The Lament About the Healthcare "Return on Investment"

The Population Health Blog had time to go back and review this New England Journal article on "return on investment" in healthcare

It's abbreviated "ROI."

In it, academic researchers David Asch, Mark Pauly and Ralph Muller lament that interest in getting a "return" from reducing healthcare utilization is unfair. While it is a sought-after metric in chronic conditions (for e.g., diabetes) it's practically unheard of other care settings (for e.g., cancer care).

The authors point out that may be because:

1) Care of conditions like cancer is very remunerative to providers, so there is little interest in reducing income. In contrast, diabetes has little "top-line" potential;

2) Unlike conditions like diabetes, reimbursement around the "episode of care" following a new diagnosis of cancer explicitly supports a known - and profitable - suite of hospital-clinic services;

3) "Savings" from reduced health care utilization can be complicated by the "back-filling" of empty appointment slots and unfilled beds with other patients with other needs and other sources of income.

There are two solutions.

The first is at the front-end by decreasing (with or without bundling) the reimbursement. That would presumably force the providers to gain care efficiencies that exceed the accompanying lower payments.

The second is at the back-end with "shared savings." This financially rewards providers who can muster efficient episodes of care. In other words, the check is the "ROI."

All good points, but written from the provider perspective.  From the perspective of buyers (businesses and individuals who buy/pay taxes for commercial or government insurance) it's more simple: services flex up to meet generous fee schedules and flex down when payment shrinks.

The right balance between the money and care can be determined by brutal and efficient markets or by all wise and mistake-prone policymakers.  Take your pick, implies the authors, but if it's the latter, the results are preordained.

The PHB would offer three other points on ROI:

1) We've seen this movie before: Using financial incentives to drive fewer hospitalizations, drugs and specialists is perilously close to rewarding the withholding of needed care.

2) Measuring non-events is hard: "ROI" in most healthcare settings is not a classic ratio of income to investment, but savings to investment to savings. The latter is ultimately based on a statistical measure of what doesn't happen vs. the baseline utilization of a large population. It's not easy to discern the "signal" of fewer pricey hospitalizations, fewer expensive drugs, or less need to see costly specialist physicians from the "noise" of healthcare inflation.

3) High health status ≠ low cost: Increasing quality of life is often a function of increased access to costly health care that is often a function of socioeconomic status.  In other words, you get what you pay for in both healthcare and lifestyle.

Which is the PHB's lament It's not a function of "saving" money, but using it wisely.  It's not a matter of ROI, but creating patient-centric value.

Image from Wikipedia

The Potential of Community Health Workers (CHWs)

He was among the highest.

Utilizers of healthcare services, that is. 

I had the pleasure of talking to a physician who is leading a group of community health workers (CHWs) assigned to taking care of dozens of patients like this.  Burdened by decades of multiple chronic conditions, patients like him are typically struggling with myriad complications of chronic illness, side effects from numerous medications, mental illness, extreme poverty and homelessness.  The result is an endless cycle of emergency room visits, admissions, discharges and more emergency room visits.

According to the physician I talked to, these highest utilizers don't need more physician care; us docs can only do so much with an office visit. They also don't need health insurance, because they already have it. 

What these patients really need are resources that can help bridge the aspirations of health reform and the reality of the street.

The Population Health Blog agrees. In its professional career, it saw plenty of insured people with access to health care who were still unable to get better.  They didn't need more of the PHB, they needed..... help, in the form of monitoring, education, coaching, encouragement and advice.

Enter this timely article by Dr. Kangovi and colleagues appearing in the June 11 issue of the New England Journal.  It's a good primer on the long history of CHWs and the work that will be necessary to mainsteam them into health reform.  
 
CHW-based programs in the U.S. have been around since the 1960s. They typically focus on the indigent, are modest in scope, and have been funded "hand-to-mouth" by community organizations.  However, they've also been used to facilitate insurance enrollment, support "Medicaid Health Homes" and provide preventive and screening services on a regional basis. 

The PHB believes, however, that their greatest value proposition may be in supporting interventions for high utilizing patients under Medicaid waiver arrangements or in managed care programs. By coordinating alternatives to the emergency room revolving doors, CHWs can save taxpayers a lot of money.

Dr. Kangovi et al describe five barriers to the widespread adoption of CHWs:

1) Insufficient integration with traditional providers - But the good news is that CHWs can now use the shared data and remote electronic communication of health information technology to extend the reach of the non-physician (e.g. nurses, social workers) members of a medical home.

2) Fragmented health care systems - But the good news is that health care organizations are slowly being forced out into the communities that surround them. CHWs are waiting.

3) Lack of treatment protocols - But the good news is that this is an emerging science. Some on-line resources already exist.

4) High worker turnover - the authors cite one Harlem program that lost a third of their workers over a matter of months.  The good news is that there are ways to identify "keepers" who will find the CHW career to be satisfying.

5) Low quality published evidence - But the good news is that the volume and the quality of published research is going up.  Even better news is that that will help inform accreditation programs.

That high utilizer mentioned above?  The PHB learned that his last encounter with the health care system was in a primary care provider's office, in the company of a CHW.

Image from Wikipedia

Rising Healthcare Costs: Delayed or Defeated?

Ready, set......

According to this just-published New England Journal article, analysts are still waiting for the twin forces of 1) an improving U.S. economy and 2) higher numbers of newly insured Americans to reignite healthcare inflation.  While the latest data from the Bureau of Economic Analysis (BEA) are conflicting, data from the early part of 2014 suggests that health costs are remaining tame.

What gives?
 
