Big Data and the Coming New Value Proposition for Disease, Care and Wellness Management Providers

Disease Management Care Blog readers know that the its latest interest is "Big Data." While the researcher-DMCB has played in the sandbox of some insurance claims data sets, the idea of combining and combing through multiple terrabytes of clinical and public data remains a topic of endless fascination. It knows it's not alone.

So, it was only a matter of time until one of the major clinical journals published an article on the topic. JAMA has stepped forward, and not a moment too soon.

It's "must reading" for the disease and care management provider community.

Drs. Murdoch and Detsky point out that Big Data offers four value propositions:

1. Observational correlations may generate insights that cannot be found using standard research approaches. Scanning text for key words in electronic record systems involving hundreds of thousands of patients may find associations or trigger early warnings faster, quicker and cheaper than any formal scientific protocol or clinical trial.

2. Those insights, especially since they can be tailored to fit the circumstances of an otherwise unique patient, can be used to guide diagnosis or treatment. Physician judgement cannot be replaced, but if Big Data points out that there were other patients with a similar pattern of illness who responded best to one treatment versus another, patient outcomes could improve.

3. A Big Data approach to genomics can correlate genetic information with outcomes and further guide therapy. While the DMCB still wonders if "genomics," outside some narrow anecdotes, will always remain the science of the future, Big Data may turn out to be the key to finally unlocking its potential.

4. Since Big Data, by its very nature, can combine clinical information to other personal data (the foods you've bought or your driving history), Big Data will necessarily tilt toward the patient-consumer and away from the health care system. Not only does permission for access lie with the patient, but the insights will be less about sickness and more about wellness.

The authors do a good job of pointing out that there are plenty of challenges. Most doctors don't get it, privacy laws could be over-interpreted or enforced, it remains to be seen who will pay for it and Big Data is still in its infancy.  The DMCB also points out that while Medicare has just discovered that alternative research innovations are possible, Big Data promises to eclipse those approaches (like traditional time series analysis, propensity matching), again making CMS a day late and another dollar over budget.

The implications for the care management and population health community are considerable. The industry has amassed years of intellectual capital in the science of predictive modeling and Big Data is it's next step. Many care management vendors have multiple clinical partners and already have access to terrabytes of data involving millions of persons. Not only is the math and the informatics well within reach, they also "get" the tilt toward wellness and consumer empowerment. Last but not least, if anyone can monetize a value proposition like this and turn insights into revenue (or "shared savings"), these nimble vendors can.

A DMCB prediction: while academics will write about Big Data in scientific journals, the care management industry will be doing it.  In fact, they probably already are.

Two particularly good quotes to use to impress your CEO and stymie your competitors:

"Data has gone from refuse to riches."

and

Economic theory describes the quantitative conversion of 3 kinds of inputs (capital, labor, and raw materials) into outputs (goods and services)...The current revolution in data management makes it clear that a fourth kind of input, information, will become just as important as these other inputs in the future of many industries.

A Money Back Guarantee in Health Care? You Bet!

Who cares about the color, so
long as it catches mice?

Talk about disruptive.

While an unholy alliance of CMS mandarins, fawning think-tank supporters and earnest academics continue to promote their top-down "mainframe" health care ideology, along comes AMCHealth and their money back guarantee.

While the Disease Management Care Blog can only speculate on the how the contracting details would work, AMC's fundamental value proposition is pretty compelling: it promises it will reduce a client's hospital readmissions by "at least 10% within 90 days of deployment" or your money back. AMC is confident it can use interactive voice response (IVR) technology and nurse case managers to identify and then help at-risk patients who might otherwise have to be rehospitalized when things are not going well.

In the meantime, the prevailing Washington DC health reform ideology is that hospitals, doctors, nursing homes and community organizations large and small should pool and sort existing resources under the twin banners of integration and coordination. Mix the solar power of CMS' innovations, the fiscal wisdom of the White House's insurance experts, the academisphere's eternally funded prospective research studies and politically targeted community grants and, if the Feds have their way, the nation's health care non-system will morph into large regional and regulated utilities. Twenty percent of the national GDP will be under the firm control of CMS.

Maybe the DMCB is being overly suspicious. That being said, many of the academics, regulators and government long-timers who are presiding over the medical-industrial complex have made no secret of their disdain of outsider-run care management to the DMCB in meetings and conversations. Using Deng Xiaoping's famous observation, they want their cats to be only one color.

The entrepreneurial AMCs of the health care world are a threat to that vision.  Not only are they a viable business option for impressive organizations like this, they've backed up their claims in the peer-reviewed literature.

If these for-profits succeed, the mainframe healthcare ideology could go the way of dinosaurs, FEMA and Amtrak. By offering solutions that are faster, cheaper and guaranteed, the ultimate success for health care institutions won't lay securing local monopolies but the decentralized and organic business approaches with a mix of build or buy being used in other sectors of the economy.

Image from Wikipedia

A Watershed Year: What 2013 Holds for the Patient Centered Medical Home (PCMH)

The savvy Jeff Levin-Scherz, who blogs over at Managing Healthcare Costs has responded to the Disease Management Care Blog's snarky "Prattling Pinheads of Pessimism" post on the topic of the Patient Centered Medical Home (PCMH). 

He's not a nattering nabob of negativity or a prattling pessimistic pinhead, says he.  He'd like to be thought of as a skeptic seeking substantiation.   The DMCB wholeheartedly approves of the agreeable alliterative appellation.

2013 may well turn out to be the watershed decision year for the PCMH:

If there's no published peer-reviewed proof that it reduces health care costs, nabobs, pinheads, skeptics and policymakers will need to decide if no evidence of an impact on costs is the same as evidence of no impact on costs.

If the answer is no, THEN we'll then have to decide if the traditional "X causes Y" mathematical approaches to derive proof (such as a comparison of averages using standard power calculations and/or impact on expected or observeed trend) are equal to the task in a very "statistically noisy" environment involving complicated human beings.

If that answer is no, THEN we'll have to decide if reasonable and informed assessments of potential cost reductions, used by countless other businesses every day in other sectors of the economy, are good enough,

If that answer is no, THEN we'll have to decide if there is face value to the PCMH. This involves a contrast of any patient benefit versus its incremental cost.  If the benefit is worth the cost.....

THEN we may have to decide if consumers are willing to pay for it, or if health care costs will need to be cut elsewhere to pay for it.

Stay tuned!

What Happened To "Disease Management?"

Early Disease Management

The Disease Management Care Blog is hard at work rehearsing its Care Continuum Alliance Forum12 Plenary Session that's scheduled later this week. Right now there are 22 slides and they have something for everyone: Laurel and Hardy, Keystone Kops, kittens, witches, Ingmar Bergman and Bill Clinton. 

And that's just for starters.

One of the topics that the DMCB will tackle is how much "disease management" (DM) has changed over the past two decades.

When DM first started, many believed it was "the" solution.  It focused solely on chronic illness.  It promoted patient consumerism. While there was some shared risk, the business model was ultimately based on fee-for-service payment mechanisms that pursued a "return on investment."  It sought 100% patient outreach. It alienated many physicians.  It didn't invest in research. The industry suffered from hubris. Many believed it was a silver bullet.  It used nurses.

What a difference 20 years makes.

Now, the population health management service providers view themselves as part of the solution. It spans the full continuum of care, including case management, prevention and wellness. It promotes patient-centric collaborative teaming.  Instead of FFS, its business model is one of value and efficiency that reduces avoidable claims and optimizes trend.  It uses risk stratification to selectively enroll persons who will benefit the most. It is achieving physician buy in. It has invested in rigorous research and a host of studies since then demonstrate increases in quality and savings.  It has sought out partnerships and collaborations.  Many regard it as a key strategy. Its nurses practice behavioral medicine.

Telephonic Nurse-Led Disease Management Saves Money .... Again

They did it again!

Before too long, the Disease Management Care Blog will start getting bored with the accumulating evidence (for example, here, here and here) that telephonic disease management (DM) reduces medical claims expense in excess of program costs.  There's only one thing that's more tiring, and that is the lingering ideological assumption among many academics that the Medicare program's inability to save money with DM means there's a problem with DM and not with Medicare.

Enter this study on diabetes telephonic care management that was just published in the American Journal of Managed Care.  This was about as real world as you can get.

