You Get What You Pay For in Cancer Care and Insurers Get What They Save With the Medical Home

The latest issue of Health Affairs is out and the Population Health Blog couldn't stay away. 

Three interesting articles:

The United States healthcare system has been criticized for spending too much of its treasure for too little in the way of outcomes.  Well, it's not that simple.  Stevens and colleagues in this just published Health Affairs study examined global cancer spending and found that increased spending on treatment correlated with drops in cancer mortality. From 1995 to 2007, the U.S. experienced a growth of $18,000 per cancer patient and dropped mortality among amenable cancers from 55 to 45 per 100,000.  Other than Japan and Finland (which benefit from already low levels of cancer plus sociodemographic factors like this and this), no other country has achieved that level of success.

In other words, you get what you pay for.  And when it comes to cancer, residents of the U.S. are not only paying, but getting a lot.

And speaking of payment, the same issue of Health Affairs has an article on multipayer medical home initiatives. The Population Health Blog didn't know this, but 17 of these initiatives have been launched since 2008.  Most were launched by states, not only because they controlled Medicaid's participation, but because they could blunt antitrust concerns. Challenges included agreeing on the criteria for provider participation, standardizing the payment models, and establishing criteria for success. What's more, the political landscape (health reform) and science (risk stratification, for example) has changed over the years. .

In other words, there is still no single approach to the medical home. When you've seen one statewide medical home initiative, you've seen one medical home initiative.

And speaking of initiatives, Geisinger's medical home program was also featured in Health Affairs. This observational study found that its care management nurses were independently associated with lower health care costs for as many as seven years.  That's good news.

But, the PHB knows that the Geisinger Health System is comprised of provider entities (such as its hospitals and the clinic) as well as a managed care insurance plan called Geisinger Health Plan (GHP). According to the article, "GHP hires, trains and manages the embedded case managers, partly because practices often lack resources to support such capabilities."

In other words, since.....

1) reducing health care costs will only benefit the holder of risk (the insurer) and

2) typical primary care settings lack the resources to change their approach to care,

....the real lesson of Geisinger's ProvenCare is that ownership of the medical home by commercial health insurers is an important option in assuring its success.

The Most Interesting Man In the World Teaches the PHB about the Medical Home

The Population Health Blog isn't sure why its Twitter account was targeted by the Dos Equis ads about the exploits of "the world's most interesting man." Tweets on how "His grandmother uses his family recipes!" and "Fish fight for his bait!" tempted the PHB succumb to Twitter followership.

Which naturally prompted the debonair PHB to ponder the exploits of the Patient Centered Medical Home (PCMH).

To wit:

The White House wants to throw the bus under the PCMH.

Health insurers like it when the PCMH loses money.

The PCMH sues malpractice attorneys.

Ezekiel Emanuel wants be enrolled in a PCMH after he turns 75.

Biker pediatricians have tattoos that say "PCMH."

When they encounter a PCMH, actuaries stop counting.

PCMH jargon about smart device apps has led to the creation of a PMCH jargon app.

"PCMH" is how "ACO" is successfully spelled.

The most interesting man in the world is enrolled in a PCMH

The PHB invites other exploits.

Stay healthy, my friends.

Health Information Technology and the Patient Centered Medical Home: Seven Additional Caveats

The Disease Management Care Blog is scheduled to participate in a November 12 PCPCC webinar on the timely topic of population health management (PHM).  We'll be focusing on the October 2013 PCPCC report "Managing Populations, Maximizing Technology." Readers can download it here and refer to page 2 where the DMCB, among other luminaries, is acknowledged for its thoughtful review.

The PCPCC report effectively reminds health system architects and policymakers that the electronic health record (EHR) is necessary - but nowhere near sufficient - for a high performing patient-centered medical neighborhood.  Other information technology (IT) components include intelligent shared decision making, registries, health information exchanges, analytics, referral tracking, telemonitoring, automated outreach, patient communications, mobile apps, decision support and risk stratification.

And that's just for starters. 

The good news here is that while Washington DC's EHR weenies remain focused on the dreary stages "meaningful use," innovative health systems with medical homes and neighborhoods are really using IT to make a thousand PHM flowers bloom.   