While many Obamacare supporters say this is more evidence of Washington's central-planning genius, author Charles Roehrig notes other factors be at play, namely:

1. The 9 million of 2014's newly insured amounts to 3% of the U.S. population. Their baseline spending was probably half of normal, so the resulting increase would expand the nation's spending by a modest additional 1.5%.  Since this group is younger, it'll likely be less than that.  Their contribution to increasing costs will be harder to detect.

2. What's more, insurance enrollments were finalized relatively late in the year, so these newly insured haven't had much of a chance to give their new benefits an early test-drive.

3. The first quarter of 2014 was an unusually cold winter. The Population Health Blog recalls how freezing temps, wind and snow made for a relaxed day at the clinic. Multiply that across millions of newly as well as long-term insured people, and it adds up.

4. Yes, stupid, it is the economy, which has a strong correlation with healthcare spending. Loss of health insurance thanks to unemployment, declining tax revenues that pressure government insurance programs to limit eligibility as well as benefits, employers' unwillingness to go along with otherwise automatic benefit increases and a general unwillingness of consumers to open their wallets in recessionary times has also added up.

5. Thanks to the expiration of some patents, prescription drug spending moderated.

Bottom line: all of the above are one-time impacts.  The economy's impact and new access to insurance are lasting fundamentals that will not go away. It's too soon to tell what is really going on.
 
The PHB will stay tuned.

CMS Succumbs to Disease Management Style Spin?

If, thanks to the medical home or disease management, you've witnessed the improvements in patients' care, you've also probably been frustrated by those silly skeptics' insistence on validation. But for traditional research designs, statistical significance, valid comparators and publication in obscure scientific journals, the face validity of nurse-led care management for high risk patients could have ushered in a new era in primary care.

Darn those academic-actuary-statistician-weenies! And double darn CMS for falling for them and not funding the medical home and disease management!

Which is why Population Health Blog readers may enjoy this bit of peer-review schadenfreude. It appears a recent CMS pronouncement that its own "Partnership for Patients Program" prevented early elective deliveries and reduced readmissions is highly suspect, thanks to "a weak design, a lack of valid metrics, and a lack of external peer review for its evaluation." 

Yikes.

It appears the amateurs at CMS used a pre-post design, selected start and stop evaluation points to gin up the outcomes, relied on imperfect administrative data and never bothered with having its outcomes validated by independent review. As a result, we really don't know if the billion of dollars that went into PPP did any good at all.

The PHB appreciates the point. Scientific discipline and peer review go a long way making sure that consumers are getting their money's worth. Now that CMS has gone from an agnostic payer to the centerpiece of health reform, there's a huge risk that its bureaucrats will succumb to shortcuts and spin.

Taxpayers deserve better.  And so do patients.

Image from Wikipedia

17 Reasons Why Care Management Is Probably Not Going To Be in a Clinic Near You Anytime Soon

Here's a good review of all the reasons why care management has not become a routine part of patient care. 

As policymakers, reformists, consultants and architects plan for a population and outcomes-based future, they'd be wise to think about the review's 17-point reality check.

1) Start-up costs are considerable;

2) Costly to maintain;

3) Multi-year time horizon for any return on investment;

4) Any success undercuts future traditional fee-for-service revenue;

5) Can't be broken down into discreet 'reimbursible" units for fee-for-service payments;

6) It's paid for with still-novel-experimental capitated payments and/or shared savings;

7) The link between increased quality today and downstream savings tomorrow is still tenuous;

8) Complicates primary care by introducing more uncertainty;

9) Non-physician manager training is time-consuming and costly;

10) It's a resource that is best reserved for high risk patients, not all patients;

11) Doesn't fit into long-standing clinical workflows in established clinics;

12) Primary care already has enough challenges and implementing care management is not a priority;

13) Most EHRs are not configured to document or support non-physician care;

14) Decision-makers need additional information on expected net savings;

15) It relies on a lot of outside-the-doc-comfort zone behavioral, vs. "medical" health interventions;

16) It requires considerable data support;

17) It's often balkanized by multiple payers.

But be of good cheer. Jimmy Cliff reminds us that half the battle is knowing what you're up against.

The Just Right "Sweet Middle" of Care Management

Finding the "just right" middle

If you're interested in care management (definition here), there's a supportive case report in the August 7 edition of the New England Journal.

But it also makes a important point that appears to have been missed by the Editors.

The Population Health Blog explains.

The case revolves around a fragile cancer patient with abnormal blood chemistries and distributed locations of care. The author describes how care management successfully improved the patient's safety, required a lot of physician-to-physician communication and relied on care management's "reach" outside the four walls of the primary care clinic.

All good points.

However, what's also true is that prior to the cancer diagnosis, this was an otherwise well patient with post-discharge needs that were amenable to care management intervention.  In other words, this patient was "high risk, high impact." These individuals make up the narrow middle in the span of patients who range from otherwise well (destined to do OK) to disastrously complicated (destined to do poorly no matter what). 

The Population Health Blog doubts the case would have been so meaningful or successful with a routine surgery patient (stable and OK) or someone with metastatic spread of the cancer (a disaster).

The Population Health Blog is all for patient safety, doc-to-doc communication and distributed care management.  However, they're not going to be of equal benefit for every patient.  If the intent is to "save money" by reducing avoidable health care utilization, it's best aimed at the patients in the middle.

Like this one.

Credble Numbers on Obamacare: And Why is the 16.3% Prevalence of Persons Without Health Insurance Good News?

The signed Affordable Care Act

We finally have some credible numbers on what's happened to insurance enrollment under Obamacare. The paper can be found here.

The authors used the ongoing Gallup-Healthways survey that questions representative samples of the U.S. population about their health insurance status. Since it began, this repeat survey has assessed changes in the coverage of adults 18 to 64 years of age. The authors used these data to assess the trends in insurance status that were associated with the roll-out of Obamacare between January 2012 to June 2014.

