 2022, can choose to be enrolled in either

1) traditional Medicare "as we know it" or,

2) a competing commercial plan with "premium support" funding provided by Medicare.  This option includes either old fashioned Medicare Advantage or a fee-for-service plan.  Either would be required to provide a benefit package that is "actuarially equivalent" to standard Medicare. 

Beneficiaries are given a voucher to pay for Medicare advantage or the fee-for-service plan.

What is the value of the voucher?  It depends on a competitive bidding process.  Competing commercial plans would have to submit premium bids to CMS. For any service area, the second lowest bid would serve as the local benchmark.  If a beneficiary chooses that plan, they would be given a voucher that pays the bid i.e. the full cost of the insurance.  Beneficiaries are free to chose other plans that submitted a losing bid, but the beneficiaries pay the difference.  If a beneficiary chooses that plan with the lowest bid, Medicare will rebate the difference.

If the beneficiary is older or sicker than average, the amount in voucher will be "risk-adjusted" upward.  Lower risk beneficiaries would have their voucher adjusted downward.  This is designed to compensate insurance plans for the increased risk of enrolling sicker patients.  Participating plans would be required to accept anyone who applies for coverage.  That means there would be no underwriting, i.e., no cherry picking i.e. there would be guaranteed issue.

Once enrollment is complete, plans would be subjected to an "annual risk review audit." Those with an excess of low risk enrollees would pay a fee to make up for a more profitable book of business, while those with an excess of high risk enrollees would get a rebate.

If, despite the introduction of competition described above, Medicare's nationwide costs exceed the growth of the U.S. gross domestic product (GDP), Congress would be "required" to act with a suite of options including reducing provider payments or requiring richer seniors to pay more (i.e., means testing).

Competing plans would be listed in an exchange.  They would also be closely overseen by CMS.

Beneficiaries could switch plans during an open enrollment period

Medicare's Part A and B deductibles would be combined and a cap that limits out of pocket spending.

So what is the DMCB's take:

"Medicare Advantage" and fee-for-service plans for Medicare beneficiaries are not new.  What's new is the introduction of vouchers. The DMCB predicts critics will view vouchers as a political Trojan Horse ultimately intended to undo traditional Medicare.

The plan relies on competitive bidding to drive down costs.  It's unclear if bidding will be the "tail" that wags the "dog" of an aging U.S. population that wants the best and a health care-technology industrial complex that wants to sell their goods at the highest price point they can justify.

Recall all those past protests from the insurance industry over the prospect of competing with a publicly funded program?  The DMCB thinks this is different because they will benefit from Medicare's price controls.

Ingredients for commercial insurer voucher success will include actuarial smarts over the details of prospective risk adjustment and retroactive claw backs, neutralizing the pernicious effects of variation with high enrollment and not only making money but doing right by the beneficiaries with a higher level of service.  If all they do is return value to their investors, Congress will shut 'em down.

Last but not least bloggers smarter than the DMCB have problems with the proposal and are worth a look.

The Heartbreak of Not Regularly Reading the Disease Management Care Blog

Upon the death of Dear Leader Kim, North Koreans discover that state censorship under his regime had prevented them from regularly reading the Disease Management Care Blog......

The New York Times, Newt Gingrich's Sins and The Merits of Creative Destruction

Where's Newt?

After watching the last Iowa Caucuses Republican Presidential debate, the Disease Management Care  Blog continues to be fascinated by The Newt's repartee prowess.  Maybe it's because the starstruck DMCB has seen the former Speaker in the flesh on a number of occasions.  National health policy conference organizers have known for years that the logorrheic and futuristic Newt Gingrich Big Idea Factory could be counted on to deliver the goods to any audience.

Yet, keynoting prowess is one thing, but being a contender for President an another.  Now that Newt has clawed is way into a leading position in the polls, greater visibility has prompted greater scrutiny. 

That's why the DMCB likes this New York Times article on Newt's unseemly mix of health advocacy and business ties.  It's not pretty, portraying Newt as a cynical political opportunist who has been brazenly willing to ally himself with popular "big-government" ideas.  What's more, The Times darkly implies that consulting fees from big pharma and insurance companies caused him to promote their business interests.

So what, according to The New York Times, are Newt's five sins?

1. While every other service industry relied on information technology, Newt had little patience for a health care system system that perpetuated reliance on pen and paper.  When HITECH passed, private citizen Newt had little problem taking some of the credit and collecting some fees while he was at it.