Naturally, during the PCPCC webinar, the DMCB isn't going to stop there. If given a chance, it will also point out:

1. Build vs. buy: While health systems generally believe that PHM - with or without its IT  trappings - can be built using local resources, a better answer may be to buy it from a vendor.  Why own it when you can rent it?

2. And speaking of outsourcing: While its physician-colleagues prize the stature that comes from "quarterbacking" a medical home team, what is less appreciated is the distinct possibility that a quarterback is often not the most important position.  Get out of the way and let the IT-empowered and enabled non-physicians do their thing.

3. The EHR gone wrong: "Portals" are preferred by EHR vendors because they push patients toward their products, often run by lawyers who fear HIPAA and typically programmed by IT geeks who only think about code. It's time to put patients first.

4. "This is not my patient!": While predictive modeling generates lists of patients that annoy physicians with multiple inaccuracies, the science is getting better.  That being said, many other tests like EKGs and chest x-rays are notorious for false negative and false positive results.  It's all part of being a doctor.

5. Apply a filter.... please!: The biggest threat from health IT is a data glut of numbers, labs, tests, surveys, messages, alerts, prompts, readings, alarms, vitals and figures that overwhelm medical home team members. That's going to involve setting thresholds and priorities.

6. It's not about the revenue: Forget about using health IT to justify additional payment. In a health system without anymore money, the purpose of health IT is to generate savings.  That means it has to pay for itself.

7. Watch out! The under-appreciated health IT event that is going to change the relationship between insurers and providers: the move from using paid insurance claims to submitted EHR claims to assess population outcomes.

Image from Wikipedia

Inconvenient Facts Get In the Way: Blue Cross Blue Shield of Michigan's Patient Centered Medical Home (PCMH) Program Savings Claims Are Not Based on Statistical Significance

Welcome to your medical home!

The Patient Centered Primary Care Collaborative announced:

"Blue Cross Blue Shield of Michigan saved an estimated $155 million in preventative claim costs over the first three years of its Patient Centered Medical Home program, based on calculations made from an analysis published this month in the Health Services Research Journal".

According to the Blue Cross Blue Shield of Michigan web site:

"'Blue Cross’ Patient-Centered Medical Home is transforming health care delivery, saving millions of dollars and improving lives,' said Daniel J. Loepp, president and CEO of Blue Cross Blue Shield of Michigan."

HIT Consultant's insightful coverage of healthcare innovation said:

"According to the analysis, 'Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs,' researchers found that its Patient Centered Medical Home model, when fully implemented, resulted in:

• 3.5 percent higher quality measure
• 5.1 percent higher preventive care measure
• $26.37 lower per member per month medical cost for adults"

"Whoa!" said the Disease Management Care Blog. Since $155 million from $300 per member per year reductions in claims expense is some very serious savings that, until now, has never been reported for the PCMH, it naturally looked at the original research.

What did the sleuthful  DMCB find?

Contrary to flattering press releases quoted above, the Blue Cross Blue Shield of Michigan did NOT conclusively save any money. The observed savings of $26.37 PMPM failed to achieve statistical significance and could have been the result of normal random variation that naturally occurs in the flow of claims payments.

The DMCB explains.

Physicians participating in the Blue Cross Blue Shield of Michigan Physician Group Incentive Program (PGIP) were in two payment tiers: 1) "partial reimbursement" for self-reported PCMH implementation and 2) 10% "fee enhancements" for self-reported "significant" PCMH implementation. As the DMCB understands it, 65% of all the PCPs in Michigan participated in the self-reporting in both June 2009 and June 2010. These docs cared for approximately 1.5 million Blue Cross Blue Shield patients.

During the course of self reporting, docs had to attest to the presence of PCMH capabilities, including use of a registry, obtaining performance measures, care management capabilities, patient self-management support, 24-7 patient access, test tracking and follow-up, e-prescribing, a web portal, specialty referral guidelines, preventive services and linkages to community services. Various domains within each of the capabilities were assigned a weight that was rolled into an overall score: the higher the score, the "more" the PCMH.

The researchers examined the claims history for the patients cared for at a total of 1,787 practices that were in the PGIP, had a minimum number of BCBS enrollees, had no missing data and were not quality outliers. Their median enrollment was 303 members and a mean per member per month (PMPM) claims expense of $311.