For all of 2012 and the first part of 2013, the nation's uninsured rate was 20% to 21%.  Following the star-crossed open enrollment period that began in the fall of 2013, the uninsured rate began to drop.  By April of 2014, it fell to 16.3%. 

Depending on the underlying statistical assumptions, the absolute percent increase in Americans with insurance ranged between 4.2% to 7.1%. States that took the Feds up on their offer to underwrite Medicaid expansion saw a absolute decline of 6%  of low-income Americans having no insurance.

The Population Health Blog predicted that the 2014 outcomes from Obamacare would have something for everyone.  For the news outlets (like this and this) with a reputation of being sympathetic to the Administration, positive spin abounded. In the meantime, more skeptical reporters tried to poke some holes in the data, saying the increase in insurance coverage was really thanks to gains in employment or was in reality a lousy deal thanks to narrow networks.

The PHB's take?

It's struck by the relatively modest decline in the percent of uninsured Americans. Considering the heavy price we've paid, that lingering 16.3% rate is a lot.

That price?  It includes not only the hit to our national fisc, but paralyzing partisan rancor, endless and unpredictable litigation and the precedents of White House 'pen and phone' fiat by regulation. The latter will almost certainly be used by a future Presidents on both sides of the aisle.

And so it goes.

Here Comes Defined Contribution: Implications for Population Health

"Here they come!"

Regular Population Health Blog readers understand that defined benefit insurance plans provide for the future coverage of services (for example, all medically necessary treatment) or income (for example, guaranteed retirement income). 

Failure to account for increasing life expectancy, growing medical demand and technology plus an unwillingness to adequately fund tomorrow's promises with today's dollars have all fueled interest in defined contribution health insurance plans.  They provide financial support before future medical demand occurs. As a result, if the ultimate cost exceeds the available funding, it's up to the beneficiary to make up the difference.

As this timely New England Journal article points out, the defined benefit plans' days are numbered, while defined contribution plans are coming. 

Economists and conservative policymakers like their twin attributes of consumer choice and "skin in the game," while transferring risk away from government and businesses. They also like to point out that employers would be helped by freeing up dollars to hire more individuals and pay them more while also investing in their businesses.  Incidentally, this would also be one solution to the U.S. government's deficit spending.

Past attempts in Congress to translate that logic into a fix for Medicare failed faster than Obama could say "middle class." While the Republicans have proposed that Uncle Sam's rate of defined contributions exceed that of general inflation, opponents pointed out that it wouldn't keep up with medical inflation.

In the meantime, more and more employers are embarking on defined contribution plans.  And as the consumer is being forced to deal with a fixed pot of money, many are finding that they can stretch their dollars by agreeing to high deductible plans or narrow networks.  According to one survey, this is now present in close to 40% of employer-sponsored insurance.

The Population Health Blog's take:

Many of the other darlings of health care reform, such as Accountable Care Organizations (ACOs), medical homes, primary care, integrated delivery systems and population health care management providers will need to adjust to the growth of defined contribution plans with a combination of

1) providing enough value that consumers will be willing to personally pay more for their wares;

2) showing once and for all that they can provide health care for a lower price i.e., save money;

3) maintaining enough geographic or niche market dominance that they can insulate themselves from being commoditized.

A Path Toward Further Health Reform Is Lined With the IRS?

As attention has shifted to phantom IRS emails, misbehaving Iraqis and our newfound national awareness of soccer's off-side rule, it's only natural for the Population Health Blog to wonder about the status of health reform.

Enter The New England Journal with a pair of perspectives on the coming prospects for the Affordable Care Act.

Over on the left, the Brooking Institution's Henry Aaron believes that, notwithstanding ascendant Republican hopes for the 2014 elections, Mr. Obama's veto power virtually guarantees the law's survival.  The only question is whether politics will get in the way of any adjustments.  Once we're into 2015 and beyond, these could include the mandate (weaken any penalties?), Medicaid (spending caps?), the states' roles (allow for local modifications?) and changing affordability standards (increasing income-based premium support for families).

Over on the right, the American Enterprise Institute's Joe Antos agrees there is no going back.  He offers up some potential conservative modifications for 2015 and beyond, such as shifting the insurance premium support to a defined contribution basis (versus a defined benefit), shielding mainstream health insurance by moving catastrophically ill persons to "high-risk" pools and requiring insurers (including Medicare) to leverage consumer education and incentives along with provider teaming to help steer beneficiaries toward lower-cost care options.

Drs. Aaron and Antos both agree that IRS-based enforcement rules may force significant changes.  Under current law, poor persons who underestimated future income for today's premium support calculations may be subject to claw-backs. According to Dr. Aaron, the IRS is responsible for administering that, and any payment would ultimately go to the insurer long after the fact.  Dr. Antos points out that the IRS's enforcement of the mandate could lead to the spectacle of tax refunds being withheld from low-income individuals and families.

The PHB is less sanguine.  While the PHB is no political pundit, the likely increase in the number of Republicans in Congress after 2013 combined with the kick-off of the 2016 Presidential race portends more of the same health reform gridlock. 

The only good news from Aaron and Antos is that growing antipathy toward the IRS may lead Congress to uncouple the IRS and it's enforcement mechanisms from the ACA. It may not be an example of pristine bipartisanship, but if it leads to necessary modifications of the ACA, that's not necessarily a bad thing.

Stay tuned!

Image from Wikipedia

More Big Insights on Big Data

Given the data, what are her chances of
getting breast cancer?

Unable to sate its big appetite for big data insights, the Population Health Blog glommed onto the New England Journal's just-published article on "Learning from Big Data."

