Why U.S. Treasury Ratings Matter To Health Insurers

Even as the Washington D.C suzerains try to demonstrate that they are capable of governance by hammering out a last minute budget compromise deal, there's still a likelihood that U.S. Treasurys could still eventually get "downgraded" by those murky rating agencies. 

If so, what's the big deal for current Treasury holders?  The Administration has made it clear that the nation's creditors will get their interest payments no matter what, even if means withholding payments for the hospitals that are caring for next year's Democratic voters.  Interest rates on future Treasurys may go up but that should be tolerable.  All is well, right?

Alas, notes the Disease Management Care Blog, it's not so simple.  That's because current Treasurys are bought, sold and therefore "priced" in a circulating secondary market.  A downgrade would make those existing Treasury's appear more risky, which could drive their secondary market price down.

For commercial insurers, including health insurers, this could turn out to be a big deal.  Much to the chagrin of liberal politicians and populists, health insurers need to keep reserves (the money held to pay future obligations) and a surplus (a financial cushion, just in case the reserves fall short).  Instead of just putting that all that money in a bank, insurers invest it in interest bearing vehicles and that includes Treasurys.  With a downgrade, their price, i.e. value, could go down, which, if pegged at a market price, could make it appear that the insurers' reserves and surplus have suddenly grown smaller. 

With an announcement of a downgrade, millions of dollars of insurer money in reserves and surplus could evaporate. That would make it appear they are at greater risk of not being able to meet their obligations.

It gets worse.  As Treasury prices go down, other commercial bond prices will follow. Treasurys' lower prices will ironically make the good faith and credit of the U.S. government comparatively more attractive for secondary market investors worldwide.  Holders of other types of bonds who want to sell will need to compete by lowering their prices also.  As other bonds go down in price, the value of the insurers' investment portfolios will contract further.

And that could mean that health insurers will have less room to move.  Since they already are a low margin business (latest number is 4.3%), the DMCB thinks a Treasury downgrade could be one more reason for commerical health insurers to not moderate their prices in the face of relentless health care cost inflation.

The DMCB offers some other asides:

An obviously overnourished New Jersey Governor Christie was recently hospitalized with asthma.  It turns out obesity is a distinct risk factor.  Hopefully the big man will be recruited into one of the New Jersey State employees' disease management programs (check out page 7 here) that is paired with a weight loss program.  In most programs, dealing with co-morbidities is standard fare.

To the non-surprise of family and friends alike, Amy Winehouse died on July 23.  Preliminary autopsy findings showed nothing amiss and toxicology is pending.  Assuming drugs were somehow involved, its no accident that it occurred at home and on a weekend day, which are a favorite place and time for recreational drug abusers.  If it was cocaine, the typical cause of death is cardiac arrest; it's not unusual for autopsies to be normal. if it was ecstasy, the cause of death is delirium followed by cardiovascular collapse.

Helping the ACO Boat Float

It’s a perfect storm. Hurricane Healthcarecosts has combined with Typhoon BudgetDeficit and a monster Category 6 is headed straight for Washington DC.  The helm of the USS America is being manned by a petulant President, a truculent Congress, a partisan media and a divided electorate.  Surrounded by political rogue waves, sinking approval ratings and zero visibility, it is little wonder, then, that politicians, their appointees and friends in academia continue to hold up Accountable Care Organizations (ACOs) as some sort of Triple Aim lifeboat that will save the health system from going down faster than 10 Year Treasurys.

Spooked by the possibility of drowning in a leaky ACO craft with all the seaworthiness of a “unicorn,” many provider groups have expressed reluctance to clamber aboard.  Stung by the reaction of the provider community to its ACO proposed rule, CMS is now considering changes.  While the Disease Management Care Blog looks forward to seeing how this turns out, academic economists Meredith Rosenthal, David M. Cutler, and Judith Feder are using the New England Journal of Medicine to offer up some suggestions to CMS on how to make this ACO boat float.

Here’s a quick summary for busy DMCB readers, some of whom work at CMS.

The authors point out that the underlying economics of an ACO is made up of a two-sided “risk corridor” that has strong incentives to control costs.  That could lead to problems.  Unseemly upside success could provoke a 1990’s style patient backlash, while the downside could lead to provider group bankruptcies.  Yet, the good news is both scenarios are unlikely, thanks to a strong pay-for-performance component, no network patient lock-ins and caps on both the upside as well as downside risk.  What’s more, there are commercial insurer ACO pilots underway that also have two-sided risk.  As a result, they think CMS should hang tough and keep the two-sided model in the final regulations. 

Given the fear of providers that they could end up being shipwrecked by financial losses, what do Drs. Rosenthal, Cutler and Feder recommend for the new ACO regs?

1. Offer a complement of financial incentives to the early ACO adopters, such as a greater share of any savings or loans that could be used to defray the considerable costs of starting up an ACO.

2. Lower or eliminate the 2% to 3.9% “minimum savings threshold” that has to be achieved before there are any shared savings.

3. Reduce some of the costly documentation and data collection requirements.

4. Reconsider the option of “prospective assignment,” since it would reduce uncertainty and allow ACOs to engage in patient outreach.

While the DMCB has seen these recommendations elsewhere, it’s still helpful that the Journal has consolidated the more important ones in one handy reference.  When the final ACO rule comes out, the DMCB will be looking for compromise in these four areas of savings, thresholds, measurement and assignment. 

Then it will be a matter of seeing how the providers react to the prospect of a small boat that purports to solve some big problems.

The Latest Cavalcade of Risk Is Up!

