Tuesday, January 31, 2012

Measuring Outcomes and Return on Investment (ROI) in Disease Management and Population Health

Changing opinion from right to left
Has marriage made the Disease Management Care Blog a better person?

While it and the spouse heartily agree on the ultimate answer, using hard numbers to prove it to a skeptical mother-in-law is a different matter. To definitively answer the question, the affable DMCB came up with some proposed measurement approaches, such as:

1. Pre vs. Post: comparing past beer guzzling to present-day chardonnay sipping;

2. Actuarialactual vs. projected appreciation for the leather-clad vampire vixens of Underworld;

3. Comparison to a Control: the DMCB's willingness to take direction on shrubbery trimming, versus that of more docile hubbies;

4. Randomized and Prospective: (the DMCB has wisely opted to not go there).

While the DMCB continues to work on the complex methodology of marital outcomes, it is reminded of a key paradox: while we live in an "Information Age," other pressing questions - such as the extent of the Eurozone's influence on GDP, the merits of vouchers in public education and the link between the President's approval rating and his governing by remote memo - likewise defy conclusive measurement.

What's more, frustrated by our world's complexity, we ironically want fewer answers. The DMCB suggests this search for simplicity partially explains the luster of a balanced budget amendment, laws on minimum medical loss ratios, Newt's bombast, Obama's rhetoric, blanket coverage of birth control and, last but not least, single approaches to assessment of population-based programs.

Which brings the DMCB to Al Lewis' $10,000 challenge, in which he dares anyone to come up with a more accurate approach to measuring disease management return on investment. 

Al is a luminary in the disease management firmament who leads the Disease Management Purchasing Consortium. He was there at the founding of the Disease Management Association of America, led the attack on the vendors' past lazy outcomes reporting and has been instrumental in questioning the conclusions about North Carolina's Medical Home Program. He now claims to offer the only approach to accurately measuring the financial impact of disease and population health management.

Maybe, but the DMCB would like to humbly offer up an alternate perspective.

Check out this DMCB paper that simultaneously deployed three uncomplicated methodologies to assess the claims expense impact of a chronic heart failure disease management program. While all three gave different answers, they all pointed in the same direction.

That was enough for the DMCB boss to continue the program's funding.

This same overlapping and multi-layed approach also underlies the Care Continuum Alliance's Outcomes Guidelines Reports, which recommend a suite of measurement approaches that pivot on important determinants such as population characteristics, the influence of confounders as well as bias and the resources available to answer the question.

None of this should be any surprise to seasoned and prudent health administrators, physician leaders, clinical program architects or DMCB readers. They know that good actuaries use complimentary and overlapping approaches to come up with the right premium. They understand that good medical researchers demand caution, skepticism and multiple research studies before reaching any conclusions.

In other words, there is no one-time and one-size fits all approach in outcomes assessment.

All this adds up to the fact that optimum outcomes measurement triangulates on the truth. The measurement approaches advocated by the DMCB, Care Continuum Alliance members and health system leaders have been around for years, are within the reach of standard statistical software, are familiar to researchers and are highly adaptable to the circumstances of 99.99% of disease management programs, not to mention the medical home and accountable care organizations.

The DMCB says that when multiple, competing, overlapping, repeated and adaptable measurement methodologies point in the same direction, that's when regulators, consumers, purchasers, buyers, providers and patients and mothers-in-law can be really confident that they have the answer they need.

Image from Wikipedia

No comments: