Disease Management Care Blog

More On The "Death" Of Disease Management

2012-01-30T20:12:00.001-05:00

At the email prodding of several colleagues, the Disease Management Care Blog next turns its attention to a blog posting by Archell Georgiou MD provocatively titled "The Death Of Disease Management (Finally!). The Archelle on Health Blog contrasts the industry's early promises of evidence-based medicine plus patient self-care with the bitter fruits of non-existent savings, the disappointing Medicare Health Support (MHS) demo and a just-published anti-disease management New England Journal article.

Using that last Journal article as the final word, Dr. Georgiou provides her readers with a graveside eulogy of what went wrong:

1. The NCQA promoted an "enroll and counsel all patients at risk" approach, when what was really needed was a focus on the patients at greatest risk.

2. The disease management industry relied on gimmicky marketing instead of reducing costs, and

3. Inflexible adherence to evidence-based medicine failed to account for individual patient circumstances.

Enter Al Lewis of the Disease Management Purchasing Consortium with a rebuttal, but, um, sort of. Al points out that the DM industry still clings to life and, even worse, uses spurious financials. Yet, thanks to ICD-10, inclusion of labs in predictive modeling, lower program costs, physician involvement and the marvelous insights of his soon-to-be-published book, he confidently predicts that the DM vendors will emerge from what is better described as a near-death experience.

Where to start?

Medicare Health Support's Lessons

That New England Journal article used by Dr. Georgiou to nail DM's coffin was a really retread of Medicare Health Support's (MSH) failings. Look deeper and what MHS really demonstrates is CMS' ineptness in demo design, program support and data interpretation. Toss in this CBO Report and it's clear that the issue isn't whether DM "works" in in FFS Medicare, but that the administrators running FFS Medicare don't know how to implement DM.

Disease Management Is In Use In Most Commercial Settings

CMS' bumbling stands in contrast the long term and continued reliance by commercial insurers on disease management in the commercial and self-insured sectors. While nattering nabobs may suggest that the commercial sector isn't paying attention to the "evidence" of studies like MHS, a cursory search of the published literature can find studies like this, this, this, this and this that suggest that the commercial sector knows what it's doing and that patients and their premiums are better off for it.

Disease Management Ver. 1.0 Deserved To Die, But Didn't. It Changed

Archelle On Health has it only partially right. When industry's own studies proved that a) an all-patient approach didn't work, b) it had to get serious about documenting outcomes and c) patients had to be "engaged" on their own terms, it didn't crawl into a hole and die. It changed to what the DMCB has characterized in past postings as "disease management Ver. 2.0," otherwise known as "population health."

And What About Al Lewis' Insights?

The DMCB agrees with four out of five. If his new book is anything like his last one (by the way, it included the DMCB as an author), make that five out of five.

But Wait, There's More!

In the original "Death" post, Dr. Georgiou points to six innovations that promise to further shake up the landscape of population health: social networking, gaming, remote biometric monitoring, wireless health management apps and "passive" environmental changes that lead denizens to lead more healthy lives. The DMCB says she's right and finds the topic endlessly fascinating. While the population health and disease management industry is using monitoring and social media, it remains to be seen how it will embrace the other innovations.

That being said, the DMCB hopes that Medicare doesn't run any demos on any innovations like gaming, apps or environmental changes, lest future bloggers end up pronouncing their death too.

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Congressional Budget Office Concludes Medicare Remains Incapable of Implementing Disease Management and Care Coordination

2012-01-29T21:00:00.000-05:00

By now, many readers may be familiar with the recently released Congressional Budget Office (CBO) report Lessons from Medicare's Demonstration Projects on Disease Management and Care Coordination.

The Disease Management Care Blog finally caught up with it.

Here's its take:

It's a well-written and traditionally crafted summary of CMS' six demonstrations that had the participation of 34 programs:

Care Management for High Cost Beneficiaries
Medicare Coordinated Care
Disease Management for Dual Eligibles
Informatics for Diabetes Education and Telemedicine
Disease Management for Severely Chronically Ill Beneficiaries
Medicare Health Support

Why Demos?

Demos are used by CMS to test innovative care strategies before they are formally adopted as a covered benefit in the fee-for-service program. These demos were funded because CMS knows that half of all Medicare beneficiaries have five or more chronic conditions and that they account for 75% of its costs. In addition, up to 50% of beneficiaries are not receiving recommended care, such as vaccinations and cancer screening.

How Did the Demo's Work?

The programs enrolled persons with a variety of chronic conditions such as diabetes and heart failure. Kick off dates ranged from 2000 to 2005. "Hierarchical condition categories" or high baseline expenditures were used to identify and target the persons at high risk. All used care coordination nurses who were typically - but not always - remote and disconnected from the physicians. There was little information on admission criteria to the programs, on the training or credentials of the care managers, the approaches used in to manage transitions across care settings or improving medication compliance.

What Was the Bottom Line?

On average, the programs were unable to achieve savings in excess of Medicare's fees.

The programs reduced hospitalizations by an average of 7%. In order for Medicare to have saved money based on the disease management fees, the hospitalizations would have had to be reduced by 11%. Programs that involved greater in-person interactions between nurses and patients appeared to have greater success in reducing admissions rates.

The evaluation was also statistically stymied by relatively low numbers of patients in some of the programs. It is possible that there were savings, but if they exist, they were too small to be detected by widely accepted statistical methods.

So What DMCB Conclusions Can Be Drawn and Why?

There are two:

1.The "versions" of disease management used by Medicare from 2000-2005 relied on approaches used in commercial settings from 1995-2000. These deployed remotely stationed nurses calling patients with worrisome cost patterns. From 2000-2005, commercial insurers and employers knew that wasn't working and transitioned to more sophisticated engagement protocols as well as in-person care programs tailored for patients with high as well as modifiable risk.

In other words, the impact of later versions - like this, this and this - of disease management in fee-for-service Medicare remains largely unknown. That's why the CBO report ends with the conclusion that....

"...the demonstration results indicate that additional experimentation, evaluation, and refinement over a period of years will probably be needed to identify policies involving disease management and care coordination that can significantly reduce Medicare expenditures."

Of course, by the time CMS gets done with more years of "experiments," "evaluation" and "refinement," those results will likewise be obsolete.

2. This begs the question: if Medicare can't achieve savings, why do practically all insurers and most self-insured employers still include disease management programs in their benefit designs?

The DMCB suggests that in addition to a growing body of peer-reviewed literature showing that more modern (and still untested by Medicare) disease management is "efficacious," non-governmental insurers have some additional advantages that increase real world effectiveness:

1.Using disease management as only one component in an overlapping suite of other mutually supportive programs, including consumer-based incentives to rely on primary care, value-based insurance designs, intelligently restricted networks and concurrent wellness and prevention programs.

2. Access to internal assessments of program success that will never be submitted for publication in the peer reviewed literature.

3. Flexible program adaptation to the myriad local cultural and community factors that determine success. After all, what works in a motorcycle factory in the Midwest may not work in a cubicle farm in Silicon Valley.

The DMCB Bottom Line:

While the CBO report is technically correct, it promotes the tired canard is that modern disease management consists of naive nurses making blind calls and exhorting baffled consumers to take better care of themselves. In addition, the idea that single standard can be implemented everywhere in a stand-alone fashion is a pipe dream. No wonder Medicare's disease management demos have failed.

The Feds need to figure out how to implement disease management, not what doesn't work.

Spin and Innovation vs. Savings and Disease Management

2012-01-26T20:32:00.000-05:00

Spinning is hard work!

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

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

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

Sooner or later in the coming months, Congress will have to agree on some sort of budget. As that moves forward, the DMCB offers up some hard "un"spun facts for consideration:

Just as effective governing is not a matter of selecting from a series of policy options, effective doctoring is not a matter of selecting from comparatively effective treatment options.

There is no proof that the versions of the electronic health record being currently adopted nationwide save money. The savings argument remains anecdotal or theoretical with considerable room for doubt. What is clear is that installing an EHR costs money.

The Patient Centered Medical Home is still a work in progress. The cost savings widely reported here did not achieve statistical significance and the real truth underlying North Carolina's medical home data is mired in actuarial debates outside the peer review process.

While ACOs are ultimately modeled on the success of large integrated systems, we know that bigger is not necessarily better. As this multi-year experiment gets ready to set sail into politically stormy seas and if (and that's a big "if") they are proven to save money, it'll take years to expand them. Any real savings are more than a decade away.

Commercial insurers' profits, while high in absolute terms, have a relatively low return on investment and, compared to their administrative burdens, are not one of the major drivers of health care costs.

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

Here's the quote:

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

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

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

Image from Wikipedia

The Latest Cavalcade of Risk Is Up!

2012-01-26T08:32:00.000-05:00

Choose the best answer:

You should head on over and read the latest Cavalcade of Risk at the Nothwithstanding Blog because:

1. It's a collection of the latest blog postings on a spectrum of business risk topics;
2. It affirms that no risk professional can go without regularly reading the Disease Management Care Blog;
3. It's a demonstration of the "chose the best answer" tests prevalent in medical undergraduate and graduate education programs;
4. After reading it, you'll once again be the smartest person in the universe and your co-workers and competitors will know it;
5. Nothing else is going on right now.

The good news is that if you chose ANY answer, you got it right!

Enjoy.

The Non-Surprise of Increased Physician Referrals

2012-01-25T22:12:00.000-05:00

Big deal!

News flash!

In the last century, American derrieres have grown by 5%!

In the last 20 years, rates of professional athlete misbehavior have skyrocketed!

And in the last 10 years, there's been a near doubling of physician referrals!

If these trends surprise and amaze you, you may want to check out the up-to-the-minute news outlets like The New York Times' "Prescriptions Blog." On the other hand, regular readers of the Disease Management Care Blog may not need to go to such extremes. They are astute observers of backsides, know how to access ESPN and can confidently predict trends in health care utilization.

That being said, the DMCB thinks a recently published article on physician referrals may be worth a look.

Michale Barnett and colleagues extracted physician survey data on a sample of clinic visits from 1999 to 2009 that had been collected by the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Physicians were asked about their type of practice setting (employed vs. physician owned), their patients' demographic variables, reasons for the visit, diagnosis, treatment and disposition, including whether or not there was a referral to another physician.

The study found that the rate of referrals increased from 4.5% of visits in 1999 to 9.3% in 2009. This increase included Medicare patients, who went from 4.2% to 9.7%. Physicians who owned their practices were less likely to refer (from 4.2% to 7.5%) and physicians with more than 50% managed care experienced an increase from 5.5% to 8.7%.

In the Discussion section of the manuscript, the authors point out that two possible explanations for the increase in referrals include 1) the increasing complexity of health care and 2) the benefit of off-loading some of the work of patient care onto another colleague.

The DMCB agrees and would add two more explanations:

1. The increase in "PPO" vs. "HMO" style managed care during the period of study, and

2. An increase in patient consumerism.

Can recent health care reforms, like ACOs, reverse this referral trend? While the DMCB awaits the answer to that question, it looks forward to the continuing roominess of its movie theater seats and the next juicy sports scandal.

Stay tuned!

Image from Wikipedia

A Work-Around for an Electronic Health Record Shortcoming Has Implications for Population Health Management

2012-01-24T23:03:00.001-05:00

An EHR screenshot... but where
is that diagnosis of diabetes?

Welcome KevinMD readers. The DMCB blogs frequently on HIT, primary care, health reform and everything in between.

Years ago, if you were elderly, had diabetes, high blood pressure, low back pain, needed a yearly flu shot and came to see this electronic health record-enabled physician (now with the nom de plume "Disease Management Care Blog"), you would have had your diabetes, high blood pressure and low back pain reassessed, you would have been given a flu shot and, for good measure, the DMCB would have tossed in a discussion about the unpleasantness of getting screened for cancer. After the indignity of your physical exam, the DMCB would have typed its clinic notes into the EHR. Then the DMCB would have [click!] opened a new window,[click!] and "processed" your clinic encounter by selecting a [click!] "principal diagnosis" and some [click!] "secondary diagnoses," set a [click!] "level of care" and then [click!] "closed" the record.

And after all that, it's very possible that, thanks multiple diagnoses, entry fields and the press of time that the DMCB would have never selected [or clicked!] "diabetes." In other words, the diagnosis of diabetes would have been an electronic tree in the forest that no one would have heard falling.

It turns out that this is another shortcoming of the EHR that fails to get mentioned by its naive paladins. While these weenies would have you believe that physicians can use this technology to magically retrieve any information on any sick patient around the world, the truth is that these systems are notoriously reliant on old fashioned human behavior. Relying on standard diagnosis coding to identify every patient with every condition remains notoriously inaccurate.

That's why work-arounds have become necessary. An interesting one is the Centers for Disease Control's "BioSense." It uses the words or text that are entered into an electronic record's chief complaint "field" in emergency rooms and clinics. Combinations of certain keywords are consistently associated, for example, with influenza and can even act as an early warning system that heralds an outbreak of the disease. Using text is also the logic behind Google's ability to gauge the presence of disease among users of its search engine.

With that background on the EHR, its coding travails and influenza, members of the population health management community may want to pay attention to this Mayo Clinic Study was recently published in the Annals of Internal Medicine.

"Why?" you ask? Read on.

Persons who had been laboratory tested for the presence of influenza comprised the study population. 1455 persons had the virus while 15,788 did not. Of the 1455 persons with influenza, 1203 had an encounter recorded by a provider at the same time as the test. The encounters were the typical "free text" typed notes that were composed by providers and included a history (including patient symptoms) and a physical examination (such as the presence of a fever or a red throat). 1455 patients with a "negative" test (i.e., no virus) were selected as control patients and of these, 905 had a recorded typed encounter.

The providers' free text encounter records were then scanned using a "Multithreaded Clinical Vocabulary Server" (MCVS) system. As the DMCB understands it, this looks for certain key words, terms and phrases in the providers' notes as well as associated x-ray reports and lab tests that, based on prior studies, seem to be associated with the presence of the influenza virus. The extract (dubbed a "synthetic derivative") was then downloaded into "SNOMED CT," which acts as a medical dictionary of medical concepts that can be used in regression algorithms to predict the presence or absence of influenza. That prediction ("the patient has influenza") was compared to the gold standard of the viral testing ("influenza virus really found").

How did MCVS do vs. the lab? By combining certain terms in the records ("fever" and "cough" for example) and excluding others (an abnormal chest x-ray, which is unusual in viral influenza) the authors found, compared to viral testing, a remarkable degree of accuracy: using a receiver-operator characteristic curve that reconciles testing accuracy over a range of assumptions, the rate for MCVS exceeded 90%. In other words, the description of the illness spotted the disease prior to any lab testing.

While the Annals paper focused on the ability of MCVS to act as an early biosurveillance warning system that can spot infectious disease outbreaks early and and accurately, the DMCB was intrigued by the implications for the population health management community and the care of persons with chronic disease.

Here's why:

1. With an accuracy rate of more than 90% for spotting persons with influenza, it's possible that systems like MCVS will likewise be able to identify those with known diabetes, COPD or heart disease who fail to have their condition officially tagged and recorded as a diagnosis. With systems like MCVS, health management providers will be able to overcome the shortcomings of the EHR and obtain a complete picture of their populations' disease burden

2. What's more, systems like MCVS may, on the basis of a scan of multiple encounter notes about risk factors (for example thirst, excessive weight and a suggestive family history), be also able to spot persons with undiagnosed conditions. Furthermore, other factors could be used to prospectively identify those persons at greatest risk for future complications, such as an avoidable hospitalization. In other words, getting access to the medical records would be another step forward in the still evolving science of predictive modeling.

3. The DMCB also wonders if systems like MCVS will eventually be used to define and submit the diagnosis codes for the provider. Not only would this unburden the physicians from what is an administrative hassle, it'd probably be ultimately more accurate. Combine that with the detail of ICD-10 coding (assuming we can actually implement it), and we may finally be on the cusp of fully understanding the care needs of populations and be that much closer to collecting on the still-unfulfilled promise of the EHR.

An ACO Debate

2012-01-23T22:30:00.000-05:00

Let the debate begin!

If the Disease Management Care Blog can't personally debate former CMS Administrator Don Berwick on the merits of Medicare-style ACOs, it'll just have to have settle for letting others do the heavy lifting. In this Wall Street Journal article, skeptics Jeff Goldsmith and Thomas Scully ably take on Dr. Berwick's cherished assumptions in a well edited point-counterpoint exchange.

Your ever helpful DMCB provides a short summary of the highlights for its busy readers.

Donald Berwick:   What the Affordable Care Act seeks is reasonable: high quality, low cost and open access that strikes a balance between unfettered fee for service and onerous managed care. ACOs take the best features of health maintenance organizations, such as coordinated care and provider incentives to save money, but without the worst, such as restricted networks that hamper patient choice. Many provider organizations seem to agree. That's why interest in participating as ACOs is high. Smart providers will figure out how to do ACOs profitably. What's more, private insurers have adopted the model, so there must be some merit to the notion of ACOs. Last but not least, if ACO's work out, the savings will accumulate into billions in the years to come. That's when we can think about next steps, such as partially capitated arrangements.

In addition, thanks to the lessons of managed care and the Physician Group Practice Demo, ACOs will be transparent and high quality with closely monitored gain sharing, governance and information systems. What's more, thanks to its Innovations Center - Medicare will find ways to be flexible over the start-up costs of ACOs with advanced payments.

Hey, this is one experiment among the many innovations of the Affordable Care Act. The negative murmurings of the malcontents below may be right, but we don't know that and ACOs are still worth a try.

Jeff Goldsmith: Berwick's vision looks good but it's an unreal mirage. That's because provider organizations a) will have to spend more money than they can possibly recoup in shared savings and b) are fundamentally configured to admit to expensive hospitals and rely on pricey high-end specialists. While CBO projects mucho savings, it's really a lot of inside-the-beltway "budget dust." We know that because in CMS's Physician Group Practice Demo that formed the basis of ACO blueprint, eight out of ten participants lost money. That's because they were unable to scale the resources necessary to care for their sickest patients.  The two participants that made money probably did so because of creative coding.   Last but not least, remember that Medicare beneficiaries in ACOs - because they're completely protected from any economic downside - have little incentive to moderate their consumption of health care.

Thomas Scully: Nice try Dr. Berwick, but there are credible data that say that ACOs cost as much as $30 million to start up.  The start up price tag is not only putting hospitals in the driver's seat, there's a good chance that they'll turn into market dominant oligopolies. It's that luster of control, not saving money, that has driven provider interest in ACOs If you want to save money, drop Medicare's dysfunctional price fixing, forget about ACOs and give the docs control of all the money in fully capitated arrangements based out of a private insurance system that fosters competition, like TriCare and the Federal Employees Health Plan.

Of Intellectual Enclaves and Self-Reinforcing Media: Crossing The Health Care Reform Divide

2012-01-22T22:47:00.000-05:00

Watch for and report any
contrary opinions!

There's an interesting Saturday Essay in The Wall Street Journal that describes the self-perpetuating socioeconomic-neighborhood enclaves that separate America's "haves" and "have nots." It's turning out that zip code is not only associated with health, it's becoming associated with destiny.

Not only fascinating, says the Disease Management Care Blog, but the essay reminds it of the pernicious twin intellectual enclaves in the health care debate. While the progressive-liberals and the market-oriented conservatives in D.C. remain stuck in their closed information loops, the political process has been boiled down to the Supreme Court's nine lawyers and vague threats to unilaterally "repeal Obamacare." Yikes, says the DMCB, the Dark Knight's Joker had it right: we deserve a better class of ~~politician~~ criminal.

And if you think Newt is being wacky over the media bearing some responsibility, check out this NPR interview with the author of the book The Information Diet. Unrepentant lefty Clay Johnson points out that the news outlets are becoming less of a solution and more of a problem. By serving pre-digested and refined reports that cater to our pre-existing biases, organizations like CNN, Fox, The New York Times and The Wall Street Journal are creating an epidemic of intellectually obese brains that are hooked on the sugar and fat of what we'd like to know, not what we should know.

Which is why the DMCB steeled itself, stepped outside its right-of-center comfort zone and sat through this C-SPAN broadcast of pro-Obamacare Jonathan Gruber being lobbed softballs by the fawning attendees at a Seattle Town Hall. It makes for a spirited retread of the merits of enlightened central government, the villainy of the health insurers and the intrusion of politics, even as Dr. Gruber characterizes opponents as either 1) uneducated or 2) mistaken. That's why he's written this comic book designed to help both classes of simpletons.

The DMCB suspects its readers won't need to order a copy.

+++++++

As an aside, the Penn State graduate DMCB sadly notes the passing of Joe Paterno, the recently fired Penn State football coach. Despite his legendary stature, even "JoePa" was no match for the toxic Sandusky scandal. It wasn't too long afterwards that Coach Paterno was diagnosed with what was eumphemistically characterized as a "treatable" form of lung cancer. Occasional news reports since then described an increasingly frail 85 year old man struggling with the side effects of his cancer treatment.

Like many friends and colleagues, the DMCB wondered if the "stress" of his ignominous departure was the real cause of his death. According to this Psychosomatics case series of 43 lung cancer patients based on used of the Hospital Anxiety and Depression Scale, baseline depression was associated with a poorer 6 month survival, but not overall survival.

In other words, they die sooner.

Image from Wikipedia

Trying To Strangle Health Insurance Exchanges (HIEs)

2012-01-19T20:34:00.000-05:00

Let's choose the health insurance channel!