2. Newt repeatedly observed that ATMs could reconcile complex financial records and yield hard cash from any ATM in the world within seconds, yet Medicare's payment systems were inaccurate, byzantine and highly vulnerable to fraud. He called for the reform of Medicare, which later also turned out to be one of the bedrock principles of the Democrat's modernizing health reform agenda.

3. Then there's this 1995 "wither on the vine" quote in which he maps out the demise of Medicare because of reforms leading Americans to "voluntarily [going to] leave it -- voluntarily."  Fast forward 15 years and Newt is supporting the Ryan-Wyden bipartisan compromise legislative proposal that is likewise based on voluntary choice and doesn't end Medicare as we know it.

4. Newt was also an ardent supporter of comparative effectiveness research (CER)  Newt specifically cited not-for-profit Cochrane as an example of the kind of CER he supported. He doesn't like this $1.1 billion boondoggle.

5. As for funding from insurers and pharma, Newt's ideas on enhanced coverage of children and diabetes care attracted like-minded companies and allies.

"Big deal," says the yawning DMCB.  The Time's concerns about Newt's past lack substantive ballast.  If nothing else, Newt's pugilistic skills will make Mitt Romney a stronger contender - assuming he makes it to the championship round .

While the DMCB is at it, it can't help but take a quick look at two other arenas of alleged Newty nuttiness:

1) That infamous criticism about his fellow conservatives' dangerous "social engineering" in the Ryan Ver. 1.0 plan:

The DMCB thinks Newt personally liked the plan but disliked the prospect of having it pass over the objections of a leery electorate.  It's one thing to dream up a good plan, but it's another to craft it behind closed doors and impose it on an unwilling citizenry.

By the way, that some logic seemed to underlie his recent debate commentary over abolishing "activist" federal courts.  He's warning that in a divided powers representative democracy, the co-equal legislative and executive branches and grumpy voters could be pushed into neutralizing flashpoint judges at either end of the political spectrum with recalls, subpoenas, impeachment and defunding.  He's not only consistent, he has a point. (A 12/22 addendum - A point which Newt is provocatively willing to to back up with U.S. Marshals.  Of course, he could just sandbang them during State of the Union Addresses.  What's next: pieing?)

2)  Being too incendiary, zany and mercurial to be President

This was best portrayed by Peggy Noonan's December 10 Wall Street Journal "Declarations"  description of Newt as a human "hand grenade" who delights in being to ready "watch this!" pull the pin at a moment's notice. 

Good point, but there is also something stubbornly dysfunctional in many parts of the health care system.  If Obamacare doesn't work out as planned, there may be merit to the notion rejecting the Republican mainstream and applying a heavy dose of creative destruction.  Newt certainly has the "creative" and "destruction" chops.  Absent anyone else with this particular skill set, Newt's biggest problem may be that we're just not ready for him to combine them... yet.

Newt's problem is that he's still far ahead of the curve.

Let the games continue.

The 12 Population Health and Care Coordination Colloquium

Mark your calendars for Philadelphia Feb 27-29, 2012! 

This premier educational event is a must for anyone interested in population health and care management.  More information on attending virtually or in person can be found here.

What Do You Know: Quality Doesn't Automatically Translate Into Savings

Goin' goin' gone!

The Disease Management Care Blog recalls years ago when it was walking with some residents and students through a decommissioned wing of a hospital as a short-cut between patient floors.  Our footsteps echoed off the dreary beige tile while we chatted up the likelihood that we could get the next patient home this afternoon.  Then the  DMCB paused and took in the eerie fluorescent silence. "What you see around you," it mused, "is some valuable and unused capital."  The team then resumed the pace. That's when the DMCB looked at the young docs and said "If we keep it up, they'll need to close another wing!" 

The fly in the ointment.  The monkey in the wrench.  The doc's raised hand at a hospital board of trustees' meeting.  Call it what you like, but sometimes our most cherished assumptions and best laid plans have a way of going all akimbo.  True to that tradition, curmudgeonly Dartmouth authors Stephen Rauh, Eric Wadsworth, William Weeks and James Weinstein examine the "illusion" of  expecting "lower costs" to come out the back end of a health system system after "quality" is put in the front end. 

