When Diet Meets Technology

This is a post authored by the folks at ph360. The Population Health Blog was intrigued by the innovative combination of personalized dietary wellness management, evidence-based medicine, consumerism, artificial intelligence and a digital concierge.

Discoveries in biology, genetics, epigenetics, biotypology, and medicine are revealing that the best approach to being healthy and staying that way is to have a diet that is right for your body (1). What works for an “average” person may – or may not - be optimum for you.

So how do you know what’s right for you?

Welcome to the future of healthcare, where mHealth diet applications will come to the rescue. While today’s apps are rudimentary and require a lot of manual input, technology advances are making dietary apps highly advanced, automated and tailored.

The ideal app of the future will reconcile individual human physiology, and its adaptation to changes in environment and lifestyle, to provide more complete, detailed and personalized recommendations for staying well and reaching health goals (2).

Emerging technology will combine algorithms that calculate the risk of disease, monitor current lifestyle habits and health trends, and predict a future trajectory with recommendations of best practices for disease prevention or management. Genetic and phenotypic factors will be used to calculate health risks, and identify trends to provide tailored protocols. Wearable technology will monitor and signal important biological functions, and the continuous data collection will increase computer learning that further refines the technology. New discoveries will automatically update these systems so that users feel more confident and minimize faddism.

Though it seems like all of this is far into the future, it’s actually not. Sophisticated applications that consider a holistic approach to preventative medicine through such technology are already emerging.

Enter Shae

Matt Riemann, suffered from a rare genetic condition called Familial Amyloid Polyneuropathy.  This causes nerve dysfunction and has a life expectancy of approximately 10 years after onset.

In the course of collaborating with many specialists, scientists, geneticists and others, Matt not only overcame his condition but created ph360. With the premise that each person is unique, the ph360 platform guides a personalized approach to dietary health.

ph360 was launched two years ago, and after accounting for body measurements, genetic data, health history, and lifestyle, aggregates 10,000 data points and more than 500 ratios to recommend personalized food, fitness and lifestyle changes that achieve optimal health.

The Details

Shae, is built on the ph360 program.

First, body shape and structure are measured to gain insight on morphology, biotypology, and genetics. Research in epigenetics, for instance, has found that height is associated with cardiovascular conditions (3), digestive health (4) and even cancer (5). Waist circumference is related to cardiovascular risk (6) and diabetes (7). Various body ratios, such as height to weight, have been medically associated with increased risk of osteoporosis (8), certain metabolic conditions (9) and important hormone levels (10).

Health surveys are also used to get a better gauge of health risks. For example, skin and hair color is associated with the risk of sun damage (11), nail structure can indicate mineral deficiencies (12), and lifestyle choices can increase or decrease the likelihood of disease onset or progression (13, 14). Chronobiology (15) and the natural human aging process are considered (16) to provide insights on how sleep and stress affect health and well being (17) or how health risks may increase or change with age (18).

Shae takes ph360’s insights one step further by providing 24-7 support for ph360 users as a “Virtual Health Assistant.”  It’s being engineered to use interactive voice and text conversations to communicate a personalized health plan with users in real time via their phone, tablet, laptop or smartwatch. Shae will connect with wearables and analyze a user’s data to make practical recommendations regarding diet, exercise, and lifestyle activities that directly influence their health.
Following users through their day and responding as circumstances – such as environment, activity, diet and stress levels change, these are some of the things that Shae will communicate:

• Recommended specific foods ideal for the person, indicate why and provide nutrient information, recipes and shopping lists for the recommended foods that the user selects.
• Recommended the very best exercises for the individual’s fitness goals and specific body type, the ideal time of day to exercise and best sports to play.
• How to integrate Geomedicine through GPS, making recommendations for foods, activities, transportation and more based on where the person is in the world.
• How to optimize your schedule based on body rhythm to help minimize stress and increase productivity.

Shae has been funded on Kickstarter and is currently being funded on Indiegogo. Version 1.0 will be available in October 2016.  Upgrade versions will be released every few months with version 1.5 arriving in July 2017.  The upgrades are all covered in the original purchase price.

References:

1. Ferguson, L. R., et al. "Guide and Position of the International Society of Nutrigenetics/Nutrigenomics on Personalised Nutrition." Journal of Nutrigenetics and Nutrigenomics 9.1 (2016): 12-27.

2. Ferguson, Lynnette R., ed. Nutrigenomics and nutrigenetics in functional foods and personalized nutrition. CRC Press, 2013.

3. Lee, Crystal Man Ying, et al. "Adult height and the risks of cardiovascular disease and major causes of death in the Asia-Pacific region: 21 000 deaths in 510 000 men and women." International Journal of Epidemiology (2009): dyp150.

4. Asao K, Kao WH, Baptiste-Roberts K, et al. Short stature and the risk of adiposity, insulin resistance, and type 2 diabetes in middle age: the Third National Health and Nutrition Examination Survey (NHANES III), 1988–1994. Diabetes Care 2006;29:1632–7.

5. Kabat, Geoffrey C., H. Dean Hosgood III, and Thomas E. Rohan. "Adult Height in Relation to the Incidence of Cancer at Different Anatomic Sites: the Epidemiology of a Challenging Association." Current Nutrition Reports 5.1 (2016): 18-28.

6. Nazare, Julie-Anne, et al. "Usefulness of measuring both body mass index and waist circumference for the estimation of visceral adiposity and related cardiometabolic risk profile (from the INSPIRE ME IAA study)." The American Journal of Cardiology 115.3 (2015): 307-315.

