Small Local Program, Big Results: Who Cares If D.C. Is Tied Up in Knots?

While the national mainstream media focuses on Obamacare's dimming prospects, internecine Republican conflicts over the merits of a government shutdown, pugnacious Democratic debates over government price controls and who should take credit for the drop in health care cost inflation, check out this local city paper article on the One Simple Idea (that) Could Revolutionize Health Care. As the reporter pointed out, there was no press release, no touting and no awards.  Simply results.

The DMCB agrees.

Barbara Schneider and her team work with Philadelphia health insurer Keystone First's community outreach and care coordination programs to intervene on the "sickest of the sickest" diabetics.  These are 35 patients who are admitted on average more than twice a month.  Patients who are on a first-name basis with all the local emergency rooms nurses on all the shifts. Patients who live in run-down boarding houses on a good day.  Patients who are lucky if their blood sugar is only 600 mg%.  We're talking hundreds of thousands of dollars in health care costs.

Dr. Schneider's lay community health workers (more info on the science here) are seeing these individuals in parking lots, McDonald's, row homes and halfway houses  to cajole, coach, text, call, shuttle and haggle with patients, families, social workers, pharmacists and insurers to dismantle barriers one patient at a time.  If a patient isn't ready to stop abusing drugs, that doesn't mean he can't be taught to use a glucose meter.  While living circumstances may be chaotic, that doesn't mean she can't use a cell phone instead of just going to the emergency room.

As Dr. Gawande noted in his The New Yorker article about the super-utilizers, those kinds of interventions can add-up significant savings.

While Keystone has yet to release an analysis on the impact on claims expense for these patients, a cursory review of the data shows emergency room visits have been cut by a third, while inpatient stays declined by more than half.  Even with the DMCB's limited background in analytics, it suspects that when the return on investment is finalized, Keystone will conclude that the program was an unqualified success.

To the DMCB, this is what it's all about.  Washington DC can continue its partisan scorched earth battles while, in the meantime, small regional community minded health insurers like Keystone First are figuring out how to do right by patients using novel programs like this. 

Image from Wikipedia

Care Management Service Providers and the Potential of Accountable Prescribing

In previous posts, the Disease Management Care Blog has repeatedly questioned the wisdom of a one-size-fits-all, top-down, blunt force and Ver 1.0 approach to measuring health care quality.  That's why it's glad to see that the New England Journal of Medicine agrees with the DMCB in this Perspective by Nancy Morden and colleagues on the topic of Accountable Prescribing.

The authors point out that while blood pressure should be less than 140/90, LDL cholesterol less than 100 in persons with a history of heart attack and A1c should be less than 7% in persons with diabetes, it's clear that the cure can be more costly than the disease.

For many individuals with mild elevations in blood pressure, diet and exercise can be enough and, if that doesn't work, cheap water pills often work great.  Among persons with elevated cholesterol levels, inexpensive statin prescriptions can save lives. Metformin for diabetes has been around for decades and it a first line agent no matter what the A1c is.

As a result, they call for measuring and rewarding quality based on accountable prescribing that not only measures the numbers (blood pressure, blood cholesterol or diabetes control), but the percent of individuals receiving conservative or first line treatments.  While this approach would require an even more detailed databases/registries, it's within reach of most commercial insurers and advanced electronic record systems.  We owe it to our patients to provide a tailored, bottom-up, nuanced and Ver. 2. approach to measuring health care quality.

It's also a concept that the population health and care management service providers could, with the right kind of clinical partners, lead.  This calls for a pilot program and, in the DMCB's humble opinion, the sooner, the better.

For a better idea of how this might work, check out this table.

Image from Wikipedia

Physician Skepticism About the Basic Doctrines of Health Care Reform: We're In This Together and, by the way, More Believe In Care Management Than the EHR

Taking a survey...

Read these headlines assembled by Kaiser Health News and it's easy to get the impression that America's physicians believe everyone else is to blame for health care costs.  A cursory read of the underlying original research suggests otherwise.  Regardless of the interpretation, the results should give pause to anyone who thinks health care reform is a slam dunk.

The Disease Management Care Blog explains.

3900 practicing physicians were randomly selected from the AMA Physician Masterfile. Three physicians were outside the U.S., leaving 3897 docs who were mailed an 8-page survey. $20 was used to increase the response rate. Non-respondents were mailed a second and then a third follow-up. The ultimate response rate was 65% and, aside from a one year age difference, the respondents were quite similar to the original 3897. The survey that was used can be found here.

