Friday, January 30, 2015

Can Our Politicians (or the Market) Improve on NICE?

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

In the halcyon dog days of summer 2009, U.S. politicians aimed their rhetorical fire on a rather odd target: the UK’s National Health Service (NHS).  With a vote on President Obama’s proposed health reform on the horizon, politicians hoped to tar the reform effort by association: The NHS was painted as inefficient; a decried relic of “socialized medicine” and state planning; some damning charges were levied against NICE (The National Institute for Clinical Excellence) as the putative “death panel” rationing potential life-saving treatments to patients.

In a strange turn of events, recent developments in implementing the ACA, particularly the legislative appropriation of basic benefits, may show the limits of the US political system in making important decisions for patients in an economically efficient matter.
 
Two recent examples may raise red flags.  ACA’s “Basic Benefit” program, originally conceptualized as a way for the federal government to standardize benefit programs offered on health care exchanges, was devolved to the states in order to dispel concerns over excessive bureaucratic intervention in the process. 

The result: massive lobbying by medical interest groups, including chiropractors and acupuncturists, to include their services in the benefit package without examination of medical evidence or economic value of their use. While these rent-seeking activities were seen as part and parcel of the political process, the Nebraska basic benefits proposal to offer a high-deductible plan did not pass muster. 

One economic case for the ACA (albeit a limited one) was predicated on leveraging efficiencies in drug prescriptions for generic drugs, particularly biosimilars.  Recent reports indicate, however, that biotechnology companies are trying to put additional roadblocks in the process to prescribe biosimilars, perhaps preventing the anticipated competition and forecast savings.
 
Although these are only a few examples, they have rapidly emerged as both the federal and (some) state governments have started to implement ACA provisions. 

Regardless of the political histrionics surrounding “socialized medicine”, the ACA is now (for better or worse) the law of the land. The issue of whether “rationing” exists in any health care system is a red herring; in a world of scarce resources, rationing is performed regardless of political ideology.

The real question is: how will rationing ultimately be conducted- out in the open as part of a rigorous deliberative process, or behind closed doors by legislative fiat?  In this sense, the US politicians’ attack on NICE was both prescient and half-correct:   the ACA would indeed give new power to legislators and bureaucrats to make decisions on the clinical and economic efficiency of medical treatments for patients, and NICE is the (sometimes unpopular) face of those rationing decisions.
 
At the end of the day, however, the implementation of the ACA raises seminal new questions about whether the business of politics can be separated from the dispassionate analysis needed to evaluate clinical treatments.  NICE is far from perfect: the institution has received withering criticism for tough decisions and a less than perfect methodology (e.g., the QALY).  One of the main challenges for US politicians, or the healthcare market, is whether they can come up with a better system. 

Thursday, January 29, 2015

How Small Business Is Helped By Obamacare... and Large Businesses Will Be Less Able to Compete Against Them

Small business points at its competitor
It wasn't until the Disease Management Care Blog had read this Jan. 30 Wall Street Journal opinion piece that it realized that its "nano" corporate" status was packed with such futuristic potential. According to the editorialist, American companies should follow the DMCB's lead and be "protean" by dropping old fashioned W-2 employees and substituting 1099 contract relationships.  That way, everyone - including a single person "nano" - can enjoy the upsides of being a corporation and stay below Obamacare's 50 employee pay-or-play $2000 penalty threshold.

Since the DMCB formed it's own corporation more than 5 years ago, it has certainly participated in "protean" business relationships. Once things get underway, the DMCB often discovers that of the many prominent organizations that it does business with really consist of a small core office populated by a few owner-founders, a single administrative aide and one or two payroll folks who oversee the outsourcing of everything else.  While the term "protean" is certainly novel, the DMCB thinks distributed, adaptable and organic business networks have been around for years.

But the WSJ editorial opens a window into an underappreciated consequence of Obamacare and the underlying assumptions of the central planners who run Washington DC.  The DMCB doesn't necessarily think it's bad, but it sure is interesting.

Read on.

While the Affordable Care Act (ACA) was intended to link employment and health insurance, what it has really done is handed many small nimble interlocked businesses another leg-up against their large traditional mainframe competitors. For example, one colleague pointed out to the DMCB that "new" pharma companies are really marketing departments that outsource manufacturing that, in turn, outsources supply management that outsources I.T. that outsources its cloud services. It's the only way they can compete. 

The new economics of health insurance will only accelerate similar trends in other manufacturing and service sectors of the economy.  Toss in the ability of people and capital to move and work across borders and the picture becomes even more dynamic. And in the meantime, Washington DC continues to implement the ACA with a legacy of large companies buying comprehensive health insurance for its employees.

Little did anyone anticipate that the ACA would hamper the success of American big business.

Image from Wikipedia

Of Medicare Shared Savings Program (MSSP) ACOs, Start-Up Costs, Preliminary Financials and Data Support

The Disease Management Care Blog didn't know there was a "National Association of ACOs" either, but they've just released results from a "web" survey of the organization member ACOs that are participating in the Medicare Shared Savings Program.  You can read more about the Program here

Of the total number of 123 MSSP participants, 35 anonymously participated in the survey. Their covered beneficiary numbers ranged from 5,100 to 78,000.

Among the findings:

Start up costs in the first year of operation averaged $2 million, with a range from $300,000 to $6.7 million.  With continued operations, the average cost over two years was $3.5 million. Total capital needs averaged $4 million.

While Medicare has yet to release any formal financial results, the ACOs' estimated results showed that 13 guessed they would break even. Nine will gain an average of $1.3 million and six will lose $1.3 million.  Six had no estimates, while other gains and losses ranged from positive $9 million to negative $10 million, respectively.

The biggest problem? "CMS data and learning to access it and process it."  This required pricey information technology with an average of $413,000 internal and $443,000 external costs.

The DMCB's take:

Running an integrated delivery system or physician-hospital organization as part of an ACO is a very expensive and capital intense enterprise.  Given the additional costs of new technology, electronic records and personnel, some of the ACOs may not be able to afford the loss of millions of dollars.  It remains to be seen how Medicare will handle the downside of hospital lay offs or clinical program discontinuations among some of the MSSP participants.  Will members of Congress have to get involved on behalf of their local constituents?  Stay tuned!

As the disease management industry learned, it's one thing to "save money," it's another to save money in excess of fees plus program costs.  $3.5 million over two years is a lot of money to make up before you break even, making the DMCB wonder if cheaper programs (such as population health management) with a more modest scope (such as reducing readmissions) may have a better long term value proposition. Once again, stay tuned.

And the Disease Management Care Blog predicted there'd be problems with the data feeds here.  Recall that one of the problems with the Medicare Health Support program were "execution" problems with the timely provision of utilization data from CMS.  ACOs - and the Medicare beneficiaries they're taking care of - deserve better. 