Compared to practices that never achieved any PCMH capabilities, the PMPM for practices that attained "full" (i.e. significant) PCMH implementation was, compared to practices that never achieved any PCMH implementation, $26.37 lower for adults.

The p value for the $26.37 quoted on page 15 of the manuscript equaled 0.0529.

Because the p value is greater than .05, it doesn't reject the null hypothesis and fails to meet the conventionally accepted threshold among health services researchers that the difference is real and not the result of randomness.

For children, the PCMH was associated with a $7.45 increase in costs. That likewise failed to achieve statistical significance (p = .096).

No where in the manuscript do the authors claim there were "155 million" in savings.  The DMCB suspects the authors of the press releases extrapolated the statistically non-significant figure of $26.37 to a population count.  Garbage in, garbage out.

The DMCB take:

1. Its highly likely that BCBS of Michigan has additional actuarial figures that support the cost effectiveness of the PCMH.  BCBS of Michigan also put its numbers into the public domain.  It's also likely that that PGIP and the PCMH represents an important opportunity to build and collaborate with a vibrant primary care network, which ultimately transcends any monetary savings. Kudos at many levels to BCBS of Michigan, says the DMCB, despite an over-generous misinterpretation of published health services research.

2. While the DMCB did not report on the quality measures that were concurrently reported in this HSR study, it also appears statistically significant quality of care gains were made.  That means there were increases in quality with no increase in cost.  That's good news and, thinks the DMCB, a more honest appraisal of the outcomes.

3. Unfortunately, BCBS of Michigan did not report the "net savings."  As noted above, providers were paid to implement the PCMH, which represents an additional and "hidden" PCMH cost.  Assuming the $155 million in reduced claims expense is real, it would have to be contrasted with the millions in additional fees that were paid to the doctors.

Population Health Must Include Social Determinants: The Approach in the Patient Centered Medical Home

Diabetes control isn't
their top concern

The Disease Management Care Blog's primary care colleagues are undoubtedly aware of how "social determinants" can undermine the best care planning. So, if you're going to rely on the Patient Centered Medical Home (PCMH) to increase health care quality and reduce costs, ignoring the impact of poverty or health literacy could lead to poor diabetes control, worsening high blood pressure or more hospital readmissions.

Arvin Garg, Brian Jack and Barry Zuckerman have written a JAMA "Viewpoint" that offers five lessons from pediatric medical homes that can mitigate harmful social determinants:

1) Include social determinants (for example, community factors, substance abuse, education, malnutrition or poverty) in the creation of national treatment guidelines.

2) Develop and implement screening programs to identify any social determinants that could impact medical treatment.

3) Colocate community resources that address social determinant in PCMHs.  Examples include housing programs, job training programs or food pantries.

4) Colocate "outside the box" social programs in PCMHs also.  This is an area ripe for piloting or researching innovative interventions

5) Integrate visiting nurse programs with the PCMH.  Think of the visiting nurses as an extension of the medical home.

As readers of the DMCB are aware, not all PCMH's can build the full suite of services that make up a medical home. Since health insurers and care management vendors are partnering with primary care physicians to build medical homes, this approach to incorporating social determinants in their programs is worth a closer look.

Three Models of Primary Care Teaming (TL, CC and ET): An Unexplored Feature of the Medical Home

What defines optimal outpatient primary care "teaming?"

The Disease Management Care Blog just assumed that if it took equal scoops of adaptable physicians, dedicated nurses and supportive culture and baked with a dollop of accountability, "teaming" would just.... happen.

It turns out that what may come out of that clinical practice oven is a lot more complicated than that. 

Which is why medical home advocates should pay attention to this article by George Washington University's Debra Goetz Goldberg and colleagues.  Interested in finding out more about primary care "teaming," they interviewed, reviewed and observed three different Virginia clinics that had embarked on transformative quality improvement programs.

Each clinic came up with a different version of "teaming":

1."Top of License" - nurses interviewed the patients, presented the problems to the docs and then documented the care plan.  They were also responsible for the patient education.  Thanks to using this model, the physicians almost doubled the number of patients they were seeing per day.

