Wecome to the Family, ACA

All big families go through this sooner or later. 

The upending of a familiar rhythm of behaviors, traditions, relationships and unspoken social rules by the unpleasant intrusion of one who is eumphemistically termed "a significant other." The disagreeable dolt who sleeps in.  The rude boyfriend who won't close his mouth when he chews. The unpleasant uncle who knows it all. In hushed whispers in the kitchen, the regulars wonder: just what in the world does she see in him?

Yet, even as families hope against hope that they'll break up, things settle into a new equilibrium. Loyalties evolve, the relatives adapt, newcomers behave and the traditions evolve. Yes, those were the good old days and he may be a horse's ass, but now he's our horse's ass.

Enter the Affordable Care Act. Whether we like it or not, the Supremes see something in this fat boy sitting in our living room and it looks like he's for keeps. The ACA may be unwieldly, expensive and prone to mischief, but it looks like he ain't going anywhere. Absent an unlikely Republican trifecta involving the Presidency, House and Senate (and that has to be filibuster proof) in the November elections, it looks like he'll be part of the family for years to come. 

Welcome to the family, ACA.

Surprise, Surprise: The Patient Centered Medical Home Costs Money!

Alt for Norge!

The Disease Management Care Blog is decamping to Norway for a meet-the-family and see-the-sights vacation.  The good news is that Europe is 8 hours ahead, which means the DMCB will know about the Supreme's Thursday decision 8 hours before anyone else.  The bad news is that in the coming days, its posts will become infrequent at best.

In the meantime, check out this just-published JAMA article on the PCMH. 669 primary care centers participated in a Harris survey commissioned by the Commonwealth Fund.  While the "Safety Net Medical Home Scale" was not based on the NCQA, it inquired about the familiar care domains.  The 0 to 100 scale was correlated with financial data from the Uniform Data System reports that reflected the clinics' operating costs.

Unsurprisingly, the authors found that as the medical home score increased, so did the operating costs. Moving from 60 points to 70 points increased the cost per patient per month by $2.26.  While the authors calculated that translated into more than half a million dollars of additional expense for the average clinic, the DMCB notes that kind of expense for an average physician panel of 1500 patients means more than $40,000 per year.

Readers familiar with the cost of disease and population health management will find that $2.26 PMPM statistic very significant because that's in the range of what is charged by many vendors.  What's more, the vendors' charges include a profit margin which was not necessarily included in the clinic's study data.

Conclusions?

The PCMH is not necessarily "cheaper" than outsourced care management.

While the PCMH may (statistically significant proof remains elusive) "save money," it appears they have the same challenge faced by the disease management industry in the early days: savings net of fees doesn't necessarily equal profit or a financial gain for the health insurer or consumer.

Stacking the Deck in Health Care Policy

If no poster, a statue maybe?

The Disease Management Care Blog is always on the lookout for wall decor for its fashionable world headquarters and all but decided on this framed poster picture. The alarmed DMCB spouse inappropriately intervened, citing a host of silly concerns*.

The politically shrewd DMCB countered the spouse's raw power play by appealing for the input from a stacked deck of friends and family. They appreciatiate the similarities between the bon vivant DMCB and The King, and they also have a sense of humor.  Thusly armed with the support of its handpicked cadre, the DMCB thought the day was won.

Why not?  The DMCB is only copying from the White House's playbook.  Check out this HHS press release.

Dare: June 20, 2012 11:30 AM PDT

Subject: External Affairs Welcomes Dr. Mandy Cohen

Dear Stakeholders,

I am pleased to announce that Dr. Mandy Cohen has joined our team in the HHS Office of Intergovernmental and External Affairs (IEA) as Senior Policy Advisor and Director of Provider Engagement. In her new role, she will focus on the Department’s work to transform the delivery system and oversee the Department’s outreach and engagement with clinicians, health professionals and other providers.

For the past two years, Dr. Cohen has been the Director of Stakeholder Engagement at the CMS Innovation Center, working with the Center’s many constituencies to develop and test new payment and delivery models. Prior to joining CMS she was the Executive Director of Doctors for America. Dr. Cohen received her medical degree from the Yale University School of Medicine and trained in internal medicine at Massachusetts General Hospital. (bolding DMCB)

Dr. Cohen and I both look forward to working with you as we improve the health care system together. 

The DMCB was first introduced to "Doctors for America" thanks to this HuffPo posting describing a mutual-admiration health reform meeting at the White House. Having never heard of Doctors for America, the DMCB naturally turned to Wikipedia, where it all became clear. 

The DFA used to be known as DFO, i.e., Doctors for Obama during the 2008 elections. While the White House also gets to conflate the "A" and the "O," it's real purpose is the portrayal of getting seemingly neutral input from an impressively named physician organization that is not the AMA.

Unfortunately, it doesn't look like the DMCB will get its way on the hanging the picture.  Unsurprisingly, the White House's stacking the deck with political backers doesn't mean they're necessary going to get their way on health care either. 

(In all fairness, however, it should be pointed out that CMS is working with former AMA President Nielson).

Statue image from Wikipedia. 

*The controversial poster shot  was taken during rehearsals for the filming of Captain EO in 1986.

Europe Likes U.S. Disease Management

Listen to public radio, read the national newspapers, surf the standard cable channels or listen to the mainstream commentariat and the message is the same: if only the U.S. would import the best of European-style health care, life-expectancy rates would increase, health care costs would decline and physicians like the Disease Management Care Blog would bask in the benevolent and enlightened management of the U.S. Department of Health and Human Services.