A running joke among many managed care medical directors is that the typical enrollee spends hours comparing features and prices for their flat screen TVs and minutes selecting their health insurance. Far too often, it's after enrollees get sick that they discover that many of their assumptions aren't meeting the reality of the provider network, coverage exclusions and out-of-pocket expenses that they chose.

What's more, juicy anecdotes of failed enrollee expectations (such as unproven cancer treatments in cute bald children) have fueled advocates' demands for a generous version of reform (such as a single payer with a rich one-size-fits-all benefit design).

That's why the Disease Management Care Blog found this Kaiser Health News report interesting. It raises two issues.

1. The Merits of Consumer Shopping.

According to the KHN report, what we're reading elsewhere isn't quite true because users of Massachesetts' health insurance exchange (HIE) are being flummoxed by a thicket of multiple insurance options with premiums that vary according to provider tiers (some hospitals will cost you more), out of pocket expenses (a.k.a "skin in the game" stuff like co-pays and co-insurance) and exclusions (some things are not covered). As a result, a shopper can expect to spend "six to eight hours" selecting a plan!

The DMCB is shocked, shocked by the specter of consumers having to spend as much time comparison-shopping for health insurance as the typical amount of time used checking out Consumer Reports, scanning the newspapers for sales, seeing if Amazon has a better deal and driving to several electronics stores for that best flat screen, Blu-Ray player or speaker system. Dammit, says the DMCB, buying health insurance is important and it deserves that much time. If an HIE forces consumers to finally pay attention, the DMCB says that is a good thing.

As an aside, the DMCB also points out that the art and science of HIEs are still evolving. With better informatics and user-friendly on-screen interfaces, it should get better. Given government's heavy hand, however, the DMCB predicts HIEs will never match the astonishing slickness of parallel on-line consumer purchasing aids, such as smart iPhone apps. ~~Taxpayer~~ consumer expectations will continue to not be exceeded. They will be eventually met, however.

That being said, however, the Massachusetts experience also speaks to the naive assumptions underlying the Affordable Care Act's HIE provisions. If that remains problematic, consumers will always have the option of letting D.C.'s Pete Stark, Max Baucus and Kathleen Sebelius save them time by arranging the details of their insurance for them.

2. Anecdotes and Framing

The underlying tone of the KHN piece vaguely suggests that consumerism and health insurance is a bad thing. From the typical use of a selected negative anecdote, the skeptical visage of the person featured in the article, a "I could not figure it out" sub-headline, the sub-text portrayal of insurers as being intentionally opaque and the prominence given to saving money all paint a picture of a system that is failing.

Good grief, HIEs have just gotten out of the crib and KHN's reporting suggests that the liberal and progressives still want to strangle this toddler. Once again, the DMCB is shocked... shocked.

The Latest Health Wonk Review Is Up

2012-01-19T10:59:00.000-05:00

You can look to the future with the latest Health Wonk Review, ably hosted by the Workers' Comp Insider blog. This is a summary of the latest and bestest of the health policy and "wonk" blog postings, with insights you won't get anywhere else.

Enjoy!

Patient Centered Medical Home (PCMH) Attributes and Correlation With Staff Morale, Satisfaction and Burn Out: From Bad to Not So Bad to So What?

2012-01-18T23:59:00.002-05:00

Nice medical home laptop, but
how do I feel about it?

Over the years, the Disease Management Care Blog has repeatedly reminded the spouse of her particularly good fortune in marriage. Her lingering skepticism, however, has prompted the DMCB to amass further evidence of her marital bliss by

a) asking other spouses in similar relationships if they feel as fortunate and, if so,

b) collecting data about the DMCB-like personality traits in their husbands.

Bonhomie? Check.

Willingness to share the TV remote? Check.

Cooking the occasional meal at great personal sacrifice? Check.

Announcing how good that meal is? Check.

Yet, when confronted with the indisputable statistical associations that correlate nuptial happiness and DMCB"ness," the spouse has remained stubbornly unmoved. At the spouse's pointed request, the DMCB is rechecking the math.

Readers will probably also remain unmoved about this publication that uses a similar approach to examining the impact of the Patient Centered Medical Home (PCMH) on clinic staff morale, satisfaction and burnout. Sara Lewis and colleagues surveyed the staff of 65 "safety net" clinics participating in a "5 Year Safety Net Medical Home Initiative" that had been co-funded by the Commonwealth Fund.

At the time of the survey, the 65 clinics were in the process of implementing becoming PCMHs but had not yet attained that status. The authors used a Likert-style survey to assess PCMH-"like" attributes among these non-PCMH clinics, such as patient access, data tracking, care management and quality improvement. The survey also asked about staff morale, satisfaction and burnout. The authors then correlated whether individual scores or a total roll-up score of all the PCMH-like attributes correlated with better clinic morale, higher satisfaction and less burn out.

There were 773 providers and staff members and 603 (78%) responded. 33% rated morale as good, 54% rated job satisfaction as very good and 40% had some burnout. Based on an analysis of odds ratios, some features of a PCMH - particularly quality improvement - resulted in up to a three fold improvement in the three measures. However, while the total PCMH score was associated with better morale, it looked like there was also a greater association with worse burn-out, which had a statistically significant lower odds ratio of .48.

The DMCB finds these up and down results about the PCMH in nonPCMH clinics unconvincing. It believes the attributes of a PCMH, if carried out as envisioned, should add up to more than the sum of its parts. While some of the parts that are outside of a medical home seem, according to this paper, to correlate with morale, satisfaction and burnout, this gives little insight on how medical staff would really react to the transformation of a primary care clinic. By the way, this is not the first time a PCMH-"like: methodology has been used, which makes the DMCB wonder if fully functioning PCMHs are less common than we think.

What is striking, however, are the basic measures of morale, stress and burnout. Based on these data, it would appear that these safety net clinics have some serious staff issues with 67% not having good morale, 46% not having good job satisfaction and just under half having burn out.

More evidence of primary care's travails says the DMCB.

The good news is that the DMCB remains optimistic that the math will eventually bring the DMCB spouse around. Maybe the enthusiasm - and the math - about the PCMH will similarly prevail someday. Until then, this paper's approach doesn't lend much insight about the real potential of the PCMH. Last but not least, if these 65 clinics are representative of primary care morale, satisfaction and burnout in general, the DMCB far less optimistic about their future with or without the PCMH.

The Digitization of Health Information: Why Primary Care Is At A Moneyball Moment

2012-01-17T23:09:00.002-05:00

In a yesterday's post, the Disease Management Care Blog used Edie Weiner's video presentation on digitization and commoditization to launch into its own version of health care futurism. While it struggled with notions of "opportunity costs," it concluded that a) highly evolved patient data bases, b) biometric monitoring systems, c) artifical intelligence-based decision support and d) growing consumer acceptance of informatics will make the need for many traditional outpatient visits obsolete.

Thanks to inspiration from the movie Moneyball, the DMCB explains why. The movie chronicles the decision of the Oakland A's General Manager (or "GM" played by Brad Pitt) to apply a more scientific approach to recruiting players. Eschewing the largely subjective evaluation process used by his veteran scouts, the GM decides to focus on a few key player statistics. As a result, he recruits players with high "on base" metrics and comparatively low salary demands. Success follows, and not only does he build a championship team, but he is offered a job with the legendary Red Sox. There is a telling scene filmed at Fenway Park in which the Sox owner salutes the new revolutionary approach to baseball by giving a small solilloquy on the merits of adapting or dying. Building a winning team is no longer a highly tailored and subjective approach to individual players, but data, information and insights.

Lesson learned.

The DMCB suggests outpatient primary care may be at a similar Moneyball moment. Patients can digitize and transport their health care information from afar and, thanks to decision support paired that can be managed by non-physicians or patients themselves, use a data driven approach to get the advice and treatment options they need without having to step into a doctor's office.

What are the implications? The DMCB can think of seven. There are probably more:

1. While this isn't happening tomorrow, it's a lot closer than most persons suspect. The DMCB thinks it's a threat to all those 5 year business plans.

2. Primary care office visits remain the most vulnerable because, even with the support of government with extra payments and medical home support, a higher proportion of its common "bread and butter" acute and chronic medical issues are particularly amenable to digitalization.

3. Not all primary care office visits will go away. Patients needing a diagnosis that defies the usual algorithms will still need to be seen. That means doctors will need to refocus on being diagnosticians and caring for patients that fall outside the algorithms. It's the usual "treat and street" clinic visits for routine follow-up of common problems will decrease considerably.

4. This will erode not only primary care offices, but be an important hit to the business model of "urgent care" clinics. The architects of these clinics will be well advised to start building remote access capabilities.

5. Think that that special something that can only be achieved in a one-on-one relationship with a physician who really really knows you will be lost? Think again because its availability will still be a function of data, not doctors, chips not one-on-one care. That being said, there will still be a market for personalized physician attention: it's called concierge practices.

6. Given the willingness of political opponents to quote from writings without accounting for context, the DMCB, thanks to its posts on the commoditization of health care, will never become President of the American Medical Association.

7. While most of the digitization-commoditization threatens the business model of primary care, don't think that physicians that offer invasive procedures or surgery are immune from what is going on. Patients are increasingly willing to transport themselves longer distances in exchange for value (across the state or, in the case of medical tourism, overseas), but a far more fascinating application of the digitization and easy transport of patient information is robotic telesurgery.

Image from Wikipedia

If It Can Be Digitized, It's Transport Can Be Commoditized: Implications for Health Care Providers

2012-01-16T19:57:00.001-05:00

Navy telemedicine, coming
to a clinic near you

The Disease Management Care Blog is not only a simultaneously superb and humble physician, it's a needy and impatient patient. In the course of recently seeing one of its doctors, it endured having to arrive early (waiting room), getting past the dreary check-in line (confirming my zip code again?), answering all the the nurse's inane questions (no, I don't have pain), seeing the doc ("Yup! Everything is fine!") and getting out (with an after-visit summary). It was a time consuming hassle that ate up half of a day.

The time is ripe for some disruptive technology.

Enter this highly interesting video by futurist Edie Weiner, who illuminates the underestimated links between "digitization" and "commoditization." While Ms. Weiner's point had more to do with the generalities of mainstream data processing, the DMCB thinks there are parallels in health care that have important downside implications for the industry's knowledge workers.

And the most vulnerable of those knowledge workers are the primary care physicians, because, thanks to digitizing of patient information, a lot of physician office visits will be going away. That's not only a lot of disruption, that's a lot of income.

The DMCB explains:

Recall that a "commodity" is any market good or service that is supplied without qualitative differentiation. Classic examples include wheat, copper and oil, which are bought and sold on the basis of upstream supply and downstream product demand (such as bread, computers and gasoline).

What does this have to do with health care? While the physician DMCB is not saying that humans are the same as wheat, copper and oil, that doesn't mean that their symptoms and treatment can't be digitized.

Before you scoff, recall that the management of upper respiratory illness can be distilled down to a fairly simple algorithm. The same is arguably true for other myriad conditions such high blood pressure, diabetes mellitus and even heart attack. "Inputs" including age, gender, concurrent conditions, disease severity, medications and other factors can be digitized. This, in turn, can be informatically processed to create evidence-based treatment recommendations from afar.

Until now, the new paradigms associated with health care reform still rely on the assumption that patients with their colds, hypertension, diabetes and chest pains will continue to personally bring their medical problems to the doctor's office. What's supposedly "new" is that advances like the teaming of a medical home, the decision support of an electronic record or the incentives of value-based insurance designs would make the office visit a more rewarding, efficient, effective and less costly affair. All well and good says the DMCB, but even with a new wrapper, it's still destined to remain a dreary and time-consuming office visit.

Thanks to Edie Weiner, the DMCB suggests that that business model and all those carefully laid policy assumptions could blow up.

Here's why.

Our clinic-based and see-the-doctor approach to care is being eclipsed by an approaching "perfect storm" made up of four key ingredients:

1. Highly organized electronic databases. Not to be confused with electronic health records, this is the access of updated and easily accessible patient information, plus

2. Networked patient monitoring systems. This is periodic assessments of, for example, blood pressure, glucose levels and EKGs in persons with hypertension, diabetes and heart disease, plus

3. Artificial intelligence-backed decision support. While this may not be ready for prime time in the average doctor's office or via a voice-activated smart phone, the recent broadcast of the game show Jeopardy featuring IBM's Watson showed us just what's possible, plus

4. A tipping point of consumer acceptance of informatics. The DMCB's spawn have applied their mobile devices to every part of their lives, why not their health care?

In a traditional care setting, patients assemble their concerns (the "data") and personally transport them to the doctor (the "processor"), who renders a treatment plan. Thanks to the four-fold perfect storm described above, the digitization of patient information will enable patients like the DMCB to avoid the high opportunity costs of a usual-care office vist. The DMCB will be able to use the network. In effect, it's the transport of the DMCB's information that will, in a round-about way, be "commoditized."

In some respects,it's already begun. Because patient problems can be be digitized, packaged and transported just like all the world's other data that are described by Edie Weiner, video physician visits, decision support-backed nurses and touch-screen kiosks are now processing the information and rendering treatment recommendations outside the office visit.

What will this mean? Many diagnoses can be made remotely. Treatment plans can be adjusted without need for a face-to-face visit. Oversight can be provided by non-physicians.

In tomorrow's post, the DMCB will review the implications and what it means for primary care physicians.

OK, You Want to Do Some Health Care Social Media. What's Next?

2012-01-15T19:54:00.000-05:00

No social media is
complete without it!

Since you're reading the Disease Management Care Blog, you already have some sense of the emerging impact of social media on health care. Yet, thanks to this "Top health industry issues of 2012: Connecting in uncertainty" report from PwC, the DMCB was reminded in a very short chapter on the topic that for population health service providers, it's not just a matter of setting up a "Facebook" and a "Twitter" account and doing internet stuff, like building brand and selling more services and engaging clients.

That stuff is important, but PwC reminds us that social media has other important roles. "Outward" social media can also act as a listening post (for example, becoming aware of service perceptions like this before they reach a critical mass) and notification tool (such as patient alerts). Then there's "inward" social media, which can collaboratively link your workforce and allied professionals for online problem solving (there are lots in the public domain, by the way).

All well and good, says the DMCB but once you commit to investing in social media and setting up some accounts, what's next? While the DMCB doesn't usually reflect other bloggers, it recommends these well written Part I and Part II posts courtesy of David Harlow's Health Care Law Blog.

Mr. Harlow recommends that companies think early about the patient confidentiality rules imposed by HIPAA, professional codes of conduct and underrecognized threats from the Federal Trade Commission and National Labor Relations Board. The eye-opener for the DMCB was the need to develop local, flexible, inclusive and protective organizational policies backed up by training that reminds users that they are "ambassadors" for the company on their social media "property.'

A Hearty Welcome to the Wing of Zock

2012-01-13T08:55:00.000-05:00

That term wasn't immediately familiar to the Disease Management Care Blog either, but then it was reminded that it was a fixture in the book The House of God. More on that in a second, but the Association of American Medical Colleges (AAMC) has created a new blog by that name. Called Wing of Zock, it's an eclectic mix of writings on the intersections between health policy, society, medical education and patient care. The DMCB says "Bravo!" and has added it to its Google reader and blog roll.

The DMCB is doubly intrigued because The House of God has come a long way. When it was first published, its unflattering and darkly humorous portrayal of medical internships was condemned by many senior academicians as an insult to the profession. While its fellow housestaff were freely quoting from it during patient rounds, the DMCB remembers attendings who were proud that they hadn't read it. The disdain spilled over into the medical science journals, which treated the book with the same kind of vitriol recently directed by physicians at the television series, House.

Lessons?

In a delicious bit of irony, the staid AAMC has shown it has a sense of humor while launching its excellent blog.

Social media-based writing is increasingly becoming a fixture in the academic medical landscape. Deans and Chairs ignore that at their peril.

The DMCB will need to reexamine its attitudes about House. What inspiration will today's medical interns draw from the "Princeton Plainsboro Teaching Hospital" and how will that play out in the coming decades when they're the ones leading the health care system?

Coverage of Fitness by Medicare Advantage Plans: Which Causes Which?

2012-01-12T21:08:00.001-05:00

The kind of enrollee Medicare
Advantage plans want.

Many years ago, the newly-minted managed care medical director Disease Management Care Blog accompanied a marketing VP on a business visit to a fitness club. We were interested in knowing if the club would offer a discount to our health plan members. During the tour of the facility's weight rooms, basketball courts and group exercise rooms, we came across a large swimming pool filled with bathing-capped seniors. "Those people," thought the DMCB, "are precisely the ones we want in our insurance plan."

Enter the paradox of offering fitness and wellness as a covered health insurance benefit. While the assumption has been that fitness causes an enrolled population to be healthier, it's just as possible for persons who are already healthy in the first place to be attracted to health plans that cover fitness. Managed care executives have known about this for a long time, but until now, no one has really measured the effect.

Enter this elegant study by Alicia Cooper and Amal Trivedi, just published in the January 12 New England Journal. Eleven Medicare Advantage (MA) health plans that added fitness as a covered benefit in either 2004 or 2005 were matched to 11 plans that did not add a fitness benefit. On average, the plans were predominantly nonstaff and nongroup models and median duration of being in business was just over ten years. The "fitness" plans had a median population of 31,540 members while the control plans had a median membership of 18,241

The authors next looked for Medicare beneficiary members in those 22 plans who had completed a "Medicare Health Outcomes Survey" (MHOS) at the time of their enrollment. This yielded 4,852 beneficiaries who were in one of the eleven "fitness MA plans" and 5,064 beneficiaries in one of the eleven "no fitness MA plans." Age, gender and the burden of illness was similar in both groups, while they differed slightly with respect to race, education and income.

The key question from the survey that was used in this analysis was self-reported health status. In the years prior to instituting the fitness benefit, the percent of newly enrolled persons reporting excellent or very good health in the MHOS was 29.1%. After the fitness benefit was instituted, it increased to 35.1%. Plans without fitness programs during that same period went from 28.5% to 30%. This contrast between a 6% increase versus a 1.5% increase was statistically significant.

The good news is that the folks in Medicare are well aware of the impact of unequal enrollment between MA plans and use risk adjustment to even out the payment levels. The bad news is that risk adjustment is notoriously inaccurate and, to the DMCB's knowledge, probably doesn't capture that 6% shift described above. Assuming the MHOS survey results translate into lower claims expense, that could represent some serious money in a program that is already under fire for over-payment.

Before readers condemn the MA plans for consciously using their fitness plans to attract a lower cost population, note that the same MA plans have been offering disease management programs for persons with chronic and costly conditions. When compared to fee-for-service Medicare, these programs may be attracting sicker seniors. Between MA plans, those with a better reputation for investing in chronic care population health management are more likely to attract a higher percent of persons with diabetes and heart disease. In other words, it works both ways.

What should the next step be? Follow-up MHOS results for those individuals who entered with a low score to determine if there was any improvement among those in "fitness" MA plans versus those plans without the fitness benefit. The DMCB looks forward to seeing those results hopefully soon.

In retrospect, the DMCB should have suspected something was up years ago. After all, it was accompanying a marketing VP and, whether we knew it or not, the visit was really all about those seniors in the pool.

Managed Care Insurer Medical Directors: A Recruiting Opportunity for Provider Organizations That Are Taking Insurance Risk

2012-01-11T20:53:00.001-05:00

The investigative Disease Management Care Blog went dumpster diving outside the headquarters of a large health care organization and found this document:

MEMO

To: The Health System CEO

From: The Front Line Docs

Re: Physician "Accountability" Leadership

Thank you for taking the time out of your busy schedule to meet with the medical staff last night. Since you arrived here a year ago, we physicians have been looking forward to our quarterly meetings and appreciate that you were able to make it this time. Thank you also for arranging the hospital cafeteria to supply the sandwiches. They and the boxed raisins were delicious!

"The white coats," as you refer to us, are very interested in your vision of the insurer-contracting opportunities around efficiency, cost reductions, "accountability" and "shared savings." Like you, we are also concerned about unnecessary health care "waste" and "variation," and endorse your call to action, or rather inaction. The health insurers' statististics that were reproduced in your presentation on the frequency of surgical procedures at our institution was very eye-opening. As a result, we've already started to let our patients know that, when a trip to the operating room cannot be justified, we'll do everything we can to achieve maximum cost-effectiveness with alternative evidence-based care pathways.

In light of the above, may I recommend that you strongly consider hiring a physician-leader with the skill-set necessary to spearhead these program initiatives. While the current Vice-President for Medical Affairs has many of the fine qualities we've come to expect of your hand-picked appointees, let's face it: he wouldn't know a PMPM if he personally passed one into a bedpan.

In my opinion, attributes of a such a physician leader should include:

1. A strong grasp of clinical and health economic outcomes, trending and statistical analysis.

2. A fundamental understanding of health insurance contracting.

3. A track record of interacting constructively with physicians, hospital administrators and community organizations. In particular, he or should she be adept at handling many of the hostile questions you faced last night. That way, you can "outsource" the anger management.

