What Is The Difference Between Pay for Performance and Accountable Care Organizations

Where's that evidence?

The Disease Management Care Blog has occasionally wondered about the difference between pay for performance (P4P) and accountable care organizations (ACOs).  While the latter involves a more explicit transfer of risk, it thinks the underlying logic for both is ultimately the same: better quality performance should translate into less sickness, fewer specialist physician visits and reduced hospitalizations which, in turn, should save money that can be shared with the providers.  Assuming that's true, the possibility of getting that kind of money should prompt physicians to prevent, coordinate, counsel, immunize and screen instead of treat, refer, ignore, not immunize and hustle out the door.

Unfortunately, a recently published Cochrane Review says otherwise. 

The DMCB likes CRs because they are state-of-the-art and highly disciplined reviews of the world's scientific medical literature.  In this instance, after an exhaustive examination of every published paper on the topic of P4P, the authors conclude....

"....there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."

The DMCB will be the first to argue that academic, rigorously conducted, randomized and controlled clinical trials are not the final answer when it comes to managing the subtle complexities of physician behavior change.  The DMCB has run into some very smart and passionate physician leaders who have few doubts about the real world links between P4P, increased quality and reduced cost.

That being said, given the commonalities between P4P and ACOs, no one should assume that ACOs are going to succeed based on any notions of "evidence" that the promise of savings will translate into a changed physician workforce.   Cochrane says it just ain't there.

What Zombies Can Teach Us About the Affordable Care Act

In George Romero's campy movie Land of the Dead, the zombies undergo a very worrisome change. While they used to just pathetically stumble around looking for brains to eat, they organize and make menacing plans. The living survivors, holed up inside the fence at the former city of Pittsburgh, have a fight on their hands.

Maybe it's the Halloween season, but the recent slew of late night walking dead horror has inspired the Disease Management Care Blog.  It's entered sweeps for a cameo appearance in AMC's cool zombie series.  It's assessed the relative merits of the undead staggering vs. running, being loners vs. in packs and being wrathful vs. both hungry and wrathful.  The DMCB has also discovered one key commonality of this fearsome species: while maximum head trauma undoes the undead, more of them just keep coming and coming. That DMCB thinks that, despite the spouse's advice to the contrary, is an important lesson.

The political dimensions of the Affordable Care Act are becoming more zombie-like with each passing week.  According to the Kaiser Health Foundation, public support for health reform has not only remained stubbornly underwhelming, it has just taken a recent downturn.  While it's too early to tell if this is bad news or statistical variation, there's no denying President and his allies are being forced to fight one-on-one with undead employer pessimism, oppositional Republicans and the CLASS Act's failures, while more ever more issues slowly stumble closer.  And who can blame the living Dems for their post-apocalyptic anxiety? It was only yesterday that the ACA was a signature achievement and the world was a wonderful place of Congressional majorities, fawning media support and supreme self-confidence.

While supporters of health reform may take comfort in the notion that the zombies have been unorganized and are attacking the margins, the DMCB worries that the Kaiser poll slide may portend a worrisome Romero-esque development: unable to grasp the details if the Affordable Care Act, Americans' support for it was always based less on the underlying policy and more on the President himself.  A slip in support, therefore, has less to do with the law's merits and more with a shift in what people fundamentally think about Mr. Obama.

With just over a year until the elections, that's a scary thought for this Halloween. It seems the folks inside the White House fence have a fight on their hands.

The Latest Health Wonk Review Is Up

Despite the spouse's derision, the Disease Management Care Blog has always suspected that but for a cape and tight leggings, it would be a hard body superhero.  Well, according to Joe Paduda, all you really need is a blog and reasonableness.  You can see exactly how that will save health care as you check out the latest and cleverly written Health Wonk Review - The Superhero Edition.

Being Bullish on Disease Management

Because it's a bellwether for the investor-owned care coordination provider companies, the Disease Management Care Blog likes to keep an eye on Healthways.  It recently eyed this drop in its share price:

Ouch.

As part of its third quarter earnings announcement, the company revealed that mega-health insurer Cigna is "winding down" its Healthways contract in 2012.  Since Cigna accounts for about $110 million in revenue, loss of 17% of the top line was not good news for the company.  Investors reacted by punishing Healthways with a  43% decline in the stock price, while S&P downgraded the company.

The DMCB is not a Healthways investor, but even if it were, it wouldn't be worried.  Stuff like this has happened before to the company and and the market will always have an cyclic pattern of purchasers deciding to insource then outsource and then later insource their care management programs.  In fact, Healthways is pointing to the arrival of some other contracts. That's simply the nature of this business.

In the announcement linked above, Healthways points out that the future's quite bright because of the following market trends:

1) Health plan preparation for the implementation of state health insurance exchanges, which is projected to cause significant disruption of their individual and small group fully insured business;

2) Change from a volume-based to a value-based payment system and the associated shift of financial risk and responsibility for cost and quality from health plans to providers;

3) Increasing payer requests for a comprehensive, integrated solution that addresses longitudinal health risk and care needs for total populations;

4) Global adoption of population health management by both foreign government and foreign private sector health organizations; and

5) Recognition by large employers of the expanded value of improved well-being to reduce medical cost and improve individual and company productivity and performance.

The DMCB finds the reasoning quite sound and applicable to the entire industry.  Based on the implacable logic of short-term investing, the loss of one big contract is a big deal.  On the other hand, the DCMB remains bullish on the industry's longer-term value-proposition built on cost control, risk mitigation and prevention.

