It's Not News: The Uptake Of The Patient Centered Medical Home (PCMH) Remains Low In Small Physician Practices: Some Good Options Are Available

Looking for that medical home

Given its near-mystical aura of quality and cost savings, endorsements by rock-star expert academics and enthusiastic prominence at D.C. health policy meetings, anyone who doesn't read the Disease Management Care Blog can't be blamed for believing primary care physicians must be flocking to the Patient Centered Medical Home (PCMH).  Regular DMCB readers know differently.  They're still skeptical about the science, have little use for academics who don't do night call and understand why regular doctors are too busy to attend multi-day oxygen-deprived meetings in swank hotel basements.

That's why DMCB readers won't be surprised by the just published on-line Health Affairs article that shows "Small and Medium-Sized Physician Practices Use Few PCMH Processes." Diane Rittenhouse and colleagues conducted a 40 minute telephone interview called the "National Study of Small and Medium Physician Practices" on 1,344 clinics operating with 1 to 19 physicians with at least 33% in working in primary care.  This represented a healthy response rate of 63%.

The survey used a 17-point system to assign an overall score. It focused on the presence of PCMH-style teaming (defined as regular staff meetings to discuss the care of a group of patients), coordination as well as integration of care (including electronic records and registries), a focus on quality and safety (including decision support, quality improvement, performance feedback and patient education) and access (not only appointments but email and telephone communication).  The survey also asked about the presence of nurse care managers.

And guess what?  On average, survey participants achieved about 22% of the possible points.  Points for teaming averaged 28%, use of an EHR was 26%, 9% met criteria for having a registry, 9% used patient e-mail and a whopping 3% had nurse care managers in place to counsel patients for chronic disease.  Smaller practices were more likely to not meet PCMH criteria, but even then, the average score was 33% in the larger practices with 12-19 docs.  If monetary incentives were in place, the uptake was greater, but even then, the mean improvement was only about 10%.

To the authors' credit in the Discussion part of the manuscript, they recognize that just because the PCMH seems nifty is no reason to expect its wholesale adoption.  Assuming the PCMH lives up to expectations (still a big if), they point out the PCMH will need lots of assistance (grants, loans and training), shared resource planning (care managers could be funded externally, for example by insurers and shared by the clinics), incentives (P4P and risk contracts) and a new generation of differently trained docs.

The DMCB wholeheartedly agrees.  It also points out that it's gratifying to see Dr. Rittenhouse and colleagues bring up the "shared services" model as an important option that will increase patient access to the care management function of a PCMH "style" of practice.  They can read more about that here.  Absent any evidence to the contrary, the DMCB doubts the average physician has any real sense of PCMH ownership and would be happy to outsource much of it.

Given the dismal uptake of the PCMH, it's time for health policymaking to recognize that.
      

Small Business Owners May Really Like Health Insurance Exchanges Built Off The Utah Model

The Disease Management Care Blog attended a local health reform education session that was sponsored by an area business journal.  While the audience of several hundred included a number of providers, brokers, health insurers, consultants, tax advisers and accountants, there was a critical mass of business-owners.  The DMCB watched them closely. 

To the DMCB, it was clear that they paying very close attention.  Their ears really perked up when they heard one speaker discuss the lessons of the Utah Health Insurance Exchange (HIE).  It was a well organized presentation.

Recall HIEs are on-line web-portals that help individual consumers shop for health insurance.  They portray and can also sort the various insurance options, their premium amounts, other basic information about coverage and - if the consumer chooses to actually buy insurance - collect the application (also on-line), confirm eligibility, determine whether any subsidies apply and then issue a policy. The Affordable Care Act encourages States to start exchanges as part of health reform.  You can read more about them here.

The Utah Exchange got a head start prior to the ACA. In contrast to its more famous cousin in Massachusetts, it is limited to employers with between two and fifty employees who are using a "defined contribution" benefit approach.  Under this system, the employer applies for admission to the exchange and provides a pretax dollar amount to the employees, which they can use to individually buy insurance on the exchange.  If the dollar amount doesn't cover the full cost of the insurance, the employee is responsible for coming up with the difference. Enrollment never closes, no one can be denied coverage, individual self-employed business owners (and their spouses) are not eligible to participate and part-time employees working two or more jobs can pool their employer contributions.  Six commercial insurers (along with two health savings account vendors) are participating with over 100 employer groups and 3000 people.

There were five things that may be of interest to DMCB readers:

1) No word on whether exchanges will list information about the availability of disease or care management programs or if their network contains a critical mass of patient centered medical homes.  If any readers one way or another please share. 

2) No, the Utah Exchange didn't appear to have any impact on the cost of insurance.  Duh.

3) While relatively modest in terms of the total number of persons serviced, the background computing technology necessary to collect the information, determine eligibility and issue an insurance policy is extremely complex.  Utah started working on this in 2005 and it took years with some hiccups to get it right.  As a result, the likelihood that well-functioning exchanges will be up and running in the remaining 48 States by the ACA target date of 2014 is about as great as Mitt Romney shaving his head and growing a goatee.

4)  The DMCB asked the speaker if the State or Federal government could use the threat of exchange "delisting" to surreptitiously regulate or even badger health insurers, as described here.  Her response was no, at least in Utah, because there's language in the enabling legislation that forbids using the Exchange to "regulate" insurers.  Um, right.

5) At the conclusion of the meeting, the DMCB chatted with a small business owner with $800,000 in health insurance costs.  He can't wait for a Utah style exchange to drop into Pennsylvania so he can push his employees into a defined benefit individual market faster than President Obama can say "no tax breaks for corporate jets!"  Is this an unintended consequence that will put another nail in the coffin of employer-sponsored insurance?  Stay tuned!

The Latest Cavalcade of Risk Is Up

There's a lot of insightful links on "risk" being offered this week, including a foray into a video presentation on the various dimensions of being vs. feeling secure.  Julie Ferguson of Workers Comp Insider does an outstanding job of hosting this latest edition.  Enjoy!

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.

The Future Burden Of Disease From Obesity May Be Underestimated (plus, how to sound like a very smart statistician)

No doc office is complete without this

In yet another instance of the medical literature being an endless font of obscure statistical jargon, check out this article in that wacky policy journal, Health Affairs, and say hello to the term "three dimensional forecasting."

Against all odds, the intrepid Disease Management Care Blog will attempt to wrestle this tricky theoretical tomfoolery to the ground, examine the implications for the obesity epidemic and, best of all, once again demonstrate how obscure epidemiologic phrasing can be used against foes and fools alike.

The Past As Prologue To The Future

According to authors Eric Reither, Jay Olshansky and Yang Yang, the accuracy of of "two dimensional" statistical trending is blunted by an underlying assumption that the trajectory of past data trends will continue into the future.  One example is the unrelenting upward march of national health care costs (which explains our national interest in "bending the trend").

Obesity

In this article, the authors apply their more accurate "three dimensional" approach to assessing the future national risks that are associated with obesity.  By way of background, the DMCB found this classic two dimensional graph that projects a 70% rate of obesity in the U.S. by 2020.  When the association between obesity and premature heart disease is considered, it's easy to conclude that that there could be a significant shortening of life expectancy in the coming decades.

Using The 3rd Dimension To Check Out The Future

Reither et al says it's much worse than that.  Their "three dimensional" methodology mathematically includes the burden of additional risk factors (for example, the prevalence of childhood obesity) that are present today that, in turn, could act as yet-unseen or "latent" drivers of more risk in the future.  This is a step up from the basic "two dimensional" modeling that bakes in past assumptions about improving overall life expectancy and ignores today's simmering time-bombs built of pizza, hot dogs and pop.

Yikes

Their conclusion?  They applied their modeling by testing it on past heart disease risk factor data and compared their predictions of the incidence of coronary artery disease with today's real incidence.  They found a surprisingly good fit.  Based on the fit of these data, they warn that the U.S. public health community's reliance on old statistical approaches is probably underestimating what we should be planning for in the future.  They recommend that "three dimensional modeling" be more broadly used and that we start by looking at obesity.  Based on some other research, they point out that we may be underestimating the projected decrease in life expectancy from obesity by as much as much as five years.

Enter The Institute Of Medicine

Speaking of which, the IOM has just released a report that lists interventions that have been shown to blunt the incidence of childhood obesity.  Children should be screened (two measures are weight for length or BMI at the 85th percentile), be encouraged to increase their physical activity (15 minutes per hour in day care for example; community outdoor recreation areas), engage in healthy eating habits (for example, attention to portion sizes) and be protected from predatory food industry marketing.  You can find lots of good stuff here; no obesity prevention program is compete without the IOM recommendatons.

3rd Dimension Verbal Swordsmanship

Armed with the concept that standard projections based on linear-statistical trending may be unequal to the task of assessing future risk, DMCB readers can now challenge know-it-all speakers, faux-expert consultants and tiresome academics by stopping them dead in their tracks - as early as PowerPoint slide 2.  Anytime you see a graph that has a dotted line extending up and into the future, you can raise your hand and ask if the plot is based on shabby two-dimensional modeling.  No boring meeting is complete without the threat of this kind of showstopper:

Er, excuse me Doctor Pintminded, but you seem to assume that the future prevalence of diabetes will be [insert number here] but does that account for present day risk factors that are typically included in a three dimensional analytic estimate of future burdens of disease?

Happy Hunting!

Image from Wikipedia

More On Posing As Patients To Monitor Access For Persons With Different Types Of Insurance

I'm listening!

In a prior post, the Disease Management Care Blog described a research study that compared Medicaid vs. commercial insurance access to care.  Research assistants posed as parents calling for an appointment for their child and found - all things being equal - that having Medicaid was associated with less access and longer appointment times.  The DMCB found the difference clinically, statistically and ethically significant.

The prescient DMCB also predicted that State Medicaid programs would...

1) adopt the same methodology to monitor access, and

2) possibly figure out a way to sanction physicians who discriminate on the basis of insurance status. 

Little did it know it would get the first part right so quickly, the only minor difference being that it's being run out of Washington D.C. 

Despite official protestations to the contrary, the veracity of the second part remains to be seen.

+++++++++++

Follow-up, 6/28/11, 21:49 hrs:  In an unusual display of common sense, CMS has decided to cancel this ill-fated initiative.  The DMCB still takes credit for the prediction.

Contrasting the States and Washington DC When It Comes To Health Reform

Speaker "All politics is local" O'Neill

Years ago, when the Disease Management Care Blog was participating in the AHIP managed care executive program, it was introduced to the organization's staff responsible for monitoring all fifty States for changes in health policy, laws or regulations.  The young DMCB quickly learned that while Washington DC's impact on health care was considerable, it was the States that were the most progressive, experimental, dangerous or exciting. 

Behold the "federal" system of government and the truism that "all politics is local."

It's still true.  While New York's legislation enabling same sex marriage is slightly off-topic, the DMCB finds it gratifying that a critical mass of Democrats and Republicans in the Empire State managed to find common ground on a contentious issue.  Good for them and good for the citizens of New York.

Recall also that Massachusetts' own health reform law was passed by a Republican governor and a Democratic-controlled legislature.  While it has its problems, state-wide support for the law appears to be holding up. 

At a personal level, the DMCB has corresponded with both its State Representative and State Senator.  It has also shook the hand of and exchanged words with its current Governor.  In the meantime, two letters to Senator Toomey have rudely gone unanswered and President Obama has unbelievably not once mentioned this blog in any of his speeches.  And while our President has professed support for marriage equality in the course of seeking donations and campaigning, his actions have been riddled with the usual cynical political calculus.

Lesson for the DMCB: Want to get it done?  Make something happen?  Make a change for the better?  The best answer may lie in your State capital, not in Washington DC.  Here's why.

Comparative Effectiveness Research Update: Greater Flexibility, More Outcomes

For an update on how the folks who are in charge of the $1.1 billion's worth of "comparative effectiveness research" (CER) are viewing the world, the Disease Management Care Blog checked out this just-published online Perspective piece in the latest New England Journal of Medicine. 