As noted previously, "big data" is the use of statistical associations ("predictors") in a) large and b) disparate data sets  to gain insights at the individual level ("outcomes"). For example, a physician could know the likelihood - based on demographic, clinical and economic inputs - that a particular patient won't fill a prescription. As an other example, the PHB spouse could know the likelihood - based on prior active-passive behaviors, incentives and maternal upbringing - the likelihood, despite numerous reminders, that her husband will "forget" to take out the trash.

It's important to recall that big data is not about causality. Just because living in a certain zip code is an independent predictor of obesity (for example) doesn't mean living in [insert name of town] causes residents to be fat. Big data is "agnostic" about the cause, but that doesn't mean Big Data Architects (BDAs) can't use the information.

According to the author, the road from the promise to the reality of big data will be lined with:

1. generalizability, or being confident that the populations used in big data studies are similar to the populations where their lessons are being applied. Propensity matching or scoring is a good step in that direction;

2. automation, so that multiple questions can be answered simultaneously by many users;

3. "data refreshes," so that associations can be retested on repeated basis as new data come on line;

4. ease-of-use, so that even an orthopedist could use the software and understand the outputs.*

Politically, we'll also need to get

5. the owners of data warehouses - including the electronic health record vendors and insurers - to agree on either a) common data formats or b) methods that allow for the interpretation of data regardless of the format. An example of the latter the use of an order, entry or insurance claim for supplemental oxygen therapy as a marker of poor health status.

6) a resolution of our absolutist privacy "impasse.""De-identification" of patients' information makes it possible, but never guaranteed, to keep personal health information secure.

*okay, the New England Journal author didn't poke fun at the orthopedists by saying that, but the PHB couldn't resist. By the way, one way to do this would be to have the outputs be in pictures.

Image from Wikipedia

Maintenance of Certification in Internal Medicine: What the Population Health Community Needs to Know

Since population health provider organizations work closely with physicians, they're aware that "board certification" is an important credential.  Being "boarded" in family practice, pediatrics or internal medicine is widely regarded as evidence of extensive training.

They may not be aware of the controversy brewing over board certification in the internal medicine physician community.

The American Board of Internal Medicine (ABIM) is the certifying Board for the nation's internists.  After meeting training requirements involving years of training after medical school graduation, candidates have to pass an examination.  Once physicians do that, they have the credential that documents their expertise. 

It used to be that once you did the training and passed the test, you were credentialed as a "board certified" internist.... forever.  With increasing recognition that skills can grow stale with time, in 1990 the ABIM decided to require recredentialing on a periodic basis. 

That process has evolved under the umbrella term "maintenance of certification" ("MOC").  You can read more about that here and here, but it basically involves earning "points" through activities such as documentation of learning, participation in quality improvement, chart audits and taking a repeat test.

Unfortunately, MOC and the ABIM have become a focus of physician ire.  While the academics and organized medical societies' leaders believe in the process, many rank and file practicing physicians disagree. 

Among their concerns that are nicely documented here and here:

1. It takes a considerable amount of time, documentation, and paperwork to complete the 10 years' worth of continued training/chart audits and to prepare for the repeat examination.  (That's especially true thanks to the difficulty at extracting electronic records data; it also puts smaller practices at a disadvantage, since they may not have the support personnel to help with all those tasks).

2. It's also expensive.

3. If a physician doesn't pass the test, it needs to be taken again at additional cost.  Over the past five years, the failure rate has increased from 10% to 22%.  Since it's unlikely that the pool of docs entering the MOC process are dumber, that suggests the test is getting unnecessarily harder. Some physicians wonder if ABIM has a financial incentive to increase the failure rate. 

4. Unlike the initial process of board certification, there is little hard evidence that MOC-credentialed physicians  attain better patient outcomes compared to non-MOC physicians.

5. Physicians are unhappy that the MOC process does not recognize the practical wisdom that comes with decades of patient care.  It is "one size fits all" and can't be tailored to account for different practice settings.

6. There is a possibility that MOC could evolve from a voluntary exercise in professionalism to a mandatory condition of licensure, hospital/insurer participation or employment.

7. ABIM not only has a monopoly, it has no oversight. Whatever the merits, the ABIM's MOC actions are seen by some as capricious, arbitrary, disconnected to the real world and only adding to physicians' low morale.  One survey suggests a majority of practicing physicians are skeptical about the MOC.

 The Population Health Blog suspects this is a controversy that is not going away anytime soon.  Population health service providers will always be interested in helping their "orphan" patients without a PCP become engaged with a physician, and may use "board" status as one criterion for referral.  It remains to be seen if "MOC" participation should be part of that calculus.

Stay tuned!

Obesity Surgery in Diabetes Mellitus: A Three Year Trial Shows High "Cure Rates." The Implications for Population Health

In case there is any doubt about the long-term efficacy of obesity surgery for diabetes, check out this three year study that was just published by the New England Journal of Medicine. 150 persons between the ages of 20 and 60 years with an A1c greater than the recommended target of 7% and a BMI greater than 27 were randomly assigned to either gastric bypass, sleeve gastrectomy or intensive medical therapy. 8 persons dropped out after being assigned to medical therapy and one patient had their surgery cancelled. Over the next 3 years, 4 persons were lost to follow up.

Of the remaining participants, two thirds were women and three quarters were white. The mean age was 48 years, the average BMI was a prodigious 36 and the mean A1c was a poor 9.3%, with an average duration of diabetes of just over 8 years. 

Of the 40 medical patients, 5% ended up with an A1c of 6%, versus 38% of the 48 bypass and 24% of the 49 sleeve patients.  The average weight loss was 4.3 kg in the medical patients vs. 26 and 21 kg in the bypass and sleeve patients. While only 2% of medically treated patients were able to stop their diabetes medications, 69% and 43% of the bypass and sleeve patients were able to do so. Only four patients in the surgery groups required additional surgery for the treatment of complications.  None died.