As the DMCB has pointed out before, comparative national data are not a slam-dunk, untangling unique non-medical cultural and economic impacts on population the U.S. is complicated and the U.S. in some instances, is getting its money's worth.  What's more, rising health care costs are a global phenomenon and there is no evidence that dropping European-style health care on the U.S. will blunt its overall cost inflation. As for the enlightened benevolence of HHS, just remember that their Board of Directors is Congress and that Taxmageddon promises that the SGR fix won't be pretty.

Yet, while DMCB readers may have a reason to be skeptical about the wisdom of of europhilism, what about the possibility that our beret-wearing, cobblestone-hopping, Audi-driving and cafe-sipping cousins across the Atlantic admire the U.S. system?  Impossible you say?

Think again.  The DMCB has personally been to Europe to share the good news about U.S. approaches to disease and management. The Care Continuum Alliance has an impressive international presence made up of organizations using elements of  disease management and population-based care. Many of the vendors sell millions of dollars' worth of services in Europe. 

To drive the point home, here's recent and telling opening quote from a internationally published paper in Health Expectations on the topic of disease management:

Inspired by American examples, several European countries are now developing disease management programmes (DMPs) to improve the quality of care for patients with chronic diseases.

A Health Care Anthem of Optimism

Our understanding of the ACA?

If Disease Management Care Blog's bold prediction holds up and the Supreme Court splits the health care baby by letting the Affordable Care Act (ACA) stand while striking down the "individual mandate," progressives will announce the world is ending, while conservatives will announce Obamacare is ending.

The DMCB argues neither will be true.  When the sun rises the next day, Ms. Pelosi's health care "constitutionality" sputterings will not cease, crafty U.S. House Republicans won't stop their devilish attempts to gut what remains of the ACA and CMS' vast bureaucracy will continue to "innovate" with long-used approaches from the commercial health insurance markets.

The DMCB also predicts that there'll be an emerging consensus that a stumbling White House somehow botched the media-public opionion-wars. According to that narrative, manipulating an unsuspecting "Jersey Shore" addled public with news conferences, speeches, town halls, favorable coverage, framing, biased polling, talking points, press releases, The Daily Show appearances, bloggery, tweets, negative ads, spin, messaging, appeals to "the base," and targeted air-time can convert uninformed numbskulls into opinionated numbskulls.  Talking heads on both sides of the partisan divide would have us believe that but for Americans being educated about the merits of one position vs. another, they'd not only make the correct judgement, it'd be our judgement.

"Bunk!" says the DMCB.

It thinks that by now most Americans "get" the broad outlines of the Affordable Care Act: expanded, mandated and regulated private as well as government-sponsored health insurance that is paid for by the Feds and therefore the taxpayer. Knowing the facts, it's not unreasonable for thinking persons on either side of the political spectrum to agree or disagree with the ACA.  Call the DMCB naive, but it thinks that the general poll trending against the ACA has less to do with media and more to do with the informed judgement and native intelligence of a messy democracy that is underestimated by a cynical partisan elite.

The DMCB is not arguing that the news cycle and media don't have an impact. They do. Yet, when it comes to the ACA, both sides have had an ample opportunity to use all the powers of persuasion to nudge public opinion.  The fact that the ACA has failed to achieve a convincing level of support speaks less to competing messages than the underlying content. In other musical words, it's not the arrangement, but the underlying chord progression.

What to make of all this wreckage?

The ACA's unfavorability, despite a generally supportive news media, suggests Congressional leadership cannot govern from the left.  This is a cautionary lesson for the emboldened Republicans, who may calculate that when their turn comes, they'll be able to govern from the right.

There's good news for health reform.  President Obama's allies forced the issue and, sooner or later, Americans, after trying every alternative, will finally do the right thing. The Supremes and public opinion seem to be telling us that the ACA is not necessarily that right thing. We're still working on it and a plan that can be supported by most Americans will eventually emerge.

"Hovering" - A New Term for Disease Management?

Hovering

"Hovering?"

That's the term used by Drs. Asch, Muller and Volpp in a New England Journal article on care management that gets it mostly right for the wrong reasons.

Noting a few hours of face-to-face visit time with a doctor over the course of a year doesn't come close to meeting the full-time needs of patients with chronic illness, the authors describe how wellness, medication compliance, transitional care and telemonitoring programs have stepped in, especially for 'hot spotter' patients.

Sounds good, say the authors, but they argue that these "conventional" disease management programs have "not fulfilled their promise" because of 1) unjustifiable personnel expenses and 2) the difficulty of maintaining patient engagement.

They feel things will change for the better. That's because

1) payment mechanisms are now demanding "accountability,

2) the science of behavioral economics allows for a better understanding of what motivates patients and

3) the price of wireless and internet-enabled devices is dropping.

So, when all three of these ingredients are optimally combined for the right kinds of patients, they say the resulting "hovering" will drop health care costs and increase quality. They describe an example of an automatic pill-bottle reminder system that is linked to patient lottery reward that has been shown to increase medication compliance and reduce hospitalizations (which, by the way, was described four years ago by the DMCB here).

Dr. Asch et al are technically correct but unfairly portray the disease and population health management service providers as behind the times. They couldn't be more wrong.

