Rockin' to Some Outcomes Numbers

There's been surge in peer review literature and twitter commentary on the merits of statin for prevention. The Population Health Blog says show clever videos like this to patients with high blood pressure, high lipids or diabetes and let them decide.



An email to Dr. McCormack said "well done, sir, well done."

Do Employer-Based Wellness Programs Work?

Reuters tackles worksite wellness outcomes

Mrs. Smith (name changed) was overweight.  She knew it and her physician, the Disease Management Care Blog, knew that she knew it.  Since the DMCB was one of the two persons on the planet who knew her true weight, she could talk to it behind closed doors about diet, exercise, fads, over the counter meds, prescription appetite suppressants and even bariatric surgery. 

What the DMCB quickly discovered was that Mrs. Smith's weight-loss goals were not only unrealistic but, like many women struggling with weight, driven more by the prospect of how she'd look in a bathing suit than any real health benefit.

Mrs. Smith wasn't alone. This seminal study demonstrated just how unrealistic women's weight loss goals (in the range of 50 lbs.) can be.  Think of the popularity of The Biggest Loser and it's easy to see why persons think thinness is just a matter of a few months of dieting and exercise, and that being skinny leads to health and happiness, 

Easy, right?

DMCB readers know otherwise. That's why they're not going to be impressed by the tone of this May 24 Reuters article on worksite wellness.  RAND, in a not-quite released report to Congress, examined the impact of several employee based programs and found, in the words of the Reuters reporter, only a "modest effect."  Average weight loss was "only" three lbs., tobacco cessation rates were significant but "short term," average cholesterol levels were unchanged and reductions in health insurance claims expense failed to achieve statistical significance.

Researchers have known for years that conservative dietary and lifestyle therapy typically results in weight loss in the range described above. In addition, cholesterol reduction as a primary prevention intervention is low yield when it comes to health. On the other hand, even short term tobacco cessation is a good thing. When it comes to the ability of wellness to reduce health care costs, weight reduction is unlikely to drive claims expense for a health insurer within two to three years, the impact of obesity on overall mortality rates is not as large as you'd think and "prevention" rarely saves money.

What's more, these programs were able to achieve their "modest" outcomes without increasing claims expense.  Participants lost weight and stopped smoking at no additional cost to the system.  Now that is something.

Mrs. Smith and Reuters are very similar.  Both are struggling with nrealistic expectations thanks to dubious fashion trends, media misinformation and scientific ignorance.  Fortunately, Mrs. Smith had access to a resource that could help her better manage her weight.  The DMCB can only hope that Reuters has access to a resource that can help it manage its lack of background knowledge.

Retail Clinics for Chronic Conditions Like Asthma, Hypertension, Lipids and Diabetes Mellitus: A Look At the Value Proposition

Is there a business model in there?

To the delight of skeptics, pundits and bloggers everywhere, U.S. health reform continues to follow its predicted trajectory: fiscal shortfalls are now biting the nominally "wealthy," the Feds aren't about to admit that they're in over their head on implementing their health insurance exchanges, opportunities for cronyism are increasing and the DMCB spouse is wondering why her supposedly expert-husband can't find health insurance for less than a thousand a month.

In the meantime, there's no sign that Washington DC will ease up on the "accomodative" money-printing presses that are feeding "QE Infinity."  That's no problem, though, because Europe is reminding us that once the paper currency is undermined, selling gold is a handy way to quell grumpy voters and prop up the welfare state.

Yet, Clayton Christensen tells us a fix is at hand: much of health care's quality and costs travails, he says, can be solved by embracing the disruptive innovation of non-physician treatment of acute and chronic conditions.  His supporters are undoubtedly cheering Walgreens' recent decision to to have its 330 Take Care Clinics add hypertension, diabetes, high cholesterol and asthma care to its portfolio of nurse practitioner services.

After reading the usual retail clinic policy tomes both for ("access to care") and against ("health care balkanization" plus "missed diagnoses"), the Disease Management Care Blog isn't convinced that Walgreens' decision is such a slam dunk.

That's because these clinics' business proposition is less about innovation and more about being a loss leader that increases retail pharmacy foot-traffic. In fact, offering free retail clinic services has been tried. The premise is that the retail customer-patients will stop by the pharmacy window for new drugs and, while they're at it, renew those other high margin prescriptions.  If they pick up some diapers and nail polish while making their way to the front of the store, all the better.

While that certainly sounds good, retail clinics are not a build-it-and-they-will-come cash machine.  Recall that CVS had to pull the plug on its retail clinics several years ago.  Foot traffic didn't materialize and the supposed loss leader turned into a money pit. 

The good news for Walgreens is that they have Jeffrey Kang in their corner.  Prior to this, he led health insurer CIGNA's disease management initiatives. He undoubtedly understands retail, population-based outcomes and care coordination. If anyone can pull this off, he can.