The authors' real focus is on hospitals and define "quality" as any intervention that reduces the utilization of health care services (versus other definitions). Despite the narrow view, the Disease Management Care Blog believes the article makes an important and yet obvious point: large and small health care organizations have rigid cost structures that cannot be flexed.  As a result, any increase in quality - such as reducing length of stay, admissions, readmissions or surgeries -  mostly results in additional dead space capacity, not bottom line savings.

Clinical improvement can reduce costs is in the general category of supplies and medications.  Unfortunately, those costs are at the margins.  Just because there are fewer readmissions won't mean all those expensive operating rooms. equipment, personnel costs and other administrative overhead will simply go away.  They don't.  They'll be idle and cost just as much.

Some economists will argue that hospitals can take beds off line and furlough nurses.  It's also been pointed out that multiple health systems can regionally consolidate high-cost low-frequency services.
Unfortunately, the quarter to quarter business cycle facing the typical hospital administrator doesn't really accommodate that kind of wishful thinking.  The only way out is to find other revenue by either charging more or providing other services.

Despite many valiant attempts, the DMCB never managed to close another hospital wing.

The Latest Cavalcade of Risk is Up!

The New Zealand domiciled Chatswood Blog is hosting the latest Cavalcade of Risk, with what writer Russell Hutchinson describes as "an eclectic and interesting collection of thoughts and comments" on a host of business risk issues.  Since the Disease Management Care Blog is in there, it couldn't have said it better itself.

Enjoy!

Weighing In On The Population-Based Lessons from The Biggest Loser

But for being born centuries
too early, another potential
TBL contestant!

Despite vowing to never let it happen again, the Disease Management Care Blog was ensnared, along with over 7 million viewers, into watching much of last night's NBC's The Biggest Loser finale.  While the participants' physical transformations were truly astonishing, it found the lachrymose blubbering, manufactured suspense, emotional vulnerability and emphasis on exercise over diet so awful, it couldn't look away.  The icing on this cupcake was $100K winner Jennifer's spooky mydriatic gazing "bedroom eyes." 'Nuff said about that.

The good news is that this media mugging didn't stop the DMCB from extracting three weighty insights.  To wit:

Focusing massive amounts of personalized counseling for persons who are simultaneously at high risk and exhibiting willingness to change is certainly part of the answer to managing the population-based dimensions of obesity. Alas, while that makes for good pseudodrama, the DMCB worries that the show is promoting a belief that all the obese really need is some gumption and a personal trainer.  The science says otherwise.

In thinking about the distribution of obesity among normal adults (a graph is here), The Biggest Loser is intensely case managing a small number of persons at the farthest right side of the curve.  Case management has a role, but the complete answer includes overlapping strategies that move the entire weight curve to the left with less sensational but proven evidence-based interventions. They include promotion of smart food choices, portion sizes, breastfeeding, school physical education, recreational spaces, walking as well as countering excess television viewing and the food industry's pernicious marketing.  That'll take blocking and tackling by schools, employers and local governments.

The overly perceptive DMCB also thought it detected the outlines of girdles under some of the contestants' spandex. Because human skin can stretch to accommodate increasing body volume, the loss of large amount of fat from under the skin can leave patients with an unsightly saggy exterior.  While the web is replete with unproven cures, the only viable option is plastic surgery. The DMCB couldn't find any population-based research that sheds light on how many formerly obese persons become baggy and how many go on to need surgery, but Google "obesity" + "compression garment" and the results suggest this is a growth industry.  Despite their success at slimming down, the DMCB suspects that many of These Biggest Losers may have lingering body sculpting issues to deal with.

Why Traditional Physicians Will Trump Walmart's Primary Care Service Offering

A big box with plenty of
room for primary care?

Several years ago, while the Disease Management Care Blog was supervising a medical resident clinic  (an example of how they work can be found here), an elderly patient came in for an appointment.  According to the resident, Mr. Jones (not his real name) would unexpectedly lose consciousness while walking. He also complained of feeling shaky and unsteady on his feet.  Prior to entering the clinic room to see Mr. Jones, the DMCB already suspected the patient had Shy-Drager Syndrome.  One look at the his staring and unblinking face confirmed it, all in the space of about five seconds.

Which is why the physician DMCB confidently thinks its profession ultimately has little to fear from Walmart's apparent interest in establishing a national network of primary care clinics in its big box stores. 

