Of Medicare Shared Savings Program (MSSP) ACOs, Start-Up Costs, Preliminary Financials and Data Support

The Disease Management Care Blog didn't know there was a "National Association of ACOs" either, but they've just released results from a "web" survey of the organization member ACOs that are participating in the Medicare Shared Savings Program.  You can read more about the Program here. 

Of the total number of 123 MSSP participants, 35 anonymously participated in the survey. Their covered beneficiary numbers ranged from 5,100 to 78,000.

Among the findings:

Start up costs in the first year of operation averaged $2 million, with a range from $300,000 to $6.7 million.  With continued operations, the average cost over two years was $3.5 million. Total capital needs averaged $4 million.

While Medicare has yet to release any formal financial results, the ACOs' estimated results showed that 13 guessed they would break even. Nine will gain an average of $1.3 million and six will lose $1.3 million.  Six had no estimates, while other gains and losses ranged from positive $9 million to negative $10 million, respectively.

The biggest problem? "CMS data and learning to access it and process it."  This required pricey information technology with an average of $413,000 internal and $443,000 external costs.

The DMCB's take:

Running an integrated delivery system or physician-hospital organization as part of an ACO is a very expensive and capital intense enterprise.  Given the additional costs of new technology, electronic records and personnel, some of the ACOs may not be able to afford the loss of millions of dollars.  It remains to be seen how Medicare will handle the downside of hospital lay offs or clinical program discontinuations among some of the MSSP participants.  Will members of Congress have to get involved on behalf of their local constituents?  Stay tuned!

As the disease management industry learned, it's one thing to "save money," it's another to save money in excess of fees plus program costs.  $3.5 million over two years is a lot of money to make up before you break even, making the DMCB wonder if cheaper programs (such as population health management) with a more modest scope (such as reducing readmissions) may have a better long term value proposition. Once again, stay tuned.

And the Disease Management Care Blog predicted there'd be problems with the data feeds here.  Recall that one of the problems with the Medicare Health Support program were "execution" problems with the timely provision of utilization data from CMS.  ACOs - and the Medicare beneficiaries they're taking care of - deserve better. 

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.

Image from Wikipedia

How The Medicare Entitlements Could Be Reformed, Why That Is Unlikely And Why Medicare Needs Disease Management More Than Ever

Will the Committee Come to Order?

In a prior post on the coming Congressional "super committee" scorched-earth Battle of the Budget, the Disease Management Care Blog predicted that there will be no time, no technical knowledge and no tolerance for any fiddling with Medicare entitlements.  That leaves reducing payments to providers.  Former HCFA Administrator Gail Wilensky agrees.

Yet, for some insight on how Congress could reduce entitlements, check out this proposal from U.S. Senators Lieberman (I-CT) and Coburn M.D. (R-OK).  Four of the more interesting features are......

Phase in an age eligibility of 67 years (because our life expectancy is increasing)

Increase the premium for Medicare Part B (it will reduce its dependence on tax revenue) and require those with higher incomes to pay more (for the same coverage, by the way).

Consolidate the deductible at $550 for Medicare A and B, while sweetening things with an out-of-pocket maximum at $7500 (but increase it for persons with higher incomes, even though they won't be getting better coverage by the way).

Prohibit "first dollar" coverage by the private Medi-gap plans (which will presumably disincent beneficiaries from using unnecessary care services; critics could charge that that could have the same impact the use of necessary care services too, especially for the poor).

While the baby-boomer DMCB ponders the prospect of having to chose between higher premiums with elevated out-of-pocket costs versus having to shop around with a premium-supported voucher, Congress has a far more fundamental choice: it is going to have to chose between making voters pay more or paying providers less.  Given the outline above combined with the toxic partisan rancor, it's already pretty clear what the political choice is going to be.

Last but not least, the DMCB continues to be mystified by the unwillingness of CMS to reconsider its posture on covering remote coaching disease and population health management.  If CMS wants to save money, here are three good reasons to do so:

 1) the suite of services, sophistication and "reach" of modern disease management have grown considerably since the bad old days of Medicare Health Support,

2) there's some evidence that Medicare Health Support actually did some good, and

3) much of the cost-saving, patient-centered care management activities of the successful Group Practice Demonstration were modeled after old fashioned disease management including phone calls by nurses that were external to the primary care sites.

