Firearm Safety, Florida Law, Guidelines and.... Pools!

A leading health threat?

JAMA has fired off this editorial on the "chilling effect" of a recently passed Florida law that muzzles doctors from talking to patients about home firearm safety.  The law was apparently triggered by policy statements like this that recommend that physicians counsel patients about a leading cause of avoidable death.  Florida's physicians are prohibited from inquiring about firearms and recording it in the medical record.  Health insurers are also prohibited from using that information in the course of underwriting.

The Disease Management Care Blog isn't worried about this intrusion into the doc-patient relationship.  Doctors are notorious for not following guidelines, and the likelihood that a law passed in Tallahassee is going to change physician behavior in Miami is practically nil.  What's more, the wording of the statute is riddled with exceptions and the likelihood that any doc will be prosecuted is zero.  The DMCB thinks this is a cynical sop to gun-toting-voters. The legislators in their smoke-filled salons know it.  Too bad the JAMA editorialist doesn't.

That being said, the DMCB will raise three contrarian points that should give its anti-gun reader-enthusiasts pause:

Physician discrimination: The DMCB is aware of pediatricians who will discharge patients from their practice if the parents refuse to go along with basic immunizations for their children.  While many health care providers would be tempted to agree with that posture, should the same principled logic apply to parents who refuse to acede to the AAP recommendations that "existing guns [should be] no longer present in the environment of children" (see page 892)?  That's exactly what happened in Florida.

Law enforcement discrimination: Privacy breaches involving EHRs are not uncommon. The leak of the personal details of gun-ownership into the public domain could be thorny, especially since law enforcement would be tempted to use that information against persons who are otherwise law abiding.  This is potentially an important privacy issue.

Insurer discrimination: Last but not least, should health insurers be allowed to refuse coverage for persons with firearms in the house?  They have access to the medical record and, knowing that firearms pose extra risks, they might be tempted to to discriminate against gun owners.

Before you say yes to all three forms of discrimination, the DMCB would remind its anti-gun readers that firearms are not the leading cause of death among children in the U.S.  Check out the data from the CDC and you'll get this graphic:

Drownings are a bigger threat.  Guidelines on pool safety state  "parents, caregivers, and pool owners should learn CPR and keep a telephone and equipment approved by the US Coast Guard (eg, life buoys, life jackets, and a reach tool such as a shepherd’s crook) at poolside."  If parents with pools fail to meet these criteria, should 1) docs also discharge them from their practice, 2) should we risk the release of the data into the public domain for used in real estate tax assessments and 3) allow insurers to exclude these persons from coverage? 

Image from Wikipedia

Once Daily Azithromycin in COPD Disease Management To Prevent Emergency Room Visits?

Chronic obstructive pulmonary disease or "COPD" is a chronic lung condition that is almost always caused by years of tobacco abuse.  Once COPD is present, patients are prone to episodic "exacerbations."  These are characterized by  progressively worse coughing, wheezing and shortness of breath over the course of several days.  If the flare is severe enough, it can force people to the emergency room.  The Disease Management Care Blog has treated such patients countless times, often at 2 in the morning. Treatment usually consists of  a mix of antibiotics, glucocorticosteroids and airway-opening inhalants. Patients often have to be hospitalized for several days.

The business case for "COPD disease management" is reducing emergency room visits and the hospitalizations that often follow.  Patients can learn how to spot an evolving exacerbation early, notify their primary care physician and start antibiotics, steroids and inhalers described above while still at home.  The logic is that early intervention can reduce the likelihood of ending up in the emergency room.  In addition, COPD disease management provides tobacco cessation programs for patients who (unbelievably) continue to smoke and also promotes the use of various types of inhalers that can reduce the incidence of exacerbations.

But suppose you could further tweak your COPD disease management program with another care option that could further  prevent exacerbations from happening in the first place?

That's the logic behind the study by Albert et al, titled "Azithromycin for Prevention of Exacerbations of COPD," that was recently published in the New England Journal.  Many DMCB readers are probably already aware that azithromycin is a "macrolide" antibiotic chemically related to erythromycin marketed under the brand name "Zithromax."  It turns out, however, that this drug also has important effects on white cell function and inflammation. That made researchers wonder if azithromycin would benefit a variety of chronic inflammatory-infectious lung diseases, including COPD.

This study went from from March of 2006 to June of 2010.  Persons over age 40 years with a diagnosis of COPD (a history of tobacco use plus confirmatory breathing tests) with either a hospitalization or emergency room visit involving glucocorticosteroids or oxygen were recruited from 17 participating institutions.   1577 persons were screened for participation and 1142 entered the study with 570 assigned to the daily antibiotic at a dose of 250 mg a day every day for one year, while 572 were assigned to a matching placebo. 12 and 13 individuals, respectively dropped out and 32 and 28, respectively, withdrew from the study. 495 and 502 completed the study. 80% of the study subjects were remained on optimal inhaler therapy during the course of the study.

After one year, 317 (57%) of the persons assigned to the antibiotic had had an exacerbation versus 380 (68%) in the placebo group.   Persons on the antibiotic went longer without exacerbations and had fewer of them.  The number needed to treat (NNT) was impressively low at 2.9.  There was no difference in overall side effects (3% vs. 4%) except for a decrease in hearing based on audiogram testing (25% vs. 20%).  There was no difference in death rates from any cause between the two groups. Patients were cultured for the presence of azithromycin-resitant organisms and persons assigned to the drug had a rate of 81% vs. 41% in the placebo group.

An accompanying editorial in the same issue of the Journal endorses the use of daily azithromycin, stating the findings of Alpert et al "tip the scales toward the benefits of azithromycin treatment."

The DMCB's impression?

In addition to all of the other interventions used in disease management for COPD, azithromycin appears to be a once-a-day treatment that can reduce exacerbations that can lead to fewer  emergency room visits.  It's hard to argue with a large randomized clinical trial like this.

The study was limited to patients who had previously experienced a severe exacerbation.  There is no evidence, therefore, that daily azithomycin should be used in patients with milder disease.

Azithromycin can effect hearing and the QT interval on EKG.  It makes sense to get an EKG  and a hearing test before starting the drug.

Patients may be at risk for future infections with azithromycin resistant infections once the year is out.  The risk may be worth it.

Since azithromycin is an antibiotic, patients may need to pay for the drug "out of pocket" or with a pharmacy co-pay.  Patients may be reluctant to do that, but it may still be worth it.

The Uncertain Certainty of Population Health Management Outcomes

So which is it? Alive or dead?