4. An ongoing commitment to patient care, including taking "call" with the rest of us.

I would like to point out that such physicians can be found among the Medical Directors that work in many of the nation's commercial health insurers. While every commercial insurance plan has a senior-level ("Vice President") medical director, each if these executives usually has several medical directors reporting to him or her. Since these individuals work in very hierarchical organizations with little chance of advancement, many would jump at the chance to deploy their skills in a risk-bearing provider organization like ours. An enterprising head-hunter recruiter should have little trouble poaching some of these highly skilled docs who possess precisely the kind of talent we need.

Once again, thank you for your time and I look forward to working with you in the future.

Sincerely yours,

(illegible)

There was a also hand written note appended at the bottom:

By the way, I've booked the MRI you requested and set up the appointment with the specialist. As we discussed, better safe than sorry!

A New Health Wonk Review Is Up!

2012-01-11T11:36:00.000-05:00

OK... it's not THAT new. But there is a great compendium of recent posts that has been assembled by the Center for Objective Health Policy. There are some great links to topics on health reform, insurance and policy.

Enjoy!

The Care Continuum Alliance Launches a Blog: Voice On Population Health

2012-01-11T09:45:00.000-05:00

The Care Continuum Alliance has boldly stepped into the brave new world of social media by launching its own blog, dubbed "Voice on Population Health." Recall that the CCA is a D.C. based member organization made up of individuals, companies and other organizations that offer or support care management programs and services. Unlike a lot of other health reform stakeholders, CCA is a real world mix of education, policymaking, member support, business savvy and optimism.

The Disease Management Care Blog welcomes the CCA blog and looks forward to checking in on it regularly.

What's The Right Diabetes Disease Management Program For Your Patients?

2012-01-10T20:28:00.000-05:00

The answer is "it depends."

For a good example of why that's true, check out this hot-off-the-presses Health Affairs article that describes two parallel approaches to disease management. Both were offered side by side to a largely Hispanic and socioeconomically disadvantaged population in Los Angeles (LA).

One program was provided in the LA Department of Health Services primary care health centers. Patients with poor diabetes control were referred to a separate turn-key "one stop" care program with non-physician educators under the direction of an endocrinologist. Using a combination of in-person and telephonic management, patients were put through a six to nine month protocol designed to optimize their medication treatment plan, foster better living habits and improve self-care. Nurse case loads averaged 125 patients.

In LA's independently-run community clinics (many of which are federally qualified health centers), case managers and clinical pharmacists were available on-site for lifestyle counseling, education on self-care and medication management that included initiating insulin and adjusting other drugs. Nurse case loads numbered 400 patients, while the pharmacists had about 200 patients.

Based on pre-post measurements involving hundreds of patients, both the LA health centers' and community clinics' patients experienced impressive improvements in blood glucose control and cholesterol levels. That's typical in disease management programs.

However, there were some differences. In the LA health clinics, the program was separate, overseen by a specialist, limited to patients with poor glucose control and involved a more intense program of patient education. In the community health clinics, the nurses and pharmacists were "part" of the clinic and, based on the caseloads, were less labor-intensive.

Despite the differences, the DMCB couldn't really tell if one approach to diabetes care management was "better" than another. There was little information on the content of the care plans and no information on costs. Yet, all things being equal, the DMCB suspects that architects of similar programs nationwide are ultimately selecting from a menu of care and staffing options based not only on patient need but highly subjective (or yet-to-be-investigated) preferences based on local physician culture (sometimes specialist leadership is important), access to special resources (like pharmacists) and local budgetary realities.

The key lesson in this article is how two parallel clinic systems in the same population serving a similar population decided to deploy different disease management programs. Both resulted in patient betterment. Both had relative strengths and weaknesses. Deciding which approach is "better" remains a matter of local judgement based on a complex number of factors.

In other words, it depends.

Image from the Kentucky Diabetes Resource Directory

Some Predictions for 2012

2012-01-10T00:47:00.001-05:00

With atypically little fanfare, the Disease Management Care Blog gazes into the crystal ball and offers ten health care predictions for 2012:

1. After Mitt Romney secures the Republican nomination for President, he and Mr. Obama will mutually try to find ways to avoid debating the issue of health care reform. Both will calculate that there’s little advantage to reminding voters of the messes they’ve made.

2. As a result of 1 above, the election will not hinge on health care reform, which, thanks to an improving economy, will otherwise be very close and not be a referendum on Obamacare.

3. Yet, the U.S. Supreme Court will stir things up with a ruling that the Affordable Care Act mandate is unconstitutional because, among other reasons, Congress should have used its power to tax, not impose a penalty.

4. There will be no generalizable and published peer reviewed studies on the Patient Centered Medical Home or the electronic health record that conclusively demonstrate that either reduces health care costs.

5. Even though CMS will have trouble providing timely claims data feeds to its newly established ACOs, we’ll hear little about it in the public domain. ACOs have every incentive to not cross CMS.

6. Speaking of ACOs, the least recognized Achilles heel as they start up will be a pervasive physician culture that trumps patient preference over shared savings.

7. We will learn that, thanks to their complexity, the deadlines for implementation of health information exchanges will need to be pushed back.

8. Congress will "kick the can" of the Sustainable Growth Rate conundrum down the road and past the 2012 election with another temporary patch.

9. More academic medical center faculty will find that it’s far more professionally rewarding to post on line than to publish in paper-based journals. Department Chairs will reluctantly find ways to use web statistics in promotion and tenure.

10. Piqued by Mr. Obama's recent recess appointments, the Republicans will respond by holding the up the appointment of Ms. Tavenner as CMS Administrator.

Putting the Doctor-Patient Relationship Into Perspective

2012-01-08T18:16:00.000-05:00

Years ago, the Disease Management Care Blog had a pediatrician colleague who was widely admired for his diagnostic acumen, attention to treatment detail and personalized attention. As further testimony to his reputation, every physician wanted him to be their childrens' doctor. The DMCB was one of those lucky docs. The luck ran out, however, when the DMCB's spouse quickly realized that she couldn't get any appointments and even if she did, the physician's clinic routinely ran two hours late.

Persons who read this New England Journal Perspective testimonial on the joy and frustrations of a primary care career should keep that physician in mind. That reality contrasts with Dr. Finegold's fantasy world of dedicated physicians with limitless time where 1) the personal physician individually guides complex patients through a complex health care system and 2) the doctor patient relationship is fountainhead of professional satisfaction and patient well being. That's why insurers should pay anything and policymakers should do everything they can to support this vision.

The DMCB sadly disagrees.

Primary care physicians are a precious resource. They're not only expensive, they are becoming more rare over time. As a result, use of their time and effort has to be restricted to circumstances when there is no one else who can deal with the paper work, make medication adjustments, work to increase treatment compliance, maximize the insurance benefit, deal with the social issues and provide psychological support. The DMCB thinks there are non-physician professionals who are better at these activities and do can do it far more cheaply. The solution is not more primary care physicians but more primary care physician support.

The DMCB physician colleagues may argue that the doctor-patient relationship is truly Holy Ground. Unfortunately, it is becoming increasingly apparent that there at too many patients and too few physicians to allow Dr. Finegold's indulgence of being so immersed in their patients' lives. The degree of personalized involvement described in this article may be a luxury - like open access to brand drugs, the latest technologies, the priciest specialists or a few extra days in the hospital - that society can no longer afford.

How Did The Disease Management Care Blog Do With Its Predictions for 2011?

2012-01-05T19:00:00.000-05:00

In the beginning of 2011, the Disease Management Care Blog amazed, astounded and impressed itself with a series of health care system and industry predictions. Unlike those lesser blogs that post predictions and conveniently neglect to report back to its readers, the DMCB's commitment to being transparently outcomes-based prompted it to pose the awkward questions that few in the blogsphere are brave enough to ask: how did its prognostications perform? What accuracy did its augury attain? How did it's foretelling function?

Here are the DMCB hunches and brutal self assessments:

1. CMS will delay the January 1 start date for the CMS Shared Savings Program. The DMCB got that one right. The usual bureaucratic inertia plus having to respond to the consternation over the initial proposed rule pushed the start date back to April 1. By the way, this is only one of many missed Affordable Care Act deadlines, so this wasn't all that hard.

2. Despite its luster, adoption of social media in health care settings will not attain a tipping point: The DMCB got that one right. It knew that front line administrators in clinics and hospitals don't see a financial return on investment for social media and remain notoriously paranoid over HIPAA.

3. Berwick will be confirmed as CMS Administrator. The DMCB blew this one but should have known that too few U.S. Senators and their staffers regularly read Disease Management Care Blog. With time, that should change.

4. Naive enthusiasm over the electronic health record and PCMH will bump into painful reality: The DMCB will call this one a draw because use of the EHR has been boosted by the CMS' "meaningful use" ~~bribes~~ payments. Without them, the EHR business case would have to be based solely on spotty quality and phantom claims of cost savings. The PCMH, still lacking any consistent and statistically significant proof that it reduces costs, is still very much alive because of its growing link to ACOs. That's appropriate, because ACOs likewise lack any proof that they reduce costs.

5. Despite the advent of a new health care era courtesy of Mr. Obama and the ACA, health care costs will depressingly continue to go up. Bingo says the DMCB. According to this report on how things are looking for 2011, medical costs are expected to hit 9%. That's less than 2010 but still far outstripping the general rate of inflation and evidence that more and more of our GDP is being gobbled up by health care.

6. The population health management industry will continue to thrive: The DMCB got this right too. The Care Continuum Alliance is as big as ever and there has been no abandonment by commercial insurers of their commitment to patient coaching and support.

7. The term "disease management" will refuse to die. To the many experts and consultants the DMCB interacts with, purchasers and buyers know that a rose by any other name still smells as sweet. Call it "care management" or "population health" or "disease management" and no one really seems to care. because they know "disease management" has matured.

8. The political stalemate will continue. Talk about a no-brainer but even the DMCB underestimated Mr. Obama's reliance on his liberal progressive roots to the detriment of bipartisan compromise. Yes, there's plenty of blame to share on both sides of the aisle and while it may not be the President's fault, the DMCB thinks he's still responsible.

9. Greater interconnectedness will make us more vulnerable and unpredictable "black swan" events will preoccupy Washington DC: while there were no unexpected health care events, who would have foreseen the Arab Spring, the near death of the Euro, the impact of the Tea Partiers and the downgrade of U.S. debt?

10 The DMCB will reach a critical mass - more on that in a future post but it's 2011 annual report suggests the DMCB juggernaut is well on its way.

Cruel Tutelage From the Group Practice Demonstration for ACO Wannabes

2012-01-04T18:21:00.000-05:00

Data is in there somewhere!

Remember the Physician Group Practice Demonstration? Its results were used by CMS to justify Accountable Care Organizations (ACOs) with the luster of millions of dollars in shared savings and the thrill of being a "partner" with the world's largest health insurance behemoth, intent on "achiev[ing] a transformed and modernized health care system."

The Disease Management Care Blog has never been all that impressed by CMS' bluster. It became less so when it checked out this short video by a physician leader from one of the Group Practice Demo participating organizations.

It's an interesting story. After being confronted by suboptimal quality scores in the first year of the Demo, the provider organization naturally responded with corrective programs. However, there was also an 18 month delay in CMS' ongoing provision of the quality measures. Since too much money was riding on meeting the CMS' performance threshold, they had to develop their own internal reporting systems. Without them, they would have been flying blind and unable to gauge whether they were making any progress.

Another lesion from the Group Practice Demo? If you're going to be an ACO, don't count on the Feds and mistake CMS' size or promises for nimbleness or action. And make sure you have your own data resources and dashboards to manage the quality "real time."

Image from the Lawrence Livermore National Laboratory

Should Health Insurer Coverage Be Conditional On Participation In Disease Management?

2012-01-03T19:03:00.000-05:00

Standing between patients
and outcomes?

The unsophisticated Disease Management Care Blog used to think the answer was a simple yes.

Its rationale was twofold:

1. The patient impact of the medical and pharmacy benefit, i.e., medications and other treatments, will be greater if there's a link to concurrent care management services that promote self care and increase doctor-patient engagement, and

2. The gateway to accessing the medications and treatments could be used to incent enrollment in care management programs which, depending on the circumstances, increase quality and lower costs.

Both factors undoubtedly underlie the decision of many insurers to combine disease management and coverage of certain services. For example:

Many Medicaid programs won't cover tobacco cessation medications unless the patient is participating in "counseling services." That's because much of the original research on the drugs showed they work if they are linked to concurrent behavioral support. By the way, the same is true when it comes to drugs for the treatment of obesity (page 53), which showed up in this coverage document.

In addition, consider the example of "external insulin pumps." These are battery powered, small and discreetly wearable devices that provide a highly tailored course of insulin to persons with diabetes. They are are also complex and expensive, which is why many commercial health insurers rely on guidelines that require participation in a diabetes program before they'll be approved.

There are exceptions to the rule. For example, while asthma treatment guidelines (page 60) recommend 'instruction, demonstrations and frequent reviews' along with the prescription of peak flow meters, coverage of these devices is not conditional on participation in an education program.

Upon further reflection, however, it occurred to the DMCB that having to enroll in disease management - whatever its merits - could be viewed by patients as a barrier which could, in turn, paradoxically reduce medication possession ratios, participation in tobacco cessation programs or use of insulin pumps.

In mulling this over, the DMCB turned to the topic of Value Based Insurance Designs. While VBID can be defined as the explicit setting of patient out-of-pocket-cost (such as co-pays or co-insurance) to the underlying value of any medical service,the DMCB thinks it can be broadened to include the removal of any barriers that stand between the patient and high value services. The highly regarded University of Michigan's Center for Value-Based Insurance Design, in this excellent review, doesn't think of disease management as a barrier but as an incentive.

Incentive or not, the good news is that it's possible to combine VBID and disease management that together achieve outcomes that are better than either one alone. Unfortunately, the DMCB fears those outcomes are limited to patients willing to enter the programs in the first place: there may be a larger unseen population outside the disease management intervention who aren't included because they don't want the hassle. In other words, good outcomes for a few known participants doesn't make up for the potentially bad outcomes for the many non-participants.

If any readers have an answer, the DMCB would appreciate hearing from you. In the meantime, the DMCB cautions that the population health management suppliers need to be aware of the downsides of linking insurance coverage to their services. They also need to do everything they can to avoid being viewed by patients as a barrier.

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A Disease Management Care Blog Annual Report for 2011

2012-01-02T21:17:00.000-05:00

Now that 2011 is gone, this is a good time for the Disease Management Care Blog pause and take stock. How is it doing?

It likes to think of itself as a unique ongoing journal club on the organization, delivery and financing of health care. If the DMCB was soup, there'd be three ingredients:

1) reliance, whenever possible, on peer-reviewed and published evidence,

2) a physician's "real world" experience and

3) a ready dash of skeptical humor.

The DMCB must be doing something right. Despite a narrow mix of medical science, economics, effectiveness and policy, the DMCB has attracted a relatively large and elite readership. If you're reading this, that means you.

Sophistication

When it looks at the ISPs of its many return visitors, the DMCB sees dozens of academic institutions, big and small name news media outlets, publishing houses, trade associations, information technology businesses, Congress, CMS, the White House, state government, foundations, commercial insurers, hospitals, health care consulting organizations and population management service providers. Many are household names.

It doesn't stop there. The DMCB has been contacted by and gotten to know folks from all levels in the health care industry. Based on those conversations, it knows this a smart group. The author of this blog is a better person for it.

The DMCB knows each regular visitor, twitter follower and Google subscriber has been earned one person at a time. It knows its elite readers are knowledgeable, active or interested in health policy, population health management, the patient centered medical home or primary care. These are not casual readers.

And you have a lot of company:

According to Google Analytics' mix of ISP addresses and cookies, DMCB Ver. 2011 had 29,000 unique visitors with 42,000 visits. A third were repeat (defined as more than one) visits. While there is no definition of a "regular" reader, the number of visitors with more than 50 DMCB "hits" in 2011 numbered 5153. There were 786 visitors with more than 200 hits.

The DMCB also has 416 Twitter followers. According to TweetReach, the DMCB regularly reaches almost 1500 persons with its tweets. Depending on re-Tweets, that number can exceed 7000.

There are also 466 Google RSS subscribers.

These 2011 numbers suggest there are thousands of persons that regularly read the DMCB. Every individual visitor, follower and subscriber returned or opted-in based on the DMCB content and only the DMCB content. There is no marketing, emailing or use of any services to promote the DMCB. It doesn't have the advantage of a sponsoring institution or explicit link to a big-name business. And it's readership continues to slowly grow.

The DMCB Web Juggernaut

The DMCB is regularly reflected and linked in many prestigious web outlets, include HealthHombre, Health Affairs, KevinMD, Forbes, and many sister blogs. It's also appeared in the web sites of USAToday, Wall Street Journal, the Washington Post, Dartmouth Atlas, Business Week and the National Review. It's also been linked in the intranet web sites of many insurers, provider organizations, and health information tech companies.

And, by the way, according to YouTube, the DMCB's videos to date have had 33,486 views.

As testimony to its growing web presence, the DMCB is on the first page when the term "disease management" is Googled. The DMCB's growing web traffic has ironically made its "Comments" section a target by spammers with links to its dubious medical web sites. With only one unobtrusive Google "Ad" that generates pennies per click, it still got a check for $100 (prompting the derision of the DMCB spouse, but that's another post). The DMCB has also been offered - and refused - cash to provide link backs. It also had one complaint lodged over copyright infringement over an image (the post has since been removed, with apologies). Simply put, folks are paying attention.

Last but not least, the DMCB is proud of its four 2011 peer reviewed publications in Population Health Management, Self Care and the Journal of Comparative Effectiveness Research.

And a thank you....

... to the readers who have commented or emailed with feedback, comments and insights. To the readers who use their precious time and keep coming back.

Five Reasons Why The Ovarian Cancer Avastin Story Is Not Finished

2011-12-29T20:14:00.001-05:00

An ovary almost completely
replaced by cancer

As regular Disease Management Care Blog readers may have predicted, the controversial anti-cancer drug Avastin went bust again in two just-published studies (here and here). This time it wasn't for the questionable treatment of breast cancer but ovarian cancer.  Yet, while the nation's mainstream media has passed sentence on Avastin's failure, the DMCB isn't quite ready to "short" the drug.

Very briefly, one randomized prospective trial involved women with high risk or disease that had spread. Participants were randomly assigned to standard chemotherapy plus Avastin, while the other group got just the chemotherapy.  Women in the Avastin group went 24.1 months without progression of their disease versus 22.4 months in the non-Avastin group. Death rates are still being analyzed.

The other trial involved women with cancer that had spread. They were randomly assigned to one of three groups: just 1) chemotherapy or 2) chemo plus either Avastin in the earlier cycles of chemotherapy or 3) Avastin with all the cycles of chemotherapy. The just chemo group went a median of 10.3 months before there was disease progression, while the Avastin groups went 11.2 and 14.1 months, respectively.

Even with the depressing results outlined above, the DMCB has several reasons for believing that we've not seen the last of Avastin for ovarian cancer.  Much of the DMCB's obstinacy has to do with the complexities of cancer treatment and how statistics are collected and interpreted:

1.  The trials involved patients with aggressive or advanced disease. Much like the logic of using a small extinguisher on a huge house fire, that doesn't mean that persons with limited or microscopic disease wouldn't be helped by Avastin. The only way to find out is to perform the same sorts of randomized trials involving patients with less widespread or aggressive disease.

2. It's possible that some of the Avastin patients may have gotten much better, but their positive results were diluted by the majority of the patients who didn't benefit. In other words, the clinical trials report the average response rate. That does little to answer the two questions that every individual cancer patient asks: 1) are there exceptions and 2) am I one of them?

3. Assuming exceptions exist, there may be a way to identify that small minority of patients who are more likely to derive a greater benefit from Avastin. Assuming ovarian cancer is a heterogeneous disease, there may be a blood test or an additional type of biopsy that can answer the two questions above.

4. "Disease progression" is just one of several cancer outcomes. While it's important, there are others that may have more meaning for patients and could simultaneously put Avastin in a better light. As a reminder, death rates in one of the trials described above are still being compiled and have yet to be reported. Stay tuned.

5. Last but not least, the most selectively generous interpretation of the data above is that Avastin helped patients go an additional 4 months before their disease started spreading again. While that may not seem worth it, the DMCB has taken care of plenty of patients who would think it's plenty worth it. While commercial insurers will have every reason to question payment for a horrendously expensive drug with only 4 months of benefit, patients and their doctors will argue that hope is "medically necessary."

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Of Accountable Care Organizations, Pioneers and Potatoes

2011-12-28T20:57:00.001-05:00

It wasn't long after the Dec. 19 CMS announcement that the Pioneer Accountable Care Organization Program had launched that the champagne health policy corks began to pop. According to writers in the Health Affairs blog, ACOs have the "potential" to align incentives, leverage electronic health records, harmonize government and commercial insurers and improve care. After that they'll potentially restore the polar ice caps, save the Euro and help Facebook finally realize that its users are the customers, not the product.

But in all seriousness, recall that Pioneer will run parallel to the bigger "Shared Savings Program." The purpose of Pioneer is to test the ability of already integrated health systems to function as ACOs. From a pool of anonymous applicants, CMS' "Innovation" center chose 32 "winners."

You can read how their contracting arrangements will work here. As the Disease Management Care Blog understands it, it'll involve an optional Chinese menu of threshold-dependent and first-dollar shared savings and/or full capitation.

It all reminds the Disease Management Care Blog of potatoes.