The DMCB's conclusions?

It won't be easy. While Walgreens' we-accept-all-insurance plans-VISA-Mastercard-and-American Express foray into primary care might work, it could also fail. Large health care systems use their primary care providers to feed their high margin and still-profitable specialty care services.  On the other side, small physician-owned practices are learning that hustling, high service standards, attention to overhead, accurate billing, patient mix and ancillaries can be profitable. Walgreens has neither. It remains to be seen whether this publicly owned company's bottom line will be aided by salaried NPs chasing pharmaceuticals' narrowing margins.

Speaking of margins, the DMCB wonders if Walgreens will use its clinics to steer patients toward favored formularies or aid rebate and market share agreements. Could they also use and eventually monetize the Big Data like Target to further the company's business interests? If any one knows, please contact the DMCB.

Commoditization?  The DMCB thinks so and it's not alone. Over time, the professionals staffing these clinics may find primary care is more complex and that they and their patients deserve better.

Ease of Exit? For who? Given that this is ultimately a business, it would be corporate malfeasance if Walgreens didn't have an exit strategy. Unfortunately, one company's exit could be another patient's abandonment. That's a real risk for the patients who come to count on Walgreens for their longitudinal care.

Patient Centered Medical Home Threat... or Friend?  The DMCB doesn't think so. If the medical home offers the value that its advocates say, savvy health care consumers will be able to vote with their feet. If the PCMH falters, it won't be because of Walgreens; in fact, the threat of competition may force help medical homes be more efficient.  In the meantime, medical homes should treat retail clinics like a community resource and refer (or outsource) appropriate patients for routine health care. Why not?

Treating High Cholesterol in Children? Think Again, But If We Must, Think Also About Disease Management

The condolences of the Disease Management Care Blog go out to all the primary care pediatricians whose phone lines will be lit up tomorrow, thanks to tonight’s news reports about treating high cholesterol in children. Moms will be calling and asking if their children need to start statins for high cholesterol. And why not? After all, chances are dad, mom, the aunts the uncles and all four grandparents are taking them also.

The reports were prompted by a July 1 ‘clinical report’ from the American Academy of Pediatrics (AAP). If you skip down to the summary at the end of the article, the good news is that unless the ‘bad’ cholesterol or LDL is extremely high, children 8 years or older who are just overweight or obese will never need to take a statin. However, if the child is obese and has an additional chronic condition such as high blood pressure, diabetes mellitus or tobacco abuse and diet is to no avail, drug treatment, depending on the LDL level, is recommended.

The notion of starting children on long-term statin therapy is not new. Other conditions including kidney disease, heart transplants, Kawasaki disease and surviving cancer treatment have been treated with statins for many years. The good news is that in these populations, the incidence of side effects has been very low.

On the other hand, the DMCB – who is the first to admit that it knows little about pediatrics – is wondering if the AAP is recommending an overly aggressive treatment approach. While it is true that even children are developing early signs of atherosclerotic vascular disease, the science here is one of primary prevention. Even among adults, the ‘yield’ from using statins to prevent disease in persons without a prior heart attack is quite low. Decreases cardiovascular events are measured in single percentage points over 5 years or single digits per 1000 patient years. Ironically, even though heart attack rates may go down, there are no data showing there is a decrease in mortality. Can we generalize the data from adults to children without the benefit of good evidence from long term prospective randomized clinical trials that go longer than just one year? What’s more, have enough children been exposed to statins over a long enough period of time to help us truly understand the long term health consequences? Last but not least, have we reached the point where our lifestyles have driven even our children into pills for all their ills?

But the DMCB isn’t about the harangue the pediatric community with rhetorical questions about the science. Instead, it is concerned that the AAP report has no mention of need for a dedicated long term drug safety registry in this age group. Lacking any insight from prospective clinical trials, we need this kind of database to assess the ongoing safety and value of statins in the pediatric population.

The DMCB also couldn’t help but notice that the AAP report did not list any potential conflicts of interests involving the authors – especially since the payoff to statin pharma manufacturers from this expansion in their market could be significant. Think there aren’t other bloggers digging into that potentially juicy possibility as I type this?

Last but not least, there is little mention of the contribution of disease management. The DMCB suggests a prescription for a statin should be accompanied by health coaching that not only engages patients in maximally managing diet and exercise, but helps assure medication adherence and is ready to help with potential side effects. And if the AAP isn’t going to lead the way, perhaps the disease management companies (or pharmacy benefit managers - who are getting into disease management) could use their considerable IT resources to help create the registries – adding even greater value to the services that could be provided in this area. If my colleagues in DM were particularly courageous, they could also open-source them.