The Population Health Blog finds the results compelling enough to believe that the surgical option for obesity-related diabetes mellitus may be turning out to be a first line option.  The complication rate is acceptably low and the "cure" rate of up to 70% (if defined as not having to take medications) is likely to be welcomed by patients facing a lifetime of otherwise chronic illness.

Criticisms?

Critics may worry that any long-term economic benefits at a population-based level may be cancelled by the cost of surgery.  The PHB understands that, but doesn't believe that obesity surgery should be viewed through a "return-on-investment" lens.  Rather, the value assessment of "outcome" (in terms of diabetes and obesity cure) per unit of cost (dollars spent) is a as good as an investment compared to, say, coronary artery bypass grafting or a knee replacement.

Critics may also worry that obesity surgery is more of a symptom of an overfed society and that our national treasure would be better spent on understanding our dietary dysfunctions.  The Population Health Blog cannot disagree, but doubts that our national health spending can be wired so that every dollar spent on the promotion of nutritional wisdom will reduce the near-term health care cost crisis from diabetes.  We need to be prepared to invest in both.

Implications for Population Health

It appears to the PHB that this was a single site "efficacy" study involving an academic medical center.  We don't know if the low complication rate observed here is typical of other hospitals that offer obesity surgery.  In addition, this study did not examine the impact of the more popular approach of banding surgery.  That being said, this three year trial suggests that bariatric surgery should be offered in the suite of options for persons meeting the criteria above.

The good news is that shared decision making has already been evaluated in this setting.  While the majority of participants are more likely to chose conservative treatment, the point is that a 40-70% chance of cure over three years should be raised in the course of patient-centric coaching.  Population health vendors in the diabetes-obesity "space" should be prepared to engage patients on this treatment option and help them decide if surgery is the right choice for them.

Image from Wikipedia

"Opt-Out" Health Insurance Enrollment

Say no to your health insurance?

Kudos to the New England Journal for providing a tidy summary of the latest Republican healthcare reform proposal. Up until now, the Population Health/Disease Management Care Blog was only vaguely aware of the GOP's evolution from the political party of "no" to one of "go," albeit with lots of caveats. 

It seems the Senate Republicans no longer want to repeal Obamacare and are OK with keeping many of its more popular reforms.  Instead, they're focusing on undoing selected provisions, such as repealing the minimum benefit, returning some aspects of medical underwriting and resurrecting the "block grants" for Medicaid.

But one of the more interesting wrinkles in the proposal is "auto-enrollment."

Those of us from the bygone days of "disease management" may recall the debates over the merits of "opt-in" versus "opt out" participation in our programs.  The former required persons to actively chose to be entered into nurse coaching, which had the advantage of committing resources to a highly motivated population.  The latter approach assumed all patients with a condition were enrolled and, only if they specifically requested it, would they allowed to stop the coaching phone calls.  Unfortunately, "opt-out" usually gathered many patients who never answered the phone and were "engaged" in name only.

Well, the Republicans are apparently proposing that states be allowed to "auto-enroll" persons eligible for premium payment support into an insurance plan or Medicaid without their up-front permission, just like the old "opt-out" disease management days.  The tax credit would cover the insurance costs, no bills would be issued to the consumer and voilà! the risk pools would expand.  Patient choice would be preserved, because persons could always just say no.

The DMCB was always of fan of opt-in disease management.  Not only were patients who wanted to be in the program more amenable to behavior change, it allowed the program to "flex" the nurses that we needed as the program grew in scope.  However, when it comes to insurance, the DMCB thinks the Republicans may be onto something with their opt-out insurance approach.

Count it as a fan.

What the Obamacare Health Insurance Exchanges Can - and Can't - Do

It looked so easy, didn't it? 

So says Massachusetts Connector architect John Kingsdale.  Writing in the prestigious New England Journal, the Obamacare insurance exchange was supposed to list health insurance options in a user-friendly fashion while simultaneously determining eligibility for exemptions and subsidies. 

What happened instead was the mother of all procurement debacles. What's worse, it was all predictable because it turns out that less than 10% of government's IT development contracts are successful.

So, if you like your government's version of insurance Expedia, you can't keep it because it was never really there.

But, says Dr. Kingsdale, assuming Uncle Sam gets its act together, there are four big reasons to like a functioning health insurance exchange:

1. User-friendly insurance shopping: transparent and easy-to-understand choices involving a core set of trade-offs can save time and fulfill conservatives' demands for market-based solutions.

2. Paperless technology: An on-line automated and scalable distribution system should eliminate much of the commercial insurers' marketing and enrollment costs.  Those savings should go to the consumer.

3. Competition: while its unlikely that plans with narrow networks and high out-of-pocket costs will ever go away, exchanges lower their barriers to market entry by other insurers, which should lead to more options for consumers.

4. Quality: as insurers collaborate with health systems, exchanges can lead users to select coverage options that are linked to particular provider entities, like ACOs.

The Disease Management Care Blog has a skeptical take to Dr. Kingsdale's vision.  Here's the downside arguments to why it may not work and why the DMCB will reserve judgment:

1. When it comes to "shopping" for the current versions health insurance, you get what you pay for, which is currently a highly regulated and rich basket of coverage mandates. Thirty year olds must now have any cancer screening they don't want, just so long as they're at least fifty years old.  All insurers are offering the same thing.

2. Outmoded paperless technology will soon be followed by outmoded desktop PC technology.  By the time the on-line bugs are worked out, iPhone enabled consumers will be wondering where's the app for handheldhealthcare.com.  And, by the way, since when do health insurers pass any savings to consumers?