Want to take a journey of personal finance?  For the Disease Management Care Blog, it's been more of a expedition, but that isn't stopping it from pointing out that a blog by that name is hosting the latest Cavalcade of Risk.  This is a summary posting with links of the best writing from the web on the latest wrinkles in business risk.  You can find a "risky sports" themed edition here.

Four Reasons Why “Loss Aversion” Could Be An Effective Weight Loss Approach in Work Site Wellness Programs Targeting Obesity

Who's Going To Pay For This?

Given the economic costs associated with obesity, should we pay persons to lose weight in the hope that this will result in a long-term return on investment?  While that may be a good idea, the Disease Management Care Blog doubts commercial or government insurers will ever pay people to diet.

Yet, that doesn’t mean that we can't leverage “behavioral economics” in wellness programs.  That brings the DMCB to this interesting gem of a study by Leslie John and colleagues that was reported in the Journal of General Internal Medicine titled “Financial Incentives for Extended Weight Loss: A Randomized Controlled Trial.”  Even though the results were ultimately disappointing, the approach that was used may have considerable merit.
 
The DMCB explains.

"Loss aversion" is the well-known tendency of persons to attach greater value to economic losses than gains.  The authors capitalized on this by testing the impact of a “deposit contract” on 66 obese Philadelphia VA patients who put their own money at risk.  This was a 32 week (24 weeks of weight loss followed by an 8 week maintenance phase) trial that randomly allocated participants to one of three treatment arms:

1) a contract in which participants contributed up to $3 per day for a month to a fund that was matched 1:1 by the researchers.  The participants had to report their weight on a daily basis by telephone.  They were given credit for the day if their weight was equal to or less than a daily weight loss goal that was configured to ultimately result in a loss of 24 pounds in 24 weeks.  After each call, participants were given feedback via telephone text message.  There was a weigh-in at the end of each month.  If the weight target for the month was not met, all the money was forfeited.  The 24 weeks was followed by an 8 week period of weight maintenance that was described to the participants as “maintenance of weight loss period”

2) the same contract but there was no description of the 8 week period as “maintenance” and

3) a concurrent control group.
 
22 persons were assigned to each of the three treatment arms.  Between 18 to 19 of each of the three groups were male.  The the BMI ranged between 34 and 35 with an average weight of around 230 lbs. 
There was no difference in the weight loss at 32 weeks for the two treatment arms of the study, with a mean weight loss of 9.7 and 7.8 lbs, respectively.  During the same period, however, the control patients only lost 1.2 lbs.  Three months into the study, 50% of the intervention patients who were not meeting target chose to continue contributions even as they were falling behind.  Once the program was over, persons returned 36 weeks later for a final weigh-in and most regained their weight.  The forfeited money was evenly distributed to participants that had lost 20 or more lbs. during the study.

As the DMCB said, this was a disappointing study.  Yet, the DMCB wonders if this approach couldn’t be successfully adapted to a typical employer-sponsored obesity wellness program. 

Here’s four reasons why:

1) One of many building blocks: there may be something to the use of behavioral economics in modern psychological approaches to behavior change.  While the purpose of this classic randomized clinical trial was to assess the impact of a single discreet financial incentive, wellness program architects understand that interventions such as this can be combined with others, resulting in a synergistic approach that is greater than the sum of its parts.  Therefore, while it doesn’t seem to work as a stand-alone program at the Philadelphia VA, it could work as a program component at a worksite wellness initiative.

2) Show me the money: employers are constantly looking for approaches in which employees have “skin in the game.”  The idea that persons would put up their own money on behalf of their own wellness is a compelling concept that should gain the approval of the flintiest hard-nosed CEO.  In fact, it appears there is a good chance this approach could actually net some money.  The DMCB says give it to charity.

3) You, yes you, can plan, execute, evaluate and adjust this: the infrastructure necessary to support an intervention such as this is well within reach of employers, who could use standard payroll deductions, employer matching, networked workplace weight scales and corporate intranet supported feedback.  They also have the data systems that could be used to support an observational data base or a quasi-experimental study to assess whether the program is meaningfully successful.

4) Part of the menu (no pun intended): Last but not least, the DMCB doesn’t think there is any single approach to weight loss.  Some persons may have a psychological profile that makes them better suited to "loss aversion" as a weight loss strategy.  Perhaps this could be measured using a health risk assessment.  By offering this side by side on a targeted basis along with other weight loss program options, the DMCB thinks an employer could achieve even greater success than with any single “one size fits all” strategy.

Seven Reasons Why "Data" Is Not Enough To Change Physician Behavior

Thie Disease Management Care Blog offers this new insight from a physician leader who was in the "ground floor" of the formation of a very large clinic in California.  Think that "information" is all that is needed to enable physicians to improve quality, reduce costs and make the patient experience of care better?

Think again....

As a physician leader who has been instrumental in founding a large group in California, I can assure DMCB readers that “information” is necessary but far from sufficient to change physician behavior. 

The reasons are as follows:

1. Doctors are uncomfortable with data that are cloaked as supporting “appropriate care” when they are really intended to reduce costs.  While the intent may be to limit or improve underutilization, correct overutilization, prevent fraud, or reduce variation, this has little meaning to docs in the course of day-to-day care with patients who need care and need it now.

2.  Thanks to ingrained physician culture, it can takes decades to align docs’ thought process on the kind of “group think” necessary to benefit patients and the health system.

3. Information must be paired with strong committed physician leadership.  In my experience, that is typically lacking and, as an aside, it remains to be seen if ACOs will recognize its critical importance.

4.   Powerful, robust, usable, stable information technology must transform to data in ways that enable coordinated care and some decision support at the point of care.  Data doesn't equal insight.  We just ain't there yet.