Study Subjects With Combinations of Conditions

While the focus will be on persons with chronic physical and mental health conditions, the real challenge for the "Patient-Centered Outcomes Research Institute" (PCORI) will be to find the right combinations of conditions (for example, persons with coronary artery disease with advanced heart failure plus depression) in sufficient numbers of individuals that will allow statistically valid inferences to be made. 

Alternative Research Methodologies

While PCORI would have preferred to use prospective randomized clinical trials to conduct their research, they must have been listening to critics like the Disease Management Care Blog.  There aren't enough patients, enough time or enough money within reach.  As a result, PCORI now recognizes that "observational studies" on heterogeneous patients outside the rarefied world of academia - despite the twin threats of confounding and bias - have to be included in the mix of funded study designs.  It turns out that it's possible if statistical controls are carefully and judiciously applied.  This will be considerably easier if large "registries" (or databases) are developed that contain the longitudinal outcomes data of large cohorts of patients.

What Outcomes?

The article also points out that untangling various outcomes involving multiple co-morbid disease states promises to be thorny, especially since treatments that help one condition (high blood pressure) may exacerbate another (low blood pressure and falls in a person with osteoporosis).  The answer will be to find outcomes that can be universally applied across multiple disease states such as "shortness of breath" or overall "quality of life."

The DMCB Reaction

"Hear hear!" says the DMCB.  This latest update indicates the folks in PCORI have recognized that good research methodologies shouldn't be the enemy of the perfect.  They have come to realize what the population health management community realized years ago: that it's possible to simultaneously provide care and intertwine robust research methods that simultaneously render insights about the population under management.

And... Uh Oh!

Unfortunately, the PCORI is widely viewed by supporters and critics as emblematic of "Obamacare" and there are threats by the ACA-hostile Republicans to defund it.  It remains to be seen how likely this is to succeed, but in the meantime the PCORI could help its cause by supporting the location of CER outside the usual insular academic institutions.  For example, it could be done in a commercial disease management setting, where huge amounts of data on millions with chronic conditions are already having their longitudinal data followed in huge terrabye servers (for example is here).

More On Electronic Records And Their Impact On Health Care Costs: No Proof Of Savings

...for Better Health and Savings?

To the continuing annonyance of electronic health record (EHR) cultists everywhere, the skeptical Disease Management Care Blog was quoted in this lead Health Data Management article on The $80 Billion Question.

It's been awhile since the DMCB looked critically at the latest news on the unending assertion that the EHR is somehow going to "save money" and reduce U.S. health care costs.  This well written article by Gary Baldwin includes interviews with a wide-ranging number of HIT leaders and, to the non-surprise of the DMCB, the evidence of savings - as of June 2011 - remains very much an open question.

The issues are the same: what a physician practice may save in filing and transcription costs is lost in hardware, maintenance and IT personnel support costs. While there may be some ultimate gains in office efficiencies, it can take months before patient flows return and even then, it's back to baseline. Claims of meaningful jumps in clinical quality are overblown, the impact on repeated unnecessary testing is questionable and clunky user interfaces can not only be frustrating to doctors, but lead to new types of medical errors.  And in the middle of all that, the real business case for the EHR lies in its ability to document additional "billable" care, enabling providers to bill more for the same services.

With the ballyhooed reliance of federal and state health policymakers on "evidence" and "science," the DMCB finds it ironic that so much of our nation's treasure is being used by CMS to promote what is more an ideology than a clinical discipline.

This makes the DMCB ask one simple question: if the EHR really saves money, can anyone point to one instance where the installation of an EHR led to a drop in hospital or physician office prices and lower expenses for patients or their insurers?  If not, why not?

Health Advocacy Groups, Evidence-Based Medicine & Shared Decision Making

Listen, here... EBM works!!

This-time-we-really- mean-it Congressional budget cutting.  The evaporation of cheap Chinese imports.  Riot-provoking Eurozone austerity.  Too much oil within the reach of Arab craziness.  Maybe it’s all random, but the dot-connecting Disease Management Care Blog suspects our collective economic pie is in for some downsizing.  

Unions, advocacy groups and various political and social institutions seem to agree.  Demanding more benefits and higher wages is simply a hedge against the strong possibility of some painful clawbacks.  The pie may be getting smaller, so the logical response is to stake out a bigger piece.

Columbia University’s Sheila Rothman doesn't disagree, but she sure is disappointed.  Writing in the June 22/29 issue of JAMA, Dr. Rothman misses the big picture and laments the unwillingness of “health advocacy organizations” to submit to the enlightenment of “evidence-based medicine” (EBM).

The DMCB explains. 

According to Dr. Rothman, groups like the Epilepsy Foundation of America, the National Alliance on Mental Illness, the National Coalition of Cancer Survivorship, Mental Health America, the American Cancer Society, Susan G Komen for the Cure and Autism Speaks have all opposed the use of EBM to restrict unfettered access to more testing, more treatment options and more services.  This is despite solid science that, depending on the circumstances, has repeatedly shown more testing doesn’t necessarily lead to better outcomes, generic medications work just fine and some treatments actually harm patients.  Dr. Rothman suspects the real underlying agenda is battling “cutbacks” and not representing a common good.

Fair enough, says the DMCB, but let’s do some reality checking and give the organizations as well as Dr. Rothman an evidence-based way out of this health advocacy antipathy, this medical maladjustment, this health policy pickle.

First off, there is no denying that EBM represents a rational, scientific and life-preserving approach to cutting waste from a bloated health care system.  Unfortunately, the political adroitness of selling this to a skeptical public has been as flatfooted as Republican’s voucher support program idea.  Scientists may get it, but moms of autistic children are scared of EBM.  The EBM brand is headed south faster than Greek bonds.  

Secondly, critics of EBM may have a point: no evidence of any benefit, especially if measured using averages, is not the same as evidence of no benefit, especially if a lucky few at the margins do benefit.  There’s EBM, but it is no match for American-style hope.  There’s the realpolitik, and then there is the Arab spring.