Why would the DMCB chose the lowly spud to make its point about ACOs, you ask? Read on:

Align incentives? Under shared savings, health care providers will ultimately bill less and receive a fraction of any savings in return. If you like that business model, the DMCB would like to pay you a dollar less for any bag of potatoes you've just bought and give you 50 cents to reward you for our "shared savings."

Electronic records? If the ultimate leveraging of the EHR is to improve care coordination, the bad news is that there is still a large gap between the hard science of EHRs (here and here) and wishful jargon. In other words, documenting they're potatoes and what you've done to them in some computer still doesn't make 'em any easier to cook.

Commercial payors? Unencumbered by miles of regulations, statutes and political meddling, commercial ACOs are already miles ahead of CMS. At a recent holiday meal, the DMCB spouse served traditional boiled spuds. She also served up a creative casserole of shredded potatoes mixed with sour cream and cheese. One was much more tasty. One was not. 'Nuff said.

Improve care? Ten years ago, James Robinson said it best: our problems are limited resources, unlimited expectations, widespread skepticism and reduced tolerance for interference with individual autonomy. We have 20 lbs of potatoes. The ACO bag is made for ten lbs. Good luck.

Image from Wikipedia

The Latest Cavalcade of Risk Is Up!

2011-12-28T13:47:00.000-05:00

Want to learn more about the ins and outs and the ups and downs of business-related risk? You can learn about that and even get some insights on the risk of starting a business in the latest Cavalcade of Risk hosted by Jacob Irwin at the My Journal of Personal Finance blog.

Enjoy!

More On the Affordable Care Act's Health Insurance Mandate

2011-12-27T20:49:00.001-05:00

Is this also some type of "mandate?"

With two prior posts under its belt ("Optics" and "Furies"), the Disease Management Care Blog continues to follow the opinionating over the constitutionality of Affordable Care Act's health insurance "mandate." The latest is this New England Journal Perspectives piece. According to author Mr. Elhauge (who personally opposes the mandate), a federal law that uses the Commerce Clause to require persons to purchase health insurance is perfectly legal and proper at multiple levels:

Congress has repeatedly used broad interpretations of the Constitution to insert itself into the conduct of commerce, so the mandate is nothing new. One past example is the prohibition against gender, religious or racial discrimination by private firms, while another is the ban on home grown medicinal marijuana. Since health care is a commercial activity in the public space, the logic is that Congress can similarly require anyone who has ever received health care in the past to purchase health insurance for the future.

While prohibiting an activity (like discrimination or pot) may not be the same as requiring an activity (health insurance), readers may be interested in knowing that the first Congress not only required ship owners to buy medical insurance for merchant seamen but later required seamen to buy hospital insurance.

And what about that mortgage deduction? If you don't buy a house, you can't take the deduction, which economically the same as a penalty for not engaging in the economic activity of home ownership.

Another favorite of mandate opponents is the argument that the Feds are on a slippery slope leading to a requirement that we all buy broccoli or General Motors cars. The counter argument is that Medicare is a system that requires the purchase of "broccoli" at government stores. What's more, if we were to privatize Medicare, wouldn't that also functionally be a mandate for the purchase of private insurance?

Last but not least, if personal liberty is the underlying issue, the argument is that no one would ever force anyone to eat the broccoli. Mandating insurance is not the same as mandating health care.

Care Continuum Alliance Insights on the Population Health and Disease Management Industry Outlook for 2012

2011-12-26T22:28:00.000-05:00

Future's so bright, gotta wear shades!

Optimism. Enthusiasm. Bullishness. Who can blame the Care Continuum Alliance for describing the future as "bright" in a ebullient 2012 population health management "Industry Outlook" white paper? Based on a survey of unnamed "industry leaders,' the CCA found that practically every high visibility health policy initiative out there is relying on the principles of care management.

They're right. Given growing recognition that "health care as usual" cannot continue, companies, vendors and organizations (and blogs) that offer new approaches will thrive. Have a good idea on reducing chronic illness and improving health and the value proposition will follow. Have a value proposition and the business model will follow. Have the business model and an early comfortable retirement will follow.

The report can be downloaded here. No company or individual resource knowledge library is complete without it. The Disease Management Care Blog also thinks that forwarding the report to colleagues, co-workers, bosses, underlings, friends and enemies will demonstrate two key traits:

1) your situational market business awareness is second to none
2) reading the DMCB is a competitive advantage

A DMCB summary review is below

ACOs and Shared Savings: the industry has a host of necessary risk assessment, predictive modeling, information technology, analytics, patient engagement and condition management tools that can be built and tailored. Provider organizations that seek to make money from "upside gainsharing" ignore these resources at their peril.

Electronic and Mobile Health: remote physiologic monitoring, 'app' based coaching and "pull" style social media engagement are all reaching a tipping point. Or rather, are all eReaching an eTipping ePoint. The Disease Management Care Blog, sharing in the eEnthusiasm, has initiated a remote "eSpouse" offering. More on the ePerils of that eBusiness model in a future ePost.

Reducing Readmissions: Come Oct. 1 2012, outlier hospitals with more than their fair share of heart failure, heart attack and pneumonia readmissions can look forward to a painful revenue cut. "Pay us now or pay later," says the industry, with too numerous-to-count proven care management strategies that have been described at the Care Continuum's annual meetings for years.

Medicare Advantage Bonus: That's right, MA plans will be eligible for bonuses from CMS based on HEDIS inspired commercial insurance outcomes that have been the bread and butter of the care management service providers since the beginning of time.

Dual Eligibles: This highly vulnerable population has been trapped in a twilight zone of overlapping and uncoordinated benefit plans thanks to a well-meaning but typical Washington-style mishmash of Medicare and Medicaid. The good news is that the Feds have finally woken up to this and are interested in funding many of the coordination strategies that the population health industry stands ready to offer.

Prevention and Wellness: The Feds have money to put into this and employers are increasingly willing to invest in it. Medicare covers annual wellness visits and covers obesity counseling. The controversial ham-fisted involvement of HHS in calculating the MLR has thankfully correctly slotted the cost of wellness programs. Wellness and prevention are one of the ten essential benefits. The industry is poised and ready to go.

And what about "build" versus "buy" and the notion that providers already know how to do all this stuff? The DMCB points to the sine wave of on-again off-again in and outsourcing that has been the norm for the commercial insurer-disease management vendor relationship for years. The DMCB suspects the same will occur for providers, hospitals, delivery systems and ACOs that have to operationalize complex programs that achieve measurable accountability. The difference is that, up until now, they haven't had to do that at all. Based on a mix of in-house competencies, interest, speed to market needs and cost comparisons, many will buy.

The population health industry's outlook is very bright indeed.

Image from Wikipedia

The Latest Health Wonk Review Is Up

2011-12-22T10:12:00.000-05:00

Gary Schwitzer offers up a holiday-styled Health Wonk review with presents/links that delight, amaze and educate. Tis the season at the Health News Watchdog.

Enjoy!

The "Doc-Fix" Debacle and Why Medicare Access Is In Jeopardy In Both Salaried and Physician Owned Settings

2011-12-21T20:13:00.000-05:00

Don't underestimate the physician dismay over the looming "Doc Fix" debacle. Unless some budget compromise gets hammered out, Medicare is about to stick it to a lot of docs.

Ever since the passage of the Balanced Budget Act of 1997, Congress has been repeatedly delaying a yearly mandated cut in Medicare's physician fees. That statutory reduction has been slowly accumulating through no fault of the physician community and is now estimated to be more than 27%. Assuming most physicians' practices are made up by a majority of Medicare beneficiaries, that represents a huge hit to their cash flow. KHN has a good summary of the partisan mutual assured destruction that has led us to this crisis here.

The docs are not happy:

From the AMA ("shameful"):

"Congress has again failed to fulfill its responsibilities. It is shameful that patients and physicians are the collateral damage; the citizens of this country deserve better. Congress had the entire year to repeal the broken physician payment formula and provide stability for the millions of seniors...who rely on Medicare... but has failed to act. It is long past time for members of Congress to act decisively and protect access to care for seniors..."

From the American Academy of Family Physicians ("outraged"):

“The American Academy of Family Physicians is outraged that Congress failed to prevent the 27.4 percent Medicare physician pay cut mandated by current law. That failure has presented their elderly and disabled constituents a bitter holiday gift — uncertainty whether their physicians will be able to provide the services they need."

A family physician blogger ("very upset"):

"I have talked some of my colleagues and some of my patients, and all of us are very upset about this. Some of my physician friends are really thinking this time about completing the necessary paperwork to stop accepting Medicare patients. How can any business (except government) run with such uncertainty as not finding a permanent fix to the broken current Medicare system. Patients will be unable to see their physicians, resulting in delayed care, increased hospitalization, and illness."

From an email that was forwarded to the Disease Management Care Blog:

"Who can help us? 28% cut are you kidding me, some of us cannot sustain the disruption of cash flow.
I had a great home equity line on my house, but it was closed (not just frozen) because my bank just got taken over by the feds."

Observers may believe that the fallout will be limited to the small-business physician-owned practices and that the larger systems with salaried physicians will be able to carry on. That would be a mistake.

Within each large provider systems, clinical "work units" are still responsible for meeting revenue expectations which, in turn, are tied to physician salaries and non-physician support staff. A fee schedule cut courtesy of Medicare will be just as much of a problem for them too.

How will both the physician-owned and salaried practices respond? The DMCB predicts that most will conclude that seeing more Medicare patients (volume) will not make up for the reduction in fees. As has been noted by persons far wiser than the DMCB, "if you're losing 25 cents on every watermelon you sell, you can't make up for it by selling more watermelons."

As a result, both physician-owned and salaried practices will limit access by Medicare patients. Most will probably continue to see their active and established Medicare patients, but they will functionally "deactivate" their other Medicare patients and decline to take on new ones. They'll then "backfill" those open appointment slots with patients who have better insurance. Here's how it's done.

The DMCB will close with three additional thoughts:

1. If rates go down by 27%, there may be increased merit to the notion of "balance billing."

2. "Concierge practices," thanks to this stand-off, just got a lot more attractive to thousands of physicians.

3. Now would be an opportune time for the population health management community to close ranks and communicate with their legislators on behalf of their physician partners.

HHS Blinks On The Affordable Care Act's Essential Health Benefit

2011-12-20T21:14:00.000-05:00

Remember that Affordable Care Act (ACA) "essential health benefit (EHB)?"

While Disease Management Care Blog doesn't want to be reminded about it either, the topic bubbled into the health policy news cycle thanks to this sleeper bulletin recently released by HHS. Recall, despite the ACA requiring an approach based on a "typical" insurance plan covering ten categories of services, that the law set the stage for a requirement that every U.S. health insurer would have to potentially cover an expansive, complicated, expensive and controversial suite of services in each and every health insurance policy. Any insurance plan not meeting the EHB would be excluded from the exchanges.

While the DMCB feared the unable-to-say-no amateurs in HHS would stumble their way into an unaffordable and one-size-fits-all package, it appears they've blinked. That's because they've discovered that the ACA misread things: while insurance policies typically cover a core set of services, they vary in coverage of other services. That includes dental care, acupuncture, bariatirc surgery, hearing aids, tobacco cessation, in-vitro fertilization, certain autism services, a variety of mental health and substance use disorders and habilitative (yes, that was a new one for the DMCB too) services.

How does HHS intend to reconcile this?

"We intend to propose that EHB be defined by a benchmark plan selected by each State."

Whoa.

In other words, there would be 50 EHBs. As the DMCB understands it, each would be calculated using an intra-state combination of the largest small group plan, any of the largest thee state employee plans, any of the large three national FEHBP plans and the largest commercial plan. If a state doesn't calculate the benefit, the Feds intend to use the one used by the largest small group insurance plan. If the calculation doesn't include sufficient coverage in all the ten categories, the ultimate default is using whatever is in the state's largest FEHBP plan.

Business groups and state leadership will probably find the local state-based approach a more palatable alternative, while some professional (for example) and patient advocacy (for example) may be disappointed.

The Wyden-Ryan Plan: Medicare Advantage Ver. 2.0 With Vouchers and Competitive Bidding

2011-12-19T21:17:00.001-05:00

Simultaneous conservative praise and liberal support for something called the "Wyden-Ryan Plan" prompted the inquisitive Disease Management Care Blog to look up the document.

Could this be **THE** template for a grand bipartisan compromise reform of Medicare? Thanks to this consolidated DMCB summary, readers will not only get to ponder that question, but contrast their health market and business acumen with non-DMCB coworkers and colleagues with self-serving and career-advancing questions like:

"So Barry, do you foresee any business opportunities related to the annual risk review audit envisioned in the Wyden Ryan plan?"

Without further ado, here are the facts:

Persons who are currently age 55, i.e. become Medicare eligible on or after January 2, 2022, can choose to be enrolled in either

1) traditional Medicare "as we know it" or,

2) a competing commercial plan with "premium support" funding provided by Medicare. This option includes either old fashioned Medicare Advantage or a fee-for-service plan. Either would be required to provide a benefit package that is "actuarially equivalent" to standard Medicare.

Beneficiaries are given a voucher to pay for Medicare advantage or the fee-for-service plan.

What is the value of the voucher? It depends on a competitive bidding process. Competing commercial plans would have to submit premium bids to CMS. For any service area, the second lowest bid would serve as the local benchmark. If a beneficiary chooses that plan, they would be given a voucher that pays the bid i.e. the full cost of the insurance. Beneficiaries are free to chose other plans that submitted a losing bid, but the beneficiaries pay the difference. If a beneficiary chooses that plan with the lowest bid, Medicare will rebate the difference.

If the beneficiary is older or sicker than average, the amount in voucher will be "risk-adjusted" upward. Lower risk beneficiaries would have their voucher adjusted downward. This is designed to compensate insurance plans for the increased risk of enrolling sicker patients. Participating plans would be required to accept anyone who applies for coverage. That means there would be no underwriting, i.e., no cherry picking i.e. there would be guaranteed issue.

Once enrollment is complete, plans would be subjected to an "annual risk review audit." Those with an excess of low risk enrollees would pay a fee to make up for a more profitable book of business, while those with an excess of high risk enrollees would get a rebate.

If, despite the introduction of competition described above, Medicare's nationwide costs exceed the growth of the U.S. gross domestic product (GDP), Congress would be "required" to act with a suite of options including reducing provider payments or requiring richer seniors to pay more (i.e., means testing).

Competing plans would be listed in an exchange. They would also be closely overseen by CMS.

Beneficiaries could switch plans during an open enrollment period

Medicare's Part A and B deductibles would be combined and a cap that limits out of pocket spending.

So what is the DMCB's take:

"Medicare Advantage" and fee-for-service plans for Medicare beneficiaries are not new. What's new is the introduction of vouchers. The DMCB predicts critics will view vouchers as a political Trojan Horse ultimately intended to undo traditional Medicare.

The plan relies on competitive bidding to drive down costs. It's unclear if bidding will be the "tail" that wags the "dog" of an aging U.S. population that wants the best and a health care-technology industrial complex that wants to sell their goods at the highest price point they can justify.

Recall all those past protests from the insurance industry over the prospect of competing with a publicly funded program? The DMCB thinks this is different because they will benefit from Medicare's price controls.

Ingredients for commercial insurer voucher success will include actuarial smarts over the details of prospective risk adjustment and retroactive claw backs, neutralizing the pernicious effects of variation with high enrollment and not only making money but doing right by the beneficiaries with a higher level of service. If all they do is return value to their investors, Congress will shut 'em down.

Last but not least bloggers smarter than the DMCB have problems with the proposal and are worth a look.

The Heartbreak of Not Regularly Reading the Disease Management Care Blog

2011-12-19T12:08:00.001-05:00

Upon the death of Dear Leader Kim, North Koreans discover that state censorship under his regime had prevented them from regularly reading the Disease Management Care Blog......

The New York Times, Newt Gingrich's Sins and The Merits of Creative Destruction

2011-12-18T19:42:00.001-05:00

Where's Newt?

After watching the last Iowa Caucuses Republican Presidential debate, the Disease Management Care Blog continues to be fascinated by The Newt's repartee prowess.  Maybe it's because the starstruck DMCB has seen the former Speaker in the flesh on a number of occasions. National health policy conference organizers have known for years that the logorrheic and futuristic Newt Gingrich Big Idea Factory could be counted on to deliver the goods to any audience.

Yet, keynoting prowess is one thing, but being a contender for President an another. Now that Newt has clawed is way into a leading position in the polls, greater visibility has prompted greater scrutiny.

That's why the DMCB likes this New York Times article on Newt's unseemly mix of health advocacy and business ties. It's not pretty, portraying Newt as a cynical political opportunist who has been brazenly willing to ally himself with popular "big-government" ideas.  What's more, The Times darkly implies that consulting fees from big pharma and insurance companies caused him to promote their business interests.

So what, according to The New York Times, are Newt's five sins?

1. While every other service industry relied on information technology, Newt had little patience for a health care system system that perpetuated reliance on pen and paper. When HITECH passed, private citizen Newt had little problem taking some of the credit and collecting some fees while he was at it.

2. Newt repeatedly observed that ATMs could reconcile complex financial records and yield hard cash from any ATM in the world within seconds, yet Medicare's payment systems were inaccurate, byzantine and highly vulnerable to fraud. He called for the reform of Medicare, which later also turned out to be one of the bedrock principles of the Democrat's modernizing health reform agenda.

3. Then there's this 1995 "wither on the vine" quote in which he maps out the demise of Medicare because of reforms leading Americans to "voluntarily [going to] leave it -- voluntarily." Fast forward 15 years and Newt is supporting the Ryan-Wyden bipartisan compromise legislative proposal that is likewise based on voluntary choice and doesn't end Medicare as we know it.

4. Newt was also an ardent supporter of comparative effectiveness research (CER) Newt specifically cited not-for-profit Cochrane as an example of the kind of CER he supported. He doesn't like this $1.1 billion boondoggle.

5. As for funding from insurers and pharma, Newt's ideas on enhanced coverage of children and diabetes care attracted like-minded companies and allies.

"Big deal," says the yawning DMCB. The Time's concerns about Newt's past lack substantive ballast. If nothing else, Newt's pugilistic skills will make Mitt Romney a stronger contender - assuming he makes it to the championship round .

While the DMCB is at it, it can't help but take a quick look at two other arenas of alleged Newty nuttiness:

1) That infamous criticism about his fellow conservatives' dangerous "social engineering" in the Ryan Ver. 1.0 plan:

The DMCB thinks Newt personally liked the plan but disliked the prospect of having it pass over the objections of a leery electorate. It's one thing to dream up a good plan, but it's another to craft it behind closed doors and impose it on an unwilling citizenry.

By the way, that some logic seemed to underlie his recent debate commentary over abolishing "activist" federal courts.  He's warning that in a divided powers representative democracy, the co-equal legislative and executive branches and grumpy voters could be pushed into neutralizing flashpoint judges at either end of the political spectrum with recalls, subpoenas, impeachment and defunding. He's not only consistent, he has a point. (A 12/22 addendum - A point which Newt is provocatively willing to to back up with U.S. Marshals. Of course, he could just sandbang them during State of the Union Addresses. What's next: pieing?)

2)  Being too incendiary, zany and mercurial to be President

This was best portrayed by Peggy Noonan's December 10 Wall Street Journal "Declarations" description of Newt as a human "hand grenade" who delights in being to ready "watch this!" pull the pin at a moment's notice.

Good point, but there is also something stubbornly dysfunctional in many parts of the health care system.  If Obamacare doesn't work out as planned, there may be merit to the notion rejecting the Republican mainstream and applying a heavy dose of creative destruction. Newt certainly has the "creative" and "destruction" chops. Absent anyone else with this particular skill set, Newt's biggest problem may be that we're just not ready for him to combine them... yet.

Newt's problem is that he's still far ahead of the curve.

Let the games continue.

The 12 Population Health and Care Coordination Colloquium

2011-12-16T09:50:00.001-05:00

Mark your calendars for Philadelphia Feb 27-29, 2012!

This premier educational event is a must for anyone interested in population health and care management. More information on attending virtually or in person can be found here.

What Do You Know: Quality Doesn't Automatically Translate Into Savings

2011-12-15T19:56:00.001-05:00

Goin' goin' gone!

The Disease Management Care Blog recalls years ago when it was walking with some residents and students through a decommissioned wing of a hospital as a short-cut between patient floors. Our footsteps echoed off the dreary beige tile while we chatted up the likelihood that we could get the next patient home this afternoon. Then the DMCB paused and took in the eerie fluorescent silence. "What you see around you," it mused, "is some valuable and unused capital." The team then resumed the pace. That's when the DMCB looked at the young docs and said "If we keep it up, they'll need to close another wing!"

The fly in the ointment. The monkey in the wrench. The doc's raised hand at a hospital board of trustees' meeting. Call it what you like, but sometimes our most cherished assumptions and best laid plans have a way of going all akimbo. True to that tradition, curmudgeonly Dartmouth authors Stephen Rauh, Eric Wadsworth, William Weeks and James Weinstein examine the "illusion" of expecting "lower costs" to come out the back end of a health system system after "quality" is put in the front end.

The authors' real focus is on hospitals and define "quality" as any intervention that reduces the utilization of health care services (versus other definitions). Despite the narrow view, the Disease Management Care Blog believes the article makes an important and yet obvious point: large and small health care organizations have rigid cost structures that cannot be flexed. As a result, any increase in quality - such as reducing length of stay, admissions, readmissions or surgeries - mostly results in additional dead space capacity, not bottom line savings.

