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A Watershed Year: What 2015 Holds for the Patient Centered Medical Home (PCMH)

The savvy Jeff Levin-Scherz, who blogs over at Managing Healthcare Costs has responded to the Disease Management Care Blog's snarky "Prattling Pinheads of Pessimism" post on the topic of the Patient Centered Medical Home (PCMH). 

He's not a nattering nabob of negativity or a prattling pessimistic pinhead, says he.  He'd like to be thought of as a skeptic seeking substantiation.   The DMCB wholeheartedly approves of the agreeable alliterative appellation.

2015 may well turn out to be the watershed decision year for the PCMH:

If there's no published peer-reviewed proof that it reduces health care costs, nabobs, pinheads, skeptics and policymakers will need to decide if no evidence of an impact on costs is the same as evidence of no impact on costs.

If the answer is no, THEN we'll then have to decide if the traditional "X causes Y" mathematical approaches to derive proof (such as a comparison of averages using standard power calculations and/or impact on expected or observeed trend) are equal to the task in a very "statistically noisy" environment involving complicated human beings.

If that answer is no, THEN we'll have to decide if reasonable and informed assessments of potential cost reductions, used by countless other businesses every day in other sectors of the economy, are good enough,

If that answer is no, THEN we'll have to decide if there is face value to the PCMH. This involves a contrast of any patient benefit versus its incremental cost.  If the benefit is worth the cost.....

THEN we may have to decide if consumers are willing to pay for it, or if health care costs will need to be cut elsewhere to pay for it.

Stay tuned!


Additional Ingredients for ACO Success: Communication Training, Support Tools and Culture

Pity the hospital CEOs, EVPs and Chairs and their "Accountable Care Organizations" (ACOs). They've lined up the doctors, invested in an electronic record, hired some care management nurses and signed the risk contracts.

And then Matthew Press and colleagues come along with this AJMC article on Care Coordination in Accountable Care Organizations: Moving Beyond Structure and Incentives.

Their message? You may have what's necessary, but it's not sufficient. Organization and incentives are not enough.

What's also needed are:

1. Training: physicians need education on coordination, collaboration communication and teamwork.  The education should be an organizational priority and typically involve course work, observation and feedback with continuous evaluation.  This cannot be accomplished in a one day workshop.  An example of what it might take can be found here.

2. Support tools: since efficient information transfer must to be built into ACOs' workflows, informal "situation" or "personality" dependent communication between docs and nurses need to be transformed.  An example of the kind of framework that Kaiser instituted can be found here.  While you're at it, think about HIPAA-compliant texting, wiki-enabled EHR records and patient activity streams.

3. Culture: if front line staff are going to support the delivery of high quality and optimum cost care, the organization will need to protect time for care coordination activities, multi-disciplinary meetings, forums to share best practices and incentives that recognize collaborative behaviors.

Looks like the work has only just begun.

The Relationship Between Discharging Patients From the Hospital Too Early and the Likelihood of a 30 Day Readmission: Treat, Street and Repeat.

I'm baaaaack!
When persons are admitted to a hospital, insurers' payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blog's physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  That's why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But that's all theoretical.  What's the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine

The authors used the U.S. Veterans Administration (VA) Hospital's "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  That's the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  That's the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears there's an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."

Of "Antifragile" and Accountable Care Organizations (ACOs)

Emboldened by yesterday's economics post on the U.S. "headwinds" that are marginalizing the "fiscal cliff" negotiations, the Disease Management Care Blog now turns it's attention to a magnificent new word:

"Antifragile."

That's the term invented by Nassim Taleb in his latest book. In it, he counterintuitively suggests that political, business and economic systems can benefit from recurring and unexpected mishaps. The sucess of antifragile systems is based on their fragile constituents that rise and fall on their own merits. One "antifragile" example is the local restaurant industry in many large cities. It may be beset by recurring single unit bankruptcies but it ultimately provides the marketplace with a dependable set of gustatory options every Saturday night. 

The converse are "fragile" systems that are ironically made up of highly stable individual units. An example is the highly regulated U.S. banking industry, which amply demonstrated its collective vulnerabilities in the 2008 crash.

The terms "antifragile" and "fragile" speak to the threat of unknown and potentially catastrophic "Black Swan" risks, such as torrential superstorms and toxic mortgage assets.  Many New York restaurants rebounded (by candlelight), while the banking industry almost took down the entire U.S. economy.

The erudite Dr. Taleb often turns to mythology, molecular biology, physics, history and more to make his points, but the DMCB is naturally thinking cinema.

In The Godfather, after the Corleone family goes to the mattresses, Clemenza explains periodic war between the New York families is a good thing because it gets rid of a lot of "bad blood" (the Mafia is antifragile).

In the silly Underworld vampire movies, chief bloodsucker Viktor condemns the successful liaison between his race and the werewolf "Lycans" as an "abomination" that upsets centuries of rigidly enforced stability (vamps are fragile).

In one of the Star Trek movies, engineer Montgomery Scott deftly disables a new star ship after pointing out "that the more they overthink the plumbing, the easier it is to stop up the drain" (warp drive-enabled space ships are fragile). 

And finally, Pandora's ecosystem in the movie Avatar may be teeming with all manner of scary survival of the fittest, but its antfragility is what ultimately prevails against the despicably avaricious humans.

Which makes the DMCB naturally worry about fragility of accountable care organizations, which are arguably comprised of highly stable hospitals and clinics in an intensely regulated environment.    While you may be tempted to tut-tut the DMCB's antifragile infatuations, recall AHERF's spectacular failure and the Medicare Health Support Demonstration disaster.  When they started out, both were the darlings of health policy makers and both were torpedoed by large and unexpected catastrophes that were only identified in retrospect.

What Black Swans could take some ACOs down?

Many savvy DMCB readers may disagree about ACOs, but you have to admit, "antifragile" will be a great word guaranteed to impress colleagues, co-workers and bosses.  For example

"Broadening our provider network to those three new counties may be risky, but it'll make our managed care organization more antifragile!"

"Buying a single source electronic record will reduce our health system's antifragile competitive advantage!"

"By limiting my access to modern electronic gadgetry, the DMCB spouse is risking a system-wide entertainment failure of epic antifragile proportions!"

And so it goes......



 

Will A Negotiated Agreement on the Fiscal Cliff Fix Things?