Last but not least, note that the commercial health insurance business hasn't abandoned disease management.  Insurers are looking to extract the greatest value and, if that means insourcing it, so be it.  Ultimately, it's the patients who win.

Shirley Temple couldn't have said it better.  Care coordination remains a reason to be optimistic and smile.....



Image from Wikipedia

Do Medicare Beneficiaries Warrant Higher Nurse-Patient Care Coordination Ratios?

In yesterday’s posting on care management nurse-staffing ratios and their associated costs, Peter McMenamin pointed out that a per member per month cost (PMPM) that ranged from $8 to $17 was a reasonable estimation.  What's more, it compared favorably to the monthly management fee in the Comprehensive Primary Care Initiative. 

This is also important for Accountable Care Organizations that are grappling with the amounts that they’ll need to invest in care coordination to achieve the shared savings.  Assuming an ACO becomes accountable for 5,000 beneficiaries, that calculates out to between $480,000 and $1,020,000 per year.

But, asked the Disease Management Care Blog, should there be any differences in care management ratios and costs for Medicare, Medicaid and commercial insurance?  If it’s a commercial ACO, should it estimate $500K, while a Medicare ACO should plan lower ratios and invest $1M?

Peter McMenamin’s thoughts:

A parity between Medicare, commercial, and Medicaid is possible but not exactly plausible.  Thanks to many co-morbidities, Medicare patients have more different docs, more visits, and more drugs.  Unless they are particularly compliant with respect to medications, you’d expect Medicare patients to be more demanding.  Unless they return to a physician so frequently that care coordination is incidental or are hospitalized so much that their care is taken care of, they need considerable care management. If Medicare patients take more time for follow-up, etc. that might explain the difference between $20 PMPM and the somewhat lower PMPM estimates from my calculations.

Good point, of course.  Yet the DMCB is not so sure that there is a correlation between savings and the intensity of care management beyond a certain threshold for any patient of any age.  In addition, while persons with Medicare have greater illness burden, that doesn’t mean the day-to-day management, care plans and shared decision making for conditions like diabetes or heart failure making varies depending on a patient’s age.

Dr. McMenamin and the DMCB will keep their eye out for answers.  More to follow.

The Per Patient Monthly Cost of Care Coordination for Accountable Care Organizations (ACOs)

by Peter McMenamin, PhD Senior Policy Fellow, American Nurses Association

In a prior posting, the Disease Management Care Blog noted that nurse-to-patient ratios in outpatient care coordination programs run between 1:750 to 1:1500. Based on 2010 Bureau of Labor Statistics data, the average annual salary of a registered nurse (RN) (in hospitals) is $68,610.  Fringe benefits for RNs add 46% for a total of $100,208.

Combine that ratio with the total compensation information and the per member per month (PMPM) cost for a care coordination nurse ranges from $5.57 to $11.13.
 
Obviously, a single RN does not care coordination make.  There are other overhead expenses, such as administration, documentation and supervision.  Assuming human resources account for the bulk of a program’s cost with an additional load of 25%, the total PMPM cost ranges goes from about $7 to $14, while 50% increases it to $8.35 to $16.70.

By my calculation, that puts monthly care coordination costs close to the CMS Innovation Center’s Comprehensive Primary Care Initiative (CPCi) within the “ballpark” of $15 to $20 per Medicare beneficiary per month (see page 3 here).
 
Based on these data:

1) CMS is being reasonable in offering a $20 monthly fee for care coordination.  It falls within industry benchmarks and supports a competitive compensation package for a typical RN.

2)  While CMS’ fee meets benchmarks, this is obviously meant to support a medical practice hiring additional personnel to take on the work of care coordination.  As a result, the fee may offer some additional margin depending on additional overhead.  Hopefully, the providers who participate in the initiative won’t assume that the $20 fee represents pure profit.  Expecting RNs currently on staff to manage care coordination on top of existing duties means that the existing duties or care coordination (and the RNs) will suffer.

3) As the Disease Management Care Blog pointed out in a prior post, this may also represent an argument for the “central” hiring and administration and the “peripheral” distribution of the care coordination nurses.  If administrative costs can be pooled and coordinated by a cluster of primary care sites, that could lower costs significantly.

4) Last but not least, this gives Accountable Care Organizations (ACOs) an important insight on one cost that they’ll need to take on if they are serious about care coordination.

Another Reason Why There Was A Decline In U.S. Hospitalizations for Heart Failure

By now, many Disease Management Care Blog readers have become aware of this JAMA research study that used Medicare fee-for-service claims data to examine the nationwide rate of hospitalizations for chronic heart failure.  From 1998 to 2008, there was a counterintuitive 30% decline in the U.S. from a baseline rate of 2845 to a new rate of 2007 admissions per 100,000 person-years. 

The authors credit better care of heart attacks (damage from a heart attack to can lead to a flabby dilated heart), better prevention (such as more aggressive treatment of high blood pressure, which also causes heart damage) and a more "effective" medical system (such as better outpatient follow-up, use of alternate levels of care, flu shots prescriptions of ACE inhibitors and beta blocker medications).  The authors of the study think the numbers are remarkable because the U.S. population is getting older and healthier persons (without heart failure) seem to be signing up for managed care Medicare Advantage.

The DMCB is wondering about another possibility that has nothing to do with epidemiology or quality.  Rather, it could be the impact of Medicare payment rates on billing patterns.  After all, if heart failure is the leading Medicare inpatient diagnosis, shouldn't a decrease there have an impact on the overall hospitalization rate?

The DMCB explains:

When beneficiaries are discharged from a hospital, the bill (or the claim) submitted to Medicare is based on a "Diagnosis Related Group."  While the invention and logic of DRGs complicated, they're important because the principal diagnosis determines the amount of the global payment for that hospitalization. While this may be overly simplistic, a discharge with a diagnosis of "heart failure" prompts Medicare to pay a hospital "X" dollars, while a diagnosis of pneumonia or kidney failure will render payments of "Y" and "Z" dollars, respectively.  In general, the more complicated the diagnosis, the greater the payment.

All well and good, but suppose the hospital has a patient with several concurrent problems and has a choice on which DRG to use?  As anyone who has taken care of hospitalized patients knows, there are usually multiple diagnoses present in any patient at one time.  Pneumonia may or may not have provoked the heart attack that led to the kidney failure that led to the leg swelling and the shortness of breath.  Given three simultaneous diagnoses, Medicare billing guidelines state that the hospital should use their best judgement to determine which DRG to bill. All things being equal, smart hospitals will probably use the DRG that renders the greatest payment.

The DMCB isn't saying that fraudulent billing (for example) accounts for the decrease in heart failure hospitalizations for Medicare. However, it knows some diagnosis related groups can be less remunerative than others and that in the last ten years, DRG payment rates have evolved and that hospitals have learned how to "code" more accurately and aggressively.  Based on the example at the bottom of this page, the DMCB wonders if some patients that were diagnosed with heart failure in 1988 would have been diagnosed with something more remunerative in 2007. 

In other words, there may have been the same number of hospitalizations involving the same patients with the same disease burden.  It was the case mix that changed?

The authors of the study to their credit can't discount the possibility:  They argue that if coding had changed there would have been a shift in the mortality rate of patients with heart failure:

"We were unable to determine whether the observed changes were due to changes by hospitals in medical coding; however, substantial up-coding or down-coding would likely result in changes to the coefficients of the CMS HF mortality model, and these coefficients remained stable from 2005 to 2008."

The authors may have a point, but that assumes the modeling - also based on claims - is trustworthy.

Of course, there is no way, based on Medicare billing claims alone, to determine whether measurement also played a role in the decline in heart failure admissions.  That would take an audit of the medical records themselves.

The 3 Legged Stool of Telemonitoring: The Device, A Non-Physician Professional and the Patient

Just when the Disease Management Care Blog has barely learned to control itself when it's in the company of clueless electronic health record (EHR) techno-weenies, enter the equally intolerable "telemonitoring" enthusiasts. Their jargon-laced claims of pan-medical and cost efficacy is enough to give the DMCB a migraine.

Their bombast is easy to spot.  According to this new class of leprechauns, small wearable telemonitoring devices for blood pressure, temperature, breathing, heart rate, weight, calories, blood sugar, cholesterol, brain waves, nail length, eye-blinks and minutes spent in the bathroom upload the data to the doctor who, thusly armed with critical insights of well-being, can do more of their... doctor stuff like... give out some prevention and stomp out disease.

For the best example of how that is simply not true, the DMCB is reminded of this negative December 2010 heart failure symptom telemonitoring study that alerted the patients' physicians about "variances."  The DMCB readership already knows that physicians are already busy and just don't have the time to fit one more task into their busy days.  That's doubly true if the data is unfiltered and without any context.

Yet, while the DMCB is unwilling to hop aboard the telemonitoring train, that doesn't mean that this has nothing to offer.  In the DMCB's estimation, it'll increase quality and probably lower costs if it is combined with two other key ingredients:

1) a non-physician professional being in the loop, who can a) monitor the information and b) contact the patient with significant variances and c) use a combination of clinical judgement and standing orders/protocols to guide a patient response (which, by the way, doesn't have to include seeing the physician).  An example is here.  They're usually nurses and they can be part of the Patient Centered Medical Home or as part of a population health management program (or both).

2) an empowered, engaged, enabled and educated patient who understands the "output" of the device and can respond autonomously, confidently and collaboratively.  While some readers may pooh-pooh the DMCB's unrealistic idealism, the DMCB has found that most patients are smarter than they are given credit for.  As far as the DMCB is concerned, if a patient can manage a telemonitoring device, they can usually deal with the non-physician professional and also have some insight about what the device is "saying."
   
The DMCB thinks of it as a three legged stool.  Having telemonitoring patients be 1) passive and 2) unsupported bystanders while their data uploads scramble their overburdened physicians' workflows isn't health reform, it isn't cost saving and it isn't quality. 

Image from Wikipedia

ACO Final and User Friendly Rule Released. Here Are The Most Important Changes

When CMS came out with the proposed regulations for Accountable Care Organizations (ACOs) in March of 2011, the Disease Management Care Blog shared in much of the provider community consternation over just how unwieldy the Feds were being.  The promise of integrated, coordinated and cost-effective care provided by hospital-physician networks had run into the reality of having to invest millions dollars with a questionable ROI, a complex maze of up and downside risk calculations, reams of burdensome quality measures and overlawyered antitrust regulations.   

Well, CMS listened to 1320 comments and, in response, released a more user-friendly "final rule" today.  While the DMCB is still tracking down and mulling over the myriad details, it found the best review of the modifications in this table appearing online in the New England Journal of Medicine. 

