Ten Contrarian Predictions for Healthcare in 2019

The Disease Management Care Blog resurfaces momentarily to repost a "Ten Healthcare Predictions for 2019" post from LinkedIn.  The busy DMCB is CEO of The Care Centered Collaborative at the Pennsylvania Medical Society and the thoughts below do not express the views of The Collaborative or of The Society. 

They do reflect a belief in physician leadership.

1. 2019 Will Be the Year of the Doctor

After a spending years in the health reform wilderness as commoditized “providers,” doctors will reassert their hard-earned professional designation.  Large health systems will see an uptick in physician-administrator tensions, physician-owned entities that honor the profession will have less trouble poaching talent and the ratio of employed to independent physicians will stabilize.  Contrary to expectations, independent physician entities will cater to millennial doctors’ underappreciated skepticism about corporate healthcare.

2. Physician-led CINs – Health Information Technology Reaches Critical Mass

As their fee-for-service (“volume”) income wanes and payments are shifted to reward quality (”value”) the independent physicians take advantage of advances in information technology to organize into clinically integrated networks (CINs).  Declining costs and increasing sophistication of these information systems is lowering the barriers to market entry. This will enable the best of both worlds: local independence and regional interdependence.  These entrepreneurial doctors will be the surprise alternative to  health system consolidation, hospital market  dominance and one-size-fits all approaches to care. Financial savings from other group purchasing arrangements will be icing on this cake.

3. From Revenue Centers to Cost Centers – The Emperor Begins to Lose His Clothes

As hospitals scramble to get even bigger by buying one another, constructing new wings and launching slick branding campaigns, these glass and steel behemoths will begin to contrast with unflattering local stories about inability of patients to get a timely appointment and a convenient care plan. These noisy patients will use more social media to point out something that elected officials, regulators and academics are missing: that these complex mega-health care organizations cost more than they give. Unfortunately, this alone won’t be enough to lead to change, but.....

4.  Unholy Alliances – It’s What Lies Under the Emperors’ Clothing

The Wall Street Journal confirmed what many physicians suspected about hospital-insurer collusion. 2019 will show how prevalent this is: enterprising local reporters will find that their health system has been using its local market dominance to dictate terms to health insurers.  No longer just a matter of fat fee schedules and lavish quality bonuses, terms of these contracts will leak and inform local markets, showing anti-steering clauses, secretive pricing arrangements, extra fees and the exclusion of lower-cost alternatives.  As news of these arrangements spreads, embarrassed health insurers will pull back from these agreements and look for network alternatives.  Combined with #2 above, patients will be willing switch to these alternatives and large health systems will begin to see declines in the rate of increase in their outpatient revenue. 

5. Risk Transfer Transfers Gain Pace

Health insurers are ultimately in the business of “risk transfer,” in which the potential cost of a future healthcare event is accepted in exchange for money.  This monetized risk increasingly being sliced, sorted, allocated and re-transferred. While this innovative area of insurance has been dominated by large systems, increasing actuarial sophistication and growing risk appetite of smaller networks – including physician CINs -  will lead to limited and profitable risk transfer arrangements.

6.  Social determinants of health – Accountability is incomplete without fixing them.

As risk transfers to providers grow, awareness of underlying socioeconomic threats to patient claims expenses will evolve in a Stages of Change arc from “precontemplation” in 2018 to “action” in 2019. An impatient mandate to “do something!” to manage social determinants will prompt frontline healthcare workers will begin to use some of the upfront premium revenue from their risk arrangements to mitigate the impact of determinants, such as poor social supports, low education, and insufficient income. Unencumbered by an insurer mindset, there will be investments in community-based supports, patient education and non-medical services.

7. More Venture Capital

The allure of artificial intelligence, connected health, the human genome, block chain, consumerism, making the inefficient more efficient and more will drive another run at finding “The Innovation” thatwill finally transform healthcare.  Alas, this is less a function of the potential of market change than the lack of investment opportunities elsewhere.  Good luck!