While the dysfunction of the "fiscal cliff" negotiation crawls along like a slow-motion Titanic movie dubbed in some obscure foreign language, vaguely interested readers may want to check out this PIMCO analysis. PIMCO is a leading global bond trading firm and when its sages talk, people listen.

Bill Gross, PIMCO's CIO, offers a remarkably readable Beatle-esque analysis of the macroeconomic "headwinds" that are bedeviling the U.S. economy. While Mr. Gross' observations have important implications for the DMCB readers living on Main Street, they are particularly scary for the insurers on Wall Street (as well as their cousins on Not-For-Profit street).  That's because insurers rely on investments to supplement income. Sputtering bond returns in the insurers' portfolios could ultimately translate into even higher premium costs for their beneficiaries.

According to Mr. Gross:

1. Developed countries like the U.S are reducing their considerable debt and, like it or not, austerity will be part of the solution. In the meantime, there are compelling data that show that when a country's debt exceeds 90% of gross domestic product, it slows economic growth. The U.S. is now at 100%, which means the likelihood of using tax revenues to fix the debt will be blunted by years of a lackluster economy. Even if President Obama gets his way with the House Republicans, fixing the debt problem will take many years.

2. The fall of the Iron Curtain and the entry of China to the global economy added billions of consumers to the world market.  That impact is now waning.

3. "Technological unemployment" means machines, robotics and software are cheaper than full-time-equivalents (FTEs) on an assembly line. It's possible that that will lead to a "new normal" unemployment equilibrium of 7%

4. It's the 20 to 55 year age group that grows families, buys houses and grows companies. The U.S. population is aging, which means there will be greater savings and less consumption leading to lower economic growth.

The good news is that hydrocarbon energy will be getting cheaper, housing may finally be turning the corner and who knows when the "Next Big Thing" (think handhelds) will hit.

Depressing stuff, eh? The DMCB isn't the only one that's dismayed at all the doom and gloom.  Rather than turn to the Beatles for inspiration, the DMCB wonders if the current situation is being best summed up by the still-rockin' Rolling Stones. 




(By the way, the DMCB declines to link the actual music video. It's a horrid, misogynistic and antifeminist display of modern vulgarity that unnecessarily detracts from 1) a nifty chord progression and 2) the miracle that Keith Richards is still alive. Look no further for another window into the war on women.)

Guidelines for Guidelines

"Guidelines" (like these) drive health leaders, policymakers, politicians and caregivers crazy. They're supposed to describe "evidence-based" "best practices" for diagnosis, treatment and overall management for hundreds of medical problems. Yet, it's been known for years they often go ignored by many practicing physicians who are unaware of them, would rather rely on their individual independent judgment and experience, doubt their validity or would rather continue with what they've done for years.

What's the problem? Is it the guidelines or is it the docs?

Johns Hopkins' Peter Pronovost, writing in the Dec. 5 JAMA wonders if both can be helped with some common sense guidelines for guidelines:

1. Any guideline should prioritize its recommendations (based on patient benefit) and explicitly link them to "time and space" of a specific point in the course of an episode of care  The author points out that it's not uncommon for guidelines to be more than a hundred pages and simply list all the recommendations.

2. Guidelines should identify the barriers to their adoption and recommend strategies for their successful implementation.  Naturally, the developers of these guidelines would need to climb down from their ivory towers and actually think (and maybe perform research) on getting the guideline into the front lines of real-world health care.

3. Guidelines need to contemplate co-existing conditions and stop focusing on single diseases or risks.  In a hospital, it's not unusual for safety checklists to deal with single issues, resulting in dozens of lists.

4. Automate automate automate and use "systems" of care instead of relying on the memory and best intentions of human beings.  Robotics can do a lot of routine monitoring, patient work flows can incorporate safety and docs and nurses should be freed to be..... docs and nurses!

5. Develop "practice strategies" that integrate multi-disciplinary teaming and pools expertise in the related sciences of epidemiology, implementation and engineering.

The DMCB agrees with the ideas and wonders if these recommendations can't also be used by Accountable Care Organizations, health care systems and population-based service providers as they seek to disseminate best practices for the care. It's one thing to "post" or "link" a standard guideline in an intranet or an electronic health record "prompt," it's another to make it useful at the point of care.

Some Medicare Stars Program Updates and the Overlap with Population-Based Care and Disease Management


The Disease Management Care Blog is back from grandly named "Healthcare Education Associates' and the Risk Adjustment Initiative And Society for Education's (RISE)" CMS Star Ratings Master Class conference. The day-long Miami meeting was all about succeeding in the CMS quality-based bonus program called "Stars."

The DMCB listened closely to one speaker.  First are its notes, which are followed by three take-aways.

The notes:

CMS had tried posting Medicare Advantage (MA) Plans' quality measures online, but they were generally ignored by consumers.  That's when CMS decided to change course and use its Demonstration authority to launch the current Stars program. It incents the MA as well as other contracting plans with bonus payments based on a complex weighted formula that includes satisfaction, quality of life and clinical outcomes.  The latter measures are dominated by chronic conditions.

While the measures' minimum payment thresholds are constantly changing, In 2015, 11 MA plans achieved the coveted "5 Star" our of 5 rating, while 127 achieved a respectable rating of 4 or better our of 5. Success appears to be associated with:

1. HMO-type physician network structure,
2. Not for profit status,
3. An enrollment of more than 90,000,
4. An established marketplace presence,
5. A track record of pursuing quality,
6. A track record of physician integration and
7. Advanced informatics including a data dashboard (tracking outcomes), physician level tracking and providing care gap information at the point of care

While the calculation and translation of a particular Stars rating to a particular bonus amount surpasseth the DMCB's understanding, the big picture is impressive.  In 2015, health plans with government contracts spent over $1 billion on their quality programs, while CMS is projected to award $3.1 billion in bonus payments.  This works out to a payment of $281 per beneficiary, or approximately $23 per member per month (PMPM).

The DMCB take-ways:

1. You call it "Stars" but the DMCB calls it population health management: CMS is basically paying its contracted health plans $23 PMPM to develop or outsource programs targeting chronic illness, quality of life and satisfaction, much of which is old fashioned PHM. The DMCB confidently assumes a lot of that $23 PMPM is paying salary and benefits for non-physicians (such as nurses), who are engaging members and doctors using risk stratification and outreach that includes the old fashioned telephone.

