Where Did The 2010 Increase In Health Care Costs Come From and Who Is Paying?

Remember the last Health Wonk Review?  The Disease Management Care Blog recalls being impressed by the description of the "Health Care Cost Institute," a not-for-profit outfit that was established to store de-identified commercial insurance claims data for research purposes. The participating health insurers are Kaiser, Aetna, UnitedHealthcare and Humana. The database covers 33 million individuals less than age 65 years with employer-sponsored insurance. The DMCB suspects its personal Aetna claims information is in there, somewhere.

The DMCB is more impressed, because the HCCI has just released its first report on 2009 and 2010 health care cost trends. It's full of insights. 

To wit:

1) If you've wondered why your 2010 personal health insurance cost so much, it's because per capita spending was $4,255. This suggests insurers are not the only problem.

2) Costs in 2010 increased over baseline by 3.3% and was driven by an increase in unit prices (i.e., charges), not by greater utilization or overall mix of services.  This suggests providers are charging more for their services.

3) While costs increased, beneficiaries' out-of-pocket costs grew at a faster rate. In 2009, they paid 15.6% of their bill, while in 2010, they paid 16.2% - an increase of 3.8%.  This suggests that insurers are passing a small but painful amount of the additional 2010 provider charges to the consumer.

The DMCB says bravo to the four insurers for making this information available.  This and promised future reports should shed light on health care cost trends.

Image from Wikipedia

ACO Ver.2.0

Accountable care organization (ACO) enthusiasts may want to check out this article, "'New' Health Organizations Will Truly Manage Care" appearing in the latest issue of Managed Care Magazine. Based on a large provider survey and his own personal insights, author Richard Stefanacci points out that the current generation of Accountable Care Organizations(ACOs) is destined to fall short.

This is how the Disease Management Care Blog pieces together Dr. Stafanacci's narrative:

Hospitals and physicians will continue to pursue merged arrangements characterized by a) shared risk, b) less physician autonomy and c) greater efficiency. Yet, it's still too easy for these first generation ACOs to underestimate the downsides of risk contracting and it's even easier for them to under-invest in care management programs. Add to this the a) "dismal" track record of past physician-hospital collaborations, b) disappointing Physician Group Practice Demo results and c) disconnect between inferred savings and hard dollars, and there is every reason to be skeptical about the ACOs' future.

Even worse, there's a government-generated health care bubble. The looming budget crisis will force Washington DC to retrench.  Many large provider organizations and ACOs, caring for tens of thousands of patients with thousands of full-time employees, will be deemed "too big to fail."  That "popping" noise will announced the start of a very destabilized market.

Coming in the wake of all this underfunded wreckage will be second generation provider-led accountable organizations. They'll use the 2012-2014 time period to build a patient-centered culture, learn about insurance risk, invest in care management and prepare for the lean times ahead. They will focus on a) the 20% of patients who are responsible for 80% of the costs, and b) understand bundled payment arrangements.  That's when having strong physician leadership, fully aligned care management-medical homes and enterprise-wide medical decision support will mean the difference between merely surviving and thriving.

The Limits of the "Return on Investment" Measure in Population Health, Disease and Care Management Programs

But where's the money?

The Disease Management Care Blog has always been leery of the "return on investment" (ROI) metric in health care. It knows that there are precious few health care interventions that actually "save" money. Many prevention, wellness and disease management programs     - depending on the analysis -  can cost money since they a) add additional resources to a system with already high fixed costs with b) a short one-year time horizon.

Yet, the good news is even if a program isn't successful in slowing the rate of cost inflation (or "bending the curve," which represents the savings), it can still represent a great value.  That's because the additional benefit represents significant benefit for each additional dollar of spending.

That's the message in this recent JAMA Viewpoint editorial Assessing Value in Health Care Programs authored by Kevin Volpp, George Loewenstein and David Asch. They offer up a thought experiment. Consider, they say, a state-of-the-art medication compliance campaign for heart attack victims that avoids a number of costly hospitalizations.  The price tag at $2000 has a positive "ROI" because the investment is less than the avoided cost of the hospitalizations.  However, if the price tag is $3000 and the investment is now greater than the cost of the hospitalizations, the ROI is "negative" even though the same number of patients didn't have to be hospitalized.

The DMCB recommends readers keep this manuscript/link handy the next time some Finance weenie demands an "ROI calculation."

Speaking of readers, the DMCB is happy to announce that it just hit 500 Twitter followers.  That's in addition to more than 500 "RSS" subscribers, 461 Google Reader subscribers and thousands of return visitors per month.  The DMCB knows each was earned one person at a time.

Why Population-Based Care and Disease Management Can Increase Access to Primary Care

If the population health management (PHM) service industry needed just one evidence-based medical journal article to justify its existence, it couldn't do better than this. Writing in the New England Journal of Medicine, Amireh Ghorob and Thomas Bodenheimer advocate for Sharing the Care to Improve Access to Primary Care.

The authors argue there can be only one solution to the twin challenges of dwindling primary care physician (PCP) numbers and the increasing burden of chronic illness : reallocating clinical responsibilities away from PCPs to empowered non-physician team members. These responsibilities include, but are not limited to a) prescription drug monitoring, titration and renewals, b) scheduling and processing of routine blood testing (like cholesterol) and imaging studies (like mammography), and c) counseling patients about lifestyle changes, medication adherence and their preferences, priorities and goals for their chronic conditions.

In order for all this to happen, Mr. Ghorob and Dr. Bodenheimer suggest two ingredients will be necessary: 1) payment reforms that make teaming profitable and 2) physician compromise over their long-cherished notions of control.

That's precisely the approach that has been used by the PHM vendors for decades.

They have nurses, they rely on the teaming, they can manage routine prescriptions, testing and counseling and they can do it for a relatively small monthly fee. They've also learned their lesson: the vendors are doing a much better job of navigating through the doctor-patient relationship and discerning the important differences between clinical responsibility and busy-work control.

A far less important issue is the location or level of service provided by the non-physicians. 

The Disease Management Care Blog argues that sorting that out is a local decision based on physician preferences, pre-existing clinical infrastructure, history and organizational culture. Highly integrated systems may prefer to achieve teaming by transforming their primary care sites into medical homes. Less integrated networks may prefer a shared services model that in or outsources the teams. 

The point is that there is no one-size-fits-all approach to relying on teaming to increase access to primary care. Dr. Bodenheimer has confirmed which are the basic ingredients.  Now it's time for the rest of the system to figure out the details.