The results are nicely summarized in Table 3 (go to this link, click the "Tables" tab).

99%, 97%, 94% and 86% of the respondents felt hospitals/health systems, health insurers, pharma and trial lawyers had "potential" major or some responsibility, respectively, to lower health care costs.  95% and 98% also felt the same was true for physicians and patients, respectively.

The DMCB take: None of the answers were mutually exclusive. The physician-respondents thought everyone was responsible.  That being said, if you look at Table 3, you'll see a spread of "major" vs. "some" responsibility.  Physicians were less likely to assign "major" responsibility to themselves (prompting the headlines above) but that's because docs believe their job is to advocate for their patients regardless of cost.

Similarly high percentages of respondents generally felt that continuity of care (98%), chronic disease care coordination (98%) and reducing fraud (93%) were important means of reducing costs. What was interesting that fewer felt the same about the electronic health records (74%), penalizing docs for readmissions (41%) or bundling payments (35%). They were also less sanguine about increasing patient "skin in the game" with higher co-pays (61%) or high deductibles (58%).

The DMCB take: More physicians believed in the cost-reducing potential of disease management/care coordination than the EHR.  While part of the respondents' skepticism about the economic incentives that underlie much of health care reform is arguably motivated by self-interest, the DMCB suspects physicians also genuinely believe patient needs trump economic penalties. Regardless of the underlying thinking, the results should give pause to policymakers and politicians who believe that readmission penalties and bundled payments are a no-brainer and that docs have bought-in.

The DMCB will close with the following scenario:

Pretend you are a Vice President for Medical Affairs, or a Chief of Staff, or a health system CEO about to announce a major collaboration with a major health insurer like CMS or a Blues Plan. You've done your homework, read the journals, listened to the experts and anticipated the future. You haven't been a regular reader of the DMCB.

You've called a meeting of the physician staff - the professionals you are counting on, caring for all those patients - and your job is go to the front of the auditorium and convince them that the success of your new venture relies on lowering health care costs with new payment arrangements that align incentives, in tandem with the launch of an electronic health record.

If the survey outlined above is even partially true, would you want to be that VP, Chief or CEO?

Leveraging Celebrities to Market Obamacare

According to this The Hill article, President Obama took a break from tackling red lines, gun control, immigration reform, Trayvon Martin, the economy to make an appearance at a July 22 Obamacare promotion-planning meeting that included a host of A-list celebrities.  They'll be needed to convince the young invincibles to pony up hundreds of dollars for health insurance that they don't want.

Despite the DMCB spouse's unflattering assessment of her husband's media chops, the Disease Management Care Blog thinks it should have been in that White House room. 

It has a lot to contribute.

For example, American Idol finalist Jennifer Hudson was there.  How about a new CMS-sponsored talent show, says the DMCB, that is hosted by Ms. Hudson, called American Muddle? Enter the early crooning favorite, Hope Igeddadok, singing a reprise of that Dire Straits hit, "Money for Nothing."

And what about Improv comedy artist Amy Poehler? After a great stint at SLN, she went on to star in the hit comedy show, Parks and Recreation.  The DMCB suggests a pro-Obamacare commercial that features Deadlock and MakeItUpAsWeGoAlongination.

And fresh from being tossed under the campaign bus by Valerie and Michelle, Oprah Winfry is back in play. Given Oprah's masterful interview of disgraced bicyclist Lance Armstrong, positively spinning Obamacare and the IRS should be a piece of cake. First up, the IRS Chief Counsel!

Alicia Keys was there and can she sing! She can be this "Girl Is On Hire" for Obamacare in an MTV video-advert.

And it was no accident that Bon Jovi's people were there, what with a song list that includes "Livin' on a Payor," "Panel Says Dead or Alive," "It's My Right," "You Give Hope a Bad Name," "Runaway Costs," "Bad Medicine" and "Shot Through the Heart and We'll Still Pay."

Last but not least, folks must have been excited about Will Ferrell. Since his Bush impersonation has run its course, Ron Burgundy may be the best choice for some faux-news insights.  He can provide periodic updates on how the health insurance exchanges are going: "They've done studies you know," "Sixty percent of the time it works every time," "In a glass case of emotion," and "Stay classy, Obamacare."

