Thursday, April 23, 2009

The Population Health Management Journal, for your quoting pleasure

Today was a good day for the Disease Management Care Blog. That's because any day that includes the latest copy of the Population Health Management Journal in its mail box is a reason to pause, get an extra cup of coffee, put up the feet, crack the cover and sample this buffet of learning from the peer reviewed, population-based care literature.

Many don't have that luxury, but no fear. The DMCB went through each manuscript and culled what it believes you need to know and what you can quote for your corporate-jousting, revenue-enhancing, client-facing, career-laddering advantage. Just another leg up when you join the many hundreds that regularly check in with the DMCB!

Anthony Stanowski: Influencing employees' attitudes and changing behaviors: A model to improve patient satisfaction. ARAMARK Healthcare conducted a national survey of 700 nurses (68%), physicians (11% and other clinical staff (the remainder) attitudes toward clinical support service employees. What follows is a descriptive journey that finds ‘a psychographic segmentation model can form the basis of a messaging strategy to create a collaborative approach with support services and the total patient experience with the health care institution.’ Despite the graphs and the percents, the DMCB was confused by how the author got from here to there, and why the PHMJ published a lead article that seem more attuned to an inpatient care oriented audience.

Amy Wilson, Holly Rodin, Nancy Garrett, Eric Bargman, Lori Harris, Melinda Pederson and David Plocher: Comparing quality of care between a consumer-directed healthplan and a traditional plan: an analysis of HEDIS measures related to management of chornic diseases. Consumer directed health plans have been accused of being the devil’s spawn because they oblige persons to actually participate in the economics of their health care services purchasing. While this may reduce global health care costs, does it also reduce medically necessary health care costs? In this study from Blue Cross Blue Shield of Minnesota, approximately 131,000 consumer directed enrollees’ HEDIS scores in heart disease, asthma, back pain, diabetes, medication monitoring and depression were compared to the HEDIS scores from just over a million traditional health plan enrollees. Ultimately there was either no difference in most of the HEDIS measures. Consumer directed plans actually did better in three of them: back pain, diabetic eye exams and diabetic urine screening. While it’d be easy, based on these data, to conclude that consumer directed plans are not the devil’s spawn, the authors didn't appear to statistically adjust the data for the baseline differences in age or gender. They also didn’t take into account the possibility that persons who chose consumer directed plans are more savvy health care purchasers. To really decide the question, better matching of consumer directed enrollees and health plan members would be necessary. It’s highly unlikely that a prospective randomized trial will ever be done, so the likelihood that the question will be ever be settled to everyone's satisfaction is remote.

John Fortney, Jeffrey Pyne, Jeff Smith, Geoffrey Curran, Jay Otero, Mark Enderle, Skye McDougall: Steps for implementing collaborative care programs for depression. Want to establish a state of the art, evidence based, clinically effective, generalizable, diffusible, CQI-oid, Plan-Do-Study-Act formatted, organizational theory-led implementation plan for the management of depression in your institution? Look no further. Here’s a series of check-listed steps with recommendations, along with a flow chart, for you or your 'team' to follow, all based on ‘lessons learned’ in two Veterans Affairs implementations. The DMCB will leave it to the reader to decide if this approach has any hope of success outside a vertically-integrated and salaried-provider care setting without a 3 month waiting list for non-emergent patients in carve out commerical plans to see a psychiatrist in the first place.

John Knight, Jeffrey Dowden, Graham Worral, Veerabhadra Gadag, Madonna Murphy: Does higher continuity of family physician care reduce hospitalizations in elderly people with diabetes? If you think one purpose of Canada’s health care system is to remind us Americans of the poor job we’re doing, you’ll like this study from the province of Newfoundland. The family medicine physicians’ insurance claims of all persons age > 65 meeting an insurance-based definition of diabetes mellitus (N=1393) were analyzed for the presence of “continuity.” Continuity was based on the patterns of claims that suggested that there was a single family practice provider responsible for the patient’s care. The higher the continuity score, the lower the likelihood of hospitalization in this group. Interestingly, the number of visits with any family practice provider was not associated with a lower hospitalization rate.

William Cardarelli: Asthma: Are we monitoring the correct measures? The DMCB thinks the asthma HEDIS measures were chosen because they’re easier to measure, not because they have any real world correlation with disease activity. It is not alone. This latest review of the literature from Atrius Health/Harvard Vanguard points out that there are several easily administered surveys that correlate quite nicely with the asthma severity as well as patients' quality of life. The author argues that clinical assessments of asthma control should be multidimensional and be partially based on these patient self-assessments. The DMCB also notes there’s a difference between individual patient assessments of asthma activity and population-based assessments of asthma quality of care. Why not, asks the DMCB, also use these surveys to supplement the insufficient HEDIS measures?

Yiduo Zhang, Timothy Dall, Sarah Mann, Yaozhu Chen, Jaana Martin, Victoria Moore, Alan Baldwin, Viviana Reidel, William Quick: The economic costs of undiagnosed diabetes. It makes sense to think that the years prior to a formal diagnosis of diabetes is probably a time when diabetes is present but hasn’t been diagnosed yet. The folks from the Lewin Group and Ingenix/i3 compared total insurance claims for the two years (2004 and 2005) prior to a first time diagnosis of diabetes in 2006 to insurance claims from persons from the same period without diabetes. The authors found the claims expense was comparatively greater. Based on these data, the authors estimate that the annual per person cost of undiagnosed diabetes and its associated complications is $2864. When extrapolated to the United States’ population, that’s $11 billion in direct medical costs, which typically goes unmentioned in all those other estimates of the already huge cost of diabetes.

Timothy Dall, Sarah Edge Mann, Yiduo Zhang, William Quick, Rita Furst Seifert, Janna Martin, Eric Huang, Shiping Zhang: Distinguishing the economic costs associated with Type 1 and Type 2 diabetes. Did you know that it’s not until folks are greater than age 45 years that direct and indirect medical costs of Type 1 diabetes becomes greater per person compared to Type 2 diabetes? By the time Type 1 diabetes reach age 65 years, much of the individual excess costs are associated with institutional care, including year-round nursing homes. Yet, the aggregate costs of all Type 1 diabetics (because there are far fewer cases) are much lower compared to Type 2 diabetes (which comprise 94% of all the cases). The most impressive number in this manuscript is $159.5 billion in total U.S. health care costs for Type 2 diabetes, vs. $14.9 billion for Type 1. That’s a lot of money that could otherwise be spent on, say, bank bailouts.


Alan said...

Your description of the article about quality differences between a consumer-directed healthplan and a traditional plan seems to be missing one important component.

You did not indicate if the study looked at performance of the two health plan models for patients treated in the same medical group?

While HEDIS measures are supposed to differentiate between health plans, performance does get muddied by the perofrmance of physician groups actually delivering care. If I rememebr some articles I read, physicians really don't differentiate among patients in differrent health plans. THey tend to treat all patients alike.

Jaan Sidorov said...

Alan, you raise an excellent point. I went back to the article and the authors didn't mention whether the CDHP enrollees used a different network. I suspect the answer is no, because BCBS of Minnesota is a regional plan. However, that point should have been spelled out. Good pick up.