More on Health Apps: Opportunities, Risks and the Implications for Population Health Management

It's called "mHealth" but others may call it "health apps." The FDA calls it a target rich regulatory opportunity. Others may call it hype.

The Disease Management Care Blog calls it inevitable.

Writing in JAMA, Drs. Steinhubl, Muse and Topol of Scripps agree and say that the future is bright for mHealth. Its adoption is being driven by the threefold convergence of:

1) the search for solutions that address otherwise unaffordable levels of healthcare spending,

2) the availability of broadband wireless connectivity, and

3) consumer demand for individualized care.

The DMCB suspects any one of the DMCB's 5000 regular readers could have written this article. Like Steinhubl et al, they already know that patients want self-diagnosis and condition monitoring. Health consumers want greater efficiencies and enhanced patient-physician collaboration.

Even tech-skeptics have to admit that it's possible that mHealth could lead to a utilization trifecta of fewer office visits, avoided emergency room visits and decreased hospitalizations. Imagine the handheld that can accurately catalog signs and symptoms that help the user discern between a simple self-limited cold vs. a more serious case of pneumonia, or benign skipped heart beats vs. a more worrisome arrythmia.

Handheld apps for chronic conditions are more available than realized. They are on the cusp of going mainstream with assisting hypertensives, diabetics and asthmatics monitor and act on their blood pressure, insulin dosing and inhalants.

If they work right, providers could review summary data and offer guidance via emails and texts in lieu of adding a patient on to the schedule at 5 PM. If done right, the background algorithms could liberate physicians to pay greater attention to the important stuff that requires their complex cognitive or procedural skills.

The authors point out that that doesn't mean it's going to be easy. Medicine is complex and getting paid for it is more so. There's also worry - warranted or not - about the decline of face-to-face doctor-patient relationship. mHealth can lead to overwhelming data gluts characterized by a lot of numbers with little actionable insight. Finally, there's the danger that an app can offer ineffective, inaccurate or dangerous guidance that leads to patient harm.

Bravo to the editors of JAMA for recognizing the importance of the topic and committing precious space to this manuscript.

That being said, however, this article fails to give a full accounting of all the opportunities as well as risks for "mHealth."

First off, as this Kaiser Health News article demonstrates, there are two additional opportunity dimensions that draw on the population health management business model:

1) Apps are not just for diagnosis and monitoring, but also for wellness, and

2) They're being principally sponsored by commercial health insurers who not only readily embrace innovation, but probably consider apps a "sticky" way to maintain customer loyalty. That is doubly true for engaged enrollees who ultimately represent a better insurance risk.  In fact, the DMCB suspects that value proposition is so compelling that insurers are willing to use apps as a "loss leader."

Oh, and while mHealth can be built, it's far more likely it's being bought. As in population health management vendors.

Risks?  You bet.....

1) The fit of mHealth with the electronic health record (EHR) remains an open question.  The DMCB is no coding geek, but it's safe to say that it's not automatic that two independently contrived technologies can automatically "speak" to each other or that the data from an app can by downloaded, summarized and coherently presented to a user at the point of care.

2)  As noted in this article on telemonitoring, it's also not necessarily true that mHealth can be equated with stand-alone technology. Depending on the condition and the need, mHealth will have to be often tethered to human support services.

3) As even casual observers are aware, allegations of "malpractice" are not unusual in health care.  Rather than comment on its friends who make a living off of contingency fees, the DMCB will only point out that mHealth may offer a target-rich rich environment for personal injury attorneys intent on using the legal theory of joint and several liability to maximum effect.  That threat may slow adoption of mHealth.

Image from Wikipedia

The Latest Cavalcade of Risk is Up

The latest Cavalcade of Risk is hosted by Jason Hull of Hull Financial Planning. Pointing out that this is more than just a board game, Jason summarizes and links a series of blogs dealing with the latest insights on managing and anticipating risk. The DMCB is included, so you know it's good stuff.

Enjoy!

The Dreaded Strike Three for Obamacare: Corrupted Exchange Data and Inaccurate Insurance Policies

While the prescient Disease Management Care Blog was among the earliest to identify the threat of an Obamacare-induced insurance "death spiral," it missed spotting the potential fallout from a delay of the individual mandate.

As shrewdly pointed out in this Politico article, health insurance timelines require at least three months of claims experience to inform future rate setting.  Once that actuarial work is done, it then has to go through the states' Insurance Departments for approval.

In other words, if large numbers of Obamacare customers are allowed to sign up after March 31, 2014, insurance companies won't know what to charge their customers on January 1, 2015. 

While overcharging can be remedied by customer rebates, it remains to be seen how accommodating Washington DC will be if the insurers undercharge. That means negative cash flows, raiding surpluses and facing the ire of their investors and Boards of Directors.

It's baseball season, so think of the death spiral as a potential strike one, and inaccurate rate setting as a potential strike two.

Which brings the DMCB to a dreaded strike three. If it happens, the health reform brand could be irretrievably tarnished.  It could also and sink the current version of Obamacare.

Strike three would be a critical mass of inaccurate insurance policies.

If reports like this and this are even remotely representative of the back-end of Obamacare enrollment, the relative trickle of individuals who are successfully navigating the exchanges are getting commercial polices that depend on a very vulnerable reconciliation process involving many moving parts.  That includes information from the "hub" as well as user-based data entry. As noted in this report, commercial insurers are being forced to manually "clean up" the information prior to issuing their exchange-generated policies.

