Cinematic Clueless Care Management

While it is no Steven Spielberg, the Disease Management Care Blog humbly posts this short cinematic opus that portrays how easy it is for the wheels to come off of the care management train.

"Hello it's so nice to interact with you today.  My name is Nurse Vera Zealus and I'd like to help you get engaged today in the personalized  ongoing management of your diabetes in the context of your medical home.  Would you like to become engaged and  ongoing and managing at home while I get a care management fee on your behalf....?"

At one point he asks if she's a doctor.

Enjoy!


(Link to YouTube: http://youtu.be/VayIpAuSQAI)

The Latest Cavalcade of Risk Is Up!

David Williams hosts the latest Cavalcade of Risk in what he describes as fest.  If you're interested in the business aspects risk, this may be worth your while!

Lessons From A Health Care Christmas Carol: The Haunting Of Three Spirits

No wonder Jacob Marley is grumpy.  He's not only dead thanks to complications following a minor surgical procedure, the links of his ephemeral chains binding his wandering soul were individually forged with every uptick in health care cost inflation. His ledger was without outcomes and his surplus without savings.  His business should have been health and his profit prevention. 

For the Disease Management Care Blog, this doomsayer is more than a blot of undigested mustard or a missed dose of an anti-psychotic.  He brings a remorseful message about weak research, academic consultants and government meddling.  We ignore this spectre at our peril.

Jacob tells the DMCB readers to take heed, for they will be visited by three ghosts!

First will be the evanescent Ghost of Healthcare Past.  He flits in and out of sight in the policy salons with inferential, observational and conditional estimates of the past impact of unseen spirits like "PCMH," "ACO," "VBP" and "bundling."  If these sips of spiked holiday punch fail to convince a coldly skeptical world, this spirit can always point to the anecdote of the Tiny Tim who, but for access to patient centeredness, wouldn’t have become such a naïve, dimwitted and crippled believer in government-run healthcare. 

Then the academic and corpulent Ghost of Healthcare Present will appear. He has been feasting off the largess of a system that rewards the confidence that comes from fashioning economic cause and effect relationships out of hope, holly and mistletoe.  Festooned with a crown of academic credentials and a velvet robe of plausibility, this pleasant apparition loves nothing more than to feast with spectral policymakers in the warm glow of mutual admiration, obscure modeling and publications that go unread by the living.  Best of all, by being a Ghost of the Present, he can ignore the past and will never have to take responsibility for the future.

Then the fearsome and faceless Ghost of Healthcare Future will intrude.  He cruelly points a crooked bony finger at an unkempt and forgotten tombstone in the cemetery of long dead medical practices, like cupping, paper charts and physicians who actually talk to patients.  In the dim moonlight of fixed budgets and the bitter cold of Big Box Store health care, the inscription names “commercial private insurance” as the interred.  Is this what could be, what will be or what should be?

Warfarin, Insulin, Anti-platelet Agents, and Hypoglyemic Medications in the Elderly May Warrant a Population Health Management Program to Reduce Avoidable Hospitalizations

Got warfarin?

100,000.

That's how many persons aged 65 years or more are seen in U.S. emergency rooms and then hospitalized every year because of an adverse drug event.

Writing in the New England Journal, Daniel Budnitz and colleagues report data from the "National Electronic Injury Surveillance System - Cooperative Adverse Drug Event Surveillance" (NEISS-CADES) project.  The Disease Management Care Blog never heard of it either, but it's a consortium of 58 typical U.S. hospitals that are participating in an ongoing observational research project.  Whenever a physician blames a drug for an emergency room (ER) visit, trained chart reviewers go through the medical record.  From 2007 through 2009, there were 12,666 drug-related ER visits in the NEISS-CADES hospitals, which extrapolates to over 265,000 in the U.S.  More than a third required hospitalization, which rounds to approximately 100,000.

Medical Directors and quality assurance types may wonder how many hospitalizations were due to HEDIS high risk medications.  The answer was very few: only 1.2%.

There is also a list of medications that meet the "Beers" criteria as being potentially inappropriate in the elderly.  Likewise, very few could be blamed here: only 6.6%

So what caused the mayhem?  Basically there were four bad actors that accounted for approximately two thirds of the hospitalizations: blood thinners (warfarin and antiplatelet agents) and diabetes drugs (insulin and hypoglycemic agents).  What's more, the rate of hospitalization was highest among persons aged 85 years or greater and if there were five or more medications being taken.  Warfarin accounted for a third, the antiplatelet drugs, insulin and hypoglycemics accounted for another third and the remainder were miscellaneous.

What should the population health management community do with this information?

1. The DMCB would advise against believing that the hospitalization rate could be driven to zero.  It's well known that despite the best of care, between 1% to 2% of persons on warfarin will experience a life threatening bleed every year and, depending on how it's defined, that between 2 and 10% of persons with diabetes will experience severe low blood sugar.  Until we develop better blood thinners and diabetes drugs, bleeding and low blood sugar may just be a price that has to be paid.

2. Nonetheless, there are 100,000 hospitalizations and while the authors don't speculate on how many are avoidable, the DMCB wonders if this doesn't represent an important opportunity for the population health service providers.  Based on these data, regular outreach and monitoring of those persons on four types of drugs (warfarin, anti-platelet agents, insulin and hypoglycemic meds) who are taking multiple other medications and who are 85 years or greater may benefit from intense monitoring.  If the hospitalization rate can be decreased, that's a whole lot of savings.

Image from Wikipedia

Will Loss Of the Individual Mandate Torpedo the Affordable Care Act?

While the Disease Management Care Blog has had more than its share of doubts about the Affordable Care Act, it ultimately agreed that the "individual health insurance mandate" may be a necessary - if perilously unconstitutional - requirement.  Conventional wisdom says that unless everyone buys into the system, healthy persons will forgo the expense of insurance. That means only the sick will pay for insurance that ultimately cannot cover the collective cost of their illness. That will lead to a rapidly escalating prices, otherwise known as a "death spiral."

And that's why, now that the mandate has been taken up by the Supreme Court, Obamacare's supporters fear that striking the mandate could unravel everything.

Which is why the DMCB found this "don't worry, be happy" analysis by Lewin Group's John Sheils and Randall Haught very interesting. They say Obamacare can still succeed without the mandate.

Based on complicated economic modeling using a mix of inputs, methods and assumptions, they found, in contrast to the widely quoted Congressional Budget Office's mix of inputs, methods and assumptions, that

1) many persons without health insurance would take advantage of the ACA's generous premium subsidies, and

2) an open enrollment window limited to one month a year would blunt the impact of persons "gaming" health insurance by only enrolling when they're sick. 

While insurance would not be universal, the Lewin authors estimate that between 21 and 24 million Americans who were previously uninsured would become insured.  While premiums could increase by 12.6%, the premium subsidies would help put the word "affordable" in the ACA. 