Wednesday, January 28, 2015

How Did the DMCB Do With It's Healthcare Predictions for 2015?

While the Disease Management Care Blog is pretty good at spotting current health policy silliness, its track record at predicting the future has been rather spotty.  Regular readers have undoubtedly forgotten this brazen attempt at 2015 health care augury, but the transparent DMCB refuses to bury its mistakes.

So how did it do with its Ten 2015 Predictions?

1. Mitt Romney will win the Republican nomination and avoid discussing health care.  The DMCB got some of this right, but who would have predicted that the President would cleverly upend his opponents by embracing the term "Obamacare?"

2. A close election will hinge on an improving economy, not on Obamacare. In the end it wasn't really that close, but the DMCB was correct in foreseeing that Mr. Romney's candidacy would be undermined by dropping unemployment levels and the bottoming out of the comatose housing market.

3. The Supreme Court will rule Obamacare unconstitutional: Boy, the DMCB got that wrong.  But in its defense, few foresaw that SCOTUS would ignore the Affordable Care Act's statutory language and rule that a penalty was really a tax all along.

4. There will be no generalizable and published peer-review studies on the electronic record of the medical home that conclusively show that either saves reduces health care costs.  "Bingo!" says the DMCB.  It hopes 2015 is different and that a p value is < 0.05.

5. ACOs will not criticize CMS about the tardy delivery of claims data necessary to manage its assigned populations. The DMCB says the silence over this issue is deafening, which means either a) CMS has overcome its dismal track record on providing timely information or b) the ACOs are reluctant to go public with any concerns.  The DMCB has heard rumors that the latter is true.

6. Speaking of ACOs, their physicians will trump patient preferences over savings.  The DMCB says the jury is still out on this, but time will tell if its call about this ACO Achilles heel is as important as it thinks it is.

7.  Health exchange deadlines will be pushed back. To the DMCB's knowledge, CMS is holding firm on the fall 2015 implementation date.  The DMCB takes some credit, however, for being among the first to spot this issue and bring it to its readers' attention.

8. CMS will kick the Sustainable Growth Rate (SGR) down the road. "Bingo again!" says the DMCB.  It got his one right and looks forward to how Congress will deal with this in 2015.

9. Medical academics will increasingly turn to social media instead of print to make their mark on the scientific world. The DMCB believes this trend is continuing but has yet to reach a tipping point.

10. CMS Interim Administrator Tavenner's status will remain in recess limbo.  OK, it wasn't all that hard to bank on continued partisan bickering, but the DMCB got this one right too.

Will the DMCB offer up predictions for 2015?  Stay tuned!

The State of the Union is Over. Advice on What's Next for Obamacare

When it comes to assessing or "monetizing" the possibility of a bad future event, the insurance-minded Disease Management Care Blog recalls that a common approach is to multiply the probability of the outcome and its value.  For example, if the chance of a $100,000 house burning down in the next year is 1%, the present value of that risk is .01 x 100,000 or $1000.  That $1000 figure is the starting basis of calculating the cost of homeowner's insurance.

While that logic only goes so far, it can be a useful way to look at other types of risk. For example, instead of confidently proclaiming that the Affordable Care Act "will" or "will not" lead to a deficit, it may be wiser to describe the range of probabilities.  So, depending on future GDP, inflation, disease burden, and other factors, it could be reasonably estimated there is an "X" percent chance it will increase the deficit by "Y" billions of dollars. Multiply that downside risk against the size of the deficit, and Congress and the White House could use that number to discuss the implications for this year's budgeting.

Fat chance of that happening.

With just hours until the State of the Union ("#SOTU") address, it appears our cerebral President won't be thinking that way. Rather, it's more likely that he extol healthcare.gov's repaired functionality, remind listeners that millions of Americans have signed up for insurance, push a "regulatory" agenda and threaten that, so long as he wields the veto pen, "there's no going back."

While the DMCB admires the President's pluck, it still fears that Obamacare could turn out to be his Napoleonic Russian invasion. While he's taken "Moscow" with the passage of the ACA, the countryside is filled with angry partisans, the 2015 elections portend a long cold winter and his supply lines are threatened by botched health insurance data feeds, a dodgy mandate, unintended consequences and costly risk pools.

Once the political theater of SOTU is over, the DMCB suggests that Mr. Obama's advisors should quietly ascertain the likelihood that the ACA gets worse (1%?, 10%?, 25%?) in 2015 and multiply that times the value of the President's legacy.  A realistic appraisal of that number may prompt the President to look at his signature achievement in a new light, gauge the political theatrics for what they are and devote a commensurate level of Oval Office attention to making the law work.

Tuesday, January 27, 2015

Five Novel Health Care Apps

The Disease Management Care Blog wonders if 2015 is the tipping point for "health care apps."

Given the turmoil surrounding Mr. Obama's reform agenda, consumers will be seeking better self-care options, policymakers will want DIY punditry and providers will want marketshare.

Here are five timely DMCB ideas for apps that can help them.

Expert Health Policy Bingo: Compete with fellow policy weenies with an on-screen bingo card with cells that are randomly populated with catch-phrases like "26 year olds," "botched," "pre-existing condition," and "ovaries." Spell out BINGO during a speech, CMS conference call or Fox News broadcast and you get bragging rights!

HandHeld Insurance Exchange: Instead of a desktop browser, this app will help health insurance consumers use their smart phones to access Obamacare. Once launched, the screen will naturally announce the functionality is down. Price in the App Store to download: $91 million.

Random Anecdote Generator: Depending on your politics, this app will tap NSA heuristics to download Facebook data to spin a mostly-true story of a [insert number] year old with [insert condition] who [did/did not] get health insurance because of health reform. Great for talking heads and politicians alike on either side of the political spectrum!

Show Me the Money: This is for users who are unsure of just how to estimate the ultimate impact of health reform on the U.S. budget, and know that the words "billions" or "trillions" are insufficient. This app generates better numbers, like "quadrillion," "gazillion" and  "shabwillion." A bonus: can be used to describe savings or costs!

Best Care: When confronted by a new diagnosis, patients naturally want to know where they can find the "best" provider for that particular condition. This app will input the condition and use the internet to match the user to the clinic. Naturally, since every hospital has been on at least "Top 100" list for every condition, the app will use geo-mapping software to really guide the user to the closest hospital.


Image from Wikipedia

Monday, January 26, 2015

Either You Give Your Patients a mHealth App, or They'll Get One Themselves

That's what the Population Health Blog learned after reading this research paper by Bauer and colleagues that recently appeared in the Journal of the America Board of Family Medicine.