The DMCB suspects that a "garbage in, garbage out" adage may apply. Thanks to sheer number of inputs, clean-up mistakes are going to be inevitable.  And it will get a whole lot worse if the healthcare.gov web site gets only partially fixed. 

While a few mistakes are acceptable in large risk pools, more than a few could be huge problem at three levels:

1. At a business level, where a core competency of insurance companies is to cover their enrollees and only their enrollees. Insurance companies are really good at knowing who is and who isn't insured for a covered or non-covered service with or without a variety of co-insurance arrangements.  It's more than just getting it right, it goes to the core of their business model. If enough policies are inaccurate, it could bring the finances of some smaller health insurers to their knees.

2. At national health policy-making level, where a critical mass of insured customers with premiums and subsidies mismatched to the risk could destabilize the market and distract our political leaders. Think about the customers who assume a service is covered, providers who expect to get paid accurately, balance sheets that don't reflect the truth about claims expense as well as IBNR and regulators who will need to sort it all out.

3. At an Obamacare "brand" level.  Think about all those unfriendly and anecdotal news reports about vulnerable patients who ended up legitimately - if mistakenly - paying more out of pocket for care, or persons mysteriously lacking insurance, or hospitals and doctors being unable to get paid. It could ultimately track back to the HealthCare.gov web site that everyone will loves to hate.

The worst part is that the White House has done such a masterful job of bullying the insurers that it's unlikely that they'll want to rock the boat by going public with any notification that their enrollment data is corrupted.  Mr. Obama will naturally claim that he wasn't in the loop and his loyal aides will deflect blame elsewhere.

Strike three, and we may not even see it coming.

Taking Patient Preferences Into Account When It Comes to Pursuing and Measuring Quality

Here's a thought: ask them what they want

One of the intellectual underpinnings of population health management is that the biopsychosocial dimensions of care is a huge determinant of real-world outcomes. As any doctor who takes care of flesh-and-blood patients knows, national treatment guidelines like these typically fall short of taking the human dimension into account. While there are plenty of good and bad reasons why docs are failing to take advantage of guidelines, one is their sterile one-size-fits-all approach that often fails to account for physician awareness of their patients' risk tolerances and economic circumstances. What's more, many widely promoted treatments only offer a small absolute benefit.

Fortunately, this disconnect is bubbling up into the mainstream scientific literature. The latest example is this Viewpoint that appears in the October 28 issue of JAMA. The authors point out that the perspectives of expert physicians who develop guidelines are typically different than the general public, caregivers or persons with a disease. For example, while the NCQA promotes an A1c threshold as a important measure of diabetes care quality, a compelling survey of patients with diabetes suggests that that emphasis may be displaced.

Where to from here? The JAMA authors offer three commonsense recommendations. Future guidelines should:

1. be developed with the input of patients and frontline clinicians.

2. encompass the full range of patient experiences, not outcomes. This means accounting for the  burden, impact on quality of life and role function dimensions of any treatment recommendations.

3. avoid strong recommendations when the best course of action depends on the patients' context, goals, values and preferences.. Lacking a clearly advantageous outcome with minimal side effects, guidelines should offer a conditional suggestions.

The DMCB modestly offers up three additional suggestions for the population health community and other stakeholders:

1) Absent a satisfactory guideline process from the usual national organizations, it would not be a bad idea to take this bull by the horns and develop a parallel set of guidelines that meet the principles outlined in this JAMA article.

2) Organizations like the NCQA and NQF need to be more flexible in promoting evidence-based guideline-based metrics by moving away from a reliance on their monodimensional clinical measures and toward more nuanced measures of meeting patient preferences.

3) Finally, while national variation in health care delivery is a huge challenge as we continue to build a coherent health system, it may be time to reconsider the notion that all variation is bad. Human beings are variation, and the likelihood of imposing local "best practices" across the U.S. will not be in the best interest of patients with different views of what it best for them.

Image from Wikipedia

The President Says You Should Ignore This Health Wonk Review

Welcome to this October 2014 edition of the Health Wonk Review, hosted by your Disease Management Care Blog. The Review is a sampling of the best recent postings by thoughtful health policy bloggers who are offering insights about healthcare delivery, insurance and reform that are outside the media mainstream.

Or White House control. While Mr. Obama would like the bloggers to sit down, be quiet and let the Washington's expert political class get on with the people's work, the DMCB respectfully disagrees. It was the bloggers who were sounding the earliest alarms about the dysfunctions of the federal health insurance exchange. Despite the advice of our President, this edition of the HWR proudly offers readers some important insights, additional warnings and lessons learned.

One of those lessons is that the HWR bloggers should be read more, not less.

Of course, this Review is not just about the exchanges. If that bungled bit of bureaucracy doesn't pique your interest, read on and you'll find other great stuff on health reform, pharmaceutical costs, Medicare's well-meaning ability to impose silly regulations on docs and how that horrific Bangladesh garment factory fire didn't really lead to any meaningful worker safety reforms.

First up, the exchanges.....