The Health Wonk Review, Come Back, We'll Leave The Light On For You Edition

The Disease Management Care Blog (DMCB) welcomes readers to this edition of the Health Wonk Review. The DMCB is a physician-writer with knowledge and experience in primary care, health insurance, population health and health information technology. That's why it's delighted to host this compendium of recent writings from the best health policy bloggers offering insights you won't find anywhere else. Read this and the DMCB assures your Huff Po addled colleagues will admire you and your USA Today reading opponents will envy you.

For example, this HWR has a conservative who actually likes health insurance exchanges and a progressive who is disappointed with a key aspect of the Affordable Care Act. There's also a unique description of an important collaboration among competing commercial health insurers and a thoughtful discussion of the downsides of preventing HIV infection.  You'll also find a detailed report on how the evening news blew the coverage of an important cancer screening guideline update.

And don't be put off by the wide ranging number of posts.  Read what captures your interest, follow the links and come back as often as you like.   The DMCB will leave the light on for ya.

HOSPITALS

Hospital Quality

Most readers of this Health Wonk Review are undoubtedly sophisticated and dispassionate experts on hospital quality, consumerism, patient satisfaction and outcomes.  Well, Neil Versel of the Meaningful Health IT News blog shows us how that learning contrasts with watching a terminally ill loved one with Multiple System Atrophy struggle with distant physicians, medication errors, incomplete care planning, lack of basic health services, ignored advance directives and occasional Keystone Kops style encounters with health workers who should know better.  And we wonder why Americans are so fed up with the U.S. health care (non) system?  Egads, says the DMCB.

A Medicare Hospital Measure Called "MSPB"

Speaking of hospitals and quality, CMS has started to publicly report peri-hospitalization health care costs using a metric called the Medicare Spending Per Beneficiary (MSPB). According to Jason Shafrin of the Healthcare Economist Blog in this post titled "Measuring Hospital Efficiency," Medicare is now reporting a roll-up of all payments made to docs and the facility three days prior, during and 30 days after a hospital stay. Non-surprisingly, some areas of the country have much higher MSPBs than others. Yet, despite its merits, Jason reports that the measure is not without controversy because we don't know enough about the link between the MSPB and outcomes (does more spending result in high quality?) or if reported higher costs were the the result of waste (for example, unnecessary or redundant testing) versus additional necessary care (perhaps extra days in a rehab facility after discharge were worth it).   The one thing the DMCB does know is how necessary it will be to use the acronym "MSPB" the next time it steps up to a microphone at a health policy confab.  It can't wait.

"Observational Status"

When is an admission to the hospital not an admission?  That's the conundrum tackled by Dr. Brad Flansbaum of The Hospitalist Leader blog, who helps the reader understand how hospitals use their inpatient facilities to treat outpatients. The key distinguishing factor is a limited 24-48 hour course of care that is aimed at returning the patient home.  Unfortunately, outpatient care is covered with an outpatient insurance benefit that can include significant out-of-pocket expenses.  Medicare has policies that require providers to inform beneficiaries of the financial impact of being in "observation status" but as the line that separates inpatient and outpatient care continues to be blurred, it's likely we'll have to wait for global payments or shared risk arrangements to reconcile patient coverage expectations and billing systems.  Until that happens, Brad has quotes a Medicare official who assures us that CMS is "considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system."  Right.

HEALTH SYSTEMS

Accountable Care Organizations

While the mainstream focuses on Medicare's ACOs (for example), Blue Shield of California, CalPERS, Hill Physicians Medical Group and Dignity Health quietly partnered back in 2007 on a shared savings program that apparently resulted in a noisy $20 million in savings.  Glenn Melnick and Lois Gree over that the Health Affairs Blog have authored an interesting interview-narrative about this initiative that is full of interesting lessons. These lessons include the importance of physician buy-in and participation, a system-wide working familiarity with old-fashioned capitation, a supportive pre-existing provider culture, an emphasis on reducing readmissions, using wellness to reduce use of pricey bariatric surgery services, data liquidity, increasing use of evidence-based guidelines at the point of care, patient "repatriation" from non-participating care settings, data dashboards and empowering non-physicians to engage patients in self-care.  The California HealthCare Foundation has committed to completing a full evaluation of the outcomes next year. The DMCB commits to using some new health policy jargon it discovered in reading this post: "actualize" and "head in a bed."

"Charismatic Leaders"

Roy Poses of Health Care Renewal continues to expose the folly running rampant in the U.S. health care system, this time by looking at the "CEO as False Messiah." Dr. Poses cautions readers to pause any time they run into local or national leaders who are uncritically hailed as "visionary."  It's far more likely that their fawning admirers have been seduced by a toxic level of charisma that often leads to catastrophe.  Get real, advises Roy, and admire such folks for being smart while keeping a skeptical eye on their ability to produce results.

PROVIDERS

The Doctor-Patient Relationship

David Williams of the Health Business Blog uses a Health Affairs article on "shared decision making" to reflect on the upsides of being labelled a "difficult patient."  Researchers found that an important barrier to forming a doctor-patient relationship is the fear among health care consumers that expressing a preference will annoy their doctor.  David argues that's not such a bad thing, especially since modern consumers now have the option of seeking a second opinion, getting another doctor and ultimately refusing a questionable treatment. The DMCB really agrees with David's perspective because it wants to be liked by him.

DRUGS

HIV Prevention Is Good News, Right?

 Nate Ogden of the InsureBlog walks readers through a fascinating exercise on the costs and ethics surrounding the FDA's approval of HIV-prevention drug called "Travuda." While readers may initially want to hail this medical breakthrough, Nate suggests it's not so simple: 1) the retail cost of the drug is $11,000 a year, which a) contrasts with the $30 a month cost of equally effective condoms and b) would be enough to treat 20 HIV positive patients, 2) persons taking the drug may misuse their new found protection and paradoxically engage in increased risk-taking sexual behaviors and 3) coverage may be mandated as an insurance benefit, which means there'll be one more driver of health care costs for all of us.  Another silk purse turned into a sow's ear, says the DMCB.

Would You Like Some Drug Monitoring Along With That Refill?