Third, advocacy groups exist to…, well, advocate.  AARP is the latest example of what happens when that is forgotten. The only way these groups will give anything up, especially in the current economic environment, is to give them something in return.  EBM is not that something.  Lecturing them about the "evidence" will get you as far as lecturing the Chinese about their currency exchange rates.     

So, what is the way out? The DMCB continues to be intrigued by the evidence-base underlying "shared decision making."  There is compelling evidence that providing user-friendly, patient-centric, clear, concise and objective information about the risks, benefits and alternatives of various treatment options not only enables consumers to choose wisely, but often leads them to forgo risky, dubious and expensive options.

Which leads the DMCB to ask: why not craft a win-win policy and political compromise with the health advocacy groups that promotes the use of SDM? 

More on this in a future post.

Image from Wikipedia  

 

Surveillance Bias: A Threat To Public Quality Reporting and Hospital Acquired Conditions

The More You Look, The More You Find

While everyone agrees that quality monitoring systems should be routinely embedded in health care settings, Elliott Haut and Peter Pronovost, writing in the June 15 issue of JAMA, correctly remind us about the risk of falling prey to "surveillance bias."

The short definition is "the more you look, the more you'll find."  In other words, the greater the number of diagnostic tests, the greater the detection of disease.  Deep venous thrombosis (DVT) is used by Drs. Haut and Pronovost as an example.  Not all patients with DVT have the typical symptoms of a swollen painful leg and not all patients with a positive test have DVT.  Yet, if a hospital decided to initiate a DVT screening program on all its bedbound inpatients, it could end up looking like it had "more" DVT cases than another otherwise identical hospital without such a screening program.

It can get even more complicated.  Noting that DVT is one of CMS' dreaded "hospital acquired conditions," physicians may worry that a surveillance bias could translate into public disparagement or financial penalty.  This could prompt them to under-test for the condition, paradoxically leading to increased patient harm.

The authors conclude with some common sense suggestions:

1) If quality surveillance must be mandated, ensure that the surveillance methods are clearly defined and uniformly applied.  By the way, policymakers will also need to consider the burden of more cost thanks to additional testing.

2)  The risks of all downstream unintended consequences need to be carefully considered, including the perverse incentives that may prompt hospitals to not look and find less.

3) Other measurement methodologies need to be considered.  For example, the authors point out that it may be useful to rely on "process" measures that look back at the care of patients with adverse events.  For example, chart audits of known DVT patients could detect whether any underlying risk factors could have been better managed.

Coda:  Soon after posting this, the DMCB came across this Kaiser Health News report deploring the increase in wrong side surgeries.  Like all modern reportage, KHN has sprinkled in some lurid anecdotes. 

Not to be outdone, the DMCB recalls one surgical colleague's witnessing of an emergency room evacuation of a subdural hematoma (a traumatic blood clot overlying the surface of the brain), which is accomplished by drilling a small hole in the skull.  After the surgeon made the preliminary incision through the skin of the scalp, he looked at the CAT scan one more time and realized it was (like a surprising number of television show x-rays) mounted backwards.  The cut and drilling on the other side was accomplished, but the preliminary incision was counted as wrong side surgery. 

Is the apparent increase in national rates of wrong side surgery partially explained by surveillance bias?  You be the judge.

Case Management: Your Ship Is Coming In

Worth every penny

The most recent leg of the Disease Management Care Blog's ongoing world tour has just successfully concluded. The latest trip was a presentation at the San Antonio annual meeting of the Case Management Society of America (CMSA).  By the way, not only is it proud member of the AMA and the ACP, but the DMCB is also proud dues-paying CMSA member.

The topic?  What else...  case management and it's impact on Accountable Care Organizations.  While the DMCB's action-oriented learning goals enumerated the many synergies between case management and population-based health care in ACO settings, the underlying message was that case managers are uniquely poised to rescue ACOs. 

In other words, my non-physician care-coordinating professional colleagues, your ship has come in.

This is what the DMCB said:

In order to manage the financial risks of being "accountable" to a population, provider organizations that want to be ACOs will have to do five things:

1) assess their assigned members' individual risk (using health risk assessments (HRAs) and predictive modeling,

2) that then segment or stratify the population into three "buckets":  high, medium and low.  Then....

3) deploy a full spectrum of communication interventions, including telephone, mail, email and social media, the purpose being to.....

4) recruit patients into the appropriate care pathways that are tailored to the level of risk.  Patients at highest risk need case management.  Patients at lower levels of risk may require less intense coaching, such as preventive counseling, telephonic reminders and, if available, wellness interventions.  Patients with a high level of readiness to change are most likely to benefit.  The purpose of all this is to...

5) apply evidence-based medicine and guidelines using shared decision making so that patients can reconcile the the care they need with what they want and, simultaneously, reduce claims expense (an example is here).

And who is responsible for all this you ask? 

Many naive policymakers, out-of-touch regulators, inflexible legal experts and physician-leader apparatchiks will tell you the primary doctors will do it.  According to this policy-insider elite, giving PCPs electronic records, 10% pay increases and medical home status will unleash the physicians' hidden lust for becoming accountable.  They'll want to counsel patients in the course of their office visits.

Poppycock, says the DMCB.  Docs don't mind being ultimately responsible, but they have little interest in reviewing, recruiting or educating lists of patients.  They're more than happy to "outsource" that job to case managers.  The DMCB thinks of these professionals as the ones who review the lists, oversee recruitment rates, provide counseling services and assure that maximum numbers of patients become engaged in their self care.  Plenty of those patients will need an appointment to see a doctor for diagnosis and treatment, and - thanks to a working relationship with their docs - the case managers can make that happen.

In other words, the case managers will be the linchpin to assuming ACO success.  Where the rubber hits the road.  Where the light shines.  Where the action is.  Where the return on investment will be achieved.

Medicaid's Travails

The Disease Management Care Blog has generally steers clear of the painful topic of Medicaid, but two recent publications in prominent journals caught its eyes.  Both are reminders of Medicaid's continuing provider payment travails.