The vendors have been working on an "accountable" risk-basis with health insurers for over a decade, have led the way in the use of behavioral economics in their programs, have been closely aligned with telemonitoring services and regularly use the technology of predictive modeling to identify those patients who are mostly likely to benefit.

One thing the vendors have not done, however, is use the term "hovering" in their marketing materials, peer-reviewed publications or national meeting presentations. 

Which begs the question: how about changing from the DMCB to "Hovering Care Blog?"

Nah.

France Says Affordable Care Act Is Seeking Asylum

En guarde for the ACA

Washington DC (DMCB) - The Affordable Care Act (ACA) sought refuge in the French Embassy today and has applied for political asylum, said U.S. officials.  France's Foreign Minister, Philipe deBird announced that the Act is now under the protection of the French government while it considers its obligations under international law.

The ACA has been appealing its numerous death sentences in U.S. courts and a final ruling is expected any day now from the U.S. Supreme Court. Many legal experts expect the Court to uphold many of the Appeal Courts' decisions, which could spell certain doom for the ACA.

Various members of Congress have denounced the Act as a threat to national security and have advocated for a remote drone attack.  "The dark references to 'severability' in speeches on the floor of the House of Representatives probably pushed the ACA over the edge" said DMCB legal expert Dawn Tzume.  "It's also no accident that the ACA chose the French Embassy, since they not only support free health care but smartly sport berets and stylishly drape their jackets over their shoulders, even when they are in Afghanistan" added Ms. Tzume.
 
Former State Department spokesperson Wanda Ostomy charged that France may use this incident to influence U.S. monetary policy.  "The French could easily deny asylum, putting the U.S. budget back in the dumpster," said Ms. Ostomy. "They'll probably 'suggest' that we convert to the Euro and use it to finance California's 2012 deficit," she added.

The DMCB contacted the White House for comment and was referred to Nancy Pelosi's office.  "We are studying the situation and let the President know what the next steps will be," said an unnamed person in Ms. Pelosi's office. 

"The ACA is at this moment enjoying some cheese, croissants and pear slices, courtesy of the French people," said Embassy spokesperson, Jean Claude deRash. "Many of our citizens are on holiday at this time of year and we wished to extend the same courtesy to our unexpected guest," he added.

The Disease Management Care Blog will continue to follow this developing story

Image from Wikipedia

Psycopathy In Health Care Organizations

Years ago, the Disease Management Care Blog tagged along as a minor player to a high level strategic meeting involving a pharmaceutical company and a provider organization. The senior leadership egos on display barely competed with the meeting room's spacious view of the Manhattan skyline as our group was hosted over yummy pastries and coffee by a good looking, gregarious, gracious, intelligent and obviously "connected" pharma executive.

The meeting progressed quite nicely until a coffee break supervened and the DMCB found itself alone in an anteroom with the host. Caught up in the enthusiasm of the moment, the DMCB parroted one of the meeting's nostrums about the internet. The executive turned and hissed at the DMCB's stupidity with dripping contempt, turned and walked out. Minutes later, the meeting restarted as if nothing happened.

That was just one of the DMCB's many encounters with an organizational psychopath. Unable to have experience any interpersonal "connection" with anyone, these soulless persons use the people around them to pursue the more tangible rewards of power, financial gain or amusement.  Excluded from the social web of human relationships, psychopaths can't access a moral compass.  As a result, they turn to social mimicry to charm, shame or bully anyone in the pursuit of their goals.  Everyone that surrounds them is a either a means to an end or,in the case of the DMCB, dirt.

While the more famous psychopaths are sadistic murderers, they're the exception.  Most of them coldly calculate that they don't need violence to achieve their ends. Deceit, predation and manipulation are more than enough while they pursue their goals in the cubicles down the hall and the offices upstairs.  And as they click along, these Sandusky-esque time bombs are often recognized too late.

Here's the DMCB's four  rules on how deal with organizational psychopath:

1.  That ill-defined "feeling" that you have that something's wrong with that person? You wonder if it's bad parenting, drugs, mental illness, curious flattery or an inflated ego?  Trust your instincts and include psychopathy among the possibilities.

2. Don't be surprised when you uncover the extent of the dysfunction.  The prevalence is at least 1% and their toxicity can bring a team, a department and even an organization to its knees before you realize what's happening.

3. The infamous Milgram experiments found that persons in positions of power can lead decent people to do awful things.  Questioning authority is a good thing. If you do it, you deserve credit. If one of your reports does it, they deserve protection.

4. Stay away, contain and remove, preferably the latter - even if it means you.  Warnings and counseling will not change their underlying motivation in any appreciable manner.

The DMCB is happy to report that the meeting didn't lead anywhere and that it was wiser for the experience. 

That's why, years later, its skin crawled in a medical meeting hotel bar. 

Following a standing ovation for a plenary session presentation by the charismatic CEO of a very successful health care organization on the merits population health, the electronic record and systems integration, the DMCB found itself behind him and one of his minions trying to get a cappuccino. English was not the hapless server's primary language and she struggled with the barista's brewing details. The CEO's cold scorn and hateful disdain were radioactive while his companion's nervous silence signalled that more than just impatience was at work.  The guy on stage just minutes before was an impostor.

Yes, it really did happen and yes, he's still out there.

Bring On The Coupons!

Most persons with insurance that includes a pharmacy benefit are probably very familiar with co-pays.  Those out-of-pocket expenses not only reduce the insurers' costs, but are a powerful tool that can incentivize the choice of a month's supply of an otherwise equivalent generic (for $5) versus an expensive brand medicine (for $30).