Joe Paduda of Managed Care Matters says the Obama Administration's roll out of the exchanges failed at several levels. Let's face it, he says, the development process was politicized and, as a result, consumers were given the green light to use a flawed web site. They're now being forced to enter too much data before they can shop for insurance, server capacity is insufficient, links to participating insurers are dodgy and patients are unable to ascertain if their doctor is in a particular network. He believes the best way forward is to completely redo the web site and to never ever forget what happens when politics trumps common sense. It's so bad, says Paduda, that the only reason not to fire HHS Secretary Sebelius is the prospect of another partisan battle over her replacement. "Ouch!" says the DMCB.

For crying out loud, says Tim Jost in the Health Affairs blog notes, we're talking about a web site, not cold fusion. While all eyes are on the individual mandate, Jost isn't worried because that's assessed on a monthly basis and the ACA allows for "hardship" exemptions. He reminds us that the key deadline date of December 15 is months away. That's the last day that individuals can enroll in time for the subsidies that will be in place on January 1 2014. If deadline is not met, it's possible that millions of Americans will be unable to obtain affordable insurance. The good news is that the Feds have broad discretion to extend enrollment periods as well as provide commercial insurers with additional assistance. Jost is confident that with the right amount of creativity, health reform can continue. After reading this, the DMCB predicts HHS's creativity will include delaying the individual mandate without "delaying" the individual mandate.

John Goodman is less optimistic. He uses his eponymously named blog to remind us that if only the sickest and most persistent Americans successfully use the exchanges, Obamacare may precipitate numerous insurer death spirals. State risk pools are closing, employer-based plans are closing, and individuals can now exit their "job lock." John predicts the sickest of these individuals will find the exchange's "gold" and "platinum" insurance plans to be relative bargains. Goodman offers some potential solutions, including flattening the subsidies, prohibiting dumping of the sickest members by insurers, requiring COBRA benefits to be exhausted first and stopping enrollees from gaming the system by enrolling at the last minute. It's the risk pools stupid!

Sean McGuire of Health Reform Explained coins the new catchphrase "nerd herd" to describe the exchange's "tech surge" repair. Despite the impressive-sounding term, he doubts the website code will be successfully rewritten any time soon. He wonders if the Feds shouldn't completely outsource to the states, because they have the track record and, with sufficient financial support, the resources to fix this problem. Code woes prompt geek fleet.

Hank Stern of the Insure Blog builds off another blogger's observation that one reason why the exchanges are not performing well is because HHS wanted to shield users from seeing the cost of their insurance prior to the calculation of the income-indexed subsidy. For us wannabe techies, this is known as a "no wrong door" approach to web portals. What HWR review is complete without a catch phrase you can use to impress your friends and stymie your enemies. And you're welcome.

So, how's health reform going?

Louse Norris, writing in Colorado Health Insurance Insider blogs with first-hand knowledge about a wrinkle in the ACA that allows for early renewal of existing insurance policies. As the DMCB understands it, this pushes back the day of reckoning when persons have to "buy up" to standard insurance benefit packages that may be more expensive than the "skinnier" policies that have lower out-of-pocket expenses. While some unnamed policy makers think that's a loophole, Louise thinks it's a good idea because, for her family - and many other Americans - that translates into hundreds of dollars a month in savings for 2014. What other loopholes are there?

Maggie Mahar of the Health Beat Blog points out that the commercial insurers were at the table when the final details of the Affordable Care Act were hammered out. They agreed to shelling out new
fees and taxes to help fund the legislation. Despite that, however, skeptics were suspicious that Mr. Obama had been too accommodating to the insurers. According to Maggie, we now can say with certainty that the skeptics were wrong. The commercial insurers' stock prices are now tanking because the investors are only now discovering, among other things, that pre-existing conditions cannot be used against patients, administrative costs are limited, preventive care now has first dollar coverage, lifetime caps no long exist, that they have to cover a standard benefit and state regulators are finally "getting some spine." She thinks the investors made two mistakes that she perceptively avoided: along with Ms. Pelosi, they didn't read the bill and they were confident that Mr. Obama wouldn't be re-elected. The DMCB wonders if investors are also worried about the commercial for-profits being battered by death spirals.

Never mind high tech, how about payment reform leading to high touch? David Harlow of The Health Blawg argues that the evidence that transformed primary care can save money is reaching critical mass. Primary care clinics that invest in systems of care may cost more in the short run, but the downstream cost savings are considerable. As fee-for-service continues to unravel, Harlow predicts these preventive and care coordination business models will become even more compelling. Which prompts the DMCB to provocatively ask if this could this also be an argument for the monthly fees commanded by the "concierge" practices?

For those of us who think there may be market solutions that can reinvigorate medical education, Roy Poses of the Healthcare Renewal blog says it's time to think again. Roy looks at some of the "outcomes" from one off-shore for-profit medical school that caters to U.S. students, including the entry of venture capitalists, the creation of shady tax shelters, deans with jet-setting lifestyles, Swiss bank accounts, laundering money and the mysterious disappearance of school Presidents once the indictments start to roll. As Roy has pointed out, however, on-shore and not-for-profit medical enterprises are not immune from bad behavior either. Health care bubble, anyone? 

Brad Flansbaum of The Hospital Leader blog examines the impact of the Medicare regulation that post-hospital home health services can only be prescribed during the course of a "face-to-face" visit. For doctors getting their patients out of the hospital, this has resulted in one more form that needs to be completed (typically by someone other than the doctor) and then signed (by the doctor).When added to the press of other things that have to happen, the result is a discharge of a thousand cuts. The DMCB's colleagues have lived with these and other unpleasantness that comes from being on the business end of Medicare.  And people wonder why docs are leery about a single payer system?