Taxpayers Get What They Pay For:  The first article is from the New England Journal, describing the success rate of research assistants' paired calls requesting new patient appointments for fake patients to 273 Cook County Illinois private practice pediatric specialty outpatient clinics.  The only difference between the two calls was one that was that one involved a child with Medicaid insurance status, while the other was for a child with Blue Cross Blue Shield (BCBS).  179 or 66% of the "Medicaid" children couldn't get an appointment, while that was true for only 29 or 11% of the "BCBS" children  - a difference that was both ethically and statistically significant.  For the children who got an appointment, the average wait time was 42 and 20 days for Medicaid and BCBS, respectively.

The authors point out that in Illinois, a moderately complex office visit is paid at $99 for Medicaid and $160 for BCBS.  While that should hint at the underlying problem, the DMCB predicts that the authors' "mystery caller" methodology will be adopted by State Medicaid programs, and that clinics that routinely turn Medicaid patients away will be somehow sanctioned.

Taxpayers Don't Get What Can't Be Measured:  The second article is from Health Affairs.  The DMCB didn't know this, but a part of Massachusetts' 2006 health reform included the state's Medicaid program ("MassHealth").  A pay-for-performance program was specifically aimed at reducing racial and ethnic health care disparities.  The clinical performance measures were based on an aggregate score based on a complex formula that used combination of observed versus optimum rates of surgical infections, pneumonia care, pediatric asthma care and maternal and neonatal health for minorities versus whites.  Hospital "structural" measures focused on governance, administration, management, service delivery and customer relations.

Despite widespread support among hospital administrators, the program was limited by low white vs. persons of color baseline differences, as well as small sample sizes that limited statistically valid comparisons.  In addition, hospital administrators reported that the program operationally burdensome, because if was layer on top of the other mandated reporting programs required by other state agencies.  The authors also point out that the legislature simply didn't anticipate that patients with varying ethnicity would be unevenly distributed across the Commonwealth's hospitals, or that the chosen measures didn't demonstrate that there were disparates.

While the program may have benefited from better planning, the DMCB thinks this was a nice try. It's also an example of  the benefit of limiting health reforms to the State level. Imagine the colossal waste of money would have occurred if this had been mandated by Congress at the federal level.

Population Health Management (PHM) Can Help Achieve Evidence Based Health

Greek for "working together"

It took a while, but the Disease Management Care Blog finally caught up with this article by David Moskowitz and Thomas Bodenheimer on "evidence-based health" or "EBH."

The authors use a different terminology (as well as acronyms) to arrive at a health care construct remarkably similar to one repeatedly described in this blog: there is no single approach that solves the twin quality and cost challenges of chronic illness.  Instead, multiple overlapping and synergistic interventions are required.  The good news for the disease and care management service providers is that Dr. Moskowitz's publication appears in the prestigious Journal of General Internal Medicine, is thoroughly referenced and specifically includes "self management support" as one of the key ingredients for success.

In multiple writings, the DMCB has identified health information technology, disease management, the medical home, payment reform, wellness and insurance benefit designs as the mix of interventions that can transform health care.  This article identifies "evidence based medicine" (or EBM) plus self management support (or SMS, where patients fit EBM to their personal circumstances) plus "community health" (or CH, where the physical and social environment can be modified to support SMS) as the key ingredients to achieve greater value.  Primary care that successfully incorporates all this can be dubbed "health homes" instead of "medical homes."

The article then goes on to describe - with the back up of lots of peer reviewed literature references - the role of turbocharged SMS in the care of diabetes, obesity, asthma and tobacco abuse.  Non-surprisingly, numerous studies and meta-analyses have shown SMS works.

The article closes with a melancholy call for changes in non-physician job descriptions and competencies, changes in how physicians achieve certification, cultivation of community-based networks, broadening of the NCQA's accreditation criteria and greater involvement of primary care in the fabric of the community.  The DMCB uses the term "melancholy" because, at the end, the author implies that significant barriers stand in the way of this new vision of EBH.

From time to time, the DMCB recommends that certain publications be included in a "resource library," filed away as "business intelligence," quoted in collaterals, inserted in a PowerPoint presentation or mentioned at a staff meeting. This may be one of those articles because it's a brief and well written piece in favor of self management support written by a credentialed academic.

The disease and care management providers can also take comfort in knowing that they're part of the solution.  They've been in the business of overcoming barriers for years, know how become integrated with other parts of the system, can provide the trained non-physicians, refer to community resources and help fulfill accreditation criteria. 

Drs. Moskowitz and Bodenheimer say "EBH = EBM + SMS + CH." 

The DMCB wonders if it's more like EBH = (EBM + SMS + CH) x (i.e. times) PHM.  And that ain't melancholy at all.

The Latest Cavalcade of Risk Is Up!

Risk.  You can measure it.  Monetize it.  Worry about it.  Mitigate it.  Best of all, you can READ about it, in the latest Cavalcade of Risk.  This edition is hosted by the anonymous and discerning IronMan.  As a special added bonus, (s)he's provided a handy calculator that ties gasoline prices to unemployment. 

Enjoy!

Is Population-Based Care and Disease Management Fair? Worse, Is It (Gasp!) Socialist?

Oncle Karl would be proud?

The Disease Management Care Blog is currently blogcasting from Newark International Airport where, along with thousands of other travelers, its best laid plans are being humbled by the sullen and fickle weather gods.  It's on its way home after being a speaker at the Florida Health Care Coalition Care Management Summit. 

The DMCB was once again reminded of just how savvy the business community is about the twin health care challenges of cost and quality.  That's not only because they're eroding their profit margins, but because these employers are highly committed to the wellbeing of their work force.  We in the health care industry ignore their insights and advice at our peril.  

The long airport sojourn has given it an opportunity to think about an excellent question that came up during the post-talk Q'nA:

What is your response to the criticism that persons with chronic illness who are already working hard to care for themselves may not have the same access to services and incentives as patients who are less engaged in their self care?

As us population-based care management'ites may recall, the more modern versions of our approach to care segments populations using two key criteria:

1) high "risk" (or need), and

2) high engagement potential (or readiness to change). 