But suppose the brand drug manufacturer fights back with a $30 coupon?

That's the topic of this JAMA paper by David Grande. While the coupons could be prohibited as "kickbacks," can be suddenly stopped and are often given on-line in exchange for otherwise private patient information, the main argument against them is that they substantially increase insurer costs.  As a result, Dr. Grande recommends that physicians resist the allure of giving their patients any coupons and that pharmaceutical companies find other ways to reduce patients' out of pocket costs.

The DMCB has another idea that is going unmentioned by JAMA.  Why not suggest that insurers compete should against the manufacturers' coupons with their own coupons?  Competition may eat into the insurers' bottom lines but the patients will win.

Patient interests: That's the point, right?

From P4P to Pay Patients for Performance (P4PP)?

Joanne Wu, writing in the Annals of Family Medicine, suggests that we dismantle the health insurers' "pay for performance" ("P4P") programs in favor of "pay patients for performance" (PP4P).  As blood pressure control, cholesterol treatment, cancer screening rates or fitness rates increase, she proposes that patients receive "health care credits" in the form of lower co-pays, discounts or premium reductions.

Good idea, says the  Disease Management Care Blog, but:

1) Long standing regulations stand in the way. Health insurance regulators generally frown on programs that compromise community-rated risk pooling that gives everyone the same benefit for the same price.  ERISA-protected plans, on the other hand, have greater latitude in flexing their insurance benefits. 

2) Politics stand in the way. Opponents argue that persons less well off will be unfairly disadvantaged by wellness incentives.  You can read more about that here. 

3) Doctors stand in the way. Last but not least, insurers generally fund P4P by diverting the money from the providers' inflation-adjusted or market-driven fee schedule increases.  In other words, taking P4P money from the docs and giving P4PP to the patients ain't gonna easily happen.

That being said, the DMCB thinks Dr. Wu may be onto something.  She recommends a pilot be tried in a small community.  Given the downstream savings, we'd be foolish to not take every advantage we can to achieve patient buy-in, and a pilot sounds like a grand idea.

We Need to Leave the Complex Legacy EHR Systems for Something Better. Here's How

Years ago, when the physician Disease Management Care Blog was first grappling with an electronic health record (EHR) system, it couldn't:

manage any text with basic word processing tools;

review a patient's summary data (like all cancer screening tests over time);

review its patients' summary data (like blood pressure control among all persons with a diagnosis of hypertension);

communicate with patients outside of an unwieldy messaging system;

perform outcomes research (based on a look-back, which approach worked better?).

support key elements of population health management, like risk stratification or facilitating nurse-physician care plan work flows.

What it could do was continue to see patients one-at-a-time, type (not write) a clinic note, click (not mark) the tests it ordered and bill a lot more for its services.  And what the DMCB's clinic could do was spend a lot of money on health information technology that was siloed (unable to communicate in any fashion with any area hospital) and complicated (the health IT department was enormous).

According to the New England Journal's Drs. Mandl and Kohane, the DMCB is not alone. Too many docs today are trapped in legacy systems that don't come close to the home technology they and their patients have, like Twitter, smartphone apps, Facebook, Google search and iTunes.

They argue that the solution is to reject the  EHR vendors' argument that health care IT has to be complicated.  We can transition from those horrid meaningful-use addled single systems to a flexible modular approach based on cheap and existing technology that is available today.  We need EHR systems that can not only document, order and bill, but:

1. Reasonably securely store retrievable patient data on the "cloud"

2. Enable providers to securely share information seamlessly using open source formatting

3. Apply project management software to patient documentation to record extended interactions over an episode of care

4. Use public domain analytics to identify, manage and follow population-based care needs

The DMCB agrees and sees an opportunity that parallels what happened when electricity was introduced to U.S. manufacturing.  According to Drs. Jones, Heaton, Rudin and Schneider writing in the same issue of the Journal, swapping electric motors for steam powered engines during the Industrial Revolution didn't result in any productivity gains. Rather, it was the follow-up distribution of small motors throughout the factory floor that transformed American industry. 

The same principle may apply to health care. We have yet to intelligently "distribute" information technology in a modular fashion throughout the clinical factory floor and adapt our old one-patient-at-a-time workflows to really take advantage of it.

Image from Wikipedia

Aggressive Insulin Treatment vs. Pills for Diabetes with Athersclerotic Disease: No Difference in Outcomes

When doctors and their patients review the treatment options for diabetes mellitus, a common question is "Why mess around?" If the blood glucose, thanks to a relative lack of the hormone "insulin," is "high," shouldn't the more "natural," tighter and physiologic answer be... insulin? While there are pills that can lower blood glucose levels and patients detest shots, it's unclear if the long term clinical, economic and quality-of-life outcomes favor one approach (oral medications) over another (insulin).

The Disease Management Care Blog thinks that these are the issues that were explored by the important, international and huge multi-center "ORIGIN" Study.  The results have just been published by the New England Journal.

Over 12,000 persons over age 50 years with

1) impaired glucose control or "pre" diabetes (more on this topic here), or

2) just-diagnosed diabetes or,

3) well-controlled diabetes (A1c less than 8 to 9%) on no or just one oral medication

and

4) established heart or atherosclerotic vascular disease

were randomly assigned to insulin glargine (with dosing that aimed for a normal blood glucose of 95 mg.%) or usual care (that relied on physician judgement and local guidelines). 