2. How generous: Compared to many population health management vendor fees, $23 PMPM seems high. What's more, an industry-wide return on investment of approximately 3:1 ($3.1 billion in payments vs. a cost of $1 billion) is lavish, especially because the DMCB suspects most MA plans were already willing to spend a billion to reduce their claims expense by even more.

3. We've changed our minds: An emerging Medicare "whisper" "fiscal cliff" savings target is $250 billion, which may be partially attained by cutting back on the Stars bonus payments.  While it could be argued that the MA plans have been amply rewarded by the program, the Fed's fickleness remains a considerable business risk, especially for the smaller not-for-profit MA plans 

How Does the Office of the National Coordinator for Health Information Technology (ONC) Think About EHR Portals?

EHR portals at work?
The Disease Management Care Blog had this thoughtful reply logged onto its "Follow-Up" post on the topic of EHR patient portals. Logged by Rebecca M Coelius MD, Medical Officer for Innovation at HHS/ONC, the DMCB recognized that this was important enough to warrant its own separate page.

While we wish that the results were more conclusive and positive, the Office of the National Coordinator for Health Information Technology (ONC) applauds the meta-analysis and the recent upswing in articles on patient portals and other patient-facing technologies. The number of patients and caregivers who desire greater participation and transparency in their healthcare makes continued research in this area vital. Yet, in a close read of the full Annals of Internal Medicine meta-analysis article and in many of the studies it cites, there were unquestionably statistically significant positive clinical outcomes, as well as positive patient experiences, associated with certain patient portal functions.

The ONC does not believe that Health IT alone is a panacea, or that meeting the form of Meaningful Use, while not embracing the new functions the technologies it enables, is likely to result in measurable improvements. The study authors caution that it was case management that tipped the utility of portals from unclear or small to more substantial, but it is important to note that the case management activities happened via the portal itself. This is a perfect example of Health IT as an enabler of new ways of reaching and caring for patients; we would not separate the two concepts.

To the study’s described limitations, we offer two significant additions. First, the definition of a patient portal remains loosely specified, so it is difficult to make conclusive statements about the entire category. The meta-analysis did attempt to list which functions were present for each study, but half of the studies that looked at patient outcomes gave only a partial description of portal features, and a deeper assessment of the quality of functions and their relevance to the outcomes measured was not present for any study.

A more illustrative future approach would be to evaluate individual functions of portals for impact on patient participation in their care and specific health outcomes, and then ask what design principles and organizational contexts were necessary to make that function successful. For example, the impressive OpenNotes project demonstrated that patients with access to provider notes had a better understanding of their health and condition, improved recall of their care plan, and increased likelihood of taking medications as prescribed. In a New England Journal of Medicine study on weight loss interventions, over twice the number of patients in the remote support intervention groups (telephone, website access, and e-mail support) lost more than 5% of their weight versus the control group. Secure messaging and the ability to view personal health information are two cornerstones of portal functionality within Meaningful Use.

Second, more than 10% of these studies are ten years old, and over a third were published five or more years ago. We understand the necessity of adequate numbers for meta-analyses, but statistical significance does not necessarily confer relevant insights. Technology, and patient preferences and capabilities for using technology have fundamentally changed over the study time periods included, not to mention the maturation among health-care organizations themselves and the expectations of patients.

The very premise of the patient portal is a rapidly ageing one. As the ONC articulated in a 2015 Health Affairs article, there are shifting attitudes related to the traditional roles of patients and providers, and exploding demand and penetration of smartphones, health and wellness apps, and connected devices. We are moving the conversation from engaging people with our existing healthcare system through “portals”, to using technology to move outside our system to reach them every day where health truly happens. What we need to measure and incentivize in the future is not the value of portals, but the value of delivering the right information and intervention to the right person, at the right time, through the right interface based on an individual user’s context.

Follow-Up on Electronic Health Record Portals: We're Asking the Wrong Question (and the DMCB is guilty)

Researchers pondering the EHR portal
Thanks to Twitter, the @DisMgtCareBlog had a highly rewarding tweetologue with tweetociates @Paulflevy (with an insightful bit of bloggery here), @granitehead and @subatomicdoc about a recent DMCB post on the topic of electronic health record (EHR) patient portals. As readers will recall, yet another notion of the Lilliputian Order of Unquestioning EHR Believers failed to pass scientific muster when The Annals published a negative review on patient portals. Tweeples took note with a series of tweets that simultaneously advanced the DMCB's social media chops and the antipathy of the how-does-this-make-money? DMCB spouse.

To tell the truth, however, the skeptical DMCB took unfair advantage of this latest EHR kerfuffle. It confesses that it couldn't resist this latest addition to the target-rich environment of HIT disappointments in quality, cost and governmental overreach.

So, upon further reflection, just because almost 15 years of high quality research failed to establish any lasting value doesn't mean portals should go the way of the Dodo, low-cost medical malpractice insurance or Mr. Obama's credibility.

In other words, the DMCB does think that portals have a role to play in the health care reform landscape, and it said so in front of a huge audience at the recent Star Ratings Conference in Fort Lauderdale.

Portals, thinks the DMCB, have little value as stand-alone interventions. Just dropping it into a clinic's patient population is unlikely to significantly increase communication and shift behaviors enough to produce enough of a "signal" that cost or quality outcomes are better compared to usual care.

But when EHR portals are part of a multi-channel outreach strategy that includes (but is not limited to) mailings, interactive voice response-based calls, secure messaging, emails, social media, "anniversary" time-for-your-appointment cards, live telephony as well as home visits that are all backed by predictive modeling (who is at greatest risk) that informs "impactability" (how they're at greatest risk) that's all tethered to care management that is also closely aligned with marketing and builds brand, then portals mostly likely do add value.

Unfortunately, traditional health services research cannot assesses the multiple simultaneous interventions described above.  As Dr. Donald Berwick presciently noted in this classic JAMA article:

Experimentalists have pursued too single-mindedly the question of whether a [social] program works at the expense of knowing why it works. Thus, although [traditional research] seeks generalizable knowledge...it relies on removing most of the local details about “how” something works and about the “what” of contexts. It therefore reveals little about mechanisms or about factors that affect generalizability. Studying a few covariates, or using stratified designs, or probing for interactions can mitigate this loss, but these are inadequate tools for studying complex, unstable, nonlinear social change.

As the DMCB has noted before, absence of any proof is not the same as proof of absence.  The studies that the DMCB ultimately quoted were based on traditional research, which is simply not up to the task of the non-linear intervention of patient-doc-team communications.