Never at a loss for words, Joe Paduda of Managed Care Matters takes umbrage with Missouri State Senator Robert Schaaf's opposition to the state's "Prescription Drug Monitoring Program Act." Joe argues that the act would reduce the incidence of drug-drug interactions and lessen prescription drug abuse through doctor shopping.  Without passage of the bill, says Joe, kids will lose their moms, Scout troops will have to meet without their den mothers and schools will have teacherless classrooms.Dr. Schaff, who by the way is a family physician and leads a prominent physician liability insurance carrier, has a different perspective. The DMCB predicts the Senator will not find Joe's disapproval very compelling.

HEALTH INFORMATION ANALYTICS

Health Insurer Data Mining

If it's one thing that Medicare has done better than the commercial insurers, it's making its claims data available to health services researchers.  The DMCB suspects that the commercial insurers have been reluctant to do so because of the considerable effort involved, concerns about inadvertently running afoul of HIPAA's unwieldy confidentiality provisions, giving their competition otherwise confidential information about payment rates and the lack any relevant value propositions. According to Martin Gaynor at the curiously named Wing of Zock Blog, those barriers have finally been overcome. Aetna, Human, Kaiser and United have all agreed to ship billions of lines of claims data to the not-for-profit Health Care Cost Institute which will make the deidentified data available to researchers.  The DMCB agrees that this is a significant development that will allow researchers to mine insights that, thanks to relatively low numbers of patients, non-generalizable health care settings and limited imagination, have been out of reach. The DMCB hopes the data will be made democratically available on as close to an "open source" basis as possible.

HEALTH INSURANCE

 Group and Individual Insurance Markets

Need a quick lesson on the fundamental differences between group and individual health insurance policies?  Louise over at Colorado Health Insider has a terrific "101" on health insurance guaranteed issue, mandates, underwriting, the role of high risk pools and the impact of Affordable Care Act. The DMCB recommends that everyone - except the White House - bookmark this page just in case we're forced by the Supreme Court into a health insurance reform do-over. The White House is being given a pass by the DMCB because if that happens, no one will really care what they think.

Speaking of the Individual Market....

In case you think all progressives uncritically support the Affordable Care Act, Maggie Mahar at the healthinsurance blog inconveniently points out that a big part of the individual health insurance market will remain broken come 2014. Maggie's post offers up some compelling statistics that demonstrate that many middle aged boomers (yikes, including the DMCB) who are between ages 50 and 64 years won't meet income thresholds for subsidies.  As a result, they're looking at the prospect that health insurance premiums could reach an unaffordable average of $7500 a year. Combine that with a lackluster job market, declining incomes and substantial out-of-pocket costs and it is clear that health reform will remain a contentious, time-consuming and difficult work in progress for years to come. In the meantime, the DMCB will wonder about the affordability of essential benefits, the merits of value-based insurance designs, how population health-based care management can help blunt the impact of chronic illness and the wisdom of  using limits on age rating to shift costs to the DMCB spawn.

STATES

One State's Perspective on Federal Health Reform

While California's budget slides into the sea thanks to an unending budgetary earthquake, every dollar counts. That's why Anthony Wright of the Health Access Blog points out that in addition to the patently obvious merits of assuring access, lowering costs and protecting consumers, the Affordable Care Act is also a windfall for the Golden State.  He quotes and links a California-based Bay Area Council Economic Institute report that calculates that the ACA will add close to a 100,000 new California-based jobs and $4.4 billion in additional state output.  Alas, says the DMCB, between the U.S. Supreme Court and less-than-expected taxable income from the disappointing Facebook IPO, it looks like fixing Sacramento''s budget woes may need a Plan C.

How Should States Respond to Health Insurance Exchanges?

Conservatives hate those ACA-mandate insurance exchanges, while progressives love them, right?  And any Republican Governor that sets up an exchange under the terms of the ACA is a hypocritical closet-supporter of Obamacare? Is that so?  John Goodman's Health Policy Blog point-counterpoint posting teaches us that it's not so simple.  It turns out that states 1) may fare better with or without the ACA if they maintain control over exchanges, 2) could use the flexibility that comes with control to make insurance exchanges more effective and fair, and 3) with that control will also have a say over the commercial insurance subsidies that will add up to gazillions of dollars.  Just in case you think John's post is just a lot of hot air, check out this telling Pennsylvania-based Op-Ed.

WORKERS COMP

Links Between Worker's Comp and Health Promotion

Many health care providers regard "worker's comp" as something as a policy sideshow, but Worker's Comp Insider Jon Coppelman shows us that this multi-billion dollar industry is not only a big deal but also not immune to the growing costs of our sedentary lifestyle. When a 50 year old fat ambulance worker's stroke was blamed on a lower extremity paradoxical embolism resulting from hours of sitting, the lifelong care costs were ruled "compensible." Next stops are the diabetes-causing donuts on our way to work and the hypertension from those generously salted fries in the company cafeteria. Mr. Coppleman recommends early adjuster involvement in the claims adjudication. The DMCB wonders if the Workers Comp insurance industry should think about being more proactive, including using risk stratification and advocating for common sense health promotion.

WELNESS AND HEALTH PROMOTION

Wellness!  Gotta Have It!

No Health Wonk Review would be complete without one enthusiastic endorsement of all things wellness. Kat Haselkorn of Corporate Wellness Insights steps into that role with copious praise of all the benefits of health promotion, including positive culture change, huge returns on investment, enriched social networks and accelerating employee productivity.  Kat suggests that if just one person buys into wellness, the effect can ripple through the company faster than spandex-clad yuppies swarming at an after-work Zumba class.

Wellness!  Gotta Keep Funding It!

New blogger Tracey Moorhead of the Care Continuum Alliance writes in the Voice On Population Health Blog about the ill-advised willingness of the U.S. House to steal from the ACA's Prevention and Public Health Fund to extend coverage of student load interest subsidies. Tracey passionately argues the fund has already led to important behavioral health screenings, data infrastructure development and expansion of wellness services in multiple states. Whoa, says the DMCB, which isn't surprised at the Care Continuum Alliance's advocacy on behalf of prevention and population health.  Good for them.

And Here's An Added Benefit of Being Fit?

Michael Gavin of the Evidence-Based blog notes that a recently published article in the medical journal Pain shows that athletes have a higher pain threshold.  From his point of view, this is why exercise should not only be promoted as an alternative to using dangerous drugs to control pain but as an added overall benefit from achieving maximum fitness.  The contrarian DMCB took a look at the abstract and wonders if persons who are naturally blessed with higher pain thresholds are attracted to exercise (or at the very least, find it less unpleasant).  While readers are figuring out which is cause and which is effect, they can also show their health knowledge chops by not only referring to exercise related "endorpins" but "endocannabinoids" as the basis for the runner's "high."