Changes that caught the DMCB's eye:

The 1st of the two "Tracks" will not have any downside risk in the 3rd year.  Two-sided risk remains in Track 2 (ACOs will still need to invest millions in care coordination infrastructure, but at least they won't have to cover CMS's downside risk if they fail to control utilization).

No 25% withhold of the shared savings (This was the amount that the Feds were going to hold in escrow just in case the ACOs' financial performance deteriorated).

Instead of the providers having to hit a 2% savings before getting any money, shared savings kicks in once the "minimum savings rate" is achieved (This is a significant concession by CMS.  The DMCB recalls the MSR is a savings target that is based on statistical significance)

Assignment of beneficiaries will be prospective, not retrospective (Likewise a concession and good news, since the ACOs will know who is in their target population that represents their risk).

Instead of 65 quality measures, there are 33 (see page 324 of the rule linked above) and the first year will involve reporting only, not performance (While managing to 33 measures will still be a challenge, this is a vast improvement)

ACO agreements start on April 1, 2012 and can continue throughout the year (It was pretty obvious that CMS was not going to make the January 1 deadline, but getting an ACO in place in 6 to 12 months will still be an uphill battle for many delivery systems).

Prior clearance by a "reviewing antitrust agency" will not be necessary, but that doesn't mean that ACOs aren't subject to antitrust law; they may want to submit to an expedited antitrust review (Given the stakes, the DMCB suspects all ACO participants will still want to lawyer up on this).

According to this press release, CMS will also make financial support available to physician- owned as well as rural providers.

The DMCB's first reaction is that CMS has done a good job of modifying its unworkable proposed rule.  It will take several days for the DMCB's sources to give it feedback.

Stay tuned!

The Latest Cavalcade of Risk is Up!

Another outstanding Cavalcade of Risk is up for your reading pleasure. Van Mayhall of the Insurance Regulatory Law blog is hosting a series of linked articles on the various aspects of business and insurance risk.  Check it out.

The Link Between Povery, Obesity and Diabetes

Having to pay for a portion of any health care leads to decreased access. Electronic medical records result in increased quality.  Primary care causes lower costs.  The Disease Management Care Blog is responsible for the DMCB spouse's migraines.  While each assertion may be technically true, the real underlying question is "By how much?"

That's why this New England Journal paper "Neighborhoods, Obesity and Diabetes - A Randomized Social Experiment" by Jens Ludwig and colleagues that examines the association between poverty and diabetes is important.  Researchers have known that low income can lead to preference for the "cheap calories" in refined and high fat foods which, in turn, lead to a high rate of obesity among indigent persons.  Now we have a better idea on how much.

Ever hear of the "Moving to Opportunity" demonstration project?  Neither did the Disease Management Care Blog, but this was a demo designed to test the long term impact of housing and poverty on health and well-being.  In the study, females with children who were candidates for public housing assistance were entered into a lottery that randomly assigned participants to one of three groups:

1) a low poverty voucher group that could use their vouchers to rent housing in a census tract with less than a 10% poverty rate (N=1425).  After one year, persons assigned this group could move anywhere they wished;

2) a traditional voucher group that could be used anywhere (N=657);

3) a control group that was SOL (N=1104).

The women were asked questions about their health at baseline, including height, weight and also provided blood samples to check an A1c to assess the presence of diabetes mellitus.  They were then followed for approximately 10 years.

Not all persons completed the follow up, so the authors used an "intention-to treat" analysis.  The rates of poverty are here, while the rates of obesity and diabetes are here.  The low poverty voucher group not only had lower rates of obesity (defined as a BMI greater than 35) but a lower rate of abnormal A1cs (16.3% vs. 20% in the control).  The traditional voucher group had lower numbers vs. the controls but they failed to achieve statistical significance.  It appears, based on this study, that living in a low poverty neighborhood reduces the rate of obesity and diabetes in the absolute range of 3% to 4%.

The authors correctly point out that not all persons in the study completed the follow-up, which could have biased the results.  In addition, the A1c results don't account for the possibility that more persons in the voucher group may have had their diabetes successfully treated.  Last but not least, much of the data were self reported.

The DMCB was surprised that poverty seemed to directly account for a relatively small amount of "new" disease.  On the other hand, an additional 3-4% involving millions of U.S. citizens represents a public health disaster.  Based on these data, we have a better insight on the role of poverty in diabetes and can point to at least one Federal program where taxpayers appear to have gotten their money's worth.

The Real Business Model For Virtual Medical Office Visits (and it's not increasing access)

"Stand up, bend over and let
me see that itchy rash!"

In another lesson on how its clinical world is changing, the Disease Management Care Blog recently witnessed a "virtual" computer-based video patient-physician office visit. The patient seemed to like the convenience, while the physician reminded the skeptical DMCB that most of any medical diagnosis is based on the patient history, not the physician examination. 

It worked pretty well.  What's more, the literature suggests that this is not all that new,  there are studies that suggest high levels of patient satisfaction and a surprising willingness to pay for the service out of pocket.  Time will tell on whether this leads to comparable clinical outcomes at an acceptable cost.

But what has struck the DMCB most of all was a business model "dichotomy."  Talk to most policymakers about virtual office visits and you'll discover that it is being hailed as another advance in increasing consumer-patient access to cost-effective care.  In other words, persons living in Faraway Montana will be able to discuss their rash with the expert Dr. Windowchat anywhere in the world.  The DMCB thinks of this as the "enlightened" side of "telemedicine."