8. All Eyes on Medicaid 

An accommodating posture in CMMS will enable the leadership of state Medicaid programs – and their managed care insurance partners – to innovate.  One area ripe for change are quality metrics, which have been dominated by entities such as the NCQA, NQF and AHRQ. Criticized for being disconnected from what patients really value, state Medicaid Directors will show a willingness to adopt new measures and reward health systems that can move these new needles.  Physician-led CINs will lead the way and they’ll start by arguing that a number one priority should be measures of social determinants of health.  By the way, venture capitalists (see 7 above) will miss this bus.

9 The JPMorgan- Amazon-Berkshire Thingy Will Go Nowhere.

Didn’t these companies’ ERISA plans already exploit the low hanging fruit?  Between Warren Buffet’s hardnosed actuaries, blockchain’s unreadiness for prime time, the limits of Alexa-style healthcare consumerism, and Atul Gawande being the Peter Principle personified, this three-way alliance will remain stuck in countless video conference rooms in Seattle, New York City and Omaha.

10. Medicare for All Takes Off

The Donald will demonstrate once again that he has no ideological moorings, no respect for fiscal responsibility and no embarrassment from co-opting his opponents’ ideas. Once the fight over The Wall has been squeezed for every possible advantage, the President will shamelessly signal he’s open to a version of “Medicare for All.”  Why not?  Insurers will see opportunity in the expansion of government-paid managed care business, employers will welcome a way out of paying for commercial health insurance, voting Boomers’ may be grateful for being fast-tracked to Medicare eligibility and the House Democrats’ momentum will become ten times more complicated. To the chagrin of his detractors everywhere, Mr. Trump will give the impression he really has a chance at a second term. MFA might even pass.

The Personalized Healthcare Ecosystem of the Future: Welcome to the Year 2030

Against your better judgment, you've just checked your contact lens-enabled news feed. You're annoyed, because President Meghan McCain has just used the Trump Doctrine to "fire" Medicare's lead administrator over the botched roll-out of the Agency's block-chain claims payment system.  The mild spike in sweat stress chemicals detected by your clothing sensors prompts a boost in the transcutaneous dosing of the blood pressure pharmaceuticals from the networked skin patch on your thigh. 

 

It's the year 2030, and personalized "eDxTx" (ecosystems of Diagnosis and Treatment) has arrived for a lucky few who are able to afford it. That has created political headaches for the President and her campaign promise to bring Medicare out of the 20th century. Your decision to opt out of "Medicare for All" (a.k.a "TrumpCare") has been expensive, but worth it because your Geico insurance plan includes eHealth as a covered benefit.  Geico's ability to automate all underwriting and claims handling means high service standards and keeping costs down. Plus, those video ads are still cool.

Thanks to ubiquitous wireless connectivity, cloud-based machine intelligence and mass-personalized medicine, you and your private doctor's team were able to configure a suite of customizable off-the-shelf apps that meet your goals for living well as well as long.  The first step was your $2 psychometric, biomic and genetic testing (the expense of a mitochondrial analysis was offset with an agreement with the laboratory, Theranos, to pool your data with other customers) that spotlighted the optimum mix of nutrition and pharmaceuticals to blunt your risk of Type 15 Hypertension and GAB15a-linked gastrointestinal cancer. 

As you sit down and use the heads up display in your lens to ponder the short-list of candidates to replace the fired administrator (a well-placed leak suggests it reportedly includes Elizabeth Holmes), the patch modulates your drug dosing to account for the change in body position.

You're hungry and looking forward to your specially tailored evening meal that is being drone-delivered to your patio in.... your contact lens again... 28 minutes. 

This is one of the five days out of the week that you adhere to a configured meal of calories, carbs, proteins, fats, nutraceuticals, probiotics and prebiotics that's adjusted to meet your taste preferences. It will also achieve an optimal body fat percentage, and reduce your risk of cancer and a host of other chronic conditions. The other two days use competitive gamification that is linked to your online preferences to reward you with a real burger for meeting your nutrition goals.  Not for everyone, but your behavioral reward profile suggested that that would help motivate you to stick to the diet. Who knew?