SPECIAL POPULATIONS

Prisoners

Talk about a disenfranchised population. Suffering with highly prevalent rates of Hepatitis C, HIV and mental illness, huge numbers of released prisoners were being left to fend on their own. Harold Pollack, also of the healthinsurance blog describes how thanks to recently passed federal legislation, hundreds of thousands of these individuals will be able to qualify for Medicaid, obtain tax credits that can defray the cost of private insurance and access basic community-based health care services. While health reform is all about the single mom waitress with two kids, the middle America steel worker and the kid with end stage cancer, Dr. Pollack says we all benefit when ex-prisoners are also staying away from crowded emergency rooms, avoiding unnecessary hospitalizations and not burdening over-stretched safety net programs.

Geriatrics

IF you believe geriatric care is important, THEN you should read this post BECAUSE you'll get to learn about the "ACOVE" framework. That's the message the DMCB got after reading Chris Langston's post on the Quality of Geriatric Care over at the John A Hartford Foundation. It turns out that the Assessing Care of Vulnerable Elders is a handy IF-THEN-BECAUSE tool that identifies the specific health issues afflicting the elderly and targets geriatriccare planning. Chris argues wider use of ACOVE would increase quality of care in geriatrics and clarify the important differences between general medical versus geriatric conditions.

CODING

Hate ICD-10?

Here's another anti-ICD-10 rant, courtesy of a post by TBD Consulting's Jonena Relth at the Healthcare Talent Transformation Blog.  She argues that veteran front-line health care workers are deeply skeptical about the ultimate value of the insurance billing system's astonishingly complicated specificity and detail. Jonena is concerned that the new coding will paradoxically lead to billing errors and enable greater health insurer mischief. Too bad there wasn't any credit given to the AMA for CMS' decision to delay implementation of ICD-10 as well as the organization's continuing advocacy on the issue. As for the health insurers, the DMCB thinks that given the circumstances of a very hostile Administration and the luster of an ACA-driven enrollment windfall, they quietly came as close as they could to expressing concerns over the wisdom of ICD-10.

and last but not least.....THE NEWS DISAPPOINTS...AGAIN

Prostate Cancer Screening and the News Media

As risks, benefits and alternatives to cancer screening move into the public square, Gary Schwitzer's HealthNewsReview blog offers up this balanced scientific review on the merits of prostate cancer screening by Richard Hoffman and this insightful description on how the mainstream news media made a mess of things. It turns out that the U.S. Preventive Task Force's recommendations weren't really all that new, that a substantial number of physicians have been PSA skeptics for years and that early detection of prostate cancer - whatever its merits - is hugely remunerative to providers. As testimony to the news elites'  selective inattention, ask yourself if you should thank Diane Sawyer et al for avoiding this new wrinkle on the topic of lung cancer screening.

Image from Wikipedia

A Cavalcade of Risk Is Up!

Better late than never, so the DMCB wants to alert readers to the May 16 edition of the Cavalcade of Risk that is ably hosted at the "Insurance Claims And Issues" blog.  The Cav is a rotating assortment of the best writings on a topic of insurance and business risk topics.

Enjoy!

Outcome Measures for Both the Patient Centered Medical Home (PCMH) and Population Health Management (PHM)

The Disease Management Care Blog remembers years ago when it watched several captains of the disease management (DM) agree in a meeting that "third party" organizations were in the best position to evaluate the industry's outcomes.  The good news is that that approach minimized the industry's conflicts of interest.  The bad news is that it also led many companies to effectively "outsource" what should have been a core competency of rigorously conducted self-evaluation.  Years later, when the Congressional Budget Office (CBO) could find no evidence supporting DM, the result was an industry-wide near death experience.  

Good thing the Patient Centered Medical Home (PCMH) isn't making the same mistake. In addition to relying on third parties like the National Committee for Quality Assurance (NCQA) to set recognition standards, PCMH advocates have committed considerable time and energy into conducting their own detailed outcomes studies. While the published results haven't been a slam dunk, they have informed the PCMH's continuing evolution.

Enter the Commonwealth Fund with this 12 page "Data Brief" on Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality. The Fund assembled 75 experienced health services researchers who, after numerous meetings, two publications, presentations at national scientific meetings and close collaboration with the NCQA and AHRQ, developed a standard set of PCMH clinical and economic measures. As you might expect, there was agreement about the need for transparency and validated algorithms.  There was less certainty over the approach to standardized pricing and risk adjustment.

Because the document does a nice job of compactly summarizing the recommended outcome metrics in easy-to-read tables, this handy brief could turn out to be a widely used reference document. Unfortunately, while HEDIS®, PQRI, AQA and CAHPS are prominently mentioned, the authors neglected to take advantage of the additional insights provided by the Care Continuum Alliance's Outcomes Report. 

That'll be important in networks where the PCMH and population health management (PHM) are converging in combined arrangements that use the best of both approaches to care, including measurement.  That's probably one reason why the PCMH's own Patient Centered Primary Care Collaborative links the CCA's document here.

Combine Chronic Conditions and Facebook: A New Start Up Called "Woebook"

It's the Disease Management Care Blog's 31st wedding anniversary. To celebrate, the happy couple is at hideaway that offers what the DMCB spouse refers to as "chaise lounges." She patted one next to her's and asked the DMCB sit, relax and "converse."

That's when the DMCB excitedly pointed out that Facebook's launch has many lessons, including the overlaps between hype and greed, the wackiness of giving money to a 28 year old hoodie-wearing oddball and the certainty that if everyone could only "friend" everyone, cheap solar power would finally prevail.  Inspired by the luster of a multi-billion dollar IPO, it thinks now is the time to cash out the retirement funds, leverage the DMCB's brand and launch its own social media offering called "Woebook."

The User Profile: This will list any and all medical conditions that may reflect a user's, family member's or friend's medical history, or a professional interest or a passing hobby. If you don't know your condition, a partnership with IBM's "Watson" will assign one to you. If you have no condition, a bank of specialists will be on call to make one up for you.

Friends: Communities of the Diseased will spring up, share symptoms and insights and give special meaning to the term "poked."