Here's a future question for the super committee to ponder as it tackles CMS' rising costs: if State Medicaid programs and commercial insurers currently rely on versions of disease management and if ACOs are likely to do so once they're up and running, why isn't it good enough for a supposedly innovative CMS?

Use Enterprise Risk Management in Your Dealings with the Feds: A Lesson From LifeMasters

The Disease Management Care Blog has been thinking some more about the LifeMasters bankruptcy debacle.

There will be some additional fall out but in the meantime the the DMCB thinks there are some important lessons for the future:

The Government Can Be a Fickle Business Partner: One classic example is the Medicare Advantage (and let's not forget Medicare+Choice) program. Like it or not, that Federal program has been a roller coaster of commitments made and unmade. While you may not feel sorry for the contracting insurers, there's still something unfair about midstream and unilateral funding cuts ultimately based on shifting politics and budget shortfalls. It's a heluva way for a government to treat its citizens, especially when it comes to insurance.

And now we have LifeMasters. As the DMCB understands it, the disease management organizations (DMOs) that participated in the Medicare Health Support (MHS) Demo are dealing with the specter of having to remit their fees minus the savings back to CMS. The DMCB hasn't been privvy to the contracting terms, but it suspects there is room for interpretation and negotiating. The fact that one of the DMOs had to resort to bankruptcy suggests that the flexible, mutually beneficial, inquiry-driven partnerships that have characterized the MHS pilot has been replaced by lawyering. How much of the government’s hardball interpretation of the pilot's terms is a function of the CMS’ legitimate fiduciary responsibility versus a change in President, the lack of a strong full time CMS administrator and budget shortfall? Are the other DMOs involved in the MHS pilot going to have to litigate their way out of this?

Beware Rosy Actuarial Projections: The DMCB remembers those heady days back in the 1990s when those of us in traditional disease management thought we could conquer the world. While there were some preliminary studies that suggested increased quality and lower costs, our enthusiasm made us generalize preliminary findings involving an underdeveloped uni-dimensional care approach to any population in any setting. The fact that we were so naïve is OK, but let's face it. The calcuations underlying CMS' and LifeMaster’s assumptions on the fees and savings were about as accurate as all the other predictions about Medicare costs. It won’t be the last time.

There is a relatively new and admittedly imperfect business tool called 'enterprise risk management.' The DMCB suggests sponsors of the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) and Co-Ops that are so anxious to do business with the Feds aggresively use their ERM to pause and think really long and really hard about all the worse case scenarios that could happen when getting into the projected savings business with CMS. Think hard about changes in the administration, funding levels, the tax code, insurance support, costs vs. upside risk, data availability, shifting regulators and the threat of litigation. It's not only good corporate governance, but when it comes to the goverment, it may be all that stands between you and bankruptcy.

The DMCB Cannot Help It: More on Medicare Health Support

While popular media tries to ascertain whether a mysterious pancreatic ‘hormone imbalance’ can be ‘nutritionally’ treated or if a media-star neurosurgeon is qualified to be U.S. Surgeon General, the Disease Management Care Blog can't help it - it's still thinking about MHS. It is marveling over how little attention is being focused on the 18 month update on the Medicare Health Support program. It didn’t show up KaiserNetwork.org and had only a brief mention in the Health Care Blog. A Google search uncovered little additional commentary. Given the new Administration's interest in the topic, you'd think there'd be more buzz. Apparently, many observers concluded long ago that disease management and fee-for-service Medicare were not to be. The DMCB hoped otherwise, because it calculated that it would take more than a year to see any meaningful outcomes. Well, a year has passed......

A more detailed review – with a promise of more to come – is over at the e-CareManagement Blog. The DMCB is especially looking forward to this, because co-blogger, colleague and epidemiologist Tom Wilson may be able to define the report’s approach to conducting t tests of mean differences using ANCOVA regression modeling.