The Denver Health's Westside Family Health Center, a federally funded community health center, randomly assigned 381 patients with diabetes to a 20-month telephone outreach program and another 381 to usual physician care.  In the intervention arm, patients not only saw their physicians, but had the involvement of 3 nurses sharing a ".75 full time equivalent" position.  The nurses used motivational interviewing and clinical protocols to guide these patients in self-care.  The nurses also independently ordered labs, initiated and titrated medications (with the use of pre-signed prescriptions as necessary), arranged vaccinations and facilitated physician appointments.  The nurses focused on control of lipids, blood glucose control and treatment of high blood pressure.

 Since many of these patients had no insurance, linear regression models were used to evaluate costs "from the perspective of the health care system" with "cost to charge ratios."  Patients with no primary care visit in the year preceding the end of the study were excluded from the analysis and the use of health care services outside of the Center was not counted. 

Aside from a slight gender imbalance (64% vs. 57% female in the intervention and control groups, respectively) as well as different rates of cerebrovascular disease (14% vs. 9%) and use of insulin (24% vs. 38%), the two patient populations were mostly similar in multiple baseline labs and co-morbid conditions.  In terms of the baseline costs, the control group had higher baseline hospitalization rates and total costs.

At the end of the study, 58% vs. 47% had achieved a target cholesterol LDL, but there was no difference in blood glucose or blood pressure control. 65 patients were lost to follow-up. The remainder were contacted an average of three times over the course of the study.

There was a significant drop in costs in the intervention group.  Over 18 months, their costs decreased from a baseline of $6390 per patient to $6217, while the control group went up from $7694 to $9033.
When the cost of the program was rolled in, the intervention resulted in $60,902 in total savings, which included the costs of $134,750 for the nurse-based intervention.  The savings appeared to be due to fewer hospitalizations.

While this study didn't use remotely positioned telephonic disease management and instead used nurses that were on-site, the DMCB points out that many telephonic programs use the same playbook. If the nurses have a good working relationship with the clinic physicians, they can do great things by telephone.  Last but not least, while the nurses pursued lipids, blood sugar and blood pressure, the DMCB suspects the real secret sauce was the countless and immeasurable other pieces of advice and help that were provided to the intervention patients.

Harnessing Market Forces to Achieve Quality and Promote Innovation

Maybe they'll put up a
plaque honoring Mr. Obama?

The health care newsie Disease Management Care Blog thought it had seen it all.  Now this.......

In a striking policy about-face, the Obama Administration has adopted a market-based approach to setting prices and controlling utilization. Everyone agrees that letting prices rise in response to demand disproportionately harms lower income Americans. We also know it's another drag on an already fragile economy. Last but not least, it's vexing the President's political base. 

Nonetheless, the Administration is being resolute. Putting political expediency aside, the White House has courageously put their faith in an unabashed conservative philosophy by arguing that long-term benefits of higher prices will ultimately pay dividends in wise consumerism, innovation and quality.

Wow.

As a result, the White will House forgo any "demand" or "supply" side interventions.  There will be no price regulation based on prevailing costs and projected outcomes. They'll spurn the suggestions of myriad legal, economic and regulatory expert panels.  They'll resist activist calls to expand the role of the Federal government. 

Politics?  Sure, but the machinery in West Wing knows how to manage that. They know a normally friendly news media will report some inflammatory anecdotes about how low income Americans are being forced chose among life's other basic necessities. They'll just ride out the news cycle and counter with populist attacks about "profits" and "fat cats" and "corporate jets."  While the messy politics sort themselves out, Mr. Obama has faith: supply, demand and the marketplace will take us where we need to be.

Is this about health care you ask?  Hardly.  Education?  Nope.  Housing? Negative. The Disease Management Care Blog points out that this is the Administration posture on an arguably equally important part of our collective national well-being: transportation and energy prices.  Mileage standards and Detroit bail-outs aside, The DMCB thinks this is quite a reversal.

A harbinger of things to come?  We can only hope. 

Image from Wikipedia

Disease Management Has Moderated U.S. Health Care Cost Inflation

Thanks to years of unapologetically quoting, citing, linking and blogging in over 1300 posts that disease management saves money, the Disease Management Care Blog has earned approbation, fear, respect and disdain nationwide.