7. Chamnan, Parinya, Hansa Choenchoopon, and Suvit Rojanasaksothorn. "Abstract MP93: Waist Circumference Has a Stronger Association With Diabetes Than Body Mass Index: Results From a Large Health Examination of 355,310 Thai Men and Women." Circulation 131.Suppl 1 (2015): AMP93-AMP93.

8. Asomaning, Kofi, et al. "The association between body mass index and osteoporosis in patients referred for a bone mineral density examination." Journal of Women's Health 15.9 (2006): 1028-1034.

9. Jacobsson, J. A., et al. "Genetic variants near the MGAT1 gene are associated with body weight, BMI and fatty acid metabolism among adults and children." International Journal of Obesity 36.1 (2012): 119-129.

10. Osuna C, J. A., et al. "Relationship between BMI, total testosterone, sex hormone-binding-globulin, leptin, insulin and insulin resistance in obese men." Archives of Andrology 52.5 (2006): 355-361.

11. Veierød, Marit Bragelien, et al. "Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi." Cancer Epidemiology Biomarkers & Prevention 19.1 (2010): 111-120.
12. Cashman, Michael W., and Steven Brett Sloan. "Nutrition and nail disease." Clinics in Dermatology 28.4 (2010): 420-425.

13. Roberts, Christian K., and R. James Barnard. "Effects of exercise and diet on chronic disease."  Journal of Applied Physiology 98.1 (2005): 3-30.

14. Moritani, Toshio. "The Role of Exercise and Nutrition in Lifestyle-Related Disease." Physical Activity, Exercise, Sedentary Behavior and Health. Springer Japan, 2015. 237-249.

15. Lloyd, David, and Ernest L. Rossi, eds. Ultradian rhythms in life processes: An inquiry into fundamental principles of chronobiology and psychobiology. Springer Science & Business Media, 2012.

16. Lin, Jue, Elissa Epel, and Elizabeth Blackburn. "Telomeres and lifestyle factors: roles in cellular aging." Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis 730.1 (2012): 85-89.

17. Mullan, Barbara A. "Sleep, stress and health: A commentary." Stress and Health 30.5 (2014): 433-435.

18. Singh, Gitanjali M., et al. "The age-specific quantitative effects of metabolic risk factors on cardiovascular diseases and diabetes: a pooled analysis."PloS One 8.7 (2013): e65174.

Ten Questions Publicly Traded Company Boards Should Ask about Employee Wellness

The Board reviews a company

health promotion program

As follow-up to this post about the peer-reviewed evidence linking company-sponsored employee wellness programs and total shareholder return (TSR), the Population Health Blog offers ten questions that these companies' boards of directors should consider when reviewing the topic with their management team:

1. Does the company have a wellness, health promotion, disease prevention or condition management program in place?  If not, why not?  If it does, what is the vision and strategy?

2. In addition to internal measures of "return on investment," are the costs of the program(s) worth the impact on total shareholder return (TSR) and will this pass muster with the due diligence of activist investors?

3. Do other companies competing in the same industry have wellness, health promotion, disease prevention or condition management programs? How have they fared?

4. Have the program(s) been subject to external review, such as Mercer, C. Everett Koop or CHAA? 

5. If the company is self-insured, what are the expectations about the impact of the program(s) on health insurance claims expense?

6. Is the programs' impact on recruitment, morale or productivity being assessed?  How, and can the results be subject to an internal audit or to third-party outside review?

7. How are regulators' and employees' concerns about discrimination or privacy being addressed?

8. Does a "Chief Health Officer" exist?  If not, why not?  If yes, does the job description include any oversight responsibility of employee health?

9. Who on the board can act as a lead in providing the necessary oversight of any of these programs?

10. Is low-cost, scalable digital technology "mHealth" being leveraged? How?

Image from Wikipedia

The Link Between Corporate Wellness Programs and Total Shareholder Return

While employer-sponsored wellness, health promotion and disease prevention programs have been linked to "human capital," talent recruitment and retention, improvements in employee morale, reductions in absenteeism, reductions in presenteeism and bending the curve of claims expense, should shareholders care?

After all, according to President Obama's latest State of the Union Address, corporate America's pursuit of profits have resulted in greater automation, less competition, loss of worker leverage and "less loyalty to their communities." According to that narrative, employees are just another commodity on the road to total shareholder return.

Well, according to an expanding body of peer-reviewed scientific literature, shareholders should care.

The latest example of why is this publication by Ray Fabius and colleagues that appeared in the January issue of the Journal of Occupational and Environmental Medicine.

First, some background.  The Corporate Health Achievement Award (CHAA) was created by the American College of Occupational and Environmental Medicine (ACOEM) to recognize companies' workplace health and safety programs.  It relies on a thousand point-based assessment system of multiple standards in four categories of 1) Leadership, 2) Healthy Workforce, 3) Healthy Environment (including Safety) and 4) Organization.  Many of the companies that have participated in CHAA are household names.

In this study, the authors tracked the stock market performance of companies that applied for the CHAA from 1997 through 2014.  As the Population Health Blog understands it, all the privately held companies as well as those that scored 175 or lower in Organization and lower than 350 combined in the Workforce and Environment categories were excluded from the analysis. Of the remaining publicly companies, those scoring at or above the 37.5 median percentile in the four categories described above (defined as high CHAA achievers) were placed in six hypothetical stock portfolios of 5 to 22 companies.  The authors then mapped out what would have happened with a January 2001 investment of $10,000. As each year passed, new high scorers were added to "rebalance" the portfolios, while the stock of repeat high scorers were added.

The results? While the benchmark Standard and Poor's (S&P) return over the study period was 105%, the portfolios easily exceeded that with returns that ranged from just from over 200% to 333%. 