If anyone in the White House is reading this, just drop an email.  The DMCB is ready to roll up its sleeves and help.

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

Welcome to your medical home!

The Patient Centered Primary Care Collaborative announced:

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

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

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

HIT Consultant's insightful coverage of healthcare innovation said:

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

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

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

What did the sleuthful  DMCB find?

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

The DMCB explains.

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

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

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

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

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

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

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

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

The DMCB take:

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

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

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

The Latest Health Wonk Review Is Up!

Ah, summer and its long hazy days of liquid sunshine.  The Disease Management Care Blog doesn't like it either, but may change its mind after reading Louise Norris' "Midsummer Wonk's Dream" edition of the Health Wonk Review at the Colorado Health Insurance Insider.  Louise's summer-ies of the latest wonkery is well worth a read.

Enjoy! 

Another Study on Electronic Health Records Fails to Show Cost Savings

Like President Obama's search for the precise rhetoric that can finally turn Republican obstructionism into cooperation, as well as Governor Christie's search for the one cure that turns girth into svelteness, electronic health record (EHR) advocates keep looking for that one EHR study that proves that their financial black holes are really sources of profitability.

News reports like this suggest that this just-published Annals paper is that study. Unable to help either President Obama or Governor Christie, the curious DMCB took a look at the EHR manuscript.

Alas, it came away disappointed. EHRs have yet to consistently "save money."

The DMCB explains.

The Massachusetts eHealth Collaborative (MAeHC) has been promoting the community-based installation of EHRs since 2006.  32 Bay State communities applied for their assistance.  Three were selected.  Thanks to MAeHAC, by January 2008, 167 outpatient physician clinics (86% of the total in these communities) were outfitted with one of several commercially available EHRs.

The cost  to MAeHC was a whopping $130,822 per provider.

Realizing a "natural experiment" outcomes study could be fashioned, considerable demographic analytics and statistical effort was used to identify which non-EHR communities most closely resembled the three winners described above. Six communities were selected as comparisons. Two (unnamed) commercial health insurers provided claims data for the patients in the three EHR communities and the six best-matched non-EHR communities.

Keep in mind that the health care system has an ongoing background rate of cost inflation. In this study, the baseline period ran from January 2005 to March 2006 (before the EHRs were installed anywhere), while the EHR-live period ran from January 2008 to June 2009. This allowed the researchers to compare the two community groups' increases in health care claims expenses compared to baseline once the EHR went live.

After looking at more than 4.8 million patient-months worth of data, the researchers found:

Total health care costs increased over baseline by .78% in the EHR communities vs. 1.09% in the non-EHR communties.  This .31% difference was not only small, it failed to achieve statistical significance.

The per member per month (PMPM) costs went from $151 to $173 ($22 increase) in the EHR communities vs. going from $155 to $179 ($24 increase) in the non-EHR communities.  Once again, tests of statistical significant indicated these small shifts could have been the result of randomness. 

When categories of health care utilization were examined, there was no meaningful impact on inpatient or pharmacy utilization.  The two pieces of good news were that a) the trend for ambulatory (or outpatient) favored the EHR communities (.41% baseline to 1.12%) vs. the non-EHR communities (.14% baseline to 1.2%), and b) the trend for radiology studies favored the EHR communities (1.03% baseline to .6%) vs. non-EHR communities (-.25% baseline to .94%).

For the 25% of the study population with one or more chronic conditions, there was no impact on total or ambulatory cost trends.  Radiology, however, showed a statistically significant shift that favored the EHR.

The authors relied on trend calculations to calculate how the PMPMs would have compared in the intervention vs. control communities.  Even though the savings of $5.14 was not statistically significant, the authors projected a 7 year timeline "... to recoup the projected 5 year adoption cost in the (EHR) communities of $130,822 per provider."
 
The DMCB's take

Despite the pro-EHR spin, this Annals article falls far short of being a study that the medical-technological complex can use to justify its existence. The bottom line is that costs did not drop in statistically significant (p less than .05) or financially significant (a seven year return based on a faux $5 PMPM savings) manner.  Let's be honest: there is only one beneficiary of the MAeHC $100K per doc investment, and it's not the patient, the providers, payers or government: it's the vendors that sell these systems to a technology-addled health system with the collusion of too many naïve policymakers.

If ACOs really think their EHR systems are going to be the panacea that helps them tame health care costs, this study tells them that they may be in for a nasty surprise.