In the meantime, the DMCB steered around the statistical gobbledygook and scrutinized the clinical quality outcomes measures. If there is supposed to be a correlation between health care quality and economic outcomes, the a) measures used in this report were disappointing and b) the degree of improvement in what was measured was small. Table 5.1 in the report displays rates of cholesterol, urinary protein, eye and A1c screening. The DMCB knows cholesterol ‘screening’ will have little impact on health care utilization in 18 months. What really counts are the use of ACE inhibitors/beta blockers in heart failure patients or the degree of glucose or blood pressure control among persons with diabetes or the promotion of flu shots or pneumovax among both types of patients. Where are these important data?

Given the disappointing lack of any reduction in emergency room visits or inpatient stays among persons with heart failure, the DMCB also wonders if the disease management organizations were unable to garner meaningful physician support. While an informal assessment of physician attitudes indicated they believed disease management was helpful to their patients, the DMCB knows that it’s one thing to teach patients to avoid the ER with daily weights and proactive calls to the PCP, another thing to have physicians say nice things about you, while it’s another thing entirely to get the PCPs to add these semi-emergently ill patients to their already overbooked schedules. Perhaps the physician owned Medical Home Demo will do better here.

The DMCB’s disappointment, however, is being tempered by a mention the Health Affairs blog. It is looking forward to the themed March 2009 issue and reading it along with Sanjay Gupta and all the Obama health advisors.

Medicare Health Support Becomes A 'Black Sheep'

Many families have them. The dysfunctional uncle that was in jail. The disreputable cousin struggling with drug abuse. The lazy n’er-do-well brother-in-law. Furtive glances at the dinner table when they’re brought up in front of strangers. Prefer not to talk about them. They’re the ‘black sheep’ and the disease management ‘family’ now has theirs: it’s called Medicare Health Support (MHS). And like that dreaded 2 AM ‘Hi, I’m in town!’ phone call, MHS is inconveniently dropping in with a 69 page update with an additional year’s worth of data.

Recall this is the largest experiment ever involving classic disease management. It’s a Medicare-sponsored, randomized and prospective trial involving eight different disease management organizations (DMOs). They have been paid an average of $67 to $118 per patient per month to manage tens of thousands of randomly assigned Medicare fee-for-service patients with chronic illness in a mix of urban, suburban and rural settings. To assess the impact of disease management, patients are being compared on satisfaction, clinical outcomes and cost to usual care patents that are serving as controls. Participants have to opt in. The goal is to save money or at least break even by reducing Medicare’s claims expense equal to the amount of the disease management fees.

Participation rates were 74-95%; 4-15% could not be reached and the remainder refused. Participants who opted in turned out to be a healthier and less costly subset. In addition, one year later, CMS offered the DMOs the option doubling down by supplementing their assigned populations with additional ‘refresh’ patients. 7 of the 8 accepted, hoping to attract greater numbers of persons with chronic heart failure. By then, LifeMasters had already backed out, but things unraveled after that. McKesson and CIGNA exited followed by XL Health and Green Ribbon requesting early termination of their contracts.

The data has continued to roll in. And what did the disease management family find when they opened the door to the black sheep this time?

Of multiple measures of satisfaction, only 13% showed a statistically significant improvement.

40% of multiple measures of clinical quality showed a modest improvement of 2-4%.

There were no statistically significant reductions in hospitalizations, rates of readmission, or emergency room (ER) visits between the intervention and comparison groups.

No statistically significant differences were observed in mortality rates.

The claims expense trend rate was not statistically different compared to control patients overall or in individual disease categories. After statistically controlling for the differences that developed after randomization, the lack of any difference in claims expense held up. Including the refresh population didn’t make any difference.

Ugh. But, the Disease Management Care Blog doesn’t exactly think it’s all that bad. It has some black sheep in its family and they’re not THAT bad either. Here’s why:

In an ‘ala cart,’ and free-range system of care, it’s becoming very apparent that it's difficult to control/steer/influence Medicare beneficiary behavior. That contrasts with controlled systems with limited networks and creative/restrictive benefit designs. Disease management works best when it’s a part of managed care which still has a significant role to play. How well physicians are able to do this in the Medical Home - absent a 'gatekeeping' approach - remains to be seen.

Secondly, MHS is testing an approach to population-based care that is already becoming obsolete. New approaches with Ver. 2.0 disease management that are better aligned with information systems, benefit designs, consumerism and primary care are already underway. Disease management has already learned what doesn’t work and is applying those lessons in the marketplace.