But its audacity is mere child's play compared to this Wall Street Journal Opinion by J.D. Kleinke.

His claim? That "disease management" was one factor in the slowing of national health care costs.

Mr. Kleinke, as you can see here, is no lightweight. He not only has experience as a real-world health care entrepreneur and executive, he's the author of the groundbreaking book, The Bleeding Edge.  When he published it ten years ago, Mr. Kleinke predicted the rise of "Emerging Healthcare Organizations" (EHOs) that would harness the forces of risk-assumption, consumerism, consolidation, integration, and industrialization and transform the health care system. If you believe ACOs will succeed, you may want to thank JD for thinking of them first - even if he got two of the initials wrong.

But is he wrong about disease management?

Mr. Kleinke uses a copyrighted bar graph in the article but the image below (lifted by the DMCB from the White House's web site) shows the same data. After an uptick in 2000, the nation's annual percentage change in total health care spending has progressively declined and is the lowest it's been since the 1980s.

Mr. Kleinke asserts that when HMOs were defanged after their '90's decade of bad behavior, insurers not only rolled out deductibles, co-payments, health savings accounts, tiered drug plans and urgent care center coverage, but they were subjected to public performance measures and started "the still emerging science of disease management." The result was an historical decrease in cost inflation.

He makes the point that it's impossible to know the relative contribution of each of the initiatives described above. Assuming that they collectively had some impact, Mr. Kleinke calls for a doubling down and change the regulations and tax code that still is preventing insurers from building on their success and finding other ways to innovate.

The DMCB agrees that he makes a good point. But it also brings up several caveats:

Just because two things happen at the same time doesn't mean one causes the other.  That being said, Mr. Kleinke's hypothesis is intriguing.

Depending on how you compare Medicare fee-for-service (FFS) (where there is no disease management) and commercial insurance costs (where there is), the rate of increase Medicare may be even lower.  It's comparing apples and oranges, but it's still an important point that deserves further analysis.  There's more discussion on why the comparison is not so simple here.

The remarkable drop in health care costs over the last two years may be result of a bad economy and not the advances described by Mr. Kleinke.  We'll find out more when the economy picks up steam.

Last but not least, a smaller rate increase on top of an ever expanding fraction of the economy is still an big increase.  We're now committing a whopping 17% of gross domestic product to health care.

Spin and Innovation vs. Savings and Disease Management

Spinning is hard work!

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

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

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

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

• 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

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

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

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

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

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

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.

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

"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.

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

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.

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Care Management Nurse to Enrollee Ratios for ACOs and the Importance of the "Soft" Side of the Nurse-Patient Relationship

We'll talk diabetes in a sec Mrs Smith,
but first, how's those darling kids?

Just being back from a whirlwind tour, the Disease Management Care Blog is happy to report that it became newly acquanted with some colleagues who are furiously at work building care management programs for newly minted integrated health systems and ACO wannabes.

They provided two big insights for the DMCB:

1) While the DMCB guesstimated that the typical ratio of care management nurses to enrollees amongthe mainstream care management service companies was in the range of 1:1500, at least two new programs are using a 1:750 ratio.  By the way, 1:800 is what was quoted in this peer reviewed article.  That's a lot of nurses for an "accountable" population and a lot of budget for a CFO to approve. 

2) There is less of an emphasis on care manager "productivity,"  thanks to a recognition that nurse-client conversations outside hard nosed chronic illness management "engagement," "barrier identification" and "shared decision making" contribute to relationship building.  The DMCB thinks of this as "magic nursing dust" that adds to the likelihood of patient behavior change.  There are no hard data on the topic, but it's important in other parts of the health care universe, so why not here?

Of Neutrinos and Populations

Neutrinos!

For a true understanding of the true nature of "reality," there's no better place to go than the extremes.  While we may think we independently inhabit a rationally reductionist and linear universe, it's not true.  The smallest particles are both energy and matter, while the gravity generated by planets curves the fabric of space. Whoa. 

If that's not difficult enough, now the Disease Management Care Blog has to deal with the recent observation that neutrinos can travel faster than the speed of light. While it awaits confirmation, the discovery has important implications for decades of assumptions about the "relativity" of time (which can now go backwards?) and mass (which can now go beyond infinity?).  You can get a good sense of just how important it is by reading Mr. Krauthammer's cogent analysis.