Clinical improvement can reduce costs is in the general category of supplies and medications. Unfortunately, those costs are at the margins. Just because there are fewer readmissions won't mean all those expensive operating rooms. equipment, personnel costs and other administrative overhead will simply go away. They don't. They'll be idle and cost just as much.

Some economists will argue that hospitals can take beds off line and furlough nurses. It's also been pointed out that multiple health systems can regionally consolidate high-cost low-frequency services.
Unfortunately, the quarter to quarter business cycle facing the typical hospital administrator doesn't really accommodate that kind of wishful thinking. The only way out is to find other revenue by either charging more or providing other services.

Despite many valiant attempts, the DMCB never managed to close another hospital wing.

The Latest Cavalcade of Risk is Up!

2011-12-15T10:23:00.000-05:00

The New Zealand domiciled Chatswood Blog is hosting the latest Cavalcade of Risk, with what writer Russell Hutchinson describes as "an eclectic and interesting collection of thoughts and comments" on a host of business risk issues. Since the Disease Management Care Blog is in there, it couldn't have said it better itself.

Enjoy!

Weighing In On The Population-Based Lessons from The Biggest Loser

2011-12-14T22:04:00.000-05:00

But for being born centuries
too early, another potential
TBL contestant!

Despite vowing to never let it happen again, the Disease Management Care Blog was ensnared, along with over 7 million viewers, into watching much of last night's NBC's The Biggest Loser finale. While the participants' physical transformations were truly astonishing, it found the lachrymose blubbering, manufactured suspense, emotional vulnerability and emphasis on exercise over diet so awful, it couldn't look away. The icing on this cupcake was $100K winner Jennifer's spooky mydriatic gazing "bedroom eyes." 'Nuff said about that.

The good news is that this media mugging didn't stop the DMCB from extracting three weighty insights. To wit:

Focusing massive amounts of personalized counseling for persons who are simultaneously at high risk and exhibiting willingness to change is certainly part of the answer to managing the population-based dimensions of obesity. Alas, while that makes for good pseudodrama, the DMCB worries that the show is promoting a belief that all the obese really need is some gumption and a personal trainer. The science says otherwise.

In thinking about the distribution of obesity among normal adults (a graph is here), The Biggest Loser is intensely case managing a small number of persons at the farthest right side of the curve. Case management has a role, but the complete answer includes overlapping strategies that move the entire weight curve to the left with less sensational but proven evidence-based interventions. They include promotion of smart food choices, portion sizes, breastfeeding, school physical education, recreational spaces, walking as well as countering excess television viewing and the food industry's pernicious marketing. That'll take blocking and tackling by schools, employers and local governments.

The overly perceptive DMCB also thought it detected the outlines of girdles under some of the contestants' spandex. Because human skin can stretch to accommodate increasing body volume, the loss of large amount of fat from under the skin can leave patients with an unsightly saggy exterior. While the web is replete with unproven cures, the only viable option is plastic surgery. The DMCB couldn't find any population-based research that sheds light on how many formerly obese persons become baggy and how many go on to need surgery, but Google "obesity" + "compression garment" and the results suggest this is a growth industry. Despite their success at slimming down, the DMCB suspects that many of These Biggest Losers may have lingering body sculpting issues to deal with.

Why Traditional Physicians Will Trump Walmart's Primary Care Service Offering

2011-12-13T21:20:00.000-05:00

A big box with plenty of
room for primary care?

Several years ago, while the Disease Management Care Blog was supervising a medical resident clinic (an example of how they work can be found here), an elderly patient came in for an appointment. According to the resident, Mr. Jones (not his real name) would unexpectedly lose consciousness while walking. He also complained of feeling shaky and unsteady on his feet. Prior to entering the clinic room to see Mr. Jones, the DMCB already suspected the patient had Shy-Drager Syndrome. One look at the his staring and unblinking face confirmed it, all in the space of about five seconds.

Which is why the physician DMCB confidently thinks its profession ultimately has little to fear from Walmart's apparent interest in establishing a national network of primary care clinics in its big box stores.

Careful scrutiny of the Walmart Request For Information (RFI) reveals that potential partner companies are welcome to showcase their health care "solutions," "applications" and "offerings" that are "convenient, accessible, affordable, consistent, scalable and integrated." Walmart wants these companies to leverage its retail and multi-channel clout to to reduce costs and increase access while maintaining or improving outcomes in clinical care, diagnostic services, prevention and wellness. Care services can include a host of general medical services, management of chronic as well as acute conditions, laboratory testing and "other." Ownership, financial arrangements, data sharing, integration, technology, logistics, back office functions and the level of customization are negotiable. To be taken seriously by Walmart, candidate companies need to have a track record of success at a national level, a credible leadership team, a business plan, timeline, access to secondary partners as necessary and familiarity with quality assurance. There is an notable absence of any reference to the "medical home."

While the similarity of "Big Box medicine" to retail clinics could be criticized at many levels, the DMCB has heard two two major concerns from its colleagues about Walmart:

1) Walmart and the like will further "Balkanize" the system, leading to more, not less, fragmentation and

2) it will commoditize health care, leading to narrow and regimented treatment protocols that don't take the "big picture" into account.

The DMCB disagrees with the first assertion because Walmart's RFI seems to envision a highly integrated system backed up by informatics, connectivity and quality metrics that - on paper - should lead to more coordination not less. That's good.

Yet, the DMCB thinks that there may be something to the second assertion. It is Walmart's style to relentlessly attack costs at every part of its service cycle and the company probably believes the strategy can be applied to health care. If that's Walmart's intention, it'll almost certainly choose a vendor that industrializes guidelines like this in a one size-fits all "protocolized" fashion all the time every time.

That's not necessarily bad, but that means there'll be little room for the kind of smart heuristics that helped the DMCB get to a quick diagnosis. The DMCB doesn't deny being "smart," but the the point is that the best primary care intelligently combines guidelines and heuristics. The DMCB's physician colleagues have that special skill. Thanks to competition from Walmart (and retail clinics), they'll hone that expertise and respond with a higher, more efficient and better quality standard of care for many patients for a long time to come.

Image from Wikipedia

Three Insights About Hospital-Physician-Insurer-Employer Health Care Market

2011-12-12T21:06:00.001-05:00

Check out the three page article on "U.S. Health Care's Future" in the Marketplace section of the December 12 Wall Street Journal. Using personal stories of a doc, hospital CEO, insurance executive, human resources manager and a patient, the news piece portrays the blurring business lines between insurers, buyers and providers. Mainstream readers of the Journal are likely to think the topic is both timely and novel.  Regular readers of the Disease Management Care Blog learned about his months ago.

Who are these five canaries in the health care coal mine, these bellwethers of the insurance business, these oracles of management and what are they telling us?

1. Dr. McCullough, a salaried physician with 28% of his income contingent on quality and satisfaction. Some measures were imposed by the local Blues plan, which was passed through to the him by his employer.

Message: Purchaser and buyer control of physician reimbursement is already big and it's growing.

2. Jim Taylor, a hospital CEO who cannot buy an electronic record system unless he merges with two other hospital systems. If the merger is approved, the hospital will also be able to take on "warranty-style" payments from insurers.

Message: "Bigger is better" for capital-constrained hospitals.

3. Chris Day, an Aetna executive who got an Arizona health system to share insurance risk. The main sticking point was the two-way mutual sharing of internal cost and contracting data.

Message: If insurers are willing to share internal pricing data, they must really mean it and think it's an important success factor.

4.Robert Jacobs, the HR person, who linked about $10 per week of employee's health insurance premiums to healthy behaviors (like tobacco) and quality test results (like blood cholesterol levels).

Message:  "Don't just stand there," say the employers, "do something."

5. Louis Kandor, an 86 year old man with advanced diabetes, who is being visited by a nurse who, in turn, is employed by a care management service provider under contract by his Medicare Advantage insurer.

Message: One key to mitigating risk for every insurer (except fee-for-service Medicare) is to use nurse-led care management.

While the Journal article doesn't spell it out, the DMCB believes the anecdotes can be distilled down into three useful insights:

1. Stakeholders are scrambling to demonstrate measurable outcomes to an increasingly educated and skeptical public. That's the basis for physician pay-for-performance and premium surcharges.

2) Sharing proprietary insurance data is important.  Is information the secret ingredient that was lacking during the similar - and mostly unsuccessful - insurer-provider collaborations back in the 1990s? We'll see.

3) For those hospitals that cannot or will not take risk, the next best answer is to merge. That will mean economies of scale, access to capital and negotiating leverage.

ACOs are an Unwelcome Bump On the Road to Inevitable Regulation of Health Care? A Former Presidential Candidate Says So

2011-12-11T22:15:00.000-05:00

Want to better understand the perpetual anguish of a chronic illness?  Well, thanks to online streaming from the Harvard School of Public Health, readers can better appreciate the eerie similarities between hyperprogressive liberalism and incurable diseases like elevated blood sugars. Both can go on for decades, are irreversible, cost a lot of money and are ultimately caused by inappropriate choices.  The Disease Management Care Blog is, of course, writing about this hour long video of former Massachusetts Governor and former Democratic Presidential candidate Michael Dukakis.

Sadly for health reform Obamaists, the supremely competent and confident Mr. Dukakis trashes the concept of accountable care organizations at about the minute 35 mark, dismissing it as a reincarnation of 1990's style HMOs and capitation.  And he doesn't stop there. The additional problem, he says, is that we'll waste ten years analyzing what he foresees will be a foregone conclusion: ACOs are destined to fail.

What's more, since health care markets are such a dismal option, he concludes the only choice that's left is price-setting "regulation."  Assume State Insurance Departments have power over hospitals, call everyone into a room, assume they're decent people, appeal to their economic self interest and everyone will be happy.

Yet, once the DMCB got over Mr. Dukakis' "legend in his own mind" persona, it believed the former Governor has a good point: if ACOs fail, we'll be left with two choices:

1) a governing class who is ready to step in with enlightened top-down governance or

2) a reintroduction of market forces that seeks bottom up competition and consumerism.

In the interest of fairness, if readers want to see a counter-argument in favor of markets, check out this one-sided nine minute Cato Institute video that teaches us we've haven't really had a health care market for decades.

Alternatively, if you're in the mood for neither of the above videos, perhaps your time would be better spent on viewing something that offers far more than either of the options above.

You Go Bizzle!

Image from Wikipedia

Scenario Planning in a Post-ACO and Post-ACA World for the Care and Population Health Management Industry

2011-12-08T20:32:00.000-05:00

....and suppose there are 55
Republican Senators?

In a prior post, the Disease Management Care Blog provocatively suggested that providers, hospital boards and policymakers should hedge their bets and prepare for the possibility of a "post-ACO world." If the Group Practice Demo's disappointing results are any guide, the likelihood of a happy ending for accountable care organizations is on numerical par with Congress' approval rating. While the DMCB likes the mutual "win-win" theoretical construct that underlies ACO gain sharing, it also recalls a life-lesson from the DMCB spouse: want you want and what you get are usually two different things.

So, if the Feds have to eventually retreat on the non-success of ACOs, what will be left in its wake? More on that in future posts.

And while the uncertainty surrounding ACOs isn't bad enough, the DMCB has also been astonished by the battered Euro, the appearance of hospital-employed cardiologists and the absence of a Lady Gaga Christmas album. Accordingly, the DMCB has learned its lesson and assumes nothing.

That's why it's only natural that it would pay attention to this short and useful New England Journal Perspective article on the 2012 U.S. elections. Author David Blumenthal portrays the "consequences" as potentially "huge." The DMCB agrees.

Three potential scenarios warrant health care leaders keeping their options open:

1. Obama wins, the House retains a Republican majority and the Senate retains a Democratic majority: Even if the individual "mandate" is struck down by the U.S. Supreme Court, the President will continue to implement the ACA's expansion of Medicaid, state exchanges, insurance subsidies and employer penalties. House Republicans will continue their "defunding" attacks and may even draw some blood over the Innovation Center and comparative effectiveness research.

This makes the DMCB believe that more insured persons will increase the demand for population health and care management services. However, if your program is dependent on grants, watch out because the money is going to dry up - even if you have good outcomes.

2. Obama wins, but both the House and Senate have Republican majorities: The Republicans will reduce funding, hollowing out the ACA's ability to expand Medicaid coverage or support insurance subsidies. Mr Obama may have to compromise on enforcement of exchanges and employer penalties. In the end, however, Presidential vetoes mean the ACA will not unravel, only slow down.

In other words, says the DMCB, because the number of persons entering the insurance market will be blunted, all those expansive population health business plans will need to be scaled back. Relentless increases in health care costs among persons with insurance will spur interest in innovative care management programs that can do it better and cheaper.

3. The Republicans win a trifecta, taking the House, Senate and Presidency: Absent a 60 vote majority that can overcome Democratic filibusters, the Republicans will rely on the reconciliation process and the power of the purse to undo many of the ACA's provisions. There'll be some modest programs involving bundling, care coordination and primary care, but the United States' "post-ACO" world will be eerily similar to the "pre-ACA" one.

To the DMCB, that means there is little hope that fee-for-service Medicare or Medicaid will cover care management. As more persons become uninsured, population health companies will not only need to do it better and cheaper, success will depend on making more money off of fewer persons. The only way out will be game-changing "killer" innovations.

The DMCB also offers up its own three scenarios:

1. Progressives, having the upper hand, will overreach and pronounce debate over the government's role in health care as over. If cost-saving innovations flounder, the federal deficit grows and costs continue to gobble up more of the nation's GDP, the Dems will raise the option of a public payer. Come to think of it, the DMCB suspects they'll bring it up anyway. Bloggers everywhere will be in hog heaven.

2. Progressives everywhere will pronounce any electoral loss as further evidence of their failure to properly educate a preoccupied and non-expert electorate on why they should let Washington run things. Conservatives will overreach and pronounce the debate over the government's role in health care as over. They'll openly conspire to repeal Medicare. Bloggers everywhere will be in hog heaven.

3. Conservatives, having the upper hand, will overreach and will assume Medicare beneficiaries want vouchers. Smarter Republicans will have little appetite to repeat Mr. Obama's mistake of spending precious political capital on health care versus something far more important, like school prayer. And... bloggers everywhere will be in hog heaven.

Free Drugs For Heart Attack Patients: The Analysis Behind the Analysis of the MI-FREEE Trial

2011-12-07T22:11:00.003-05:00

Assuming drugs are not free, should all patients in an insurance plan that covers medications get the same coverage at the same price?

While that may seem to be a no-brainer, there's plenty of research (for example) that demonstrates that out-of-pocket costs can reduce persons' willingness to take their pills as prescribed. While that may be the price of doing business, why not give persons who really need a particular life-saving medication a price break? While that may seem unfair, suppose everyone in the risk pool benefits from lower health care costs?

Enter the Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial.

Too long to read at one sitting you say? The Disease Management Care Blog at your service!

The study involved Aetna beneficiaries who had just been discharged from a hospital following a heart attack. While the trial was randomized and prospective, the randomization occurred at the level of the insurance plan. Various employer, union, local government or other association groups (and their patients) were randomized to one of two arms:

1) an intervention group where patients had no out of pocket cost sharing or co-pays for brands or generics in four classes of drugs that have been shown (go to page e227) to reduce the risk of death after a heart attack: 1) statins, 2) beta blockers, 3) ACE inhibitors and 4) ARBs, or

2) the usual co-pay for statins, beta blockers, ACEs and ARBs.

2845 persons were placed in the "no-cost" arm of the study and 3010 were in the "usual cost" arm of the study. The mean age was 53 years and 75% were men. About 34% and 27% of both groups had diabetes and heart failure, respectively. Over time, the percent of persons that were fully compliant with their medications became different: 31% in the usual cost vs. 41% in the no-cost group. The median duration of follow-up was 394 days.

And what happened? When the number of first-time fatal and nonfatal cardiovascular events were grouped in and counted with heart surgeries (that included angioplasties, stenting or open bypass), there was no statistical difference between the two study arms: 18.8 events per 100 person-years "usual cost" vs. 17.6 per 100 person-years in the "no-cost" group. There was no difference in the cardiovascular death rate either: 2.0 vs. 1.7 deaths per 100 person years.

However, there was some good news. The combined endpoint similarity was largely driven by a high equal number of heart procedures in both groups (which seemed to involve more than 10% of the entire study cohort). If the surgery patients are backed out, there were fewer first time fatal or non-fatal vascular events and strokes in the "no-cost" group.

There is even more good news. Some patients had more than one event (a patient could have a heart attack, a stroke and then open heart surgery, for example). When the total number of events was added up, there was a difference and it was statistically significant: 329 per 100 person-years in the "no-cost" group vs. 406 per 100 person years in the "usual cost" (p=.03).

Did the insurers save any money? Yes and no. Average total spending in the "no-cost" group tallied up to $18,254, while the "usual cost" group averaged $20,238. While that's a $2000 difference per patient, it failed to achieve statistical significance. However, when the DMCB multiplies those savings by the number of persons in the no-cost treatment arm, it calculates $5,690,000 in total savings. That sure sounds financially significant.

DMCB criticisms:

1. Heart procedures - which may be prone to factors other than clinical need - may have diluted the results in this trial, especially if a significant proportion of them were not evidence-based.

2. The secondary prevention benefit of drugs for heart attack patients extends beyond 394 days. If this study had gone longer, the difference may have expanded over time and achieved statistical significance.

3. While a cost difference of $2000 did not reach statistical significance, that may have been because insurance claims follow a non-Gaussian distribution, making their analysis very tricky. In addition, the DMCB thinks that a real world savings potentially exceeding $5 million is very noteworthy.

DMCB questions:

1. It'd be nice to know if patients with a higher burden of disease (for example heart failure or diabetes) and therefore more vulnerable benefited more than persons with less disease burden. If so, would it make sense to limit the "no-cost" option to heart attack patients at the highest level of risk?

2. There is no information on the level of out-of-pocket costs in the usual-pay group. As co-pays increase, medication adherence goes down. We don't know if Aetna's pharmacy benefit is typical of the rest of the market.

DMCB insights:

1. The possibility of $5 million (or more if compliance can be increased beyond 41%) in savings may make paying patients to take their pills seem reasonable. Silly you say? Think again.

2. Since $5 million in cost reductions that can result from just a 10% swing in medication compliance, readers should gain a better appreciation on the stakes behind disease management. If nurses can talk patients into taking their pills, the downstream savings can be potentially huge. And why stop there, why not combine no out-of-pocket costs with disease management?

Summary:

While the authors dutifully report that the primary outcome of the study (the number of first non-fatal or fatal heart attacks or some type of heart procedure) was the same in both groups, the DMCB remains impressed that free drugs for heart attack patients may be worth it and that Oncle Karl may have been right and that the University of Michigan VBID folks are on to something. That's because the total number of events achieved statistical significance and there were some specifics that may have blunted the study's ability to get at the other outcomes.

Image from Wikipedia

Retrospective Vs. Prospective Identification of "Wasteful" Medical Care

2011-12-06T23:40:00.000-05:00

Pneumonia....uh oh!

Thanks to its prior posts, the Disease Management Care Blog has established its Donald Berwick Fan Club bona fides. However, it disagrees that Dr. Berwick is a slam dunk hero, martyr or role model. While Dr. Berwick has some strengths, the DMCB has had some fundamental disagreements with the former CMS Administrator.

The DMCB explains one of them.

It recalls a very elderly patient (let's call her Mary) who was desperately ill with a bad infection. Before coming in the hospital, Mary was mildly confused, had multiple chronic conditions and rarely left her apartment. The DMCB thought she was a goner, but thanks to prompt, evidence-based and very expensive therapy, Mary not only avoided the ICU but eventually walked out of the hospital. Mary is important because her admission to the DMCB's hospital service was bracketed by similar patients (let's call them Bob and Alice) who were not so lucky.

Given the prevailing metrics of our evidence-based age, Bob and Alice would be considered to have received wasteful care, while Mary would be considered a success. The problem for the DMCB is that that definition of waste can only be made in retrospect. When it was standing outside Mary's, Bob's and Alice's hospital rooms, it didn't know who was going to survive.

Consider the "crumbling sand pile" thought experiment made famous by Nassim Taleb's The Black Swan. While it's very possible to predict the general size and shape of a pile made by the one-at-a-time addition of sand grains, it's impossible to predict when it will reach a critical mass and where or how big the avalanche will appear. However, once it happens, it is possible to look backward and reconstruct the event.

And so it was with the DMCB's three patients. Survival for many conditions such as infections near the end of life is surprisingly random and unpredictable. Retrospective reconstruction of events (even with an autopsy) isn't of much use for the next patient, even if the hospital is littered with "avalanches" that can be categorized as wasteful failures.

Which is why the DMCB wished Dr. Berwick had long ago stopped repeating the simplistic 30% waste canard, especially when he is smart enough to grasp the shortcomings of retrospectively measuring waste. While there are plenty of opportunities to reduce costs and increase quality, too much of the science is based on flawed and backwards logic. Go into any hospital on any given day and doctors will ask this about their care for their patients:

Which ones won't benefit and which ones will?

Image from Wikipedia

Building A Care Management Program

2011-12-05T19:13:00.000-05:00

Care management planning

Hot off the heels of this cinematic debut on how NOT to conduct care management comes this handy Alliance of Community Health Plans 29 page handbook review on how to do it right. Some of the experienced members of the Alliance shared insights on successful population health approaches, data on the "return on investment" and how to deal with the physicians.