Marketing: Instead of relying of some claptrap on how targeted and intrusive ads somehow "enrich" the users' "experience," Woebook will be honest and announce its intent to bludgeon users with what they really want: information on pricey brand name drugs and the latest and most expensive medical devices.

Privacy Settings: While the default is HIPAA-level privacy and the threat of unending visits by U.S. Department of Justice bullies, Woebook will maintain a jumbotron in Silicon Valley that will rotate the pages of users who have selected the "maximally voyeur" privacy setting. Banner ads scrolling across the bottom will generate tons of advertising revenue. Best of all, those annoying Millennials in their BMWs will be reminded that something incurable is waiting them just a few years away.

Speaking of Ads: You'll have to give permission to have them appear on your pages. If you accept that option, the DMCB's Woebook will share its vast ad income with you. Users will also have the option of sanctioning spurious, malicious or uncool ads and, if enough votes are collected, the ad and the sponsoring company will be banned. That includes for profits, not-for-profits, government agencies and candidates for U.S President.

Photo sharing: You bet, including but not limited to that unsightly and tough-to-diagnose rash or non-healing sore, x-ray images and scans of the mysterious "this is not a bill" documentation.

The DMCB spouse is unsurprisingly not ready to cash out and commit the 401K. Angel investors are free to call for a copy of the Woebook business plan.

Facebook and ACO's Similarities

Investors just ponied up well over $100 billion for a piece of the social media giant Facebook. While Mr. Zuckerberg and his co-founders deserve a hearty congratulations, the Disease Management Care Blog finds some eerie parallels between Facebook and accountable care organizations.  The similarity does not bode well for either business model.

1. The users are not the customers: Facebook sells its users to marketeers.  ACOs sells its patients' health care utilization to insurers. 

2. It's the data and it's not yours: Facebook's targeted ads are constructed off of prior usage patterns. ACO's shared savings calculations are built off off actuarially determined health care utilization patterns.

3. Sovereign hostility: Washington DC views information technology and health care as distractions from the true task at hand: restoring the U.S. manufacturing base.

4. Do you care, really? Now that the wunderkids in charge of Facebook have made their millions, it remains to be seen if they'll work as hard in delivering value to its users.  Ditto for all the salaried docs working for ACOs, who no longer have to arrive early, skip lunch and stay late.

5. The long term: Yahoo once was the darling of internet investors.  Even if ACOs have initial success, is a better care model being developed as you are reading this?

Population Health Management: A Road Map for Primary Care Practices

Too-big-to-fail JP Morgan is losing billions of dollars. Greece is getting ready to prop up their banks with devalued drachmas. Facebook is getting ready to monetize your personal data. Dozens of health care organizations are jumping into shared financial risk arrangements. The good news is that while nothing is standing between utter disaster and the U.S. stock markets, the Euro or your privacy, physicians have this handy Care Continuum Alliance resource titled "Population Health Management: A Road Map for Primary Care Practices."

Thanks to this well written, extensively referenced and evidence-based report, primary care leaders can learn how to align population health management (PHM) with their primary care physician network to reduce risk, maximize savings, achieve efficiencies and minimize any disruption of their physicians' work flows.  The rest of the world may be going to hell in a hand basket, but docs will be far better positioned to bend the cost curve and be rewarded with that fat end-of-year reconciliation check.

The report discusses:

1) how health risk assessments (HRAs) can be used to gauge the risk of those patients you don't know about;

2) the role of predictive modeling in stratifying the risk of your attributed population;

3) how to recruit and engage patients at greatest risk

4) how clinical guidelines can be best applied at the point of care

5) why care managers can assume responsibility for identifying and recruiting at risk patients and advocating on behalf of the guidelines.

How can the Disease Management Care Blog be so confident that this report is all that and more?  It helped write it.

And the best part is that the document download is for free.

Emergency Room Overutilization

It's no secret that Americans are overusing emergency rooms and it's only destined to get worse. And Washington state's Medicaid program, according to this New England Journal article, is ground zero.

Alarmed by rising rates of costly emergency visits, the state decided to stop paying for certain emergency room diagnoses that failed to meet the definition of a true "emergency." The state's governor stepped in at the last minute to put a hold on the program.

According to the authors, the problem is twofold: 1) an inability of "prudent laypersons" to safely discern which symptoms comprise a "true emergency" versus those symptoms that can wait, and 2) a shortage of alternative care settings, especially primary care.

The Disease Management Care Blog agrees but also points out that not paying for these diagnoses will financially penalize otherwise "innocent" emergency providers who cannot control the utilization of their services.  That threat will be enough tempt emergency rooms to turn to "creative" upcoding to justify payment. The result will be a billing arms race that will contribute to the already high administrative costs for the Medicaid program as well as the hospitals.

In the meantime, there are studies like this that demonstrate that population health management (PHM) telephonic advice lines can be used to help patients decide whether they have a true emergency or not.

The Governor did the right thing.  It'll be interesting to see what happens next and if Washington will consider using telephonic triage.

Image from Wikipedia

Health Insurance Rebates: A $1.3 Billion Non-Event

The Disease Management Care Blog has a lingering weakness for garden statuary. It thinks that nothing quite compliments phlox and snapdragons better than a weenie cherub or squatting amphibian.

The skeptical DMCB spouse disagrees. Tired of  kneeling trolls disturbing her carefully laid mulch, she questions whether her husband's admiration for toadstools, rabbits or fairies projects the right level of curbside sophistication. 

Skepticism may also be a reaction of 16 million Americans who are about to discover a health insurance garden gnome rebate check in their mailbox.  According to The Hill, the commercial insurers that haven't met the Affordable Care Act's 80 to 85 percent medical loss ratio rule will have to give back a total of $1.3 billion in premium rebates this summer. What's more, the checks will have to be accompanied by a statement that they're the result of Affordable Care Act.

The DMCB thinks this will turn out to be a non-event for four reasons:

1) What Does This Really Mean to an Individual?

When the DMCB does the math, $1.3 billion spread over 16 million eligible Americans works out to $81.25.  This article says the amount will be higher at $127.  While the DMCB thinks any free cash is always welcome, its inner behavioral economist doesn't think a check for around a hundred bucks is going to generate much buzz among health care consumers, especially among a population segment that can already afford to buy commercial insurance. 

2) Remember the Tax Rebate Checks of 2008?