This study builds on other studies that used the CHAA as well as other wellness award programs including Mercer's HERO Employee Health Management Best Practices Scorecard and the C. Everett Koop National Health Award.

Now that's total shareholder return.

In another demonstration of why peer-review is so important, Dr. Fabius and his colleagues correctly point out that correlation is not the same as causation. As a result, there is no evidence that importing wellness programs into other companies will translate into better stock performance. In addition, elementary statistics tells us that corporate wellness and TSR won't necessarily correlate over shorter periods of time for individual companies.

Bottom line? The PHB doesn't think investors in public companies are necessarily interested in "causation" as they are in market signals. It stands to reason that a commitment to company wellness is an important signal about where to put their money. 

Which raises three questions....

1) This was raised by Fabius et al: should investors or regulators demand that companies publicly report whether they have employee wellness programs?

2) Should companies invest in a "Chief Health Officer?"

3) Why isn't corporate wellness part of the national conversation about capitalism in America?

Coda: For additional reading, see this link on the ten questions about employee wellness that should be asked by boards of directors.

Image from Wikipedia

Everything You Need to Know About Health Care Reform, Thanks to a 25 Minute Video, Courtesy of Managed Care Magazine

Thanks to Managed Care Magazine, the Disease Management Care Blog can post this interesting 25 minute interview with Princeton healthcare economist Uwe Reindardt.  Suitable for desk-bound meal-break viewing by overachieving DMCB readers, the modest and insightful Dr. Reindardt gets it mostly right:

No, the slowdown in the U.S. rate of health care costs cannot be ascribed to passage of the Affordable Care Act.  It started wayyyy before Obamacare was passed and is more likely due to the economic slowdown and increased consumer cost-sharing.

Accountable Care Organizations remain an "iffy" experimental proposition because they "don't go all the way like Kaiser."

Republican proposals to let health insurers sell their products across state lines are hardly a health reform panacea, because prices (and therefore premiums) are not a function of where the insurer is domiciled, but where the care is rendered.  Texas insurers would still have to pay New York prices.

Americans use fewer pills, occupy less bed-days and see fewer doctors, but we pay more because providers can charge more.  Despite being relatively small vs. the behemoths like Aetna and Cigna, regional hospitals have considerable market power that translates into take-it-or-leave it local single seller monopsonies.   Europeans, in contrast, have lower prices because their system is dominated by single purchaser monopolies.

We're headed toward a three-tier system comprised of 1) the indigent safety-net public programs, 2) the middle class "reference pricing" "networks" where consumers pay the difference if they want to buy up and 3) "boutique" health care for the 5%.

There's reason to be optimistic about the next five years thanks to a sluggish labor market (making it easier to impose networks and even more cost sharing) and innovation (computational capacity is putting meaningful quality measurement within reach, while techy gizmos are making self-care simultaneously cheap and fun). 

Plus, there's reason to be of good cheer.  Compared to the U.S. education and the legal systems, health care is far more efficient and consumer-friendly.  Stop beating up on yourselves.

(The DMCB didn't quite agree with Dr. Reinhardt's views on worksite wellness.  He finds the notion counterintuitive and intrusive, preferring that insurers own wellness.  He neglects to mention that the employers who invest heavily in wellness are typically self-insured and that employers have an arguable stake in improving the quality of their human capital.)

Time for Docs to Get Out of the Food Wars

In Food Fad Fantasyland, rotund patients can see their primary care physicians and discuss the merits of Atkins versus South Beach vs. [insert name here].  Armed with the latest nostrums, patients go forth and diet until the next twerk comes along.

Bleh.

While physicians and the for-profit care management vendors can disagree about many things, one thing they can agree on is the ability of their corpulent patients to swear by an endless number of diets.  Whether its "low carbs" or "Mediterranean" or "mini-fasts," docs and coaches alike are expected to not only endorse these fads, but deploy insider jargon like DMCB spawn watching the MTV Video Music Awards. Taylor Swift was crooning about... who?

Which is why, after reading this JAMA Viewpoint article, the Disease Management Care Blog agrees that it's time call a time-out.  It's also time for the DMCB primary care colleagues to exit.

The DMCB explains.

Drs. Pagoto and Appelhans point out that when it comes to weight loss and risk factor reduction, there is no research that convincingly proves that one dietary approach is superior to any other.  Outside of individual preference, the mix of nutrients makes no real difference.  Instead, say the authors, what's important is adherence.  In other words, once patients embark on their preferred diet, they have to stick to it.

Unfortunately, that message has been lost in the multi-billion dollar faddism that has come to dominate the food industry marketplace.

Skeptics will point out that getting persons to stick to a particular diet is a fool's errand.

Not so, say the JAMA authors. Pointing to the Finnish Diabetes Prevention Study, The Da Qing Diabetes Prevention Study and the Diabetes Prevention Program, they note that long-term behavior change that includes behavioral modification and lifestyle change is very possible. 

"Hear hear!" says the DMCB.

As most doctors are aware, most health insurers (including Medicare) don't really reimburse enough to meaningfully cover the true costs of life-style related counseling.  What's more, selective memory recall means that physicians generally remember just how often their counseling leads to their individual patients being as fat as ever.  Most of us physicians are not that good at coaching anyway.

Which is why the DMCB thinks dietary counseling should be outsourced outside of the doctors' offices.  The good news is that wellness and health promotion programs are becoming more adept at focusing on patients' adherence to lifestyle change, mostly by finding those with a willingness to change. It's then a matter supporting those individuals over the course of a year or more. 

This is just one example of the approach.  There are more to come.