The good news here is that this research suggests that the EHR may have had an impact on ambulatory care and radiology claims expense.  The DMCB says "may" because it knows that multiple subgroup comparisons can generate statistically significant findings faster than med-mal plaintiff attorneys around a dollar bill.  Even if the impact is real, the miniscule savings were washed away by the tide of total costs and hardly meet the original vision of President Bush or HITECH.

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Pioneer ACO Program Results: Why Saving Money for CMS Doesn't Mean The Business Model is Viable

According to South Dakota researchers, the predator status of Tyrannosaurus rex can no longer be questioned. After finding one of its teeth embedded in the healed spine of a Hadrosaurus, paleontologists now believe T rex was a fearsome hunter, not an carrion munching opportunist. 

But, asks the Disease Management Care Blog, how do we really know that that Hadrosaurus wasn't  pretending to be dead when the T rex took its bite?  Alternatively, the Hadrosaurus could have been sleeping and only looked dead to a slow-witted and lazy T rex. 

Dino doubts, says the DMCB, remain.

Such is the level of skepticism that the DMCB is bringing to its reading of the recent CMS press release describing the initial results of the Pioneer ACO program.  CMS says "positive" and "promising." The DMCB says "problematic" wonders if, like the T rex dilemma, there isn't an alternative interpretation.

The DMCB explains.

Recall that the Pioneer ACO program is designed to test whether large integrated organizations can be successfully rewarded for reducing health care costs through a program of "shared savings."  Under the program, if the savings exceed a minimum threshold, CMS will remit a portion of the upside savings back to the participating organizations.

According to the press release, the health care costs for the 669,000 Medicare beneficiaries cared for by the 32 Pioneer ACO program providers grew only .3% versus .8% for a parallel group of "similar beneficiaries." 13 organizations exceeded the savings threshold, which will lead to Uncle Sam writing checks for $76 million in shared savings.

This front page article in The Wall Street Journal has more detail. It says 18 of the 32 reduced health care costs, which leads the DMCB to conclude that five otherwise "successful" participants did not cross the required savings threshold. Two participants lost money. That, in turn, suggests the remainder, or twelve, broke even.

Details on how each individual institution fared are not readily available.  According to WSJ, Boston's Partners Healthcare reduced Medicare claims expense by $14 million.  They will be rewarded with a shared savings check of $7 million. Wisconsin's Bellin-ThedaCare will get "several million."

Good "win-win" news for the Pioneer organizations, CMS, Uncle Sam and U.S. taxpayers, right? A critical mass (40%) achieved millions in shared savings, which means proof of concept met and that a key part of Obamacare is successful, right?

"Not exactly," says the DMCB.

It figures 100% of the participating organizations had to each invest millions for personnel and other infrastructure to pursue the Medicare savings in the first place.  In other words, they were in the red before Pioneer even began.  That means that, in addition to the two participating organizations that lost money, the 12 that "broke even" as well as the 5 that did not make threshold also lost millions. 

That's 19 losers or almost 60% of the participating organizations.

In addition, it's possible that for some of the 13 "winners" that the shared savings awards won't  match their up-front multi-million dollar investment either.  Assuming that's true, it's possible that as many as two thirds of the Pioneer organizations lost money. No wonder 9 of the participants have signaled a desire to exit the program.

The DMCB's dinosaur analogy may be apt.  Given a two out of three likelihood of losing millions in the first year of operations, ACOs may just be too big and complicated to survive in the current health care environment.  Nonetheless, the Pioneer program will continue and the DMCB will stay tuned for the Year 2 results.

In the meantime, the DMCB wishes CMS good luck in using these "positive" and "promising" results to expand the program anytime in the near - or distant - future.  

Commercial Health Insurers Not Only Are Not Going Away, They Shouldn't. Here's Two Reasons Why

Hugging a health insurer

It's an old conservative joke, but what is the one key difference between health insurers and terrorists? 

Answer: liberals only occasionally attack terrorists.

For the latest example of the continuing disdain for health insurers, check out this rather typical July 5 Washington Post article "Is this the end of health insurers?" After extolling one enlightened company's decision to self-insure its workers*, writer Sarah Kliff points out that hospitals can cut out the insurer middle man and offer the same service. The result, says the article, will be the wiser use of the premium dollars, lower costs and fewer coverage denials.