Careful scrutiny of the Walmart Request For Information (RFI) reveals that potential partner companies are welcome to showcase their health care "solutions," "applications" and "offerings" that are "convenient, accessible, affordable, consistent, scalable and integrated."  Walmart wants these companies to leverage its retail and multi-channel clout to to reduce costs and increase access while maintaining or improving outcomes in clinical care, diagnostic services, prevention and wellness. Care services can include a host of general medical services, management of chronic as well as acute conditions, laboratory testing and "other."  Ownership, financial arrangements, data sharing, integration, technology, logistics, back office functions and the level of customization are negotiable.  To be taken seriously by Walmart, candidate companies need to have a track record of success at a national level, a credible leadership team, a business plan, timeline, access to secondary partners as necessary and familiarity with quality assurance.  There is an notable absence of any reference to the "medical home."

While the similarity of "Big Box medicine" to retail clinics could be criticized at many levels, the DMCB has heard two two major concerns from its colleagues about Walmart:

1) Walmart and the like will further "Balkanize" the system, leading to more, not less, fragmentation and

2) it will commoditize health care, leading to narrow and regimented treatment protocols that don't take the "big picture" into account.

The DMCB disagrees with the first assertion because Walmart's RFI seems to envision a highly integrated system backed up by informatics, connectivity and quality metrics that - on paper - should lead to more coordination not less.  That's good.

Yet, the DMCB thinks that there may be something to the second  assertion. It is Walmart's style to relentlessly attack costs at every part of its service cycle and the company probably believes the strategy can be applied to health care.  If that's Walmart's intention, it'll almost certainly choose a vendor that industrializes guidelines like this in a one size-fits all "protocolized" fashion all the time every time.

That's not necessarily bad, but that means there'll be little room for the kind of smart heuristics that helped the DMCB get to a quick diagnosis.  The DMCB doesn't deny being "smart," but the the point is that the best primary care intelligently combines guidelines and heuristics.  The DMCB's physician colleagues have that special skill.  Thanks to competition from Walmart (and retail clinics), they'll hone that expertise and respond with a higher, more efficient and better quality standard of care for many patients for a long time to come.

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Three Insights About Hospital-Physician-Insurer-Employer Health Care Market

Check out the three page article on "U.S. Health Care's Future" in the Marketplace section of the December 12 Wall Street Journal. Using personal stories of a doc, hospital CEO, insurance executive, human resources manager and a patient, the news piece portrays the blurring business lines between insurers, buyers and providers.  Mainstream readers of the Journal are likely to think the topic is both timely and novel.  Regular readers of the Disease Management Care Blog learned about his months ago.

Who are these five canaries in the health care coal mine, these bellwethers of the insurance business, these oracles of management and what are they telling us?

1. Dr. McCullough, a salaried physician with 28% of his income contingent on quality and satisfaction.  Some measures were imposed by the local Blues plan, which was passed through to the him by his employer.

Message: Purchaser and buyer control of physician reimbursement is already big and it's growing.

2. Jim Taylor, a hospital CEO who cannot buy an electronic record system unless he merges with two other hospital systems.  If the merger is approved, the hospital will also be able to take on "warranty-style" payments from insurers.

Message: "Bigger is better" for capital-constrained hospitals.

3. Chris Day, an Aetna executive who got an Arizona health system to share insurance risk.  The main sticking point was the two-way mutual sharing of internal cost and contracting data.

Message: If insurers are willing to share internal pricing data, they must really mean it and think it's an important success factor.

4.Robert Jacobs, the HR person, who linked about $10 per week of employee's health insurance premiums to healthy behaviors (like tobacco) and quality test results (like blood cholesterol levels).

Message:  "Don't just stand there," say the employers, "do something."

5. Louis Kandor, an 86 year old man with advanced diabetes, who is being visited by a nurse who, in turn, is employed by a care management service provider under contract by his Medicare Advantage insurer.

Message: One key to mitigating risk for every insurer (except fee-for-service Medicare) is to use nurse-led care management.

While the Journal article doesn't spell it out, the DMCB believes the anecdotes can be distilled down into three useful insights:

1. Stakeholders are scrambling to demonstrate measurable outcomes to an increasingly educated and  skeptical public.  That's the basis for physician pay-for-performance and premium surcharges.

2) Sharing proprietary insurance data is important.  Is information the secret ingredient that was lacking during the similar - and mostly unsuccessful - insurer-provider collaborations back in the 1990s?  We'll see. 