The insights gained from "extremes" applies to other corners of reality, including people. The DMCB spouse is regularly tested by the various extremes of her husband's attitudes and behaviors.  At a far more magnified level, spend some time in a delivery suite at the earliest beginnings of life or attending to those at the end of life and you'll gain some insights there too. 

Neutrino speed reminds the DMCB the it's made up of subatomic dust gathered from infinitely large galaxies.  If that's true, why would we ever have the hubris to think that we're even close to understanding what makes us tick?  True understanding about health, wellness and achieving our greatest potential is to be gained at one end by examining subcellular genomics (for example, a "selfish gene") and at the other by, you guessed it, using huge observational clinical population bases (for the latest example, the true impact of dietary vitamin supplements). 

The future yield from ongoing investigations at either extreme end of the human spectrum promises to be phenomenal. 

We ARE all made of stars.....

Practical Approaches to Obesity Care and Chronic Illness In Busy Clinical Settings: Three Key Ingredients

If anything is true about the population health management service providers, they are constantly looking for better ways to fit their programs into busy clinical settings.

That's why this article on New and Emerging Weight Management Strategies for Busy Ambulatory Settings, courtesy of the American Heart Association, should be "must" reading for the vendor industry.  It's chock full of practical advice on how to "engineer" the PHM-physician partnership. While the focus of the article is on a practical approach to obesity, its approach can be applied to other conditions, such as diabetes or tobacco abuse. 

Among the three key lessons that resonated with the physician Disease Management Care Blog:

1. Providers and PHM vendors should make liberal use of surveys outside of the provider-patient encounter.  The surveys should include a assessment of readiness to change and measures of baseline behaviors.  In the specific area of weight-loss, there is a short 5 item survey (go here, then Table 1 and then scroll to the 3rd of 4 lists) that assesses readiness that can then be paired with measures of diet and exercise knowledge and activity.  By the way, the paper has other references that describe other validated surveys that can used in weight management.

2.  The physician's role is important because he or she can non-judgementally endorse, encourage and even "medicalize" the patients' interest in lifestyle change  That being said however, "collaborative approaches that involve physicians, nurses, or other providers" can be first stop for the assessing the survey results and with tailored counseling and follow-up that practically matches the expertise of a physician.  In other words, the docs don't need to do it.

3. The "internet" is emerging as an important option. It works best if it offers education, enables self monitoring, provides individualized goals, builds on motivation and has peer support.  It also helps if there is a "live" person somewhere in the loop.  There are some promising handheld device "apps" too.

While no one can argue that obesity is an important health issue and that primary care physicians have an important role to play, it's difficult to address it in the usual course of a doctor-patient encounter.  The good news, however, is that if you call a busy doc up and point out that assessments can be done via survey, that there are effective counseling strategies that involve other health professionals and that the internet is a resource, they'll endorse the approach.

Good news for the vendors, the docs and, most importantly, for the patients.

11 Insights for the Disease Management Community From Dr. Lundberg

The Disease Management Care Blog couldn't have said it better.  It's not often that the DMCB "reflects" web-based content from elsewhere, but this deserves an exception.

Writing for the MedPage web site, former JAMA Editor-in-Chief George Lundberg describes 11 "false assumptions, practice failures, clinical errors and things amiss" in health care today. 

If these defects were corrected, the DMCB guarantees that U.S. medical quality and cost would improve.  The list also speaks to the difficulty of relying on laws, economists, budgets, Rose Garden announcements, regulations, policy-making, hearings, benefit design tweaks and politicians to have any meaningful impact on the real underlying problems in health care today. 

The good news, however, is that disease management offers some solutions to the 11 points.  That's why practically every health insurer in the U.S, with the exception of Medicare, offers some form of population health and care management.

To wit:

1. "Physician persuasion is powerful": in other words, patients need to actively participate in calling the shots.  That's called shared decision making, which is a bedrock principle of the population health management service provider industry.

2.  "Medical tests can lie":  when physicians intuitively disregard "positive" tests, low pre-test odds can make that the right decision.  Smart and experienced care management nurses understand that and can support the physician's decision in care planning.