5. Good information management is starved for capital.  Most physicians don't have access to it and, even if they did, are not willing to risk any losses for first 3-5 years of any implementation.

6.  The data support for robust care coordination infrastructure doesn't develop overnight.  It took ten years for me to develop thanks to countless small but accumulating delays.  Some health care systems haven't even started yet.

7.  In my estimation, disease and care management information systems are not mature enough to capture a long term return on investment.  It can take years before unit costs and trends can reach a point where savings can truly be measured.

Usual Telephonic Outreach To Get Patients To Change Their Minds About Refusing Preventive Services Doesn't Work

Pick up the phone, will ya?

It's a no brainer, isn't it?  Patients who don't submit to being immunized, mammogramed, pap'd, colonscopied, blood-worked or pricked, poked or imaged by other inconvenient, uncomfortable and icky preventive tests only need to be "educated."  And once they are enlightened, the average person will stampede toward their recommended testings faster than legislators going to the White House for some serious budget scolding, right?

Not so fast.  Stephen Persell and colleagues at Northwestern University culled 407 patients with refusals for 520 recommended preventive services from a large internal medicine clinic in Chicago, Illinois.  In this particular practice, physicians were committed to promoting prevention among their patients and, what's more, they recorded when patients said "no."  Unless the physician refused permission or there was an active medical or psychosocial reason not to, a case manager telephoned (with up to three attempts) the 407 refusniks with some added "education," helped remove any potential barriers, arranged additional referrals if necessary and, if it would help, got the doctor re-involved.

And six months later, what happened?  19% of the patients were not called based on what was written in the medical record, 11% of the patients were not called based on physician feedback and only 11% of the patients answered the phone. Compared to a parallel control group of refusniks who were not called, there was no statistically significant improvement in the receipt of preventive services: 6.1% of intervention group cooperated versus 4.8% in the control group.  While the authors didn't mention it, caller ID probably helped patients to not answer the phone.

While the study may have been statistically hobbled by a low number of observations (making any conclusions about the lack of statistical significance less trustworthy) the authors concluded that one-on-one educational outreach may not sufficient to overcome patient refusals for preventive services.  The DMCB, based on its own professional experience agrees: tracking persons down outside the clinic can be difficult and if patients are willing to say "no" to their doctor, it's unlikely that they'll say "yes" to someone else.

This speaks to the possibility that in any population, there is going to be a percent that refuse preventive services and that there is little that physicians can ultimately do about it.  This has implications for the assumptions that underlie many quality reporting and provider pay-for performance programs.

This also has implications for the population health and disease management service providers.  While this study used a "nonclinician case manager" to provide the education, the DMCB has to wonder if the intervention was hobbled by not using state-of-the-art "engagement" strategies that are configured for behavior change that delivered by credentialed nurse health professionals.  If correct, it's possible that a commercial prevention program would have compared more favorably to the "usual care" telephonic outreach described by Northwestern. 

That's another research study for another day.

Include Information on Disease Management and the Patient Centered Medical Home (PCMH) In Health Insurance Exchanges (HIEs)

Hmm... which insurance plan...?

According to Kaiser Health News, CMS deputy administrator Steve Larson has confirmed what regular Disease Management Care Blog readers have long known.

Web-based health insurance exchanges (HIE) (to be used by consumers to buy health insurance on-line) will have to reconcile lots of complicated enrollment and eligibility information using multiple insurer and government databases and, as a result, it's unlikely that they'll be up and running by the 2014 deadline.  What's more, there doesn't appear to be anything in the proposed regulations to keep the Feds from intruding into the States' traditionally independent regulation of health insurance by unilaterally "delisting" any health insurer that fails to meet HHS' expectations.  The DMCB suspects Uncle Sam can ultimately get away with that because Federal money is being used to subsidize the insurance premiums for low income individuals who use the HIEs.

But what about "disease management?" asks the DMCB.  As it understands it, the Affordable Care Act only permits the listing of "qualified health plans" (QHPs) in state exchanges.  The benefits and coverage levels that must be in place in order for an insurer to meet that "qualified" moniker is currently under development (and, by the way, attracting its own share of controversy).  The DMCB hopes that the Secretary of HHS will take advantage of the ACA's language that gives the Secretary of HHS latitude in setting "other benefits" in QHPs as an opportunity to include "disease" or "population health management" in the mix.

Even if the final regulations don't include disease management as a qualified benefit, that doesn't mean that the Feds or the States can't ask qualified health plans to also include consumer information on whether they offer disease management programs (along with the chronic conditions that are addressed) and what percent of their primary care network are covered by patient centered medical homes.

This is an opportune time to bring this up.  While States and the Feds are scrambling to get the exchanges up and running, having two additional fields on line that describe the depth of care management coverage is a no brainer.  Who could possibly disagree with the idea that consumers need information to better help them access high quality primary care and manage chronic conditions?

Never Mind Health Services Research, How About Health Delivery Research?

Imagine the following scenario:

A patient with a chronic condition is not being treated with a potentially life-extending medication.  In response, the patient's physician's office is telephoned by a nurse with a friendly alert.  Someone at the office takes the message and promises to tell the doctor and...... nothing happens.

Sound familiar?

No one who has worked in the clinical side of population health and disease management industry would be surprised by this anecdote.  The reasons for such lapses are myriad, including overworked and distracted physicians, intruding clinical priorities, lack of information, incomplete information transfers and patient misidentification.  Yet, while the Disease Management Care Blog and colleagues think they know what the problem is, they have no idea on how to consistently overcome it.  Does it take more money?  Patient engagement?  Something else?