To further buttress their argument, they point out that in 1993 New York State required its health insurers to accept all applicants regardless of health status.  Despite many dire predictions, there was no spiral and no documented loss of coverage.

What can the DMCB conclude after reading this?  It's easy: no one really knows what is going to happen in 2014 with or without the mandate. 

It looks like there is only way to find out.

Who Is CMS Administrator Marilyn Tavenner and What Does Her Nomination Mean?

Say hello to the CMS Administrator

Bowing to the implacably oppositional Republicans, President Obama's first selection for Administrator of CMS tendered his resignation and made way for second-in-command Marilyn Tavenner.  What's more, instead of using a recess appointment, the White House has submitted her nomination to the U.S. Senate.

So who, asks the Disease Management Care Blog, is she?

According to this biosketch (scroll down, you'll find her), Ms. Tavenner has a 25 year hospital administrator pedigree that includes being CEO at two Virginia Hospital Corporation of America hospitals (Chippenham and Johston Willis).  That part of her career culminated in her being the company's "President of Outpatient Services."  As the DMCB understands it, she entered the major leagues of public service in 2006 when Democratic Governor Tim Kaine tapped her as Virginia's Secretary of Health and Human Resources.  Thanks in part to her links with Mr. Kaine, she later jumped to CMS, where she became the "Principal Deputy Administrator and Chief Operating Officer."  Unsurprisingly, her duties have included loyally defending the Affordable Care Act (ACA).  You can see her in action here on C-SPAN.

By the way, did the DMCB mention that Ms. Tavenner is a registered nurse?

She has an Virginia Commonwealth University BSN undergraduate degree and apparently climbed the HCA ranks one patient care unit at a time.  Somewhere along the line she also nabbed a Masters in Health Administration.

Four initial thoughts from the DMCB:

1. The new CMS nominee is another example of the emergence of nurses as go-to health leaders.  Not only does the public trust them, they're able to bring a real-world understanding of hands-on patient care to the high falutin' mix of operations, policy, politics and finance.  The good ones know how to deal with grumpy doctors and neutralize clueless administrators.  That being said, the physician DMCB can't help it and still wishes there was a doc at CMS' helm. 

2. In its long career, DMCB has witnessed the Dark Side Transformation of many well-meaning physician or nurse administrators to a type that places profits over patients. What's more, few have become hospital CEOs without making some enemies along the way.  Will any past foes come forward with unpleasant anecdotes from an otherwise forgotten past?  Stay tuned.

3. Despite lots of searching, the DMCB couldn't find much of a track record outside some speaking gigs and serving on some boards.  As far as it can tell, she has no peer-reviewed publications and her public statements have been pretty vanilla.  While that may impair Mr. Obama's foes' ability to attack Ms. Tavenner's record, the DMCB wants to know more about someone who is going to be leading the world's largest health insurer.

4.  The absence of a track record doesn't mean that the nomination process isn't an opportunity for politically motivated mischief.  It remains to be seen how well Ms. Tavenner testimony holds up to the Republicans' intense "gotcha" scrutiny and whether her nomination ultimately becomes a toxic partisan (re)hearing on the merits of the ACA.

The Playbook For Medical Innovation Success (and a great example)

Along with co-authors Robert Epstein, Jean-Pierre Lehner and Tehseen Salimi, the unrelenting Disease Management Care Blog has penned yet another peer-reviewed article (on page 9 here), this time in the newly established Journal of Comparative Effectiveness Research.  While the title "Integrating Scientific and Real-World Evidence Within and Beyond the Drug Development Process" speaks to the development of pharmaceuticals, the DMCB humbly submits that the article's lessons can be applied to any medical innovation.  That includes not only medical devices but population-based disease and care management, the Patient Centered Medical Home, value-based purchasing, ACOs and bundled payments.

The DMCB argues that in order for medical innovations to succeed, there has to be a readily identifiable value proposition. The challenge for innovators is that this perception of "value" varies greatly between patients, physicians, payers and government.  Meeting the expectations of these disparate stakeholders means creating a three phase process of integrating clinical data, economic information, patient centered outcomes, population-based and observational real-world evidence obtained from networks, communities, countries and populations:  

1) The Definition Phase: understand unmet needs and catalog how any potential benefits will meet those needs.

2) The Generation Phase:  formulate and validate the benefits by collecting the information that spans population health science, clinical epidemiology, economic modeling, patient reported outcomes, econometric studies, clinical trials and observational data bases.

3) The Translation Phase: establish the benefits from the very outset of any implementation through continuous monitoring and updating of any and all outcomes data for an increasingly sophisticated marketplace.

What ingredients are necessary to sustain the three phases?

1) Informatics that aggregate qualitative and quantitative analyses that include not only all that traditional research but spans meta-analyses, public databases, insurance networks and social networks that integrate patient, provider and payer insights.  This has to evolve in tandem with shifting market conditions;

2) An on-line and highly accessible intelligence repository that functions simultaneously as a database, library and registry;

3) A dossier that catalogs all quantitative and qualitative assessments that build the clinical and economic case for coverage and reimbursement;

4) High performing and interdependent expert teams that can interact with multiple stakeholders.

The DMCB thinks that the success of the Patient Centered Primary Care Collaborative can be credited to following this playbook.  Click around its web site and it's patently obvious that this coalition has worked to align the vision of transformed primary care with society's unmet needs, have prospectively collected any and all study outcomes and are continuously monitoring its impact in the real world.  Their PCPCC web site is a target rich collection of informatics, databases, dossiers and teams.

Super Committee To Physicians: Go Texan or Go Dishwasher

Room for one more!

Once again, the Disease Management Care Blog got it right: the prognosis for the Congressional 12-person Super Committee was only slightly better than the likelihood that the DMCB was a Justin Bieber love-child.  How could the Committee ever succeed with the 13th Man being elsewhere overseas, while Dr. Krugman on the left and the WSJ's editorialists on the right were both agreeing that any deal would be Satan's spawn?

But if budget cutting is a good thing, why are the equity markets down?   In addition to the lingering threat of an eventual Moody's downgrade, the DMCB suspects stock holders a) have calculated a $1.2 trillion budget cut was never really up to the task*, and b) fear that the 2012 Congress won't stick to its guns.

So, asks the DMCB, what's next? 

Automatic cuts will be applied to discretionary federal spending as well as the defense budget.  While Medicaid is spared (much to the relief of our nation's governors), Medicare is facing a 2% sequestration which, because premiums and cost sharing will go untouched, translates into payment cuts for hospitals, doctors and other providers.  An additionally toxic wild card is a looming additional "SGR" 27.4% Medicare physician fee schedule cut.

How will the DMCB's physician colleagues react to this dysfunction? 

Not well:

1) for those in physician owned practices, it may come down to deciding whether or not to go postal Texan.