The DMCB conclusion

1. Docs should be "agnostic" when it comes to one diet fad vs. another.  It's patient preference.  Next.

2. What really counts is adherence to long-term lifestyle change.  Since many physicians are not good at that kind of long-term coaching, better to let other programs offer their wares to insurers.  The key for these programs is to focus on lifestyle change for those patients who want it and can accomplish it.

More on Penn State's Wellness Woes and The Evolving Science of Evaluating Health Promotion Program Outcomes: There Is No Gold Standard

Aside from keeping up to date with work buddies, the Disease Management Care Blog doesn't really use LinkedIn all that much. But when "Support our Penn State Colleagues in their Fight to Prevent Coercive Junk-Science Wellness Programs" postings began to appear in a Discussions board, the DMCB couldn't resist. It rose in support of its alma mater (College of Medicine, '77) faster than a med-mal attorney can calculate a contingency fee.

 As noted in this prior DMCB posting, Penn State University launched a rather routine health promotion program that prompted some nasty and very public teaching faculty resentment. Calls for "civil disobedience" and sinister references to "eugenics" made the DMCB wonder how much of the reported push-back was mainstream employee opinion vs. mainstream media's biased reporting. That distinction didn't stop the LinkedIn board from running a mostly one-sided dialogue on the matter.

So, undeterred by the unfairness of so many vs. just one, the contrarian DMCB naturally jumped right in.  Among the issues raised:

The RAND Study on wellness casts doubts on the merits of employer sponsored wellness programs:

Actually, RAND found employer-sponsored programs lead to statistically significant increases in exercise levels as well as reductions in tobacco abuse and body weight.  To the disappointment of wellness vendors everywhere, however, these programs did not lead to statistically significant reductions in health insurance claims expense.  The ever-optimistic DMCB points out that that means that these health improvements occurred without an increase in health care costs.

While cost neutrality alone is good news, the DMCB also believes that an emerging generation of wellness programs will do a far better job of identifying persons with 1) actionable risk and 2) who are willing to take action.  By husbanding wellness resources for subpopulations where it will have the greatest "bang," program costs will go down and claims savings will achieve statistical significance.

The author of the widely quoted Health Affairs paper on the merits of employer sponsored wellness programs has back-pedaled away ("too early to tell") from her study's original conclusions.

Actually, the original Health Affairs paper said that the finding of a $3.27 return on every dollar spent is subject to:

 "(f)urther study.... to elucidate the time path of return on investment.... The assumption of a linear trend in savings from the beginning to the end of program evaluation may not reflect the reality of behavior change within organizations."

The point is that nuanced and calibrated conservatism is typical of excellent peer-reviewed research and, taken in context, the authors are being quite consistent in-print and on-air.  Academics will always say more research is needed.  Skeptics will over read that.

There are powerful arguments against the common wisdom that "wellness saves money," suggesting that the health promotion industry has been intentionally ripping employers off.

Actually, when it comes to wellness outcomes, there is no agreement on "the" measurement "gold standard." Without any consensus on which assessment approach (for e.g., this vs. this) is truly "better," only one thing is certain: much like the Betamax vs. VHS wars, the future owner of "the" standard stands to reap a consultant's bonanza. Until we declare a winner, assessing the truth will be a messy mix of triangulating on means, medians, confidence intervals, imperfect reference controls, suspect generalizability, human judgment, moving targets and evolving interventions.

What about [insert name of wellness program here] that is an obvious sham?

There have been women who have had mammograms with missed cancer, victims of car crashes who have died despite seat belts and times when the DMCB did something really dumb despite the advice of the DMCB spouse.  That doesn't mean mammogram, seat belts or advice are worthless.  The plural of anecdotes is not data.

Coda: By the way, the statistically significant "value of  0.05" is more of a consensus than a gold standard.  Why is a 5% chance that an observed result is not the result of randomness wiser than a 6% chance or a 4% chance?

Penn State's Wellness Woes: Seven Lessons Learned About Launching a Worksite Employer-Based Health Promotion Program

Penn State's mascot goes on the
prowl for a good wellness program

Listen to this NPR report and it's easy to conclude that another employer-based health promotion program has gone amok. Reporter Jeff Brady implies rising health care costs have led Penn State University to force its employees into an intrusive wellness initiative, pitting David-like faculty members against the Goliath-Administration.

What can wellness architects and service providers learn from this imbroglio?

Here's the facts:

Penn State provides health benefits to over 45,000 employees and dependents. It's self-insured (administered by Highmark), which means the University, not some remote insurer, is on the hook for any unanticipated health care costs. 

Those costs have led to a whopping $217 million health care budget for 2013-2014 and a long term $3 billion pension liability. In response to the threat of budgetary "crowd out," the University made some important changes to the insurance benefit that included a high deductible option and value-based benefits.

It also hatched a health promotion initiative. It checked in with the Faculty Benefits Committee in the early spring of 2013 and then used the summer to unveil a "comprehensive wellness-focused strategy."  This included the "Take Care of Your Health" program that packaged biometric screening (some labs, weight blood pressure), an on-line WebMD wellness survey and preventive health exam. Failure to complete that screening, survey and exam will result in a $100 per month payroll deduction in 2014.

The plan didn't sit well with everyone. Faculty members Matthew Woessner fretted about privacy and penned a "call for action and civil resistance," Barry Ickes doubted the economics and Larry Backer invoked eugenics, human dignity and sinister profit-motives.  Brian Curran used the Change.Org website to post an anti-wellness petition for "employees, alumni and friends" that has reached 2000 signatories.  Naturally, wellness gadflies Vik Khanna and Al Lewis were unable to resist and used The Health Care Blog to pile on any wellness program with the temerity to not use their consulting services.