Enter this timely article by Drs. Pronovost and Goeschel writing in the Commentary section of the current issue of JAMA.  Noting that biomedical research has been focused for too long on biomedical advances, they argue that it's time to start asking questions about achieving health care outcomes.  In other words, we need "health delivery research," so that we can figure out why patients only receive about half of all recommended therapies.

Health delivery research finds the links between classic clinical research and improved health by determining how barriers can be removed, how teamwork can be enhanced, what feedback should be used and how behaviors can be changed.  It determines the best outcome that should be achieved and - unlike classic "prospective" hypothesis testing - works backwards to find the elements that achieve success.

According to the authors, "HDR" has must have two characteristics to succeed:

1) It has to occur side by side with the ongoing practice of medicine,

and

2) it has to involve social scientists and systems engineers in the research "mix."

"Hear hear!" says the DMCB.  This is precisely the kind of research that has been sponsored by the population health management service providers.  Yet, there is only so much they can do.  The notion that HDR should become a national priority is a wonderful idea.  Hopefully policy makers, foundations and the many agencies overseeing the Fed's expanded health research funding are paying attention.

The Latest Health Wonk Review Is Up!

... and this one is a summer sizzler thanks to Julie Ferguson of WorkersCompInsider!  Check out the best and the brightest of the latest health care reform wonkiness from around the web.

More On The Impact of Health Information Technology on Medical Practice: Errors of Ommission

Technology meets reality

From time to time, the Disease Management Care Blog is honored to provide a guest post.  The insights from an anonymous colleague below provide some important insights on the pernicious impact of health information technology on the       day-to-day practice of real medicine, involving real patients being taken care of by real doctors.

It doesn't paint a pretty picture.

I am a rural Family Physician who has been in solo practice for more than 22 years.  I am neither a technophobe nor an information technology Luddite.  I have been using electronic prescribing for over 6 years and am in the market for an EHR that is net-based, scalable, interoperable and linked to a nationwide patient database.

While I wait, over the years I am seeing more and more patient care that is less co-ordinated and even thwarted by the very health information technology (HIT) that is supposed to increase efficiency. In my opinion, this is leading to decreased information transfer that is wasting precious time and putting patients at risk with errors of omission.

I will give anecdotal and real examples of HIT run amok that I suspect are more common than generally appreciated.  Alarmed by the lack of awareness of the potential frequency of these errors, I am writing this hoping that the blogosphere can somehow counter the momentum of an all-powerful HIT cerebrosphere.

1.     e-Prescribing (ERX):  While mandated alerts about potential drug interactions in this software is often life-saving, it can also be life impairing.  There are two reasons for this:  1) at point of care, the warnings are just too darn sensitive and I’m being conditioned to ignore 90 percent of them.  I am afraid that this will cause me to click the “ignore” pop-up at the wrong time.  For instance, doxycycline and Dilantin have an interaction and a prescription of one in the presence in the other always prompts a warning.  When I researched this, I found the plasma concentration of doxycycline is decreased by a clinically negligible amount.   2) at the pharmacy window, the warnings can override physician judgment. A colleague of mine described to me how he prescribed a fluoroquinolone antibiotic to a patient on Coumadin and, aware that there was an interaction,  ordered the appropriate follow up testing and dosage modifications.  The pharmacist not only refused to fill the prescription,  they also did not notify him.  Instead, he asked the patient to call the doctor.  Two days later the patient was admitted to an ICU with life-threatening sepsis.  In both cases, needed prescriptions were omitted.

2.     Electronic Health Records (EHR):  In the old days, when I received a consultant’s letter, (unless it was an internist with OCD who was so thorough, he put a 3rd year medical student to shame) I could always count on an easy-to-read last paragraph that clearly stated the impression, plan, and suggestions.  What’s more, if there was something really important, the consultant often gave me a call.  Now I am typically faxed a 15 page electronic note in various and sundry fonts packed with 2 years of medical detritus from previous notes and labs.  I often cannot find an impression or plan.  This is a time consuming and opaque breeding ground for clinical errors of omission.

3.     Centralized Scheduling:  Instead of being able to directly call a consultant’s office for an urgent patient referral, I am now obliged to use centralized computerized scheduling that is basically transforming them into big box specialty centers.  It seems that most of the smaller independent cardiologists, gastroenterologists, orthopedists, vascular surgeons and other specialists have now banded together in large group practices protected by a phalanx of  centralized schedulers, often at an off-site call center.  Now instead of “send the patient right down and we’ll squeeze them in”, it becomes “fax the pertinent records to our intake coordinator and we will call the patient back in 48 hours to schedule an appropriate appointment”.  Aside from the fact, that I now have to call the patient in 48 hours to see if they got an appointment, I also often have to send the patient with suspected appendicitis or acute renal failure to an emergency room .  Last but not least, these systems cannot handle patient-specific nuances.  For example, a patient who may need a carotid stent may not be scheduled with the specialist expert in that procedure.  In other words, poorly functioning scheduling systems can lead to important lapses in connecting the right patient to the right doctor at the right time.
.
4.     Radiology Precertifications:  Last week I saw a patient with severe flank pain and bloody urine.  Thinking that a kidney stone was the most likely diagnosis, I wanted to order a CT scan to confirm an obvious diagnosis.  After going through a web-based electronic precertification process, I was informed that an answer to my request would be made available in 24 hours.  Of course the hospital refused to schedule the test without an approval number.  My office notified me of the situation and, after additional time consuming calls, I was able to force an expedited review by a live on-call person.  In this instance, a precertification system led to an unnecessary delay in an important test.