Drugs!

Jason Shafrin of the Healthcare Economist blog describes how the Italian city of Naples recently saved 20 million euros in pharmaceutical costs. There was no single solution, but a combination approaches that may hold lessons for the United States. They include direct purchasing of drugs by patients, providing a supply of necessary medicines when patients leave the hospital, accepting generic drug names for prescriptions and making patients pay the difference when they insist on a brand-name drug. That doesn't mean that Italy's cost problems are automatically solved. New agents are constantly coming on line and the Italians do recognize that manufacturers need to recoup their development costs. That's OK, however, because Italy uses multiple administrative levels of review for efficacy, a rigorous "pay for performance evaluation process and "soft" spending global limits. In the end, if a drug is worth it, they'll pay for it. U.S. drug company executives may end up taking some of their own products if this system gets adopted here.

If reports are true, David Williams of the Health Business Blog points out that the Food and Drug Administration's public service mission is being undercut by the "invitation-only" meddling of pharmaceutical companies in the Agency's pain management evaluation meeting panels. Either pharma should get out, says Williams, or other legitimate stakeholders, like patients, payers, academics, advocacy groups and other government agencies should also be in the room. So, with news like this, why is bloggery a bad thing?

And last but certainly not least.....

We all remember that horrendous garment factory fire in Bangladesh that killed over a thousand workers. If you still enjoy wearing that name-brand clothing, you won't want to read Julie Ferguson's summary and review of a multi-part series of articles on the topic appearing in Workers Comp Insider. If you do, you'll either want to go naked or start paying attention to which retailers have truly committed to international worker safety. Unfortunately, it appears that most continue to put low-cost fashion as their number one priority, even if it means putting more lives at risk. Behold the health implications of our throw-away clothing life style.  Maybe it's time to reward clothing manufacturers that offer products made in the U.S.A. 

The Progressives' Point of View When It Comes to Health Reform

While the Disease Management Care Blog tries to be an equal opportunity cynic and generally sides with policy underdogs and lost causes, it supposes that its conservative leanings sometimes comes through in its writing. 

That was enough to prompt a series of well-written email exchanges with Greg Brown, a retired educator from the Kansas City area. He did a great job of compactly summarizing the views of supporters of the current version of health reform. 

It seems to boil down to five main arguments:

1. Medicare and Social Security: While passage of these landmark safety net programs was likewise met with deep concerns about the erosion of liberty, their ultimate success cannot be denied.  Most of the persons who are against the Affordable Care Act are ironically happy to have the feds appropriate a portion of their income in exchange for economic security in their old age. They can't have it both ways.

2. This is not buying shoes:  One role of the federal government is to step in when markets fail, and that has been amply demonstrated when it comes to health insurance. While it's difficult enough to remember to even buy a product that you may not need, shopping for the best value in commercial insurance is practically impossible.  Proposals to expand this unworkable solution are a pipedream.

3. The public good: Keeping people from going bankrupt in the course of an unexpected illness is everyone's interest.  It's ultimately a better bargain for society to proactively manage this with near-universal insurance than to deal with poverty after the fact.

4. Purchasing power: To date, Washington DC has chosen to not flex its purchasing power with providers.  Think of how much cheaper drugs would be if Medicare leveraged this for Part D.  Just wait until the happens in the rest of health care system and how much all of us will all benefit. 

4. Status quo: Even if you don't accept the track record of Medicare, the realities of buying insurance, the merits of a public good and the advantages of purchasing power, the status quo has led the U.S., compared to the rest of the developed world, to be a unsustainable per-capita cost outlier.  Something has to change. and theACA is doing just that.

I am not an expert by any stretch. I am just an interested layman. I really wish Obama had pushed for a single payer or at least a strong government alternative delivery system. But here we are and as imperfect as it is, it is the best thing I see on the horizon right now. It does at least attempt some cost controls, it broadens access, and it may lead to better quality with a focus on health outcomes rather than billable procedures. At least it attempts to address all three.

Image from Wikipedia

The High Price of High Deductible Plans and the Potential Role of Population Health Management

Your bronze plan ticket to health care?

Should patients be forced to reach a spending threshold before their insurance kicks in? At first glance, it makes sense, because health consumers' "skin in the game" forces them to think twice before going to the emergency room for a sore throat, or an orthopedic surgeon for simple back pain.

Wharam and colleagues examine the science behind high deductible insurance in this just-written article in the New England Journal.

And the science says there is a lot we do not know.

Once insurance risk is monetized into premiums, policymakers as well as insurers are operating in the dark about calculating the right deduction for a given income level. One example is Cover Oregon's $5000 deductible for persons who are at 200% to 400% of the federal poverty level. That means a family with a yearly income as low as $47,000 would have to spend more than 10% of their income on health care before seeing a dime of insurance coverage.

"Egads," says the DMCB.

Given that stark reality, the challenge is to figure out how an up-front deductible influences "buying behavior" once persons get sick. Unfortunately, most of the research out there is on the impact of relatively "small" amounts of out-of-pocket expenses on health care utilization, especially in low-income populations. The bad news is that lay-persons - who are unable to discern the difference between a simple headache vs. a brain tumor - tend to "indiscriminately" lower all utilization as their cost sharing goes up.