It also confirmed that chronic care management apps are a business opportunity.

What was the research and what did it show?

All adult patients receiving care at six clinics in a northwest U.S. primary care network during a two week window of time (June 2015) were anonymously surveyed about their use of mHealth.

Depending on the clinic, 22% to 62% of the patients were insured by Medicaid.  More demographic info can be found here.

1363 surveys were distributed and 918 (67%) were completed. 

91% had a mobile phone and more than half (55%) owned a smart phone.

Among the smart phone owners, 70% had used "mHealth." 57% had downloaded at least one app. Of these, 69% used it less than 3 times a month, while 11% used it on a daily basis.

There was no association of mHealth participation with health literacy, chronic conditions or depression. Use was more prevalent among persons less than age 45.

One third used "general" health apps, while one quarter used fitness, diet or weight-loss apps. Only 3% used it for chronic disease management.

The authors asked respondents to use a 1-5 scale to rate the desirability of various app features. Appointment reminders came in first, followed by medication reminders and general health information.

10% learned about this from their physicians and only 31% "prioritized" their physician's involvement.

The PHB's summary:

Smart phone and app use may be more prevalent in the northwest, which may make the findings of this survey less generalizable to the rest of the United States.  With that caveat, approximately 40% of the patients sitting in the average primary care clinic waiting room are mHealth users and about 20% are using health apps. And what do patients most prize in their apps?  Reminders about appointments and medications.

What's more, most of this is occurring without the benefit of their providers' participation.

Last but not least, apps have not penetrated the chronic disease population.

The PHB's take?

1) If all those patients with smart phones are going to download apps, they might as well download ones that - at a minimum - are endorsed by their providers. Optimally, they should complement their providers' services.  Used right, they might be able meet their patient's desires for coordinated appointments and increased medication compliance. 

Providers and patients would benefit from better quality and lower costs.

2) And patients with chronic conditions have yet to discover apps.  That may be a function of age, but it may also be a function of the conspicuous silence of their providers as well as the failure of the currently available apps to meet their potential customers' desires. 

That spells opportunity.  Recall the adage of the two shoe salespersons who were sent to Africa.  The more pessimistic of the two found that none of the natives were using shoes and decided to return home.  The optimist likewise found that no one was using shoes, but he called back to the home office and asked for help.

The market for chronic care apps needs help.

Image from Wikipedia

Sunday, January 25, 2015

The Latest Cavalcade of Risk Is Up!

The latest Cavalcade of Risk happens over at Lynch Ryan' Worker's Comp Insider. Light bulbs, threats to health worker safety, coming costs for individual health insurance, the regulatory environment, claims management and the details behind life insurance are among the many interesting topics for your risky reading pleasure.

Enjoy!

Friday, January 23, 2015

The Fight Over Community Care of North Carolina's Claims of Savings Continue

Nothing like academic fisticuffs to capture the Disease Management Care Blog's interest. The well timed punch that exposes a methodologic weakness.  The counter punch that quotes past research.  The bob and weave of spin and framing.  Misquoting blows below the belt. Statistical pokes in the eye.  The DMCB says it's better than foreign politicians brawling, Kill Bill sword fights and lurid professional wrestling.

Which is why it's enjoying a big dust-up over the Community Care of North Carolina's medical home initiative in the "Letters to the Editor" section of the January 2015 issue of American Journal of Managed Care (AJMC).

Regular readers may recall this early 2009 DMCB alert about the CCNC's actuarially derived claims of savings with its medical home.  Al Lewis of the Disease Management Purchasing Consortium eventually caught-up the the DMCB with his own three-fold roundhouse of a punch directed at CCNC that was published in August 2015 AJMC:

1. Claims of $250 million in avoided hospitalization costs on a baseline 2006 cost of $114 million is very unlikely,

2. Outside data indicate that Medicaid admissions in the state only fell from 36 to 34 per thousand, which also makes any claim of hundreds of millions in savings suspect, and

3. Two neighboring states without a medical home initiative experienced the same modest declines in hospitalizations without the same savings.

Well, the actuaries involved in the original Community Care report have jabbed back:

1. The baseline that was used was an actuarial projection of what costs would have been, based on prior trends, not 2006

2. The observed savings were never ascribed to avoided hospitalizations

3. The medical home initiative had been in place for many years, which could explain its impact.

The CEO of Community Care also penned his own counter-strike.  He argues:

"Evaluating complex programs is a difficult and evolving science, but [the] approach to estimating CCNC’s impact is reasonable, measured, and up to the latest standards in the field. Its analysis plays by the same actuarial rules as everyone else—including disease management vendors calculating a return on investment and insurance companies setting rates."

.The rest of the letter uses terms like "disturbing," "facile" "erroneous" "mistakes" "misrepresents" "circular references." Ouch.

The DMCB fully expects the spat to continue and looks forward to enjoying its ringside seat.  In the meantime, it's sticking to it's original point from more than 3 years ago: the CCNC analysis was an opaque actuarial analysis that was never subjected to the scrutiny (and editing) from independent peer review.  If it had been, the reviewers would have spotted many of Mr. Lewis' concerns and forced the authors to be more transparent with their methods.

Lesson learned.

Thursday, January 22, 2015

Physicians Generating Millions of Dollars in Losses and the Implications for Accountable Care Organizations (ACOs)

"I wonder how I can lose less money?"
The ever resourceful HealthHombre Blog quotes an interesting academic review paper to make an important point: many of the widespread assumptions of smooth sailing for the 106 new ACOs still remain unproven.

The DMCB agrees with this important HealthHombre insight. In addition to the many "known unknowns" (including just how physician-hospital organizations will perform in managing insurance risk), there are also the "known known" year-to-year random fluctuations in claims expense.  And, as the DMCB noted, there's the "unknown unknown" "antifragile" threats to a highly protected sector of the economy that could bring the whole ACO-thing down, 2008-style.

And here's a case in point that backs up HealthHombre.  "Wellspan" is a highly regarded and well-run hospital system that is local to the DMCB. This recent news report is telling because Wellspan's success and challenges probably apply to other emerging integrated institutions that have an appetite for risk contracting.

According to the press report, Wellspan garnered an excellent credit rating because...

"766 physicians — more than 75 percent of those in the hospital's market — are affiliated with WellSpan, which [was] counted as a key credit strength."

But the bad news is that the rating also....

.....noted that WellSpan's physician group, which employs 411 of those doctors, generated losses of $19.6 million in 2011 and $21.4 million in 2015 (bolding DMCB).

The DMCB has heard similar statements from seasoned health system administrators both locally and nationally.  If "physician integration" is supposed to be the bedrock of ACOs, how is it that the docs are responsible for millions of dollars in losses?  What is the likelihood that these organizations will finish December 31, 2015 in the black?

Could mHealth Apps Be a Reprise of the EHR? The Need for Clinician Input

While the Population Health Blog continues to delight in the emerging science of "mHealth" as a newly minted start-up Chief Medical Officer, it ran across this interesting article on risk and patient safety.

Authors Thomas Lewis and Jeremy Wyatt worry that "apps" can lead to patient harm. 

They posit that the likelihood of harm is mainly a function of 1) the nature of the mistake itself (miscalculating a body mass index is far less problematic than miscalculating a drug dose) and 2) its severity (overdosing on a cupcake versus a narcotic).  When you include other "inherent and external variables," including the display, the user interface, network issues, information storage, informational complexity and the number of patients using it, the risks can grow from a simple case of developer embarrassment to catastrophic patient loss of life.

In response, they propose that app developers think about  this "two dimensional app space" that relies on a risk assessment coupled to a staggered regulation model.  That regulation can range from simple clinical self assessment to a more complex and formal approval process.

What's clear to the PHB is that hidebound mainframe entities like the Food and Drug Administration are no match for the app "ecosystem".  Rather than try to formulate a one-size-fits-all "not function as intended" model like this, maybe it should triage its oversight using the Lewis and Wyatt framework.

In addition, the PHB agrees with Lewis and Wyatt that safety is also a function of clinician input.  Docs and nurses can assess possible mistakes, their downside severity and the impact of all those variables.

The PHB couldn't have put it better:

".... many app developers have little or no formal medical training and do not involve clinicians in the development process and may therefore be unaware of patient safety issues raised by inappropriate app content or functioning."

Without the insights of seasoned real-world doctors and nurses, apps could end up with the same safety issues that are plaguing electronic health records, many of which were also developed with little regard to physician or nurse input

In other words, just because it's a "health" app doesn't mean its necessarily so.

Image from Wikipedia

The Behavioral Economics Behind the Individual Mandate

Thanks to analyses like these, the Disease Management Care Blog is coming down with a tiresome case of individual mandatosis complicated by penaltyalgia.

Former CBO Director Douglas Holtz-Eakin's American Action Forum just posted that erudite and well-referenced article. It contrasts the simple cost of a) paying for subsidized insurance with "silver "and "bronze" high out-of-pocket costs vs. b) foregoing insurance, paying the penalty and paying retail for health care.  News outlets are reporting that the average person with average utilization will come out ahead with option B.  By implication, therefore, the penalty attached to the individual mandate is too small to make a difference.

"That's not the point," says the conservative DMCB.

The mandate was originally developed as a smaller part in a grand national experiment in behavioral economics.   It was long since departed White House Advisor Peter Orszag who betted that Obamacare's new "social norm" would nudge citizens toward doing right by buying health insurance.  The mandate was never intended to tip the financial scales, but act as a gentle reminder that could symbolically promote greater civic duty like voting or using seat belts.

The fundamental problem with the mandate isn't that the penalty is too small to change buying behavior.  The problem is that this building block of health reform remains an experiment.  It will be years before we can assess Orszag's bet on the impact of these behavioral penalties attached to the mandate.

The DMCB also remains wary of "average" outcomes.  While a typical silver or bronze buyer would come out ahead by being wary of the famous nine words about government "help," there is a small segment of individuals who would be protected from bankruptcy.  The purpose of insurance is to monetize risk and transfer it. That's a real cost for everyone, except the unlucky few who need it.

Image from Wikipedia

Wednesday, January 21, 2015

What Is the Plan B for Healthcare.gov's IT Problems

While Obamacare skeptics have glommed onto this government document for all the usual reasons of partisan advantage, the Disease Management Care Blog has a different take.

Titled "Justification for Other than Full and Open Competition," its ultimate purpose is to justify the non-compete and hurry-up hiring of IT company Accenture to fix the star-crossed healthcare.gov web site. It makes for interesting reading, with scary references to "the entire healthcare reform program [being] jeopardized" by "inaccurate... payments" to health insurers "potentially leading to their default" as well as "inaccurate forecasting of risk adjustment, reinsurance and risk corridor[s]" "potentially putting the entire health insurance industry at risk."

The deadline for the fix is less than two months away in "mid-March 2015" with an additional taxpayer cost of $91.1 million.

1) The DMCB doesn't mind a little bit of bureaucratic alarmism to justify the cutting of some red tape.  The considerable back-end transaction errors and reconciliation issues of healthcare.gov need to be fixed and the Justification is a refreshing alternative to CMS's wildly political pablum.  Good for them.

2) Check out the last two pages of the document and you'll find separate authorizing signatures from a "Project Officer," "Immediate Supervisor," "Head of the Sponsoring Program Office," "Contracting Officer," "Cognizant Group Director," "Cognizant Policy Director," "Director 'OAGM,'" "Competition Advocate" and "HHS Senior Procurement Executive."  Despite the vulnerability of the U.S. health insurance market and the threat to the credibility of healthcare.gov, nine signatures were needed from relatively unknown government officials buried deep inside a vast government bureaucracy.

3) Worst of all, the document makes no mention of a Plan B.  If the President's signature health health reform program is in jeopardy, what happens, asks the DMCB, if Accenture falls short?

The Intersection of Writing, Blogging, Speechmaking and Compromising: Why Today's Inauguration Does Not Bode Well for Mr. Obama

Once again, it is the Disease Management Care Blog's pleasure to wish our President the best for his coming second term.  Not like he needs any help, of course. Mr. Obama certainly started things off with a bang with today's soaring and forceful inauguration speech.

Which naturally worries the contrarian DMCB.

In Bob Woodward's tell-all book The Price of Politics, Mr. Obama reportedly  reassured a skeptical Speaker Boehner by saying  "John, I've got great confidence in my ability to sway the American people." 

That was certainly evident today.  He really thinks speeches can win hearts and minds.

Contrast Mr. Obama's oratory self-assurance with his predecessor, Ronald Reagan.  In the book, Reagan, A Life In Letters, it seems our 40th President used the written word to not only hone his communication skills but to internally develop and refine his thinking on the great issues of the day. Armed with that kind of self-clarity, Mr. Reagan speeches were secondary to his far more important skill of compromising without giving up on his principles.

Über academic Pat Thomson says it best: "Binge writing" allows authors to become immersed in a topic "to make sense of it."  Fifty Shades of Gray author, E.L. James, may have expressed it best: “Write for yourself,” she said. "That’s it. And write every day."

The modest DMCB agrees. Its bloggery (just over 1500 posts and counting) helps it better fashion real-world business plans that involve inevitable trade-offs between what the scientific evidence says what should be with what clients have already decided what will be.