After one year, 50% of the insulin group hit their targeted blood glucose level and their median A1c (a measure of average blood glucose control over time) was 5.9%.  The usual care group achieved a median glucose level of 123 mg.% and after one year the A1c was 6.2%.  The difference in A1cs persisted over the remainder of the study (Table here)

The mean age of the participants was 63 years with an impressive median follow-up of 6 years that yielded outcome results on 99% of the participants.

Results?  No difference in heart attacks or kidney disease.

When cardiovascular death, nonfatal heart attack, non-fatal stroke were combined, the incidence was the same in both groups - about 3% per year.  There was no difference in kidney outcomes including deterioration in function or need for dialysis.  Hospitalization rates for any cause were the same in both groups.  There was an isolated difference involving angina that, in the DMCB's mind, may have been a statistical fluke.  You can look at the outcomes for yourself here.

There was one important difference.  Among the 1456 persons without formal diabetes (the "impaired" group - see above), persons given the insulin were less likely to progress to a formal diagnosis of diabetes (25% vs. 31%).  Unfortunately, they paid a price, because they had a higher rate of insulin-induced low blood sugar reactions (an incidence of 17 vs. 5 per 100 person-years).

Based on these results, the DMCB thinks:

1. Turning to insulin treatment early in the course of pre or diabetes treatment for persons with heart disease doesn't appear to offer any important difference in macrovascular (heart attack and stroke) disease or kidney disease outcomes. However, that's only true among patients who have achieved an A1c below 7%.  (The DMCB can't figure out what happened to the patients with a baseline A1c in the 8% to 9% range who didn't get to an A1c below 7 - did insulin help them?)

2. What's more, it's possible that driving an A1c lower - once it's below 7% - doesn't offer any additional outcomes advantage.

3.  While early insulin supplementation may prevent the "burn out" of the insulin-producing cells of the pancreas, the price for that is a higher incidence of low blood sugar reactions.  Even though this "cure" of diabetes may seem like a big deal, why bother if there's no difference in survivorship?

4. As the population health management service providers discuss care planning with their patients with diabetes and heart disease, the topic of early aggressive insulin may come up.  Here's an answer to that question.

5. If accountable or risk-assuming organizations believe that early aggressive insulin treatment will lower the direct costs attributable to heart disease among their patients and enrollees with diabetes, the answer is no.

That out-of-ate but compelling image is from a 2003 HHS website on why Prevention Makes Common Cents

Telephonic Screening for Intimate Partner Violence? Why Not?

In the this-post-won't-go-anywhere-but-what-the-hell category, the Disease Management Care Blog was intrigued by this Annals of Internal Medicine update to the USPSTF guideline about screening women for intimate partner violence.  Basically, there is enough outcomes evidence to warrant routinely asking about it during the course of a clinic visit.

The statistics are sobering. According to the American College of Obstetrics and Gynecology, U.S. women experience 4.8 million incidents of physical or sexual assault annually and one third will experienced rape, an assault or stalking by an intimate partner in their lifetime.  One study found almost 14% of the women in the physician waiting room had recently experienced abuse. Long validated screening tools can be found here.

Despite the evidence that supports screening, the response of the medical community has been tepid.  While patient advocates may be justifiably annoyed by another example of the health care system's failure to identify and help patients in need, the docs will point out that aren't enough hours in a clinic day to address every important preventive need.

Enter population health management (PHM).  It's not clear to the DMCB that screening and referral for abuse victims has to be performed by the physician in the course of a one-on-one patient encounter.  For example, this study relied on non-physician research assistants to do the screening who, in turn, notified the physician if the screen was positive.

It's also not clear to the DMCB that screening - and possibly even referral - has to be done on a face-to-face basis.  Why not rely on other means of communication?  Studies have shown that remotely conducted surveys for and routine and not so routine health matters are a surprisingly viable and cost-effective alternative. While the stakes are obviously higher and the planning would be complex, the DMCB asks:

Why not?

The DMCB conducted a literature search and could find no published studies on the topic of using remote communication technologies (like the telephone) to screen for intimate partner violence against women.  It also suspects most of the population health management service providers do not ask about it in the course of their nurse-patient interactions.  It doubts medical homes rely on telephony, web-based technologies or remotely-based EHR technologies either.  The USPSTF is conspicuously silent on the topic.

Given the prevalence of the problem and the struggle of the traditional health care system to manage this on the usual face-to-face basis, it seems to the DMCB that this may be a problem that the PHM and PCMH community may want to explore.

Why not.

CMS' and The Possible Obsolescence of Its Versions of the EHR, PCMH and ACO

Let thousands bloom

After reading this Huffington Post (HuffPo) article by National Physicians Alliance board member Ricky Choi, the Disease Management Care Blog is worried.

According to Dr. Choi, sometime last week, the White House hosted a meeting of national physician leaders to talk about the Affordable Care Act.  HHS Secretary Sebelius was there along with other CMS administrators.  The conversation focused on electronic health records (EHRs), the patient centered medical home (PCMH) and accountable care organizations (ACOs). 

The DMCB is not worried about another Cabinet member blurring the line between policy and election-year political grandstanding.  It is not concerned that naive ACA supporters are unwittingly being used to promote the Administration's health reform nostrums.  It is not surprised that this flattering article seemed only fit for liberal HuffPo and is destined to reinforce the biases of an already committed base. It is not wondering about a curious commitment to care approaches that still are not conclusively backed up by a critical mass of peer-reviewed evidence. Finally, the DMCB isn't shocked that it was not invited to the White House.