Patients with a pattern or a profile that suggests a high likelihood of future avoidable hospitalizations or complications are good candidates for intervention.  Patients who express a willingness to assume greater responsibility for self-care are good candidates for intervention.  Patients who exhibit both are ideal candidates for the interventions.  This includes one-on-one coaching, telephonic support and, depending on the circumstances, various incentives, home-based telemonitoring and expedited care.

The DMCB suggests this works because targeting complex care management at the patients most likely to benefit not only preserves precious resources and has a return on investment, it is more likely to achieve disease control.  What's more, the early versions of "disease management" that tried to "call everyone" generally failed.

Despite its merits, the questioner correctly pointed out that this "Ver 2.0" approach could be criticized for effectively shutting out other patients who may not "make the cut" because they already minimized their risk through their own grit and determination.  Yet, these patients could also benefit from the "boost" of participating in a care management program and many might welcome the chance to reduce their risk even lower. What's more, its "from each according to ability and to each according to need" approach strikes the mostly conservative DMCB as a curiously socialist posture for a health care program. Last but not least, accepted social policy not only strives to "pool" insurance risk but pool the social benefits that flow from that.

The DMCB response?  Inadequate at the time of the presentation and it will continue to ponder this, preferably soon and on the other side of an airport security check point. 

Some initial thoughts:

1. To the DMCB's knowledge, the issue hasn't really come up in the market-place to any significant degree.  While being "shut out" is a theoretical worry, patients in the" real" world who are already doing a good job of self-care may be less concerned and the vast majority may think of this as a non-issue.

2.  While lack of access could paint a picture of social injustice, all patients ultimately win if there is an impact on health care costs.  This assumes, of course, that the health care system savings translates into lower prices.  Not a strong argument.

3. One potential fix is to prominently advertise the program and agree to all patient requests for entry into the care management program.  In other words, in addition to high risk and high readiness, high interest is also a criterion for entry.

4. Financial incentives linked to participation in disease or care management programs may be more complicated, says the DMCB.  It's no lawyer, but beware of potential limits on how that can be used.

5. Last but not least, this is an area that may benefit from having a patient advisory committee, an appointed advocate or an ombudsman to help steer policy and maintain fairness from the consumers' point of view.

The DMCB welcomes input from readers on the topic.

Two. That Was The Number Of Questions in a Two Hour Republican Presidential Candidates' Debate

The Disease Management Care Blog spent the evening glued to the June 13 CNN New Hampshire Republican Presidential candidates' debate.

It wasn't health care that dominated, but the economy and jobs. While the Affordable Care Act (ACA) promises to be an important topic in the 2012, the DMCB is thinking that'll be small change compared to a stubbornly high unemployment rate, a moribund housing market and an anemic economic growth. 

When health care did come up, Mitt Romney made an interesting point: for all of President's fawning over the merits of Massachusetts' health reform Mr. Obama never once called the Governor to ask him about any lessons that could have made the ACA better. 

A single Medicare question divided the candidates into three camps: 1) "full speed ahead" on fixing a looming funding crisis with some       Ryan-esque variation of a voucher or "premium support" plan, 2) a grimly solitary Newt, who pointed out there are other options and 3) dissembling tentative and vague nostrums. Figuring the Republicans will want to emphasize the economy, the DMCB predicts the third camp will win the day.

And some quick DMCB answers to the inquiries designed to humanize the candidates: Conan or Leno, just so long as it's not creepy Uncle Letterman.  June Cash, not Johnny. Dancing with the Stars because the older contestants give the DMCB hope.  iPhone because that's used far more often to access the DMCB.  Home made "Deep Dish" made with goat cheese, figs, bacon and arugula. 10⁵ Scoville Heat Unit (SHU) Spicy Wings.  The DMCB spouse says "Pepsi" because the DMCB can't taste any difference, perhaps as a result of SHU abuse.

Disease Management for Accountable Care Organization Success: One Tool Among Many

Ready... aim....

An arrow in the quiver.  A tool in the box.  One of the instruments in the orchestra.   That's how the Disease Management Care Blog has described the methodology of "population-based care management."  It's one in a suite of approaches necessary to reduce health care costs and increase clinical quality for a population that is defined by a condition (such as diabetes), geography (surrounding a clinic) or insurance status.

For the latest on how disease management is an important option in the formation of "Accountable Care Organizations," check out this (regrettably ad cluttered) HealthLeaders article describing how the 4-hospital-17-clinic Essentia Health System's positive experience with their nurse-led disease management program is giving them a leg-up on keeping patients out of the emergency room and the hospital.  Its success has led the way in making Essentia's confident that it can be a successful ACO.

Any why not?  Even the U.S. Agency for Healthcare Research and Quality says there is pretty good ("moderate") evidence that Essentia's heart failure program was a home run.  As the DMCB understands it, patients either self referred or were referred by doctors, especially after an admission for heart failure. A mix of nurse practitioners and registered nurses conducted series of one-on-one or group visits to educate patients as well as start or adjust medications under an established protocol. In-bound calling was also available and selected patients were given home telemonitoring weight scales.

Minnesota Blue Cross Blue Shield analyzed the program's results for its participating insureds and determined the readmission rate dropped, length of stay decreased, medication use increased and cardiologists were freed up to care for high priority patients.  Based on a subpopulation of  "29 patients," they estimated there were $1.25 million in savings.

Essentia points out that "disease management" is not a physician skill set.  The DMCB wholeheartedly agrees and also thinks that its physician colleagues don't really mind that characterization, especially since this is a team sport.  After all, the nurses in the program are performing many of the rote duties of clinical management while simultaneously deferring to the docs when needed.  Some friction is inevitable, but the advantages and the outcomes outweigh the disadvantages.  This program speaks for itself.

While the DMCB has been leery of the proposed ACO regulations as now written, if anyone can succeed at this, it seems Essentia can.

Will the Affordable Care Act (ACA) Cause Employers to Drop Insurance? Why The McKinsey Report Is Credible

...and the battle continues!

By now readers may have heard about the McKinsey Quarterly Report "How US health care reform will affect employee benefits" that purports to show, as a result of the Affordable Care Act (ACA), that a significant number of employers are going to abandon offering health insurance for their employees.