3) For those hospitals that cannot or will not take risk, the next best answer is to merge.  That will mean economies of scale, access to capital and negotiating leverage.

ACOs are an Unwelcome Bump On the Road to Inevitable Regulation of Health Care? A Former Presidential Candidate Says So

Want to better understand the perpetual anguish of a chronic illness?  Well, thanks to online streaming from the Harvard School of Public Health, readers can better appreciate the eerie similarities between hyperprogressive liberalism and incurable diseases like elevated blood sugars.  Both can go on for decades, are irreversible, cost a lot of money and are ultimately caused by inappropriate choices.  The Disease Management Care Blog is, of course, writing about this hour long video of former Massachusetts Governor and former Democratic Presidential candidate Michael Dukakis.

Sadly for health reform Obamaists, the supremely competent and confident Mr. Dukakis trashes the concept of accountable care organizations at about the minute 35 mark, dismissing it as a reincarnation of 1990's style HMOs and capitation.  And he doesn't stop there. The additional problem, he says, is that we'll waste ten years analyzing what he foresees will be a foregone conclusion: ACOs are destined to fail. 

What's more, since health care markets are such a dismal option, he concludes the only choice that's left is price-setting "regulation."  Assume State Insurance Departments have power over hospitals, call everyone into a room, assume they're decent people, appeal to their economic self interest and everyone will be happy.

Yet, once the DMCB got over Mr. Dukakis' "legend in his own mind" persona, it believed the former Governor has a good point: if ACOs fail, we'll be left with two choices:

1) a governing class who is ready to step in with enlightened top-down governance or

2) a reintroduction of market forces that seeks bottom up competition and consumerism.

In the interest of fairness, if readers want to see a counter-argument in favor of markets, check out this one-sided nine minute Cato Institute video that teaches us we've haven't really had a health care market for decades. 

Alternatively, if you're in the mood for neither of the above videos, perhaps your time would be better spent on viewing something that offers far more than either of the options above. 

You Go Bizzle!



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Scenario Planning in a Post-ACO and Post-ACA World for the Care and Population Health Management Industry



....and suppose there are 55
Republican Senators?

In a prior post, the Disease Management Care Blog provocatively suggested that providers, hospital boards and policymakers should hedge their bets and prepare for the possibility of a "post-ACO world."  If the Group Practice Demo's disappointing results are any guide, the likelihood of a happy ending for accountable care organizations is on numerical par with Congress' approval rating. While the DMCB likes the mutual "win-win" theoretical construct that underlies ACO gain sharing, it also recalls a life-lesson from the DMCB spouse: want you want and what you get are usually two different things.

So, if the Feds have to eventually retreat on the non-success of ACOs, what will be left in its wake?  More on that in future posts.

And while the uncertainty surrounding ACOs isn't bad enough, the DMCB has also been astonished by the battered Euro, the appearance of hospital-employed cardiologists and the absence of a Lady Gaga Christmas album.  Accordingly, the DMCB has learned its lesson and assumes nothing. 

That's why it's only natural that it would pay attention to this short and useful New England Journal Perspective article on the 2012 U.S. elections. Author David Blumenthal portrays the "consequences" as potentially "huge." The DMCB agrees. 

Three potential scenarios warrant health care leaders keeping their options open:

1. Obama wins, the House retains a Republican majority and the Senate retains a Democratic majority: Even if the individual "mandate" is struck down by the U.S. Supreme Court, the President will continue to implement the ACA's expansion of Medicaid, state exchanges, insurance subsidies and employer penalties.  House Republicans will continue their "defunding" attacks and may even draw some blood over the Innovation Center and comparative effectiveness research.

This makes the DMCB believe that more insured persons will increase the demand for population health and care management services. However, if your program is dependent on grants, watch out because the money is going to dry up - even if you have good outcomes.

2. Obama wins, but both the House and Senate have Republican majorities: The Republicans will reduce funding, hollowing out the ACA's ability to expand Medicaid coverage or support insurance subsidies. Mr Obama may have to compromise on enforcement of exchanges and employer penalties.  In the end, however, Presidential vetoes mean the ACA will not unravel, only slow down.

In other words, says the DMCB, because the number of persons entering the insurance market will be blunted, all those expansive population health business plans will need to be scaled back.  Relentless increases in health care costs among persons with insurance will spur interest in innovative care management programs that can do it better and cheaper.