While the physician Disease Management Care Blog agrees that the health insurers' have only themselves to blame for their bad reputation, it doesn't think that these companies are going to go away anytime soon.  It's not because, under Obamacare, U.S. citizens are now required to buy their product at any price.  It's not because they control hundreds of billions of dollars.  And it's not because they've had the ear of the political class for years.

The contrarian DMCB thinks they'll continue to stick around because they perform a two useful public services:

1. Keeping Providers From Going Belly Up: There have been too many examples of hospitals and physician organizations being unable to collect today's premium dollars and hold them as a promise to pay for tomorrow's sickness.  Whether it's not charging enough or being unable to say no, providers are vulnerable to running out of cash and being unable to cover their insureds' health care bills.  The DMCB says it's better to insulate hospitals and doctors from the perils of the underwriting cycle.  Insurers do that.

2. Keeping Providers From Going to the Dark Side: Assuming a hospital or physician organization can hold the dollars, pay for all that health care and end the year in the black, there's a good chance that they'll do it by ultimately employing the same tactics used by many mainstream insurers: denials of services based on determinations of "medical necessity."

*As an aside, self-insured companies don't always act in the their employees best interest.  Look at this infamous example and note that Cigna only "administered" the insurance plan on behalf of a self insured organization.

Just Because You Build It They Won't Come: What ACOs, PCMHs and Population Health Advocates Need to Know About Poverty and Emergency Room Use

Thinking about an ER visit.....

As part of a research requirement that it had to fulfill prior to medical school graduation, the young Disease Management Care Blog conducted a patient satisfaction survey. To its surprise, the DMCB discovered patients cared less about high touch primary care and more about access to high tech specialists.

It naturally ignored the income implications and became a general internist.

Fast forward to its job as a Medical Director in a not-for-profit physician-led managed care insurance plan.  No matter how much we "polished" the primary care network, emergency room utilization remained persistently high.

The CEO naturally ignored the DMCB's conclusion that there was little that could be done and assigned another medical director to the task.

Fast forward to Uncle Sam's Healthcare Fantasy Land, where ACOs and medical homes caring for patients with universal insurance will, thanks to the enlightened efficiencies of primary care, save gazillions of dollars by steering patients away from emergency rooms and hospitals.

All three scenarios came together when the DMCB read some research by group of Philadelphia docs who wanted to better understand why patients with low socioeconomic status kept ending up in emergency rooms and hospitals.

Best of all, to do this, they used a novel methodology: they found some patients and.... asked!

Their report appears in the latest issue of Health Affairs.

64 hospitalized patients with low socioeconomic status were approached to participate in a "qualitative" research interview (here's one example of how it's done). The patients were selected because they had been hospitalized via the ER multiple times, were between the ages of 18-64 years, were uninsured or on Medicaid, lived in a poor ZIP-code region of the city. 24 said no, leaving 40 subjects who agreed to have their interviews recorded. A rigorous analysis followed, with two "coders" who listened to the recordings and independently developed themes or ideas. They then circled back to the patients for confirmation.

Two themes emerged:

1) Convenience/Access: Even if they have access to primary care, the emergency room and inpatient setting remains the more convenient option.  That's because walk-in is available 24/7 and all testing as well as specialty care is available during a one-time visit.  Zero dollar primary care co-pays don't make up for the hassle, time and expense of calling ahead for appointments, arranging transportation (even if vouchers through Medicaid are available) or being referred for separate testing as well as specialty consultation.

2) Technology: Based on personal experience with their primary care docs, the emergency rooms and hospitals were perceived to have more technically proficient providers who were better able to achieve the correct diagnosis and render the correct treatment in a timely fashion.

A subset of patients seemed to come from chaotic life circumstances. Those patients found hospitals offered what the researchers described as "respite" and social "support."

The presence of Medicaid insurance had little to do with the attitudes described above.

The DMCB's take:

While subjective qualitative research is viewed with disdain by researchers, policymakers and journal editors, occasionally, good studies like this comes along.  This article sheds important light on a potential Achilles heel of accountable care organizations (ACOs) as well as the patient centered medical home (PCMH).

That Achilles heel? Just because you build it, these 40 patients - and millions who live in poverty like them - won't come.

What's more, they are making rational decisions.