Knowing that readers may not have time to sign-up for an email address and password McKinsey "account" or read the 11 page report, the Disease Management Care Blog has summarized the highlights and the controversy below.  The bottom line, however, is that a respected consulting firm has punched a small hole in the side of the U.S.S. Administration Assumptions.

The DMCB presented at and listened in on a number of Washington DC health policy conferences during the Fall of 2010.  It specifically recalls a common refrain among the human resource experts and benefits consultant speakers: they wanted to continue offering employer-based insurance, they said, but they needed more time understanding what the ACA did and did not do. 

As a result, the DMCB suspects most employers in the earliest days of the ACA were inclined toward the status quo.  The DMCB also suspects that the nation's larger employers were not inclined to say anything publicly that might annoy the Administration and prompt Mr. Obama to introduce some of them to the political underside of Mr. Bus.

Now that employers have had a chance to mull over all of the ACA's provisions, a substantial minority have apparently decided that the upsides of dropping employer-based insurance outweigh the downsides.  Not only could "Medicare as we know it" change, but, based on these data, "if you like your insurance..." you won't be able to keep it. 

Now onto the report itself:

Noting that the Affordable Care Act in 2014.....

1) guarantees individual coverage for all, arguably absolving employers of their duty to provide insurance,

2) requires employers to provide a comprehensive - and relatively more expensive - insurance benefit package,

3) provides income-indexed premium support as well as premium caps that will make it easier for workers to get coverage in the individual market and

4) fines employers only $2000 per employee that isn't insured,

....authors Shubham Singhal, Jeris Stueland and Drew Ungerman surveyed "more than 1300 employers across industries, geographies and sizes" using "proprietary" research and found:

• the $2000 penalty will cost less than offering health insurance

• "45% to 50%" of employers are seriously looking at insurance "alternatives" such as dropping out, going with a defined contribution model or limiting access to a minority of employees

• "30%" of employers will drop coverage.  This will enable them to offer higher wages

• employees will no longer prize their employer sponsored insurance, making it less of a retention tool.  85% of employees will not quit if their employer stops offering insurance.

The White House respectfully disagrees and has provided summaries with links to supportive no-impact-on-employer-insurance policy analyses. They are an employer survey by Mercer (released in November of 2010 - potentially when employers hadn't had a chance to fully digest the ACA) and two "economic simulation" models by the Urban Institute and Rand.

The Latest Health Wonk Review Is Up!

Wow.  If you want to be dunked up to your eyeballs in a pool of insightful, contrarian and unique bloggery dealing with every dimension of health policy, then click your way over to the latest edition of the Health Wonk Review, courtesy of the granddaddy of them all, The Health Care Blog.  This is one not to be missed!

The DMCB Is Now Optimized For Mobile Device Viewing

YOU: A harried health professional, perma-tethered to the 'net and inundated by an unceasing stream of emails, memos, reports and articles. Unwilling, unable and undisciplined to listen to your boss, coworkers, and spouse, you can't stop using precious minutes to check out the Disease Management Care Blog post.  You wish there was another way to access its unique content.

DMCB: A blog that understands the Internet-addled dilemma of its many-thousand of repeat readers, it's content is now optimized for on-screen mobile-device viewing.  Now you can read it while waiting for your mocha cappuccino, that boarding announcement and for the end of that interminable staff meeting. 

What CMS Administrator Dr. Berwick Didn't Say...

In a wide-ranging and brief Kaiser Health News interview, CMS Administrator Don Berwick is asked about Medicaid, ACOs, the Ryan Plan and cutting costs.  Regular readers of the Disease Management Care Blog can probably predict what Dr. Berwick had to say. 

The DMCB is more interested in what he didn't say.

Medicaid: While the "flexibility" and federal "help" are the rhetoric of the Obama Administration, there was nothing in Dr. Berwick's murmurings to suggest that there will be any substantially new approaches to a deeply troubled program that is not only blowing a huge hole in State budgets, but is a disservice to patients and doctors alike.  The reason it's called "CMS," is because Medicaid (the other "M" in CMMS) remains an orphaned afterthought.

Accountable Care Organizations:  Putting a brave face on things, Dr. Berwick ignored the huge push-back by providers on the ACO regulations, spinning the comments that have been received by CMS to date as "exciting," and "of help."  To the DMCB, it suggests that the Administration doesn't really intend back off from the onerous conditions of the current proposed rule and save this sinking ship.

Medicare's Unsustainable Costs: While Dr. Berwick unsurprisingly has little appetite for any changes in funding or benefit levels, his statement that "I go to work every morning with 100 million people in mind" and "I've got the back of the Medicare beneficiary" belies the real unsaid message underlying any notions of private-public, federal-state "partnerships": an astonishing faith in central command and control by Washington DC.

Recess appointment: The lack of any discussion on reversing the hostile Senate Republicans suggests he's given up on being confirmed by the Senate.

Quality Equals Cost Reductions? Not Sure? Welcome to the Club

It's so simple, right?

Does health care quality lead to reductions in health care costs?  If your answer is "don't know," the Disease Management Care Blog welcomes you to the club.  This brave article in Managed Care Magazine (where the DMCB serves on the Editorial Advisory Board) smartly tackles the issue and summarizes just how little we really know.

Among the DMCB insights:

The definition of "quality" among regulators and policymakers is surprisingly imprecise.  As a result, the notion can be used to advance any ideology.

There is no underestimating the huge "better quality reduces costs" gamble in the Obama Administration's Affordable Care Act.  How astonishing.

If high costs don't correlate with high quality, then why would any quality correlate with any costs?

Specific interventions that simultaneously improve quality and reduce costs do exist.  Examples include 1) fewer medical errors, 2) reduced hospital readmissions, 3) less 'unnecessary' (repeat) testing, 4) reduced (over) treatments and 5) administrative efficiencies.  The DMCB would add generics, flu shots and tobacco cessation. 

Any of the big savings from the specific interventions are translated into profits by providers or insurers.  The consumer never sees lower prices or insurance premiums.