3. The Republicans win a trifecta, taking the House, Senate and Presidency: Absent a 60 vote majority that can overcome Democratic filibusters, the Republicans will rely on the reconciliation process and the power of the purse to undo many of the ACA's provisions.  There'll be some modest programs involving bundling, care coordination and primary care, but the United States' "post-ACO" world will be eerily similar to the "pre-ACA" one.

To the DMCB, that means there is little hope that fee-for-service Medicare or Medicaid will cover care management.  As more persons become uninsured, population health companies will not only need to do it better and cheaper, success will depend on making more money off of fewer persons.  The only way out will be game-changing "killer" innovations.

The DMCB also offers up its own three scenarios:
  
1. Progressives, having the upper hand, will overreach and pronounce debate over the government's role in health care as over.  If cost-saving innovations flounder, the federal deficit grows and costs continue to gobble up more of the nation's GDP, the Dems will raise the option of a public payer.  Come to think of it, the DMCB suspects they'll bring it up anyway. Bloggers everywhere will be in hog heaven.

2. Progressives everywhere will pronounce any electoral loss as further evidence of their failure to properly educate a preoccupied and non-expert electorate on why they should let Washington run things.  Conservatives will overreach and pronounce the debate over the government's role in health care as over. They'll openly conspire to repeal Medicare.  Bloggers everywhere will be in hog heaven.

3. Conservatives, having the upper hand, will overreach and will assume Medicare beneficiaries want vouchers.  Smarter Republicans will have little appetite to repeat Mr. Obama's mistake of spending precious political capital on health care versus something far more important, like school prayer.  And...  bloggers everywhere will be in hog heaven.

Free Drugs For Heart Attack Patients: The Analysis Behind the Analysis of the MI-FREEE Trial

Assuming drugs are not free, should all patients in an insurance plan that covers medications get the same coverage at the same price?

While that may seem to be a no-brainer, there's plenty of research (for example) that demonstrates that out-of-pocket costs can reduce persons' willingness to take their pills as prescribed.  While that may be the price of doing business, why not give persons who really need a particular life-saving medication a price break?  While that may seem unfair, suppose everyone in the risk pool benefits from lower health care costs?

Enter the Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial. 

Too long to read at one sitting you say?  The Disease Management Care Blog at your service!

The study involved Aetna beneficiaries who had just been discharged from a hospital following a heart attack.  While the trial was randomized and prospective, the randomization occurred at the level of the insurance plan. Various employer, union, local government or other association groups (and their patients) were randomized to one of two arms:

1) an intervention group where patients had no out of pocket cost sharing or co-pays for brands or generics in four classes of drugs that have been shown (go to page e227) to reduce the risk of death after a heart attack: 1) statins, 2) beta blockers, 3) ACE inhibitors and 4) ARBs, or

2) the usual co-pay for statins, beta blockers, ACEs and ARBs.

2845 persons were placed in the "no-cost" arm of the study and 3010 were in the "usual cost" arm of the study.  The mean age was 53 years and 75% were men.  About 34% and 27% of both groups had diabetes and heart failure, respectively.  Over time, the percent of persons that were fully compliant with their medications became different: 31% in the usual cost vs. 41% in the no-cost group.  The median duration of follow-up was 394 days.

And what happened?  When the number of first-time fatal and nonfatal cardiovascular events were grouped in and counted with heart surgeries (that included angioplasties, stenting or open bypass), there was no statistical difference between the two study arms: 18.8 events per 100 person-years "usual cost" vs. 17.6 per 100 person-years in the "no-cost" group.  There was no difference in the cardiovascular death rate either: 2.0 vs. 1.7 deaths per 100 person years.

However, there was some good news.  The combined endpoint similarity was largely driven by a high equal number of heart procedures in both groups (which seemed to involve more than 10% of the entire study cohort).  If the surgery patients are backed out, there were fewer first time fatal or non-fatal vascular events and strokes in the "no-cost" group. 

There is even more good news. Some patients had more than one event (a patient could have a heart attack, a stroke and then open heart surgery, for example). When the total number of events was added up, there was a difference and it was statistically significant: 329 per 100 person-years in the "no-cost" group vs. 406 per 100 person years in the "usual cost" (p=.03).