The Disease Management Care Blog speculates on lessons learned......

While worksite wellness programs have a reputation for increasing employee morale, it stands to reason for that any stressed organization (and here's why that may be true here), it runs both ways: low employee morale can hinder acceptance of a wellness program. The faculty backlash may be as much of a symptom as a problem.

Lesson: Health promotion programs should tread lightly in times of organization turmoil.  This is no time for "big bang" multidimensional interventions, especially if they involve a $100 per month penalty.

There is good evidence that employer-sponsored wellness programs save money, but it's unlikely that any health promotion will be enough to tame a $217 million budget.  To Penn State's credit, they simultaneously made some health insurance benefit changes, but that's been lost in this controversy.

Lesson: If you're fighting high health care cost trends, don't let the positive return on investment (ROI) from health promotion take the lead. It won't work that well, and employees will think this about reducing your costs, not about increasing their well-being.

Similar on-line WebMD wellness assessments for Pittsburgh city employees and the Mennonite Church have gone without any substantial privacy concerns.

Lesson: If there are two employee groups with a special talent for indignant paranoiac outrage over any employer-sponsored health initiative, it's medical providers and university faculty. There are plenty of reasons, but the DMCB suspects both are victims of the decades-long twin cultures of 1) autonomy and 2) abundance in health care and higher education.  Stopping by a Faculty Benefits Committee is not enough to secure buy-in.

Interestingly, Penn State's College of Medicine has a long standing agreement with Highmark that includes the joint development of evidence-based health, wellness and prevention programs.  Unless that's been cancelled, the medical science faculty's silence is deafening.

Lesson: Search for and engage employee subgroups that can be your allies in launching a health promotion initiative. Their advocacy may really help.

There are wellness service providers like this and this with established records of performance that can successfully reconcile employee and employer needs.

Lesson: There's nothing wrong with preferring to "build" over "buy," but only if both options are carefully considered at the outset.  External wellness providers are often subject to financial performance and recruitment standards. If the petition gains traction, the latter would sure come in handy here.

Critics of wellness programs in general and this one in particular say that they lead to unnecessary testing.

Lesson: The science is still evolving, but here is one answer to that criticism: it's not wellness per se but our society's love of technology.  Wellness programs can use initiatives like Choosing Wisely to develop even better programs.

As a self-insured entity, Penn State technically already has access to all the employees' insurance and claims information.  The WebMD privacy concern is silly.

Lesson: Now would not be a good time for Penn State's administration to point that out.

 

Image from Wikipedia

Which of These Four News Reports Is False? Insights from the Wacky World of Health Care Reform

Baron Von Munchhausen

Despite host Peter Segal's occasionally highbrow insider cleverness, The Disease Management Care Blog remains a loyal fan of NPR's "Wait Wait... Don't Tell Me" radio show.  While the DMCB has its suspicions about the ratio of truly spontaneous wit to pre-planned ripostes, that won't stop it from turning to a part of the show called 'Bluff the Listener' for bloggy inspiration.

BtL has guests try to guess which of three funny stories is based on a real true news report. The DMCB thinks health care is so wacky that it'd be more challenging to guess which of the four stories below is false.

Unfortunately, if you win, getting the DMCB to put its voice on your home answering machine is unlikely to impress anyone. However, if you can pick out which story is a complete Munchhausenesque fabrication, you will deserve the respect of your friends and co-workers.

Ready to try to get some bragging rights?

+++++

Even doltish man-trolls know better than to try to organize an all-male blogging conference. Unable to reach out to that demographic, HHS Secretary Kathleen Sebelius did what's best: appeared before the annual "BlogHer" Conference in an appeal to women bloggers to tout the benefits of Obamacare. Her outreach supplements plans to rely on celebrities to help with a nationwide drive to increase enrollment through the insurance exchanges. Next up will be effort to recruit motor scooter owners to sport pro-Obamacare ads on the back of their helmets.  Then it's on to asking members of the European Beret Society to host recruitment drives at their monthly chardonnay tastings.

Answer here.

+++++

Al Lewis and Vik Khanna condemned the wellness industry in a Wall Street Journal editorial when they proclaimed that "workplace programs don't work." They went on to say that they are "ineffective at reducing costs, lack support in the medical literature, are unpopular enough to require incentives and are occasionally even harmful." Yet, the Khanna On Health Blog's “workplace wellness consulting” page suggests the authors’ unique consulting insights can help potential customers “do wellness right.” Did the DMCB mention that both individuals are lawyers?

Answer here.

+++++

Writing in a separate issue of the Wall Street Journal, former Vermont Governor and Democratic National Committee Chair Howard Dean actually attacked Obamacare by criticizing its Independent Payment Advisory Board as a rate setting enterprise that is doomed to failure. Brazenly using Tea Party terms such as "bureaucrats" and "health rationing," Dr. Dean's liberal-progressive apostasy prompted ACA architect Peter Orszag to curiously opine in a separate article in Bloomberg that the argument favoring IPAB is that it will be a much better rate setting body than Congress. If this keeps up, even labor unions will start criticizing Obamacare.

Answer here.

+++++

While partisan blood continues to spill over Obamacare in Washington DC, there is much good news outside the beltway.  It's been announced that the IRS will not only rely on self-reporting of income levels in setting premium subsidies. Even better, individuals who qualify for tax credits while buying their health insurance with the on-line exchanges will get a two-fer: 1) the option of applying the rebates to reduce their monthly premiums, and 2) confidence that there won't be any tax liability "claw backs" should their final income be higher than anticipated. Interest and penalties will be optional.