You ponder getting a burger tonight, but fight the temptation by triggering a mindfulness app through your lens.  The lights in your living space also dim and a riff made up of an pleasing artificial jazz-indie chord progression offers a well-placed distraction.

Diet and risk reduction are not the only an ingredients you use to achieve your goal of living 105 years, but also participating in next month's Goggle Spartan Race.  Come to think of it, time to tailor a set of 3D printed sneakers. You look forward to you and your personal life-drone (your spouse suggests it's more evidence of your narcissism; you've named it "Donald" to confirm her suspicions and annoy her) competing in a mix of virtual and real obstacles in a course of that includes real rope climbing and a virtual 3-D avatar obstacle course. The drone and wearables will network, monitor and heads-up display your neuro and cardiovascular dashboard for optimal performance. It will also use the same technology that they used in hospitals to anticipate any medical emergencies that could happen to you.

Naturally, your drone will use artificial intelligence to image, edit and securely post the race video for friends and family to view.

That's what you did last year, when the video also showed you twisting your ankle.  You had to go to a treatment center and be evaluated the old fashioned way, where a doctor treated you.  Some things never change, but avoiding those opaque bills and paying your deductible using virtual currency was so convenient.

As your pour yourself your recommended 1.2 ounces of bourbon (personalized by the distillery with a proprietary combination of esters and lactones to create your preferred finish), you reflect on how healthcare has changed since the days of in-home monitoring and physician teleconferencing. It worked well while it lasted, but was soon eclipsed by the cloud-based technology that combined physician intelligence ("physint") with Watson (artificial intelligence) that "scaled" in an era of fully automated care. 

Sort of like the driverless car that will take you to next month's race.

Speaking of old fashioned cars, that eDxTx medical alert last year reminded you of that old fashioned "check engine" light.  It seems a biochemical marker profile was consistent with the presence of an early stage tumor.  Based on your past medical data, the calculated Bayesian risk that the tumor was real approached 1%.  Watchful waiting using Medicare's IPAB guideline recommendations was raised as an option by your doctor, but you decided to undergo the additional testing to rule it out.  Naturally, your insurance covered most of that cost.

You finish your bourbon after you get an alert that the pizza has arrived.  You silently wish President McCain good luck. Some things never change.

Image from Wikipedia

Twelve Health Care Predictions for 2014

While the Disease Management Care Blog eschewed forecasting for 2013, it has decided to reverse course and inaugurate the 2014 blogging season with a contrarian duodecimal exercise in futurism.

Will this antidecimal augury align with the mysterious cosmic order and governing perfection?  Let the thousands of DMCB readers (more on that in a future post) be the judge in January 2015......

1. Obamacare will neither succeed nor fail.  This hugely complex law will have too many outcomes, statistics and analyses that will be subject to too much spin by both supporters and detractors. Like puppies clamoring for the mother's attention, the loudest wins, but only in 15 minute media increments.

2. Inflation returns, with a vengeance: While we won't know it until well into 2015 or 2016, 2014 will be the year that the sleeping giant of healthcare costs awakens. Millions of new insureds in an improving economy will finally get their pent-up pricey preference-sensitive health care needs fulfilled.

3. All boats benefit.....While the PHM industry will continue to extol its cost-savings value proposition, its investors will profitably ride the rising tide of overall increased health spending.

4. Duh, it's the delays stupid: While low income Americans will appreciate having access to subsidized health insurance and Medicaid, the middle class' unsubsidized sticker shock will threaten the fall 2014 elections. Caught between conflicting advice of insurance actuaries and political hacks, the White House's regulatory choices will be obvious.