3. "Disease onset can be gradual" and persons in the earliest stages of chronic illness may not meet the definition of even having a "disease" - yet:  That's why active disease management is best suited for later stage conditions and offers prevention and wellness programs for the rest.

4. "Preventive public health deserves more credit": part of disease management's success lies in its value proposition of applied public health.

5. "There is an overreliance on the indirectly obtained information of labs and imaging" and testing begets more testing as well as avoidable treatments that are the hidden part of health care cost iceberg:  Disease management can help patients understand that they don't need another MRI.

6. "Long term outcomes data for many age/gender groups are lacking": this is why disease management approaches long-term risk contracts cautiously and why the industry can help keep ACOs from jumping off a 3 year cliff.

7. "It's not all in their heads": care management coaching understands the false allure of the mind body dichotomy.

8. "There is what is known and then what is believed": reliance on still evolving evidence-based research that taps a variety of investigative methodologies is not only the best long-term approach, it's becoming the bricks and mortar of disease management.

9. Some conditions cannot be treated: and some patients should be discharged from disease management programs.

10. There is a difference between "biology" and "medicine":  this is why seasoned nurses make the best care managers

11. There is no test that distinguishes the well from the sick: seasoned care management coaches don't necessarily assume their clients are "patients" who are "sick."  They assume their clients want a say on getting from their current health status to a desired health status and strive to help them get there.

The Uncertain Certainty of Population Health Management Outcomes

So which is it? Alive or dead?

The Disease Management Care Blog is trapped in universe of perpetually shifting probabilities. It knows events may or may not result from multiple overlapping inputs arrayed against a distribution of likely and unlikely events.  Closer scrutiny only generates more shades of grey in a world that forces the DMCB into a dense unsatisfying miasma of cognitive dissonance. Sorting cause from effect from association from randomness (and from occasional miracles) was tough enough when humankind was spearing woolly mammoths by torchlight. No wonder we're debating the merits of early detection of cancer.  Like it or not, ours is a cat-is-BOTH-alive-and-dead "quantum" world.

Little wonder, then, that the DMCB is simply unable to answer the spouse when she asks "if" the "trash" has been taken "outside."

That's why the DMCB sympathizes with authors Suzanne Felt-Lisk and Tricia Higgins when they tackled the potential benefits of population health management (PHM) in an August 2011 Mathematica Issue Brief.  Recall that Mathmatica is a highly regarded policy and research outfit that performs a lot of analyses for the Feds, including (for example) this one.  When they talk, it pays to listen.

Recall that PHM may be thought of as Ver. 2.0 "disease management," newly defined as any "set of interventions designed to improve people's health across the full continuum of care" that includes a full scope of disease management plus preventive services and health promotion," typically on behalf of "an employer, health plan or other purchaser that bears responsibility."  PHM also emphasizes individual patient centeredness and outcomes measures to tailor and constantly adjust the program delivery.

A Mathematica "environmental scan" determined that 68% of purchasers currently and 84% plan to buy PHM services.  Yet, while the future is bright for the PHM industry, "it is not clear whether [these] programs can deliver better health outcomes." 

Two problems that stymied the report's authors are 1)"methods" for improving the health of populations have yet to be "identified" and 2) more has to be done to determine how they will be "fit together."  They noted that while some interventions work (for example, health promotion directed at blood lipid levels), the specifics in terms of programs and participants vary considerably.  As a result, they found that 66% of purchasers of PHM services are skeptical about whether they are getting their money's worth.

Nonetheless, "desirable" features of PHM include 1) integrating it into the benefit, i.e., covering it, 2) using a combination of interventions, 3) offering beneficiaries incentives for participation, 4) individually tailoring the interventions and 5) pursuing NCQA Wellness and Health Promotion accreditation.

So there you have it: a state-of-the-art assessment. While the answer is continued monitoring and evaluation, the decade-old industry is still in its "infancy."  There is uncertainty over outcomes, yet many desirable features.  It's being bought by a majority of insurers who simultaneously doubt its effectiveness.

The DMCB understands Mathematica's pain, especially on Tuesday nights.  That's when the trash may or may not make it outside in time for the morning pick-up.