Neither can the DMCB. But tracking polls at the time suggested they did little to capture America's imagination or boost consumer confidence. That doesn't mean that Washington DC doesn't continue believe that giving something for nothing will generate gratitude and votes. All the better if it's done just prior to a major election and humiliates health insurers.

3) Speaking of Which....

Why aren't the health insurers pushing back by pointing out that the rebates pale next to the cost of the ACA's mandates and that a one-size-fits-all medical loss ratio rule is unfair to the individual insurance market? Could it have something to do with $1 trillion in new business or the threat of being resurrected as an anti-progressive bogeyman? The DMCB calculates that $1.3 billion will be viewed by consumers as the price of doing business with a hostile federal government. 

4) Plus, Is A Billion A Lot?  Really?

The DMCB looks forward to hearing our chattering politicians extol the rebate of "$1.3 billion." While that used to sound like a lot, our unending budget fiasco has since taught Americans that the term "billion" is now synonymous with a federal budget rounding error. Who can forget Harry Reid's quote that the billions saved in passing tort reform was insignificant?

Next stop for the DMCB will be a bunch of solar powered lamps and a volleyball-sized mirrored gazing ball.  What the Administration has planned for our health insurers is another matter.

Comprehensive Care Management for COPD .... Kills?

That was a possible conclusion thanks to a just-published study in the latest Annals of Internal Medicine titled "A Comprehensive Care Management Program to Prevent Chronic Obstructive Pulmonary Disease Hospitalizations.

It's not on-line yet, and the DMCB will link it when it becomes available.  You can learn more about this chronic condition otherwise known as "COPD" here.  And by the way, thusands of regular Disease Management Care Blog readers won't be that surprised by the study, because they had a warning about this back in March of 2011.

The Study Design

The authors set out to test whether a "comprehensive care management program" (which they abbreviated "CMMP") reduced hospitalizations or death among persons with COPD by recruiting patients with the condition at six Veterans Affairs (VA) hospitals. In order to be eligible for participation in the study, patients had to have been hospitalized for COPD in the preceding 12 months, be older than age 40, have breathing tests that showed significant airway disease and have a history of at least 10 pack years of tobacco exposure.

Patients were randomly assigned to either 1) CMMP or 2) usual care.

CMMP consisted of an educational program made up of four 90 minute one-on-one weekly educational sessions that included an overview of COPD, a review of the importance of self monitoring and instructions for self-treatment of exacerbations with antibiotics or prednisone (rationale here).  The program was reinforced with a group session and monthly case management calls once a month for 3 months and then every 3 months thereafter. Patients got written "action plans," were encouraged to keep medications on hand and to call the case manager and or doctor when they initiated the antibiotics or the prednisone.  There was a case manager at each of the participating sites.

The study was not double blinded, but the pulmonologists who reviewed the discharge summaries of the patients to determine the cause of the hospitalization or death were blinded to the treatment assignment group.

Outcomes

209 were assigned to CMMP, while 217 were assigned to usual care. Eight and ten patients dropped out of the CMMP and usual care groups, respectively.

The study was initiated in January 2007 and prematurely stopped in February of 2009. That's because 28 persons (17%) in the CMMP group had died, versus only 10 (7%) in the usual care group.  Among the 28 patients, 10 deaths were ascribed to COPD, versus only 3 in the usual care group. 

Patients were followed for another 6 months and there were an additional 15 deaths in the CMMP group, vs. 11 in the usual care group. 

The difference in death rates didn't appear to be accounted for by any one of the study sites or any baseline factor, such as age, breathing test results or quality of life.

Up until that time, 97% of the CMMP patients had completed all four of the individual visits and 56% attended the group session. 89% of the scheduled case manager telephone calls were completed.

While there was a difference in death rates, there was no difference in hospitalization rates (27% and 24% CCMP and usual care respectively).  There was no difference in the frequency of COPD exacerbations (around 4.4 per patient-year), but the CMMP patients were more likely to be treated with prednisone; there was no statistically significant difference in the use of antibiotics.  While patients in the CMMP group indicated that they had greater self-confidence, there was no difference between the groups in quality of life.

Conclusions?

When the DMCB reads the manuscript's "Discussion" as well as the accompanying Annals editorial, it's very clear that that the authors were very surprised by the results.  They looked hard for a clinical or statistical anomaly and couldn't find one.  As a result, this paper is either good science or just accidental fluke that runs contrary to the conclusions from multiple other positive COPD care management studies like this and this.

That being said, the DMCB notes this is a VA study that may not be generalizable to commercial settings. It also scrutinized the participant's baseline breathing tests and discovered that the mean FEV1 predicted was 38%, which is consistent with a severe level of disease.  Assuming the results of the study are true, the DMCB wonders if CMMP would have worked for persons with more moderate COPD.

The results also speak to the necessity of constantly questioning cherished assumptions about the benefits of care management by subjecting it to repeated studies.  While a randomized clinical trial is not always possible or necessary, comparing results to a valid baseline is well within the reach of just about any provider group, hospital, delivery system or ACO.  This study teaches us that you never know what you may find.

Unfortunately, despite a critical mass of peer reviewed science that suggests care management "works," it's studies like this that can steal the limelight.  Naysayers will need to be reminded that one single study like this should not be overinterpreted.

Last but not least, it's striking that results that were known about back in March of 2011 took a whole year to appear in print.  Patients, their doctors and the care management service providers deserve better.

CODA: U.S News & World Report summary here.
Image from the NHLBI web site

The Latest Health Wonk Review Is Up!

A host of brainy insightful posts awaits you at the Spring Hath Sprung edition of the Health Wonk Review, ably hosted by Hank Sterns Insure Blog.  There's contrarian stuff here you won't find anywhere else.

Enjoy!

Some Raffle Ideas for the Obama Campaign

Who wants a raffle ticket?

President Obama's reelection campaign is continuing with its hallmark electoral innovation, including entering small dollar donors into "Dinner With The President" raffles like this and this. 

Thinking that this novel approach could become a important means of leveraging the Administration's policy agenda in America's body politic, the Disease Management Care Blog proposes that the White House offer a suite of raffles for other prizes, like:

1. A front row seat at one of HHS Secretary Sebelius' upcoming speeches on the merits of Affordable Care Act.  Sit through 5 or more of these tedious speeches and CMS will refund the raffle price; sit through 10 and you'll get a Medicaid coverage for a much needed visit with a mental health provider (with the disclaimer that finding a provider who will accept Medicaid is up to you).