While that may have merit, when the DMCB googles "virtual office visits," it finds a decidedly contrary business model: busy and computer-savvy suburbanites with the kind of disposable income who can pay out-of-pocket for the convenience of not having to sit in a waiting room.  From a health insurance perspective, this is quite compelling, since it substitutes a lower level of service for a population that is prone to overutilization.  The DMCB knows the doctors like it better when the insurers aren't involved in a high cash-flow 'yes-I'll-take-VISA' transactional business.  This is the "real" side of telemedicine.

The DMCB suspects this is one of those innovations that offers something for everyone: increased access for those with not enough of it and "disruptive" technology for a health care industry still locked into expensive and labor intensive one-on-one doctor-patient visits.  From all points of view, this form of telemedicine's future is very bright.

The Unfortunate Name of "Medical Home" and Some Suggested Taglines to Aid With the Marketing

A place "where you go to die?" That's how a consultant summarized the awareness of Connecticut's Medicaid beneficiaries about the "medical home."  Like multiple other States that are attracted by the patient centered medical home's (PCMH) allure of lower cost and increased quality, the Nutmeg State is apparently planning on assigning most of its Medicaid enrollees to primary care sites that offer this emerging approach to care.  Based on the negative connotations of being "put away" in a "home," however, rank and file patients aren't exactly happy about the idea.

The consultant recommends that marketing be used to deal with this medical misperception.  The Disease Management Care Blog not only seconds that motion, it wants to help by humbly submitting some medical home taglines gratis to help kick things off:

Got some groans?  Medical home!  Got an ache?  PCMH!

The Medical Home: your gateway to specialists.

This is not your father's nursing home.

Nursing home? Death; Medical home? The rest.

Millions of policymaking man-hours can be all wrong!

The Medical Home:  where you are not just a number, but a primary care fee.

Where your hope meets the Affordable Care Act's assumptions!

Your team will see or telephone or email you now.

Care Management Nurse to Enrollee Ratios for ACOs and the Importance of the "Soft" Side of the Nurse-Patient Relationship

We'll talk diabetes in a sec Mrs Smith,
but first, how's those darling kids?

Just being back from a whirlwind tour, the Disease Management Care Blog is happy to report that it became newly acquanted with some colleagues who are furiously at work building care management programs for newly minted integrated health systems and ACO wannabes.

They provided two big insights for the DMCB:

1) While the DMCB guesstimated that the typical ratio of care management nurses to enrollees amongthe mainstream care management service companies was in the range of 1:1500, at least two new programs are using a 1:750 ratio.  By the way, 1:800 is what was quoted in this peer reviewed article.  That's a lot of nurses for an "accountable" population and a lot of budget for a CFO to approve. 

2) There is less of an emphasis on care manager "productivity,"  thanks to a recognition that nurse-client conversations outside hard nosed chronic illness management "engagement," "barrier identification" and "shared decision making" contribute to relationship building.  The DMCB thinks of this as "magic nursing dust" that adds to the likelihood of patient behavior change.  There are no hard data on the topic, but it's important in other parts of the health care universe, so why not here?

Lots of Reasons Why You Should Attend The Patient Centered Primary Care Collaborative's Oct. 21 5th Annual Summit

There are several reasons to attend the Oct 21 Patient Centered Primary Care Collaborative's 5th Annual Summit.

You'll see the good work that the PCPCC is doing as the leading national organization advocating on behalf of the Patient Centered Medical Home (PCMH).

Along with an auditorium-full of like-minded learners, you'll benefit from an agenda that is packed with clinicians from the real world of medical practice who have developed successful medical homes. 

You'll get to meet others who share your interest in an innovative and rapidly evolving approach to primary care.   

You'll be in Washington DC at the height of beautiful fall weather. 

And, last but not least, you'll get your own copy of the PCPCC Report, Care value, community connections: Care coordination in the medical home.  According to this newswire press release, the report "includes the insights of thought leaders" on the theories and tactics behind the definition, role and function of care coordination.

The immodest Disease Management Care Blog couldn't have put it better itself, especially because it's the author of the first second chapter.

Of Neutrinos and Populations

Neutrinos!

For a true understanding of the true nature of "reality," there's no better place to go than the extremes.  While we may think we independently inhabit a rationally reductionist and linear universe, it's not true.  The smallest particles are both energy and matter, while the gravity generated by planets curves the fabric of space. Whoa. 

If that's not difficult enough, now the Disease Management Care Blog has to deal with the recent observation that neutrinos can travel faster than the speed of light. While it awaits confirmation, the discovery has important implications for decades of assumptions about the "relativity" of time (which can now go backwards?) and mass (which can now go beyond infinity?).  You can get a good sense of just how important it is by reading Mr. Krauthammer's cogent analysis.

The insights gained from "extremes" applies to other corners of reality, including people. The DMCB spouse is regularly tested by the various extremes of her husband's attitudes and behaviors.  At a far more magnified level, spend some time in a delivery suite at the earliest beginnings of life or attending to those at the end of life and you'll gain some insights there too. 

Neutrino speed reminds the DMCB the it's made up of subatomic dust gathered from infinitely large galaxies.  If that's true, why would we ever have the hubris to think that we're even close to understanding what makes us tick?  True understanding about health, wellness and achieving our greatest potential is to be gained at one end by examining subcellular genomics (for example, a "selfish gene") and at the other by, you guessed it, using huge observational clinical population bases (for the latest example, the true impact of dietary vitamin supplements). 

The future yield from ongoing investigations at either extreme end of the human spectrum promises to be phenomenal. 

We ARE all made of stars.....