The Disease Management Care Blog is trapped in universe of perpetually shifting probabilities. It knows events may or may not result from multiple overlapping inputs arrayed against a distribution of likely and unlikely events.  Closer scrutiny only generates more shades of grey in a world that forces the DMCB into a dense unsatisfying miasma of cognitive dissonance. Sorting cause from effect from association from randomness (and from occasional miracles) was tough enough when humankind was spearing woolly mammoths by torchlight. No wonder we're debating the merits of early detection of cancer.  Like it or not, ours is a cat-is-BOTH-alive-and-dead "quantum" world.

Little wonder, then, that the DMCB is simply unable to answer the spouse when she asks "if" the "trash" has been taken "outside."

That's why the DMCB sympathizes with authors Suzanne Felt-Lisk and Tricia Higgins when they tackled the potential benefits of population health management (PHM) in an August 2011 Mathematica Issue Brief.  Recall that Mathmatica is a highly regarded policy and research outfit that performs a lot of analyses for the Feds, including (for example) this one.  When they talk, it pays to listen.

Recall that PHM may be thought of as Ver. 2.0 "disease management," newly defined as any "set of interventions designed to improve people's health across the full continuum of care" that includes a full scope of disease management plus preventive services and health promotion," typically on behalf of "an employer, health plan or other purchaser that bears responsibility."  PHM also emphasizes individual patient centeredness and outcomes measures to tailor and constantly adjust the program delivery.

A Mathematica "environmental scan" determined that 68% of purchasers currently and 84% plan to buy PHM services.  Yet, while the future is bright for the PHM industry, "it is not clear whether [these] programs can deliver better health outcomes." 

Two problems that stymied the report's authors are 1)"methods" for improving the health of populations have yet to be "identified" and 2) more has to be done to determine how they will be "fit together."  They noted that while some interventions work (for example, health promotion directed at blood lipid levels), the specifics in terms of programs and participants vary considerably.  As a result, they found that 66% of purchasers of PHM services are skeptical about whether they are getting their money's worth.

Nonetheless, "desirable" features of PHM include 1) integrating it into the benefit, i.e., covering it, 2) using a combination of interventions, 3) offering beneficiaries incentives for participation, 4) individually tailoring the interventions and 5) pursuing NCQA Wellness and Health Promotion accreditation.

So there you have it: a state-of-the-art assessment. While the answer is continued monitoring and evaluation, the decade-old industry is still in its "infancy."  There is uncertainty over outcomes, yet many desirable features.  It's being bought by a majority of insurers who simultaneously doubt its effectiveness.

The DMCB understands Mathematica's pain, especially on Tuesday nights.  That's when the trash may or may not make it outside in time for the morning pick-up.

More On the Storminess of Medicare's Risk Transfer

Hurricane Disease Management Care Blog has made quite a splash with its Health Affairs Blog article that examines Uncle Sam's bipartisan and simultaneously sneaky solution to CMS' bankruptcy.  Its contrarian posting argues that liberal-progressives want to soak the providers with a transfer of under-monetized insurance risk in the form of ACOs, while conservatives want beneficiaries to sop the risk up with under-funded vouchers. 

Other bloggers are surging around the concept.  The Think Progress Health Blog dives into the DMCB's conclusions, while the Incidental Economist pours some additional thoughts on the topic by asking weather better information can make a difference.  In the meantime, the Care and Cost Blog showers the DMCB with admiration by posting the article's content its entirety.  Even Politico makes a mention.  In the meantime, emails from colleagues continue to flood the DMCB with supportive comments. 

Will the DMCB be able to rain in this torrent of self-congratulation?  The DMCB spouse, unable to reverse this indulgent tide, can only respond: "Now I'vreen it all."

Yet, while the DMCB was distracted by weather puns, storms wider than the European continent, 8 hour power outages, chain sawing downed branches and battling wind gusts up to 50 MPH, it still had a chance to ponder the derision that met Michele Bachmann's claim that her Presidency will lead to $2 a gallon gas prices.  "What's the big deal?" asks the DMCB: she's obviously relied on the same economic logic that was responsible for the passage of Mr. Obama's Affordable Care Act.

Natural Language Processing: Implications for Population Health and Disease Management

While the topic of "natural language processing" may seem esoteric and far afield from the science of  population health management (PHM), the Disease Management Care Blog thinks this JAMA article on the topic may be important to the industry.

Briefly, the authors tested an automated "Multi-threaded Clinical Vocabulary Server natural language processor system" to scour the free text (such as progress notes and discharge summaries) of the electronic health records of  a sample of Veterans Affairs patients for evidence of post-operative complications.  Recall that up until now, the only way to measure complications is to pay someone to go through every page of the record or rely on largely self-reported and voluntary "coding" billing systems.  Compared to expert nurse reviewers, the automated natural language processing system in this study correctly identified - depending on the type of post-operative complication - about 60 to 90% of the cases.

This is important to the PHM industry because its care and case managers typically enter their interactions with patients into their own electronic documentation systems using a combination of 1) close-ended and goal-oriented check boxes ("importance of daily self-weighing discussed with client") in combination with free text that documents more open-ended conversations.  While buyers of PHM services pay to have every patient get every intervention all the time and every time, the industry has been criticized for imposing one-size-fits-all care management protocols on its patients.  That's why they force their nurses to use those check-boxes.

While detecting the occurrence of complications following surgery is not the same as measuring the content of patient coaching, the DMCB predicts the technology can be readily adapted to PHM.  When that happens, coaching nurses won't have to put up with as many of those check boxes and be able to focus on having "real" open ended conversations with their clients. Free-text systems will be able to count whether "weighing" was included in the documentation and nurses will be able to focus more on the patient and less on data entry.

That's a good thing.

And by the way, the DMCB thinks it's just a matter of time until the next step: analysis of voice recordings between nurse-coaches and their patients.

The Bipartisan Agreement On How To Fix Medicare

Ever wonder about the logic underlying the science of insurance "risk transfer?" 

The Disease Management Care Blog understands why not, but that didn't stop it from submitting an article to the prestigious Health Affairs blog on the topic.  Titled "Medicare's Looming Risk Transfer," it describes the rationale that undergirds the exchange of money for risk.

"Big deal" you retort?  "Bleh!" you say?  "That's so.... actuarial?"

Fair enough, but the insightful DMCB doesn't stop there.  It then shrewdly points out that when it comes to the Medicare's looming bankruptcy, the political elites from all sides of the political spectrum have ironically agreed on two key points:

1) Congress and CMS are utterly incapable of managing the insurance risk that Uncle Sam accepted in exchange for trillions in payroll taxes and premium payments,

and

2) The solution is to have CMS' "re" transfer its under-monetized risk elsewhere.  The Dems want to transfer (or dump) that risk on providers  in the form of bundling or ACOs, while the GOP wants to repackage (or dump) that risk on beneficiaries in the form of vouchers.