There has also been no research on the impact of high deductible plans on mortality or chronic condition control.

Concluding that the U.S. is "poorly prepared" for what will happen under Obamacare's bronze high deductible plans, Wharam et al recommend there be more research on the topic.  Pending that, they suggest consumers be educated about their insurance purchases and be encouraged to chose low-deductible plans. They note that the star-crossed insurance exchanges (once they're fixed) can be configured to help do that. When there is employer-based insurance, employers could be encouraged to make the deductibles more proportional to income. In addition, health savings accounts could also help.

While the authors don't use the words "population health management," they tap this discipline as one solution to this Obamacare problem. They point out that predictive modeling/risk stratification can be used to create "personalized" insurance designs that optimize high-risk patients' access to care. Patients in these plans could have access to decision-aids and coaching that help them figure out when it's a simple headache and then they should seek medical care.

On Death Marches and Lost Causes

As of this writing, it appears the U.S. Senate has achieved a bipartisan compromise over the shutdown and the debt ceiling. It is highly likely the House will agree and a funding bill will reach the President's desk in time to avoid a default. 

As the Disease Management Care Blog understands it, the contentious issues of the size of government and debt will have to be revisited in a matter of weeks.  That practically guarantees another round of brinksmanship and frothy bloggery in December.

So what has the DMCB learned from this imbroglio?

It is of two minds.......

While a critical mass of Congressional Republicans have embarrassed their party with a forced death march to nowhere, there's something to be said for sticking to your principles. Nice try. After all, advocates of the quintessentially liberal cause of gun control vow to inconveniently bring the topic up again and again. While their odds are long, the DMCB is reminded that that was a tactic that may have ultimately turned the tide on same sex marriage. The DMCB hopes the "nagging and haranguing" strategy ultimately prevails on behalf of reasonable tort reforms nationally and getting the DMCB spouse to yield her HGTV tuning locally.

As Mr. Smith points out, the only things worth fighting for are "lost causes."



On the other hand, it can be argued that the rancorous and bitter fruits of the Affordable Care Act are likewise the result of a Democratic majority's unwillingness to compromise. While supporters of Obamacare correctly point out that its provisions were interdependent and based on Republican ideas, there is some truth to the perspective that the process was a blunt force exercise in partisan political jujitsu and an historical lesson in how not to pass and implement a big law.  In other words, Mr. Smith makes for good Hollywood but makes for lousy governance.

Aetna Talks Exchanges

One of the stories behind the story of Affordable Care Act's successful passage and survival to date has been the silence of the commercial insurers. It's not a good political or technical sign for the health insurance exchanges when Aetna's CEO goes public like this.....

Demanding Medical Excellence: How Do Things Stand?

Disease Management Care Blog colleague Michael Millenson has written a book called Demanding Medical Excellence. Like many other insightful observers, he wrote that only a minority of care interventions are evidence-based and that it can take years for proven therapies to be mainstreamed in clinical practice. Practice variation is rampant, avoidable errors occur too often, patients are passive bystanders in their own care and the U.S. health care system is spending money like trial attorneys at an anti-tort reform political fundraiser.

What few realize is that Millenson was among the first to recognize these issues when he wrote his groundbreaking book over 15 years ago. 

And, you ask, how have things fared since then?

Millenson answers the question in this Health Affairs article with some good as well as some bad news.

The bad news is that the U.S. health care system pays little attention to the prescient insights of smart people like Michael Millenson. The DMCB shares his pain because many of the things it has blogged about have likewise been ignored by the health care system.  The DMCB spouse and most persons working inside the health care system are not surprised.
 
The good news is that, while it may have taken 15 years to address these issues, things, according to Mr. Millensen, are finally beginning to get better.

In his view, the long delay was due to the commercial insurers' unwillingness to give up on their misaligned payment systems that continued to reward preventable complications, prolonged hospitalizations and readmissions. 

This was finally overcome by the twin forces of public insurer activism and patient consumerism. . 

The former imposed no-pay for "never events," required computerized physician order entry (CPOE), promoted accountable care, introduced bundled payments, made physician quality reporting a reality, and reduced payment for hospital acquired conditions. The latter is now represented by internet-enabled consumers who can use their lap tops and handhelds to compare symptoms with other patients, assess treatment options and compare provider outcomes.

The result? According to Millenson, we're finally seeing a long-due "paradigm shift" that is leading to transparent measurement and meaningful rewarding of quality improvement, accountability, safety, quality and value. Providers who are unwilling or unable to participate are seeing their services commoditized.

The DMCB agrees and is reminded that, from time to time, government can be a force for good.
 
That being said, it was the managed care backlash of the 1990s that scuttled the commercial insurers' ability to implement many of their ideas that were eventually adopted by Medicare and Medicaid. 

What's more, federal policy doesn't necessarily automatically translate into win-win, higher quality, lower costs and no unintended consequences for never events (here), CPOE (here), accountable care (here), bundled payments (here) or physician quality reporting (here). 

It may take a few more years before we can know if Millenson can write a follow-on book titled Achieving Medical Excellence.