Did the insurers save any money?  Yes and no.  Average total spending in the "no-cost" group tallied up to $18,254, while the "usual cost" group averaged $20,238.  While that's a $2000 difference per patient, it failed to achieve statistical significance. However, when the DMCB multiplies those savings by the number of persons in the no-cost treatment arm, it calculates $5,690,000 in total savings. That sure sounds financially significant. 

DMCB criticisms:

1.  Heart procedures - which may be prone to factors other than clinical need - may have diluted the results in this trial, especially if a significant proportion of them were not evidence-based.

2.  The secondary prevention benefit of drugs for heart attack patients extends beyond 394 days.  If this study had gone longer, the difference may have expanded over time and achieved statistical significance.

3.  While a cost difference of $2000 did not reach statistical significance, that may have been because insurance claims follow a non-Gaussian distribution, making their analysis very tricky.  In addition, the DMCB thinks that a real world savings potentially exceeding $5 million is very noteworthy.

DMCB questions:

1. It'd be nice to know if patients with a higher burden of disease (for example heart failure or diabetes) and therefore more vulnerable benefited more than persons with less disease burden.  If so, would it make sense to limit the "no-cost" option to heart attack patients at the highest level of risk? 

2. There is no information on the level of out-of-pocket costs in the usual-pay group. As co-pays increase, medication adherence goes down. We don't know if Aetna's pharmacy benefit is typical of the rest of the market.

DMCB insights:

1. The possibility of $5 million (or more if compliance can be increased beyond 41%) in savings may make paying patients to take their pills seem reasonable.  Silly you say?  Think again.

2. Since $5 million in cost reductions that can result from just a 10% swing in medication compliance, readers should gain a better appreciation on the stakes behind disease management.  If nurses can talk patients into taking their pills, the downstream savings can be potentially huge.  And why stop there, why not combine no out-of-pocket costs with disease management?

Summary:

While the authors dutifully report that the primary outcome of the study (the number of first non-fatal or fatal heart attacks or some type of heart procedure) was the same in both groups, the DMCB remains impressed that free drugs for heart attack patients may be worth it and that Oncle Karl may have been right and that the University of Michigan VBID folks are on to something.  That's because the total number of events achieved statistical significance and there were some specifics that may have blunted the study's ability to get at the other outcomes.

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Retrospective Vs. Prospective Identification of "Wasteful" Medical Care

Pneumonia....uh oh!

Thanks to its prior posts, the Disease Management Care Blog has established its Donald Berwick Fan Club bona fides. However, it disagrees that Dr. Berwick is a slam dunk hero, martyr or role model.  While Dr. Berwick has some strengths, the DMCB has had some fundamental disagreements with the former CMS Administrator.

The DMCB explains one of them.

It recalls a very elderly patient (let's call her Mary) who was desperately ill with a bad infection.  Before coming in the hospital, Mary was mildly confused, had multiple chronic conditions and rarely left her apartment.  The DMCB thought she was a goner, but thanks to prompt, evidence-based and very expensive therapy, Mary not only avoided the ICU but eventually walked out of the hospital.  Mary is important because her admission to the DMCB's hospital service was bracketed by similar patients (let's call them Bob and Alice) who were not so lucky. 

Given the prevailing metrics of our evidence-based age, Bob and Alice would be considered to have received wasteful care, while Mary would be considered a success.  The problem for the DMCB is that that definition of waste can only be made in retrospect.  When it was standing outside Mary's, Bob's and Alice's hospital rooms, it didn't know who was going to survive.

Consider the "crumbling sand pile" thought experiment made famous by Nassim Taleb's The Black Swan.  While it's very possible to predict the general size and shape of a pile made by the one-at-a-time addition of sand grains, it's impossible to predict when it will reach a critical mass and where or how big the avalanche will appear.  However, once it happens, it is possible to look backward and reconstruct the event.

And so it was with the DMCB's three patients.  Survival for many conditions such as infections near the end of life is surprisingly random and unpredictable. Retrospective reconstruction of events (even with an autopsy) isn't of much use for the next patient, even if the hospital is littered with "avalanches" that can be categorized as wasteful failures.

Which is why the DMCB wished Dr. Berwick had long ago stopped repeating the simplistic 30% waste canard, especially when he is smart enough to grasp the shortcomings of retrospectively measuring waste.  While there are plenty of opportunities to reduce costs and increase quality, too much of the science is based on flawed and backwards logic.  Go into any hospital on any given day and doctors will ask this about their care for their patients:

Which ones won't benefit and which ones will? 