5. Unfavorable prognosis for physician income means an emerging bull market for concierge medicine: Past attempts to replace the SGR never fail to disappoint and 2014 will be no exception. That, however, will only be on the icing on the bitter cake of foregone co-pays and coinsurance by patients who chose all those stinky bronze plans.  As a result, more docs will bail on their insurance contracts and open "concierge" practices.

6. Navigators Ver. 2.0: Knowing that 2014 could be a high water mark for top-line income from newly insured patients, hospitals will step up and hire their own "navigators." Unsurprisingly, they will not seek out the healthy millennials. And insurers, thanks to the "3Rs" that are largely backed by Uncle Sam, won't care about the resulting adverse selection.  

7. Snowden blow-back: as the promise of big-data grows, fearful health care consumers will be even less inclined toward allowing access to their health information.  Too bad they won't be given a say.

8. Innovator's Dilemma for health tech: solutions that are simple, transparent and modular will continue to make 'from the bottom' inroads into a tech industry that - like early data storage - is too complex, opaque and entangled.

9. Speaking of health tech, patient-monitoring solutions that offer more insight and less data will grab market share.  Instead of a series of blood glucose results dumped into an electronic inbox, think algorithms that suggest insulin dose adjustments.

10. Thanks to the battered healthcare.gov brand, conservatives will be better positioned to thwart other "big government" proposals in 2014 outside of health care (for example, education, carbon markets or immigration reform). Progressives will focus on simpler stuff, like increasing the minimum wage and keeping The New York Times afloat, but miss a decades-long setback of Obama-inspired liberalism.

11. ACOs stumble: Far more ACOs will fail than succeed in hitting their risk-share thresholds because docs can't say no, one patient at a time. As a result, we'll see these organizations begin to cut costs by parting company with some of their recently hired physicians, further fueling the concierge medicine movement.

12 Commercial scientific misconduct: Unable to resist the allure of bonus payments (like this) or the branding that is dependent on the public release of quality outcomes, at least one large health entity will be caught committing "reporting fraud."

How Did the DMCB Do With It's Healthcare Predictions for 2012?

While the Disease Management Care Blog is pretty good at spotting current health policy silliness, its track record at predicting the future has been rather spotty.  Regular readers have undoubtedly forgotten this brazen attempt at 2012 health care augury, but the transparent DMCB refuses to bury its mistakes.

So how did it do with its Ten 2012 Predictions?

1. Mitt Romney will win the Republican nomination and avoid discussing health care.  The DMCB got some of this right, but who would have predicted that the President would cleverly upend his opponents by embracing the term "Obamacare?"

2. A close election will hinge on an improving economy, not on Obamacare. In the end it wasn't really that close, but the DMCB was correct in foreseeing that Mr. Romney's candidacy would be undermined by dropping unemployment levels and the bottoming out of the comatose housing market.

3. The Supreme Court will rule Obamacare unconstitutional: Boy, the DMCB got that wrong.  But in its defense, few foresaw that SCOTUS would ignore the Affordable Care Act's statutory language and rule that a penalty was really a tax all along.

4. There will be no generalizable and published peer-review studies on the electronic record of the medical home that conclusively show that either saves reduces health care costs.  "Bingo!" says the DMCB.  It hopes 2013 is different and that a p value is < 0.05.

5. ACOs will not criticize CMS about the tardy delivery of claims data necessary to manage its assigned populations. The DMCB says the silence over this issue is deafening, which means either a) CMS has overcome its dismal track record on providing timely information or b) the ACOs are reluctant to go public with any concerns.  The DMCB has heard rumors that the latter is true.

6. Speaking of ACOs, their physicians will trump patient preferences over savings.  The DMCB says the jury is still out on this, but time will tell if its call about this ACO Achilles heel is as important as it thinks it is.

7.  Health exchange deadlines will be pushed back. To the DMCB's knowledge, CMS is holding firm on the fall 2013 implementation date.  The DMCB takes some credit, however, for being among the first to spot this issue and bring it to its readers' attention.

8. CMS will kick the Sustainable Growth Rate (SGR) down the road. "Bingo again!" says the DMCB.  It got his one right and looks forward to how Congress will deal with this in 2013.