2) for those in salaried positions, they can look forward to their Administrators turning to the "dishwasher" approach of maximizing patient throughput-dependent revenue: there's always room for a few more.  And if docs expect Uncle Sam to have any sympathy, they need to think again.

Let the games continue.

(HT to George Will)

Technocrats Running Amok: What It Could Mean For America Inc.

Check out The New York Times columnist David Brook's most recent article for an insightful look at how the Europeans entrusted their collective economic future to an expert technocratic class.  Once those mandarins were unleashed, their bureaucratic disdain for undereducated commoners was only exceeded by their skill at complex obfuscation.  Egads.

On the other side of the globe, China's state-managed businesses are making a mess of high speed rail, creating a housing bubble and are enabling an autonomous People's Liberation Army.  And last but not least, the Russians have taken the concept of state sponsored oligarchy to a whole new level.

Compared to the rest of the world, carrying mortgages, automobile manufacturers and solar panel plants on the U.S. balance sheet may just have to be a new way of doing business.  If that's the case, we'll also need our pool of cool, pedigreed, hyper-educated Masters of the Universe like Energy Secretary Mr. Chu, who can easily triangulate on policy, politics and returns on investment. Thanks to brainy virtuosos like him, Uncle Sam, Inc. will be able to roll the dice and be a venture capitalist. 

And health insurance isn't immune. The virtuosos in Washington are busy setting the essential benefit, determining the best medical loss ratio and which companies can compete in exchanges.  Generics are regulated and if there is no approval, drugs won't be covered.  Even though elections have consequences and Disease Management Care Blog readers may loyally disagree from time to time, how can we turnips dare to cross swords with experts like this?

It's ironic that with this as background, our political class can claim to understand the concerns of "Occupy Wall Street."  So does the DMCB, but that doesn't mean it isn't also worrying about those elite technocrats helping Washington become Wall Street.

A Population-Based Care Management Lesson: What Telephonic Disease Management Lacks In Individual Effectiveness Is Made Up By It's Greater Reach

What did that study show?

In yesterday's post on the role of telephonic disease management for obesity, the Disease Management Care Blog pointed out that POWER was a landmark study that demonstrated that remote lifestyle counseling performed as well as traditional face-to-face counseling.

A New England Journal of Medicine editorial accompanying the POWER article points out that there may have been an additional factor that explained the results: patient attendance at the in-person counseling sessions dropped off precipitously as the trial progressed (an average of only 2 out of 24 scheduled visits after the seventh month), while the telephonic approach achieved 16 out of 18 scheduled contacts.

The DMCB agrees and suggests this is an additional virtue of remote telephonic disease management.  While in-person counseling may have more of an individual impact, it does little good if  patients no-show.  In contrast, "high volume" telephonic counseling may have more of a population-based effect, because a lower intensity intervention has greater absolute impact if it's delivered to more persons.

NIH scientist Susan Yanovski's editorial falls short on capitalizing on that insight.  While it grudgingly points out that POWER shows "PCPs can deliver safe and effective weight-loss interventions in primary care settings," it neglects to mention the two important implications of POWER:

1) non-physician team members acting collaboration with PCPs are an important resource in the national battle against obesity and

2) offering a variety of communication channels increases reach and gives more patients new and effective options to access anti-obesity programs.

The Latest Cavalcade of Risk Is Up!

The Disease Management Care Blog can't believe it's only a week until Thanksgiving.  One more reminder of how time flies is this holiday themed Cavalcade that is hosted by Nancy Germond at the Insurance Writer Blog.  Enoy!

Lessons From The Practice-based Opportunities for Weight Reduction (POWER) Study: More Evidence of the Effectiveness of Remote Care Management for Obesity

"I need to call someone..."

The Disease Management Care Blog apologizes in advance for a long post about an important study comparing two state-of-the-art weight loss interventions.  Get some caffeine and hang in there.  If you are interested in the science of disease management and its role in obesity, you will not be disappointed.

Talk to some of the Ayatollahs dominating the academic medical-industrial complex about telephonic disease management and they'll give you the same look that they give to something unsightly that they just discovered on the end of their finger after rubbing their nose.  The idea that some remote (ugh!), telephone-based (bleh!) for-profit (yuck!) company could contribute anything to their vision of the health delivery is health policy apostasy.

But what how does this ideology stack up against the evidence?  

Until recently, we haven’t really known because there were few head-to-head comparisons of traditional “disease management” vs. traditional patient counseling.  But now we have the just-published POWER (“Practice-based Opportunities for Weight Reduction” study that was funded by the NHLBI and (whoa!) Healthways.  The authors were from Johns Hopkins University, which has a long-term consulting agreement with Healthways. They had final say on the research methodology and the paper's contents.

POWER was a prospective clinical trial that randomly assigned patients to one of three weight loss intervention strategies.  One consisted of “remote” telephonic treatment counseling, the second provided in-person counseling and the third was a control group.  The in-person sessions were provided by Johns Hopkins employees while the remote telephone counseling was provided by Healthways.

Study patients with obesity and at least one risk factor (hypertension, hyperlipidemia or diabetes) were recruited from six Baltimore primary care practices from 2008 through 2009.

All the interventions used basic nutritional and exercise guidelines that were delivered with state-of-the art “social cognitive theory,” "behavioral self-management,” “positive reinforcement” and “motivational interviewing.” Both of the intervention groups had access to a web site with learning modules plus feedback. If there was no log-on to the web site every 7 days, patients were sent a reminder email. 

Persons in the disease management-style remote support arm of the study got 12 weekly calls lasting 20 minutes for three months, which was followed by 3 monthly calls.   Persons assigned to the traditional in-person coaching arm got nine group sessions and three individual sessions over the 3 months followed by one group and two individual monthly sessions over three months. 

Participants’ weight loss was assessed at 6 and 24 months.

The patients' primary care physicians received summary reports and encouraged their patients’ participation.

Readers should note that this was an “effectiveness” trial.  Unlike “efficacy” trials, the protocol dispensed with the usual run-in period or making sure patients were adherent to the protocol before or during the study.

1370 persons were screened and 415 were randomized.  64% were women, the mean age was 54 years, 41% were black, 97% had commercial insurance and the mean BMI was a hefty 36.6.

After randomization, there was some drop out: 366 were weighed at 6 months, 355 at 12 months and 392 at 24 months. 

At 6 months: the control group lost 1.4 kilograms (kg) while there was 6.1 kg lost in the remote support, and 5.8 kg. lost in the in-person group.  That's 3.1 lbs vs. 13.4 lbs vs. 12.8 lbs.