Image from Wikipedia

The Exchangeacillin Package Insert: Black Box Warnings and Adverse Reactions

The Disease Management Care Blog is pleased to assist the U.S. Department of Health and Human Services with this FDA-inspired "medication package insert" that is designed to help consumer-shoppers grapple with the star-crossed health insurance exchanges.
             +++++++++++++++++++++++++++

Exchangeacillin®
(online bunglecide)
Virtual Suspension

Prescribing Information

**Black Box Warning**
Health insurance exchanges increase the risk compared to placebo of wishful behavior in adults and politicians in recent short term studies. Anyone considering the use of EXHANGEACILLIN must balance the risk of unintended consequences involving a federal bureaucracy unfamiliar with fundamental principles of insurance 101. There are no studies that assess the success of online exchanges, and persons of all ages who use Exchangeacillin should be closely observed for hours-long vacant staring at computer screens.  Long term use may lead to loss of confidence in big government and unpredictable election cycles. (See WARNINGS: Insurance Markets and Bureaucratic Meddling: Information for Consumers, PRECAUTIONS: Information for navigators)

DESCRIPTION
Exchangeacillin (online bunglecide) is a virtually administered insurance platform with approximately one billion lines of unstable computer code. It has a melting point range that falls within room temperature and zero resemblance to modern web-based architectures.

CLINICAL PHARMACOLOGY
The efficacy of exchangeacillin in the treatment of underinsurance, access to care or life expectancy remains an open question.  Preliminary studies in humans have demonstrated accelerated partisan animus, selective interpretations and media spin, leading to one of the largest live social experiments in modern history. In vitro and binding studies may demonstrate that persons at risk for near-term insurance claims expense are preferentially attracted to Exchangeacillin. The impact on Millenials, Generation X'ers, Slackers and Dudes is speculative.

PHARMACOKINETICS
Exchangeacillin is unpredictably absorbed and has been shown to lead to one or more commercial insurance accounts with an elimination half life for redundant applications that may extend for six months or more. Nonlinear kinetics can lead to botched income estimations, claw backs and opaque tax consequences. 

INDICATIONS AND USAGE
Exchangeacillin is indicated for the treatment of underinsurance, being uninsured, high co-pays, unwanted co-insurance, double-digit co-pays, skinny insurance benefits, benefit exclusions, windfall profits, high administrative costs, coverage denials, not having birth control and showing the health insurers a thing or two.

PRECAUTIONS AND ADVERSE REACTIONS
Post-marketing surveillance studies have shown an increased risk of buttock decubiti, White House embarrassment, yawning, consumer disappointment, carpal tunnel syndrome, insomina, gridlock, hypersomnia, digit calluses, onychophagia, boredom, bluescreenosis, resentment, death spiraling, employer mandate delays, government shutdowns, war memorial posturing, bombast, biased reporting, deficits, speechifying, inflation, carve-outs, administrative exceptions, skepticism, income non-verification, disbelief, distrust, bickering, hyperpartisanship, multiple-accounts, insurance death spirals, closed national parks, can kicked down the roadedness, comparisons to Medicare, comparisons to Medicaid, tiresome pundits, nausea, bloggery, anecdotes, generalizations, wealth transfer, increased federal deficits, decreased federal deficits, higher taxes, government savings, higher for-profit health insurance stock prices, elevated media ratings, anxiety, confusion, dizziness, breathlessness, wordiness, emotional lability, dubious claims, confident predictions, foolishness, restlessness, cancelled WH meetings and DMCB spouse exasperation.

INTERACTIONS
Use of Exchangeacillin may interfere with budgets, debt limits, sequester agreements and elections.

DOSAGE AND ADMINISTRATION
While Exchangeacillin should be administered following months of testing and debugging, the FDA has approved its administration in a let-'er-rip "big bang" fashion with ad hoc adjustments and unpredictable shut-downs.

HOW SUPPLIED
On-line with "Apply Now" code that prompts "we have a lot of visitors on the site right now. Please stay on this page.... Thanks for your patience!"

The Latest Health Wonk Review is Up!

If you're looking for new insights on the government shutdown and what it means for U.S. healthcare reform, head on over to Joe Paduda's hosting of the Health Wonk Review.  The Review is a periodic summary of the best of the health policy bloggers who have information that you just can't find in the mainstream media.

A Reader Responds to Let Them Eat Cake

The Disease Management Care Blog is happy to post thoughtful rejoinders from readers.  This is one from Joe Morris, who remains a health policy observer, having migrated from an early policy background as manager of the NJ DRG case mix payment project and Assistant NJ Health Commissioner to executive positions with hospitals and healthcare trade associations.

In this October 7 "Let Them Eat Cake" posting, the DMCB argues that the entire health care system is not ailing and that not all of it needs to be fixed by the Affordable Care Act.  Outside its identification of the broken individual market, however, there were other segments that were troubled, including the widespread practice of excluding pre-existing conditions as well as the ability of insurers to land windfall profits from withholding medical care.  All warranted some statutory or regulatory intervention. 

That being said, implementation of anything as complex as health reform is bound to be complicated. It makes sense to set priorities and roll out health reform so that the more important parts come first.  A good local non-healthcare example was the implementation of EZPass, which had its share of start-up problems.  It wasn’t rolled back and it’s since been quite successful.

Too bad that the ACA continues to be bedeviled by a lack of stakeholders who want to constructively reconcile public health needs and needed revisions of the ACA without the negative influence of politics.  Perhaps one solution is to get the elected leaders out of the mix and turn to clinicians who have real insights about their patients needs.