3. If the Massachusetts Connector fosters "competition," why does Boston lead the nation in physician wait times?  The answer is complicated but has more to do with the nature of commercial monopsonies and government price controls, neither of which will ever be helped by IT.

4. The movement of risk from insurers to providers could eventually lead those providers to use the same tricks as insurers, including utilization management and closed walled-garden networks that are ultimately designed to protect their capitation. Insurer-provider collaboration has more to do with who is monetizing and minimizing risk and consumers won't ultimately see any difference when it comes to the "what" of bad behavior. Quality has little to do with it.

The Disease Management Care Blog Annual Report: Three Insights on Social Media in Health Care

It's that time for the Disease Management Care Blog to reflect on the state of social media, both in general and for this blog. 

First off: an annual report for this blog.

Stats: While overall readership in 2013 was down compared to prior years (37,000 vs. 49,000 unique visits) the number of  "regular readers" (at least once a month) has increased from approximately 5000 to 5200.  And these DMCB regulars are a brainy bunch, with ISPs that include health systems, government agencies, policy shops, regional and national health insurers, population health service providers, hospitals, consultants, news organizations, organized medical societies, universities, pharma companies, health care trade associations, foundations, state as well as city governments and other bloggers.  The DMCB doubts many CEOs or SVPs are reading its bloggery; more likely it's front line managers, supervisors and other leaders who are looking for that extra insight.

It's also been a good year for the DMCB Twitter, with over 700 followers. They likewise reflect the spread of health care stakeholders described above.

What has the DMCB's learned in the last year?

A New Wrinkle on An Old Digital Divide: Health writers have pointed out that the socioeconomically disadvantaged and the hospitals that serve them have been unable afford the power of health information technology. Yet, many well-off health care organizations with knowledge and cultural disadvantages are likewise failing to leverage social media to build visibility and enrich their brand.  Some with established accounts are using them to achieve a competitive advantage, but far fewer have actually done anything useful with them.  The DMCB has listened and their silence is embarrassingly deafening.

Cloud Beats Complicated: While the dominant mainsteam media continues to get complicated medical and health policy news stories half right, the good news is that a collective "cloud" of critically thinking bloggers and twitterers are getting things completely right with an on-line wisdom of crowds. As news sources consolidate and their market power grows more concentrated, social media will come to the rescue.

Print and Social Media beat Print Alone: While the prestigious New England Journal has 200,000 subscribers, the DMCB doubts every published article has the same number of readers.  In contrast, Kevin MD has 100,000 readers and a million monthly page views.  To make a real splash, policy authors would be well advised to have their insights appear in both outlets; that's doubly true because the Digital Divide is likewise present in the medical community.  What's more, social media will place an increasing role in increasing awareness - and the implementation - of discoveries from research extending from the bench to the organization of care.

Image from Wikipedia

How Does the Office of the National Coordinator for Health Information Technology (ONC) Think About EHR Portals?

EHR portals at work?

The Disease Management Care Blog had this thoughtful reply logged onto its "Follow-Up" post on the topic of EHR patient portals. Logged by Rebecca M Coelius MD, Medical Officer for Innovation at HHS/ONC, the DMCB recognized that this was important enough to warrant its own separate page.

While we wish that the results were more conclusive and positive, the Office of the National Coordinator for Health Information Technology (ONC) applauds the meta-analysis and the recent upswing in articles on patient portals and other patient-facing technologies. The number of patients and caregivers who desire greater participation and transparency in their healthcare makes continued research in this area vital. Yet, in a close read of the full Annals of Internal Medicine meta-analysis article and in many of the studies it cites, there were unquestionably statistically significant positive clinical outcomes, as well as positive patient experiences, associated with certain patient portal functions.

The ONC does not believe that Health IT alone is a panacea, or that meeting the form of Meaningful Use, while not embracing the new functions the technologies it enables, is likely to result in measurable improvements. The study authors caution that it was case management that tipped the utility of portals from unclear or small to more substantial, but it is important to note that the case management activities happened via the portal itself. This is a perfect example of Health IT as an enabler of new ways of reaching and caring for patients; we would not separate the two concepts.

To the study’s described limitations, we offer two significant additions. First, the definition of a patient portal remains loosely specified, so it is difficult to make conclusive statements about the entire category. The meta-analysis did attempt to list which functions were present for each study, but half of the studies that looked at patient outcomes gave only a partial description of portal features, and a deeper assessment of the quality of functions and their relevance to the outcomes measured was not present for any study.

A more illustrative future approach would be to evaluate individual functions of portals for impact on patient participation in their care and specific health outcomes, and then ask what design principles and organizational contexts were necessary to make that function successful. For example, the impressive OpenNotes project demonstrated that patients with access to provider notes had a better understanding of their health and condition, improved recall of their care plan, and increased likelihood of taking medications as prescribed. In a New England Journal of Medicine study on weight loss interventions, over twice the number of patients in the remote support intervention groups (telephone, website access, and e-mail support) lost more than 5% of their weight versus the control group. Secure messaging and the ability to view personal health information are two cornerstones of portal functionality within Meaningful Use.

Second, more than 10% of these studies are ten years old, and over a third were published five or more years ago. We understand the necessity of adequate numbers for meta-analyses, but statistical significance does not necessarily confer relevant insights. Technology, and patient preferences and capabilities for using technology have fundamentally changed over the study time periods included, not to mention the maturation among health-care organizations themselves and the expectations of patients.

The very premise of the patient portal is a rapidly ageing one. As the ONC articulated in a 2013 Health Affairs article, there are shifting attitudes related to the traditional roles of patients and providers, and exploding demand and penetration of smartphones, health and wellness apps, and connected devices. We are moving the conversation from engaging people with our existing healthcare system through “portals”, to using technology to move outside our system to reach them every day where health truly happens. What we need to measure and incentivize in the future is not the value of portals, but the value of delivering the right information and intervention to the right person, at the right time, through the right interface based on an individual user’s context.