2. "Care Coordinator" - nurses focused on helping patients undergoing care "transitions" (typically out of the hospital) and provided self-management and health education to high-risk, high complexity patients.  Interestingly, unsatisfactory reimbursement levels forced the practice to cut back, but they still doubled mammography and blood pressure control rates among persons with diabetes mellitus.

3. "Enhanced Traditional" - the physicians still performed the bulk of the patient care but the researchers observed that the other clinic personnel benefited from increased trust, communication and hand-offs that translated into patient centered care, shared responsibility and heightened volunteerism.  The practice was unable to measure any outcomes.

"Very interesting!" says the DMCB. Authoritative web-sites like this or this and peer-reviewed articles like this refer to "teaming," but fail to precisely define it.  Assuming the three categories described by Goetz-Goldberg (in shorthand, "TL," "CC" and "ET") hold up in future studies, the DMCB looks forward to learning which approach results in the greatest quality or cost-savings.

Coda: As a reader bonus, the authors offer up a definition of "team-based care" that seems to span all three models and can be used for the DMCB readers' quoting pleasure:

"A group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients."

When It Comes to Nurse Care Managers in Primary Care Settings, It's Not "Build or Buy," It's INVENT or Buy

Seen one of these lately?

The Passenger Pigeon. The Dodo bird.  The primary care clinic nurse.  All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they've last seen these species and you're likely to get the same baffled look that the of DMCB spouse gives when she's asked about her compliant husband who does what he's told.

Yet, the Disease Management Care Blog wasn't aware of the primary care nurses' total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs.  "There are no 'nurses'" she said. "They've all been replaced by office assistants and the docs are trying to get them to do the patient education."

Which makes sense. While articles like this have been lauding health care "teams" made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms.  True, some of the larger health systems with a stake in primary care have kept nurses in the mix, the DMCB thinks that's merely part of a market-preserving loss-leader strategy.

The DMCB looked for medical literature on the topic.  It can't find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape.  If it's wrong, it wants to hear from its readers.

If true, what are the implications?

In large swaths of the primary care landscape, there is no "build or buy."  It's invent or buy.

What's more, younger PCP's are even less familiar with the notion of an office-based nurse, let alone partnering with one.  Physician knowledge may have gone extinct too.

No wonder the Patient Centered Medical Home hasn't caught on.

The Ugly Truth About Patient Satisfaction

Years ago, the Disease Management Care Blog crossed swords with a clinic administrator who was unsatisfied with its Department's patient satisfaction metrics. The DMCB argued sometimes having to say "no" to patients' demands for easy cures, specialist referrals, sophisticated imaging studies or off-formulary drugs could result in low satisfaction rates. It was about then that the DMCB was informed that the patient satisfaction surveys were going to be tied to portion of its income.

Administrator: 1, DMCB: 0.

That's why years later, the DMCB feels partially redeemed by an interesting peer-reviewed publication that examines the lack of any relationship between patient satisfaction and patient centered care.  In case you think they're both the same, think again.

Writing in the July 11 issue of JAMA, authors Joel Kupfer and Edward Bond point out that the former is a consumerist concept that compares service or product delivery to customers' expectations, while the latter is a medical concept that uses patient values to guide medical decision making.

It's been long-known that exceeding expectations leads to customer loyalty which, in turn, leads to greater profits. That's one of the reasons why business-minded hospital administrators typically rely on satisfaction surveys as a key metric of success. Despite their wide use in health care settings, however, Drs. Kupfer and Bond find that "satisfaction" is a poorly researched concept that has little correlation with the important domains of quality, safety, effectiveness, efficiency or equitability. For example, it's possible for over-testing and over-prescribing to give patients the false impression of action and progress. In addition, because patients don't usually bear the full cost of medical care, their opinions don't have to reconcile price and product, like they would for a car or a bottle of shampoo.

What did the DMCB learn, other than, once again, it was right all along?

1. Building a patient centered medical care practice won't necessarily generate high patient satisfaction. Conversely, pursuing high satisfaction rates is not the same as initiating patient centered medical care.

2. "Patient satisfaction rates" are a Ver. 1.0 primitive window into one slice of patient experience that, by itself, ultimately offers little insight about overall quality.  Patients and their doctors deserve better.

Of Thermopylae, The Simpsons and Patient Centered Medicine

The Battle of Thermopylae or
an image of modern patient care?