The "triple aim" you thought?  "Innovation?" you believed? "Improving Medicare?" you understood?

Read the Health Affairs blog and think again.

The Latest Cavalcade of Risk Is Up!

This one is ably hosted by insurance lawyer-expert Nina Kallen, who has arrayed the best and the brightest bloggery on the business of risk, including health insurance.  You can scan the summaries and link to a post that catches your eye.  Enjoy!

More On Vermont's Single Payer System, Act 128 and Health Care Price Controls

In response to this pessimistic petulant post on Vermont's health reform initiative, one astute Disease Management Care  Blog reader pointed out that that the Green Mountain State has put a lot of thinking into its single payer proposal.  Can the DMCB seriously dare to question the brainy conclusions of such smart Harvard economists?

Unable to resist, it first looked at Vermont's Act 128.  This authorizes a health reform Commission that is charged with hiring a consultant to present three single payer options to the State Legislature.  Then the DMCB checked out the consultant's report that came out last February.  This is what apparently formed the basis of Dr. Wallack's enthusiastic New England Journal perspective piece on this single payer paradise, this health care haven, this Shangri-La of systemness.

The consultant report is a whopping 184 pages long, so the DMCB rolled up its sleeves, donned its nerdy spectacles and tried to take it all in.  Briefly, the consultant-economists are proposing a payroll tax-funded single-payer system that pays all the claims from all the state's still-independent health care providers.  Basic administrative functions would be put up for bid for management by a 3rd party. The state-run insurance program would provide every legal resident a standard benefits package (while non-residents could 'buy-in').  The fund would be run by a politically insulated Board, populated by state government officials, payers, employers and workers, which would negotiate with consumers and providers over the benefit package and payment rates. This Board could also include health policy experts or put them in a separate advisory panel. 

Based on data from published reports on the impact of various types of health reform plus some economic modeling, the consultants estimate that 1) administrative simplification, 2) reductions in fraud (a single payer would be better able to spot questionable bills), 3) clinical efficiency from 'integration' (like ACOs and medical homes) and 4) a "no-fault' medical malpractice system will ultimately result in a 25.3% reduction or a savings of $1.6 billion in health care costs over a 2015-2024 ten year period. During that time, it will be up to the Board to transition from the current fee-for-service payment systems to quality-dependent, risk-adjusted capitation or global payment arrangements. It sounds like each of the 14 regional community centers would hopefully agree to form accountable care organizations; those that don't would be subject to spending targets. Free standing physicians would probably be subject to forms of capitation.  And, by the way, the savings would fund everything - without any need for additional revenue.

Very seductive says the DMCB.  Yet, based on its more than 1100 posts over three years, this simplistic and naive non-PhD physician still wonders - assuming the consultant report is used as the basis of legislation........

1. Is administrative simplification really that... simple?

2. If Medicaid and Medicare are so vulnerable to fraud, why would a another government-run payer be any less so?

3. If ACOs are really such a savings no-brainer?  Medical homes are a slam dunk (see page 8 of the Robert Wood Johnson Report)?

4. If physician liability reform in today's over-lawyered environment is even possible and if there's a risk that every recommendation will pass in Vermont except a no-fault system.

Unlikely says the DMCB.  If this works and squeezes $1.6 billion out, it will be because the Board will assume that its reforms are laden with savings and impose them in its "negotiations" with the provider community, leading to a very creative but still blunt-force version of price control. 

Hopefully, Vermont's leaders will be vigilant to the twin downsides of any form of cost control and caps, namely 1) shortages of services and 2) profits-before-patients withholding of care.  Hopefully the docs will not settle for anything less than real liability reform. Last but not least, hopefully the taxpayers will realize that once this passes, there is no going back, even if the whole thing fails miserably.

And while it's slightly off topic, the DMCB happily notes that it survived a 5.9 earthquake today.  To celebrate being all shook up, its thoughts only naturally turned to Elvis.  It takes comfort in knowing that there is a little bit of The King in all of us.  Enjoy.

The 100 Year Shift? Part 4 On Why Physicians Still Have Plenty Of Reasons To Remain Independent

"After looking at the proposed buy-out
contract, I need some of this gas...."

The e-CareManagement series on the 100 Year Shift continues with this latest post, "The Practice of Medicine: from Marcus Welby to ???"

Readers will recall that this is the 4th in a series of blog posts that argues that physicians and health insurers are destined to become partners in the drive to increase quality and reduce unnecessary health care costs.  While the common wisdom is that physicians and hospitals will aggregate into large regionally dominant provider organizations, your Disease Management Care Blog and the talented and insightful Vince Kuraitis have a contrarian point of view.

Think we're wrong?  Keep in mind that we've gotten a lot of supportive comments and invitations to review this in greater detail in some national forums.  If you think we're all wet, tell us why.  We need to learn from you.

Software Eating The World of Health Care

Munch, Chomp, Swallow

In an August 20 WSJ Weekend Edition article on "Why Software Is Eating the World," IT investor-entrepreneur Marc Andreessen argues in favor of an intriguing "disruptive" business model.  While he's at it, he's also defending IT behemoth HP's new non-PC strategy against considerable investor ire. 

His thesis is that it is internet-based programming - a.k.a "software" - that is providing goods and services in an increasingly digital marketplace. While the more obvious examples of this transition include books, the entertainment industry, photography, gaming, job recruiting and communications, the Disease Management Care Blog didn't appreciate software's newly dominant role in energy development, agriculture, financial services and national defense.  For example, FedEx is really a "network with trucks" while U.S. soldiers can be thought of as an "application" on the business end of a computer program.

While Mr. Andreessen makes only a passing reference to the implications for healthcare, the pseudo-Luddite  DMCB agrees that he may be onto something.  While healthcare is a decidedly different industry, it's possible to envision a hospital setting in which patients are embedded in an intranet that noninvasively monitors vital signs, assembles data into user-friendly displays of summary information, robotically ensures safe medication delivery every time all the time and enables nurses and physicians to focus on what's really important - aided by artificial intelligence that ranges from alerts to best practices.  In fact, it's already begun and bound to get better.

And it won't be too much longer until this care model spreads to the outpatient setting.  Persons with diabetes will have their Bluetoothed blood glucose and activity levels non-invasively monitored, while face-recognition software will then be able to calculate portion sizes off of a picture of a plate and recommend insulin doses.  Frail elders living at home won't have to trigger a "fallen-and-I-can't-get-up" Life Call because movement and position monitoring algorithms will do that for them.  Think asthma inhalers with RFID chips, blood pressure cuffs tethered to the internet and Skype-oid communication for every patient 30 days after discharge.