Rather, says the DMCB, it's worried that this is all the White House has.  A precious day of CMS leadership attention spent in recycling stale EHR, PCMH and ACO acronyms and jargon with a fawning circle of fellow ideologues? What gives?

While the CMS' EHR's meaningful use program continues, health care technology is evolving away from fixed desktops and mainframes toward mobile smart devices, apps, the cloud and social media. The transition is bound to shift doctor's and patients' highly personalized management of information in ways that we haven't thought of. 

CMS' "PCMH Ver. 1" entails a wholly contained primary care provider team reimbursed with a monthly fee.  In the meantime, other health systems and insurers are already figuring out how to simultaneously out and insource team members depending on local resources and patient risk. 

CMS is just getting its ACO pilots and programs off the ground. In contrast, commercial insurers launched a host of "accountability" initiatives years ago. Many are focused on a single clinical domain (such as avoidable emergency use, patients who are high risk, or post-discharge readmissions) and are highly flexible and expandable.

The distinctly modular approach to health IT, medical homes and provider-insurer risk transfer certainly contrasts with CMS' plodding one-size-fits-all and top-down planning.  While a thousand commercial sector flowers bloom, CMS risks presiding over demos and pilots that could become obsolete before the the data collection has been completed.  Why aren't they meeting about that?

Last but not least, the Administration seems to be putting all of the ACA's eggs in the EHR, PCMH and ACO baskets. If they don't work out, it would further undermine the brand of the star-crossed Affordable Care Act.

Image from Wikipedia

Friday Links

Of interest:

If integrated delivery systems (and their virtual twins, accountable care organizations or ACOs) are such good ideas, why this?

Yes, we need published, peer-reviewed, transparent, public-domain, statistically valid, scientific and prospectively conducted studies using a valid comparator. Health insurers operating businesses in real markets don't.

Speaking of Washington DC-based Blues CareFirst's success with the patient centered medical home model, they outsource the care coordinators to the PCP clinics.

Unrepentantly progressive Maggie Mahar hosts the latest Health Wonk Review at her new blog lair, healthinsurance.org blog.  The DMCB is in there, wayyyyy at the bottom.  The links up top are more interesting and worth a look.

Image from Wikipedia

A Bipartisan Press Release For When the Supreme Court Announces Its Affordable Care Act Decision

While D.C. borders on getting all wee-weed (remember that?) over the Supremes' any-day-now ruling on the constitutionality of the Affordable Care Act, Dems and Republicans alike are intensely scenario planning. The Disease Management Care Blog is no expert at that sort of political jujitsu, but it suspects that in addition to teeing up the talking points, news conferences and interviews, some sort of press release will be necessary.

Knowing how busy both the White House and the House Speaker's office are dealing with other pressing business, like sponsoring multiple bills that have no hope of passage, the patriotic DMCB is pleased to do its part. It offers a partisan but "generic" and plug n' play press release that explains a lot of what's been going on. This novel release can be put out on the wire within minutes of the coming Supreme Court's decision:

(Select one) From The White House  or Speaker of the House
Office of the Press Secretary
______________________________
For Immediate Release

[Select: President Obama/Speaker Boehner] Use Astrophysics To Praise Supreme Court Affordable Care Act Ruling

WASHINGTON, DC - Today [select one: President Obama/Speaker Boehner] reacted to the Supreme Court's ACA ruling with the following statement:

"While today's U.S. Supreme Court's ruling was not what the American people wanted, I want my fellow citizens to know that, while we will abide by the decision, the large majorities of Americans in the many parallel universes who support my party's position are benefiting from a different Court decision as I speak to you today."

"In addition to having travelled all over the United States, I and my staff have spent considerable time in alternate time-space realities where there are hundreds of millions of other Americans in the multiverse. They have agreed with my party's agenda. There are also dozens of Supreme Court Justices such as [select: Nancy Pelosi/Newt Gingrich] who have upheld the jurisprudence contained in the closed information loops on this version of planet Earth."

Thanks to the success of the [select: President's/Speaker's] novel approach to splitting quarks to convert dark matter to antienergy, he can now go beyond the simple legal and political pseudorealities of this universe and tap the wisdom of other pseudorealities. For example, in one universe, where bicoastal California and New York [select: are the only states that exist/don't exist], the [select: President/Speaker] noted "This decision puts the momentum for the fall elections on our side. We don't have to talk to anyone and care about their opinions."
------------------------

As an aside, after hearing an erudite webinar on health reform, checking with Intrade and communing with the prognostication spirits, the DMCB **predicts** that the Supreme Court will overturn the Affordable Care Act's individual mandate provision.  That's because

1) oral arguments suggested the Justices have serious concerns with it, but more importantly...

2) striking down only the mandate means leaving the rest of the law intact. The gives something to everyone, which

3) preserves the reputation of the Court, which is also being increasingly painted as partisan.

Health Insurers: The Success Factor for Accountable Care Organizations?

Insurers chatting about ACOs

What a weird week it's been.  Mrs. Obama didn't mean it when she said she supported a NYC soda ban, President Clinton didn't mean it when he said he admires venture capitalists and Wisconsin voters didn't mean it when they said they wanted to recall Gov. Walker. While the Disease Management Care Blog ponders the possible causes, it takes comfort in knowing that the "dean of American health economists" Victor Fuchs always means what he says, and says what he means.