An Unbalanced and Harmful Approach to Quality Measurement: Is Life Expectancy Enough?

Sei Lee and Louise Walter, in this Commentary published in the Oct 5 issue of JAMA, argue that the current  approach to measuring health care quality often leads to unintended harm for many older adults.  That's because the guidelines-driven and evidence-based measures are "unbalanced."

The Disease Management Care Blog agrees that the state-of-the-art is unbalanced, but it's even worse than Drs. Lee and Walter describe. 

First, the Commentary.....

Right now, standard methods for assessing the degree of blood pressure control (typically defined as being less than 140/90) doesn't account for some elders being prone to getting low blood pressure and dizzy when they're upright. Blood sugar control is a good idea among most persons with diabetes, but for many reasons, older persons are more prone to having dangerously low dips in their glucose levels.  Last but not least, there's also the questionable wisdom of screening for cancer when the likelihood of death from other causes is far greater.

Most nationally recognized clinical guidelines usually have a disclaimer that they are not intended to be used as an inflexible and one-size-fits-all standard of care (for example, read the 4th paragraph of the high blood pressure guideline here).  Yet, in contrast to the flexible guidelines, the all-or-none quality approach to measurement (for example) are inflexible and fail to give "credit" when testing or treating in individual patients are unwarranted. 

Drs. Lee and Walter propose to fix this by reconciling the measures with life expectancy.  If better blood pressure, diabetes or cancer screening can mathematically be expected to result in more years of life, then they should be implemented and only then should credit be given.  While this could get complicated (think life expectancy tables being used during a visit with your doctor or, egads, politically underhanded accusations of ageism and death panels), the authors point out that electronic health records' decision support - despite its disappointing track record - could enable life expectancy awareness during physician office visits. What's more, doctors wouldn't necessarily have to follow the decision support recommendations, but the fact that they were considered could be also be rolled into quality measurement.

What does the DMCB think?

It salutes the authors and JAMA for raising an important point. The idea of accounting for clinical benefit in quality measures is intriguing.  Yet, the DMCB doesn't think the authors go far enough in addressing the imbalance.  It would go one step further and make the measures depend on the on a rather radical patient-centered approach: if the patient was engaged and became aware of the risks, benefits and alternatives to the guidelines-based testing and treatment, was allowed to make an independent, educated and reasoned judgement and gave either active consent or refusal, only then is credit given.  Life expectancy can be part of that shared decision making, but it's not the only ingredient.

Novel thought hm?  It's not up to any utilitarian calculation of life expectancy.  It's not up to some buggy computerized decision support algorithm.  It's not up to any expert guidelines.  It's not up to national quality setting organizations.  Heck, it's not even up to the physician.  That's all unbalanced.

Want true balance? Once all the above inputs are understood, it's up to the patient.

The Institute of Medicine and the Inconvenient Truth of the Real Affordability of the "Affordable Care Act"

Enshrining a term only an actuary could love, the Affordable Care Act sets health insurance coverage on the basis of "actuarial value" (AV).  A good summary can be found in this Consumers Union Health Policy Brief.  As the Disease Management Care Blog understands it, AV is the percent of typical medical expenses that a health insurance policy will cover for a typical population.  In other words, some individuals will have no out of pocket expenses (deductibles, coinsurance and limits) while other individuals will have end up paying for most of their services.  When those expenses are rolled up over thousands of persons and compared to total health care costs, the percent left over is the "AV."

Once the Disease Management Care Blog wrapped its head around the AV, it next tackled the ACA concept of the "essential health benefit" (EHB).  This is the minimum package of covered services (outpatient, emergency room, maternity, hospitalization, medications, rehabilitation and the like) that a health insurer must include in its coverage plan.  This will ultimately be defined in yet-to-be-determined federal regulations. 

Now that we have the jargon nailed down, plans that fail to meet at least 60% of AV on the EHB will be excluded from the exchanges and ineligible for federal subsidies.  60% is "bronze" coverage, while 70%, 80% and 90% are "silver," "gold" and "platinum," respectively.  This is important because not only did most members of Congress not understand AV (consumer costs) or EHB (coverage), but because both will determine the future cost of our nation's health care bill. 

Enter the Institute of Medicine (IOM), which has just released a report on how the Feds should best determine the EHB.  A handy summary can be found here.

Bottom line? 

The IOM has backed into the EHB, not basing it on notions of optimum health coverage but on affordability.  It recommends that the basic affordable EHB be based on a survey of what is typically covered by an insurance plan that is purchased by a small business employer.  With that as the baseline, the EHB be further modified (based on scientific evidence and public input) so that the premium ultimately matches 70% of the small business AV.  According to John Iglehart writing in the New England Journal of Medicine, that could work out to be about $5000 per year for individuals and about $13,500 for families.

This is significant because the key underlying assumption of the ACA was that forcing everyone in the risk pool (with the Constitutionally suspect "play or pay" provision) with insurance rich in wellness, prevention and services like rehab, mental health and pediatric oral care would, by itself, drive down health costs.

The smart folks over at the Institute of Medicine respectfully disagree.  They believe the best approach is to figure out what is affordable first and then define the insurance coverage second.

It's finally happened.  While it's not explicitly stated, the Federal deficit has noisily bumped into the Affordable Care Act. The IOM has given the ACA's supporters cover over the inconvenient intrusion of costs into coverage, affordability into access and reality into fantasy.  Even if the IOM recommendations fall on deaf ears, DMCB readers can expect the the Federal budget's problems to now and forever be part and parcel of the ACA.

What to do?  When the Disease Management Care Blog is flummoxed, it likes to break into song.  One song that comes to mind is Taxman......

Where Is Healthcare's Steve Jobs?

Will the future Steve please stand up?

At his now famous Stanford University commencement speech, Steve Jobs made a point of telling the audience that he never graduated from college.  In listening to his story, the Disease Management Care Blog suspects Mr. Jobs really "programmed" his own higher education with a combination of internships and on-the-job training that enabled him to achieve those 10,000 hours necessary to create a world-class expert.

Which begs a DMCB question: where are the Steve Jobs of the healthcare industry?  While we've certainly had our visionaries and there is no shortage of 10,000 hour trainees (including yours truly), healthcare just hasn't had any of the Job-esque breakthroughs that have combined technological excellence and boundless consumerism. 

One reason for this, of course, is that healthcare, compared to the computer/handheld industry is truly different: unlike those glowing devices at BestBuy, healthcare intermediaries approve products and set pricing in a dense web of protective regulations.  This suggests that the absence of a "medical Steve Jobs" is no historical accident.  Rather, it's symptomatic of a market that makes true breakthrough innovations practically impossible.  Instead of visionaries, we have Secretaries of HHS; instead of "killer apps," we await more outcomes data; instead of product launches, we have the Federal Register; instead of cheaper, better products today, we're constantly trying to get someone else to pay for what we needed yesterday.

Nothing new there, but here's one more thing to consider when we think about Mr. Job's training:  A key ingredient in his education was his "outsider" status that enabled him to bring a unique perspective and turn the industry on its head.  Contrast his lack of any recognizable credentials with healthcare's unceasing reliance on vetted and insider MDs, PhDs, economists, academics, administrators, bureaucrats and other such experts on various Boards, Agencies and Panels. 

Steve Jobs tested his insights in a marketplace filled with consumers and changed the world.  Healthcare's expert class is imposing their assumptions on the same consumers and are preserving a dysfunctional system.

The Latest Cavalcade of Risk Is Up!

Louise Norris of Colorado Health Insurance Inside has posted a terrific and bucolic Cavalcade of Risk.  This is a summary with links to the best that the blogs have to offer on the business of "risk."

Enjoy!

Hospitals, Insurers and Pricing: What It Can Mean For Patients

The Disease Management Care Blog remembers Emily (name changed). She had a rare and lethal cancer that had spread to her liver.  When her oncologist had nothing more to offer, she wanted to go to a large academic medical center for a second opinion.  Because it was outside her health insurance company's network, her out-of-pocket expenses promised to be unaffordable.  The DMCB's case manager couldn't get her insurer to change its mind and cover the referral.

How can we help patients like Emily?  To many amateur politicians and regulators, the answer is to force health insurers to pay for every visit with "any willing provider."  However, as noted in this just published New England Journal Perspective, that approach often leads to unsustainable cost increases.  Unable to negotiate on price, health insurers are forced to charge everyone higher premiums because of too many Emilys seeking too much care at too many large expensive medical centers.

Thankfully, the article's author, Dr. Paul Ginsburg, doesn't condemn health insurers as the Evil Devil Incarnate.  Instead, he discusses two realistic options:

1) regulate hospital prices (a topic that the DMCB examined here) so that Emily and her insurer can better afford the treatments, or

2) use out-of-pocket expense "tiering," with insurance benefit plans that pay proportionately more for physicians and hospitals that are willing to negotiate on price.

Dr. Ginsburg points out that increasing provider consolidation, the hiring of physicians by hospitals and the formation of accountable organizations has complicated option 2 above.  Thanks to increased market power, they don't have to negotiate.  What's more, they're less willing to come to terms because of the real threat of unilateral Medicare and Medicaid rate cuts.

Savvy DMCB readers may wonder if hospital and provider tiering should be based on quality.  Excellent thought, but in the DMCB's experience, 1) its difficult to find quality metrics that are big or meaningful enough to translate into pricing differences and 2) if the quality is truly high, shouldn't that ultimately translate into lower hospital costs?  Fewer readmissions and complications should enable hospitals to charge less and still have a high margin, right?  The DMCB has found the answer is generally "no."

Unfortunately, Emily never made it to the academic medical center.  Not only did the insurer refuse to cover it, but the medical center refused to make an exception and give Emily a discount.  She was offered a referral to another large institution for evaluation and treatment, which she accepted.  She passed away approximately 9 months later.

The American Medical Association Recognizes Shared Decision Making

Readers of the Disease Management Care Blog may be surprised to learn that the American Medical Association "recognizes" shared decision making.  A document recommending precisely that is available for your reading pleasure here.

It's a good review of the topic and makes for interesting reading. While the DMCB knew that the term "shared decision making" was specifically mentioned in the Affordable Care Act, it didn't know that there was an group called the International Patient Decision Aids Standards (IPDAS) Collaboration that is developing and piloting standards.  It also didn't know that there is an academic entity in Canada called the Ottawa Health Research Institute (OHRI) that is devoted to research on the topic.  The one area in which the Americans seem to still be leading, however, is commercializing the concept.

The AMA also recognizes that shared decision making can make the physician-patient relationship stronger, opposes any effort to link it to insurance coverage and supports more pilot programs.

This makes the DMCB happy to be an AMA member.

Predictive Modeling: The Second Most Important Ingredient for Provider Accountability

When accountability fails

"Accountability."  Everyone wants it, right?