Of course evidence-based purists will quibble over the lack of published proof. Skeptical managed care actuaries will fight to have health care software excluded from the insurance benefit.  Patient advocates will fret about privacy and its Big Brother intrusiveness.  Not a problem, says the DMCB, because the world is changing.  Physicians will demand it, insurers will cover it and both partners in the new "doctor-payer" dyad will use bundling or other flexible means of payment to get it covered.  What's more, the price point for most of this stuff will come down anyway, especially if it ends up being commoditized just like that PC business that HP is dumping.  Last but not least, the "settings" can be calibrated in a patient-centered way that meets individual preferences.

Software with a health care application. Mr. Andreessen raises the concept, the DMCB fills in some of the substance. 

Image from Wikipedia

Hospital-Physician Mergers: All Is Not Well

"Our doctors really like it here, no really!"

The Disease Management Care Blog, believing that the ultimate end game will be an historic insurer-physician alignment, checked out an "Issue Brief" on the Rising Employment of Physicians, courtesy of the Center for Studying Health Center Change (hat-tip to the folks at KHN).  The authors interviewed hospital, health plan and other provider executives from 12 representative locations around the country and came away with some telling impressions on what's happening in the hospital market place. 

The authors didn't find much in the way of insurer-physician alliances, but they sure found evidence of increasing employment of physicians by hospitals.  Why?  For the docs, it's a perfect storm of declining reimbursement, growing overhead, increasing insurer hassles, the cost of implementing an EHR and the high premium for liability (malpractice) insurance.  In addition, younger physicians are attracted to the prospect of a better work-life balance that comes with steady employment.  For the hospitals, it's the opportunity consolidate market-power, maintain a referral base and do away with the revenue-stealing physicians' in-office and surgi-center procedures.

Yet, while economics are driving docs into the arms of the hospitals, the authors cautioned that all is not well when it comes to 1) coordination of care/quality, 2) costs and 3) access to care.

To wit:

1.  Employing doctors is not the same as "integrating" care services.  There is little evidence that that alone leads to coordination of care - outside of some limited service-line issues, like reducing readmissions among patients with chronic heart failure.

2.  The continued reliance on fee-for-service as the predominant mode of payment is leading hospitals to increase revenue by encouraging their newly employed physicians to increase the volume of services.  In addition, hospitals can charge insurers a "facility fee" for many of the services that were previously independently performed by physicians.  Wanting to control the market for some services also leads to "bidding wars" for certain types of physicians, and if the bidding is successful, hospitals can command higher prices from payers. These four factors spells increased costs.

3. There isn't anything about hospital-physician employment that automatically does anything to increase access to care.

"Precisely!" says the DMCB. 

The threat of losing leverage with ascendant hospitals in their networks is one reason why large insurers have every reason to start courting the physicians in their networks.  They also understand that it's the physicians that can increase quality, reduce costs and increase access.  All they have to do is develop the information systems, joint programs and incentives to make it happen.  As the bloom comes off the rose of hospital-physician mergers, the DMCB predicts that tide will turn in the other direction.

Stay tuned to the future installments on this e-CareManagement series on how it's going to happen.

Healthcare Lessons For Our Broken Educational System

Rising costs outpacing the rate of inflation.  Grumpy taxpayers unwilling to pay even one penny more.  Government meddling with unintended consequences.  Anecdotes of complete system breakdowns. Vouchers used by right-wingers as a panacea.  Business-types circling like vultures ready to make a quick buck. And in the middle of it are the innocent victims.

The Disease Management Care Blog is certainly out of it's depth at the above description our nation's K-12 school system, but that doesn't mean it can't draw some health care parallels and offer up some lessons:

1. Teachers are shocked at turning from heroes to zeros in surveys of public opinion. Physicians pine for the old days also, but they've adapted.  Get used to it. 

2. The politicians' narrative that schools have turned into bloated overpriced and unresponsive bureaucracies is eerily similar to the early criticisms about hospitals.  What did the hospitals do?  They learned about measurement and used their own data about costs and outcomes to fight back.  Some even got better at serving patients..

3. Speaking of measurement, "testing" is a travesty that fails to capture the real work and value of education, you say? Well, students who apparently can't read reminds the DMCB of reports of patients not getting basic immunizations.  With that kind of damning data, physicians learned that measurement and testing will not go away. A better response is to shape the testing that does capture what's important.  In other words, docs figured out that it's better to do it to yourselves before someone does it to you.

4. It's breakdowns in home discipline or declines in social order that are the real problem in the class room? People unreasonably expect teachers to fix all that ails America you say?  Welcome to our world of dangerously overcrowded emergency rooms and hospitalized patients who are unable to go home because they have no home, say the docs.

5. Hate vouchers and home schooling?  Well, docs are leery about insurance vouchers and home births too. Yet, in our increasingly consumerist society, people have a right to make bad choices.  Do a good job of educating and exceeding expectations and they sometimes chose correctly.

The DMCB is not suggesting that any of the lessons above are a panacea for our teachers, that they're easily adapted to the classroom, that there are affordable solutions or that School Boards or parents would understand.  That being said, the commonalities between health care and education are remarkable, and some of the insights above may help.

Vermont's Single Payer Model: Evolving or Naive?

And so it shall be.....

Newly launched pharmaceuticals and medical devices follow a predictable business cycle. Powered by glowing research reports, there is an initial period of marked enthusiasm and high sales.  Then, as experience accumulates, reports of limited real world effectiveness and side effects unanticipated by all those smart scientists rudely intrude. Sales peter out and the market awaits the next miracle, the next Blockbuster, the Next Big Idea.

Is the same pattern true for health care policy?  Will Vermont’s foray into a “single payer system” fall victim to the same cycle of frothy acceptance followed by bitter disappointment?  Those questions were on the Disease Management Care Blog’s mind when it read Amy Wallack’s self-assured two pager New England Journal perspective “Single Payer Ahead – Cost Control and the Evolving Vermont Model.” 