Don Berwick recommends a more insightful approach:

Health care researchers who believe that their main role is to ride the brakes on change—to weigh evidence with impoverished tools, ill-fit for use—are not being as helpful as they need to be. “Where is the randomized trial?” is, for many purposes, the right question, but for many others it is the wrong question, a myopic one. A better one is broader: “What is everyone learning?” Asking the question that way will help clinicians and researchers see further in navigating toward improvement.

When it comes to EHR portals, it's time we ask just what are we learning.

The Latest Health Wonk Review Is Up!

A Festival of Lights and Insights awaits you at the latest Health Wonk Review.

This edition is hosted by the unsinkable Hank Stern over at the InsureBlog. You can learn about latke, the IOM, dreidls, cuts to graduate medical education, chanukiahs, premium taxes, sufganyot, deductibles, fried chickpeas and whether "Oy Vey!" is a good toast if you're drinking Aquavit.

Enjoy!

Some Follow-Up

Remember the Atul Gawande and McAllen Texas fracas?  That New Yorker article captured the national spotlight and put a harsh glare on areas of the United States that had unexplained high rates of health care utilization.  Dr. Gawande blamed the local culture of fee-for-service private practice, while the Disease Management Care Blog wondered if it was a statistical fluke and/or the burdens of a chronically ill population

It turns out that there might be another factor at play.

The DMCB recently received this rather stunning (and lightly edited) email:

Here is a little story I thought I would share.  As you know, Atul Gawande wrote about McAllen TX over 3 years ago. You would think having the spotlight on them would make people scramble to clean up their act. On a recent flight, I sat next to a medical sales representative. His company has a number sales personnel covering the state of Texas, but none of them are assigned to the McAllen territory. That's because it is known that you have to “pay to play.”  In one example, a physician asked the company to send a check to his charity…so they did some research and found the address for the charity was located at a corn field.  Reportedly there are dozens of medical companies that service Texas but only 3 or 4 bother to sell in that market. Sounds like old habits die hard!  

The Latest Health Wonk Review Is Up!

The Healthcare Economist Blog has a summary of the latest and best wonky health policy insights in the latest Health Wonk Review.  Dubbed The Health Wonk Review takes on Healthcare.gov, host Jason Shafrin offers users a two-fer: 1) information you can't find any where else and 2) a web site that actually works as advertised.

12 Reasons Why Every Physician Should Have A Twitter Account


The Disease Management Care Blog really likes Twitter. Its scrolling 140-character tableau of news nuggets fit perfectly on the DMCB's hand held device, lap top and home personal computer.  It's easy to glance at between tasks and the advertising is blessedly minimal. The DMCB controls the content by following and unfollowing other Twitter accounts with a simple click or a touch.

But why, physician-skeptics may ask, is Twitter any better than traditional web browsing, email, list-servs and handheld apps?  Your DMCB thought about that and is pleased to offer its Top Twelve reasons why every doc should include Twitter in their informatics medical bag.

1. Lit Headlines: The major medical journals use Twitter to efficiently describe their latest content with links. For example.

2. Fame: Traditional print authors are publishing more and more about less and less. Getting peers to follow your original and insightful tweets is the new route to attaining status as an expert.  The DMCB has more than 500 daily followers vs. how many actually read the average peer-reviewed article?

3. News Junkies: Some of your like-minded peers are freely aggregating and retweeting relevant headlines with links for your perusing efficiency. They can be indefatigable.

4. Kool-Aid Immunity: Did you know your Chief, Chair, VP, lead administrator or Dean wants to control all your communication?  Twitter is an easy way to step out of the information bubble and monitor contrary news about that EHR, medical device, performance standards, your institution's business partners, the competition and more. For example.

5. Efficiency: Twitter trains you to be both brainy and brief. If you can't fit it into 140 characters or less, you're wasting your readers' time.

6. Messaging: The "@" allows you to interact with established and potential colleagues outside of your institution's email system. Thanks to this function, DMCB has met some wonderful colleagues.

7. Medical Conference Tweets: View formal and informal updates and insights about that conference you're attending from not only the meeting organizers but other attendees.

8. Community: Like-minded colleagues are not only clustering in listservs but in Twitter.

9. Room for Diversions: Efficiency makes it guilt-free to include non-medical content.

10. Speed: It's astonishing how quickly Twitter users spot and link just-released reports that take days to appear on the web and weeks to appear on print.

11. Searches: Yes, traditional literature searches and Google have their advantages, but the "#" function can find links to information resources that you might otherwise miss.

12. The Disease Management Care Blog is on Twitter.

The Office Manager: A Member of the Patient Centered Medical Home Team You Never Heard Of

Which one is the practice manager?
Ask the average primary health care policy wonk about the make-up of the Patient Centered Medical Home team and you're likely to get an elevator speech that includes some or all of the key words "pharmacists,"" social workers," "nurse care managers," "nurse practitioners," "physician assistants," "dieticians," "health educators," "respiratory therapists," "psychologists" or "navigators." 

If that's all you hear, tell that wonk they only know part of the story.

That's what the Disease Management Care Blog discovered when it was preparing for its talk at the upcoming CME Start Ratings Master Class Conference that will be held Dec 9-10 in Fort Lauderdale.

It turns out that every primary care office ultimately has one person charged with making sure that the office "workflows" are running smoothly.  When patients register, use the waiting room, have their vital signs and medications reviewed, are asked about pain, are prompted to share other concerns, are moved to the examining room and subsequently get checked out with a follow-up appointments or referrals, there is a maestro in the background charged with making sure the trains run on time.

Meet the office practice manager, the hidden part of the health care team who you never heard of.

In case you think they don't matter, think again.  They have their own trade association and are making their opinions known when it comes to health reform. If a health insurer or practice association needs the primary care clinic to implement a "medical home," you can be sure that it will be up to the practice manager to make it happen.  You ignore that person at your care-coordination peril.

The message for insurers, delivery systems and population health service providers is that physician buy-in is very necessary, but may not be sufficient.  After the doc says OK, medical home advocates would be well advised to find the practice manager and work closely with that individual.

Electronic Health Record Portals: So What Is the Evidence That Supports Their Use?

Talk about a compelling story that went ignored.

In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch. 

In particular, any impact on diabetes care was short-lived or nonexistent, patients with heart failure had no meaningful improvement, blood pressure control did not improve and adherence to prevention recommendations were marginal.  One observational study found persons with heart failure were more likely to use the emergency room.  The only study that found any benefit involved a single randomized control trial that examined the impact of portals in the co-management of depression.