At 24 months, the weight loss .8 kg in the control, 4.6 Kg in remote support and 5.1 Kg for in-person.  That's 1.8 lbs, 10.1 lbs and 11.2 lbs. That translates to body weight changes of 1.1%, 5.0% and 5.2%.  The percent of persons hitting at least 5% weight loss was 18.8% in the control group, 41.4% in the in-person support group and 38.2% in the group getting remote support. 7.8% of controls, 27.5% and 18.8% of controls, remote and in-person support patients, respectively, reached a BMI less than 30  

There was no statistically significant difference in weight loss outcomes between the two intervention groups.  In other words, the small changes between the disease management and in-person counseling could have been the result of chance.

What can readers conclude?

1.  This was a solidly performed study with important implications for a still-evolving national strategy in the battle against obesity.  If an intervention can lead approximately 40% of persons to lose 5% of their weight over two years, maybe the science of non-invasive weight reduction has gotten to the point where insurers should cover it.  While the DMCB remains suspicious about “mandates” and “the minimum benefit,” there are other policy levers that could be pushed to make this happen.  This is doubly true when you think about the costly alternatives of drugs and weight loss surgery.

2.  Seen through the lens of a disease management vs. in-person counseling competition, the industry’s “best” (Healthways) went toe to toe with the health system’s best (Johns Hopkins) and it was a tie.  When it comes to weight loss, it now comes down to who can do it cheaper and who can scale it.

3.  While this was a solid study, readers should be aware of its imperfections.  Since there were so few patients on Medicare or Medicaid, we don't know how this would work in patients with public insurance. This was not double blinded, so it’s possible that the outcomes were skewed because patients and their doctors were aware of their assigned treatment arm. The drops-outs' weights went unmeasured and their data could have changed the results.  There was a high reliance on group sessions in the "in-person" arm of the study, which may not be as effective as one-on-one counseling. The in-person sessions were also “remote” from the PCPs’ offices and may have been a poor substitute for the one-on-one counseling envisioned for a robust PCMH.  Successful weight loss is usually defined at 10% of body weight at one year instead of 5% at 2 years.  It’s also difficult to discern the relative contribution of the web site vs. the physician support vs. the nurse counseling.  We don’t know what happened to the patients’ blood pressure, cholesterol levels or their blood glucose control.  Finally, Hopkins had a doubtful but potential conflict of interest in a study that showed non-superiority vs. one of their customers.

4 While the DMCB doesn’t want to quibble, close scrutiny of the p-values in a table comparing the percent of persons reaching a BMI less than 30 for the in-person vs. remote support cohorts shows that it came quite close to being statistically significant at p = .07.  In other words, Healthways (27.5%)  almost beat Johns Hopkins (18.8%).  Using the same criteria in this study widely hailed as proving that Group Health’s medical home saves money, Healthways did beat Johns Hopkins.

5  Healthways deserves kudos for submitting to and committing resources to a clinical trial.  To the DMCB, the search for scientific truth is a price of doing business.  Their shareholders may think that cash is better spent on pursuing customers or driving efficiencies, but this research is an investment that will yield returns over the long run.  Other for-profits "get it" and so does Healthways.  The only question is why isn't this spashed on the company's web site?

6  If both interventions are equivalent, the DMCB suggests that they are not necessarily exclusive.  A truly enlighted approach to this would be to let patients choose which form of counseling they prefer.  What's more, if patients were allowed to choose, the amount of weight loss for both groups would probably be even greater.

7. Last but not least, this is further evidence that "disease management" has grown up.  This "DM Ver 2.0" is based on far more sophisticated principles of behavior change than those used in the Medicare Health Support debacle.  What's more, this Johns Hopkins paper reminds us that physicians, in the course of routine patient encounters, are simply not an option when it comes to weight loss counseling.  They're too busy and their job is to provide a supporting role.

"POWER" - one more acronym and one more piece of evidence to use in defense of disease and population-based care management.

What Are The Presidential Candidates' Positions On The Patient Centered Medical Home?

As a public service, the Disease Management Care Blog is happy to build on what we know about the positions of the Republican Presidential candidates on health reform and speculate on the likely debate answers that the front runners would give if they were asked about the Patient Centered Medical Home.  By facilitating this political narrative, the DMCB hopes our candidates are now free to address the issues that really matter, like whether exposed men's toes are ever appropriate in the workplace, why airport skybridge personnel vanish when flights arrive after 11 PM and whether dermatologists working in ACOs could ever relearn which part of a stethoscope goes in the ears.

Rick Perry:  "I'm opposed to P-C-M-H because they are one, 'patient centered,' two 'medical' and three.... um, I forgot what that third H is for.....ooops."

Mitt Romney: "While I supported it in Massachusetts, I oppose it now because the federal government supports it in other states, where it is both supported and opposed.  We also don't know if this approach to care will reduce elevated costs going down."

Newt Gingrich: "This is a constitutionally catastrophic and unprecedented intrusion of enormous federal power of stunning proportions.  Truman wouldn't have stood for this and Lincoln would be shocked, which is why you should buy my book."

Herman Cain:" I am opposed to the patient centered medical home because primary care should rely on teaming and electronic records so that they can take better care of patients."

Michelle Bachman: "A woman told me that her baby is brain damaged because of care received at a medical home!"

Ron Paul: "I don't see the words "patient centered" in the U.S. Constitution and what's more, when we switch to the gold standard, we won't be able to afford it."

Potentially Preventable Hospitalizations (PPH) Among Persons With Diabetes Mellitus

All aboard!

If you’re expecting your newly established Patient Centered Medical Home (PCMH), Accountable Care Organization (ACO) or Population-Care Management Program to reduce hospitalizations among persons with diabetes, you may want to sprinkle the acronym “PPH” into your business plans, talking points and meeting pitches. It stands for “potentially preventable hospitalizations.”  It’s not only a timely topic, but by brandishing the term “PPH,” compared to all those unfortunate knuckleheads who don’t read the Disease Management Care Blog, you’ll once again remind everyone about your health industry chops.

That’s why a look at this AJMC article examining “PPH” in a population of persons with diabetes may be worth your time.  555,538 California ’05-’06 hospitalizations for 361,858 persons aged 65 years or greater were examined for the presence of an "ambulatory care sensitive condition" or "ACSC".  The science underlying the use of ACSC metrics in this study has shown that the effective outpatient care of persons with certain concurrent ACSCs can reduce hospitalizations. The ACSCs used by the researchers in the AJMC article were bacterial pneumonia, dehydration, urine infection, COPD, heart failure, hypertension, diabetes complications and uncontrolled diabetes. 

In addition to ACSCs, the the authors looked at the impact of age, gender, race, neighborhood, income, insurance type (Medicare, Medicaid or commercial) and the number of other chronic conditions (as determined by insurance claims).

The results?  More than 112,000 (about 20%) of the hospitalizations were due to an ACSC and therefore were PPHs.   The most common conditions were pneumonia and heart failure; the length of stay averaged 5 days with a per hospitalization cost of approximately $9900.  The authors estimated that PPHs resulted in 570,000 hospital days and a cost of more than $1.1 billion  Being female, Medicaid, rural dwelling, low income, having multiple co-morbidities and having to be admitted via the emergency room were all associated with PPHs.