What can the Battle of Thermopylae and The Simpsons teach us about patient centered medicine?

The Disease Management Care Blog says read on.

At one testosterone-laden point in the six-pack riddled fantasy movie "300," the Spartan narrator admires how some non-Spartan warriors made a "wondrous mess of things" at the Battle of Thermopylae.  It was professional warriors accommodating the pitchfork wielding non-professional farmers in the drive to victory.

And so it is with "patient centered medicine." When it read the New England Journal Perspective by Charles Bardes titled Defining "Patient Centered Medicine," the DMCB was reminded of a coming mess in health care.  That includes the doctor-patient relationship, payment and quality measurement, all of which promise to be scrambled by a decidedly non-professional, imprecise and radical notion: consumers are going to have a big role in what drives value in health care.

While DMCB readers are already familiar with the rhetoric of consumerism, empowerment and shared decision making, Dr. Bardes reminds us that full adoption of PCM will go far deeper. PCM is based in a "biopsychosocial model" that trumps illness over disease and caring over curing. It's rooted in 1960's style psychotherapy that involves a highly tailored, shared and special therapist-client relationship where the journey was no less important than the destination. Graft that onto modern notions of consumerism and medical "value" goes from being scientific, precise, quantitative and measurable to being subjective, shifting, qualitative and immeasurable.

This is important because it redefines the one-sided "special knowledge" that defines the doctor-patient relationship,threatens the business-as-usual payment methods and calls into question the use of measures like HEDIS and Medicare's HospitalCompare.

This may be silly, but think about donut munching Homer Simpson and what this could mean for primary care.  While one would expect Homer to get a prescription to control his diabetes, generate a monthly management fee for his patient centered medical home and have an A1c (that would probably undermine his PCP's quality scores), that goes all away in PCM. What we have instead is empowered Homer ultimately deciding if he really wants to take any pills, payment that is based on his subjective satisfaction and quality measures that record whether Homer was allowed to make informed choice among several treatment options. Whether Marge gets a mammogram is not important; it's whether Marge actively choses to get a mammogram or choses not to.

To Sparta's credit and Hollywood fiction aside, the historical record shows Spartan King Leonides et al welcomed the help of their amateur Greek brethren in stopping the Persian invasion. So, here's a question for the the DMCB's professionals colleagues running the health care system: are we prepared to accept the participation of Homer and Marge in reshaping a dysfunctional health care system?  If the answer is yes, where in the battle can we use them and how much "mess" are we willing to put up with?

Is 'Patient Centered Care' the Jordan River for Health Reform? Thoughts on Dr. Berwick's Piece in Health Affairs & Implications for Disease Management

Ever hear of 'patient centered care?' You might think those are just the standard buzzwords applied to any healthcare initiative that means well. Like.... reducing rehospitalizations, promoting access to primary care, increasing immunization rates and expanding coverage to the uninsured. They’re all ‘patient centered,” right?

Wrong.

The ever insightful and occasionally contrarian Don Berwick of the famous Insitute of Healthcare Improvement takes up the topic in a Health Affairs 'web exclusive.' It's worth a look for anyone interested in treading on the less traveled paths of health reform. While there is a surprising amount of policy history behind the idea, patient centeredness ultimately means that the patient is in charge. Period. That means it's the responsibility of the health care system to meet the patient's needs as defined by the patient - not the professionals, not HIPAA weenies, not pencil headed administrators and certainly not picayune insurers hiding behind reductionist definitions of medical necessity.

Wow.

Before you snort derisively at such a naïve notion and decide to surf on over to the Health Care Blog for more tiresome reruns on the virtues of single payer systems, the wonderfulness of EHRs and the evils of AHIP, pause and think about walking on this wild-side. Then realize Dr. Berwick has already anticipated the three biggest objections from us know-it-alls in the healthcare expert class:

1) Patients may override evidence-based medicine. Dr. Berwick thinks that is a small price pay in exchange for responding to a population of patients that are far better informed than we give them credit for. It is very possible to rely on education coupled with lots of provider dialogue to help patients choose wisely. While some may make unwise decisions, that’s more likely a function of the quality of the education and the dialogue. Last but not least, a few crazy and demanding patients should not hold the rest of the medical world hostage.