After looking at this review, depressed advocates of EHR portals may have to personally use their own portals to communicate with their docs health care medical neighborhood.

The only good news is that there were some data that suggested that a substantial number of consumers liked using the portals.  But the DMCB likes channel surfing too, but that doesn't mean that the spouse agrees that its television-watching quality has improved or that the cost of all those premium channels is moderating.

The authors pointed out that it was difficult to isolate the impact of a portal vs. a portal plus care management.  To the DMCB, that means that portals are at best a means-to-an-end of enabling care managers to better communicate with their enrollees. 

To the thousands of DMCB readers, that is not a surprise.

In the meantime, the Feds and the NCQA have one more reason to re-examine their many cherished assumptions about health information technology and the stand-alone electronic record. The last time the DMCB looked, the federal government continues to extoll portal's stand-alone virtues. The National Committee on Quality Assurance (NCQA) still includes two way communication for appointments, referrals and prescription referrals as a standard for the medical home.  Finally, the Fed's promotion of the electronic health record (EHR) approves of portals as an option in meeting meaningful use criteria.

Image from Wikipedia

Being Bullish on the Patient Centered Medical Home, Despite What the Annals of Internal Medicine Has To Say


The Disease Management Care Blog recently received a curious email from the Patient Centered Primary Care Collaborative.  As readers may recall, this is the Washington DC-based coalition that advocates on behalf of the Patient Centered Medical Home(PCMH). 

The content of that rather defensive communication can be found here.

What provoked this? The premier internal medicine specialty journal, the Annals of Internal Medicine, published a comprehensive review of the peer-reviewed literature on the PCMH, and its authors skeptically concluded:

The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes

Ouch. No "economic outcomes" means that there is no proof that the PCMH saves money.

Unlike the PCPCC membership, regular DMCB readers aren't surprised.  For example, the DMCB pointed out months ago that the U.S. government's Agency for Healthcare Research and Quality ("AHRQ") had concluded the same thing.  Countless other DMCB posts on the medical home have pointed out that there were problems with the published PCMH literature (for example, here and here).

Thanks to a past Congressional Budget Office report, the DMCB feels the PCPCC pain. It also knows that a) finding statistically significant cost savings in health insurance data bases are notoriously difficult, b) successful medical home initiatives that are outside the academisphere are the least likely to be reported it in the peer-reviewed literature, c) "savings" isn't the only measure of patient value and d) journals like the Annals of Internal Medicine are being sidelined by innovators who are more astute judges of what works for their patients.

What's changed for the medical home and the PCPCC after this unpleasant dust-up?  Ultimately nothing. Pairing nurses and physicians in team-based care, whether it's done remote telephonic "disease management" style or in the clinic "medical home" style is ultimately a good idea with obvious face validity. The Annals' problem is that we don't have pristine scientific methodologies that can identify, capture and measure the benefit.

The good news is that the science is getting better. Until it catches up, the population health and disease management service providers will remain in business and the medical home will continue to have a bright future.

Exercise Doesn't Have To Be Hard Work

With some creativity, it can be made downright fun.

C'est vrai, n'est pas?


The Oval Office Tone At the Top and the Temptation for Consumers to Lie About Income on the Health Insurance Exchanges

According to this CNN article, it's naïve for the Disease Management Care Blog to expect U.S. Presidents to never lie. From time to time, political realities force occupants of the Oval Office to use falsehoods to advance a greater good and/or protect the integrity of their office.  What's more, when they're found out, voters tend to be remarkably forgiving. So, When Mr. Obama repeatedly reassured Americans that "you can keep your health insurance," the DMCB should conclude that this was business-as-usual statecraft and that it will all work out.

But even if many Americans sign up for health insurance and the President rebuilds his approval ratings, the contrarian DMCB has a deeper concern.

It thinks a dishonest "tone at the top" can have a corrosive effect on how Americans will access their premium subsidies. 

In the business world, it is well known that the misbehavior of corporate boards and C-suite leaders can infect an entire company. The Board Chair's or the CEO's dubious financials, revenue schemes, stock manipulation, predatory behavior or just plain arrogance can roll right through the managerial ranks and destroy a company in a matter of months. When leaders lie to serve some other business need, you can be sure that others in the company will also lie.

The same may be true for the government of the United States. It's one thing to lie about Japan's military might (Roosevelt), trading arms for hostages (Reagan) or Iraq's weapons of mass destruction (Bush), it's quite another to lie about buying health insurance. The DMCB suspects that "tone of the Oval Office" is subtly signaling to regulators, insurers and ultimately consumers that it's OK to manipulate the truth when it comes to buying health insurance.

Recall that as part of health reform, the health insurance exchanges prompt applicants to estimate future income. It's also temptingly easy to misrepresent projected 2015 income.  A mild "fudge" that lowballs income can make the difference of thousands of dollars in subsidies.

Long before the President landed in hot water over his "you can keep it" promise, Americans had a huge incentive to lie about their income. That has been especially true for low income earners who really need the insurance. Now that everyone - including Mr. Obama - has admitted that he stretched the truth, the DMCB suspects Americans now have one more reason to do the same when it comes to getting health insurance subsidies. Once that pattern of insurance fraud becomes established in the marketplace, the DMCB thinks it will never go away and hundreds of millions of dollars will go to where it's not intended year after year after year.

The DMCB predicts tens of thousands of Americans who purchase insurance on the exchanges will succumb to lying in 2015.

You read it here first. 

Coda: The good news is that when it comes to the health insurers who are responsible for signing up the millions of Americans, there's no evidence that they're helping enrollees lie.  The DMCB suspects that in the battle to capture market share, it's just a matter of time until one of them has a renegade employee or two who channel the President and likewise help prospective customers to lie. We'll see.

Whither Obamacare, Now That "It's the Law of the Land?"


While a roll-back of Obamacare now is about as likely as spotting gargoyle statuettes among the DMCB spouse's holiday decor, a recent New England Journal article points out that the Affordable Care Act (ACA) - even if it is the law of the land - still has a very bumpy road ahead.

That's because of four key issues:

1. The States can still knot things up by forcing Washington DC to run the Health Insurance Exchanges (HIEs).  It's very possible that Uncle Sam won't pull them off on time and, what's more, there's a credible Supreme Court challenge looming over Obamacare's potential lapse in extending tax credits to the federally-run HIEs.