How can this information help the PCMH-savvy, ACO-adroit and care management cognoscenti?  While the authors of the AJMC article vaguely suggest that better vaccination rates against flu and pneumonia may work, the DMCB offers up some additional observations:

1. Baseline:  Now readers have an idea of the extent of the problem in a diabetes population.  20% is a lot of PPHs, a lot of hospital days and a lot of money.

2. Reality Check:  In this study, 80% of the admissions for persons with diabetes were NOT potentially preventable.  This should give pause to anyone believing that their initiative can precipitously reduce hospitalization rates.  Doctors (the kind that actually take care of patients) will also tell you that many PPHs are not truly preventable also: many people get acute pneumonia and heart failure exacerbations despite the best of care. As a result, more than 90% of hospitalizations among elderly persons with diabetes may not be preventable.

3. Generalist Care Management, not just diabetes care: your organization's nursing care plans have to not only address blood glucose control, but a host of other co-morbidities that are the real short term drivers of inpatient use.

4. But, Cake and Eat It Too: There are scant data on this, but the DMCB believes that good blood glucose control leads to fewer infections and atherothrombotic complications.  If it is correct, good care management not only has to manage multiple co-morbidities (the cake) but achieve good blood sugar control (the eats).

5. ER Chicken and Egg:  Does becoming very ill with an ACSC make ER visits more likely which, in turn, makes a PPH more likely?  The DMCB agrees that that is one causal pathway accounting for the data above.  However, it also wonders if presenting to an ER with any ACSC at any stage of illness is more likely to lead to an admission.  If the DMCB is correct, it stands to reason that 1) developing initiatives that keep patients away from the ER (with outpatient care options) may materially reduce admissions and 2) putting care management resources in the ER to assist with discharge planning is an option because it may divert patients to the outpatient setting.

Planning for a Post-ACO World

The great Wayne Gretzky once famously observed that he achieved ice hockey prowess because he made a habit of skating to where the puck was going, not where it is.  That important lesson may have been lost on countless health care executives who, now that the Department of Health and Human Services has told us what an "Accountable Care Organization" (ACO) is, are furiously skating to fill out this application.

The Disease Management Care Blog suggests they also think about where this ACO puck could go.  Listen to the ACO zealots and its easy to believe that the triple aim will become manifest and providers will rolling in shared savings moolah in less than 18 months.

Regular DMCB readers know better.  They know that Medicare's ACOs have no track record and that the ACO-like models have had a checkered experience.  As data on the Medicare's ACOs come in, it is quite possible that we may discover a penalty box where a) shared risk translates to shared losses, b) the Feds are fickle partners, c) the correlation between cost inflation and quality is implacably positive and d) only a few hospital-physician alliances have the kind of non-generalizable culture necessary to make ACOs financially viable.

In other words, this is not going to be a preordained power play. By the time they get there, ACOs could find the puck went somewhere else. 

The DMCB humbly suggests that that somewhere else could be a post-ACO world.  That’s why the DMCB suggests that no organization’s long-term ACO strategic planning is complete without serious contemplation of why they should not follow the herd and plan on a 3rd quarter where:

The Bubble Bursts?  The hangover of lost millions in misallocated capital and human resource investments could preoccupy key partners and hobble lead competitors for years to come.  This has important implications for future business relationships, mergers and acquisitions and growing market share.

The Ascendancy of Physician Groups.  As hospital-physician arrangements unravel, the larger  independent physician-owned practices left behind could fill the vacuum with an array of contained, discreet and non-global commercial insurer payment arrangements that are based on 1) a level playing field and 2) what both sides value.  That is, of course, assuming these practices don't run afoul of any market dominance scrutiny by the FTC.

Federal Retrenchment:  Despite any prior deals on the SGR, a perfect storm of entitlement non-reform, rebounding cost inflation and the lack of any new innovative ideas forces CM to cut rates. The impact on physician participation in Medicare is anyone’s guess, but the new urgency to control costs means physicians will 1) have one more business reason to seek the efficiencies of larger groups and 2) be even less willing to take on additional practice costs that ranges from hiring to technology.

Should provider organizations skate toward this post-ACO world?  The DMCB suggests it's not unreasonable.  Time will tell if they win this game.

Vendors Agree To Monitor, Measure Patient Injuries Related to the EHR

Lest readers believe the skeptical Disease Management Care Blog has been unnecessarily harsh on the pro-electronic health record zealots, check out this news article on a  long overdue agreement among 44 vendors who have agreed to pool data on EHR-related adverse events.  Hopefully this on-line reporting system will be able to collect information on the extent and of type of medical mistakes associated with our brave new digital-medical world. 

Two points deserve emphasis:

1) Physician liability insurers (the companies that defend physicians against allegations of malpractice) are paying close attention and could use information like this in their underwriting.  It seems some are ready to conclude that bad EHRs can not only lead to patient injury, but may deserve increased premiums.

2) Nothing spurs action more than the threat of an outside or unfriendly regulator or government entity willing to independently collect this kind of information and act on it.  The DMCB wonders if that was one ingredient in the formation of this initiative.

The DMCB is looking forward to seeing the numbers in the coming months.  Stay tuned!

The Latest Health Wonk Review Is Up!

So now you can know about oilos, but only if you check out the latest Health Wonk Review, hosted by Hank Stern of the InsureBlog.  Hank treats us to a symphony of the best health policy posts with perspectives you won't really find anywhere else.  Enjoy!

Another Look At An "All Payer" System For Hospitals.

Why do different insurers pay different amounts for the same service?  While Medicaid and Medicare are notorious for their take-it-or-leave-it fee schedules, competing commercial insurers' payment rates for vary considerably across providers, even within the same region.

Uwe Reinhardt tackles this mystery in a just-published article in Health Affairs.  Not only is this “price discrimination” untidy, says he, it’s also been unfairly credited as being evidence of “cost shifting.”

It turns out that there are some credible studies that show that as public payer fee schedules get squeezed, commercial insurers seem to pay more.  Yet, in order for a cause and effect to be present, that would mean that providers are not acting in their own economic self interest and are waiting on Medicare and Medicaid before bargaining with their local managed care plans. To Dr. Uwe, that seems suspect.  That would mean commercial insurers have little negotiating leverage which would also mean that the U.S. cannot rely on them to control costs.  Yikes.

Compounding this untidiness are the big swings in the costs of goods and services in an opaque market that seems better suited to upside price gouging and not downside discounting. This is not only hurting the uninsured, the dysfunction is now reaching into the pocketbooks of the middle class.  No wonder Americans are grumpy about the cost of health care.

Dr. Uwe’s suggestion? An “all payer” system.  Not to be confused with a “single payer” system involving some sort of Obamaesque Price Czar, all payers would negotiate prices with all providers in regional blocks across counties, regions or even states.