Last but not least, the DMCB thinks the market and the Feds decided months ago that ‘disease management’ in fee-for-service Medicare doesn’t have much of a future. This latest report is merely a reaffirmation of that.

Everyone knows about the black sheep. Time to move on.

Mr. Daschle and Medicare Health Support

From the savvy Merrill Goozner of the GoozNews blog about Mr. Daschle's likely ascent to head of the U.S. Dept. of Health and Human Services (HHS) (italics mine):

'.... he has the knowledge that will allow him to make his mark in the short run by instituting bold administrative changes at the agencies under his new command, especially the Center for Medicare and Medicaid Services. Changes in the government's two big health care programs, which account for half of all health care spending, can pave the way for changes throughout the system.

For instance, look for him to reinstitute programs like Medicare Health Support, which offered individualized chronic care management to beneficiaries with heart disease and diabetes, but was abruptly canceled by the Bush administration earlier this year. He may experiment with broader pay-for-performance rules for physicians, or tinker with the relative compensation system that pays radiologists and surgeons three times the salary of primary care physicians. Look for an exponential increase in pilot programs at HHS that could set the stage for broad-based reform.'

Healthways and CMS Shakes Hands. Is a Phase II Next?

Healthways and CMS have signed an "Amendment" which 'changes the financial performance target for both its Initial Cohort and Refresh Cohort to budget neutrality from 5.0% net savings and 2.5% net savings, respectively.' The Disease Management Care Blog checked the CMS web site for more info. Finding none, it listened in on a recording of the May 6 Healthways Investor Relations web cast.

As the DMCB understands it, a new analysis of a 'refresh cohort' consisting of approximately 4000 enrollees with just chronic heart failure shows the company is within reach of achieving budget neutrality. They feel it is possible that in the remaining months, they can demonstrate an additional $3-$4 hundred thousand in savings and get from 93% of fees to 100%. If they reach it, they note that the original legislation requires the Secretary of HHS to launch Phase II because (and this was read out loud during the call):

"With respect to chronic care improvement programs conducted under subsection (b), if the Secretary finds that the results of the independent evaluation conducted under subsection (b)(6) indicate that the conditions specified in paragraph (2) have been met by a program (or components of such program), the Secretary shall enter into agreements consistent with subsection (f) to expand the implementation of the program (or components) to additional geographic areas not covered under the program as conducted under subsection (b), which may include the implementation of the program on a national basis.

special emphasis on 'a program' not all programs.

Because of the budget neutrality agreement, Healthways has been able to recognize $5.2 million of revenue that was otherwise tied up in its Medicare Health Support pilot. Guess what they are doing with this money? Instead of letting it flow into the company's bottom line, they are using it to disperse bonuses to the 'colleague' employees who are working in the MHS Program.

Does anyone have any doubt that the colleagues are going to work hard in the coming months to achieve the neutrality? Einstein has been quoted as saying the two most powerful forces in the Universe are gravity and compounding interest. From previous experience, the DMCB knows a 3rd force is nurses. It also knows of all the chronic illnesses, heart failure is probably the most amenable to efforts to decrease inpatient utilization.

Disease Management: Are We Asking the Right Questions?

Suppose it was reported that a widely used condition-management program that relied on nurses didn’t work? That, according to an exhaustive review of the available literature, there is ‘scant evidence to support [its] effectiveness in terms of outcomes or economic cost?’ What’s more, that the studies that do exist ‘have been hindered by methodological challenges,’ including inappropriate sample size calculations and contamination of the referent control groups? Would you wonder why commercial insurers are willing to pay for it? Would you recommend against including it in the Medicare benefit?

Well, say goodbye to hospice, you cruel, malicious heel. Zimmerman and colleagues, reporting in the April 9 JAMA (subscription required to get to the full article) found that there were 22 randomized control clinical trials evaluating ‘palliative care,’ which was defined as a service that provides or coordinates comprehensive care for patients with terminal illness. Only 4 of 13 studies found that there was an improvement in quality of life, 1 of 14 found that there was symptom improvement and 1 of 7 found that there were cost savings. Yet, palliative care is a growth industry with approximately 4,500 standing programs, of which 46% are for profit, involving 1.3 million patients. It’s been covered by Medicare since 1982, along with the vast majority of other commercial and government health insurance programs.