9. Medical academics will increasingly turn to social media instead of print to make their mark on the scientific world. The DMCB believes this trend is continuing but has yet to reach a tipping point.

10. CMS Interim Administrator Tavenner's status will remain in recess limbo.  OK, it wasn't all that hard to bank on continued partisan bickering, but the DMCB got this one right too.

Will the DMCB offer up predictions for 2013?  Stay tuned!

Some Predictions for 2012

With atypically little fanfare, the Disease Management Care Blog gazes into the crystal ball and offers ten health care predictions for 2012:

1.  After Mitt Romney secures the Republican nomination for President, he and Mr. Obama will mutually try to find ways to avoid debating the issue of health care reform.  Both will calculate that there’s little advantage to reminding voters of the messes they’ve made.

2.  As a result of 1 above, the election will not hinge on health care reform, which, thanks to an improving economy, will otherwise be very close and not be a referendum on Obamacare.

3. Yet, the U.S. Supreme Court will stir things up with a ruling that the Affordable Care Act mandate is unconstitutional because, among other reasons, Congress should have used its power to tax, not impose a penalty.

4.  There will be no generalizable and published peer reviewed studies on the Patient Centered Medical Home or the electronic health record that conclusively demonstrate that either reduces health care costs.

5.  Even though CMS will have trouble providing timely claims data feeds to its newly established ACOs, we’ll hear little about it in the public domain.  ACOs have every incentive to not cross CMS.

6. Speaking of ACOs, the least recognized Achilles heel as they start up will be a pervasive physician culture that trumps patient preference over shared savings.

7.  We will learn that, thanks to their complexity, the deadlines for implementation of health information exchanges will need to be pushed back.

8.  Congress will "kick the can" of the Sustainable Growth Rate conundrum down the road and past the 2012 election with another temporary patch.

9.  More academic medical center faculty will find that it’s far more professionally rewarding to post on line than to publish in paper-based journals.  Department Chairs will reluctantly find ways to use web statistics in promotion and tenure.

10. Piqued by Mr. Obama's recent recess appointments, the Republicans will respond by holding the up the appointment of Ms. Tavenner as CMS Administrator.

How Did The Disease Management Care Blog Do With Its Predictions for 2011?

In the beginning of 2011, the Disease Management Care Blog amazed, astounded and impressed itself with a series of health care system and industry predictions.  Unlike those lesser blogs that post predictions and conveniently neglect to report back to its readers, the DMCB's commitment to being transparently outcomes-based prompted it to pose the awkward questions that few in the blogsphere are brave enough to ask:  how did its prognostications perform? What accuracy did its augury attain? How did it's foretelling function?

Here are the DMCB hunches and brutal self assessments:

1. CMS will delay the January 1 start date for the CMS Shared Savings Program.  The DMCB got that one right.  The usual bureaucratic inertia plus having to respond to the consternation over the initial proposed rule pushed the start date back to April 1.  By the way, this is only one of many missed Affordable Care Act deadlines, so this wasn't all that hard.

2. Despite its luster, adoption of social media in health care settings will not attain a tipping point:  The DMCB got that one right. It knew that front line administrators in clinics and hospitals don't see a financial return on investment for social media and remain notoriously paranoid over HIPAA.

3. Berwick will be confirmed as CMS Administrator.  The DMCB blew this one but should have known that too few U.S. Senators and their staffers regularly read Disease Management Care Blog.  With time, that should change.

4. Naive enthusiasm over the electronic health record and PCMH will bump into painful reality: The DMCB will call this one a draw because use of the EHR has been boosted by the CMS' "meaningful use" bribes payments.  Without them, the EHR business case would have to be based solely on spotty quality and phantom claims of cost savings. The PCMH, still lacking any consistent and statistically significant proof that it reduces costs, is still very much alive because of its growing link to ACOs. That's appropriate, because ACOs likewise lack any proof that they reduce costs.