Some of the European countries use this approach and so, by the way, does the state of Maryland.  The role of government would presumably be limited to brokering a yearly Big Meeting between representatives of both camps; in fact, government could make sure all parties agree to prices that are indexed to the GDP.  The result?  Patients would benefit from an average price applied equally to all, insurers would know they’re paying their fair share and best of all, hospitals would get a fair price for their services.

The DMCB likes the approach but suspects that politicians would be tempted to meddle by showing favoritism.   It would prefer to see it implemented at the state level while the Feds are kept at arms length.  It should be limited to hospitals at first.  Depending on how things work out, it could be tested on a trial basis involving physicians, such as the Patient Centered Medical Home.

Asynchronous Prescribing: A Primary Care Divorce and the Basis for Medication Irreconciliation

The Disease Management Care Blog welcomes this essay from a physician colleague.

When I first started in practice, face-to-face “medication reconciliation” was built into my drug prescribing.  The prescriptions were written by hand at the time of the clinic visit and each one, including the dosing and their purpose, were discussed with the patient.  New prescriptions by physician-specialists were noted during the time of the initial history taking, meds that the patient stopped on their own and the reasons why were reviewed, intolerances to recently prescribed meds were discussed, allergies were updated, and side effects were explained.  Prescriptions were written for one month supplies and enough refills were given until the next encounter.  They were then handed to the patient.  If there was a problem, I could count on my patient to notify me right away.

As time went on, things changed.  Thanks to how many pharmacy benefits plans are run, mail order prescriptions are now typically given for ninety days with four refills.  I think of this as medication irreconciliation.

While ninety days may look like a good idea, for the primary care physician, this was the beginning of a divorce between medication prescribing and the clinic visit.  Face-to-face medication reconciliation is no longer synchronized with the doctor visit.  Since this now asynchronous disconnect allows patients to skip appointments and continue medications, many physicians no longer

1) perform frequent medication reconciliations and

2) use the reconciliation process to monitor their patients.  

This problem is greatest for those diseases that require more than annual visits.  Instead of using the medication reconciliation process to follow complex hypertensive, hypercholesterolemic or diabetic patients every three months, one-on-one appointments, because of skipped appointments, are now happening annually.   This has made it difficult to schedule other appropriate preventive interventions such as testing, preventive screening and immunizations such as flu shots and other timely care.  

This was the reason that primary care often wrote prescriptions that were only good until the next encounter.  As Reaganites like to quote “Trust and Verify”.

It doesn't stop there.  What has finalized the divorce between the drug and the visit is the new auto refill program being used by many pharmacies (examples are here and here).

Thanks to auto refill, the patient and physician are even more disconnected with each other.  Under this system, expired refills prompt automatic refills requests that are not patient or physician initiated.  I have found in my practice that these auto refills are often for discontinued medications.  What’s worse, I have also received refill requests from pharmacy benefit managers that have apparently opened expanded operations in the afterworld for deceased patients. Humorously, one note attached for the deceased patient’s request stated that he was expecting to pick it up at 11 am on Thursday.

I am not the only one who has noticed this (here and here).

This divorce between face-to-face visits with my patients and medication prescribing has made the problem of “medication irreconcilation” even worse. It’s now necessary to reconcile each and every prescription asynchronous with the office encounter.  This may be efficient for the pharmacy providers, but it is disastrous for primary care and dangerous for patients.  For many primary care physicians, the best time to reconcile medications is when all parties are present.  During a traditional office visit, patient labs and tests are reviewed, vital signs are taken, the history is updated and an exam is performed.  That’s the perfect time when all the appropriate medications for an appropriate length of time should be prescribed.

Thanks to the divorce, accurate reconciliation has become at times impossible.  Physicians can’t use clinic visits to query their patients about new developments in their care or new prescriptions by other providers.  New doses can’t be reviewed, compliance can’t be discussed and patient concerns can’t be addressed. 

This divorce between prescribing and seeing the patient has become grounds for irreconcilable differences.  It sure was easier when it was the other way around.

Unsophisticated Government Regulation of Generic Drug Manufacturing: Shortages Are Surprising?

Contrary to what readers may think, the Disease Management Care Blog is not an inflexible nutcase ideologue that is 100% opposed to the government financing or regulation of health care.  It knows that it can make eminent sense for the Feds to step in when markets fail. The DMCB also understands that stepping in not only means additional spending, but laws, regulations and oversight to make sure patients as well as taxpayers get their money's worth.

And so it goes with overseas drug manufacturing.  Recall back in 2010, the widely used blood thinner heparin was tainted with look-alike chondroitin.  The source appears to have been China and in typical fashion, the plaintiff attorneys have begun to swarm. Given that recent fiasco, who could argue about the stepping up the FDA's role?

Well, since then, a generic drug shortage has emerged and no one is getting their money's worth. 

Readers can the depressing explanations here and here.  As the DMCB understands it, only a few overseas manufacturers are willing to put up with the United States' quality oversight and average-cost-plus-6%-margin price controls.  As inevitable manufacturing problems arise or as upgrading of production makes them go offline, the flow of drugs dries up. In response, middlemen and end-users resort to stockpiling, which only makes the shortages worse.  Finally, since generics aren't available, physicians have ironically turned to using more expensive brand name drugs.

And this outcome is surprising?

The U.S. Congress and the Administration have responded with characteristic pretzel logic: if government intervention and regulations have failed, the answer is more intervention and more regulations.  By recent executive order, manufacturers are now being forced to announce impending shortages (which has been criticized as likely to prompt even more stockpiling), maintain redundant production systems (which is probably one more barrier to running a profitable business) and, while keeping price controls in place, allow for more of a profit margin (which, of course, will be unilaterally set by deficit-ridden Uncle Sam in no mood for generosity).

But wait! 

None other than physician and former White House Health Policy Golden Boy Ezekiel Emanuel penned this opinion piece back in August. While not explicitly endorsing the idea that the Feds should get out of the way, he does want his former boss to reconsider:

"A more radical approach would be to take Medicare out of the generic cancer drug business entirely. Once a drug becomes generic, Medicare should stop paying, and it should be covered by a private pharmacy plan. That way prices can better reflect the market, and market incentives can work to prevent shortages."       

The DMCB finds it telling that such an ardent supporter of health reform would even consider such a notion.  Yet, when taxpayers are being forced to choose between the two extremes of a decidedly unsophisticated approach to overseas generic drug manufacturing with unintended consequences versus a competitive market-based laissez faire approach, maybe Ayn Rand had a point.

It's enough to make the DMCB think about becoming a nutcase ideologue.

But not yet.

The Latest Cavalcade of Risk Is Up

It'll be a blogerful day in the neighborhood when you check out the latest Cavalcade of Risk, hosted by Julie Ferguson at the Workers Comp Insider.  This is a compendium of the latest and bestest business-risk posts by a variety of authors.  There is something for everyone.... link.