2) Patients may use up precious resources. Dr. Berwick asks 'as defined by who,' especially when you consider that demand for health care services doesn't drive supply, rather it's vice versa. Paradoxically, if persons were truly allowed to make their own decisions, the overall demand for health care services could go down.

3) Patients may lose out on the two-way doctor-patient relationship. Dr. Berwick points out that it is far more common for docs’ to tell patients what they can’t have, coupled with emotional distancing. This is a way out of the ‘no, because…’ Desert to the Promised Land of 'yes, if....' Patient Centeredness is our way of getting over the Jordan River.

And he has some simple suggestions. For patients, care needs to be customized, transparent and fully under their control. The training of young physicians needs to be retooled. Older physicians need to be reassured. Finally, providers of health care services can measure performance on patient centeredness using long established and validated surveys created for that very purpose.

The DMCB is intrigued. While Dr. Berwick can be forgiven for restricting his perspective to the patient-physician axis, that doesn’t mean those of us in the population-based care business can’t go further in thinking about this outside the box:

First off, disease management organizations need to approach the topic with cautious optimism. Veterans will recall that the earliest underpinnings of the industry was "patient empowerment." It sounded good at the time, but we were accused of undercutting the physicians' authority. The DMCB appreciates the irony, but doubts a word switch from 'empowerment' to 'centeredness' - even if embraced by Dr. Berwick - will make it any more palatable. That doesn't mean our colleagues in the population-care business shouldn't be prepared to speak to the topic. After all, we are experts.

A small minority of self insured employers and their broker-consultants would be the most likely to embrace a yet-to-be developed 'patient-centered health benefit.' If they can be found (and if the Obamacare blob doesn't impede innovation in commerical employer-based settings), these brave souls could end up being the vanguard of a new chapter in health care reform. An innovative disease management organization could help. Medicare will be struggling on how to sponsor a demo on the topic years from now.

The DMCB thinks the industry-wide focus on ‘evidence-based’ discreet HEDIS measures is a barrier to patient centered care. One way to dispatch this is for insurers to think about a) waiving any and all utilization review and b) pay full P4P to any provider group that convincingly demonstrates they adhere to patient centeredness. Why not? If a patient doesn’t get a mammogram, it’s because the educated patient chose not to. If a high dollar MRI is ordered, it’s because the educated patient wanted it. To go even further, insurers could offer up their own X-Prize to any physician group that develops the criteria and delivers on the promises of the patient centered care approach. Disease management organizations could provide the necessary support for a patient centeredness initiative and help sponsor the Prize.

Why not?

Patient Centered Medical Care and Disease Management

The Disease Management Care Blog is ashamed to admit that 'Patient-Centered Medical Care' (PCMC) has been treated by it as something of an afterthought. What is this concept and what are the implications for disease management?

It turns out that the famous Crossing the Quality Chasm report has included ‘patient centeredness’ as one of the six pillars for the reform of healthcare. In order to achieve this, health care delivery should be customized based on the patient’s values, have open sharing of information, be evidence based and placed under the ultimate control of the patient. There is a good review on the topic here.

This has several important implications:

1) health care delivery will need to be far more flexible and accommodate a range of patient preferences, including doing nothing to being highly aggressive.

2) variation, that bane of the Dartmouth Atlas, the NCQA and quality improvement weenies everywhere could turn out to be a good thing if it is the result of truly empowered patients using their own values and preferences.

3) measurement of 'quality' will be a heluva lot more difficult, since the ‘denominator’ will need to be based on what a reasonable fully informed patient would have chosen for treatment of their back pain, management of their diabetes or use of the ICU with life threatening illness at the age of 90. That reasonableness includes getting an MRI anyway, opting for an A1c of 7.2 and having everything done even if the chance of survival is less than 1%.

4) insurers should embrace it because, in balance, when reasonable patients are fully informed about the risks, benefits and alternatives to various treatment options, proportionately more opt for less invasive (and therefore less expensive and possibly higher value) treatment.

5) once again, disease management should have a huge role to play because it has the resources and institutional intelligence to pull off fully informed patient empowerment. In fact, the DMCB believes disease management organizations should not only emphasize 'PCMC' as part of its suite of services and embrace it as part of its policy advocacy.

PCMC is not an afterthought. It's what disease management has been doing all along.