To wit:

"...the operational infrastructure required to create and manage ACO is found in large health plans, both not for profit and for profit."

Academician Dr. Fuchs knows of what he speaks, especially when he's writing in the Journal of the American Medical Association (JAMA).  In a viewpoint article titled "If Accountable Care Organizations Are the Answer, Who Should Create Them?", he describes the several things ACOs have going for them:

1) providers will be under less pressure to pursue top line revenue through overutilization of care resources,

2) pharmacy use will be tilted in favor of lower cost generics,

3) there'll be better primary and specialty care coordination, and

4) administrative savings will increase thanks to capitatation and not having to bill for individual services.

And which constituency, he asks, is in the best position to pull this off?   According to Dr. Fuchs:

Not employers. They don't have the skills.

Not physicians. While they understand cost-effective medicine, they've underinvested in systems, administration, customer service and financial functions.

Not Hospitals. They might have the capital and the professional expertise, but it's been focused on filling beds.  What's more, they could also come to anti-competitively dominate their local markets.

That leaves the insurers as the most "feasible" candidate.  Dr. Fuchs points out that they have capital, understand risk, possess the financial expertise and can manage disparate data sources.  They are also seeking provider ACO partnerships.  Examples of this, he notes, include UnitedHealth, Humana, Aetna, WellPoint and Highmark.

The DMCB couldn't have said it better but it did raise this a lot sooner.  It and colleague Vince Kuraitis argued that insurer-provider ACO alliances would emerge as a viable market alternative almost a year ago.

In addition to claiming some credit for helping DMCB readers scoop JAMA by almost a year, the DMCB also points out that it thinks some hospital or physician-led ACOs will ultimately prevail.

One key success ingredient for ACOs will be population health and care management resources.  It's no accident, says the DMCB, that commerical insurers like Humana and Aetna stand poised to succeed in the ACO biz.  In addition to their capital resources, awareness of the economics of risk, financial expertise and data skills, they've also been doing cost-effective PHM for years. 

The physician and hospital groups that catch up to the insurers on this will be the ones that prove Dr. Fuchs wrong.

Electronic Health Record (EHR) "Robots" and The Need for a Legal Framework

Hal of 2001: A Space Odyssey

The Economist's recent scrutiny of battlefield and automotive robotics prompted the Disease Management Care Blog to ponder the parallels of "robot-like" health care. 

Sounds too weird, you say?  Alarmist?  Silly?  Read on.

Consider the following scenario:

After checking in with her primary care provider, a check of Mrs. Smith's (not her real name) diabetes revealed her blood sugar was not in the generally recommended A1c range of 6.5-7% (see page 16).  She was free of low blood sugar spells and was otherwise healthy. The electronic health record (EHR) decision support protocols (like "Diabetes Wizard") prompted the care manager to OK a standard increase in Mrs. Smith's insulin dose ("Share the Care"). This was not only consistent with good clinical practice, the decision promised a pay-for-performance payday for the doc's employer and fewer costly complications for the health insurer.
 
Several days later, her fatal car accident was ascribed to low blood sugar.  It turns out that the science of blood sugar control is still evolving, because tight diabetes control isn't necessary associated with better outcomes. In response, the Smith family lawyered-up.

The Economist article asks about the legal dilemmas inherent in robotic decision logic.  Can battlefield drones be adequately programmed to protect civilians?  Can driverless cars intentionally run over a dog if it means avoiding a child? Short of banning these automatons entirely, it's obvious, says The Economist, that we're going to have to develop a legal framework to deal with them: 

"...laws are needed to determine whether the designer, the programmer, the manufacturer or the operator is at fault if an autonomous drone strike goes wrong or a driverless car has an accident."

The DMCB agrees and suggests that this sensible recommendation be extended to the health care arena. EHR clinical programming may only imperfectly reconcile maximum near-term safety with longer term outcomes and fail to discern the subtleties that favor one treatment over another.

While white-coated plastic and metal cybertrons aren't taking care of diabetic Mrs. Smiths (yet), machine logic reminiscent of "Hal 9000" of 2001: A Space Odyssey already is. Instead of an unblinking red orb, there are on-screen decision-support icons. Instead of a disembodied voice, there are clinical pathways (for example, see page 8). And instead of having control over vacuum locks that exit to space, these computer entities are using logic trees to direct, prompt and recommend that doctors and their team-nurses to chose treatment "A" over treatment "B."  If you think that the DMCB is being alarmist, consider that decision support, at last count, is involved in 17% of all outpatient visits in the U.S.  That's a lot of legal exposure.

That's why reasonable laws are needed here too, since it's unclear how physicians, care managers, decision support programmers, EHR manufacturers (even with their notorious hold harmless clauses), physician clinics and health insurers would share in the culpability for allegedly awry decision-making.  Since, in the current U.S. tort system, all could be named in a suit, the risk is arguably intolerable. Just ask any physician, whose dread of being sued has already resulted in billions of unnecessary costs. 

Allowing that dysfunction to creep into computer-based clinical decision will increase costs there too, add uncertainty and slow adoption. 

The Economist has it right.

Image from Wikipedia

The Latest Cavalcade of Risk Is Up!

It's worth a click to check out Nina Kallen's return as host of the latest Cavalcade of Risk.  This is a great linked summary of the best and brightest posts on business-related risk including insurance.  Nina points out that's she living in Massachusetts and her current health insurance costs more than her mortgage. 