Natural Language Processing: Implications for Population Health and Disease Management

While the topic of "natural language processing" may seem esoteric and far afield from the science of  population health management (PHM), the Disease Management Care Blog thinks this JAMA article on the topic may be important to the industry.

Briefly, the authors tested an automated "Multi-threaded Clinical Vocabulary Server natural language processor system" to scour the free text (such as progress notes and discharge summaries) of the electronic health records of  a sample of Veterans Affairs patients for evidence of post-operative complications.  Recall that up until now, the only way to measure complications is to pay someone to go through every page of the record or rely on largely self-reported and voluntary "coding" billing systems.  Compared to expert nurse reviewers, the automated natural language processing system in this study correctly identified - depending on the type of post-operative complication - about 60 to 90% of the cases.

This is important to the PHM industry because its care and case managers typically enter their interactions with patients into their own electronic documentation systems using a combination of 1) close-ended and goal-oriented check boxes ("importance of daily self-weighing discussed with client") in combination with free text that documents more open-ended conversations.  While buyers of PHM services pay to have every patient get every intervention all the time and every time, the industry has been criticized for imposing one-size-fits-all care management protocols on its patients.  That's why they force their nurses to use those check-boxes.

While detecting the occurrence of complications following surgery is not the same as measuring the content of patient coaching, the DMCB predicts the technology can be readily adapted to PHM.  When that happens, coaching nurses won't have to put up with as many of those check boxes and be able to focus on having "real" open ended conversations with their clients. Free-text systems will be able to count whether "weighing" was included in the documentation and nurses will be able to focus more on the patient and less on data entry.

That's a good thing.

And by the way, the DMCB thinks it's just a matter of time until the next step: analysis of voice recordings between nurse-coaches and their patients.

Software Eating The World of Health Care

Munch, Chomp, Swallow

In an August 20 WSJ Weekend Edition article on "Why Software Is Eating the World," IT investor-entrepreneur Marc Andreessen argues in favor of an intriguing "disruptive" business model.  While he's at it, he's also defending IT behemoth HP's new non-PC strategy against considerable investor ire. 

His thesis is that it is internet-based programming - a.k.a "software" - that is providing goods and services in an increasingly digital marketplace. While the more obvious examples of this transition include books, the entertainment industry, photography, gaming, job recruiting and communications, the Disease Management Care Blog didn't appreciate software's newly dominant role in energy development, agriculture, financial services and national defense.  For example, FedEx is really a "network with trucks" while U.S. soldiers can be thought of as an "application" on the business end of a computer program.

While Mr. Andreessen makes only a passing reference to the implications for healthcare, the pseudo-Luddite  DMCB agrees that he may be onto something.  While healthcare is a decidedly different industry, it's possible to envision a hospital setting in which patients are embedded in an intranet that noninvasively monitors vital signs, assembles data into user-friendly displays of summary information, robotically ensures safe medication delivery every time all the time and enables nurses and physicians to focus on what's really important - aided by artificial intelligence that ranges from alerts to best practices.  In fact, it's already begun and bound to get better.

And it won't be too much longer until this care model spreads to the outpatient setting.  Persons with diabetes will have their Bluetoothed blood glucose and activity levels non-invasively monitored, while face-recognition software will then be able to calculate portion sizes off of a picture of a plate and recommend insulin doses.  Frail elders living at home won't have to trigger a "fallen-and-I-can't-get-up" Life Call because movement and position monitoring algorithms will do that for them.  Think asthma inhalers with RFID chips, blood pressure cuffs tethered to the internet and Skype-oid communication for every patient 30 days after discharge.

Of course evidence-based purists will quibble over the lack of published proof. Skeptical managed care actuaries will fight to have health care software excluded from the insurance benefit.  Patient advocates will fret about privacy and its Big Brother intrusiveness.  Not a problem, says the DMCB, because the world is changing.  Physicians will demand it, insurers will cover it and both partners in the new "doctor-payer" dyad will use bundling or other flexible means of payment to get it covered.  What's more, the price point for most of this stuff will come down anyway, especially if it ends up being commoditized just like that PC business that HP is dumping.  Last but not least, the "settings" can be calibrated in a patient-centered way that meets individual preferences.

Software with a health care application. Mr. Andreessen raises the concept, the DMCB fills in some of the substance. 

Image from Wikipedia