Three Population Health Management Principles for Reconciling Quality-Based Pay for Performance and the Doctor-Patient Relationship

Writing in the New England Journal, Robert Berenson and Deborah Kay of the Urban Institute say a linchpin of Washington DC's pursuit of quality is a "policy overreach [that] could undermine the quest for higher-value health care."

Yikes.  The Disease Management Care Blog turns to population health management to ponder their unhappiness.

The authors' concern is over Medicare's "Physician Quality Reporting System" or "PQRS."  As the DMCB understands it, PQRS rewards (and penalizes) physicians for outcomes that are calculated from a set of quality "modifiers" that are submitted as part of the Medicare billing statement (an example can be found here).  The amount of money at stake is in the range of 1%-2% of the Medicare reimbursements.

Berensen and Kay point out that while the system has been ramping up over 6 years, 70% of Medicare participating physicians do not submit any modifiers.  In their opinion, that's because:

1) the loss of 1% of any payment is practically meaningless,

2) physicians distrust the metrics and

3) there is a fundamental disconnect between the modifiers and the complex world of clinical practice. 

As examples, radiologists are being dinged for total x-ray exposure while surgeons are being held accountable for pre-op antibiotic administration. While these and other quality measures are important, they fall far short of recognizing what keeps docs up at night, like reading the x-ray correctly and getting a patient through surgery and out of the hospital.

"Hear hear!" says the Disease Management Care Blog.  In the course of a normal day, it is job of doctors to do "doctor stuff" involving one patient at a time. 

But, you ask, isn't that contrary to being accountable to the health of populations? 

The DMCB doesn't think so, because state-of-the-art population health management (PHM) agrees that:

A. Physicians need to be immunized from disruptions their "customer facing" (i.e., the patient) activities.  Otherwise known as the doctor-patient relationship, that's the part of the health care system that relies on the seven or more years of undergraduate and graduate training that turns smart people into exquisitely trained physicians.  Let the doctors be doctors, says the DMCB, and let them worry about their patients.

B. High performing systems - as much as possible - need to be configured around those customer-facing activities, further enabling the doc to focus on the patient who is right here and right now. 

From time to time, PHM might have to intrude.  When it does, the DMCB suggests policymakers recognize that they should proceed:

1) only when it's really important

2) only infrequently and

3) whenever possible, when it reduces physician work by outsourcing (an example in primary care can be found here) those things that don't require the personal involvement of a doc.

It would seem that Medicare's PQRS failed to recognize the fundamentals.

Image fromWikipedia

Insights on Delaying Obamacare's Employer Mandate: Four Potential Unintended Consequences?

Which is it?

Look at we did!

Delaying the employer mandate for one year is simply more evidence of Obamacare's unworkable complexity, says detractors.

The delay is flexibility and democracy in action, says supporters. 

The Disease Management Care Blog is troubled by how Congress and the Obama administration underestimated the complexity of the local implementation of a one-size-fits-all national health program.  It also knows that the White House needs some Affordable Care Act (ACA's) elbow room.

To gain a better understand what's going on, check out this article appearing in the New England Journal. 

Recall that the intent of the ACA was to preserve employer-based insurance while enabling individuals to access similar levels of coverage in on-line exchanges. Toss in some income-based subsidies on the upside along with IRS penalties on the downside, and the intended outcome is that millions of Americans will enter the national risk pools. That, in turn, should lead to premium drops and greater access to health care.

So what could be the impact of the delay?

First off, there's what won't happen. The authors estimate that 2014 will be business-as usual for the vast majority of persons with employer-based insurance.

But here's four things that could happen:

1. Approximately 5 million part-time workers may be closed out from access to their employer's insurance for another year. In addition, the $10 billion in government income from the $2000-per-worker) will be lost.  Both these numbers are small potatoes in a trillion-dollar enterprise involving tens of millions of workers, unless, of course, you happen to be one of those workers.

2. Millions of employed full time workers will continue to take a pass on taking the paycheck deduction for their employer-based insurance.  Whether they change their mind in 2014 will not depend on how hard their employers work to sign them up, but how aggressively the IRS pursues the individual mandate. 

3. Attached to the employer mandate were regulations that would have forced employers with a workforce of greater than 50 persons to offer competitive (read "low") insurance premiums.  Since that's also been delayed, employers and their employees who want insurance have an even greater incentive to access the on-line individual exchanges.  Employers get to reduce their insurance costs while individuals get to take advantage of those upside subsidies. The employer-employee win-win arrangement could not only undercut employer-based insurance, but "triple" the Fed's subsidy budget.

4. The DMCB's physician colleagues are not immune either.  There is emerging evidence that the individual exchanges are likely to offer "frugal" insurance plans.  Early indications are that these plans will turn to the old tricks of restricted networks and low provider reimbursement levels. This could result in millions of newly insured persons further stressing an overloaded primary care provider network.

Care Management Service Providers and the Potential of Accountable Prescribing

In previous posts, the Disease Management Care Blog has repeatedly questioned the wisdom of a one-size-fits-all, top-down, blunt force and Ver 1.0 approach to measuring health care quality.  That's why it's glad to see that the New England Journal of Medicine agrees with the DMCB in this Perspective by Nancy Morden and colleagues on the topic of Accountable Prescribing.

The authors point out that while blood pressure should be less than 140/90, LDL cholesterol less than 100 in persons with a history of heart attack and A1c should be less than 7% in persons with diabetes, it's clear that the cure can be more costly than the disease.