Enjoy!

More on the Parallels Between the Sugary Beverage Ban and the Accountability Movement in Health Care

Time for some DMCB humble pie.

Check out Troeltsch's perspicacious response to the Disease Management Care Blog assertion in yesterday's posting that a New York City ban on the sale of 16 oz. calorie dense beverages would "work":

What evidence do you have for the comment "it works?" particularly in light of the fact that soda is simply banned in restaurants, and not any where else in the city?

Troeltsch has both right. 

The proposal, as it now stands, would limit the ban to restaurants, street vendors and concession stands and spares grocery stores. So while New Yorkers couldn't buy that "Big Gulp" to-go, they'd still be able to buy that liter of fructose corn syrup-loaded soda and continue their gluttonous ways in the privacy of their own homes.

And what's more, the DMCB did a literature search and can find no published evidence that a calorie-dense beverage ban reduces the prevalence of obesity. Yesterday's claim that "it works" was simply overzealous. DMCB readers can not only spot non-scientific puffery at meetings, in news reports and in marketing materials, but also in the DMCB's weaker-moment writings.

Well done.

That being said, the DMCB still gives the Big Apple some credit. If you go to the original proposal, you'll see that the ban is only one of 26 initiatives that seek to improve nutrition and increase exercise in the city's public schools, alter sidewalk and building codes to promote physical activity, require hospitals to offer healthy menus, increase the availability and appeal of tap water and promote wellness, especially among public employees. This is commercial population health management writ large.

And the DMCB still stands by its original assertions. Mayor Bloomberg's attack on obesity in the name of public health should remind health care providers that a similar fate awaits their costly ways if shared savings, accountability, bundling, electronic records, the demos and ACOs fail to bend the curve. Instead of trimming excess calories, our politicians will trim excess costs by proclamation.

The DMCB offers three additional observations:

1) Peter Orzag, one of Mr. Obama's health reform architects, famously asserted that the Affordable Care Act's health mandate provision would increase a collective expectation that we should all buy health insurance, much like seat belt laws prompted most of us to buckle up. There may be something to that in the anti-obesity fight, says the DMCB, and Mayor Bloomberg's very public attack on sugary drinks may prompt his city to shift to a new cultural norm

2) The DMCB hopes NYC's Department of Health and Mental Hygiene devotes the resources it takes to adequately measure the impact of the ban. The rest of the country needs to know if this works.

3) Last but not least, if nothing comes of this, this is one more warning to a largely uncooperative and unrepentant food industry.

Parallels Between the Sugary Beverage Ban and the Accountability Movement in Health Care

If New York City's Mayor Michael Bloomberg has his anti-obesity way, the Big Apple will begin banning the restaurant and concession sale of sugary beverages that exceed a volume 16 fluid ounces as early as March of 2013.  The Disease Management Care Blog suspects there is one big reason why Hizonner is deploying brute force in this battle of the bulge, this confrontation of the calories, this attack on adiposity:

It works.

Contrast the approach of simply outlawing obesogenic drinks with kinder and gentler approaches, like those based on education (food labeling and warnings), economic incentives (fat taxes), appeals to self-interest ("you'll look and feel better!") or enculturation (starting with food choices in our schools' cafeterias).  They all have their role, but let's face it: we don't heed labels, hate taxes, find life-style changes difficult, are suckers for the food industry's marketing and ultimately like the taste rush of corn syrup.  Take a stroll through Manhattan and it's pretty obvious we have a problem.

The Big Apple is doing this for our own public health good.

This lesson prompts the Disease Management Care Blog to ponder the largest threat to the success of the "accountability" movement in health care.  By "aligning" economic interests, offering savings-based "gain-sharing," leveraging decision support and enculturating physicians into "systems" of care imbued with best practices championed by physician leadership, we believe our collective taste for high cost testing, technology and pharmaceuticals will fade faster than the flab on The Biggest Loser.

Is that so?  Maybe not, and so the DMCB offers up two observations:

1. Assuming physicians are people and patients have their self-interest at heart, the likelihood that our appetitite for over-testing, the latest tech and brand name drugs will be blunted by electronic health record decision-support warnings, the promise of some savings-based future bonus, appeals at staff meetings to do the right thing or an expectation that physician culture will change is about as realistic as a successful John Edwards White House run in 2016.

2. And assuming that none of that works, the likelihood that future local and national politicians will use the same public health logic and announce a Bloomberg-esque "ban" of some high cost low value tests, technology and drugs is almost certain.

You read it here first.

Image from Wikipedia   

The DMCB Speaks

The Disease Management Care Blog is pleased to be among the faculty at the upcoming educational conference Star Ratings Congress for Medicare Advantage Plans.  The DMCB is always happy to hear itself speak, but what it really wants is to be in the audience and hear from the real experts on how to translate HEDIS and CAHPS scores into ACA mandated bonuses and rebates.

 The DMCB will address approaches to engaging primary care physicians in population health management (PHM).  While it's still fine-tuning its presentation, one of the points it intends to make is that physician engagement may be one of those areas where "variation" may not only be necessary but desirable.  Patient populations and physician cultures vary considerably and, as a result, state-of-the-art PHM must likewise be correspondingly adaptable.

The DMCB looks forward to gauging the audience's reaction to this brazen notion and describing it in a future post.

You can register for the Congress, which will be in Las Vegas July 12 and 13, here.