The Disease Management Care Blog has already fussed over the “evidence-based” double standard being applied by many of the health care illuminati to ‘population-based care approaches’ to care versus yearly check-ups, the medical home and integrated delivery systems. While that cognitive dissonance can be a source of great fun, it’s time to be serious.

The DMCB thinks it’s difficult for the vast majority of hospice programs to accommodate randomized clinical trials (RCTs) let alone concoct one. It’s simply “out of reach” in terms of their business model or available resources. What’s more, the vast majority of hospice programs leaders, their workers, their patients, the families and the physicians wouldn’t want to bother with RCTs because the questions they answer wouldn’t add to their knowledge. Sound familiar?

How can we reconcile what we know and accept about hospice versus the lack of evidence? The DMCB commends an excellent essay authored by Don Berwick in a preceding issue of JAMA (subscription again). In it, he points out RCTs are better suited for the circumscribed evaluation of tests, drugs and procedures. They fall short, however, in evaluating complex multi-component interventions that depend on ‘context’ and the ‘mechanism.’ It’s not a matter of getting to the right answers, it’s a matter of getting to the right questions.

He suggests new evaluation methodologies are necessary when the question is not if something works, but why and under what circumstances. He also recommends that a) the high threshold used to decide whether change is warranted needs to shift if the status quo is unacceptable, b) sources of bias are better accommodated than eliminated and c) academician-front-line caregiver gap needs to be bridged.

Can you think of a big health care policy debate that would benefit from this approach? Hint here.

Disease Management Tells Us Why There Are So Many Black Holes

And so it came to pass in the days of Medicare Health Support that there was great gnashing of teeth and consternation of the disease management organizations’ CEOs. So each CEO went up alone to his or her computer screen and came upon a WEB CAM, and the WEB CAM was activated and pointed at the CEO and the computer screen together.

When they gazed upon the computer screen, each image from the WEB CAM was of a screen with a WEB CAM image with a screen of a WEB CAM image with a screen and so forth and so on. And the physics were such that each image was slightly delayed compared to the previous screen image. The CEOs found that by looking into the delayed images of the delayed images of the delayed images and so on and so forth that the delays could be summated one upon the other and they could peer into the distant past.

And they looked onto joyous days that were upon disease management before Medicare Health Support. They lusted mightily for those past days of prodigious commercial growth, publication of flawed peer-reviewed studies and the adoration of all those who sought the Big Bang Solution To All That Ails Health Care. They compared those blissful times to the present age of great despondence, filled with heinous stipulations of “evidence,” and “proof.” They pondered greatly and silently wondered if pursuing Medicare Health Support was a grievous blunder. The wished they could go back and right what was wrong. They were desirous of a do-over.

But more physics intruded. For across the oceans a great and powerful supercollider that spun subatomic particles of infinitesimal smallness was borne of man’s curiosity about spaghettification and the antigravitational implications of Aretha Franklin’s bodice. Alas, man’s intellectual hubris failed to heed warnings that supercolliders can spawn planet-munching world-chomping black holes. For the CEOs’ WEB CAMS pointed the wrong way. They discerned the past, but were unable to foretell the future.

And it happened that one day when the supercollider on-switch was pressed upon, another black hole was created. A cataclysmic reaction sucked Earth into an event horizon vortex of singularity that created a rent in the time-space continuum. But a worm hole emerged and the Earth was propelled to a past time in another universe. The CEOs had their do-over.

But the Metaverse had the last laugh. For despite James T Kirk’s exploits, time travel also results in memory befuddlement. And so the CEOs fell onto Medicare Health Support, again. And, after the passing of some time, they again coveted for the days before Medicare Health Support. And then another black hole was created.

And so it happened again and again and again.

The New York Times and Medicare Health Support

Read all the news that's fit to print about Medicare Health Support.

'Outcomes' in a Medicare population is not only difficult, so is changing Medicare

The data are preliminary.

No final decisions have been made.