As the DMCB understands it, the Swedish Green Mountain People’s Republic has decreed that its health insurance exchange (HIE) will offer a “public option” insurance plan that will be designed and funded to drive other insurers out of the state, including Medicare and the military’s health plan, TriCare. Capitalizing on the widespread frustration with fee-for-service provider reimbursement, Vermont will launch a payment system packed with the latest darlings of health reformists everywhere, including “medical homes,” “bonuses,” “quality metrics,” “pay for performance,” ”global payment” and “bundled payment.”  Top this off with an “Green Mountain Care Board” that can set provider fees, deny coverage for unproven “technology” and review competing commercial insurers’ rates, and 650,000 Vermonters will be participating in a cluster of top-of-the-enthusiasm-cycle policy preferences that, until now, liberals and progressives could only fantasize about.
 
Snarkiness aside, thousands of regular DMCB readers know that every one of the reforms described above have not consistently fared well in the real world.  While glossed-over statistics, idealistic generalizations, selective interpretations and a neo-European ideology have convinced much of the political class, the inconvenient truth is that we simply don’t know how this will work out for the patients being cared for by the docs at Vermont’s 14 community hospitals.  It also remains to be seen how a government-run insurer will be any more responsive, cheaper or better quality-wise than a similarly sized not-for-profit health plan – outside of its ability to dictate take-it-or-leave-it prices and hide costs by spreading them out over a tax base.

The good news is that any possible damage will be contained to a single state, versus the slow-motion car wreck that could happen under a similarly contrived one-size-fits-all nationwide plan.  Which is why, in the end, the DMCB is all for Vermont’s foray, just like it thinks the Massachusetts plan was a good idea.  If Vermont’s model works out for its citizen-patients, the DMCB will be the first to congratulate Dr. Wallack and her colleagues on the Governor’s staff for a job well done. 

If not, the DMCB will be there to help think – and be simultaneously cautious - about the Next Big Idea.

Congress Turns Its Attention to the Perils of the Electronic Health Record (EHR)

"Hmmm.... sure hope this works...!"

The Disease Management Care Blog admittedly enjoys being contrarian.  Yet, its skepticism about  the value of the electronic health record may have crossed into the clinical pathology of an oppositional-defiant disorder when it was recently quoted in the Pittsburgh Post Gazette. 

Is it time for the DMCB to let this go and move on?  Readers are probably immune to its dysfunctional anti-EHR bombast and Dr. Mostashari and his EHR-blinkered colleagues are unlikely to change their minds anyway.  Why bother?

But suppose it wasn't the DMCB but a member of Congress that raised the alarm?  Anything they do wouldn't make much difference to the DMCB either, but it's still worth reading this letter from Representative Renee Ellmers (R-NC). As Chair of the House Subcommittee on Healthcare and Technology, this nurse-legislator is alarmed over the same issues raised by your DMCB: persistent prescribing errors as well as the advent of new ways to harm patients.  While Representative Ellmers reminds readers that anecdotes of patient injury continue to mount, the DMCB did a quick literature search and had no trouble finding strong research studies that show that the EHR's vaunted "decision support" systems that are supposed to guide physician in the course of patient care are duds, the overall impact on basic cost and quality is questionable and, even worse, that we often don't even know how to reliably measure quality in an EHR environment.  And in the meantime, a vulgar mix of political money and connections may have only just begun.

But suppose it wasn't a member of Congress, but John Halamka, the wunderkind physician CIO of Beth Israel Deaconess who was warning us that health care is.... different?  Now that's a shrewd insight says the DMCB.  But it wonders how Dr. H can be so confident that this will get all straightened out by 2015.

Until the EHR supposedly gets fixed four years from now, Representative Ellmers is worried about how many more patients could be harmed. She is asking Secretary Sebelius to consider a study to examine the issue.  Good idea, but the DMCB wonders if Ms. Sebelius will even bother with a response.  Given the partisan disdain between the Administration and the House Republicans, the DMCB thinks the likelihood so low, that there's a better chance it will see Representative Bachman blink during a televised interview.  Stay tuned!

A Realistic Appraisal of Patient Centered Medical Home, Courtesy of the Robert Wood Johnson Foundation

REALLY close look at the PMCH

While supporters of the Patient Centered Medical Home (PCMH) believe it is the greatest thing since the invention of the poultice, realists may appreciate this more evidence-based examination of the topic by Bob Berensen and colleagues, courtesy of the Robert Wood Johnson Foundation.   Among the take-aways for the Disease Management Care Blog:

1.  There is no evidence that the entire suite of services or "principles" provided by a PCMH improve quality or reduce costs.  Rather, only some do.  Research is needed on which combinations produce the greatest value for patients, and which ones can be jettisoned.  We also don't know if it works in all practice settings (for example, in smaller, physician owned practices) and for all types of patients.

2. Current measures of PCMH rely on survey tools that ask about processes of care.  Given the emerging consensus that real goal of primary care is patient centeredness, it's possible that PCMH "recognition" and "accreditation" will become dependent on patient surveys.

3. Estimates of costs to physicians to become PCMHs run from a few thousand to more than a hundred thousand dollars.  In other words, we have no idea.

4. PMCH fee schedules can take a number of forms, including some combination of a) increases in fee-for-service payments, b) coverage for specific services, such as patient coaching, c) monthly lump payments, d) capitation, e) pay-for-performance for outcomes tied to the PCMH,  f) shared savings.

5. While dozens of pilots are underway, the largest is being sponsored by Blue Cross Blue Shield of Michigan.  This is likely to be eclipsed by a "Patient Aligned Care Team" initiative in all of the Veterans Administration's primary care clinics.

6. There are no data on what percentage of primary care physicians believe in the PCMH.  We also don't know how many plan to make the transition to one.  We also don't know if medical students will find the PCMH a compelling reason to go into primary care.

7. Last but not least, many past studies and current pilots are using only some of the PCMH principles, have inexact evaluation plans and many are not using a valid comparator.  It will be difficult to draw any consistent conclusions.

The DMCB will end with this closing quote by Dr. Berensen et al, which reminds it of what happened to the disease management industry.  It could not have said it better itself. Backers of the PCMH ignore this sage advice at their peril:

"The medical home model does have the potential to transform the way health care is delivered – but 'potential' is the key word here. The danger posed by the current enthusiasm for the concept is that it could lead to the adoption of unproven models on a wide scale nationwide before evaluations of existing pilots can show us what works in what situations, and what levels of reimbursement are needed to get providers to engage in all the new activities encompassed by the medical home model. This could lead to a failure to improve quality or save costs, and could result in a good idea being dismissed as ineffective before it has a chance to succeed. Whether we have the patience to nurture and recalibrate the medical home model as evidence comes in from evaluations before jumping to conclusions about its success or failure remains to be seen."

What Do Many Docs Who Get Sued and the President Have In Common

Not a good place to be....