But, say the Hardball-inspired Disease Management Care Blog readers, "tell us something we don't already know."

The DMCB found three useful nuggets of information:

1. There is no firm rule on the operational balance between central administration and peripheral distribution. Some of the Plans hire and oversee the care management nurses while others pay their network primary care sites to hire their own nurses. If the practices employ the nurses, they are free to let the managers see patients on an all-payer basis.

2. Care management caseloads vary from 35 to 150 persons and the enrollee to nurse ratio ranges from one full time nurse to 5000 to 14,000 commercial members. If less than 5000 Plan members are assigned to a primary care site, care managers split their time among multiple sites. As Plan members are further diluted or distributed through a network, there is greater reliance on remote telephonic communication and coaching.

3. Reduced costs? Group Health, Fallon and Security Health plan say they saved over $2.5 million, $2.3 million, and $1 million, respectively. Tufts Health Plan says they saved $1.90 for every dollar spent.

Other points known but worth repeating:

Features of successful care management include appropriate patient selection, person-to-person outreach, credentialed professionals, teaming, coaching on self-management, family involvement and access to community-based programs.

Embedding care managers in the primary care sites is worthwhile not only because face-to-face patient care has more of an impact, but because the physicians will benefit from the consultations, participation in "huddles" and discussion of the treatment plans. That also leads to a greater level of trust between the docs and the nurses.

There's better buy-in if the care managers are viewed by enrollees as an extension of the physicians, not the sponsoring insurers.

Technology is important: effective care managers are made more effective by electronic records, telemonitoring, decision support, work-flow aids and video/mobile communication.

The backbone of care management is made up of generalist nurses who are simultaneously comfortable with multiple conditions such as, for example COPD, mental illness and diabetes. That being said, there is a role for focused nurse support for patients with special needs, such as hospice, transplant or bariatric surgery.

An abundance of data support is only the beginning because the reports will need to be tailored to the physicians' clinical needs and communication preferences. They also have to be paired with regular meetings that promote best practices and solicit feedback.

When care management is first rolled out, physicians will first suspect this is another managed care ruse, assume it's a fast track to prior authorization or try to "downjob" clinical duties to the nurses that are outside of their scope of practice. It will take many months and much collaboration to sort out turf issues, control, office space, and offering care management to some but not all patients.

What Can Martial Arts Teach Us About the Health Reform Debate

2011-12-04T20:55:00.002-05:00

Despite years of training, the weakling Disease Management Care Blog was never able to prevail in martial arts tournament sparring. While it might score some points in the early rounds, coming up against a six foot plus 220 lb guy with a kick able to reach Toronto was usually an exercise in Tae Kwon Do humility.

Despite the certainty of defeat, how would the DMCB deal with such superior adversaries?

One survival technique was to to reduce its profile by standing obliquely sideways. Both arms were kept up with fists poised on either side of the face and with both elbows on either side of the abdomen. Since tournament points could only be scored from the waist up, the DMCB found it could block most strikes with minimum arm movement of just a few inches. Then the DMCB simply waited for Toronto to attack. Assuming the block was successful, the DMCB would then quickly and sneakily move in while the opponent was pulling back its punch or kick. That's when he was most vulnerable.

This technique of blocking and then striking on the rebound is not only on ample display in televised cage fighting, but in the sparring over health reform. Whether its modifying the ACA, reforming Medicare or fixing the SGR, the playbook is the same: simply sit tight, await your opponent's proposal and then strike back immediately with a mix of rhetoric, partisanship and invective.

Unfortunately for our Republic, martial arts also teaches us that while that approach may in aid in the short-term survival of weaklings, it's ultimately not a strategy for winners. The DMCB never got a trophy by hunkering down, and that sparring technique will not create the kinds of thoughtful solutions that can overcome Medicare's cost spiral or the Affordable Care Act's shortcomings.

What wins is initiative, innovation and risk-taking in an aggressive series of proactive moves. Say what you like about progressive Obamacare or the conservative Ryan Plan, their champions went on the offensive. That skill not only wins tournaments, it ultimately wins in politics.

Image from Wikipedia

Four Steps To System Improvement in Care Management

2011-12-01T20:29:00.000-05:00

The Disease Management Care Blog sympathizes with all those minimally titled and disempowered health system "directors," "managers," "VPs," and "team leaders" who look up from their trenches at the folks running things from afar in their C suites and wonder: how can my bosses be so foolish? With their one-size-fits-all management, organization-wide metrics and devotion to "accreditation," and "recognition" and "certification," they've forgotten about the patient. Something is so wrong.

If you're one of these unfortunates, you may want to send the boss a copy of this New England Journal article on the four habits of high value care organizations. While it's clear that some provider groups are star performers, policymakers are struggling to find the characteristics that separate the wheat from the chaff. Author Richard Bohmer helps out by pointing to four key characteristics that drive value. They're not what the C-suite typically wants.

Those characteristics are:

1. Specification and planning: all patient care activities are based on explicit criteria that are tailored for patient subgroups. As a result, any intake process, intervention, pathway, communication or discharge process is directly linked to predetermined criteria that are tailored to categories of need. One-size-fits-all is thrown out the window.

2. Microsystem design: staff, technology, policies and procedures are also fitted to serve the patient subpopulations. Team members have roles, supply chains are branching and information systems are tailored. While the trick is to harmonize it all, in the end everyone knows what to do depending on predetermined and very local engineering.

3. Measurement and oversight: it's all about internal process control and performance management based on the patient populations and the organization's culture. Those external accreditation metrics are important, but they're a necessary evil that has little to do with the real work at hand.

4. Self-study: this makes use of all that internal measurement to better understand any positive or negative deviation from their own established internal benchmarks. This may include conducting ad-hoc prospective research-lite protocols. In addition, understanding what the measurement is saying becomes part of the organizations' culture.

While C-suite types may be aghast over these recommendations, the DMCB has seen them work in day-to-day care management programs. It believes a good tide of risk segmentation, tailored care planning, ongoing measurement and a virtuous cycle of quality improvement will be a tide that not only improves HEDIS® scores, it will also reduce costs and improve quality.

Bravo says the DMCB. It's mentioned many of these characteristics in prior posts, but this article does a nice job of pulling it all together. Best of all, it's open access. Whether you're a small physician owned practice or a large ACO wannabe, this article deserves to be in your library.

Cinematic Clueless Care Management

2011-11-30T19:00:00.000-05:00

While it is no Steven Spielberg, the Disease Management Care Blog humbly posts this short cinematic opus that portrays how easy it is for the wheels to come off of the care management train.

"Hello it's so nice to interact with you today. My name is Nurse Vera Zealus and I'd like to help you get engaged today in the personalized ongoing management of your diabetes in the context of your medical home. Would you like to become engaged and ongoing and managing at home while I get a care management fee on your behalf....?"

At one point he asks if she's a doctor.

Enjoy!

(Link to YouTube: http://youtu.be/VayIpAuSQAI)

The Latest Cavalcade of Risk Is Up!

2011-11-30T10:16:00.000-05:00

David Williams hosts the latest Cavalcade of Risk in what he describes as fest. If you're interested in the business aspects risk, this may be worth your while!

Lessons From A Health Care Christmas Carol: The Haunting Of Three Spirits

2011-11-29T22:04:00.000-05:00

No wonder Jacob Marley is grumpy. He's not only dead thanks to complications following a minor surgical procedure, the links of his ephemeral chains binding his wandering soul were individually forged with every uptick in health care cost inflation. His ledger was without outcomes and his surplus without savings. His business should have been health and his profit prevention.

For the Disease Management Care Blog, this doomsayer is more than a blot of undigested mustard or a missed dose of an anti-psychotic. He brings a remorseful message about weak research, academic consultants and government meddling. We ignore this spectre at our peril.

Jacob tells the DMCB readers to take heed, for they will be visited by three ghosts!

First will be the evanescent Ghost of Healthcare Past. He flits in and out of sight in the policy salons with inferential, observational and conditional estimates of the past impact of unseen spirits like "PCMH," "ACO," "VBP" and "bundling." If these sips of spiked holiday punch fail to convince a coldly skeptical world, this spirit can always point to the anecdote of the Tiny Tim who, but for access to patient centeredness, wouldn’t have become such a naïve, dimwitted and crippled believer in government-run healthcare.

Then the academic and corpulent Ghost of Healthcare Present will appear. He has been feasting off the largess of a system that rewards the confidence that comes from fashioning economic cause and effect relationships out of hope, holly and mistletoe. Festooned with a crown of academic credentials and a velvet robe of plausibility, this pleasant apparition loves nothing more than to feast with spectral policymakers in the warm glow of mutual admiration, obscure modeling and publications that go unread by the living. Best of all, by being a Ghost of the Present, he can ignore the past and will never have to take responsibility for the future.

Then the fearsome and faceless Ghost of Healthcare Future will intrude. He cruelly points a crooked bony finger at an unkempt and forgotten tombstone in the cemetery of long dead medical practices, like cupping, paper charts and physicians who actually talk to patients. In the dim moonlight of fixed budgets and the bitter cold of Big Box Store health care, the inscription names “commercial private insurance” as the interred. Is this what could be, what will be or what should be?

Warfarin, Insulin, Anti-platelet Agents, and Hypoglyemic Medications in the Elderly May Warrant a Population Health Management Program to Reduce Avoidable Hospitalizations

2011-11-28T19:30:00.004-05:00

Got warfarin?

100,000.

That's how many persons aged 65 years or more are seen in U.S. emergency rooms and then hospitalized every year because of an adverse drug event.

Writing in the New England Journal, Daniel Budnitz and colleagues report data from the "National Electronic Injury Surveillance System - Cooperative Adverse Drug Event Surveillance" (NEISS-CADES) project. The Disease Management Care Blog never heard of it either, but it's a consortium of 58 typical U.S. hospitals that are participating in an ongoing observational research project. Whenever a physician blames a drug for an emergency room (ER) visit, trained chart reviewers go through the medical record. From 2007 through 2009, there were 12,666 drug-related ER visits in the NEISS-CADES hospitals, which extrapolates to over 265,000 in the U.S. More than a third required hospitalization, which rounds to approximately 100,000.

Medical Directors and quality assurance types may wonder how many hospitalizations were due to HEDIS high risk medications. The answer was very few: only 1.2%.

There is also a list of medications that meet the "Beers" criteria as being potentially inappropriate in the elderly. Likewise, very few could be blamed here: only 6.6%

So what caused the mayhem? Basically there were four bad actors that accounted for approximately two thirds of the hospitalizations: blood thinners (warfarin and antiplatelet agents) and diabetes drugs (insulin and hypoglycemic agents). What's more, the rate of hospitalization was highest among persons aged 85 years or greater and if there were five or more medications being taken. Warfarin accounted for a third, the antiplatelet drugs, insulin and hypoglycemics accounted for another third and the remainder were miscellaneous.

What should the population health management community do with this information?

1. The DMCB would advise against believing that the hospitalization rate could be driven to zero. It's well known that despite the best of care, between 1% to 2% of persons on warfarin will experience a life threatening bleed every year and, depending on how it's defined, that between 2 and 10% of persons with diabetes will experience severe low blood sugar. Until we develop better blood thinners and diabetes drugs, bleeding and low blood sugar may just be a price that has to be paid.

2. Nonetheless, there are 100,000 hospitalizations and while the authors don't speculate on how many are avoidable, the DMCB wonders if this doesn't represent an important opportunity for the population health service providers. Based on these data, regular outreach and monitoring of those persons on four types of drugs (warfarin, anti-platelet agents, insulin and hypoglycemic meds) who are taking multiple other medications and who are 85 years or greater may benefit from intense monitoring. If the hospitalization rate can be decreased, that's a whole lot of savings.

Image from Wikipedia

Will Loss Of the Individual Mandate Torpedo the Affordable Care Act?

2011-11-27T22:26:00.002-05:00

While the Disease Management Care Blog has had more than its share of doubts about the Affordable Care Act, it ultimately agreed that the "individual health insurance mandate" may be a necessary - if perilously unconstitutional - requirement. Conventional wisdom says that unless everyone buys into the system, healthy persons will forgo the expense of insurance. That means only the sick will pay for insurance that ultimately cannot cover the collective cost of their illness. That will lead to a rapidly escalating prices, otherwise known as a "death spiral."

And that's why, now that the mandate has been taken up by the Supreme Court, Obamacare's supporters fear that striking the mandate could unravel everything.

Which is why the DMCB found this "don't worry, be happy" analysis by Lewin Group's John Sheils and Randall Haught very interesting. They say Obamacare can still succeed without the mandate.

Based on complicated economic modeling using a mix of inputs, methods and assumptions, they found, in contrast to the widely quoted Congressional Budget Office's mix of inputs, methods and assumptions, that

1) many persons without health insurance would take advantage of the ACA's generous premium subsidies, and

2) an open enrollment window limited to one month a year would blunt the impact of persons "gaming" health insurance by only enrolling when they're sick.

While insurance would not be universal, the Lewin authors estimate that between 21 and 24 million Americans who were previously uninsured would become insured. While premiums could increase by 12.6%, the premium subsidies would help put the word "affordable" in the ACA.

To further buttress their argument, they point out that in 1993 New York State required its health insurers to accept all applicants regardless of health status. Despite many dire predictions, there was no spiral and no documented loss of coverage.

What can the DMCB conclude after reading this? It's easy: no one really knows what is going to happen in 2014 with or without the mandate.

It looks like there is only way to find out.

Who Is CMS Administrator Marilyn Tavenner and What Does Her Nomination Mean?

2011-11-24T19:44:00.001-05:00

Say hello to the CMS Administrator

Bowing to the implacably oppositional Republicans, President Obama's first selection for Administrator of CMS tendered his resignation and made way for second-in-command Marilyn Tavenner. What's more, instead of using a recess appointment, the White House has submitted her nomination to the U.S. Senate.

So who, asks the Disease Management Care Blog, is she?

According to this biosketch (scroll down, you'll find her), Ms. Tavenner has a 25 year hospital administrator pedigree that includes being CEO at two Virginia Hospital Corporation of America hospitals (Chippenham and Johston Willis). That part of her career culminated in her being the company's "President of Outpatient Services." As the DMCB understands it, she entered the major leagues of public service in 2006 when Democratic Governor Tim Kaine tapped her as Virginia's Secretary of Health and Human Resources. Thanks in part to her links with Mr. Kaine, she later jumped to CMS, where she became the "Principal Deputy Administrator and Chief Operating Officer." Unsurprisingly, her duties have included loyally defending the Affordable Care Act (ACA). You can see her in action here on C-SPAN.

By the way, did the DMCB mention that Ms. Tavenner is a registered nurse?

She has an Virginia Commonwealth University BSN undergraduate degree and apparently climbed the HCA ranks one patient care unit at a time. Somewhere along the line she also nabbed a Masters in Health Administration.

Four initial thoughts from the DMCB:

1. The new CMS nominee is another example of the emergence of nurses as go-to health leaders. Not only does the public trust them, they're able to bring a real-world understanding of hands-on patient care to the high falutin' mix of operations, policy, politics and finance. The good ones know how to deal with grumpy doctors and neutralize clueless administrators. That being said, the physician DMCB can't help it and still wishes there was a doc at CMS' helm.

2. In its long career, DMCB has witnessed the Dark Side Transformation of many well-meaning physician or nurse administrators to a type that places profits over patients. What's more, few have become hospital CEOs without making some enemies along the way. Will any past foes come forward with unpleasant anecdotes from an otherwise forgotten past? Stay tuned.

3. Despite lots of searching, the DMCB couldn't find much of a track record outside some speaking gigs and serving on some boards. As far as it can tell, she has no peer-reviewed publications and her public statements have been pretty vanilla. While that may impair Mr. Obama's foes' ability to attack Ms. Tavenner's record, the DMCB wants to know more about someone who is going to be leading the world's largest health insurer.

4. The absence of a track record doesn't mean that the nomination process isn't an opportunity for politically motivated mischief. It remains to be seen how well Ms. Tavenner testimony holds up to the Republicans' intense "gotcha" scrutiny and whether her nomination ultimately becomes a toxic partisan (re)hearing on the merits of the ACA.

The Playbook For Medical Innovation Success (and a great example)

2011-11-22T21:31:00.000-05:00

Along with co-authors Robert Epstein, Jean-Pierre Lehner and Tehseen Salimi, the unrelenting Disease Management Care Blog has penned yet another peer-reviewed article (on page 9 here), this time in the newly established Journal of Comparative Effectiveness Research. While the title "Integrating Scientific and Real-World Evidence Within and Beyond the Drug Development Process" speaks to the development of pharmaceuticals, the DMCB humbly submits that the article's lessons can be applied to any medical innovation. That includes not only medical devices but population-based disease and care management, the Patient Centered Medical Home, value-based purchasing, ACOs and bundled payments.

The DMCB argues that in order for medical innovations to succeed, there has to be a readily identifiable value proposition. The challenge for innovators is that this perception of "value" varies greatly between patients, physicians, payers and government. Meeting the expectations of these disparate stakeholders means creating a three phase process of integrating clinical data, economic information, patient centered outcomes, population-based and observational real-world evidence obtained from networks, communities, countries and populations:

1) The Definition Phase: understand unmet needs and catalog how any potential benefits will meet those needs.

2) The Generation Phase: formulate and validate the benefits by collecting the information that spans population health science, clinical epidemiology, economic modeling, patient reported outcomes, econometric studies, clinical trials and observational data bases.

3) The Translation Phase: establish the benefits from the very outset of any implementation through continuous monitoring and updating of any and all outcomes data for an increasingly sophisticated marketplace.

What ingredients are necessary to sustain the three phases?

1) Informatics that aggregate qualitative and quantitative analyses that include not only all that traditional research but spans meta-analyses, public databases, insurance networks and social networks that integrate patient, provider and payer insights. This has to evolve in tandem with shifting market conditions;

2) An on-line and highly accessible intelligence repository that functions simultaneously as a database, library and registry;

3) A dossier that catalogs all quantitative and qualitative assessments that build the clinical and economic case for coverage and reimbursement;

4) High performing and interdependent expert teams that can interact with multiple stakeholders.

The DMCB thinks that the success of the Patient Centered Primary Care Collaborative can be credited to following this playbook. Click around its web site and it's patently obvious that this coalition has worked to align the vision of transformed primary care with society's unmet needs, have prospectively collected any and all study outcomes and are continuously monitoring its impact in the real world. Their PCPCC web site is a target rich collection of informatics, databases, dossiers and teams.

Super Committee To Physicians: Go Texan or Go Dishwasher

2011-11-21T19:51:00.000-05:00

Room for one more!

Once again, the Disease Management Care Blog got it right: the prognosis for the Congressional 12-person Super Committee was only slightly better than the likelihood that the DMCB was a Justin Bieber love-child. How could the Committee ever succeed with the 13th Man being elsewhere overseas, while Dr. Krugman on the left and the WSJ's editorialists on the right were both agreeing that any deal would be Satan's spawn?

But if budget cutting is a good thing, why are the equity markets down? In addition to the lingering threat of an eventual Moody's downgrade, the DMCB suspects stock holders a) have calculated a $1.2 trillion budget cut was never really up to the task*, and b) fear that the 2012 Congress won't stick to its guns.

So, asks the DMCB, what's next?

Automatic cuts will be applied to discretionary federal spending as well as the defense budget. While Medicaid is spared (much to the relief of our nation's governors), Medicare is facing a 2% sequestration which, because premiums and cost sharing will go untouched, translates into payment cuts for hospitals, doctors and other providers. An additionally toxic wild card is a looming additional "SGR" 27.4% Medicare physician fee schedule cut.

How will the DMCB's physician colleagues react to this dysfunction?

Not well:

1) for those in physician owned practices, it may come down to deciding whether or not to go ~~postal~~ Texan.

2) for those in salaried positions, they can look forward to their Administrators turning to the "dishwasher" approach of maximizing patient throughput-dependent revenue: there's always room for a few more. And if docs expect Uncle Sam to have any sympathy, they need to think again.

Let the games continue.

(HT to George Will)

Technocrats Running Amok: What It Could Mean For America Inc.

2011-11-20T20:00:00.000-05:00

Check out The New York Times columnist David Brook's most recent article for an insightful look at how the Europeans entrusted their collective economic future to an expert technocratic class. Once those mandarins were unleashed, their bureaucratic disdain for undereducated commoners was only exceeded by their skill at complex obfuscation. Egads.

On the other side of the globe, China's state-managed businesses are making a mess of high speed rail, creating a housing bubble and are enabling an autonomous People's Liberation Army. And last but not least, the Russians have taken the concept of state sponsored oligarchy to a whole new level.

Compared to the rest of the world, carrying mortgages, automobile manufacturers and solar panel plants on the U.S. balance sheet may just have to be a new way of doing business. If that's the case, we'll also need our pool of cool, pedigreed, hyper-educated Masters of the Universe like Energy Secretary Mr. Chu, who can easily triangulate on policy, politics and returns on investment. Thanks to brainy virtuosos like him, Uncle Sam, Inc. will be able to roll the dice and be a venture capitalist.