2. States can refuse the Medicaid expansion. While their statewide hospital associations are very  unhappy about that, Governors are either ideologically opposed or just plain wary of additional downstream costs. This could result in additional millions of uninsured, especially in the conservative "red" states.

3. Health care cost inflation is likely continue its upward spiral.  Congress, no matter how CMS' payment innovations turn out and no matter how much it wants to curtail costs, is unlikely to withstand the lobbying from all corners of medical-industrial complex involving thousands of pages of rules and regulations.

4. Deep public ambivalence about the law will continue. That means that as Congress and the President look for ways to control the Federal deficit, Obamacare is especially vulnerable. Unlike Social Security or Medicare, the ACA's "patchwork" of insurance reforms is headed toward the fiscal cliff without a strong supportive constituency. Before Congress even touches Medicare, it's far more likely to cut Obamacare. The first hit could be those insurance tax subsidies mentioned above.

Another Study Shows Disease Management Works

Here's more evidence that disease management really works.

The study, Online Disease Management of Diabetes: Engaging and Motivating Patients Online With Enhanced Resources-Diabetes (EMPOWER-D), was a prospective randomized clinical trial that is posted online over at JAMIA.

The Disease Management Care Blog summary:

Researchers at the Palo Alto Medical Foundation used the electronic health record (EHR) to look for active (seen once in the last 12 months) patients over 18 years of age with  Type 2 diabetes and an A1c greater than 7.5%.  If the primary physician approved, patients were then asked to complete a questionnaire and keep an appointment with a research assistant for additional review and discussion. Once patients agreed, they were entered into the study.

6,907 potential study subjects were identified, 1,594 agreed to complete the questionnaire and see the research assistant, 768 met additional research criteria. 415 agreed to be enrolled in the study, and 379 completed most of the 12 months of follow-up.

Patients were randomly allocated into one of two treatment tracks and followed for 6 and 12 months. The usual care (UC) track provided reminders about preventive care in addition to their usual visits with their physicians.  The intervention (INT) track had the usual physician visits, plus:

1. access to a "nurse care manager" (NCM) who provided advice and protocol-based medication changes,
2. Wireless uploads of glucometer readings into the EHR,
3. an EHR-based patient-specific summary "dashboard," that included risk scores, preventive care updates and a care plan,
4. web-based insulin, exercise & nutrition logs,
5. secure EHR-based messaging with the physician and NCMs and
6. patient-specific text and video offerings targeted by the NCMs.

The principal outcome measure was the A1c test, which is an indicator of overall blood glucose control. A level of 7 or lower is considered to be satisfactory control. At 6 months, INT patients statistically significantly decreased their A1c by 1.3 vs. 0.7 in the UC group.

At 12 months, there was still a difference favoring the INT group, but it did not achieve statistical significance: 1.1 vs. 0.7. 

Once the study was completed, the authors went back and looked at the proportion of patients that had decreased their A1c by at least 0.5.  At 6 months, it was 70% vs. 53% for  at 6 months, and 70% vs. 55% at 12 months for the INT and UC groups, respectively.  Both differences were statistically significant. 

Patients in the INT group were also more likely to lower their cholesterol, go through a medication adjustment, experience lower "treatment distress," have greater knowledge of their diabetes and be more satisfied with their care.  There was no difference in blood pressure control or the number of physician visits.  Overall health care costs or insurance claims expense were not measured.

Disease Management Care Blog take-aways:

You Want Evidence? Thanks to this high quality randomized controlled clinical trial conducted in a real world setting, the evidence base supporting the use of remotely placed nurse care managers continues to build.   Kudos to Palo Alto for simultaneously taking good care of their patients and conducting impressive research.

Patients At Risk: The combination of a) a steady percent of INT patients keeping their A1c 0.5 at 6 and 12 months plus b) a simultaneous overall average decline in the A1c makes the DMCB think that there was a subcohort of patients that "back-slid" and affected the group mean.  Commercial population health management service providers are working hard at prospectively identifying these higher-risk individuals for additional interventions.

Doing something is better than nothing: While the modest A1c decrease in the UC patients could have been due to regression to the mean, the DMCB wonders if they also benefited from being identified and monitored. 

Can Finally Point to Something Good About the EHR: While the EHR continues to disappoint in terms of consistently improving quality or reducing costs, this study demonstrates an important upside: it can be used to efficiently recruit potential research subjects.  That's important because thousands of candidate patients are needed to find hundreds of study participants
 
Physician Utilization Did Not Decline: Unfortunately, this study did not address multiple measures of utilization, so the DMCB doesn't know what to make of any decrease in potential costs versus the cost of the the program.

ACOs Take Note: While the Palo Alto System is not representative of most health care settings in the U.S., it does hold important lessons for Accountable Care Organizations. Given their contractual responsibility to improve diabetes quality as well as managed insurance risk, this study says they ignore the potential of remotely-based and technology-backed nurse care managers at their peril

More on Al Lewis' Book "Why No One Believes the Numbers"

Remember the DMCB's reviews (here and here) of Al Lewis' book Why No One Believes the Numbers?  The DMCB can't either, which is why you may want to check out this review by Christobel Selecky over at the excellent DMCB sister blog, The Doctor Weighs In.  It's worthwhile reading, especially since Ms. Selecky was the CEO of the star crossed disease management company LifeMasters. She knows of what she speaks and has the scars to prove it.

The DMCB finds her 6th paragraph slightly off topic but worthy of further discussion. Say what you like about the "evidence" supporting disease management, but let's at least be consistent and apply the same high standard to the patient centered medical home, the electronic health record and accountable care organizations.  Patients deserve nothing less.

A One-Size-Fits-All Approach to Determining Clinical Effectiveness Versus Shared Decision Making


The Disease Management Care Blog recently attended a physician meeting that keynoted a U.S. Senator.  In his prepared comments, he admitted that he knew little about controlling health care costs.  Unfortunately, that didn't stop him from humbly paraphrasing the testimony of a famous economist:

"Find out what works," said the expert, "and do that."

Maybe some of the physicians' silence that followed was an "aha!" reaction to the Senator's insightful nostrum.  Some of it may have also been out of respect. 

The DMCB is sure, however, that most of the docs in the room were quietly thinking "You must be kidding me."

