Thursday, January 26, 2012

Spin and Innovation vs. Savings and Disease Management

Spinning is hard work!
With the 2012 political theater season underway with a faux budget rejection and a re-energized President, The Disease Management Care Blog is reminded of an inconvenient truth: the nation's unsustainable health care cost trajectory continues and is the single biggest threat to a bipartisan "grand bargain." 

So our pols' response?  Spin.  For a hot-off-the-presses example, check out this press release from CMS' Innovations Center lauding the creation of quality-boosting and cost-cutting health care "models." There's also a "one year of innovation" monograph describing hundreds of millions of dollars worth of demonstrations, initiatives, programs, partnerships and sessions.

Impressive says the DMCB, but the bottom line is that these are ongoing and innovative experiments. There are no outcomes data, cost savings are far from certain and the mainstream FFS Medicare program in place today hasn't really changed its stultifying and high cost ways.

Sooner or later in the coming months, Congress will have to agree on some sort of budget. As that moves forward, the DMCB offers up some hard "un"spun facts for consideration:
  • There is no proof that the versions of the electronic health record being currently adopted nationwide save money. The savings argument remains anecdotal or theoretical with considerable room for doubt. What is clear is that installing an EHR costs money.
  • While ACOs are ultimately modeled on the success of large integrated systems, we know that bigger is not necessarily better.  As this multi-year experiment gets ready to set sail into politically stormy seas and if (and that's a big "if") they are proven to save money, it'll take years to expand them. Any real savings are more than a decade away.

So where do the real cost savings lie? Former White House advisor Ezekiel Emanuel, in this just published JAMA Viewpoint, points out that the best answer is not any of the notions above but but controlling chronic illness with what essentially can be described in two words: disease management.

Here's the quote:

Successful efforts seem to entail instituting at least 4 common changes: (1) installing electronic health records and using them to track patients' health status and physician performance, as well as using decision supports to increase adherence to treatment pathways; (2) using the information for more intensive interactions between patients, caregivers, and clinic staff, including use of care coordinators, 24/7 access, interventions to increase medication adherence, specialized clinic services for recurrent problems of patients with chronic disease such as anticoagulation clinics; (3) reducing use of specialists, and when specialists are involved using those who are more efficient; and (4) providing services not traditionally covered by fee-for-service reimbursement, such as e-mail, wireless monitoring to increase medication adherence, home evaluations to minimize falls, lifestyle interventions to improve nutrition and exercise, and transportation services for office visits. Cumulatively, the savings appear to occur through fewer hospitalizations, emergency department visits, and lower use of specialist services (bolding from the DCMB)

The DMCB couldn't have said it better itself.  Dr. Emanuel describes the ingredients of successful commercial disease and population health management programs in place today today: a later generation EHR that is coupled with decision support and registries, risk stratification to identify the patients at great risk, care coordination with expedited access to specialized services and support for preventive care. 

He's right, and that's no spin.

Image from Wikipedia

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