5.     Offsite Radiology readings:  Last week I ordered a mammogram and a CT of the pelvis on two different patients .  The mammogram was performed at the local hospital, the radiologist took the time to examine the patient and he called me with the results. That patient in question is now scheduled for a biopsy.  On the same day I sent a woman in for a CT of a very enlarged inguinal lymph node.  This was done at the same hospital but was read by a radiology group across the state.  I still have not received the report but I will be going to the office today  (Sunday) to check the fax machine.  This is an example of a delay in getting the results of an important test.
 
6.     Offsite cardiology studies:  Whenever I can, I try to send my stress tests to the local cardiologist because, if there is an abnormality, I am called and if necessary they will even (gasp) see them for an urgent formal consult after the exam. In contrast, the large institutions often act as technicians only.  It has been more than once that I see a patient 2 weeks after a stress test, call medical records to get a report, and find an abnormal result.  Luckily, there have been no fatalities to date, technically no error was made, but I also consider this an error of omission.

In effect, what I am seeing is not an increase of medical errors.  In fact every prescription, test and consultation is of the same if not better quality.  However, the workflow and communication supporting them seem are being hindered by the HIT. 

This may seem counterintuitive to the administrative, policy, informatics, politicians and the academic types but it is my practicing opinion, forged in the real world.

Image from Wikipedia

The 100 Year Shift? Part 3 On Why There Is Less To Physician-Hospital Integration Than Meets The Eye

What's ahead?

The third in a series of provocative essays on the emerging alignment of health insurers and physicians has been posted at Vince Kuraitis' e-CareManagement blog. 

In it, we review the transition of hospitals from "revenue" to risk-bearing "cost" centers and speculate on how physicians are likely to react.  While perceptive Disease Management Care Blog readers may ask about the recent spate of physician practice purchases by hospitals as well as the looming specter of "accountable care organizations," Vince and the DMCB have eight reasons why hospital-physician marriages have a lot more Schwarzenegger and a lot less steadfastness than generally appreciated.

Is the DMCB's prognostications full of hot air?  A flight of fancy?  Wishful thinking?  Read for yourself and decide.  Comments remain always welcome.

Image from Wikipedia

Shared Savings Accountable Care Organization Summer Humor

"So the ACO says to the bartender....."

It's summer, things are slow and picnics, parties and other outside gatherings can struggle from the oppressive heat.  You've already talked about Oprah never seeming to go away and Pittsburgh's improbable standings in the NL Central Division.  Well, if there are some health wonks about, why not crack open another round of sudsy beverages and jazz things up with some insider Shared Savings ACO humor? 

This won't win you a gig on Comedy Central but every little bit helps... sometimes.

Q: Why did the ACO chicken cross the road?
A: To look less like a unicorn!

Q: Whats the difference between an ACO and a HMO?
A: An ACO is just like a HMO but with more government oversight.  It will have the discipline of the Securities and Exchange Commission mixed with IRS-style responsiveness, all brought to you courtesy of CMS.

Q:  What's the nicest thing a VP for Medical Affairs could spin about ACOs to a room full of skeptical doctors?
A:  "It's not entirely without merit, but close."

Q: Do ACOs have a tagline yet?
A: No, but one that's been recommended is: "ACOs... where healthcare innovation transforms to imagination!"

Q: What is the difference between an ACO and a bank robbery?
A: The bank robbery is illegal.

Q: What is the difference between an ACO and quicksand?
A: People don't go into quicksand on purpose.

Q: Why is it called an "ACO?"
A: To honor the folks who thought of it: academics, consultants and Obama.

Image from Wikipedia.

What Can Highmark's Merger with West Penn Allegheny Teach Us About the 100 Year Shift?

The ever self-promoting Disease Management Care Blog is quoted on the July 17 front page of Pittsburgh's premier newspaper, the Post Gazette.  In it, the DMCB holds forth about the Highmark Blue Cross Blue Shield merger with the West Penn Allegheny Hospital. 

Readers may recall prior DMCB posts (here and here) predicting the unwinding of physician-hospital alignments and the corresponding rise of physician-insurer chumminess.  While the Highmark to-do is a hospital-insurer merger, the DMCB speculates that Highmark's circumstances are skewed by a) West Penn's financial travails and b) Highmark's business need to have a low-cost inpatient alternative to the behemoth University of Pittsburgh Medical Center (UPMC) monopsony. 

The DMCB won't let a few facts get in a the way of a good generalization. It discerns the same underlying dynamic at work: consternation over rising inpatient-related costs and recognition that physicians are the key to achieving value. Look to Highmark supporting West Penn as a low-cost alternative to UPMC while it tries to curry favor and build bridges with the hospital's medical staff.

More On Electronic Health Record Prescribing Errors

In a prior post, the Disease Management Care Blog described the results of a study that demonstrated that electronic health records (EHRs) are not necessarily synonymous with medication safety.  It's finally gotten its hands on the manuscript and looked at the details.

Copies of 3898 electronically faxed prescriptions from multiple outpatient clinics to a single pharmacy chain operating in three states (31% Florida, 22% Arizona and the remainder Massachusetts) from a 4 week period were reviewed. The researchers were also aware of the EHR system being used to fax the 'scripts.   A two member clinician panel reviewed the all the prescriptions for errors and, if any were found, a second two-member clinician panel confirmed them and identified the type of error.

Types of errors included omission of - or an unclear description -  of the treatment duration, dose, frequency or route, as well as a mismatch between the directions, dose and written frequency.  Examples included vague directions (like "take as directed"), conflicts (like "take 200 mg. twice a day" appearing with "take 400 twice a day for one day, then 200 mg twice a day"), and doses that were just plain dangerous (high levels of narcotics mixed with potentially toxic doses of acetaminophen)

48 copies were illegible, leaving 3850 available for study. 452 or 12% had errors and 165, or about 4% of the total, were classified as having a potential for patient harm. Nothing immediately life-threatening was found. Some EHRs appeared to have a higher rates of errors than others, with error rates ranging from approximately 5% to 37%.  Only one system had zero prescriptions with a potential for patient harm.

The authors point to a considerable body of literature that document that these kinds of errors seem to be equally common among written and electronic prescriptions.  What was surprising however, is that some EHRs seemed to have more than their fair share or errors.

The authors recommended that EHRs have "forcing" functions (nothing happens unless all the fields are completed), electronic decision support back-up ("are you sure you want to do this?") and calculators (that reconcile the number of pills prescribed with the instructions for use).  As for the physicians, the authors recommend that docs carefully scrutinize the prescribing system when they select an EHR.
 
The DMCB is not surprised by the results of this robuststudy. This (and the other studies quoted by the authors) should make the EHR weenies think again about their insistence that computers will fix all that ails health care.  As EHRs become more prevalent in health care settings, it may be appropriate to start directing quality (QI) analyses. Last but not least, physicians need to closely examine the "hold harmless" clauses in their EHR vendor contracts.

The Latest Cavalcade of Risk is Up

The well written and cryptically named Notwithstanding  Blog is hosting the latest, flag-festooned and independently minded Cavalcade of Risk.  Your only risk in not checking it out is not being up to date on the latest musings of some very smart people on business, personal and - a DMCB favorite - health insurance risk.

Enjoy!

Some #AskObama Health Reform Tweets That May Not Have Gotten Past The Town Hall Filter

"Well, according to the DMCB...."

Disease Management Care Blog readers may recall that the President held a July 6 non-event using the hashtag "#AskObama."  The DMCB salutes him for using social media to further enrich our democracy, but is disappointed that this corner of twitosphere was somewhat stage-managed by a filtering algorithm.

That inspired the DMCB (which can also be followed on Twitter, by the way) to speculate about some of the healthreform-minded tweets that may have been prevented from making their way to the President:

#Golf, Basketball do not for #FITNESS make. Will you commit to #EBM-based 150 minutes/week w/ 2 days muscle strengthening?

Can you launch a pilotless drone to find me a PCP?

If #MichelleObama doesn't like you smelling of #tobacco, call us: we can help!

Functioning #ACO spotted on HBO #Trueblood in Faerieland! Evil Republicans threw light grenades! 

Is #WHITEHOUSE aware that #HEALTHREFORM advisor Nancy DeParle has never personally taken care of patients?

Please, oh please tell Sebelius to cover disease management services, please please please?

Which was the right answer from that past town healthreform hall meeting: the blue pill or the red pill?

Next stop for health insurance exchanges: online resource to help CIA find Taliban terrorists?

Suggestion: #WH announces that anytime says #PREVENTION and "bend the cost curve" in same sentence that somewhere a kitten dies?

#CMS Adminstrator Berwick: Driving the #MEDICARE bus or thrown under it?

U.S #HEALTHCARE costs and #LadyGaga popularity tracking together: just a coincidence? Explain.

How about #MEDICAID reimbursing for #PHYSICIAN tweets? 

If I throw my awful #EHR out the window and police cuff me, will you invite for Rose Garden brewskis?

"Metabias," the Limits of Evidence Based Medicine and Implications for Disease Management

The font of all wisdom?

It was the Disease Management Care Blog that alerted readers to the term "surveillance bias."  The ever-alert DMCB has found another catch phrase that nicely sums up another limitation of evidence-based medicine (EBM). 

This one is "metabias."

Recall that EBM is the practice of applying the high quality science of peer-reviewed medical literature to day-to-day clinical practice.  Knowing the details of the study populations, the absolute risk improvement, sample sizes and possible biases reported in prestigious medical journals should enable scientist-physicians to divine the "gold standard" of "Level 1" evidence for the betterment of their patients.  The young DMCB grew up on this.  It remembers the hospital "roundsmanship" of debating the latest published clinical trial results before entering patient rooms, much like rabbis debating the finer details of the Talmud.  Heady stuff.

Yet, EBM has had more than its fair share of problems.  Add one more, courtesy of Stephen Goodman and Kay Dickersin, writing in the Annals of Internal Medicine.  They point out that it is not unusual for physicians to "group" all of the published studies about a particular condition and pool the results, in what is commonly referred to as a "meta-analysis."  If, after summing things up, one treatment appears to result in better outcomes versus another, physicians can be more confident about the merits of the treatment, right?

Maybe not.  It turns out that one example of metabias is a "publication" bias.  That describes the phenomenon that authors are more likely to submit and medical journals are more likely to report only "positive" studies.  Contrarian negative studies typically do not see the light of day. Think of it as selective publication.

A new metabias discussed by the authors is the finding that positive studies from single institutions generally show a larger effect of treatment than studies performed in multiple institutions.  One explanation is that solo scientist-investigators may not be subject to the checks and balances of a third party and be unconsciously tilting the execution of the study in a direction that they want. 

In other words, all those prospective randomized clinical trials from single academic institutions may not be much of a gold standard after all. 

No kidding says Alison Stuebe, writing in the July 6 New England Journal.  She was a believer in EBM when she started out, but she quickly found that it didn't quite compare to the wisdom she gained through personal experience. Metabias may be one explanation.

This is important from several perspectives.  The disease and population health management community has long been criticized for the "lack of evidence" that their processes result in greater quality and lower costs.  Maybe the processes for creating that evidence are less robust than generally realized.