And health insurance isn't immune. The virtuosos in Washington are busy setting the essential benefit, determining the best medical loss ratio and which companies can compete in exchanges. Generics are regulated and if there is no approval, drugs won't be covered. Even though elections have consequences and Disease Management Care Blog readers may loyally disagree from time to time, how can we turnips dare to cross swords with experts like this?

It's ironic that with this as background, our political class can claim to understand the concerns of "Occupy Wall Street." So does the DMCB, but that doesn't mean it isn't also worrying about those elite technocrats helping Washington become Wall Street.

A Population-Based Care Management Lesson: What Telephonic Disease Management Lacks In Individual Effectiveness Is Made Up By It's Greater Reach

2011-11-17T21:54:00.001-05:00

What did that study show?

In yesterday's post on the role of telephonic disease management for obesity, the Disease Management Care Blog pointed out that POWER was a landmark study that demonstrated that remote lifestyle counseling performed as well as traditional face-to-face counseling.

A New England Journal of Medicine editorial accompanying the POWER article points out that there may have been an additional factor that explained the results: patient attendance at the in-person counseling sessions dropped off precipitously as the trial progressed (an average of only 2 out of 24 scheduled visits after the seventh month), while the telephonic approach achieved 16 out of 18 scheduled contacts.

The DMCB agrees and suggests this is an additional virtue of remote telephonic disease management. While in-person counseling may have more of an individual impact, it does little good if patients no-show. In contrast, "high volume" telephonic counseling may have more of a population-based effect, because a lower intensity intervention has greater absolute impact if it's delivered to more persons.

NIH scientist Susan Yanovski's editorial falls short on capitalizing on that insight. While it grudgingly points out that POWER shows "PCPs can deliver safe and effective weight-loss interventions in primary care settings," it neglects to mention the two important implications of POWER:

1) non-physician team members acting collaboration with PCPs are an important resource in the national battle against obesity and

2) offering a variety of communication channels increases reach and gives more patients new and effective options to access anti-obesity programs.

The Latest Cavalcade of Risk Is Up!

2011-11-17T09:36:00.000-05:00

The Disease Management Care Blog can't believe it's only a week until Thanksgiving. One more reminder of how time flies is this holiday themed Cavalcade that is hosted by Nancy Germond at the Insurance Writer Blog. Enoy!

Lessons From The Practice-based Opportunities for Weight Reduction (POWER) Study: More Evidence of the Effectiveness of Remote Care Management for Obesity

2011-11-16T20:29:00.002-05:00

"I need to call someone..."

The Disease Management Care Blog apologizes in advance for a long post about an important study comparing two state-of-the-art weight loss interventions. Get some caffeine and hang in there. If you are interested in the science of disease management and its role in obesity, you will not be disappointed.

Talk to some of the Ayatollahs dominating the academic medical-industrial complex about telephonic disease management and they'll give you the same look that they give to something unsightly that they just discovered on the end of their finger after rubbing their nose. The idea that some remote (ugh!), telephone-based (bleh!) for-profit (yuck!) company could contribute anything to their vision of the health delivery is health policy apostasy.

But what how does this ideology stack up against the evidence?

Until recently, we haven’t really known because there were few head-to-head comparisons of traditional “disease management” vs. traditional patient counseling. But now we have the just-published POWER (“Practice-based Opportunities for Weight Reduction” study that was funded by the NHLBI and (whoa!) Healthways. The authors were from Johns Hopkins University, which has a long-term consulting agreement with Healthways. They had final say on the research methodology and the paper's contents.

POWER was a prospective clinical trial that randomly assigned patients to one of three weight loss intervention strategies. One consisted of “remote” telephonic treatment counseling, the second provided in-person counseling and the third was a control group. The in-person sessions were provided by Johns Hopkins employees while the remote telephone counseling was provided by Healthways.

Study patients with obesity and at least one risk factor (hypertension, hyperlipidemia or diabetes) were recruited from six Baltimore primary care practices from 2008 through 2009.

All the interventions used basic nutritional and exercise guidelines that were delivered with state-of-the art “social cognitive theory,” "behavioral self-management,” “positive reinforcement” and “motivational interviewing.” Both of the intervention groups had access to a web site with learning modules plus feedback. If there was no log-on to the web site every 7 days, patients were sent a reminder email.

Persons in the disease management-style remote support arm of the study got 12 weekly calls lasting 20 minutes for three months, which was followed by 3 monthly calls.   Persons assigned to the traditional in-person coaching arm got nine group sessions and three individual sessions over the 3 months followed by one group and two individual monthly sessions over three months.

Participants’ weight loss was assessed at 6 and 24 months.

The patients' primary care physicians received summary reports and encouraged their patients’ participation.

Readers should note that this was an “effectiveness” trial. Unlike “efficacy” trials, the protocol dispensed with the usual run-in period or making sure patients were adherent to the protocol before or during the study.

1370 persons were screened and 415 were randomized. 64% were women, the mean age was 54 years, 41% were black, 97% had commercial insurance and the mean BMI was a hefty 36.6.

After randomization, there was some drop out: 366 were weighed at 6 months, 355 at 12 months and 392 at 24 months.

At 6 months: the control group lost 1.4 kilograms (kg) while there was 6.1 kg lost in the remote support, and 5.8 kg. lost in the in-person group. That's 3.1 lbs vs. 13.4 lbs vs. 12.8 lbs.

At 24 months, the weight loss .8 kg in the control, 4.6 Kg in remote support and 5.1 Kg for in-person. That's 1.8 lbs, 10.1 lbs and 11.2 lbs. That translates to body weight changes of 1.1%, 5.0% and 5.2%. The percent of persons hitting at least 5% weight loss was 18.8% in the control group, 41.4% in the in-person support group and 38.2% in the group getting remote support. 7.8% of controls, 27.5% and 18.8% of controls, remote and in-person support patients, respectively, reached a BMI less than 30

There was no statistically significant difference in weight loss outcomes between the two intervention groups. In other words, the small changes between the disease management and in-person counseling could have been the result of chance.

What can readers conclude?

1. This was a solidly performed study with important implications for a still-evolving national strategy in the battle against obesity. If an intervention can lead approximately 40% of persons to lose 5% of their weight over two years, maybe the science of non-invasive weight reduction has gotten to the point where insurers should cover it. While the DMCB remains suspicious about “mandates” and “the minimum benefit,” there are other policy levers that could be pushed to make this happen. This is doubly true when you think about the costly alternatives of drugs and weight loss surgery.

2. Seen through the lens of a disease management vs. in-person counseling competition, the industry’s “best” (Healthways) went toe to toe with the health system’s best (Johns Hopkins) and it was a tie. When it comes to weight loss, it now comes down to who can do it cheaper and who can scale it.

3. While this was a solid study, readers should be aware of its imperfections.  Since there were so few patients on Medicare or Medicaid, we don't know how this would work in patients with public insurance. This was not double blinded, so it’s possible that the outcomes were skewed because patients and their doctors were aware of their assigned treatment arm. The drops-outs' weights went unmeasured and their data could have changed the results. There was a high reliance on group sessions in the "in-person" arm of the study, which may not be as effective as one-on-one counseling. The in-person sessions were also “remote” from the PCPs’ offices and may have been a poor substitute for the one-on-one counseling envisioned for a robust PCMH. Successful weight loss is usually defined at 10% of body weight at one year instead of 5% at 2 years. It’s also difficult to discern the relative contribution of the web site vs. the physician support vs. the nurse counseling. We don’t know what happened to the patients’ blood pressure, cholesterol levels or their blood glucose control. Finally, Hopkins had a doubtful but potential conflict of interest in a study that showed non-superiority vs. one of their customers.

4 While the DMCB doesn’t want to quibble, close scrutiny of the p-values in a table comparing the percent of persons reaching a BMI less than 30 for the in-person vs. remote support cohorts shows that it came quite close to being statistically significant at p = .07. In other words, Healthways (27.5%) almost beat Johns Hopkins (18.8%). Using the same criteria in this study widely hailed as proving that Group Health’s medical home saves money, Healthways did beat Johns Hopkins.

5 Healthways deserves kudos for submitting to and committing resources to a clinical trial. To the DMCB, the search for scientific truth is a price of doing business. Their shareholders may think that cash is better spent on pursuing customers or driving efficiencies, but this research is an investment that will yield returns over the long run. Other for-profits "get it" and so does Healthways. The only question is why isn't this spashed on the company's web site?

6  If both interventions are equivalent, the DMCB suggests that they are not necessarily exclusive. A truly enlighted approach to this would be to let patients choose which form of counseling they prefer.  What's more, if patients were allowed to choose, the amount of weight loss for both groups would probably be even greater.

7. Last but not least, this is further evidence that "disease management" has grown up. This "DM Ver 2.0" is based on far more sophisticated principles of behavior change than those used in the Medicare Health Support debacle. What's more, this Johns Hopkins paper reminds us that physicians, in the course of routine patient encounters, are simply not an option when it comes to weight loss counseling. They're too busy and their job is to provide a supporting role.

"POWER" - one more acronym and one more piece of evidence to use in defense of disease and population-based care management.

What Are The Presidential Candidates' Positions On The Patient Centered Medical Home?

2011-11-15T21:59:00.000-05:00

As a public service, the Disease Management Care Blog is happy to build on what we know about the positions of the Republican Presidential candidates on health reform and speculate on the likely debate answers that the front runners would give if they were asked about the Patient Centered Medical Home. By facilitating this political narrative, the DMCB hopes our candidates are now free to address the issues that really matter, like whether exposed men's toes are ever appropriate in the workplace, why airport skybridge personnel vanish when flights arrive after 11 PM and whether dermatologists working in ACOs could ever relearn which part of a stethoscope goes in the ears.

Rick Perry: "I'm opposed to P-C-M-H because they are one, 'patient centered,' two 'medical' and three.... um, I forgot what that third H is for.....ooops."

Mitt Romney: "While I supported it in Massachusetts, I oppose it now because the federal government supports it in other states, where it is both supported and opposed. We also don't know if this approach to care will reduce elevated costs going down."

Newt Gingrich: "This is a constitutionally catastrophic and unprecedented intrusion of enormous federal power of stunning proportions. Truman wouldn't have stood for this and Lincoln would be shocked, which is why you should buy my book."

Herman Cain:" I am opposed to the patient centered medical home because primary care should rely on teaming and electronic records so that they can take better care of patients."

Michelle Bachman: "A woman told me that her baby is brain damaged because of care received at a medical home!"

Ron Paul: "I don't see the words "patient centered" in the U.S. Constitution and what's more, when we switch to the gold standard, we won't be able to afford it."

Potentially Preventable Hospitalizations (PPH) Among Persons With Diabetes Mellitus

2011-11-15T03:42:00.000-05:00

All aboard!

If you’re expecting your newly established Patient Centered Medical Home (PCMH), Accountable Care Organization (ACO) or Population-Care Management Program to reduce hospitalizations among persons with diabetes, you may want to sprinkle the acronym “PPH” into your business plans, talking points and meeting pitches. It stands for “potentially preventable hospitalizations.” It’s not only a timely topic, but by brandishing the term “PPH,” compared to all those unfortunate knuckleheads who don’t read the Disease Management Care Blog, you’ll once again remind everyone about your health industry chops.

That’s why a look at this AJMC article examining “PPH” in a population of persons with diabetes may be worth your time. 555,538 California ’05-’06 hospitalizations for 361,858 persons aged 65 years or greater were examined for the presence of an "ambulatory care sensitive condition" or "ACSC". The science underlying the use of ACSC metrics in this study has shown that the effective outpatient care of persons with certain concurrent ACSCs can reduce hospitalizations. The ACSCs used by the researchers in the AJMC article were bacterial pneumonia, dehydration, urine infection, COPD, heart failure, hypertension, diabetes complications and uncontrolled diabetes.

In addition to ACSCs, the the authors looked at the impact of age, gender, race, neighborhood, income, insurance type (Medicare, Medicaid or commercial) and the number of other chronic conditions (as determined by insurance claims).

The results? More than 112,000 (about 20%) of the hospitalizations were due to an ACSC and therefore were PPHs. The most common conditions were pneumonia and heart failure; the length of stay averaged 5 days with a per hospitalization cost of approximately $9900. The authors estimated that PPHs resulted in 570,000 hospital days and a cost of more than $1.1 billion Being female, Medicaid, rural dwelling, low income, having multiple co-morbidities and having to be admitted via the emergency room were all associated with PPHs.

How can this information help the PCMH-savvy, ACO-adroit and care management cognoscenti? While the authors of the AJMC article vaguely suggest that better vaccination rates against flu and pneumonia may work, the DMCB offers up some additional observations:

1. Baseline: Now readers have an idea of the extent of the problem in a diabetes population. 20% is a lot of PPHs, a lot of hospital days and a lot of money.

2. Reality Check: In this study, 80% of the admissions for persons with diabetes were NOT potentially preventable. This should give pause to anyone believing that their initiative can precipitously reduce hospitalization rates. Doctors (the kind that actually take care of patients) will also tell you that many PPHs are not truly preventable also: many people get acute pneumonia and heart failure exacerbations despite the best of care. As a result, more than 90% of hospitalizations among elderly persons with diabetes may not be preventable.

3. Generalist Care Management, not just diabetes care: your organization's nursing care plans have to not only address blood glucose control, but a host of other co-morbidities that are the real short term drivers of inpatient use.

4. But, Cake and Eat It Too: There are scant data on this, but the DMCB believes that good blood glucose control leads to fewer infections and atherothrombotic complications. If it is correct, good care management not only has to manage multiple co-morbidities (the cake) but achieve good blood sugar control (the eats).

5. ER Chicken and Egg: Does becoming very ill with an ACSC make ER visits more likely which, in turn, makes a PPH more likely? The DMCB agrees that that is one causal pathway accounting for the data above. However, it also wonders if presenting to an ER with any ACSC at any stage of illness is more likely to lead to an admission. If the DMCB is correct, it stands to reason that 1) developing initiatives that keep patients away from the ER (with outpatient care options) may materially reduce admissions and 2) putting care management resources in the ER to assist with discharge planning is an option because it may divert patients to the outpatient setting.

Planning for a Post-ACO World

2011-11-13T18:54:00.001-05:00

The great Wayne Gretzky once famously observed that he achieved ice hockey prowess because he made a habit of skating to where the puck was going, not where it is. That important lesson may have been lost on countless health care executives who, now that the Department of Health and Human Services has told us what an "Accountable Care Organization" (ACO) is, are furiously skating to fill out this application.

The Disease Management Care Blog suggests they also think about where this ACO puck could go. Listen to the ACO zealots and its easy to believe that the triple aim will become manifest and providers will rolling in shared savings moolah in less than 18 months.

Regular DMCB readers know better. They know that Medicare's ACOs have no track record and that the ACO-like models have had a checkered experience. As data on the Medicare's ACOs come in, it is quite possible that we may discover a penalty box where a) shared risk translates to shared losses, b) the Feds are fickle partners, c) the correlation between cost inflation and quality is implacably positive and d) only a few hospital-physician alliances have the kind of non-generalizable culture necessary to make ACOs financially viable.

In other words, this is not going to be a preordained power play. By the time they get there, ACOs could find the puck went somewhere else.

The DMCB humbly suggests that that somewhere else could be a post-ACO world. That’s why the DMCB suggests that no organization’s long-term ACO strategic planning is complete without serious contemplation of why they should not follow the herd and plan on a 3rd quarter where:

The Bubble Bursts? The hangover of lost millions in misallocated capital and human resource investments could preoccupy key partners and hobble lead competitors for years to come. This has important implications for future business relationships, mergers and acquisitions and growing market share.

The Ascendancy of Physician Groups. As hospital-physician arrangements unravel, the larger independent physician-owned practices left behind could fill the vacuum with an array of contained, discreet and non-global commercial insurer payment arrangements that are based on 1) a level playing field and 2) what both sides value. That is, of course, assuming these practices don't run afoul of any market dominance scrutiny by the FTC.

Federal Retrenchment: Despite any prior deals on the SGR, a perfect storm of entitlement non-reform, rebounding cost inflation and the lack of any new innovative ideas forces CM to cut rates. The impact on physician participation in Medicare is anyone’s guess, but the new urgency to control costs means physicians will 1) have one more business reason to seek the efficiencies of larger groups and 2) be even less willing to take on additional practice costs that ranges from hiring to technology.

Should provider organizations skate toward this post-ACO world? The DMCB suggests it's not unreasonable. Time will tell if they win this game.

Vendors Agree To Monitor, Measure Patient Injuries Related to the EHR

2011-11-11T00:59:00.000-05:00

Lest readers believe the skeptical Disease Management Care Blog has been unnecessarily harsh on the pro-electronic health record zealots, check out this news article on a long overdue agreement among 44 vendors who have agreed to pool data on EHR-related adverse events. Hopefully this on-line reporting system will be able to collect information on the extent and of type of medical mistakes associated with our brave new digital-medical world.

Two points deserve emphasis:

1) Physician liability insurers (the companies that defend physicians against allegations of malpractice) are paying close attention and could use information like this in their underwriting. It seems some are ready to conclude that bad EHRs can not only lead to patient injury, but may deserve increased premiums.

2) Nothing spurs action more than the threat of an outside or unfriendly regulator or government entity willing to independently collect this kind of information and act on it. The DMCB wonders if that was one ingredient in the formation of this initiative.

The DMCB is looking forward to seeing the numbers in the coming months. Stay tuned!

The Latest Health Wonk Review Is Up!

2011-11-10T09:22:00.000-05:00

So now you can know about oilos, but only if you check out the latest Health Wonk Review, hosted by Hank Stern of the InsureBlog. Hank treats us to a symphony of the best health policy posts with perspectives you won't really find anywhere else. Enjoy!

Another Look At An "All Payer" System For Hospitals.

2011-11-10T00:25:00.000-05:00

Why do different insurers pay different amounts for the same service? While Medicaid and Medicare are notorious for their take-it-or-leave-it fee schedules, competing commercial insurers' payment rates for vary considerably across providers, even within the same region.

Uwe Reinhardt tackles this mystery in a just-published article in Health Affairs. Not only is this “price discrimination” untidy, says he, it’s also been unfairly credited as being evidence of “cost shifting.”

It turns out that there are some credible studies that show that as public payer fee schedules get squeezed, commercial insurers seem to pay more. Yet, in order for a cause and effect to be present, that would mean that providers are not acting in their own economic self interest and are waiting on Medicare and Medicaid before bargaining with their local managed care plans. To Dr. Uwe, that seems suspect. That would mean commercial insurers have little negotiating leverage which would also mean that the U.S. cannot rely on them to control costs. Yikes.

Compounding this untidiness are the big swings in the costs of goods and services in an opaque market that seems better suited to upside price gouging and not downside discounting. This is not only hurting the uninsured, the dysfunction is now reaching into the pocketbooks of the middle class. No wonder Americans are grumpy about the cost of health care.

Dr. Uwe’s suggestion? An “all payer” system. Not to be confused with a “single payer” system involving some sort of Obamaesque Price Czar, all payers would negotiate prices with all providers in regional blocks across counties, regions or even states.

Some of the European countries use this approach and so, by the way, does the state of Maryland. The role of government would presumably be limited to brokering a yearly Big Meeting between representatives of both camps; in fact, government could make sure all parties agree to prices that are indexed to the GDP. The result? Patients would benefit from an average price applied equally to all, insurers would know they’re paying their fair share and best of all, hospitals would get a fair price for their services.

The DMCB likes the approach but suspects that politicians would be tempted to meddle by showing favoritism. It would prefer to see it implemented at the state level while the Feds are kept at arms length. It should be limited to hospitals at first. Depending on how things work out, it could be tested on a trial basis involving physicians, such as the Patient Centered Medical Home.

Asynchronous Prescribing: A Primary Care Divorce and the Basis for Medication Irreconciliation

2011-11-08T23:54:00.001-05:00

The Disease Management Care Blog welcomes this essay from a physician colleague.

When I first started in practice, face-to-face “medication reconciliation” was built into my drug prescribing. The prescriptions were written by hand at the time of the clinic visit and each one, including the dosing and their purpose, were discussed with the patient. New prescriptions by physician-specialists were noted during the time of the initial history taking, meds that the patient stopped on their own and the reasons why were reviewed, intolerances to recently prescribed meds were discussed, allergies were updated, and side effects were explained. Prescriptions were written for one month supplies and enough refills were given until the next encounter. They were then handed to the patient. If there was a problem, I could count on my patient to notify me right away.

As time went on, things changed. Thanks to how many pharmacy benefits plans are run, mail order prescriptions are now typically given for ninety days with four refills. I think of this as medication irreconciliation.

While ninety days may look like a good idea, for the primary care physician, this was the beginning of a divorce between medication prescribing and the clinic visit. Face-to-face medication reconciliation is no longer synchronized with the doctor visit. Since this now asynchronous disconnect allows patients to skip appointments and continue medications, many physicians no longer

1) perform frequent medication reconciliations and

2) use the reconciliation process to monitor their patients.

This problem is greatest for those diseases that require more than annual visits. Instead of using the medication reconciliation process to follow complex hypertensive, hypercholesterolemic or diabetic patients every three months, one-on-one appointments, because of skipped appointments, are now happening annually. This has made it difficult to schedule other appropriate preventive interventions such as testing, preventive screening and immunizations such as flu shots and other timely care.

This was the reason that primary care often wrote prescriptions that were only good until the next encounter. As Reaganites like to quote “Trust and Verify”.