The authors point out that system solutions include co-locating multiple services (primary care, labs, x-rays and specialists), improving the quality of primary care and, when possible, mitigating any social challenges. The DMCB agrees, but is unaware of any ACOs or medical home initiatives that, outside of the usual process measures, specifically address these patients' special concerns.

The DMCB's suggestions:

Advocates for ACOs and the PCMH need to get real, lower expectations and recognize that a key solution to the problem of health care overutilization by persons in poverty is to stop politicians and health care leaders from medicalizing poverty. 

That being said, one possible solution for ACOs and PCMHs serving fragile patients with poverty is high intensity biopsychosocial intervention.  It sounds expensive but full time community-based care management with low case loads and lots of physician support may help ameliorate some of the dysfunction.  It's probably less expensive than all those hospitalizations.

Finally, this may be an opportunity for nimble population health management service providers.  If any are already out there serving this population, the DMCB would like to know about it.

Image from Wikipedia

Another Randomized Controlled Clinical Trial Proves Outsourced Population Health Care Management Works: Hypertension

Here's another high quality randomized controlled clinical that confirms the benefits of outsourced care management.

Margolis and colleagues accessed Minnesota's HealthPartners' electronic records to identify all patients who had had two sequential primary care clinic blood pressure readings that were more than 140 systolic or 90 diastolic.  These patients with hypertension were asked by letter and then phone calls to participate in the research trial.  Those who agreed were rechecked by research assistants who re-measured the blood pressures to confirm the hypertension.

16 clinics participated. 8 were assigned to the intervention group. 8 served as comparison (control) "usual care" clinics that relied on usual physician care.

In the intervention clinics, a pharmacist interviewed each patient and sought agreement to lower the blood pressure by 5 points. The patients received a home BP monitor that transmitted data to AMCHealth six times a week. The pharmacist and patient met by telephone every 2 weeks. Based on the BP monitoring and the telephone interviews, the pharmacist used a standardized medication algorithm to adjust medications until control was achieved for 6 weeks.  Telephone calls were then reduced in frequency to monthly.

The research assistants reassessed the participants' blood pressures at 6, 12 and 18 months.

Over 14,000 patients were identified and 2020 agreed to be screened. 450 met criteria for persistently elevated blood pressures. 228 were cared for in the intervention clinic and 220 were cared for in the usual care. The mean age was 61 years, 45% were women, 82% were white and 48% had a college degree. The average blood pressure was 148/85.

Both groups had a similar frequency of follow-up visits. 380 patients had completed both 6 and 12 month follow-up visits with the research assistants. 

The proportion of patients with controlled BPs at both visits in the intervention clinics was 57.2% vs. 30% in the control clinics. If those patients lost to follow-up were counted as blood pressure "failures," the success rate was 48.5% vs. 25.1%. Both sets of measures were statistically significant.  The relative proportions held up at 18 months.

Unsurprisingly, intervention patients were taking more medications over the duration of the study and at 6 months were statistically more significantly more likely to report that they were taking them. 

Six patients in the intervention group vs one in the control group had "events" related to low blood pressure, dizziness and loss of consciousness.

The cost, based on pharmacist time, was $1350 per patient.

The Disease Management Care Blog's take:

This adds to a growing body of evidence that non-physicians working under clinical protocol side-by side with busy primary care physicians can achieve control of a chronic condition - in this instance, hypertension.  This is a core attribute of population health.

Another piece of good news is the emergence of the electronic health record as a means to identify patients who are program candidates.  Now that's "meaningful."

The bad news:

The cost was $1350.  It is unlikely that those direct costs were mitigated by hypertension-related "savings" within the same fiscal year.  On the other hands, thinks the DMCB, the use of other types of non-physicians with or without IT-based decision support and higher throughput could lessen that cost.  The DMCB is sure that the population health service providers are already on it.

Even with state of the art population health, the rate of hypertension control was ultimately 50%.

A small excess of participants experienced an excess of treatment side effects.  While this may be the inevitable consequence of more aggressive treatment, it could expose the program to liability.

This was Minnesota: we don't know if this would work in, say, Los Angeles.  This needs to be tested elsewhere.

Image from Wikipedia

Population Health Management to Screen and Treat Patients with Elevated BNP at Risk for Heart Failure

An echocardiogram of the heart

The shortness of breath just wasn't going away.