Last but not least, the "science" of EBM has a role to play in health care reform, but it is not the answer to all that ails health care.  Much like Dr. Stuebe, we need to be more circumspect about what the medical literature is - and isn't - telling us.

The One Question That Any Board Should Ask Management About Participating As An Accountable Care Organization (ACO)

The minimum knowledge needed to get from Point A to Point B

We've all thought about the "suppose just one" questions.  For example, "suppose" you could only eat "just one" type of meal for the rest of your life, what would it be? (Disease Management Care Blog answer: pizza).  "Suppose" you had "just one" wish granted by an all powerful genie? (Answer: whatever the DMCB spouse would want).  It's not only a useful exercise in behavioral neuroeconomics and "what if" mind gaming, but it also puts things (like pizza and the pervasive influence of the DMCB spouse) into perspective. 

Well, suppose you're on the Board of Trustees or Directors for a hospital or physician provider group and you're at a "go" or "no" meeting that will decide about participating in a risk-bearing Accountable Care Organization type of arrangement.  Imagine that your Management Team, tantalized by the luster of riches, quality and cornering the local market is recommending "go."  They've done their PowerPoint presentation and the lights go up. 

Now "suppose," asks the DMCB, that you have "just one" question to ask. 

What will be that question be?  "Will this eventually lead to full risk bearing?"  Or....."What actuarial methods will be used by CMS to adjust the per member per month claims expense target?" Maybe...."Egads, haven't you read what the DMCB has written about ACOs?"

All excellent questions, but the DMCB has scoured the universe of possible queries and landed on a "just one" recommended question for Board members.  It is.....

"How will the dashboard be set up?"

The concept of a "dashboard" implies exactly what it says: an ongoing, graphic and up-to-the-minute display of the key parameters necessary for the successful operation of a vehicle that are necessary to get you to where you are going.  That dashboard question packs in a lot of issues with a marvelous economy of words, because the answer will tell you if your operations team....

1) Understands the need to have as close to "real time" data as possible, so that they can spot any adverse trends and act on them promptly;

2)  Has selected the handful of lead economic and clinical outcomes that will encompass the end-of-contract financial reconciliations;

3) Is prepared to secure and coordinate data from several sources, such as (for example) the "speedometer" of readmission rates, the "tachometer" of primary care appointment wait times and the "fuel gauge" of diabetes quality measures;

4) Will use a enterprise-wide graphic display of a small number of "lead" metrics so that everyone is on the same page;

5) Understands that actively managing to too many targets is fraught with the risk of data overload;

6) Has thought about securing the assurance from any outside parties (such as insurers) that their data feeds going into the dashboard will be accurate, complete and timely.

7) regularly reads the DMCB.

If you get blank looks to that "just one" question, the next answer should probably not be "go," but "no."

Some Facts About "Pioneer" Accountable Care Organizations

You know its pretty bad when a lead review article in the health reform-friendly journal, Health Affairs, likens the Shared Savings Program's Accountable Care Organization (ACO) model to an Edsel, "widely considered one of the worst cars of all time." 

All well and good, but what author Harris Meyer also did was update the Disease Management Care Blog on a parallel ACO program launched by the CMMS Innovation Center on May 17.

It's been dubbed "Pioneer."

Knowing that DMCB readers may be interested in some background about this "Pioneer" thingy, here's a quick summary of what the DMCB thinks are the more important parts:

Purpose:

This three to five year Pioneer ACO Program is tailored to fast-track health provider organizations that already have care coordination programs up and running to what the Feds believe is the next level: ACO status.  During the first 2 years, the candidate organizations will operate under a shared savings arrangement.  If successful, payments will transition, as the DMCB understands it, to a "population-based payment model" that involves a mix of capitation and fee-for-service reimbursements.

Money:

Payment to the participating ACOs will be based on historically projected and risk and inflation-adjusted per capita  targets. At the end of the various measurement periods, the Pioneer ACOs' claims expenses will be judged against their targets.  To get any money, they will have to be above a 1% threshold.   Once that is achieved, the shared savings will range from 60 to 75% and be capped at 10% of total expenditures.  Downside losses will also be possible. Like the Shared Savings Program, any unmet quality measures (to be defined in the final Shared Savings regulations) will also be used to subtract from the shared payment. CMS promises to provide historically, monthly and quarterly data reports.

Other insurers also have to join in and the number of their patients has to comprise more than 50% of the total. 

Last but not least, much of the payment details are being left intentionally vague so that CMS can be flexible.

Patients:

At least 15,000 Medicare beneficiaries (or, if rural, 5000)  have to be available in order for an organization to participate in Pioneer.  While the default is to assign patients prospectively, the organizations can ask for retrospective assignment.  Patients will not be locked into any network.

In the application process, these ACOs will also need to document how they are prepared to meet the needs and preferences of their patients with "patient centered care."  Patients will notified that they can call an 1-800 number with any concerns.  CMMI promises to analyze utilization data and audit any ACOs with claims patterns that suggest care is being withheld. 

What else?

The Innovations Center hopes 30 programs will eventually participate. If you are interested, it may be too late. Letters of intent were due June 30. The application process closes on August 19. 

A fact sheet is here.

The 100 Year Shift? Part 2 On The Transformation Of Payment From Volume to Value

Can't wait for Part 3!

As promised, the second part of the audacious series  on "The 100 Year Shift" has been posted at Vince Kuraitis'                e-CareManagement Blog.  Co-authored by your Disease Management Care Blog, this latest addition looks at why payment reimbursement for "value" is trumping "volume," how this is driving increased "accountability" (of which ACOs are merely one version) and the looming shake-up of hospitals, physicians and insurers. 