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Building A Care Management Program

Care management planning

Hot off the heels of this cinematic debut on how NOT to conduct care management comes this handy Alliance of Community Health Plans 29 page handbook review on how to do it right.  Some of the experienced members of the Alliance shared insights on successful population health approaches, data on the "return on investment" and how to deal with the physicians.

But, say the Hardball-inspired Disease Management Care Blog readers, "tell us something we don't already know." 

The DMCB found three useful nuggets of information:

1. There is no firm rule on the operational balance between central administration and peripheral distribution.  Some of the Plans hire and oversee the care management nurses while others pay their network primary care sites to hire their own nurses.  If the practices employ the nurses, they are free to let the managers see patients on an all-payer basis.

2. Care management caseloads vary from 35 to 150 persons and the enrollee to nurse ratio ranges from one full time nurse to 5000 to 14,000 commercial members. If less than 5000 Plan members are assigned to a primary care site, care managers split their time among multiple sites.  As Plan members are further diluted or distributed through a network, there is greater reliance on remote telephonic communication and coaching. 

3. Reduced costs?  Group Health, Fallon and Security Health plan say they saved over $2.5 million, $2.3 million, and $1 million, respectively. Tufts Health Plan says they saved $1.90 for every dollar spent.

Other points known but worth repeating:

Features of successful care management include appropriate patient selection, person-to-person outreach, credentialed professionals, teaming, coaching on self-management, family involvement and access to community-based programs.

Embedding care managers in the primary care sites is worthwhile not only because face-to-face patient care has more of an impact, but because the physicians will benefit from the consultations, participation in "huddles" and discussion of the treatment plans. That also leads to a greater level of trust between the docs and the nurses.

There's better buy-in if the care managers are viewed by enrollees as an extension of the physicians, not the sponsoring insurers. 

Technology is important: effective care managers are made more effective by electronic records, telemonitoring, decision support, work-flow aids and video/mobile communication.

 The backbone of care management is made up of generalist nurses who are simultaneously comfortable with multiple conditions such as, for example COPD, mental illness and diabetes.  That being said, there is a role for focused nurse support for patients with special needs, such as hospice, transplant or bariatric surgery.

An abundance of data support is only the beginning because the reports will need to be tailored to the physicians' clinical needs  and communication preferences.  They also have to be paired with regular meetings that promote best practices and solicit feedback.

When care management is first rolled out, physicians will first suspect this is another managed care ruse, assume it's a fast track to prior authorization or try to "downjob" clinical duties to the nurses that are outside of their scope of practice.  It will take many months and much collaboration to sort out turf issues, control, office space, and offering care management to some but not all patients.

What Can Martial Arts Teach Us About the Health Reform Debate

Despite years of training, the weakling Disease Management Care Blog was never able to prevail in martial arts tournament sparring.  While it might score some points in the early rounds, coming up against a six foot plus 220 lb guy with a kick able to reach Toronto was usually an exercise in Tae Kwon Do humility.

Despite the certainty of defeat, how would the DMCB deal with such superior adversaries? 

One survival technique was to to reduce its profile by standing obliquely sideways.  Both arms were kept up with fists poised on either side of the face and with both elbows on either side of the abdomen.  Since tournament points could only be scored from the waist up, the DMCB found it could block most strikes with minimum arm movement of just a few inches.  Then the DMCB simply waited for Toronto to attack.  Assuming the block was successful, the DMCB would then quickly and sneakily move in while the opponent was pulling back its punch or kick.  That's when he was most vulnerable.

This technique of blocking and then striking on the rebound is not only on ample display in televised cage fighting, but in the sparring over health reform. Whether its modifying the ACA, reforming Medicare or fixing the SGR, the playbook is the same: simply sit tight, await your opponent's proposal and then strike back immediately with a mix of rhetoric, partisanship and invective.

Unfortunately for our Republic, martial arts also teaches us that while that approach may in aid in the short-term survival of weaklings, it's ultimately not a strategy for winners.  The DMCB never got a trophy by hunkering down, and that sparring technique will not create the kinds of thoughtful solutions that can overcome Medicare's cost spiral or the Affordable Care Act's shortcomings.

What wins is initiative, innovation and risk-taking in an aggressive series of proactive moves.  Say what you like about progressive Obamacare or the conservative Ryan Plan, their champions went on the offensive.  That skill not only wins tournaments, it ultimately wins in politics.

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