5. Despite the advent of a new health care era courtesy of Mr. Obama and the ACA, health care costs will depressingly continue to go up.  Bingo says the DMCB.  According to this report on how things are looking for 2011, medical costs are expected to hit 9%.  That's less than 2010 but still far outstripping the general rate of inflation and evidence that more and more of our GDP is being gobbled up by health care.

6. The population health management industry will continue to thrive:  The DMCB got this right too.  The Care Continuum Alliance is as big as ever and there has been no abandonment by commercial insurers of their commitment to patient coaching and support. 

7. The term "disease management" will refuse to die.  To the many experts and consultants the DMCB interacts with, purchasers and buyers know that a rose by any other name still smells as sweet.  Call it "care management" or "population health" or "disease management" and no one really seems to care. because they know "disease management" has matured.

8. The political stalemate will continue.  Talk about a no-brainer but even the DMCB underestimated Mr. Obama's reliance on his liberal progressive roots to the detriment of bipartisan compromise.  Yes, there's plenty of blame to share on both sides of the aisle and while it may not be the President's fault, the DMCB thinks he's still responsible.

9. Greater interconnectedness will make us more vulnerable and unpredictable "black swan" events will preoccupy Washington DC: while there were no unexpected health care events, who would have foreseen the Arab Spring, the near death of the Euro, the impact of the Tea Partiers and the downgrade of U.S. debt?

10 The DMCB will reach a critical mass - more on that in a future post but it's 2011 annual report suggests the DMCB juggernaut is well on its way.

Ten Predictions for 2011

The Disease Management Care Blog was interviewed today on blogradio by Gregg Masters of ACOWatch. If you missed it, the podcast is linked below. The audio can be accessed by clicking the "play" arrow button toward the left side of the badge. Think of it as informative background talk complimenting that extra cup of caffeine as you clean out your email inbox.

In the podcast, the DMCB makes a brazen prediction:

1. CMS will delay the targeted January 1, 2012 start date for Accountable Care Organizations. Note that none of the proposed enabling regulations have been released as of this writing. The DMCB calculates that the a) time required by CMS to solicit, digest and respond to the follow-on public commentary to the proposed rules, plus b) the the inability of most ACO wannabes to plan and organize in the time remaining, makes the current ten month window a daunting proposition. Toss in hostile Congressional meddling as well as growing uncertainty over the fate of the ACA and the deadline has now become practically impossible.

While it is at it, the prescient DMCB has some other audacious predictions for 2011:

2. While healthcare-based social media will continue to expand, its full potential as a catalyst of personalized patient behavior change will be hampered not only by the uncertainty imposed by the privacy restrictions of HIPAA, but "no you can't" Homeland Security concerns over Twitter encryption.

3. Donald Berwick will be confirmed by the U.S. Senate as Administrator for CMS. Republicans will use Dr. Berwick as the poster boy for their newfound - if cynically opportunistic - bipartisanship because a) it's just a matter of time until the Administrator's independent streak begins to vex the Obama Administration, b) the shrewdly targeted use of CMS' grants will curry favor with key individual Senators and c) health care reform is enough of a target rich environment without picking on Dr. Berwick.

4. Reality will not only continue to intrude into the naive enthusiasm over the electronic health record but rear its ugly head in the emerging evaluations of the Patient Centered Medical Home. Both will disappoint when stakeholders seek "proof" of increased quality and lower costs.

5. Speaking of health care costs, they will continue to go up a rate that exceeds the general rate of inflation. That's because, despite health reform, the twin inconvenient truths of our advancing age and voracious appetite for technology refuse to go away. That being said, opportunists will continue to blame the health insurance industry.

6. The population health management (PHM) née disease management industry will continue to hold its own thanks to the grudging acceptance of nurse-based care management as part of the suite of services required to manage insurance risk. Vendors will also have the advantage of being able to couple or decouple PHM with other sophisticated wellness, prevention and health promotion programs.