The adage, quoted by CMS Administrators and high profile medical journal editors, that "30% of the system is waste" is based on an expert estimate that appeared in an obscure 2003 report.  There are no formal studies that have actually established this as fact.

What the iCloud Means to Population Health and Disease Management

Behold the cloud!

Intrigued by the spouse's enthusiastic embrace of her iPad, the Disease Management Care Blog has started paying better attention to the Apple company.  So when "iCloud" hit today's news cycle, the amateur informatician DMCB decided to take a closer look.

"Cloud" computing can be defined as the use of computer resources that are on a computer network (such as the World Wide Web) instead of those that are on the hard drive of that computer you are currently using.  So, instead of using "Word," or storing images or tunes on your "C" drive, the "cloud" enables you to use any network-enabled device to access a word processing program or store images on servers located anywhere on the globe.  So, for example, when the DMCB wants to edit a PowerPoint presentation while on the road next week in San Antonio using a friend's laptop, that will not only be possible, but it will also be able to sync it's calendar, upload a new blog post and make some tasty blueberry waffles.

Among health care services, readers may think this is simply an expansion of the on-line medical records phenomenon courtesy of companies such as Microsoft' "HealthVault."  The DMCB agrees but wonders if this cloud thingy takes things one step further:

Much more information is much more available real time.   Colleague Vince Kuraitis likes to refer to a rapidly evolving information technology "ecosystem."  The term may finally start to fit.  This goes beyond the notion of active patient engagement in reviewing, uploading and shepherding their personal health information (PHI).  To the DMCB, the "cloud" concept seems much bigger, with PHI consisting of interlocking evolving "clusters" of data from the patient, traditional providers, health insurers and     - good news - care management companies. 

The converse will also be true: information "monopolies" will wane.  Thanks to the favorable economics of and savings from storing petabytes of clinical data on the cloud (such as medical imaging), traditional health care providers will find it harder to deny access to their patients' data by patients and families as well as cooperating and competing health care providers. Persons with a need to know will find it easier to find that CAT scan from two years ago.  Whether traditional providers will gum things up with high data "viscosity" and overlawyered notions of patient privacy remains to be seen.

It won't be easy: Data integrity and privacy will face new challenges (for example) requiring significant system redundancy, distribution, back ups and yet-to-be-developed engineering and security systems.  The caution here is that we still have a way to go; between here and there will lie data breaches, network outages and critics - like the DMCB - who will wonder when patients will finally get to benefit from all of this.

A central role for care management programs?  In addition to the immediate need for a tailored Google-like search engine (that includes passwords) that can "pull" needed information on a particular patient from the "cloud," the DMCB wonders if care and disease management organizations are best positioned to help some patients access, use and organize multiple clouds of data.  These companies are heavily invested in IT, span the continuum of care across multiple providers and are closely aligned with patients anyway.  More on this in a future post.

The bottom line for disease management: this is good news for care management service organizations, who will be better able to both access and contribute to their patients' information.

Image from Wikipedia

The Cavalcade of Risk Has Been Up!

It's a late notification, but the DMCB was included in this very special 5th Anniversary Edition of the Cavalcade or Risk.  Russel Hutchinson does an excellent job of assembling the best of the "risk" related blog writings of the past few weeks.  Check it out.

ICD-10: Rough Seas Ahead

Have you heard of "ICD-10?"  In addition to the many requirements of the Affordable Care Act, this may turn out to be another big headache for insurers and providers.  According to CMS' web site, under the authority granted to it under the 2003 Health Insurance Portability and Accountability Act (HIPAA), if you want to do business with Medicare or any other health insurer...

"ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2013. Otherwise, your claims and other transactions may be rejected, and you will need to resubmit them with the ICD-10 codes. This could result in delays and may impact your reimbursements, so it is important to start now to prepare for the changeover to ICD-10 codes."

Which is why the DMCB paid attention to this "Report from the Field" Health Affairs article "Coding Complexity: US Health Care Gets Ready For The Coming Of ICD-10." 

The Disease Management Care Blog was reminded that "International Classification of Disease" or "ICD" is an alphanumeric billing system used to specify and describe diseases and treatments.  Originally developed in 1763, it was adopted by the World Health Organization in 1948 for use in public health reporting.  It was later used by physicians, hospitals and health insurers to specify diagnosis coding and payment levels.  For example, persons with "diabetes" may think they saw a doctor for that particular disease, but as far as their insurer goes, they were really seen for "250." 

As medical care has grown more complex, ICD has undergone periodic updates of its nomenclature, making each successive version more detailed. The ninth version (or "ICD-9") is currently in use in the United States, while most of the countries in Europe use "ICD-10."   In ICD-9, there are about 14,000 diagnosis billing codes; in ICD-10 there are 69,000.  ICD-9 has 3800 treatment procedure codes, while ICD-10 has 72,000.  As a result, if you are a health insurer, care management provider, public health advocate, government organization or a fan of Disease Management Care Blog interested in data and billing accuracy, you'd probably prefer ICD-10.

It turns out that if you're a doctor or hospital, you might hate it.

That's probably how providers are going to react on Oct 1, 2013 when the Feds start requiring ICD-10 instead of ICD-9.  That's because they'll have had to retrain the folks working in their billing offices and buy totally revamped software for a brand new coding system.  For a three physician practice, that could cost as much as $83,000. For a hospital, it'll cost millions.

As this unfolds there will be two things for DMCB readers to to watch out for:

1) Some providers are not going to be able to meet the deadline.  That means CMS and other commercial health insurers will have to decide whether to accept any ICD-9 bills and use their own information technology systems "remap" the codes into "ICD-10-speak."  If they don't, they may have to refuse payment, which could drive some physicians out of business.  There is even talk of providers and insurers setting up credit lines in case there are any disruptions in cash flow.

2) The switch from ICD-9 to 10 could lead to another round in the coding arms race.  Despite the coming advent of bundled payments, there will be plenty of fee-for service in the system. Insurers will be sorely tempted to use the greater claims detail to "downcode" anything that doesn't meet their guidelines, while providers might use ICD-10 to "upcode" and unbundle their services in attempts to shake more money from the insurers.