The doctor Disease Management Care Blog has a confession to make: it has read the House of God.  The DMCB's older physician readers will readily recognize the title of this controversial 1970's book and remember the quirky and strangely wise physician Fat Man.  One fav DMCB scene involves a patient who was readmitted with a death sentence diagnosis.  Hours later, the Fat Man and the patient were upstairs in the hospital, playing cards and.... laughing. 

Such is the art and science of medicine, where one difference between good and not so good physicians hinges on an ability understand the fundamental difference between healing and curing.  Discerning this isn't necessarily a function of intellect: the DMCB has worked with many astonishingly brilliant physicians with a near encyclopedic technical knowledge who have been dismissed by their patients as unfeeling.  In fact, when things don't work out and that expertise is combined with a distant, aloof and humorless demeanor, it's these brainiacs that often end up getting sued.

Which brings the DMCB to the topic of President Obama.  His impressive oratory and technocratic mastery is not only being eclipsed by events outside his control, his sterile and "not-my-fault" dialectic - even if he is ultimately correct - is the sort of behavior that among docs can contribute to angry allegations of "malpractice." Constituents and patients alike need to know that they're not alone in their fear and heartbreak. Ivy leagued advisers and evidence-based medicine are no substitute for being emotionally distant.

Many of Mr. Obama's dimmer predecessors were advantaged by being able to "connect" with their constituents.  It reminds the DMCB of a recent encounter with a doltish State politician: the spouse agreed he was a horse's ass, but hey, he was our horse's ass.

Board Members: Here's An Article on Accountable Care Organizations That Your CEO May Not Want You To Know About

Hat In The Ring

In a prior post, the Disease Management Care Blog nominated one question that every hospital, clinic, IPA, medical group or health system Board of Directors should ask when it is being asked to endorse the CEO's decision to form an "Accountable Care Organization."  Well, that question and nine others have been poised by Sara Singer and Stephen Shortell in a JAMA Online Commentary titled "Implementing Accountable Care Organizations - Ten Potential Mistakes and How to Learn From Them."

Well, they're not exactly worded as questions, but the issues in this "must read" article do need to be addressed by any organization's Board that is contemplating throwing a hat in the ACO ring:

1. How well can the organization perform as a single risk bearing entity and is the ability to merge hospital and physician performance being overestimated?

2. Will the electronic health record perform as anticipated, and what is the likelihood of inadequate provider training, clinic down-time and incompatibilities between physician and hospital systems?

3. Since quality measures will impact payment, how well has the organization performed in other pay-for-performance arrangements and will the collecting, analyzing and reporting of data meet muster (this was the DMCB's primary question by the way, when it examined the issue of dashboards).

4. Are the care management protocols ready to go, and do they have the doctors' buy in?

5. What is the likelihood that all the moving parts, including the hospitals, physician groups, key specialists or other partners will play nicely when inevitable disagreements arise, like who gets the money or the blame?

6.  How has the organization embraced the strategy of patient engagement in self-care using cost-saving and variation-reducing shared decision making?

7.  Since it is the pens of specialist physicians that account for a lot of unnecessary health care costs and patients will be free to see any doctor they please, how will we identify the most cost-effective specialist physicians and how will we encourage patients to rely on them for their care?

8. Knowing that the Feds are very attentive to antitrust and Stark rules, what is being done maximize our transparency and navigate a shifting regulatory and legal environment?

9. Organizational charts are fine, but how closely is everyone really aligned in making this work?

10, Since there are a significant number of interdependencies, if the answer is "don't know" to any of the preceding nine questions, how will that impact any of the remaining questions you just yes to?

The authors end with two recommendations for "the way forward":

1. Collective leadership involving CMS and the ACOs that promote mutual learning and....

2. "....the development of a mature performance measurement system to provide rapid feedback about what works in different local environments. What is not measured cannot be managed, but what is measured must still be managed. Management and measurement hold the keys to ACO success or failure."  In other words.... a dashboard!

The DMCB would like to modestly add a third recommendation:  tapping into the expertise of a population health management organization.  These vendors understand risk, have learned the painful lessons of reporting quality measures, have evidence-based care management protocols that have passed physician scrutiny, "live and breathe" patient self-management and - since ACOs are supposed to kick off in a matter of months - they can "stand-up" infrastructure in a matter of months.

The Latest Cavalcade of Risk Is Up

Savvy bloggery about risk.  You have questions.  You want just the headlines. Both can be found here, courtesy of the Healthcare Economist.

The Patient Centered Medical Home: An AHRQ Search Engine and A Note About A Cancer PCMH

Candidate for a Medical Home?

Do you wish you could find and quote some published scientific evidence on the Patient Centered Medical Home (PCMH)?  While you already have a leg up thanks to joining thousands of readers that regularly check the DMCB, you may also want to use and bookmark this very handy AHRQ site.  It provides a definition, a bibliography of "foundational" articles and, best of all, a search engine that will provide the citation, an abstract and a link to PubMed.  Unfortunately, however, the full article remains under the control of the publisher which may or may not be open access.

Speaking of the PCMH, the DMCB was alerted to this interesting article on the PCMH for cancer patients that appeared in a journal called Community Oncology.  An independent Philadelphia area oncology practice used a high performance EHR, relied on "patient navigators" to coordinate care and routinely worked with patients to make them be as fully engaged as possible in self-care.  While they were at it, they attained Level III NCQA PCC PCMH recognition.  While the outcomes are presented in a narrative pre-post fashion, the author John Sprandio MD describes a credible increase in patient phone calls, greater reliance on the care of symptoms at home, a "50%" drop in referrals to the emergency room, a sustained 9-16% drop in admissions, expanded use of standardized protocols that anticipated and prevented dehydration, fewer admissions for gastroenteritis, less chemo-induced nausea and greater use of same day clinic appointments.

The DMCB is intrigued by the idea of expanding the PCMH to the field of outpatient cancer treatment.  It used the AHRQ site above to search for similar studies and didn't find much.  On the other hand, the concept seems promising, especially if robust non-physician care coordination is paired with physician leadership.  It been long known to work in classic oncology disease management, so why shouldn't it be adapted here?

Image from Wikipedia

The Care Continuum Alliance Webinar Series on ACOs: Not To Be Missed

The internet can make me smarter?!

Feigning modesty once again, the Disease Management Care Blog is very pleased by the strong audience strong speaker ratings for the ACO webinar "Realizing the Potential: Assessment and Stratification Tools for Accountable Care Populations"  that it co-presented back on July 28.  You can find out more about what you missed by accessing a recording, plus finding out more about the follow-on presentations here. 