Answer here

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.

Big Data and the Coming New Value Proposition for Disease, Care and Wellness Management Providers

Disease Management Care Blog readers know that the its latest interest is "Big Data." While the researcher-DMCB has played in the sandbox of some insurance claims data sets, the idea of combining and combing through multiple terrabytes of clinical and public data remains a topic of endless fascination. It knows it's not alone.

So, it was only a matter of time until one of the major clinical journals published an article on the topic. JAMA has stepped forward, and not a moment too soon.

It's "must reading" for the disease and care management provider community.

Drs. Murdoch and Detsky point out that Big Data offers four value propositions:

1. Observational correlations may generate insights that cannot be found using standard research approaches. Scanning text for key words in electronic record systems involving hundreds of thousands of patients may find associations or trigger early warnings faster, quicker and cheaper than any formal scientific protocol or clinical trial.

2. Those insights, especially since they can be tailored to fit the circumstances of an otherwise unique patient, can be used to guide diagnosis or treatment. Physician judgement cannot be replaced, but if Big Data points out that there were other patients with a similar pattern of illness who responded best to one treatment versus another, patient outcomes could improve.

3. A Big Data approach to genomics can correlate genetic information with outcomes and further guide therapy. While the DMCB still wonders if "genomics," outside some narrow anecdotes, will always remain the science of the future, Big Data may turn out to be the key to finally unlocking its potential.

4. Since Big Data, by its very nature, can combine clinical information to other personal data (the foods you've bought or your driving history), Big Data will necessarily tilt toward the patient-consumer and away from the health care system. Not only does permission for access lie with the patient, but the insights will be less about sickness and more about wellness.

The authors do a good job of pointing out that there are plenty of challenges. Most doctors don't get it, privacy laws could be over-interpreted or enforced, it remains to be seen who will pay for it and Big Data is still in its infancy.  The DMCB also points out that while Medicare has just discovered that alternative research innovations are possible, Big Data promises to eclipse those approaches (like traditional time series analysis, propensity matching), again making CMS a day late and another dollar over budget.

The implications for the care management and population health community are considerable. The industry has amassed years of intellectual capital in the science of predictive modeling and Big Data is it's next step. Many care management vendors have multiple clinical partners and already have access to terrabytes of data involving millions of persons. Not only is the math and the informatics well within reach, they also "get" the tilt toward wellness and consumer empowerment. Last but not least, if anyone can monetize a value proposition like this and turn insights into revenue (or "shared savings"), these nimble vendors can.

A DMCB prediction: while academics will write about Big Data in scientific journals, the care management industry will be doing it.  In fact, they probably already are.

Two particularly good quotes to use to impress your CEO and stymie your competitors:

"Data has gone from refuse to riches."

and

Economic theory describes the quantitative conversion of 3 kinds of inputs (capital, labor, and raw materials) into outputs (goods and services)...The current revolution in data management makes it clear that a fourth kind of input, information, will become just as important as these other inputs in the future of many industries.

Does Worksite Wellness Work? A Critical Look at the "Wellness Incentives In the Workplace" Article

A waste of money and
a basis for discrimination?

The answer to the "Does Worksite Wellness Work?" question depends on your frame of reference.

If you read this 2010 review by Baicker, Cutler and Song, you'll see that there are 32 peer-reviewed published studies from work settings that a) transparently described the intervention and b) used a valid parallel control group - persons who did not receive the intervention - as a comparison. When interventions like these were deployed, impressive reductions in medical costs and absenteeism like these were achieved in the intervention groups, compared to the groups that did not receive the wellness programs.

If you read this just-published 2013 review by Jill Horwitz, Brenna Kelly and John DiNardo, you'll see that it's possible to use a "conceptual framework" to completely trash the notion that worksite wellness programs offer any benefit.  Oh, and by the way, they also result in discrimination.

How is that you ask?

This framework asks:

1) Do employees with chronic conditions or health risks spend more?  The authors' answer is that most studies for most conditions indicate the answer is yes.

2) Do financial incentives change behavior? The authors' answer, based on a review of the literature, is that obese persons tend to gain weight and many persons who quit tobacco relapse.  The impact on high blood pressure and lipids is less certain.

3) Do health improvements lead to employer savings? The authors' brief three paragraph answer, based on two references (here and here), is "uncertain," "depends" and "erroneously assuming."

The authors also

a) point to the abundant literature that questions the relationship between "process" and "intermediate" outcomes (blood glucose testing or control in persons with diabetes mellitus) versus long-term outcomes (like mortality - an example is here),

b) note that aggressive treatment can lead to unintended consequences (an example is here), and

c) suggest that wellness programs disproportionately benefit persons from higher socioeconomic classes who suffer from less disease. It's frankly difficult for the Disease Management Care Blog to follow the authors' logic, but as it understands it, anything that benefits one segment of a population is a zero-sum loss for the remaining segment.

The DMCB's two-fold take:

1) The 2010 review examines state-of-the-art clinical trial data, while the 2013 "conceptual framework" interprets the underlying published literature and finds it wanting.  According to the framework authors, the value of any counseling is ultimately unproven.

Big deal. The DMCB would like to point out that a similarly conducted review of primary care (where there are no randomized control clinical trials), Medicare (a social experiment if there ever was one) and parachutes (to combat "gravitational challenges") could also conclude that there's no proof.

Bottom line: Lack of proof for a benefit is not the same as proof that there is a lack of any benefit.  What's more, the business persons that run worksite wellness programs know that evidence based medicine is necessary, but not sufficient.  They don't demand proof, they use reasonable assurance.  The 58% of large employers that are offering worksite wellness are using seasoned logic in a world of conflicting data.  Good for them.