On the other hand, removing politicians has its own risk, since government involvement in health care is here to stay.  What’s more, they did a good job with Medicare and no one, other than a radical fringe, is proposing that that program be defunded, repealed or replaced.

The Health Insurance Death Spiral: Is High Health Insurance Exchange Use An Early Symptom?

According to the White House, the health insurance exchange glitches are a symptom of high demand from a grateful citizenry eager to embrace Obamacare. While articles like this and this suggest that sloppy and amateurish programming is really behind the website crashes, the Disease Management Care Blog is concerned that early high demand - if it exists - could be an early sign of a coming insurance death spiral.

"Death spirals" occur when persons with high levels of risk disproportionately enter an insured population.  When that happens, premiums have to rise to match the increased expenses. That, in turn, causes persons with lower risk to drop their insurance, leading to an even higher proportion of high risk individuals, who drive prices even higher.

The DMCB intuitively doubts that the early high demand described by the White House is the result of healthy latte-sipping millenials and young invincibles having nothing better to do with their web-surfing time.  Rather, the persons most likely to be in a rush to get into the web site are persons who really need insurance.  Those would be the ones facing huge health care bills.
 
Another indication is the relative lack of the standard individual anecdote or "ledes" in media reports that hook the reader into paying attention.  Used by politicians and journalists alike, ledes put a "human face" on a narrative by bridging the personal and the policy.   

Supporters of exchanges would probably like to see something ledes along the lines of...

For years, 25 year old Ivanna Ceeadoc could only lurk outside the local health clinic and watch helplessly as her friends from the coffee shop down the street got free health communications from the nurse practitioners within.  But after using the health insurance exchange....

or

Until he signed up in the health insurance exchange, part-time jazz drummer and retail specialist Hank Erinfersumburgers never had to see a health care provider. Previously unaware of a bleak future of fast food and tight clothes, Hank's zero dollar co-pay now lets him see a dietician and have enough money left over for a lunch......

Young Ivanna and Hank haven't made an appearance in the national health insurance exchange narrative because they probably aren't part of the story.  More likely, it's persons in their 50's and early 60's who have been hold they need a joint replacement, an angioplasty or back surgery....

 Ima Medeesazter was looking at a stack of medical bills a mile high.  Her surgeons' plans included weeks in a hospital costing her hundreds of thousands of dollars. Ima put things off, but now that she used the exchange, she can look forward to getting to know her ICU nurses really well.......

Even more worrisome: this astonishing statement by HHS Administrator Kathleen Sebelius that she "doesn't know" how many have enrolled in health insurance since the October 1 opening date.  If the experts running the shop are unaware the Insurance 101 principle of knowing who and why persons are signing up for health insurance, they have no idea about the spiral threat.

Image from Wikipedia

Let Them Eat Cake: Stepping Outside the Health Care Reform Comfort Zone

How would Ms. Antoinette
ponder health reform
with her advisors?

While commonly attributed to Marie Antoinette, the phrase may actually be testimony to Jean Jacque Rousseau's genius in using four words to capture an elites' inability to grasp the plight of a struggling underclass.  For a more modern depiction of a lifestyle bubble, think of the 1% not getting just how difficult it can be to make a living wage.

And it's not just the 1%. African Americans, with some justification, note that whites have yet to grasp "the set of experiences and a history" that perpetuates racial inequality. It's not just the "facts" but how facts are sorted, prioritized and interpreted by a brain wired by decades of being surrounded by like-minded people caught up in their information loops.

But it cuts both ways. When confronted by the hostility of tens of millions of Americans to the Affordable Care Act, liberal-progressives likewise respond with similar puzzlement. Who can blame them for rationalizing things with attempts to provide more "education" or blaming it all on obstinate Tea Bagger and "Birther" wackiness?

It's not that simple.  As pointed out in this The Atlantic article, conservative skepticism about the size, regulatory reach and spending of government was well underway long before Mr. Obama set foot in the White House.  Focus groups have little trouble finding deeply held opposition to expanding government entitlements, middle class dependency, pro-business globalization, wealth transfers and scary levels of deficit spending. Given the big picture,  Obamacare is less of a problem than a symptom. 

As result, even if the White House and its Democratic allies prevail on the shutdown showdown, successfully raise the October 17 debt ceiling, cancel the January 1 2014 sequester and take back the House in November 2014, the opposition to the health care law isn't going to simply fade away.

But, say my liberal friends.....

1. Much of the Affordable Care Act is based on Republican ideas, including the mandate and Romneycare.

The mandate and Romneycare were never intended to be imposed nationally, but adapted by each of the states. 

2.  It will save money.

Health care consumption declined before the passage of the Affordable Care Act. Experts legitimately disagree on the impact on future health care costs but it stands to reason that more people with insurance will lead to increased demand and higher spending..

3.  The health care system is broken

Actually, the part of the system that was broken was the individual insurance market.  This objective OECD Report summary points out that, compared to many other developed countries, U.S. quality has been quite good and our cost trends are lower.  And while it's too early to tell, the health insurance exchanges travails combined with multiple other self-inflicted wounds suggest that the cure may end up being worse than the disease.

The point here isn't who's wrong or who's right.  Rather, it's clear that skepticism over Obamacare's ability to deliver on all its promises is not crazy.  Its critics not only deserve their time in the public square but to have their preferences reflected in policy and legislation..