Physicians Support Medicare Health Support

Healthways is continuing to pull out all the stops in getting Medicare Health Support back on track. According to its press release, ‘more than 500 health care professionals’ and ‘400 family care givers’ have ‘appealed’ to members of Congress on behalf continuing the program. There is even a web site that hosts the scripting of personal emails.

The DMCB suspects Healthways had a hand in prompting the appeals but nonetheless, getting 500 health care professionals to do anything in unison is remarkable.

But then again, influencing health care providers is one of the things that the disease management industry strives to do. Maybe it's better at it than previously appreciated.

The Medicare Trust Fund: Problems and Non-Solutions

The Disease Management Care Blog has been reading about the Federal Government’s indolent cherry blossom-induced somnambulism over the downward spiral of the Medicare trust fund. But do not fret, present and future beneficiaries, because the same folks that brought you the Medicare Health Support imbroglio have ridden to the rescue with a press release outlining their recommendations for meaningful reform:

• ‘Basing payment levels on provider reports on quality and their ability to prevent costly and life-threatening hospital acquired infections’

Hospital acquired infections include but are not limited to line sepsis, ventilator associated pneumonia, pseudomembranous colitis and surgical incisions. The latter probably get the most attention. One good study found the rate of these could be reduced from just under 4% to 0.6% with the administration of properly timed antibiotics. Don’t get me wrong, any avoidable infection is one too many, but I’m not sure the economics of making 99.5% vs. 96 % is all that compelling in the big picture.

• ‘Providing transparent quality and cost information to beneficiaries and providers;’

With all this attention on evidence-based medicine, where is the evidence that this really works? Here's a report that casts doubt on the notion that patients use publicly available quality information in choosing one hospital versus another. As for the providers, skepticism abounds. I once presented a hospital’s Medicare data at a Grand Rounds at an academic medical center and was met with incredulity. I was also not invited back.

• ‘Developing and testing strategies to pay more for better results rather than more services;’

The hospital P4P data is still young, but what information exists in the peer review literature suggests that the gains are modest at best.

• ‘Implementing competitive bidding approaches to the delivery of care;’

The DMCB heard of this at a policy conference years ago and it makes sense. Note that the latest example of competitive programmatic bidding in the Medicare program was Medicare Health Support. If it’s good enough for Healthways, the DMCB figures it must be good enough for the nation’s hospitals.

• ‘Promoting the adoption of interoperable health information technology;’

The DMCB doubts this is as big a money saver as many seem to think. It is not alone.

• ‘Implementing reductions in market basket rates of growth, as proposed in the President’s 2009 Budget, including a proposed 0.4 percent reduction in the growth rate of Medicare payments if Congress does not pass a specific alternative proposal to achieve needed improvements in sustainability; ‘

Do not worry my fellow physicians. Pending the eventual discovery of MedPAC that there is a problem, other revenue opportunities include concierge medicine, botox parties, tattoo removal, depiliation, internet medication prescribing, personal wellness coaching, IT based virtual care, circuit riding around the country to testify in malpractice cases, and taxi driving.

• ‘Increasing the share of program costs paid by the highest-income beneficiaries, as proposed in the 2009 Budget.’

So in other words, we each pay different amounts for the same health insurance benefit. In the opinion of the DMCB, that’s not a problem if the lowest income beneficiaries get their money’s worth, let alone mine.

But the DMCB won’t stop there. Notably absent was any mention of increasing the role of primary care physicians, determining how the chronic care model may address the health care needs of the costliest Medicare beneficiaries and – of course – capitalizing on the latest generation disease management programs that are being relied on by the majority of nation’s commercial insurers. Last but not least, how about using the Medicare Health Support program to find what works - and what doesn't

Medicare Health Support - the DMAA Weighs In

Important article in the March 24 issue of Modern Healthcare:

The unsinkable Tracey Moorhead has penned an opinion on behalf of DMAA about the recent CMS decision to suspend Medicare Health Support.