7. The term "disease management", despite the DMCB's vast supportive readership, will not be resurrected in policy parlance. It will, however, also refuse to die.

8. A political stalemate will prevail as socially-minded progressives and market-minded conservatives battle for the hearts and minds of the body politic. Conflicting public opinion surveys, a divided government and the slow march of the ACA through the appeals process will not lead to any winners or losers. Deciding that will have to wait until 2012.

9. Ours is a time of "Black Swans." Despite our scientific modernism, our worldwide interconnectedness has ironically made us ever more vulnerable to unknown unknowns like pandemics (H1N1), economic dislocations (mortgage meltdowns) and political revolutions (Egypt). Compounding our budgetary travails, another **Big Event** is going to further distract the Administration and Congress from taking constructive action on health reform.

10. The Disease Management Care Blog will not achieve the popularity or the revenue potential of the Huffington Post, leading to further DMCB spousal skepticism over the merits of this whole blogging thingy. She will be unimpressed by the hundreds of thousands of hits, the thousands of return readers, the growing number of links to media outlets such as New York Times, The Washington Post and the Wall Street Journal and vast blogging income amounting to the tens of dollars.

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Health Reform, Disease Management, Patient Centered Medical Home and Health Insurance Preditions for 2010

The Disease Management Care Blog is really looking forward to 2010. And why not? Fergie’s ubiquitous media presence is only bound to grow, Washington’s work of fixing all that ails us has only just begun and the DMCB hasn’t made any predictions yet. Well, at least we don’t have to wait for the predictions, because they have arrived. Concocted with a witches’s brew of post-party cogeners, caffeine, ibuprofen and tomato juice, the crystal-gazing and prophesying DMCB offers up these horseshoes of the future, because close is good enough.

Without further ado: Here are the DMCB Ten Predictions for 2010......

1. Things are not going to change much. What you say? After the continuous cacophony of talking heads, political duct tape and late night votes, it’s going to be the same old same old? Alas, the parallel with most first-time acts of, er….intimacy will be uncanny: after so much… anticipation, so much… passion, the first insight afterward will be ‘is THAT all there is to it?’ When the sun goes up, insurance rates will increase, busts for Medicare fraud with continue, the academic elite will continue to publish clueless articles dealing with more and more about less and less and the number of uninsured will remain stubbornly high.

2. The battle has only just begun. Whatever bill gets passed, look forward to continuing mortal combat over the regulations that shape the real authority when it comes to the Fed’s foray into its new vistas of health care. Most of us will miss it though, thanks to the news spotlight moving on to really important stuff, like the yet-to-be-discovered foibles of other sports stars and whether Jack Bauer’s bone marrow transplant really cured his Prion Disease.

3. The market has decided. Disease management will continue to thrive in its niche. Or rather multiple niches, offering a cafeteria-style suite of low cost and mostly remote care management, prevention and wellness offerings for commercial insurers and self-insured companies. Prevention and wellness will lead the way because most insurers and employers want it but few know how to deliver it. They already have the disease management and will want to keep it.

4. The growth of registries as a source of new medical knowledge. Sure, the academiverse will continue its infinite expansionism thanks to Federal funding bloat, but the rise of terrabyte servers containing all (and the DMCB means all) demographic, claims and medical data will enable startling insights about correlations that were impossible last year and will become routine the next year.

5. The line between insuring and providing will continue to blur. Insurers will provide care services that could be done by the providers in their networks, such as case management and home monitoring. In the meantime, providers will assume partial levels of risk that put them on the financial hook if claims expense exceeds target thresholds.

6. The advent of PCMH Ver 2.0 or rather Ver 2.a-z. The PCMH will remain more of a concept than any implementable or operational model of care. As the return-on-investment bloom comes off this rose in the many national pilots, its architects will appropriately scramble to tweak the model, perhaps by adopting some of the lessons from disease management. In the meantime, insurers will continue to be simultaneously pressured and stymied in their efforts to create a uniform benefit that includes a ‘PCMH.’