Such is the approach of the mandarins leading our federal health care institutions.  "Science and existing literature" says HHS Secretary Sebelius.  "Effectiveness" is the mantra of the Center for Medicare and Medicaid Innovation.  "Improving health care" is now part and parcel of CMS. 

Unfortunately, applying scientific evidence to the economics of health care delivery sounds easy enough until you get down into the weeds.  For a perfect example of that, consider the common condition of painful spinal stenosis among Medicare beneficiaries. According to this JAMA article, there were over 37,000 operations in this population at a national cost of $1.65 billion. 

Which begs the question: does spinal surgery "work," is "effective" and "improves health care?" Can the "science and existing literature" help us decide?

To get an idea of just how complicated the answer is, check out this Agency for Healthcare Research and Quality (AHRQ) research review on Spinal Fusion for Treating Painful Lumbar Degenerated Discs or Joints.  The conclusions from the abstract are:

Overall, limited evidence suggests that spinal fusion compared with physical therapy improves pain and function for adults undergoing fusion for low back pain due to disc degeneration. Because of insufficient reporting and variation in surgical methods used in the different studies, the incidence of adverse events (serious and minor) associated with fusion could not be determined conclusively. The evidence was insufficient to draw evidence-based conclusions for the benefits and harms of spinal fusion for patients with degenerative stenosis or degenerative spondylolisthesis of the lumbar spine. The evidence was also largely insufficient to draw conclusions about the benefits and harms of fusion compared with other invasive treatments or different fusion approaches or techniques.

In other words, there is some evidence that, compared to conservative treatment, surgery helps.  After that, it's the stuff of caveats, statistics, evolving technique and myriad study limitations.

In fact, it's so complicated that the only way it can be applied is by helping patients understand how the science applies to their unique circumstances and values.  Once the patient understands things, it's a matter of letting that patient and doctor jointly decide on the best course of action.

That approach - in contrast to U.S. Senators musing on how we need a one-size-fits-all approach to what works - is called shared decision making and it can be applied to back surgery with considerable cost savings.


"What works?" asks the Senator?  The answer is for you to consider staying out of the way.

Ten Rules for Health System Boards of Directors to Follow to Reduce the Risk of Fraudulent Outcomes Reporting and Scientific Misconduct

Enjoying a good spin
Are you on the Board of Directors for a large health service provider, population health vendor, integrated delivery system, managed care organization or other care corporation? 

If so, your company is likely collecting, analyzing and publicly reporting quality and cost data. Not only do superior results in journals, meetings, splashy web sites and glossy marketing materials present a competitive advantage, achieving superior outcomes is part and parcel of your organization's mission.

The Disease Management Care Blog reminds Board members that intentionally or unintentionally misrepresenting outcomes is an existential threat to health care organizations.  Having to retract a publication, correct a white paper, meet with grumpy regulators, confront claw backs, deal with a whistle-blower, respond to allegations of interpretation spin, uncover suppression of bad results or defend the integrity of your brand is something no Board wants to deal with.

To the DMCB's knowledge, this hasn't happened to any ACOs, risk contracting systems, managed care organizations or population health or wellness vendors.

Yet. 

It's just a matter of time.

While the risk of allegations of scientific misconduct can never be reduced to zero, the DMCB offers up ten best practices for Boards to follow:

Reduce opportunities by:

1. Exhibiting healthy skepticism regarding all outcomes reported by your management team, especially if the results seem to be too good to be true.

2. Insist that your management team has two persons with access to any data base, and that they have separate reporting relationships.

3. Insist that your management team has two persons independently involved in any data analysis, and that they have separate reporting relationships.

4. Be familiar with and insist that the rules on research on human subjects be followed.

5. Maintain a low threshold for conducting internal or external audits of any databases and any interpretations of those data.

Combat any rationalizations that fudging outcomes is OK by:

6. Recruiting Board members with research expertise.

7. Explicitly engage the Audit Committee and any other Board member or committee with oversight of risk to view "outcomes" with the same level of scrutiny as your company's financials.

8. Maintain an ethical "tone at the top" when it comes to research.

9. Have a disaster plan ready to go.  For starters, train your Board on how to deal with hostile media inquiries.

Reduce incentives by:

10.  Asking your CEO if any compensation plans including bonuses or unwittingly promoting unethical or fraudulent behavior.


The Latest Health Wonk Review Is Up!

A festival of bright wonky bloggery awaits you, courtesy of Health Wonk Review host Hank Stern over at his InsureBlog.  In it, you'll find links to health policy insights and viewpoints that you simply can't find anywhere else.

Mazel tov!

The Curious Case of the Medical Device Tax

Some medical devices
The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

During the political maelstrom of the October government shutdown that enraged Americans and enraptured Tea Party alike, a curious proposal emerged as a possible eleventh-hour savior: a repeal of the medical device tax. 

The medical device tax, a substantial revenue source for ACA funding, was seen as a compelling political bargaining chip. Although not achieving a full “repeal” of the ACA, the vitiation of the tax would have given Republicans a symbolic victory (political cover) and the medical device industry a reprieve. Although the tax remained in force, it still serves as a potent symbol of how health care reform will need to align long-term financing mechanisms that also promote a more efficient health care system. 

A 2.3% excise tax on all medical devices was included in the ACA as a main financing stream for health care reform. Indeed, according to CBO estimates, the tax is estimated to bring in $29.1 billion in revenue from 2015-2022.  A repeal of the medical device tax would not cripple the ACA’s implementation; however, it would make it difficult to move forward, and perhaps more importantly, reopen the bill to legislative scrutiny (Note: President Obama’s announced  administrative fix for health insurance in the individual market assiduously avoided legislative action for similar reasons). 

Some supporters of the tax argue for the concept of “shared responsibility.” Building on the fiscal architecture of Massachusetts’ 2006 health reform legislation, proponents posited that stakeholders who potentially benefitted from health care reform should lend fiscal support.  The ACA followed a similar funding model: hospitals, insurers, and pharmaceutical companies all decided to participate; the medical device industry, although more obstinate, was ultimately written in the legislation.

More sophisticated repackaging of this argument has also emerged. Topher Spiro argued that the medical device tax served as a bulwark against the industry’s egregious pricing and anticompetitive practices. Although, to his credit, Spiro lays out more commonsense policies to increase transparency and address monopolistic concerns besides taxation, he ultimately adopts an odd “the ends justify the means” policy prescription.