While it's one thing for health care providers to be "accountable" for costs, it's another for them to actually make money at it.  The Disease Management Care Blog is continuously amazed at how many physicians and administrators believe that dollops of "primary care," "prevention" and "wellness" will empty hospital beds and cause insurance money to appear like the morning dew on a windshield of a physician specialist's BMW. 

Believe that and the DMCB has an ORD-SFO United Airlines upgrade "departure management card" it would like to sell you.

If the DMCB could do only one thing to reduce costs within one fiscal year for a health care system , it wouldn't be PCPs, wellness or prevention. Instead, it would place one vastly overpaid case manager in every emergency room in the network.  His or her job would be to find alternative levels of care for persons that don't really need to be in the hospital and begin discharge planning for those who do.

The second thing the DMCB would do is implement predictive modeling.  That's why it's immodestly tooting its horn and suggesting research like this is so important.  In this web first publication, Chris Hollenbeak, Mark Chirumbole, Benjamin Novinger, Frank Din and your humble DMCB examined the baseline demographic data and medical conditions that can predict the likelihood of a future high cost hospitalization within a Medicaid population.  Armed with knowing which of its patients are at risk ahead of time is a critical level of intelligence for any newly "accountable" hospital, clinic, IPA, PHO or IDN.  By reaching out to high risk individuals prior to any crisis, physicians and administrators can engage these patients in outpatient settings and keep them away from the emergency room.

The good news is that the art and science of predictive modeling is within reach of most data bases, desk-top computers, statistical software packages and trained analysts.  The bad news is that interpreting and executing on that information remains a daunting challenge. 

Health systems like HealthCare Partners is a good example of how it can work well.  As this "accountability" movement in health care evolves, the DMCB will undoubtedly learn about other good examples. 

The systems that rely on vague notions about primary care, fail to understand the role of case management and ignore the business case for predictive modeling will form the bad examples.

Commerical Insurers' Research vs. The Patient Centered Outcomes Research Institute

Government researchers get to work

The Disease Management Care Blog confesses that, from time to time and only when it's alone, it enjoys listening to Taylor Swift, watching cage fighting and taking Newt Gingrich's bombast seriously.  During a typical superlative-laced ("Enormous!"  "Monumental!") New Contract update on CSPAN, the quixotic Presidential candidate pointed out that Medicare (the poster child for government incompetence) will never be able to match the private sector's golden boys Visa and Mastercard's fraud-fighting expertise.  He argues CMS should "outsource" catching crooks.

The Speaker may have a point and it doesn't apply to just fraud.  How about the conduct of research?

Check out this update on the ACA's Patient Centered Outcomes Research Institute, a $3 billion federally-funded not-for-profit "aiming to assist people in making choices that are consistent with the values, preferences and goals" of patients everywhere.  Its Board of Governors and Methodology Committee has been appointed by the GAO, it's been meeting every other month on "framework," "consensus," "priorities," "processes" and "agenda."  It has a mission statement, stakeholders, understanding, speakers bureau and a fix on the landscape that will "inform national priorities." State-of the art methods are currently being reviewed and summarized.

Contrast the progress of this PCORI  baronage with the likes of a 14-plan integrated database involving 33 million persons that can churn out four-year studies like this.  The authors compared the fracture rates of tens of thousands of persons taking 3 different anti-osteoporosis drugs and found one drug appeared to perform better than the two others.  Without the outside interference support of any pharma or government, the authors came up with an important insight that has implications for the coverage of osteoporosis drugs in the commercially insured population.  

While the good intentions and the talent are considerable, the DMCB has to wonder if this slow-motion PCORI suzerainty will ever be able to clearly and efficiently match the research speed and skill of the commercial health insurance industry.  Time will tell, but if the PCORI fails to give taxpayers their money's worth soon, perhaps they should be "Newted" and completely outsourced.

If Michael Jackson Had Been Enrolled In An HMO, He'd Still Be Alive

The Disease Management Care Blog has really been trying to not pay attention to the trial of Conrad Murray MD, the infamous propofol-wielding personal physician for pop legend Michael Jackson.  Unfortunately, the whole thing is so lurid, it's difficult to not gawk.

While no one should come to any conclusions about any allegations until all the facts are known, one thing is certain: Mr. Jackson is a poster child for the downsides of having unfettered access to all the health care anyone could ever want.  Dissatisfaction with a first round of plastic surgery and insomnia are common place, but few patients have the resources to go on to decimate their nose and turn their bedroom into an anesthesia suite.

Which brings up a good point.  Regular DMCB readers are well aware of this graph from the Kaiser Family Foundation report on Trends in Health Care Costs and Spending:

Back in the late 1990s, many HMOs made the mistake of controlling costs by aggressively denying payment for anything that didn't meet their definition of "medical necessity."  When it came to costs, it worked quite well.  While that style of managed care has since been defanged, health insurers including HMOs continue to apply a gentler, more transparent, regulated and still evolving standard of only covering treatments that are 1) appropriate and 2) effective when 3) there are no other safer alternatives.

While Mr. Jackson's death is allegedly an example of health care run amok, many mainstream physicians agree that "overtreatment" happens far too often.  Until a better system comes along, classic "1-800-MotherMayI" may have a role to play in keeping other Michael Jacksons from happening. 

The next time the DMCB reads that a "right" to health care should translate into coverage for anything and everything a doctor and patient would want, it'll ask a very simple question:  who's job, then, is it to say no, and if that happens, is it always bad?