Among her many points, the decision means:

• gains made to date will be jeopardized
  

• new initiatives will be difficult to re-start

• local alliances will be disrupted

• lessons learned will be lost

• beneficiaries who seem to like it so far will be denied an important service
  

• it's too early to tell

• flexibility is called for

• additional analyses may offer new insights

Healthways Tells Us About the State of the Disease Management Industry

Ben Leedle, Healthways’ CEO, recently completed that quarterly ritual known as the Earnings Call. The Disease Management Care Blog looked past the nascent optimism and went for the story behind the transcript – it makes for interesting reading because it tells us a lot about the disease management industry in general. I’ve culled telling (if sometimes awkwardly worded) parts of the transcript below and paired them with my industry insights. See if you agree:

The DM market is more than just outsourcing vs. not outsourcing by individual insurers - insurers are seeking to do both:

‘we believe the best in class solutions for health plans will always be a combination of in-source and out-sourced capabilities that are well-knit together.’

The U.S. business environment for DM is good:

‘continuing success in g rowing [sic] our domestic business can be found in the more than 200 contracts signed year-to-date.’

One reason it’s good is because there is demand for wellness intertwined DM:

‘we are seeing is a very strong shift and a rapid move for disease management and wellness programs to be integrated.’

Another reason why it’s good is because health plans want to use DM to avoid becoming commoditized and just paying claims:

‘pressure on the health plans to show their relevancy to do just that. So I think it is going to press them, as we’ve said for a long, long time, that at the end of the day it will be about outcome and that the market will pursue at a higher rate of expectation that you can deliver and improve those outcomes.’

And international markets too:

‘Our second central growth initiative is to expand our addressable market beyond our domestic business. One way we are doing this is through our international initiative…with DAK, the second largest statutory insurer in Germany….Brazil became our latest new addressable market with the signing of a ten year disease management services agreement with Fleury FA'

As far as we’re concerned, the debate about the science is over:

‘Twenty-one significant publications, nearly one-third of all the published peer reviewed outcome studies in our industry over the past ten years have evaluated our solutions and proven the value of the work that we do with our customers. Sixteen of these studies evaluated our disease management outcomes. Five evaluated results of health improvement solutions.’

Turning terabytes of data to information and information to insight are an emerging and important part of the business model:

'Gallup will make at least 365,000+ annual surveys for the next 25 years. Coupled with the deep clinical, behavior change and claims data Healthways will provide, the Gallup Healthways Well-being Index will…measure the health and well being of population(s) to guide strategies for improvement and to evaluate the effectiveness of selected solutions….We leverage one of the largest and diverse databases for health improvement on the planet. We maintain more than 200 terabytes of consumer data across claims, clinical, utilization and intervention support categories.'

What was not said:

Chronic care model, medical home.

We’re from the government and we’re here to help you with timely access to data, following the intent of Congress and complete transparency, not:

'What we don’t know any more than you do is where that data came from or have the opportunity for CMS to share with us how they came to those conclusions…we went public with a statement about request for that clarification….I think the one thing to keep in mind is the difference between any kind of financial reconciliation related to the Cooperative Agreement and the construct and concept and work that will be done to evaluate the performance of these pilots consistent with the way that the Statute was written. I think there is still confusion in the marketplace around the difference in those two things and it is going to be really important that you keep that in mind….I can’t draw any conclusion around it until I understand directly from CMS how they arrived at those numbers and for what time periods they arrived for it and what was their work done in being able to calculate relative trend lines and the rate of change that has to occur with remaining months.'

Update on Medicare Health Support - Democracy in Action

Modern Healthcare Online (free subscription required for full access) is first out with an interesting story describing the letter sent by four U.S. Senators to CMS about the halting of Medicare Health Support. They are "concerned." Hints about which Senators are here and here.

News on Medicare Health Support and Healthways

Check out the press release about a letter to CMS.

The disease management blog is a big fan of Grammy winning Amy Winehouse. While his dream is to someday serve in background vocals, for now he'll have to settle for drawing inspiration from her lyrics. With apologies to Ms. Winehouse and her song "Rehab"........

They’re trying to kill off Health Support
N’ it’s bad luck luck luck
Yes, results r’ bad, n’ industry says egads
That’s a lot of bucks, bucks bucks.

We got press releases
And lots of letters sayin’ please
Weems’ stomping all over Health Support
Want benes t’say no no no.