2) The Homer Simpson-inspired DMCB doesn't quite "get" the framework's socioeconomic argument.  If persons from lower socioeconomic classes have a higher burden of obesity, diabetes, high cholesterol levels and poor fitness, anything that offers increased access to a higher level of care is not only good policy but a proportionately noble thing.

What's more, if worksite wellness results in no economic benefit and doesn't shift costs in any direction, how does that result in any discrimination?

While economic incentives in a zero sum game can be problematic, the DMCB believes that Horwitz, Kelly and DiNardo's logic is overlawyered worksite nihilism run amok. Their ultimate unspoken conclusion is that when it comes to employees, all should be treated to the same level of neglect.

Image from Wikipedia

Another Endorsement of Population Health Management

While it's not an explicit endorsement of the population health management industry, it comes pretty darn close.

Writing in the New England Journal, David Asch and Kevin Volpp point to three market "signals" that are being missed by the traditional medical-industrial complex:

1. There is growing consensus that the doctors have it wrong: being healthy is not a merely a "biologic" process.  Rather, social circumstances, environmental influences and personal behavior account for the bulk of well being. 

2. While providers are being called to task on a host of specific process and outcome measures, communities and employers are more interested in and getting better at measuring overall health.

3. While there are short-term approaches to reducing waste and increasing efficiency in the health care system (like bundled payments or episodes of care), everyone agrees on the long-term solution: a healthier population.

Drs. Asch and Volpp predict health systems will transition from selling product-oriented sickness treatment "within their walls" to customer-oriented "health" delivery. They better, or they'll end up like bankrupt Eastman Kodak, which thought it was the film, not imaging, business

And the Disease Management Care Blog agrees. Look no further than this web site of an outsider business devoted to the very services described in this Journal article.  In fact, as far back as March of 2009, the DMCB described one PHM industry veteran's challenge to make America rank #1 in the world in an overarching, comprehensive and easy understood measure of health status.

It sounded like a good idea back then.  This timely Journal article reminds us it still is.

And the good news is that the PHM service providers are already working on it.

Image from alaska.gov

More on the Parallels Between the Sugary Beverage Ban and the Accountability Movement in Health Care

Time for some DMCB humble pie.

Check out Troeltsch's perspicacious response to the Disease Management Care Blog assertion in yesterday's posting that a New York City ban on the sale of 16 oz. calorie dense beverages would "work":

What evidence do you have for the comment "it works?" particularly in light of the fact that soda is simply banned in restaurants, and not any where else in the city?

Troeltsch has both right. 

The proposal, as it now stands, would limit the ban to restaurants, street vendors and concession stands and spares grocery stores. So while New Yorkers couldn't buy that "Big Gulp" to-go, they'd still be able to buy that liter of fructose corn syrup-loaded soda and continue their gluttonous ways in the privacy of their own homes.

And what's more, the DMCB did a literature search and can find no published evidence that a calorie-dense beverage ban reduces the prevalence of obesity. Yesterday's claim that "it works" was simply overzealous. DMCB readers can not only spot non-scientific puffery at meetings, in news reports and in marketing materials, but also in the DMCB's weaker-moment writings.

Well done.

That being said, the DMCB still gives the Big Apple some credit. If you go to the original proposal, you'll see that the ban is only one of 26 initiatives that seek to improve nutrition and increase exercise in the city's public schools, alter sidewalk and building codes to promote physical activity, require hospitals to offer healthy menus, increase the availability and appeal of tap water and promote wellness, especially among public employees. This is commercial population health management writ large.

And the DMCB still stands by its original assertions. Mayor Bloomberg's attack on obesity in the name of public health should remind health care providers that a similar fate awaits their costly ways if shared savings, accountability, bundling, electronic records, the demos and ACOs fail to bend the curve. Instead of trimming excess calories, our politicians will trim excess costs by proclamation.

The DMCB offers three additional observations:

1) Peter Orzag, one of Mr. Obama's health reform architects, famously asserted that the Affordable Care Act's health mandate provision would increase a collective expectation that we should all buy health insurance, much like seat belt laws prompted most of us to buckle up. There may be something to that in the anti-obesity fight, says the DMCB, and Mayor Bloomberg's very public attack on sugary drinks may prompt his city to shift to a new cultural norm

2) The DMCB hopes NYC's Department of Health and Mental Hygiene devotes the resources it takes to adequately measure the impact of the ban. The rest of the country needs to know if this works.

3) Last but not least, if nothing comes of this, this is one more warning to a largely uncooperative and unrepentant food industry.

Behavioral Economics and Work Site Wellness Program Financial Incentives

Give that lady some money!

Even though this New England Journal article by Kevin Volpp, David Asch, Robert Galvin and George Loewenstein on the interesting topic of behavioral economics opens with a retread of many of the arguments against the use of financial incentives in worksite wellness programs, it offers some interesting insights on how these dollars can be used for maximum impact. 

The Disease Management Care Blog figures the message here is that they don't like it, but, hey... if you must......

1.  Participants place more value in the present than in the future, even if both are of the same value.

This is why the hassle and cost of taking pills today outweighs the future benefit of fewer complications or a lower risk of death tomorrow.  One way to leverage this in a wellness program is to give tangible rewards at the time of participation (for example, something of monetary value) instead of a future reward (for example a year-end reduction in a health insurance premium or a lower co-pay for a clinic visit).