Seven Reasons Why Small Physician Owned Practices Will Continue to Do Well Despite Accountable Care Organizations (ACOs)

Since the Disease Management Care Blog not only wants to be informative but also helpful to its readers, it has developed a seven point generic physician employment inquiry response and recruitment letter.  It is available below. 

The DMCB is confident that those smaller physician-owned private practices that remain independent will find this form letter very helpful in the coming years.  The DMCB releases this to the public domain and its colleagues are welcome to copy, paste, distribute, share, alter, modify or adapt all or some of the document as it becomes necessary.

Dear [insert name of physician here]:

Thank you for your recent [select: tweet, email, Facebook posting or VM] inquiry about leaving your current salaried position and joining our practice.  Thanks to widespread patient dissatisfaction with the institutions that were spawned by "health reform," our small business has experienced tremendous growth. We are constantly on the lookout for new talent that complements our projected demand.  Maybe you can join our team!

As you are undoubtedly aware, many of our colleagues nationwide have been lured into full time employed positions involving large complicated corporate practice arrangements, many of which were set up to be ACOs. Savings haven't materialized and many of these organizations have responded by demanding more patient "throughput" from their employed physicians and imposing cutbacks in vital support services.

In contrast to those organizations, our practice offers you:

1) a completely transparent compensation arrangement that equitably divides our net revenue income among the owner-physicians.   No more having to deal with an unwieldy administration that allocates salary amounts based on some opaque budget of anticipated revenues and upside savings minus overhead and capital allocations that you have no say in.

2) a team-based environment that not only relies on your expertise but knows who's boss.  Unlike those other complicated practice settings with layers of middle management, our office personnel report directly to you, period.

3) a patient population that is not only grateful for our high "same day" service standards and efficient and compassionate practice style, but who also recognize that unnecessarily calling at the end of the business day or repeatedly while we're on night call is reason to be assisted in finding another physician.  We have carefully cultivated a very loyal following of patients who genuinely partner with us.

4) a highly trained and motivated administrative support and care management staff that not only uses state-of-the-art approaches to deal with private managed care commercial insurers, but uses a "3A" approach of Anticipating, Automating and Appealing any service that requires prior authorization from you.  You'll only get involved in these matters when it's necessary.

5) a stable practice environment. Speaking of managed care insurers, they comprise the bulk of our business. While they are far from perfect, Medicare and Medicaid they are not.  They don't threaten us with arbitrary fee schedule cuts, audits, and payment delays.  We firmly believe patients and taxpayers should get what they pay for.  It's not our fault if they haven't paid for our level of clinical and consumer excellence. 

6) an EHR system is not only low cost and user-friendly, it's modular and cloud-based.  Our vendor has agreed to performance guarantees, there are no one-sided "hold-harmless" clauses and it's seamlessly compatible with any hand held device of your choice any time and any where.

7) a unique market niche that sits in that "sweet spot" between a local employer community that likes us, insurers that respect us, specialist physicians work with us and a multispecialty ACO close by that welcomes our referrals.

Once again, thank you for contacting us.  Please send your CV to [insert P.O Box address here] where we will store it in strictest confidence along with dozens of your colleaques' CVs.  We promise you that when we get to it in the coming months, we will contact you. 

Best regards,

Some Inconvenient Cautions for the PCMH and ACOs, Courtesy of the Medicare Health Support Program

Remember Medicare Health Support (MHS)?  That now defunct Medicare program is widely regarded as "the" study that "proved" that "disease management doesn't work."

If you're one of those disease management skeptics, you might enjoy the lingering anti-vendor schadenfreude of this bottom-up re-analysis of the MHS program that was just published in the New England Journal.  However, if you are a fan of the Fed's programs for the Patient Centered Medical Home or Accountable Care Organizations, you'll also want to pay close attention to a timely reminder about the perils of contracting with CMS.

The Disease Management Care Blog explains.

Recall MHS was a CMS program designed to test old fashioned disease management in fee-for-service Medicare.  A total of eight vendors launched their programs in separate geographic areas across the U.S. in the latter half of 2005.  Each area had about 30,000 beneficiaries with diabetes and heart failure who were randomized to disease management or usual care in a 2:1 ratio.  Participants were ill with an average of more than one recent hospitalization in the previous 12 months and more than $15,000 in baseline costs.  The programs consisted of remote call centers staffed by nurse-coaches who counselled patients on a regular basis.  Each of the vendors negotiated a monthly "at risk" administrative fee from CMS.  To retain the fee, the companies had to reduce costs in excess of the fee and simultaneously achieve a variety of quality and satisfaction targets vs. the usual care patients.  If they failed to save enough money, CMS clawed the money back.

The Journal's reanalysis, involving more than 240,000 beneficiary-participants, didn't shed any new light on the original depressing report to Congress.  Among the eight vendors, the change in the per beneficiary per month (PBPM) cost ranged from $22 in savings to $38 in additional costs; most of the PBPM changes were in the single digits.  In contrast, the fees ranged between $74 to $159 per beneficiary per month.  Only three of the eight vendors had lower costs, none achieved statistical significance and none had savings that exceeded their fees. There were some improvements in quality, but they were spotty and quite modest.

Participation rates among eligible beneficiaries averaged 85%.  Mean telephone contacts per patient was .7 per month and ranged from .4 to 1 per month.  Patients were telephoned on average every 2.7 months; over a 30 month period, 59% were contacted at least 10 times and 23% were contacted fewer than 5 times. 

And what are the lessons?

The authors had five, all of which also apply to the medical home and ACOs.  The DMCB has two more.

1) Show me the money:  In retrospect, the research that led to MHS that suggested that disease management "worked" was imperfect.  By the way, the same can be said of the largely observational and underpowered research supporting medical homes and the total lack of any meaningful experience with ACOs.  Will these innovative care approaches share the same fate as MHS?  Based on what we know at this time, it can't be ruled out.

2) Needy patients:  Medicare beneficiaries with diabetes and heart failure are sick. The nurse-coaches were unprepared to meet all of their patients' needs.  Medical homes and ACOs may end up being surprised also.

3) Analytics:  In the CMS' "data dumps" to the vendors, it was difficult to find the patients who were the most vulnerable.  This good news is that modern predictive modeling analytics - despite its limitations - may enable medical homes and ACOs to target their care management at those patients with the greatest need and at the highest risk for increased costs.

4) Timely access to data: CMS' data transfers to the vendors could be tardy, resulting in telephonic outreach to patients long after it could have done any good.  ACOs will need to worry about this in their dealings with CMS. 

5) The doctors: despite the vendors' assurances, the disease management programs were not aligned with the beneficiaries' doctors.  This is less likely to be a problem in medical homes and ACOs, but doesn't mean that they won't have to worry that their docs aren't fully buying into the notion of teaming with non-physicians.