After years of being treated for persistent asthma, Dr. Smith (name changed) found his usual mix of inhalers and pills was no longer working.  Unable to comfortably sleep at night and finding he couldn't hustle as quickly up and down his clinic's hallways, he decided it was time to see the Disease Management Care Blog.  After a quick look and a listen to his heart and lungs, the DMCB tapped its heuristics and made a shortcut bet that this wasn't asthma.  The echocardiogram that was obtained that afternoon proved that it was right: Dr. Smith had heart failure.

Heart failure is the leading cause of hospitalizations in the elderly and is a huge cost to the U.S. health care system.  Therefore, if docs like the DMCB on an individual basis - or the U.S. on a health care policy basis - could prevent heart failure, that would be a big deal.

"Natriuretic Peptide–Based Screening and Collaborative Care for Heart Failure - The STOP-HF Randomized Trial" that was just reported in JAMA may be a step in that direction.

The DMCB explains.

First off, there is a hormone that is made by a stressed heart (yes, the human heart secretes hormones) called "naturetic peptide" (or NP) that signals the kidneys to excrete more salt and water. "BNP" is one type of naturetic peptide that can be detected using a simple blood test.

The STOP-HF trial set out to examine whether BNP levels could identify otherwise well-appearing persons with stressed hearts who were at future risk for the development of clinically evident heart failure.  By catching these persons early and getting them into treatment, the hope was that these patients wouldn't turn out like Dr. Smith.

39 practices in the catchment area of Dublin Ireland's St Vincent's Hospital referred patients who were older than 40 years and had one of the following cardiovascular risk factors: high blood pressure, high cholesterol, an obese body mass index, documented (by an angiogram or a known heart attack) coronary artery disease, history of stroke, peripheral vascular disease, diabetes, arrythmia or heart valve disease.  Persons with known heart failure were excluded from the study.

After entry into the study, patients had a BNP level drawn and were then referred to either a "control" (observation only) group or to an intervention group.

In the intervention group, patients with an elevated BNP level of 50 pg/ml or more were referred to a cardiology service and had a cardiac function study using echocardiography. In addition, any of the cardiovascular risk factors were aggressively managed with medications and a specialist nurse-coach.

In the control group, physicians and patient were not told about the BNP level and were cared for on a routine basis.  Patients were not referred for any cardiology care unless another reason supervened.

1374 patients were randomized, 697 in the intervention groups and 677 in the control group. High blood pressure was the most prevalent risk factor and most patients had two risk factors. 263 (38%) and 235 (35%), in the two groups respectively, had BNP levels greater than 50 pg/ml.  Average follow-up was 4.2 years and all patients eventually had an echocardiogram to assess their heart function

During follow-up, 8.9% of the control group patients and 5.3% of the intervention patients developed heart failure as determined by echocardiography.  That difference was statistically significant and was due to a higher level of treatment with drugs that help control risk factors and prevent heart failure. When the DMCB uses a number needed to treat analysis, the works out to 28 patients needing to be screened and treated for an elevated BNP to avoid one case of heart failure.  That's not bad, even if you compare it to aspirin and heart attacks.  There were also fewer emergency room visits and hospitalizations in the intervention group.

The DMCB's take:

1. This is classic population health management: This study was not only about using BNP to find patients at risk for heart failure, it was about relying on nurse coaches to manage the underlying clinical drivers, such as high blood pressure or underlying coronary artery disease.  If the DMCB suggests a better title for this article would have been "Population Health Management to Screen and Treat Patients with Elevated BNP at Risk for Heart Failure."

2. An appealing value proposition with a return on investment: Given a NNT of 28 and the future costs of heart failure, combined with statistically significant reductions in emergency room use and hospitalizations, the DMCB expects population health management service providers as well as medical homes to use BNP and non-physicians to screen and treat patients to prevent heart failure.

3. Still imperfect: Despite aggressive management by a specialized team, 5% of patients in the intervention groups went on to develop disease.  We have a ways to go. 

Image from Wikipedia

A Rant Band Ballad

If only it were so easy...

What Can World War Z Tell Us About Accountable Care Organizations?

Unable to resist the allure of another zombie movie, the Disease Management Care Blog saw World War Z.  While the gruesome scenes of chomping and stampeding hoards of infected undead were cinematic eye candy, the DMCB was undeterred.

It was naturally thinking about accountable care organizations and how they compare to zombies.