2. A free and thorough "Welcome to Medicare" physical examination by a gloved TSA employee.  At the end of it, you may not feel too safe, but the rest of us will.

3. Accompanying Treasury Secretary Geithner on an all expense-paid tour of Beijing (with the disclaimer that that the trip will be generously supported through a loan provided by the People's Republic of China). A potential bonus: make it one way!

4. If you would rather not donate at this time, the President could offer a raffle to help change your mind: a "couple's massage" at the resort of your choice with Department of Homeland Security Secretary Janet Napolitano

5. For those who care or dare to annoyingly donate to the Republican ticket anyway, the Obama-Biden campaign could have a separate raffle: a drawing for a prominent mention on a Obama campaign web site or the chance at being the subject of opposition research.

6.  Not to be outdone, the Romney camp could also respond with a meal-with-the-candidate raffle.  The DMCB recommends that the dinner be modelled after the Ryan "premium support" approach where the prize is a meal "voucher" that does not include beverage, appetizer, salad, main course or dessert and the winner would need to bring his or her own utensils.

Image from the White House web site

Population Health Management Talking Points

Getting ready for another announcement

Cornered by the politically inconvenient utterings of members of his Administration, President Obama threw election-year caution to the wind and stepped away from his "evolving" gay marriage perspective into an logorrheic gay marriage perspective: 

"At a certain point I've just concluded that for me personally it is important for me to go ahead and affirm that I think same sex couples should be able to get married."

Sensing that wordiness may be that secret ingredient that turns feckless dodging into political determination, the public service-minded Disease Management Care Blog would like to offer the White House similarly crafted talking points in support of population health management.  These can be deployed by the President as the need arises at any time:

"After reading the science, I've have reached a level of belief that warrants an individual decision to think that it's important to conclude that population health management should be affirmed as a good thing."

"At a certain level, I've just decided that for me, after regularly reading the Disease Management Care Blog, to support population health management and discern that the time has arrived in a manner that should prompt a level of commitment that I'm willing to provide at this time."

"As the evidence reaches a degree of credibility that for population health management, I agree that a decision should be made in favor of incorporating this as a important option to consider as a worthwhile approach to care in the various programs supported in some manner by CMS."

Commercializing On-Site Care Management for Primary Care: The Outsourcing Option They Won't Tell You About

Disease Management Care Blog regulars are fully aware of the rich variety of care coordination approaches that exist outside of the patient centered medical home (PCMH).

They also know that the mainstream health policy dons have it wrong and that care coordination doesn’t come down to choosing between a Medicare PCMH and an ACO PCMH.  Other options are in or outsourcing a cohort of generalist, credentialed, dedicated and fulltime nurse-coaches on a shared service basis.  When done right, there is little physician disruption and a high degree of patient acceptance.

Prevailing common wisdom is wrong: primary care sites don't always need to individually hire, train and pay for a full-time nurse-coach when this human resource can be centrally managed by smart provider organizations, commercial insurers or self-insured employers using economies of scale.

In prior posts, the DMCB has repeatedly linked peer-reviewed literature describing successful "turnkey" approaches to care coordination and management.  Knowing, however, that published evidence is necessary but not sufficient for changing policy, the DMCB has also been keeping its eyes peeled for real world examples of outsourced care management.
  
It found one during the last Care Continuum Alliance webcast.

Webcast listeners got to hear from another company that has successfully commercialized outsourced care management.  MedAssurant does business with hundreds of provider organizations that ultimately touch 118 million persons. While MedAssurant is perfectly capable of providing modern remote telephonic disease management, it also offers a care management "solution" that relies on nurses who are embedded in physician offices and clinics.  Their value proposition is to complement the physicians' care with additional face-to-face coaching that helps patients engage in greater levels of self-care. The nurses are backed up by predictive modeling that identifies the patients at greatest risk, a telephonic coaching program when appropriate and access to other community based services including social workers. 

While MedAssurant's outcomes data haven't been formally published anywhere, it has some compelling data in the graphic above as well as information here describing increases in HEDIS and CMS Stars Ratings as well as drops in condition-related inpatient and emergency room visits.  The DMCB also knows that the health insurers, employers and provider organizations that are buying or using MedAssurant's offerings are skeptical, sophisticated and demanding. 

MedAssurant is doing something right.  

Mergers Ahead!

Mergers ahead!

The Disease Management Care Blog doesn't intentionally subscribe to many health care email newsletters.  But, here's a weekly one authored by Deloitte's Paul Keckley that the picky DMCB actually likes. 

In his May 7 edition, Mr. Keckley agrees with the DMCB that, despite what the common wisdom tells us, health care is still largely a "local" phenomenon.  Currently, only 1.2% of U.S. medical practices have more than 11 physicians on site and 74.5% of health insurers have fewer than 250,000 enrollees. Most hospitals remain single institutions.  That's why ACOs, integrated delivery systems and medical homes remain a health policy sideshow.  The real action is in figuring out what to do with the rest of the health care system.  

And just where is that "rest" going?  When a highly fragmented health care industry is combined with lackluster worker productivity, burgeoning capital needs and growing consumer demand, Mr. Keckley predicts that the business case for economies of scale will become irresistible. 

In other words, a wave of health care industry consolidation is imminent.  Accordingly, our health care future going to be filled by opportunists scrambling to be at the top of a heap made up of national-scope providers, government clearinghouses, product lines, service offerings, alternative insurance options, bio-monitoring, mobile decision-support technology and on-line consumerism. 

The DMCB agrees, but adds an additional wrinkle.  Health care entities that can simultaneously consolidate and make the transition from "local" to "personal" will win.  While access to capital and economies of scale ultimately mean bigger is truly better, patients also want responsiveness, individualized attention, tailored care and a relationship. Companies that combine the best efficiencies that size brings on the back end while exceeding individual's personalized expectations on the front end will be among the elite "Apple" health care systems of the future.

The DMCB recently telephoned United to combine frequent flier miles and two savings vouchers in a complex multicity itinerary that included the high travel maintenance DMCB spouse and request for an upgrade. While the airline industry has a dreary reputation for customer service, this particular call went exceedingly well.  This was a huge company that wasn't local, but it sure was personal.  And the person on the end of the line sure sounded like a population health management nurse.  She was a guide and coached the DMCB to where it needed to go.