2. Participants use "mental accounting" to judge the value of any reward.

In other words, participants tend to "allocate" financial rewards into categories and, if the result leads to the incentives being bundled into another pool of money, the impact can be diluted.  $50 going into a larger  health savings account is not as attractive as a separate check for $50.  This is an important issue, since employers may be tempted to use existing payroll mechanisms instead of cutting a check.  It can also get complicated because of existing tax regulations.

3. Penalties appeal to notions of efficiency and fairness, while rewards may appeal to a sense of community.

One way to think of this is to consider financial incentives to combat tobacco abuse: should everyone who doesn't smoke be rewarded, or should those who do smoke be hit with a penalty?  The authors note there is little formal research that helps sort this out, so this may ultimately have to be determined based on the company's culture.

The good news in all of this is that the Affordable Care Act has given employers considerable leeway in fashioning financial incentives to support worksite wellness programs.  Hopefully they'll pay close attention to what is - and isn't - known about boosting employee participation.  The DMCB also hopes that they'll write down and describe what happens, so that the rest of us can learn.

Ten Reasons Why Population Health Management Service Providers and Disease Management Companies Are A Choice For A Wellness Program

Worksite footwear?

At a recent conference on the role of wellness in the work setting, the Disease Management Care Blog pointed out that there are ten very good reasons why outsourcing worksite wellness to a "population health management" (PHM) service provider (the old disease management companies) is still a strong option.  No one disagreed with the DMCB, so it must have gotten something right.

The reasons are

1. PHM companies understand insurance-based risk transfer: they understand that this is ultimately about reducing health care costs in the short as well as long run.  In contrast, many wellness providers see this as a "retail" product and simply want to sell their services.
  
2. They can offer their programs at little incremental cost:  this is a situation where size matters and if the employer has a preexisting relationship involving a program for chronic conditions, wellness can typically be tacked on for a very reasonable amount.

3. These vendors have a track record of managing within of "risk corridors": if there are performance guarantees, expect these companies to work with you on the upside and downside caps that can limit the exposure of both parties.

4. Cafeteria versus a “total solution” approach: hand-offs between programs are very important since, for example, persons with chronic illness may benefit from wellness and persons screened for participation in a wellness program may have a previously undiagnosed chronic condition.  Smooth and offs between programs are more likely to occur if both the chronic care management and wellness are working for the same company and share the same leadership.

5. Prevention already active in programs: don't believe those allegations that "disease management" programs only focus on a single condition.  These companies have been offering an interlocking suite of services for decades and that includes wellness.  They already know how to engage patients with chronic illness in prevention and wellness while simultaneously helping them to better manage their condition.

6. Depth and width market expansion:  PHM companies are broadening the number of services that they can bring to market.  As a result, within any wellness offering, these vendors are constantly working to increase the number of approaches and program options.  Many retail programs have a one-size-fits-all approach.

7. Resists commoditization: sure, you may think it's just a matter of giving employees health club memberships and emails reminding them to eat their veggies, but good PHM companies know that's a lot of bunk.  If that's all you want, they may ask you to go deal with one of those retail outfits.  If you want quality, be prepared to pay for it.

8. Bariatric surgery costs: frightening!  As the threshold for bariatric surgery continues to drop and more and more patients become candidates for this expensive procedure, PHM vendors understand that there are ways to give patients other options short of getting an abdominal scar.

9. Remote interventions for tobacco & obesity “as effective as traditional face to face.”  There is an emerging body of evidence that suggests that telephonic coaching has a role to play for many patients, depending on their disease burden and personal preferences.  There are many patients in any population who would respond to telephonic coaching, and the PHM vendors know how to navigate that.

10. You're in a hurry.  If you want to build this yourself with your own employees, perhaps with the help of the local medical center, you can expect the planning to take many months, and then you'll need to wait additional months before anything gets launched.  If you want to do this in a hurry, why not call in the experts that can get this going within 4 to 6 months?  You'll have some preliminary data within a year.

A Reason To Be Bearish On Wellness Vendors For 2014

Human capital

The Disease Management Care Blog is furiously preparing for the July 26-28 World Congress' Wellness As A Strategic Business Priority meeting.  The speaker-DMCB mission is to tackle the "population-based" implications of "wellness" programs, with a special focus on ....

1) data management: observational database analytics is well within the reach of most desktops;

2) maximizing participation: combine claims, on-site biometric screening, health risk assessments, population needs assessments, predictive modeling and most of all, do a good job of building it and "they will come";

3) using incentives: multiple overlapping approaches with multiple and repetitive communication channels are a must. It helps to integrate wellness programs with prevention, population health management and standard insurance programs.  Finally, don't forget that, if this is an employer-based program, senior management needs to buy in and participate

4) offering a suite of options: this means including web and telephonic self education materials, individual counseling, group activities and social media aimed at weight loss, fitness, tobacco cessation and risk factor mitigation.

This promises to be a highly educational conference.  If interested in finding out more, you can register here.

And, as an added bonus and because it cannot help it, the DMCB is also going to point out that the employer class that is typically most likely to sponsor wellness programs for its employees are the  self-insured "ERISA" protected plans.  In the meantime, the commercial "fully-insured" group and individual insurance plans generally don't include "wellness" as a benefit. That's because a) it's a cost and b) there's lingering doubt among health insurance actuaries about the cost-benefit ratio of wellness programs in the commercial setting.

Which means that, if the controversial McKinsey Report predicting Obamacare will result in large numbers of employers exiting the insurance market is correct, the wellness vendors can ironically look forward to a down market in 2014.  ERISA-protected plans that offer wellness will contract, while commercial insurance, which doesn't cover wellness, will expand.

You read it here first.