The DMCB will never give a speech on the Washington Mall, thank goodness, and it's not like Presidents will ever seek its counsel.  But it knows that philosophic certitude is better tasked to navigating inevitable compromises in the real world, not convincing skeptical listeners to give in.

Let the games continue!

Tuesday, January 20, 2015

The Value of Introverts

One of the few things the Disease Management Care Blog enjoys more than talking about itself is reading about itself.  That's one reason it's downloaded Susan Cain's Quiet: The Power of Introverts in a World That Can't Stop Talking

Aside from feeding us introverts' narcissism, Quiet is a worthwhile read.  It describes how Dale Carnegie helped undo the American culture of "character" in the first century, and paved the way to our second century culture of "personality." The DMCB admires confident showmanship as much as anybody, but the bad news is that there is little correlation between a leader's bravura and a leader's success.  In fact, it's the quiet and unassuming leaders who seem to have a better track record.

No wonder brainy competent experts like Tom Nichols are so upset that no one is prepared shut up and just take their word for it. As the 24-7 news cycle is coarsened by blustery talking heads and perpetually outraged social media, notions trump knowledge.

On the other hand, JAMA's Bob McNutt points out in The Health Care Blog that expertise can be put to good use when it informs individual decision makers.  If the DMCB is reading this right, experts need to not only be expert, but able to efficiently convey their knowledge for maximum impact one person at a time.

Which leads the DMCB to offer two insights:

1. Board of Directors and C-suite leaders would be well advised to think long and hard about the risk of "group think" that can arise from a charismatic and convincing leader.  Let that dominate your company's strategic planning and you expose your company to a concentrated unforeseen risk, including a classic Black Swan event.  Seek out that quiet person in the back of the room with a contrarian perspective and listen for ways to keep your options open.
 
2. The new definition of expertise is to not only be truly expert but to be able to convey your insights convincingly and quickly in a few paragraphs, a short email or within a 140 character "tweet."  The DMCB suspects that persons who can combine both skills will prevail in today's media markets, the public square and in business settings.  Electronic communication and social media - which engages persons one individual at a time - are leveling the playing field for wise introverts, which is good news.

The Latest Health Wonk Review Is Up!

The Health Affairs Blog, organized by Chris Fleming, has an Inauguration Edition of the Health Wonk Review.  Think of it as a timely and linked summary of savvy insights from the best health policy bloggers that the web has to offer.  There's a gold mind of information on health care costs, the mechanics of insurance and population health.

Enjoy!

Monday, January 19, 2015

The PHB is Back

The Population Health Blog received a gratifying number of "Where'd ya go?" reader posts, emails.  Thank you......



It didn't need a handgun to know it wasn't going anywhere.

Rather, the PHB recharged over the holidays, continued to build its Twitter followership and, best of all, was busy with medSolis.

It's paid off. We've closed 2015 with a solid product, two customers, one investor and more than a dozen employees. Looking ahead to 2015, it's gonna need shades.

Speaking of a bright future, it recently got to surf the JP Morgan Health Care Conference ecosystem, described by CNBC as the "biggest health care investing event of the year." In addition to some promising additional investor leads, the PHB came away with two memories:

1) San Francisco's Union Square is usually populated by a pleasant mix of tourists, shoppers and natives. During the conference, however, it was thick with (mostly white male) suits, most of whom were staring off into space while pressing the latest handheld technology against the side of their heads. They moved very little.  The PHB knows this because it watched them very closely.

2) Overcome by the bursts of electromagnetism, the PHB retreated and sought out quiet time in those oases formally known as "hotel lobbies." They too were packed with suits, but they were excitedly clustered around open lap tops or lustfully stroking some piece of monitoring gadgetry. Open seats and cheap coffee were nowhere to be found.

And what has it learned in the last two months? In addition to discovering that the PHB spouse doesn't believe $400 San Francisco hotel rooms are a "biggest health care investing week" bargain, the PHB also confirmed that the most promising population health technology solutions are simple and scalable.

More on that in a future post.

Friday, January 16, 2015

It's Easy to Get In, But Harder to Get Out: Post Hospital Syndrome or "PHS"

Bad for your health?
When the Disease Management Care Blog was told by the intern, the hospital social worker, the VP for Medical Affairs or the family that an inpatient "was ready for discharge," it had a favorite test to see if it was really true.  The DMCB would walk into its patient's room and ask her to do what she had easily done before she was admitted to the hospital: swing your legs out of bed, stand up and walk across the room.

The DMCB was impressed by how often elderly patients were unable to perform that simple but telling task.

Of course, the best approach was to not let the patient become that debilitated in the first place.  That's the point of Harlan Krumholz's article on "Post-Hospital Syndrome" that was recently published in the January 10 New England Journal.

In it, Dr. Krumholz shares an important secret: being in the hospital can result in starvation, sleep deprivation, muscular deconditioning, confusion and myriad poly-pharmacy side effects.  In fact, it's probably those issues, not the original medical problem that led to the hospitalization, that account for much of the infamous 20% 30-day readmission rate for Medicare beneficiaries.

Dr. Krumholz recommends that hospitals be more attentive to assuring better nutrition, provide a less noisy environment, promote early activity and keep the use of sedative, pain and hypnotic (i.e., sleeping pill) drugs to a minimum. The DMCB seconds that motion and suggests that many of its more savvy colleagues think of this as discharge planning that begins the minute the patient is admitted to the hospital.

And when patients are ready to go home, it's not a matter of continuing outpatient treatment for the initial diagnosis.  These patients need comprehensive assessment and planning.  While the author doesn't come out and say it, the DMCB will: these patients need nurse-led care planning and management that addresses the full spectrum of needs that are too often ignored by hospital personnel in the rush to collect on the DRG and minimize length of stay.

Last but not least, the DMCB recommends adoption of the term "post-hospital syndrome" and wonders if it may not deserve the "PHS" acronym.

Anyone who has ever witnessed a previously well person be unable to stand up and walk will know exactly what it means.

Thursday, January 15, 2015

Health Care Reform in the U.S. vs. Other Developed Countries.

Your doctor will see you now!
If only the U.S. health care system had the democracy of the French, the efficiency of the Germans, the primary care of the Brits and the common sense of the Swiss. Then we'd be able to see our beret-wearing PCPs ad lib, receive care in 9 minute aliquots, mutter "bullocks!" when we're told we're too old for dialysis and then die old and quietly at home.

Victor Fuchs, writing in the Jan 2 edition of JAMA, has a slightly different perspective.  He notes that American history is dominated by waves of immigrants who came here to escape oppression. We are far more distrustful of government.  We are also less likely to support redistributive public policies. That may be partly due to a more heterogeneous population that is less sympathetic to the less fortunate when they fall outside the right social or demographic class. Last but not least, our system of government is quite inefficient compared, say, to a parliamentary system.