7. Social media will expand. Docs will ‘tweet’ each other in hospitals, insurers will push all sorts of web-enabled messaging and the disease management industry will find ever novel ways to combine industrial psychology with cell phone communications.

8. Little to no insurer consolidation. Barring the usual short-term hiccups, the fact that it will be a crime to not buy what the health insurers are selling will give all insurers some breathing room. For now. In the meantime, the health insurers will stick to their knitting: no new lines of business.

9. Republican allegations of the unconstitutionality of health reform bill will have legs. Speaking of which, the DMCB suspects there may be an outside chance that the courts will get in the way of a bill that requires U.S. citizens to buy insurance. Never mind this article in the oppositionally minded Wall Street Journal. The DMCB wouldn't have paid attention if the Manager’s Amendment didn't curiously have a lot of lot of language (starting on page 67) defending the constitutionality of the bill. Doth it protest too much?

10. The Electronic Health Record (EHR) will continue to disappoint. This one is easy, especially now that the same folks that brought us TARP, mortgage relief and undie bombs are involved.

A Review of the Disease Management Blog's Predictions for 2009: How Did It Do?

The Disease Management Care Blog is not above the blogosphere's emerging tradition of marking the end of an annum with bloggy predictions. Unlike many other corners of the blogmos however, the DMCB is also willing to publicly review its earlier predictions and conduct a blogopsy. Just how did the DMCB do, or rather, how much did the DMCB readers benefit from it's blognostications?

Here's the post. In it, the hopefully prescient DMCB said:

The death of the Disease Management Business Model will turn out to be greatly exaggerated.

The DMCB sure got that right. All of the big disease management organizations, save one, are still standing and, for example, looking healthy. The one bankruptcy was not due to any market forces but rather, some strange dysfunction of the Federal government. Who could have predicted that? Lesson learned.

The first reports from the multiple insurer sponsored pilots on the patient centered medical home (PCMH) will be a mix of reality-checking reports that show modest gains in quality and disappointing lack of savings, failures, lack of uptake among many of the non-entrepreneurial primary care sites.

Once again, the DMCB got it right with its doubts over the business case of the current generation of the Ver 1.0 PCMH. There are reports of quality gains, but no proof of savings and no spontaneous uptake outside of money-sweetened pilots or collaboratives, especially among small physician owned practices. In fact, the DMCB wonders if the lack of any peer-reviewed publications showing definitive savings doesn't mean the research is pending, but that the studies are negative and subject to publication bias.

The rise of Disease Management Lite (defined by the DMCB as any remote intervention that doesn’t principally rely on expensive nurses).

Well, while the DMCB predicted a groundswell, this particular trend turned out to be more of a wavelet. However, the future for this still looks bright. For example, iPhone aps.

The Medicare Medical Home Demonstration will lumber along.

The DMCB was too generous. While others expected great things, it lumbered along, alright.... right into a corner where it curled up and died.

Blogs will become even more important in the shaping of health care policy.

What better example than the President having a phone conference involving the big liberal bloggers to whip up support for health reform?

Early reports of health care reform will be tempered by vexing unhappiness over lack of progress for the middle class. Testy impatience will drive a political/policy mandate to include all that looks good, including disease management (and electronic health records).

The DMCB says bingo! Unfortunately, this was powered by the economy unpredictably tanking and allowing too many in the middle class to lose their employer-based insurance. The rest of us have come to realize how close we were to having to personally pay $1500 a month for insufficient health insurance. What the DMCB missed was how subsequent reform would include all that looks good, fair or resembling a kitchen sink in demos and pilots.

Lacking any credible short term fixes, primary care shortages will spike.

Well, it didn't quite spike, but interest in the topic certainly did. Folks have come to realize that health insurance reform won't help access to primary care.

Not 100% accurate, but pretty good. The DMCB takes a lesson from the President and awards itself a B plus.

Next posting: the DMCB's predictions for 2010.

In the meantime, here's wishing you a Happy and Healthy New Year.