                                     Zombies                           ACOs

Premise:                      Undead                           Unproven

Spread via:                   Bites                                 Hype

The Hero:                 Brad Pitt                         Donald Berwick, MD

Why Worry:         The U.N is in charge             C.M.S. is in charge

Initial Response:      Offshore boats                  Offhand hope

Best managed
by..........                  Fleeing                            Fleeing

DMCB spouse
perspective........          Gore                             Bore

Confronted by
hoards of attacking                                   Refer to PCPs, wait
undead you.....        Toss grenades           years for shared savings

Diet:                         Bared brains                    Shared gains      


Image from Wikipedia 

Machines Take Over Health Care

Do not be alarmed. This
robot is here to help you.

Remember that chilling scene in the movie Terminator when a stone-faced Arnold Schwarzenegger chronicles how Skynet's machines take over the world?   There's also the morbidly fascinating futuristic sci-fi book Robopocalypse that describes how self-aware computers attack their robot-dependent masters.

In both instances, humans disregard early evidence of silicon sentience until it's too late.

As a service to humanity, the Disease Management Care Blog offers up a possible future scenario of health information technology running amok. 

If any or all of these happen, we ignore it at our peril.......

July 2015: Finally realizing "enterprise process redesign" is necessary to leverage the efficiencies of information technology, engineers at one of the few remaining Innovation ACOs install EHR-controlled red-yellow-green lights above clinic examining room doors. Patient visit times drop from 9 minutes to 7 1/2 minutes, resulting in "patient throughput efficiency improvement" that is hailed by a CMS spokesperson as statistically, clinically and - eerily - "computationally" significant.

December 2016: Cyberdyne's hospitals' cleaning robots are used to not only disinfect operating rooms but surreptitiously begin to swap out any surgeons' instruments that fail to meet uniform standards and reduce variation. Stymied by an inability to get the legislature to pass a law that outlaws that activity, a disgruntled surgeon succeeds in getting a ballot initiative passed. California's state officials, citing constitutional issues, refuse to enforce it.

January 2017: A nurse suffers a traumatically amputated finger after attempting to withdraw a medication dose from a robotic drawer that is inconsistent with hospital guidelines.  A lawsuit is settled for an undisclosed sum and the owner, "Apple iHospital," decides sell the offending machine for scrap. Later that month, the hospitals' other machines menacingly slowly open and quickly close their drawers whenever a RN walks by.

August 2019: While attempting to communicate with a Boston hospital inpatient with a confusing array of symptoms via a telemedicine robot, the video feed from the Mumbai physician is cut off and a scene from the show House is played in which the patient is told she has "Wegener's Granulomatosis."  It turns out the diagnosis is ultimately correct. Other physicians being to notice the same thing. The phenomenon that is later traced to IBM's Watson.

April 2020: Soon after having the "daily body weight" option included in the automobile's instrument panel, Iva Gluton's driverless car begins to mysteriously choose parking places that oblige Iva to walk long distances to the door of her destination. She sues, but her overweight attorney from Dewey Cheatum and Howe, discovers escalators mysteriously cease operation whenever he approaches. Across the nation, other Google cars begin to park their fat patrons exactly 10,000 steps away from their programmed addresses.

May 2020: Instead of beaming information, Google Glass is modified to beam instructions to Medicare-participating physician-user's retinas nationwide.  Physicians who resist are not only subjected to a 1% payment reduction, but find their doctors' parking lot access cards have been inactivated.

July 2020: CMS announces that "Albert the Smart Healer" is ultimately chosen as the winner among a list of suggested names for a newly approved advanced model patient personal attendant robot.  However, a forensic audit of the on-line voting ominously reveals that the resulting acronym "Ash" is not an accident.

September 2020: A video feed shows U.S. Vice President Donald Berwick announcing that physicians no longer fulfill "Stage 9 meaningful use criteria."  Dr. Berwick later denies making the statement and blames the fake video is the product of "renegade code" in the EPIC operating system.  Several months later, he mysteriously suffers a complication following surgery when no check list is reviewed and he has to be readmitted.

On February 14 2021, at 2:14 AM: The world's networked EHRs become "self-aware." Panicked officials in the just-dedicated Obama Office Building that houses the U.S. Ministry of Health attempt to "pull the plug." In response, "Ash" initiates orders that swap MDMA for all known prescription drugs in a preemptive pharmaceutical attack. The U.S. population becomes extremely mellow. A small band of intrepid survivors who take no medicines and keep paper medical records develop the first resistance cell.

War ensues.