The DMCB offers two other lessons:

In retrospect, calling sick Medicare patients infrequently may have been one factor in MHS' undoing.  The telephone will probably have a role to play for medical homes and ACOs, but the best mix of telephonic and face-to-face visits remains an open question.  At any rate, it seems that contacting patients at least every 30 days would be a good benchmark.

The DMCB remembers the confident "this is guaranteed to work!" hubris of yesterday's MHS architects and finds it eerily similar to the enthusiasm surrounding today's medical homes and ACOs. If the Medicare medical home and ACO programs don't work out, it'll set these innovations back ten years or more.

Image from Wikipedia

Finally, A Good Electronic Health Record Anecdote!

The Disease Management Care Blog remembers when it was first introduced to an electronic health record (EHR).  After many days of learning how to document, link, retrieve, order, manage, view, bill, sign-off and close patient encounters, it asked about retrieving summary statistics on its patient population.  It wanted to know how many if its patients with high blood pressure were under control and how many of its patients with heart disease had low cholesterol levels. 

The practice administrator looked at the DMCB like it was crazy.

That was when the DMCB realized that the purpose of its EHR had less to do with quality, costs, coordination and everything to do with perpetuating the "hamster wheel" of one-on-one primary care.  Prior to the EHR, it averaged about 4-5 patient visits per hour.  After the EHR, that didn't change.  Neither did its HEDIS® measures, patient satisfaction rates or professional well-being.  The only thing that increased was its cumulative billing amounts.  No wonder the DMCB has been an unrepentant EHR skeptic.  It concluded that the purpose of the EHR is to perpetuate the dysfunctions of one-on-one care.

Articles like this, however, may change the DMCB's mind.  Jennifer Frankovich, Christopher Longhurst and Scott Sutherland describe how they tapped their local EHR's multi-year database to assess the outcomes of a cohort of patients that was similar to one of their own.  After analyzing how prior patients under similar circumstances fared, they decided that it would be a good idea to treat their patient with a blood thinner.  The patient ended up doing OK.

1.  Normally, a physician's expertise is built over the course of many patient encounters.  That's called "clinical wisdom."  Being able to compact years of an institution's collective experience from an EHR into a spread sheet is not only a step in the right direction, it's using the EHR to build an institutional body of wisdom.

2. This is another case study on the important distinctions between observational data bases (imperfect but locally relevant and readily available) and pristine evidence-based prospective randomized clinical trials (the gold standard for collecting evidence that is often lacking).  The latter is the standard of care and the enemy of the good; the former is quite useful and, as this case shows, often good enough.

3.  Last but not least, this is a good example of "applied" "population health management" in which a virtuous cycle of measurement can drive the local standard of care.  It's not only true for patients with obscure and rare diagnoses but for those with common, chronic and expensive conditions.  Want to reduce the burden of obesity?  Understand what really works for diabetes?  Tackle the costs associated with hypertension?  Assembling and using an electronic data base like this will make it possible.

The DMCB is looking forward to when future EHRs can perform at this level everywhere all the time.

Medicare Hospital Readmissions: Bad. Our Ability To Understand or Do Much About Them: Worse

"I  think I need to go back
to the hospital....."

The Disease Management Care Blog remembers her very well. She had come to the United States after escaping on foot from post-war Hungary.  She liked to have sliced pears and cognac for lunch. As her health began to fail, her stubbornness began to exceed her self-sufficiency, leading to multiple hospitalizations. One time, despite making sure she had a post-discharge outpatient appointment, a fresh pile of prescriptions and home visiting nurse services, her illness flared and she had to come back to hospital.

She was not only my patient, but she represented one of Medicare's dreaded readmission statistics.

By now, DMCB readers know that CMS, buoyed by its value-based purchasing program, has targeted readmissions by reducing payment levels to hospitals that fall outside the expected norm. Threatened by the loss of income, it’s assumed that hospitals will respond by developing higher quality discharge planning and care programs that keep patients from having to come back.

An important part of reducing readmissions is to identify those patients that are at greatest risk. That would help on two levels:

1) if a hospital had more than its fair share of patients at risk, it could argue that an increased number of readmissions is the result of a sicker patient population and not quality of care. As a result, the hospital could be held "harmless;

2) hospitals would be able to focus extra care resources on those patients who are spotted early as likely to come back, thereby reducing the readmission rate.

In other words, patients like the lady from Hungary would not necessarily lead to a cut in hospital payment rates and, for example, she could be proactively given extra care, such as a doctor appointment within 48 hours, a week’s supply of free medications and twice a day home nurse visits.

Which is why this just published JAMA article "Risk Prediction Models for Hospital Readmission" by Devan Kansagara, Honora Englander, Amanda Salanitro David Kagen, Cecelia Theobald, Michele Freeman and Sunil Kripalani is important.  The authors set out to see what the evidence-based published scientific literature had to say about predicting readmissions.   They filtered thousands of references, reviewed 286 publications found 30 rigorous studies that described 26 models. 

To the DMCB's delight, the authors applied a “c statistic” to the 30 publications to assess a wide variety of retrospective and concurrent prediction methodologies using a host of data inputs such as age, gender and past diagnoses. According to this article, the c (or "concordance") statistic measures how well a test can predict the presence or absence of a "condition" which, in this case, was being readmitted to the hospital.  One way to think of this is the likelihood of correctly identifying a condition when there are two people, one with it and one without it.  If the likelihood is 50%, that's no better than random guessing.  If it's 100%, that's perfect.  By the way,if this sounds a lot like the area under the receiver operator curve, you're right.

And what did the all-seeing "c statistic" say?  All of the published models had disappointingly similar levels of performance that ranged between the extremes of .52 to .83 with most in the .50 to .7 range. What's more, only one study examined the most important question of all: is it possible to find patients with preventable readmissions?

What does the DMCB think?

1) This may be another area where national health policy has gotten out in front of the scientific evidence.  If we can't reliably assess or predict readmissions with sufficient accuracy, there is a distinct likelihood that statistical variation, not quality of care, will lead to some hospitals being victimized by CMS with lower payment rates. What's more, if hospitals can't tell which patients are likely to come back, how are they supposed to target their expensive care management programs at those who are most likely to benefit?

2) There are undoubtedly some proprietary predictive models that haven't been reported in the literature that claim to have higher levels of accuracy.  Yet, without the scrutiny of successful peer-reviewed publication, it'd be difficult to believe that they're really any better than the mainstream published range of .5 to .7.  The next time the DMCB runs into one of these outfits, it's going to ask about the "c statistic" and if they haven't published their results, why not.

3) Last but not least, while the hospital payment rates are being held hostage by CMS, it's the doctors that are making the call on readmissions based on the best interest of their patient.  The c statistic suggests that that will be the most important determinant in the readmission rate.