The DMCB's advice?  Mergers and consolidation makes sense when they:

1. Stop worrying about what Washington DC, Medicare, the Supreme Court, U.S. Congress, the CBO, the think tanks and, yes, what the DMCB occasionally has to say, about health reform.  Health system architects need worry first and foremost about using consolidated economies of scale to serve patients faster, better and cheaper.

2. Develop the in house expertise it takes to efficiently reconcile running a large company while still meeting their customers' individualized demands.

3. Include empowered and friendly "customer-facing" individuals and plan to use every "channel" at their disposal to communicate and interact with their customers  They need to explicitly plan on answering emails within one business day, answering the phone in three rings, shepherding social media with the resources it deserves and leveraging population health management.

How About Some Shared Decision Making on the Merits of Shared Decision Making?

"Shared decision making" (SDM) is a good thing, right? Defined as "model of patient-centered care that enables and encourages people to play a role in the management of their own health" it's achieved a level of admiration only exceeded by the Cat Daddy dance and owning Facebook stock.  Yet, while there's considerable research to support the immediate use of SDM in doctor's offices, it seems there's a problem.

No one asked patients what they think.

Well, this just published Health Affairs study summarizes the opinions about SDM that were gleaned from six focus groups involving 48 health care consumers (out of 458 patients contacted) who resided close to San Francisco.  Participants first watched a video that showcased how shared decision making worked and how it could be used to empower consumers to choose among several recommended treatment options. Then they were asked about their opinions.
The DMCB thought the results were disappointing.

Patients feel vulnerable.  They reported that:

1. they feel pressured to "conform" to a "role" that was subservient not only to the expertise of the physician, but his or her good will. Patients didn't want to be viewed as being "uncooperative."

2. it can be futile to overcome the authoritarian demeanor of their physicians. Patients feel powerless.

3.  there isn't enough time to reconcile the information they've collected on their own with the information at their physicians' fingertips.

4. They need to have at least one other family member or friend at the encounter. Patients are unable to absorb all the information they need to make an truly informed decision.

Up until now, the DMCB has assumed that the relatively low uptake of SDM in mainstream clinical care was a function of provider skepticism if not outright hostility. It seems another problem may be lingering patient doubts too.

Based on their results and a review of the peer reviewed literature, the authors offer some suggestions on how to foster the use of SDM including 1) increasing physician reimbursement, 2) developing efficient decision support tools, 3) increasing patient-physician face-to face time, 4) helping physicians become aware of the need for more open communication and 5) creating "signals" by the "system" that patient "engagement" is important.

The DMCB agrees, but points out that the road to SDM is not necessarily lined with physicians. They're busy and there's little room in the course of a clinic day for more disruptions of their work flow.  That's why it makes sense to think about SDM through the prism of population health management.  Here's why.

More on the topic in a future post.

Image from the SAMHSA website.

Disease and Population Health Management Programs Do NOT Exclude Other Conditions

Playing 'whacamole'

"Immunizations cause autism." 

"Health care blogging will never lead any serious beer money."

"Disease management coaching focuses exclusively on just one disease."

These are three falsehoods that bubble up in the unlikeliest of places, including cable news outlets, replying to the DMCB spouse's asking "and what did you do today?" and webinars, webcasts and other educational meetings about population health and disease management.

While the Disease Management Care Blog finds all three vexing, the most irksome is the canard that the commercial health coaching service providers purposely limit their programs to just one chronic condition, like diabetes, weight loss or readmission prevention.

While that may have been the case in the earliest versions of disease management, that narrow approach was dropped years ago. That's because patients typically seek advice for a wide range of overlapping concerns and the good nurses hired by the vendors will respond to them.  The vendors also understand that their shared risk and performance guarantees depend on claims expense that is driven by the synergies of multiple co-morbidities. 

While a purchaser, insurer or accountable provider organization may start out with a focus on a population defined by a single condition - such as diabetes mellitus - that doesn't mean their protocols and care plans won't span the continuum of care and include hypertension, tobacco abuse, depression, housing, chatting about the grandkid and responding to concerns whether this will be finally be NBA superstar LeBron James' year.

And the published literature supports the DMCB's contention that modern population health management is multifaceted.  Examples include this seven-condition program for dually eligible Medicaid beneficiaries in Georgia, this Midwest employer-sponsored program that enrolled persons with multiple care needs and this physician-focused program that used pay-for-performance to improve measures across multiple conditions.  Check out some vendor web sites and you'll see references to "whole person health," the "interrelated aspects of social, emotional, and physical health" and "a holistic view of member health across internal and external care management initiatives."

That being said, the DMCB knows that perception and reality can be two different things. Given the whac-a-mole persistence of the "single disease" myth, the DMCB says the population health management community may benefit clarifying the broadness as well as the depth of their offerings as they continue to build their brand.

Image from Wikipedia

Medicare's Costs: Current Law vs. Looming Reality

So, how bad is it?

While HHS Secretary Sebelius' Affordable Care Act nostrums help the Obama Administration's muddling of policy and election year politics, CMS Chief Actuary Richard Foster has stepped forward (see page 277) with some blunt language about Medicare's solvency.  As the Disease Management Care Blog understands it, official projections on just when the money runs out are based on current law. 

That's the rub:  

"While the Part B projections.... are reasonable in their portrayal of future costs under current law, they are not reasonable as an indication of actual future costs. Current law would require a physician fee reduction of an estimated 30.9 percent on January 1, 2013—an implausible expectation."

"[W]hile the Affordable Care Act makes important changes..., there is a strong likelihood that certain of these changes will not be viable in the long range. Specifically, the [anticipated] annual price updates for most categories of non-physician health services will be adjusted downward each year by the growth in economy-wide productivity. The best available evidence indicates that most health care providers cannot improve their productivity to this degree—or even approach such a level—as a result of the labor-intensive nature of these services."

"Without unprecedented changes in health care delivery systems and payment mechanisms, the prices paid by Medicare for health services are very likely to fall increasingly short of the costs of providing these services. By the end of the long-range projection period, Medicare prices for ... many services would be less than half of their level under the prior law. Medicare prices would be considerably below the current relative level of Medicaid prices, which have already led to access problems.... Well before that point, Congress would have to intervene to prevent the withdrawal of providers from the Medicare market.... "

"Finally, the economic outlook remains more uncertain than usual. Due to the sensitivity of HI trust fund operations to wage increases and unemployment, the current slow recovery from the recent recession adds a significant further element of uncertainty to the trust fund projections."