If you accept our logic, it's easier to see why insurers remain quite powerful, hospitals stand to lose the most in the current U.S. deficit reduction negotiations and the physicians may have a shot at reversing the scheduled sustainable growth rate (SGR) cuts.

Part 2 is posted here.

Whether you think this is naive, delusional or the work of buffoons, your interest is appreciated and comments are always welcome.

Parallels Between The Lessons of "Reckless Endangerment" and the Ideological Promotion of the Electronic Health Record

The Disease Management Care Blog is avidly reading the page-turner "Reckless Endangerment."  In it, authors Gretchen Morgenson and Joshua Rosner vividly describe the decade-long assumptions and hubris that fueled a reckless home-ownership ideology.  Convinced that manipulating mortgages and lowering lending standards would promote middle and lower class prosperity, government and parts of the finance industry ultimately created a housing black hole that is still with us today: millions of Americans are not only stuck with property that is "below water," but lingering  "un" and "under" employment that is reaching historical proportions.

While the DMCB understood the vague outlines of what happened, the real insight it has gained from this book is how awful things can happen when a President, both parties in Congress and an entire regulated industry combine to promote semi-public "partnerships."  Despite occasional warnings from some smart economists on the fringes, the "a home for every American" borg sucked caution of the room faster than U.S. Representative Barney Frank could speed-dial his buddies in Fannie Mae.

Which reminds the DMCB of a parallel borg called the electronic health record (EHR). A eerily  similar bipartisan government-industry ideology has somehow decreed that EHRs will increase clinical quality, enhance efficiency, promote safety and reduce costs.  While the downsides of a miscalculation don't come close the magnitude of a "Too Big To Fail" disaster, that doesn't mean we won't be left with a lot of ill-suited and expensive legacy information technology systems that do little to make medical care any better than it already is.

Case in point is this recent publication appearing in JAMIA.  While the DMCB awaits a reprint request so it can dive into the details, the methodology seems simple enough: a "clinician panel" looked at the appropriateness of 3850 consecutive electronic prescriptions forwarded to a large pharmacy chain. They found at least one error in a whopping 11.7%.  While omitted information was the most common mistake, a potential "adverse drug event" accounted for a third of the mistakes.  The authors point out the interesting statistic that an approximate 12% error rate is about the same that's been reported for hand-written prescriptions.

And this is what we're spending our national treasure on?  Egads.

While Americans bemoan partisan gridlock, an allegedly rudderless Presidency, complex regulations and uncooperative private industry, the DMCB is learning to fear its opposite: a confidently wrong Chief Executive backed by an enthusiastic and misinformed Congress that bulldozes its way through economic sectors like the healthcare industry. 

The 100 Year Shift? Introduction and Overview



Coming to an end?

The Disease Management Care Blog is proud to introduce a series of jointly authored postings on the topic of "The 100 Year Shift" that will be hosted by Vince Kuraitis at the e-CareManagement blog.

This series will examine a major shift underway in the hospital-physician-insurer triad.  While hospitals and physicians have been closely affiliated for decades, we suggest that this historically cozy relationship may be coming to an end.  What's more, we brazenly predict that health insurers (yes, insurers) and physicians will find that they have more in common, leading to a significant new alignment between these two entities.

"Hmph!" you say? "No way!" is your reaction?  You think the DMCB has really gone off the deep end this time?  You may be right, but check out the posts and then decide if any of it could be possible.

The first introductory post is here.

A Primer on Motivational Interviewing: The Definition and a Review of the Supporting Science for Disease Management

First, I'll express empathy....

The Disease Management Care Blog typically doesn't don the peer-review swimmies for a jump into the pool of nursing journals, but the title "Motivational Interviewing: A Useful Approach to Improving Cardiovascular Health" was too much to resist.  While "motivational interviewing" is one of those widely quoted catch-phrases that sound good in care management marketing collaterals, what's the science behind the concept and does it really work?

Your handy DMCB investigates by summarizing the article for its thousands of readers.

According to the authors, motivational interviewing (MI) can be defined as "a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence."  Four underling principles of MI are 1) expressing empathy, 2) developing discrepancies between current and desired behaviors, 3) 'rolling' with any client resistance by finding a different way to respond and 4) supporting self-efficacy by building on the client's choosing and carrying out ways of changing. 

It turns out there have been 29 randomized trials that compare MI to usual care, many of which involve substance as well as tobacco abuse, HIV risk behaviors, healthy eating and exercise.  They generally show a positive effect, a dose-response relationship and some evidence that it works even during brief encounters.  That being said, in the area of cardiovascular risk management, the science is still limited by only 6 studies with small sample sizes, varied outcomes, bias, confounding and limited generalizability. 

What's more, we still don't know which elements of MI are essential, which patients are most likely to respond, how it can be made more culturally appropriate, how long it takes to train a health professional (for example, is a one day workshop enough?), how well it addresses underlying patient misconceptions and the best fit in high-volume or fast-paced clinical settings.  It also turns out that there are times when simple advice and nothing more is all that is needed, so MI is not the answer to every patient counseling need.

This was a very helpful review and will be tucked away in the DMCB intelligence files.  It also stands as a good reminder that this corner of disease and population-based care management is still in its infancy and more work needs to be done in better understanding the role of MI.  As population health management continues to evolve, look to the industry to perform additional studies to gain additional insights on how it can be used to drive quality and reduce unnecessary costs. 

Last but not least, the DMCB points out that, based on its reading, MI remains very much a nurse-led intervention: few physicians have the skills or the interest to provide this particular kind of counseling.