Note that the second webinar of the series is happening today at 1:30 EST and that it's not too late to register.  The speakers are eHealth Initiative CEO Jennifer Covich Bordenick and the extremely smart Emory University and Thomson Reuters researcher Ron Goetzel.  They'll be tackling measurement, reporting and finding solutions when it comes to optimizing outcomes for ACO populations.  Click here so you can see whether an ACO is a good idea and how your competition may be appoaching this important topic.

Added bonus: If you're a practicing doc or a hospital administrator, the good news is that you may qualify for free access to the webinar plus DMCB recorded presentation!  Is that a good deal or what?

This high octane ACO learning series culminates in two half day special sessions that are part of the Care Continuum Alliance Forum 11. Confirmed speakers represent a broad variety of prominent stakeholders, including The Lewin Group, Centers for Medicare and Medicaid Services, National Committee for Quality Assurance, TransforMED, TowerBrook Capital Partners, Park Nicollet Health Services, MedAssurant and others.

Not Pretty: Year 5 Physician Group Practice Demonstration Results (and lessons for Accountable Care Organizations - ACOs)

The Disease Management Care Blog was alerted by a colleague to this hot-off-the-presses CMS release announcing that the five year Physician Group Practice (PGP) Demo results have been compiled.  All ten participating groups increased their quality of care measures and seven achieved scores of 100%.  Four out of the ten groups were awarded $29.4 million in shared savings.  You can look at a results summary here and read the background report here.

Here's a visual display, courtesy of your DMCB, of the payouts for each of the five years to each of the participating clinics:

As you can see, four out of the ten, Billings ($0), Everett ($129,000, barely registering on the graph), Forsyth ($0), Middlesex ($0) didn't do very well for any of the years.  Dartmouth hit a $6 million jackpot only in Year 2, Park Nicolette hit $5 million in Year 5, Geisinger had modestly successful Years 2 and 3.  The only institutions with any consistency were Marshfield, St. Johns and Michigan. 

While the CMS press release generously refers to "positive results" and "significant progress," it also uses the word "lessons" in reference to "Accountable Care Organizations."  In looking at the graph above, the DMCB's initial learnings are that.....

1) assuming these results are generalizable, there is a 40% chance that an organization participating in a shared savings arrangement with CMS will come away practically empty handed, 30% of the participating organizations will have some good and and more bad years, there is 10% chance that an organization can get a huge amount of money and that this will work as intended only 20% of the time;

2) assuming that these Medicare claims results are the product of randomness and had nothing to do with actual planning, anything can happen and it mostly isn't good;

3) even if there is "savings," we don't know if the millions of  those shared savings are greater than the millions in investments that each of the clinics had to make.  That key information on "return on investment" remains conspicuously absent;

4) there is little relationship between achieving "quality" and saving money.  If improving diabetes, heart failure, coronary disease and preventive care was all it took (see page 3), each of the clinics should have made a bundle.

The DMCB will continue to commune with these outcomes data and await the on-line and printed interpretations of academics and bloggers.  In the meantime, if any reader would like a PowerPoint slide with the graph above, just email.

Of Downgrades, Treasurys, Sins of Omission vs. Commission, Spin and the Affordable Care Act

The Disease Management Care Blog hopes that when this interview was recorded, Treasury Secretary Geithner was engaging in some "spin" for public consumption and didn't really discount the possibility of a rating agency downgrade when he was working behind closed doors at the White House:



While Standard and Poor's (S&P's) action has been called into doubt because of the agency's past gaffs, the DMCB points out that the mortgage backed security mess was a sin of omission.  In other words, they missed the risk to investors.  However, once they spot a risk, S&P doesn't have a reputation for unnecessary exaggeration.  It remains to be seen if the markets to decide if the downgrade was a sin of commission. 

Which brings the DMCB to the Affordable Care Act.  Do the Adminsitration and its allies really believe this or is this some sort of spin also?

How The Medicare Entitlements Could Be Reformed, Why That Is Unlikely And Why Medicare Needs Disease Management More Than Ever

Will the Committee Come to Order?

In a prior post on the coming Congressional "super committee" scorched-earth Battle of the Budget, the Disease Management Care Blog predicted that there will be no time, no technical knowledge and no tolerance for any fiddling with Medicare entitlements.  That leaves reducing payments to providers.  Former HCFA Administrator Gail Wilensky agrees.

Yet, for some insight on how Congress could reduce entitlements, check out this proposal from U.S. Senators Lieberman (I-CT) and Coburn M.D. (R-OK).  Four of the more interesting features are......

Phase in an age eligibility of 67 years (because our life expectancy is increasing)

Increase the premium for Medicare Part B (it will reduce its dependence on tax revenue) and require those with higher incomes to pay more (for the same coverage, by the way).

Consolidate the deductible at $550 for Medicare A and B, while sweetening things with an out-of-pocket maximum at $7500 (but increase it for persons with higher incomes, even though they won't be getting better coverage by the way).

Prohibit "first dollar" coverage by the private Medi-gap plans (which will presumably disincent beneficiaries from using unnecessary care services; critics could charge that that could have the same impact the use of necessary care services too, especially for the poor).

While the baby-boomer DMCB ponders the prospect of having to chose between higher premiums with elevated out-of-pocket costs versus having to shop around with a premium-supported voucher, Congress has a far more fundamental choice: it is going to have to chose between making voters pay more or paying providers less.  Given the outline above combined with the toxic partisan rancor, it's already pretty clear what the political choice is going to be.

Last but not least, the DMCB continues to be mystified by the unwillingness of CMS to reconsider its posture on covering remote coaching disease and population health management.  If CMS wants to save money, here are three good reasons to do so:

 1) the suite of services, sophistication and "reach" of modern disease management have grown considerably since the bad old days of Medicare Health Support,

2) there's some evidence that Medicare Health Support actually did some good, and

3) much of the cost-saving, patient-centered care management activities of the successful Group Practice Demonstration were modeled after old fashioned disease management including phone calls by nurses that were external to the primary care sites.

Here's a future question for the super committee to ponder as it tackles CMS' rising costs: if State Medicaid programs and commercial insurers currently rely on versions of disease management and if ACOs are likely to do so once they're up and running, why isn't it good enough for a supposedly innovative CMS?

The Latest Health Wonk Review Is Up!

Grab the iced-tea, don those sunglasses and grab a fan, because you're going to need it after reading a Heat Wave edition of the Health Wonk Review hosted by Joe Paduda of Managed Care Matters.  Lots of hot topics with sizzling links resulting in plenty of cool learning courtesy of the best health policy bloggers!

Behavioral Economics and Work Site Wellness Program Financial Incentives

Give that lady some money!