It doesn't stop there. What has finalized the divorce between the drug and the visit is the new auto refill program being used by many pharmacies (examples are here and here).

Thanks to auto refill, the patient and physician are even more disconnected with each other. Under this system, expired refills prompt automatic refills requests that are not patient or physician initiated. I have found in my practice that these auto refills are often for discontinued medications. What’s worse, I have also received refill requests from pharmacy benefit managers that have apparently opened expanded operations in the afterworld for deceased patients. Humorously, one note attached for the deceased patient’s request stated that he was expecting to pick it up at 11 am on Thursday.

I am not the only one who has noticed this (here and here).

This divorce between face-to-face visits with my patients and medication prescribing has made the problem of “medication irreconcilation” even worse. It’s now necessary to reconcile each and every prescription asynchronous with the office encounter. This may be efficient for the pharmacy providers, but it is disastrous for primary care and dangerous for patients. For many primary care physicians, the best time to reconcile medications is when all parties are present. During a traditional office visit, patient labs and tests are reviewed, vital signs are taken, the history is updated and an exam is performed. That’s the perfect time when all the appropriate medications for an appropriate length of time should be prescribed.

Thanks to the divorce, accurate reconciliation has become at times impossible. Physicians can’t use clinic visits to query their patients about new developments in their care or new prescriptions by other providers. New doses can’t be reviewed, compliance can’t be discussed and patient concerns can’t be addressed.

This divorce between prescribing and seeing the patient has become grounds for irreconcilable differences. It sure was easier when it was the other way around.

Unsophisticated Government Regulation of Generic Drug Manufacturing: Shortages Are Surprising?

2011-11-07T19:51:00.000-05:00

Contrary to what readers may think, the Disease Management Care Blog is not an inflexible nutcase ideologue that is 100% opposed to the government financing or regulation of health care. It knows that it can make eminent sense for the Feds to step in when markets fail. The DMCB also understands that stepping in not only means additional spending, but laws, regulations and oversight to make sure patients as well as taxpayers get their money's worth.

And so it goes with overseas drug manufacturing. Recall back in 2010, the widely used blood thinner heparin was tainted with look-alike chondroitin. The source appears to have been China and in typical fashion, the plaintiff attorneys have begun to swarm. Given that recent fiasco, who could argue about the stepping up the FDA's role?

Well, since then, a generic drug shortage has emerged and no one is getting their money's worth.

Readers can the depressing explanations here and here. As the DMCB understands it, only a few overseas manufacturers are willing to put up with the United States' quality oversight and average-cost-plus-6%-margin price controls. As inevitable manufacturing problems arise or as upgrading of production makes them go offline, the flow of drugs dries up. In response, middlemen and end-users resort to stockpiling, which only makes the shortages worse. Finally, since generics aren't available, physicians have ironically turned to using more expensive brand name drugs.

And this outcome is surprising?

The U.S. Congress and the Administration have responded with characteristic pretzel logic: if government intervention and regulations have failed, the answer is more intervention and more regulations. By recent executive order, manufacturers are now being forced to announce impending shortages (which has been criticized as likely to prompt even more stockpiling), maintain redundant production systems (which is probably one more barrier to running a profitable business) and, while keeping price controls in place, allow for more of a profit margin (which, of course, will be unilaterally set by deficit-ridden Uncle Sam in no mood for generosity).

But wait!

None other than physician and former White House Health Policy Golden Boy Ezekiel Emanuel penned this opinion piece back in August. While not explicitly endorsing the idea that the Feds should get out of the way, he does want his former boss to reconsider:

"A more radical approach would be to take Medicare out of the generic cancer drug business entirely. Once a drug becomes generic, Medicare should stop paying, and it should be covered by a private pharmacy plan. That way prices can better reflect the market, and market incentives can work to prevent shortages."

The DMCB finds it telling that such an ardent supporter of health reform would even consider such a notion. Yet, when taxpayers are being forced to choose between the two extremes of a decidedly unsophisticated approach to overseas generic drug manufacturing with unintended consequences versus a competitive market-based laissez faire approach, maybe Ayn Rand had a point.

It's enough to make the DMCB think about becoming a nutcase ideologue.

But not yet.

The Latest Cavalcade of Risk Is Up

2011-11-07T12:24:00.000-05:00

It'll be a blogerful day in the neighborhood when you check out the latest Cavalcade of Risk, hosted by Julie Ferguson at the Workers Comp Insider. This is a compendium of the latest and bestest business-risk posts by a variety of authors. There is something for everyone.... link.

Seven Reasons Why Small Physician Owned Practices Will Continue to Do Well Despite Accountable Care Organizations (ACOs)

2011-11-06T19:45:00.002-05:00

Since the Disease Management Care Blog not only wants to be informative but also helpful to its readers, it has developed a seven point generic physician employment inquiry response and recruitment letter. It is available below.

The DMCB is confident that those smaller physician-owned private practices that remain independent will find this form letter very helpful in the coming years. The DMCB releases this to the public domain and its colleagues are welcome to copy, paste, distribute, share, alter, modify or adapt all or some of the document as it becomes necessary.

Dear [insert name of physician here]:

Thank you for your recent [select: tweet, email, Facebook posting or VM] inquiry about leaving your current salaried position and joining our practice. Thanks to widespread patient dissatisfaction with the institutions that were spawned by "health reform," our small business has experienced tremendous growth. We are constantly on the lookout for new talent that complements our projected demand. Maybe you can join our team!

As you are undoubtedly aware, many of our colleagues nationwide have been lured into full time employed positions involving large complicated corporate practice arrangements, many of which were set up to be ACOs. Savings haven't materialized and many of these organizations have responded by demanding more patient "throughput" from their employed physicians and imposing cutbacks in vital support services.

In contrast to those organizations, our practice offers you:

1) a completely transparent compensation arrangement that equitably divides our net revenue income among the owner-physicians. No more having to deal with an unwieldy administration that allocates salary amounts based on some opaque budget of anticipated revenues and upside savings minus overhead and capital allocations that you have no say in.

2) a team-based environment that not only relies on your expertise but knows who's boss. Unlike those other complicated practice settings with layers of middle management, our office personnel report directly to you, period.

3) a patient population that is not only grateful for our high "same day" service standards and efficient and compassionate practice style, but who also recognize that unnecessarily calling at the end of the business day or repeatedly while we're on night call is reason to be assisted in finding another physician. We have carefully cultivated a very loyal following of patients who genuinely partner with us.

4) a highly trained and motivated administrative support and care management staff that not only uses state-of-the-art approaches to deal with private managed care commercial insurers, but uses a "3A" approach of Anticipating, Automating and Appealing any service that requires prior authorization from you. You'll only get involved in these matters when it's necessary.

5) a stable practice environment. Speaking of managed care insurers, they comprise the bulk of our business. While they are far from perfect, Medicare and Medicaid they are not. They don't threaten us with arbitrary fee schedule cuts, audits, and payment delays. We firmly believe patients and taxpayers should get what they pay for. It's not our fault if they haven't paid for our level of clinical and consumer excellence.

6) an EHR system is not only low cost and user-friendly, it's modular and cloud-based. Our vendor has agreed to performance guarantees, there are no one-sided "hold-harmless" clauses and it's seamlessly compatible with any hand held device of your choice any time and any where.

7) a unique market niche that sits in that "sweet spot" between a local employer community that likes us, insurers that respect us, specialist physicians work with us and a multispecialty ACO close by that welcomes our referrals.

Once again, thank you for contacting us. Please send your CV to [insert P.O Box address here] where we will store it in strictest confidence along with dozens of your colleaques' CVs. We promise you that when we get to it in the coming months, we will contact you.

Best regards,

Some Inconvenient Cautions for the PCMH and ACOs, Courtesy of the Medicare Health Support Program

2011-11-03T17:48:00.001-04:00

Remember Medicare Health Support (MHS)? That now defunct Medicare program is widely regarded as "the" study that "proved" that "disease management doesn't work."

If you're one of those disease management skeptics, you might enjoy the lingering anti-vendor schadenfreude of this bottom-up re-analysis of the MHS program that was just published in the New England Journal. However, if you are a fan of the Fed's programs for the Patient Centered Medical Home or Accountable Care Organizations, you'll also want to pay close attention to a timely reminder about the perils of contracting with CMS.

The Disease Management Care Blog explains.

Recall MHS was a CMS program designed to test old fashioned disease management in fee-for-service Medicare. A total of eight vendors launched their programs in separate geographic areas across the U.S. in the latter half of 2005. Each area had about 30,000 beneficiaries with diabetes and heart failure who were randomized to disease management or usual care in a 2:1 ratio. Participants were ill with an average of more than one recent hospitalization in the previous 12 months and more than $15,000 in baseline costs. The programs consisted of remote call centers staffed by nurse-coaches who counselled patients on a regular basis. Each of the vendors negotiated a monthly "at risk" administrative fee from CMS. To retain the fee, the companies had to reduce costs in excess of the fee and simultaneously achieve a variety of quality and satisfaction targets vs. the usual care patients. If they failed to save enough money, CMS clawed the money back.

The Journal's reanalysis, involving more than 240,000 beneficiary-participants, didn't shed any new light on the original depressing report to Congress.  Among the eight vendors, the change in the per beneficiary per month (PBPM) cost ranged from $22 in savings to $38 in additional costs; most of the PBPM changes were in the single digits. In contrast, the fees ranged between $74 to $159 per beneficiary per month. Only three of the eight vendors had lower costs, none achieved statistical significance and none had savings that exceeded their fees. There were some improvements in quality, but they were spotty and quite modest.

Participation rates among eligible beneficiaries averaged 85%. Mean telephone contacts per patient was .7 per month and ranged from .4 to 1 per month. Patients were telephoned on average every 2.7 months; over a 30 month period, 59% were contacted at least 10 times and 23% were contacted fewer than 5 times.

And what are the lessons?

The authors had five, all of which also apply to the medical home and ACOs. The DMCB has two more.

1) Show me the money:  In retrospect, the research that led to MHS that suggested that disease management "worked" was imperfect. By the way, the same can be said of the largely observational and underpowered research supporting medical homes and the total lack of any meaningful experience with ACOs. Will these innovative care approaches share the same fate as MHS? Based on what we know at this time, it can't be ruled out.

2) Needy patients: Medicare beneficiaries with diabetes and heart failure are sick. The nurse-coaches were unprepared to meet all of their patients' needs. Medical homes and ACOs may end up being surprised also.

3) Analytics: In the CMS' "data dumps" to the vendors, it was difficult to find the patients who were the most vulnerable. This good news is that modern predictive modeling analytics - despite its limitations - may enable medical homes and ACOs to target their care management at those patients with the greatest need and at the highest risk for increased costs.

4) Timely access to data: CMS' data transfers to the vendors could be tardy, resulting in telephonic outreach to patients long after it could have done any good.  ACOs will need to worry about this in their dealings with CMS.

5) The doctors: despite the vendors' assurances, the disease management programs were not aligned with the beneficiaries' doctors. This is less likely to be a problem in medical homes and ACOs, but doesn't mean that they won't have to worry that their docs aren't fully buying into the notion of teaming with non-physicians.

The DMCB offers two other lessons:

In retrospect, calling sick Medicare patients infrequently may have been one factor in MHS' undoing.  The telephone will probably have a role to play for medical homes and ACOs, but the best mix of telephonic and face-to-face visits remains an open question.  At any rate, it seems that contacting patients at least every 30 days would be a good benchmark.

The DMCB remembers the confident "this is guaranteed to work!" hubris of yesterday's MHS architects and finds it eerily similar to the enthusiasm surrounding today's medical homes and ACOs. If the Medicare medical home and ACO programs don't work out, it'll set these innovations back ten years or more.

Image from Wikipedia

Finally, A Good Electronic Health Record Anecdote!

2011-11-02T21:27:00.000-04:00

The Disease Management Care Blog remembers when it was first introduced to an electronic health record (EHR). After many days of learning how to document, link, retrieve, order, manage, view, bill, sign-off and close patient encounters, it asked about retrieving summary statistics on its patient population. It wanted to know how many if its patients with high blood pressure were under control and how many of its patients with heart disease had low cholesterol levels.

The practice administrator looked at the DMCB like it was crazy.

That was when the DMCB realized that the purpose of its EHR had less to do with quality, costs, coordination and everything to do with perpetuating the "hamster wheel" of one-on-one primary care. Prior to the EHR, it averaged about 4-5 patient visits per hour. After the EHR, that didn't change. Neither did its HEDIS® measures, patient satisfaction rates or professional well-being. The only thing that increased was its cumulative billing amounts. No wonder the DMCB has been an unrepentant EHR skeptic. It concluded that the purpose of the EHR is to perpetuate the dysfunctions of one-on-one care.

Articles like this, however, may change the DMCB's mind. Jennifer Frankovich, Christopher Longhurst and Scott Sutherland describe how they tapped their local EHR's multi-year database to assess the outcomes of a cohort of patients that was similar to one of their own. After analyzing how prior patients under similar circumstances fared, they decided that it would be a good idea to treat their patient with a blood thinner. The patient ended up doing OK.

1. Normally, a physician's expertise is built over the course of many patient encounters. That's called "clinical wisdom." Being able to compact years of an institution's collective experience from an EHR into a spread sheet is not only a step in the right direction, it's using the EHR to build an institutional body of wisdom.

2. This is another case study on the important distinctions between observational data bases (imperfect but locally relevant and readily available) and pristine evidence-based prospective randomized clinical trials (the gold standard for collecting evidence that is often lacking). The latter is the standard of care and the enemy of the good; the former is quite useful and, as this case shows, often good enough.

3. Last but not least, this is a good example of "applied" "population health management" in which a virtuous cycle of measurement can drive the local standard of care. It's not only true for patients with obscure and rare diagnoses but for those with common, chronic and expensive conditions. Want to reduce the burden of obesity? Understand what really works for diabetes? Tackle the costs associated with hypertension? Assembling and using an electronic data base like this will make it possible.

The DMCB is looking forward to when future EHRs can perform at this level everywhere all the time.

Medicare Hospital Readmissions: Bad. Our Ability To Understand or Do Much About Them: Worse

2011-11-01T22:22:00.000-04:00

"I think I need to go back
to the hospital....."

The Disease Management Care Blog remembers her very well. She had come to the United States after escaping on foot from post-war Hungary. She liked to have sliced pears and cognac for lunch. As her health began to fail, her stubbornness began to exceed her self-sufficiency, leading to multiple hospitalizations. One time, despite making sure she had a post-discharge outpatient appointment, a fresh pile of prescriptions and home visiting nurse services, her illness flared and she had to come back to hospital.

She was not only my patient, but she represented one of Medicare's dreaded readmission statistics.

By now, DMCB readers know that CMS, buoyed by its value-based purchasing program, has targeted readmissions by reducing payment levels to hospitals that fall outside the expected norm. Threatened by the loss of income, it’s assumed that hospitals will respond by developing higher quality discharge planning and care programs that keep patients from having to come back.

An important part of reducing readmissions is to identify those patients that are at greatest risk. That would help on two levels:

1) if a hospital had more than its fair share of patients at risk, it could argue that an increased number of readmissions is the result of a sicker patient population and not quality of care. As a result, the hospital could be held "harmless;

2) hospitals would be able to focus extra care resources on those patients who are spotted early as likely to come back, thereby reducing the readmission rate.

In other words, patients like the lady from Hungary would not necessarily lead to a cut in hospital payment rates and, for example, she could be proactively given extra care, such as a doctor appointment within 48 hours, a week’s supply of free medications and twice a day home nurse visits.

Which is why this just published JAMA article "Risk Prediction Models for Hospital Readmission" by Devan Kansagara, Honora Englander, Amanda Salanitro David Kagen, Cecelia Theobald, Michele Freeman and Sunil Kripalani is important. The authors set out to see what the evidence-based published scientific literature had to say about predicting readmissions. They filtered thousands of references, reviewed 286 publications found 30 rigorous studies that described 26 models.

To the DMCB's delight, the authors applied a “c statistic” to the 30 publications to assess a wide variety of retrospective and concurrent prediction methodologies using a host of data inputs such as age, gender and past diagnoses. According to this article, the c (or "concordance") statistic measures how well a test can predict the presence or absence of a "condition" which, in this case, was being readmitted to the hospital. One way to think of this is the likelihood of correctly identifying a condition when there are two people, one with it and one without it. If the likelihood is 50%, that's no better than random guessing. If it's 100%, that's perfect. By the way,if this sounds a lot like the area under the receiver operator curve, you're right.

And what did the all-seeing "c statistic" say? All of the published models had disappointingly similar levels of performance that ranged between the extremes of .52 to .83 with most in the .50 to .7 range. What's more, only one study examined the most important question of all: is it possible to find patients with preventable readmissions?

What does the DMCB think?

1) This may be another area where national health policy has gotten out in front of the scientific evidence. If we can't reliably assess or predict readmissions with sufficient accuracy, there is a distinct likelihood that statistical variation, not quality of care, will lead to some hospitals being victimized by CMS with lower payment rates. What's more, if hospitals can't tell which patients are likely to come back, how are they supposed to target their expensive care management programs at those who are most likely to benefit?

2) There are undoubtedly some proprietary predictive models that haven't been reported in the literature that claim to have higher levels of accuracy. Yet, without the scrutiny of successful peer-reviewed publication, it'd be difficult to believe that they're really any better than the mainstream published range of .5 to .7. The next time the DMCB runs into one of these outfits, it's going to ask about the "c statistic" and if they haven't published their results, why not.

3) Last but not least, while the hospital payment rates are being held hostage by CMS, it's the doctors that are making the call on readmissions based on the best interest of their patient. The c statistic suggests that that will be the most important determinant in the readmission rate.

What Is The Difference Between Pay for Performance and Accountable Care Organizations

2011-10-31T20:48:00.000-04:00

Where's that evidence?

The Disease Management Care Blog has occasionally wondered about the difference between pay for performance (P4P) and accountable care organizations (ACOs). While the latter involves a more explicit transfer of risk, it thinks the underlying logic for both is ultimately the same: better quality performance should translate into less sickness, fewer specialist physician visits and reduced hospitalizations which, in turn, should save money that can be shared with the providers. Assuming that's true, the possibility of getting that kind of money should prompt physicians to prevent, coordinate, counsel, immunize and screen instead of treat, refer, ignore, not immunize and hustle out the door.

Unfortunately, a recently published Cochrane Review says otherwise.

The DMCB likes CRs because they are state-of-the-art and highly disciplined reviews of the world's scientific medical literature. In this instance, after an exhaustive examination of every published paper on the topic of P4P, the authors conclude....

"....there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."

The DMCB will be the first to argue that academic, rigorously conducted, randomized and controlled clinical trials are not the final answer when it comes to managing the subtle complexities of physician behavior change. The DMCB has run into some very smart and passionate physician leaders who have few doubts about the real world links between P4P, increased quality and reduced cost.

That being said, given the commonalities between P4P and ACOs, no one should assume that ACOs are going to succeed based on any notions of "evidence" that the promise of savings will translate into a changed physician workforce. Cochrane says it just ain't there.

What Zombies Can Teach Us About the Affordable Care Act

2011-10-30T19:00:00.001-04:00

In George Romero's campy movie Land of the Dead, the zombies undergo a very worrisome change. While they used to just pathetically stumble around looking for brains to eat, they organize and make menacing plans. The living survivors, holed up inside the fence at the former city of Pittsburgh, have a fight on their hands.

Maybe it's the Halloween season, but the recent slew of late night walking dead horror has inspired the Disease Management Care Blog. It's entered sweeps for a cameo appearance in AMC's cool zombie series. It's assessed the relative merits of the undead staggering vs. running, being loners vs. in packs and being wrathful vs. both hungry and wrathful. The DMCB has also discovered one key commonality of this fearsome species: while maximum head trauma undoes the undead, more of them just keep coming and coming. That DMCB thinks that, despite the spouse's advice to the contrary, is an important lesson.

The political dimensions of the Affordable Care Act are becoming more zombie-like with each passing week. According to the Kaiser Health Foundation, public support for health reform has not only remained stubbornly underwhelming, it has just taken a recent downturn. While it's too early to tell if this is bad news or statistical variation, there's no denying President and his allies are being forced to fight one-on-one with undead employer pessimism, oppositional Republicans and the CLASS Act's failures, while more ever more issues slowly stumble closer. And who can blame the living Dems for their post-apocalyptic anxiety? It was only yesterday that the ACA was a signature achievement and the world was a wonderful place of Congressional majorities, fawning media support and supreme self-confidence.

While supporters of health reform may take comfort in the notion that the zombies have been unorganized and are attacking the margins, the DMCB worries that the Kaiser poll slide may portend a worrisome Romero-esque development: unable to grasp the details if the Affordable Care Act, Americans' support for it was always based less on the underlying policy and more on the President himself. A slip in support, therefore, has less to do with the law's merits and more with a shift in what people fundamentally think about Mr. Obama.

With just over a year until the elections, that's a scary thought for this Halloween. It seems the folks inside the White House fence have a fight on their hands.

The Latest Health Wonk Review Is Up

2011-10-28T11:10:00.000-04:00

Despite the spouse's derision, the Disease Management Care Blog has always suspected that but for a cape and tight leggings, it would be a hard body superhero. Well, according to Joe Paduda, all you really need is a blog and reasonableness. You can see exactly how that will save health care as you check out the latest and cleverly written Health Wonk Review - The Superhero Edition.