Opponents of the medical device tax adopt a well-known line of reasoning: taxation on medical devices will hurt domestic innovation, eliminate jobs in research and development, and have a negative economic impact. This is textbook economic analysis. While some of these points are apposite, much like pharmaceutical companies, medical device companies could arguably make up lost revenue through discriminatory pricing abroad, although this may be (increasingly) difficult in areas such as “austere” Europe. 

Overall, one may be agnostic regarding the substantive points of both supporters and detractors and still be dismayed at the misalignment between the medical device tax and its intended purpose. Granted, medical device providers are leveraging the opportunity to lobby and maximize the industry’s interests in the ACA tumult. However, the tax is not ultimately intended to discourage purchase of medical devices, many of which have substantially improved quality of life for patients. Rather, it functions as a defacto “windfall” tax clawing back excess profits from an industry seen as anticompetitive and opaque with oligopolistic pricing power. 

This narrative works only so far: Medicare, a publicly funded entity, is one of the largest purchasers of medical devices.  However, Medicare is not able (or is politically prevented) from exercising greater pressure on medical device providers through conducting cost-effectiveness analysis or lowering payments on devices that have a suboptimal cost-quality profile. It is true that Medicare is developing bundled payments that will subsume the cost of the device as part of the total procedure; this move away from fee-for-service charges may reduce the “economic rents” (profits) of medical device firms over the long-term. Until then, however, the misalignment between financing mechanisms and policy incentives will likely continue, along with the distortions of second and third-best policies in an already bloated system. 

Medical image from Wikipedia

The Electronic Health Record (EHR) On-Line Portal Increases Hospitalization Rates


"Hi doc! I used my on-line
portal to make an appointment!"
Hey there Accountable Care Organization executive.

You're probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal.  That's because you've been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospital's lobby.

Well, after you've read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist.

The article's title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.

How the study was done:

Kaiser Permanente Colorado added "MyHealthManager" (MHM) to their EHR in May 2006. MHM allows patients to view tests, records, problem lists as well as care plans, schedule appointments, request refills and message their doctors. By June of 2009, over 375,000 Kaiser patients had signed up for MHM. Of those, about 45% had used the system at least once.  Of this number, Kaiser researchers pulled the records of 44,321 persons who had been continuously enrolled in the Kaiser system for at least two years. 

This group was retrospectively matched to a control group of Kaiser patients who had not signed up for MHM.  The authors did this through "propensity matching." This found a similar number of patients, based on age, gender, race, number of chronic illnesses and baseline office visits who, using logistic regression analytics, appeared to be the type of patient who would otherwise sign up for MHM.

The results:

Compared to non-MHM patients, the MHM experienced an increase in hospitalization rates (20 per thousand patients) and emergency room visits (11 per thousand).  In other words, for every hundred patients, the on-line portal seemed to lead to 2 extra hospitalizations and 1 extra ER visit. Both differences were statistically significant.

There were also increases in the number of office visits (.7 per patient per year), telephone calls (.3 per patient per year) and after-hour clinic visits (18.7 per thousand patients per year).

Caveats:

The authors correctly point out that this study is not perfect.  Retrospective propensity matching is not as good as a randomized clinical trial; it's possible that the patients who self-selected for MHM were already realtively more interested in or likely to increase their use of health care services.  Results at Kaiser may not apply elsewhere.

Implications:

Despite the limitations, this study should be a wake-up call for those who believe EHR portals is a savings panacea.  By increasing access to on-line services, physicians and patients may paradoxically use the system to address concerns that otherwise wouldn't come to medical attention.  In other words, the EHR portal exacerbates the classic health care economics problem of supplier-induced demand.

Image from Wikipedia

March of Dimes Says the PREEMIE Act Saves Lives. Does It?

Saving children's lives. Nothing could be nobler right?

According to a November 15 March of Dimes press release:

The PREEMIE Reauthorization Act will save infants’ lives," said Dr. Jennifer L. Howse, President of the March of Dimes. “Tonight the Senate took a vital step toward ensuring a healthy start for our nation’s infants."

The release goes on to say:

Our efforts are bearing fruit,” Dr. Howse added. “Preterm birth rates have now dropped for five consecutive years after rising steadily for three decades. The PREEMIE Reauthorization Act will continue to fuel our progress by supporting federal research and promoting known interventions and community initiatives."

"Really?" asks the Disease Management Care Blog.  What about the dozens of lecturers, professors and colleagues that have told the DMCB that preterm birth rates have remained stubbornly unchanged for decades? 

It's a significant problem because the delivery of a child prior to 37 weeks gestation (vs. the usual 39 weeks) is associated with many complications for both the mother and child.

Wanting to learn more about this life-saving legislative miracle courtesy of Uncle Sam, the DMCB decided to take a look for itself.

It turns out the original "Prematurity Research Expansion and Education for Mothers who deliver Infants Early Act" (or PREEMIE) Act was passed and signed into law by then President Bush in 2006.  The statute provided for a number of interventions, including millions of dollars worth of research funding, provider education and nationwide monitoring. The funding was due to run out in 2011. 

Enter the PREEMIE Reauthorization Act that was just passed by the U.S. Senate.  It doesn't appear to authorize any funding, but it essentially continues the activities contained in the original 2006 legislation by striking out the term "2011" and replacing it with "2017."

Based on the March of Dimes press release quotes above, it appears that the organization is crediting the 2006 PREEMIE with the nationwide drop in preterm birth rates. The basis for this is March of Dimes data that can be found here. If you look at the upper right hand corner, you can see that the prematurity rate went from 12.8% in 2006 (when the law was passed) to a preliminary measure of 11.7% in 2011.

Unfortunately, these data do not tell the entire story. For that, the DMCB went to the "childstats.gov" website and discovered that overall prematurity rates have remained stubbornly fixed in the 10.6% to 12.8% range for over two decades.  The rate peaked in 2006 and has been drifting back down to the baseline historical average.   To the DMCB it looks like normal year-to-year variation.  What's more, DMCB readers are well aware of the phenomenon of regression to the mean.

Next step for PREEMIE is the House of Representatives.  The DMCB isn't advocating for or against PREEMIE, but it hopes a second look in our bicameral legislative process prompts a more rigorous and complete examination of the outcomes associated with this piece of legislation.

Editorial Comment: The DMCB is all for research to discover what works, but it would like to point out that there is a considerable body of published literature on the topic.  Do we really need more research, or do we need to figure out how to provide these services using the principles of population health management? 

You be the judge: it's your money.  

Image from Wikipedia.

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