That's why:

1. Government spending on health care is comparatively lower: 46% in the U.S. vs. 75% in Organization for Economic Co-operation and Development (OECD) countries.  As a result, a) administrative costs are fragmented, and b) there is less ability to negotiate prices with providers and suppliers

2. There is a different mix of services: in the U.S., less top-down control means more high tech, specialists and amenities with relatively less reliance on physicians and hospitals to render health care services.

What is the way forward?  Dr. Fuchs recommends that future health reform efforts not be modeled on Europe.  Instead, Americans should scale back their expectations and focus on what is necessary, not desireable.

If government is to assume a greater share of health care costs beyond the current 46% level, it should probably worry about funding basic care, not all care.  In addition, Americans are less likely to support total equality; they want to preserve the option of "buying up" when they can afford it.  Last but not least, future reform is going to have to find a middle ground between all the advocacy groups, stakeholders and special interests that dominate the mix of services.

Image from Wikipedia

One Proposed Measure of Obamacare Success: Drop-Outs from the Bronze and Silver Plans


Quick: if you had to chose a limited number of measures to gauge success of the Affordable Care Act, what would you choose?  Would it be the number of persons who have enrolled in healthcare.gov? The number of persons who have paid for their insurance and have coverage?  The number of young people with coverage?  The degree of spin used by the White House?

Naturally, the quizzical Disease Management Care Blog proposes a different metric:

The percent of persons with either 1) "silver" or 2) "bronze" plans who have gone two or more months without paying their insurance premium.

Why, you ask?

1) The silver and bronze plans, because their monthly premium is lower, will attract a disproportionate number of persons who were previously unable to afford health insurance and are now newly insured;

2) According to this just published JAMA article, even if their monthly premiums are fully or partially subsidized, these lower-cost insurance plans cover only up to 60% to 70% of medical expenses. That means cost sharing that can be excess of $6000 and $12,000 for individuals and families, respectively.

As these newly insured persons begin to access health care, high out-of-pocket expenses can lead to two scenarios:

1) Those with subsidized insurance will resent paying anything for a plan that stretches the very definition of "health insurance," or

2) Those with partially subsidized or unsubsidized insurance, because of their mounting bills, won't be able to pay the premium

Either drop-out scenario is very possible.  The DMCB isn't aware of any data that describes the normal drop-out rate in low-premium/high out of pocket health insurance plans, but that number exists somewhere.  If Obamacare has a higher than expected rate of of drop-outs, that could spell trouble.  If the drop-out rate is low, things are going well.

CODA: The image above is an example of an enterprise data dashboard, which is intended to help companies track real time success in achieving specified targets.  It's arguably a best management practice and it shouldn't be too much to expect the White House to post an ACA "healthcare" dashboard on their web site.  Why not?

Image from Wikipedia

The Latest Health Wonk Review Is Up

Who cares if the health policy beverage container is half full or half empty, the Disease Management Care Blog hoists a toast to David Williams and his Health Business Blog.  His roundup of the latest and bestest musings from the web can be found here.  Enjoy!

Wednesday, January 14, 2015

Medication Errors and Injectable Drugs: The $5 Billion Price Tag

uh oh......
Writing in the latest issue of American Health & Drug Benefits, the Disease Management Care Blog reviews a study on medical errors associated with injectable drugs (go to page 25).

After mining and correlating multiple national data bases, Betsy Lahue and colleagues found believable evidence that 1 of every 400 U.S. hospital injections results in avoidable error.  While that number seems low, that means the average hospital can experience 25 accidents a day.  While the vast majority of these events don't necessarily lead to significant patient harm, the financial toll adds up to more than $5 billion in additional expense.

While $5 billion may not impress the thousands that make up the sophisticated DMCB readership, they also know that there are no simple and single trillion-dollar-coin-type answers to the long-term challenge of rising health care costs. Bending the curve will ultimately involve multiple solutions that include utilization management, payment reform, tort reform, care management, consumerism, attacks on fraud and abuse and and emphasis on increasing medical quality. That also means reductions in all types of medication errors.

The DMCB really likes Lahue et al's paper because most hospitals should be able to replicate much of this study's methodology using their own data bases. That means they can establish a baseline ("25 errors a day") and work to reduce it.  In the meantime, if CMS is truly interested in giving taxpayers their money's worth, they'll also be able to use this information to track this nationally and, perhaps, use it to develop additional value-based purchasing initiatives.

And patients and their families?  Next time they're at the business end of a needle in a hospital, they should wonder if that's one of the 25.  While they're doing that, they should also ask what the local error rate is and what's being done to reduce it.

Image from Wikipedia

Insights on Health Reform, Courtesy of Medical Home News

Getting more brainy
To the chagrin of the DMCB spouse, the Disease Management Care Blog serves for free on several editorial boards. In its estimation, it's well worth the time.  It's closer to breaking news, has met interesting colleagues, gets to read interesting manuscripts and has one more excuse to take a pass on sharing in the intensely engaging drama of Downton Abbey.

One such publication is Medical Home News, and the latest edition, thanks to a back-page "Catching Up With...." interview with former Deloitte executive Paul Keckley, did not disappoint. The DMCB has seen Dr. Keckley's smarts in person in several venues and the MHN piece did not disappoint. When he opines, the DMCB thinks.

Among his brainy insights....

The struggle to prove that the medical home saves money continues not only because there are many models serving many populations with many metrics.  In addition, "each prominent medical home promotes its model as uniquely effective."  The DMCB saw how pride of ownership and proprietary business models balkanized the early disease management industry.  PCMH advocates, you've been warned.

In "some form" ACOs will survive.  The road from where-we-are to where-we-need-to-be will need to include skills in managing populations on a "risk basis." If that's true, the DMCB provocatively wonders if that means that that ACO "form" will be some sort of HMO, which was very good at manging populations on a risk basis.  Time will tell.

The three things getting in the way of "value-based" care are 1) operational and infrastructure costs, 2) payer-provider agreement on how savings will be shared and 3) "the regulatory framework in the ACA and future laws that will define fair play in value-based purchasing."  At first glance, thinks the DMCB, makes sense until it ponders the irony of that 3rd one.

"Tranparency about prices means little."  It's all about networks, reference pricing and leveraging them to extract value.  The DMCB cannot disagree and is reminded that's how health care markets really work.

The biggest disappointment in health reform is how disconnected the consumer remains, while the biggest plus has been the advent of data-driven health care.  The DMCB wonders if the biggest disappointment has been the battering of the "big government" brand, while another plus has been the growth of the DMCB readership.  Time, naturally, will tell.