Even though this New England Journal article by Kevin Volpp, David Asch, Robert Galvin and George Loewenstein on the interesting topic of behavioral economics opens with a retread of many of the arguments against the use of financial incentives in worksite wellness programs, it offers some interesting insights on how these dollars can be used for maximum impact. 

The Disease Management Care Blog figures the message here is that they don't like it, but, hey... if you must......

1.  Participants place more value in the present than in the future, even if both are of the same value.

This is why the hassle and cost of taking pills today outweighs the future benefit of fewer complications or a lower risk of death tomorrow.  One way to leverage this in a wellness program is to give tangible rewards at the time of participation (for example, something of monetary value) instead of a future reward (for example a year-end reduction in a health insurance premium or a lower co-pay for a clinic visit).

2. Participants use "mental accounting" to judge the value of any reward.

In other words, participants tend to "allocate" financial rewards into categories and, if the result leads to the incentives being bundled into another pool of money, the impact can be diluted.  $50 going into a larger  health savings account is not as attractive as a separate check for $50.  This is an important issue, since employers may be tempted to use existing payroll mechanisms instead of cutting a check.  It can also get complicated because of existing tax regulations.

3. Penalties appeal to notions of efficiency and fairness, while rewards may appeal to a sense of community.

One way to think of this is to consider financial incentives to combat tobacco abuse: should everyone who doesn't smoke be rewarded, or should those who do smoke be hit with a penalty?  The authors note there is little formal research that helps sort this out, so this may ultimately have to be determined based on the company's culture.

The good news in all of this is that the Affordable Care Act has given employers considerable leeway in fashioning financial incentives to support worksite wellness programs.  Hopefully they'll pay close attention to what is - and isn't - known about boosting employee participation.  The DMCB also hopes that they'll write down and describe what happens, so that the rest of us can learn.

The Fight Over Health Care Funding Has Entered A New Phase

Even if it is out of fashion, Disease Management Care Blog continues to strive to be among those wealthy Americans that, thanks to countless tax breaks and loopholes for jets and golf shoe tassels, are not paying their fair share for shovels and readiness.  Unfortunately, its likelihood of being admitted to that club, even with its vast blogging income, seems remote. A second option, says the DMCB, is personally help our economy by embarking on some serious consumer spending, starting with a new blazer and a matching high-performance laptop. Too bad the DMCB spouse disagrees.

Since it's stuck in the water, the DMCB's economic status will be forced to await the details surrounding the latest Federal budget agreement of undefined cuts that amount to $917 billion. Then there's the $1.2 trillion in additional cuts that will be decided upon by a 12 person Congressional "Super Committee." As the DMCB understands it, that initial  $917 billion did not include Medicare or Medicaid, thanks to a reprieve wrestled from the White House at the last minute by House Minority Leader, Nancy Pelosi (D-CA).  Whether the Super Committee protects Medicare and Medicaid in the second round of cuts remains to be seen.  If they fail to come to an agreement, automatic cuts will kick in, which will include an across-the-board 2% reduction for Medicare.  Ouch.

After reading Bob Laszewski's Health Care Policy and Marketplace Review, the DMCB isn't optimistic on how how these health care entitlement programs will fare. It's unlikely that eligibility will be tackled in four short months and less than a year before an election. That leaves payment cuts. Cuts to States, cuts in payment rates to hospitals, and, most ominously, reneging on the likely backroom political promises that were made to organized physician organizations over fixing a looming 29.5% sustainable growth rate (SGR) pay-cut debacle.

The bulk of the Republicans have made it clear that they won't go along with any "new revenue" ideas, while the White House was surprisingly prepared to offer a 4% cut for Medicare payment rates.  None of this bodes well for providers. 

The DMCB will be watching carefully to see how they respond.

Ten Reasons Why Population Health Management Service Providers and Disease Management Companies Are A Choice For A Wellness Program

Worksite footwear?

At a recent conference on the role of wellness in the work setting, the Disease Management Care Blog pointed out that there are ten very good reasons why outsourcing worksite wellness to a "population health management" (PHM) service provider (the old disease management companies) is still a strong option.  No one disagreed with the DMCB, so it must have gotten something right.

The reasons are

1. PHM companies understand insurance-based risk transfer: they understand that this is ultimately about reducing health care costs in the short as well as long run.  In contrast, many wellness providers see this as a "retail" product and simply want to sell their services.
  
2. They can offer their programs at little incremental cost:  this is a situation where size matters and if the employer has a preexisting relationship involving a program for chronic conditions, wellness can typically be tacked on for a very reasonable amount.

3. These vendors have a track record of managing within of "risk corridors": if there are performance guarantees, expect these companies to work with you on the upside and downside caps that can limit the exposure of both parties.

4. Cafeteria versus a “total solution” approach: hand-offs between programs are very important since, for example, persons with chronic illness may benefit from wellness and persons screened for participation in a wellness program may have a previously undiagnosed chronic condition.  Smooth and offs between programs are more likely to occur if both the chronic care management and wellness are working for the same company and share the same leadership.

5. Prevention already active in programs: don't believe those allegations that "disease management" programs only focus on a single condition.  These companies have been offering an interlocking suite of services for decades and that includes wellness.  They already know how to engage patients with chronic illness in prevention and wellness while simultaneously helping them to better manage their condition.

6. Depth and width market expansion:  PHM companies are broadening the number of services that they can bring to market.  As a result, within any wellness offering, these vendors are constantly working to increase the number of approaches and program options.  Many retail programs have a one-size-fits-all approach.

7. Resists commoditization: sure, you may think it's just a matter of giving employees health club memberships and emails reminding them to eat their veggies, but good PHM companies know that's a lot of bunk.  If that's all you want, they may ask you to go deal with one of those retail outfits.  If you want quality, be prepared to pay for it.

8. Bariatric surgery costs: frightening!  As the threshold for bariatric surgery continues to drop and more and more patients become candidates for this expensive procedure, PHM vendors understand that there are ways to give patients other options short of getting an abdominal scar.

9. Remote interventions for tobacco & obesity “as effective as traditional face to face.”  There is an emerging body of evidence that suggests that telephonic coaching has a role to play for many patients, depending on their disease burden and personal preferences.  There are many patients in any population who would respond to telephonic coaching, and the PHM vendors know how to navigate that.

10. You're in a hurry.  If you want to build this yourself with your own employees, perhaps with the help of the local medical center, you can expect the planning to take many months, and then you'll need to wait additional months before anything gets launched.  If you want to do this in a hurry, why not call in the experts that can get this going within 4 to 6 months?  You'll have some preliminary data within a year.