Feds coulda done a better job
We feels we been robbbbedddd.
Slow data sharing n’ flawed method’s was done
Hoping Congress passes legislationnnn

We don’t know a lot of stats
But we know Congress has its own math

They’re trying to kill off Med’Care Health Support
Say hell no no no
More to tell, but term’s confidential
Ouch! A lot of dough, dough dough

More news on Medicare Health Support: Mass. Senator Kerry weighs in.....

According to DMAA eNews Feb 12:

"An influential Senate lawmaker last week told a health policy publication that he would consider legislation to keep Medicare Health Support (MHS) operational past the scheduled end of the pilot's first phase.

If he succeeds, Sen. John Kerry, D-Mass., would block a recent and controversial decision by the Centers for Medicare and Medicaid Services (CMS) to end the pilot this year without providing continuity of services to the 68,000 beneficiaries in MHS. In an unexpected announcement Jan. 29, CMS said it would begin closing out five MHS programs this summer as each reached the end of the three-year Phase I pilot. Transition to a second phase could be delayed up to three years while CMS evaluates Phase I results, the agency said.

In an e-mail last week to the online newsletter Inside CMS, Kerry blasted the CMS decision and pledged to explore a legislative remedy. "This hold-up places red tape right over a solution that works for 68,000 seniors who rely on this program for the care they need," Kerry told the publication.

"The Bush Administration complains that we aren't doing enough to control costs, yet they are halting a promising pilot mid-stream, cutting seniors off at the knees," Kerry told Inside CMS. "The government should be encouraging solutions that help solve our nation's healthcare crisis, and I am looking at legislative options to fix this short-sighted decision."

DMAA and others decried the CMS decision, saying it will strand thousands of Medicare beneficiaries and their physicians without important chronic care coordination support. "These beneficiaries, as well as their providers and family caregivers, enthusiastically welcomed these services, as evidenced by participation rates, satisfaction measures and a demonstrated willingness to take important steps toward better health," DMAA President and CEO Tracey Moorhead said in a Jan. 30 statement.

Further, DMAA argued, the CMS claim of poor Phase I results is not supported by the findings of an interim MHS report last year and serious flaws in the program design and operation have hampered Medicare Health Support Organizations' efforts."

More on Medicare Health Support

While we wait for a better explanation from CMS, the Disease Management Blog has turned to popular culture for solace over the stealthy and what Vince Kuraitis eruditely describes as the bizarre Medicare Health Support Phase I announcement.

Werewolves from London played a big role in my formative years and there is a familiar chord progression that speaks to the topic - with posthumous apologies to eternal Warren Zevon:

Well we went and asked the Congress
Like everyone must do
How were we to know
If that five percent was true?

We gambled in the Beltway

We thought the law was passed
Send lawyers guns and money
Our lobbyists must act!

We're the innocent fee holderrrrr
And somehow we will pay
If not in a claw-back,
Then it's in the market cap
It's in the market cap
And it's in the market cap

Now we're hiding from investors
Medical Home has advanced!
Send lawyers guns and money
The **** has hit the fan!


I'm also a big fan of Dennis Hopper who reminds us that he doesn't really care, he's got his own point of view punctuated by bolding and hand gestures made famous from his counterculture Easy Rider biker days:

Fade in, play Spencer Davis Group, Gimme Some Lovin'
Dunda dunda duh, UNH, Dunda dunda duh UNH

Your healthcare attitudes are crazy.... they're impossible! They're not in this textbook. You're not some monthly fee, some guideline! (Toss book onto sand). Your generation is definitely not going to be told by some health provider how to manage anything. You're going to write your own book that's going to turn healthcare upside down. When I'm 62, I decide what pills. I decide which tests. Time to redefine outcomes, man.

(Voiceover) The best healthcare you'll get is your own. Your adviser can help you get it started and get to a degree of health defined by your dreams. Work with you one-on-one to make sure your health helps your dreams become a reality.

I just don't see you not being in charge. (Grin... nod).

(Fade out gimme gimme sum lovin... gimme gimme some lovin.....)

Ouch!







The Disease Management Blog remembers this is not the first time that the Medicare Program has "pulled the plug" and left its business partners feeling as if their expectations were not being exceeded. As a service to my colleagues at Healthways, I offer this link.


It's turning out to be a busy week for the disease management community. There's more news:






?Rumors about Matria here.











And XLHealth gets shaken.