For many individuals with mild elevations in blood pressure, diet and exercise can be enough and, if that doesn't work, cheap water pills often work great.  Among persons with elevated cholesterol levels, inexpensive statin prescriptions can save lives. Metformin for diabetes has been around for decades and it a first line agent no matter what the A1c is.

As a result, they call for measuring and rewarding quality based on accountable prescribing that not only measures the numbers (blood pressure, blood cholesterol or diabetes control), but the percent of individuals receiving conservative or first line treatments.  While this approach would require an even more detailed databases/registries, it's within reach of most commercial insurers and advanced electronic record systems.  We owe it to our patients to provide a tailored, bottom-up, nuanced and Ver. 2. approach to measuring health care quality.

It's also a concept that the population health and care management service providers could, with the right kind of clinical partners, lead.  This calls for a pilot program and, in the DMCB's humble opinion, the sooner, the better.

For a better idea of how this might work, check out this table.

Image from Wikipedia

The Important Look AHEAD (Action for Health in Diabetes) Study: No Benefit from Exercise and Weight Loss in Diabetes?

Diabetes? Exercise and then die just as soon.

It makes sense, doesn't it? If persons are overweight and have diabetes, diet and exercise-based "prevention" should translate into fewer heart attacks, strokes and deaths, right?

Wrong.

It turns out that a just-published and high quality research study shows it's not so simple.  What's more, the Disease Management Care Blog brazenly suggests that the disease management/population health vendors discovered this years ago.

The just-published study is here in the prestigious New England Journal of Medicine. The DMCB suspects that, thanks to the mainstream media's fixation on Snowden, SCOTUS, and Shakira possibly hawking Obamacare, this important research may not get the front-page attention it deserves.  Considering that it was ten-year, prospective, randomized multi-center academic study involving over 5000 patients, that'd be a shame.

Here's the DMCB's summary:

Eligibility: Participants had to be between 45 and 75 years of age with adequately controlled (A1c less than 11) "type 2" diabetes, an "overweight" body mass index (BMI) of 25 or more, blood pressure less than 160/100, an ability to exercise and access to a primary care provider. 

Recruitment: This went from August of 2001 through April of 2004. It was also tailored to keep insulin-using participants to less than 30% of the study group.

Interventions That Were Compared: Participants were randomly assigned to an "intensive lifestyle intervention" study arm or a "support and education" study arm.  The intensive group received weekly group and individual counseling for six months that subsequently tapered over the subsequent duration of the study. The counseling included a 1200-1800 calorie diet plus 175 minutes of moderate physical activity per week that was aimed at achieving a weight loss of at least 7% of body weight.  The support group got only three group sessions per year. Medicines and their doses were generally left to the primary care provider.

Outcomes Studied: Participants' waist circumference, weight, blood pressure, medications and exercise tolerance were assessed once a year. Hospital and other medical records were reviewed to assess the number of deaths and cardiovascular events, such has heart attack or stroke.

The Study Population: 5,124 persons were enrolled; 2570 were randomly assigned to the intensive group while 2575 were assigned to the support group. The average age was 59 years, 60% were women, the median duration of the diabetes diagnosis was 5 years and the average body mass index was a hefty 36. Only 4% were lost to follow-up.

Outcomes:  After a median of 9.6 years of follow-up......

• patients assigned to the intensive group lost approximately three cm. from their waist and six kg. in weight vs. zero cm. and four kg., respectively, in the support group. This translated to a weight loss of 6% of body weight (vs. the target of 7%) in the intensive group vs. about 3.5% in the support group.

• the A1c, which is a test of overall blood sugar control, was about two tenths of a point (7.4% vs. 7.2%) lower (i.e. better) in the intensive group. LDL cholesterol was also lower. Better control of the diabetes meant that the persons in the intensive group were taking fewer medicines at lower doses.

• But it was all for naught.  During the course of the study, there were 403 cardiovascular deaths, non-fatal heart attacks or heart-related ("angina") hospitalizations in the intensive group, vs. 418 in the support group. The calculated rates of 1.8 vs. 1.9 events per 100 person years was too small to be statistically significant and was more likely the result of chance or randomness.

The Disease Management Care Blog's take?

The early painful lesson of the "disease management" industry was that a broad life-style intervention applied to a large group of diabetics was not going to meaningfully improve outcomes. Critics believed that while the interventions were conceptually sound (diet, exercise, weight loss), the delivery was flawed. 

This just published NEJM study would suggest the intervention itself is futile. If so, that is bad news.

"Not so fast!" says the DMCB.

In addition to renaming itself (now "population health"), the industry responded to the science and the critics by retooling.  It learned to channel tailored interventions at population sub-segments who are most likely to experience a specific benefit. Instead of an "intensive" weight loss intervention for all overweight diabetics, population health can use baseline survey, insurance or clinical data to spot (risk stratify) those diabetics who are most likely to achieve a specific benefit that could range from (for example) a sustained 7% weight loss to reduced readmissions.

This NEJM study tried to benefit all diabetics.  A better approach is to find which diabetics will benefit.

As an aside there were some other issues with the study to bring up when debating the study with colleagues and foes:

The BMI of 36 suggests this was a very obese study population that lost only 6% of their body weight during the course of the study.  Since weight was still a health risk at the end of the study, the DMCB wonders if the intervention would have shown more benefit with a less heavy population.

The support group also lost weight and lowered their A1c, which could have obscured the clinically significant benefit in the intervention group. 

This accompanying editorial points out that lower statin and ACE drug use in the intervention group could have paradoxically increased their risk, since these drugs are known to lower the incidence of stroke and heart attack.

The editorial also points out that spin-off studies have already shown that the intervention group benefitted from higher quality of life.