Image from Wikipedia

Tuesday, January 13, 2015

Medicare's Expenses Increased by 0.4%? Really? And It's All Because of the Affordable Care Act?

If you're the head of Google and you want to teach about the internet, North Korea is a swell place to visit.  If your goal is air travel safety, the 787 Dreamliner is the plane for you.  If you would like to get the puck from an opposing professional hockey player, saying "please" helps.  And if Medicare costs dip, the Affordable Care Act (ACA) obviously deserves the credit.

Writing on an HHS website, Richard Kronick and Rosa Po announce that 2015 Medicare expenditures per beneficiary grew only by 0.4% over the 2011 baseline.  They credit the ACA's value-based payment (VBP) system, attacks on fraud and abuse, reduced payments to Medicare Advantage plans, cutting hospitals payments and "innovation."

The Disease Management Care Blog isn't too sure about that.

1. This Kaiser Health News article notes the VPB program withholds 1% of hospital payments and uses that fund to award bonuses in what is really a zero sum game.  And this Health Affairs article suggests the overall financial impact of VPB on hospitals is quite minimal anyway. 

2. While there have certainly been some big fraud and abuse busts, there's plenty of reason to still be skeptical about the ability of Medicare's ossified bureaucracy to catch up with the sophisticated criminal enterprises that are routinely fleecing billions from the U.S. taxpayer.

3. As for the one-time payment cuts to providers and insurers, the DMCB is confident that they'll figure out ways to get their money back.  They always do.

4. The innovations are in demonstration phase.  It's too early to tell.

In addition, the DMCB is surprised that Medicare's 2015 insurance claims were ready to be rolled up and quantitated in early 2015. Check out this telling quote from the website:

"2010 and 2011 statistics are calculated on a calendar year incurred-basis. 2015 statistics are calculated on a fiscal year cash-basis, because calendar year incurred-basis data are not yet available." (bolding from the DMCB).

Last but not least, the DMCB believes the lackluster economy has probably had the biggest impact on consumers' willingness to use their Medicare benefit.  While Kronick and Ro state" Medigap" insurance benefits have protected the beneficiaries from the financial pain of Medicare's out-of-pocket expenses, the expense of using a hospital or seeing a doctor is more than the sum of all those medical bills.

Is the DMCB being too skeptical?  Perhaps, but this particular HHS spin is built on assumptions that are backed by associations that are biased by partisan loyalty.  Taxpayers deserve better.

Image from Wikipedia

The Disease Management Care Blog Annual Report: Three Insights on Social Media in Health Care

It's that time for the Disease Management Care Blog to reflect on the state of social media, both in general and for this blog. 

First off: an annual report for this blog.

Stats: While overall readership in 2015 was down compared to prior years (37,000 vs. 49,000 unique visits) the number of  "regular readers" (at least once a month) has increased from approximately 5000 to 5200.  And these DMCB regulars are a brainy bunch, with ISPs that include health systems, government agencies, policy shops, regional and national health insurers, population health service providers, hospitals, consultants, news organizations, organized medical societies, universities, pharma companies, health care trade associations, foundations, state as well as city governments and other bloggers.  The DMCB doubts many CEOs or SVPs are reading its bloggery; more likely it's front line managers, supervisors and other leaders who are looking for that extra insight.

It's also been a good year for the DMCB Twitter, with over 700 followers. They likewise reflect the spread of health care stakeholders described above.

What has the DMCB's learned in the last year?

A New Wrinkle on An Old Digital Divide: Health writers have pointed out that the socioeconomically disadvantaged and the hospitals that serve them have been unable afford the power of health information technology. Yet, many well-off health care organizations with knowledge and cultural disadvantages are likewise failing to leverage social media to build visibility and enrich their brand.  Some with established accounts are using them to achieve a competitive advantage, but far fewer have actually done anything useful with them.  The DMCB has listened and their silence is embarrassingly deafening.

Cloud Beats Complicated: While the dominant mainsteam media continues to get complicated medical and health policy news stories half right, the good news is that a collective "cloud" of critically thinking bloggers and twitterers are getting things completely right with an on-line wisdom of crowds. As news sources consolidate and their market power grows more concentrated, social media will come to the rescue.

Print and Social Media beat Print Alone: While the prestigious New England Journal has 200,000 subscribers, the DMCB doubts every published article has the same number of readers.  In contrast, Kevin MD has 100,000 readers and a million monthly page views.  To make a real splash, policy authors would be well advised to have their insights appear in both outlets; that's doubly true because the Digital Divide is likewise present in the medical community.  What's more, social media will place an increasing role in increasing awareness - and the implementation - of discoveries from research extending from the bench to the organization of care.

Image from Wikipedia

Friday, January 9, 2015

Is U.S. Health Care Really THAT Bad?

Is American health care that awful?  Listen to the pundits and it's easy to believe that other developed nations are blessed with 24-7 access to primary care, minimum out-of-pocket expenses and highly integrated electronic record systems and information sharing.

Cathy Schoen and colleagues from the Commonwealth Fund and Harris Interactive say it's not quite that simple.  While the U.S. system could be better and cheaper, there were some areas where is wasn't all that bad.

Their article was published in the December 12 issue of Health Affairs.

The authors conducted follow-up mail and phone interviews of primary care physicians from ten developed countries* who had previously participated in a 2009 quality survey.  Physicians were asked about topics that included their patients' access to care, use of health information technology (HIT) and satisfaction with medical practice. Sample sizes of interviewees from each country ranged from 500 to 2000 and response rates ranged from a low of 20% (Germany) to 48% (Netherlands).

Among the more interesting findings:

The majority of Dutch, French, German And Swiss docs are in clinics with 2 or fewer physicians.
86% of respondents from France said most patients can obtain same day access vs. 22% in Canada. The U.S. rate was 47%, which was higher than Norway and Australia.

The Netherlands (94%) and New Zealand (90%) led the way in access to after-hours care. The U.S. rate was the lowest at 34%.

59% of U.S. physicians said their patients had difficulty paying for health care.  At the same time, only 28% had long waits to see a specialist.  In Canada, the rates were 25% (payment) and 73% (specialists), respectively.  In Norway, 4% had difficulty paying but 60% had long waits for specialists.

Nearly all physicians in Australia, the Netherlands, New Zealand, Norway and the United Kingdom use electronic records.  The U.S. rate was 69%, while in Switzerland, Canada and France it's 41%, 56% and 67%, respectively.

The top four countries reporting that they had "engaged" a nurse case manager were the United Kingdom (78%), the Netherlands (73%), New Zealand (68%) and Switzerland (68%).  The rates in Canada, the U.S and Germany were 44%, 43% and 20%, respectively. 