What's more, the Obamacare dust-up is part of a bigger concern over the expanding role of government that tens of millions of Americans find potentially intrusive and unaffordable.  The inability of the DMCB's liberal progressive colleagues to comprehend that may be a less a function of their superior intellect or the stupidity of the opposition than an Antoinette-esque inability to step outside their familiar biases and ponder a different point of view. 

Valuable Personal, Political and Health Reform Lessons, Courtesy of the Federal Government Shutdown

Coming to consensus
the old fashioned way

The Disease Management Care Blog views the federal government shutdown with the same morbid fascination of watching personal injury lawyers justify their double digit malpractice suit contingency fees: it's so awful, it's hard to look away.

The good news is that that doesn't mean that the shutdown doesn't hold some important personal and political lessons.  They can make DMCB readers better citizens and our political class a credit to our Republic. 

To wit......

When the DMCB spouse expresses consternation over the boneheaded actions of her husband, the DMCB can now respond by:

1. changing the subject,
2. retreating to the DMCB World Headquarters and blogging about the spouse's unreasonableness,
3. referring to the alleged lapse as a "glitch."

Things don't go well in the opening day of a widely anticipated unveiling of the largest health care achievement in the history of the United States.  If you were in charge, you would respond to the health insurance exchange breakdown by:

1. recognizing the problem and promising to fix it,
2. reminding the public about the painful gap between lofty campaign promises and disappointing bureaucratic reality,
3. shrewdly drawing flattering comparisons to Apple, the most widely admired brand in the world.

As the leader of a political coalition, you are stymied by the division of powers in the world's longest lasting democracy.  In response you:

1. seek consensus
2. deploy ad hominem attacks in press conferences
3. offer to compromise by allowing the opposition to do things your way.

Wanting to be an informed member of the electorate, you regularly watch either CNN, FOX News, MSNBC, PBS, CBS, NBC or ABC because:

1. These broadcasts' news editors subtly frame their closed information loops to meet your own political biases,
2. You haven't discovered BBC or Al Jazeera
3. There aren't any movies on TV featuring svelte vixen vampire babes having their way with their mesmerized male victims.

By pointing out that Obamacare is "the law of the land," you are really saying:

1. Our representative democracy passed legislation that was signed by the President and upheld by the Supreme Court, so get over it,
2. Now wait a minute, our representative democracy can modify or even roll back health care laws.
3. Enough with the debate, time to move on and figure out how to make preschool education, low interest mortgages and low-fat frozen yogurt protected federal entitlements.

Being a Game of Thrones fan, you wonder if the following might not be useful in settling the budget impasse:

1. Asking what the honorable Ned Stark would do, until you recall that he was beheaded.
2. Invite the opposition to a Red Wedding
3. Call up your elected representative and say "Hodor!"
4. Call up your elected representative and hear him or her say "Hodor!"

The Remarkable Consensus Over the Next Steps for Health Reform, Including the Role of Population Health Management

Let's fix it!

While noisy media leprechauns dispense blame and declare winners in the government shutdown imbroglio, the Disease Management Care Blog remains focused on the next steps for meaningful health reform. So are JAMA authors Jack Lewin, Lawrence Atkins and Larry McNeely who, other than one lapse in their editorial, get it mostly right.

Their important insight is that the Bipartisan Policy Center, Brookings Institution, Commonwealth Fund, Kaiser Family Foundation, the National Coalition on Health Care, Partnership for Sustainable Health Care and Urban Institute all have a remarkable degree of overlap in their recommendations for the next phases of health reform. 

Most of these expert organizations agree on the merits of value-based payment as well as insurance reform (pay for quality), information technology, competition, tort reform, evidence-based benefit design (paying when there's evidence that it works), workforce changes (greater efficiency), reforming Medicare, changing tax policy (the exemption for health insurance) and instituting regional or local caps (stick to a budget or there's consequences).

The DMCB wholeheartedly agrees and hopes that the bipartisan consensus evident among these think-tank institutions leads Congress (if not this one, the next) and the President (if not this one....) to use these ingredients to build on the successes and correct the many deficiencies of the Affordable Care Act.

And the lapse? 

Jack Lewin et al were missing one thing. The DMCB looked in each of these organizations' web sites and found that there was also considerable support for population health management.

To wit:

The Bipartisan Policy Center - while the emphasis of this report is on health information technology, the real dividends are pretty clear when it mentions "population health" 14 times:

This plan should address the development and adoption of policies and standards needed for the delivery of care, the empowerment of individuals, and improvements in population health based on national health and health care priorities.

The Commonwealth Fund:

 Effective population health management requires fundamental change in care delivery that must be supported by changes in payment.

National Coalition

Real reform means engaging consumers in their own health and health care choices. In both Medicare and too many private plans today, benefit design neither supports self-management of chronic disease nor distinguishes between care that is effective and care that is not.

Partnership for Sustainable Health Care - see page 22:

Federal nurse education funding should be refocused to equip registered nurses to assume the roles of case manager and population health coordinator.

The Urban Institute - see page 17 on the topic of Medicaid reform:

States can start in select geographic areas or specific population groups (adults and children or specific chronic conditions), and then incrementally expand them after learning from experience and making program improvements and adjustments. Broader efforts typically mean additional stakeholders, increased collaboration and communication.