Transfer of information about an emergency room visit or a hospital discharged occurred less than half the time in Australia, Canada, France, Germany, Switzerland, United States, Norway and the United Kingdom.

DMCB takeaways:

If other developed nations are role models for the U.S., large clinic systems are not necessarily the way to go.

There may be an inverse correlation between patients' ability to pay for care and access to specialist care.

The U.S. is in the middle of the pack when it comes to EHR use.

Nurse-led care manage is not uncommon overseas and a 43% rate in the U.S. is higher than generally realized.

Timely transmittal of emergency room and hospital discharge information seems to be a problem everywhere.


*Australia, Canada, France, Germany, Switzerland, United States, Netherlands, New Zealand, Norway and the United Kingdom

Thursday, January 8, 2015

Seven Things You Need to Know About 2011 Health Care Spending

If you're interested in learning more about the latest U.S. health care cost trends, everything you need to know is in this article in the January 2015 issue of Health Affairs.

Or you could rely on the Disease Management Care Blog to point out the article's 7 most important points.  Use them to impress your colleagues and stymie your foes:

1) The data only go up to 2011; we'll have to wait another year before we'll know about 2015.

2) 2011 health care spending, as a percent of gross domestic product, remained at 17.9%.  The overall economy was slow and that took its toll on the health care sector.

3) That comes out to $2.7 trillion or $8,680 in health care spending per person.

4) While the percent remained stable, the economy experienced modest growth in 2011. The health care sector, thanks to an overall growth rate of 3.9%, kept pace. Prices for services grew less than the demand for services.  As we grow older, demand is likely to grow.

5) Medicare and private insurance grew faster than the economy, which was offset by Medicaid cost cutting by the states.

6) If the past is any guide, when the U. S. economy rebounds, health care spending is likely to accelerate and resume its march toward becoming 20% of GDP.

7) The relative stabilization of 2011 health care costs is independent of the Affordable Care Act.  Many of its important provisions (such as the mandate) don't kick in until 2015.

Health & Human Services Office of the Inspector General: EHRs Can Facilitate Medicare Fraud

EHR fraud police?
Disease Management Care Blog readers are well aware that it is a nattering nabob of electronic health record (EHR) negativity. It not only has the professional scars from past encounters with these on-screen scourges, the DMCB's literature reviews suggest the impact of the EHR on quality is questionable and its ability to reduce costs is illusory In fact, there's evidence that it can increase costs and hike hospitalization rates.

In addition, the DMCB has repeatedly raised the phenomena of copying and pasting and zombie diagnoses that lead to bloated and inaccurate EHR notes.

Well, readers and detractors no longer have to take just the DMCB's word for it. Things are so bad that even CMS should be worried.

According to this just-released report from the Department of Health and Human Services' (HHS) Office of the Inspector General (OIG), "copy-pasting" and "overdocumentation" are increasing the rates of Medicare fraud.

The former can pepper the EHR with inaccurate information that leads to unnecessary testing and treatment, while the latter makes the work of patient care appear more complicated than it really is.

What's more, the OIG points out that while HHS has been very active (and remuneratively generous) in promoting EHR "meaningful use," it has done little to respond to EHR-enabled fraud. Short of a live human personally comparing multiple notes simultaneously, CMS and its contractors have no ability to systematically audit patient billing records. What's more, there are no consistent internal policies in place or agreement on what to do even if it is detected (such as payment suspensions, overpayment adjustments or referrals to law enforcement).

The DMCB's take:

It remains to be seen if this warning will lead the HHS bureaucracy to catch up with another unintended consequence of health information technology.  If it does, the DMCB is worried that CMS may take its cue from the hostile RAC audits and further alienate physicians. 

Time will tell.

Image from Wikipedia

Wednesday, January 7, 2015

Is $1 Billion a Good Investment for Disease Management? We May Finally Have an Answer

Take two of these and call for
savings in the morning
Anyone familiar with the history of disease management industry will almost certainly can recall Soeren Mattke's 2007 article that provocatively asked Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment? Based on what was known in the peer reviewed literature at that time, Dr. Mattke's answer was a desultory "uncertain," and he recommended that buyers of disease management services approach the industry's vendors with "skepticism."

Well, it took him seven years, but Dr. Mattke has finally agreed with the Disease Management Care Blog that investment in disease management can be good.  Writing in the January 2015 issue of Health Affairs, Dr. Mattke and other colleagues from RAND look at the impact of disease management involving thousands of employees at PepsiCo.

In 2003, Pepsi started an employee health program that included risk assessments, on-site wellness events, lifestyle management, disease management, complex care management, telephone nurse advice lines, and maternity management. By 2011, there were 5 telephonic lifestyle programs (weight management, nutrition management, fitness, stress management and tobacco cessation) and 10 telephonic chronic disease management programs (asthma, coronary artery disease, atrial fibrillation, congestive heart failure, stroke, hyperlipidemia, hypertension, diabetes, low back pain, and chronic obstructive pulmonary disease).

Of the greater than 67,000 Pepsi employee participants, 2,610, 17,432 and 2,162 persons with an average 6.4 years of participation in disease management, lifestyle management and both, respectively, were matched, using propensity scoring, to Pepsi non-participants. The two groups' insurance claims expense and absenteeism were compared.

Overall, all the participants had an average of $360 per member per year (PMPY) less cost compared to the non-participants. The participants' vs. the non participants' cost curves diverged and became statistically significant after 3 years

However, it turned out that the savings was confined to the disease management population, which had a lower cost of $1632 PMPY.  Participants in the lifestyle management had negligible savings.  Disease management had a return on investment of $3.78

Participants in both disease management and lifestyle programs had a savings of $1,920 per year.

Despite the lack of any impact on claims expense, lifestyle management was associated with a reduction in self-reported absenteeism of .13 days per year.  In contrast, disease management had no impact on absenteeism.

The DMCB's take:

This builds on the evidence (like this and this) that later generation, remotely based telephonic disease management can reduce claims expense.  $360 PMPY for $67,000 employees translates to more than $24 million in savings per year for Pepsi. Even if the company spent millions on its health programs, the impact is something that both the employees and shareholders can be happy about.

As skeptics continue to wonder at the continuing commercial success of the disease management (now called "population health") industry, the DMCB reminds them that many other companies like Pepsi are also looking at their return on investment. They undoubtedly like what they see, but unlike Pepsi, are not taking the time or effort to publish their results.  Pepsi, in the meantime, deserves kudos for their commitment to the science of population health.

That being said, this is a company sponsored disease management program that is limited to employees and dependents.  The DMCB is less certain about the impact of these programs in typical "free range" commercial or government insurance settings.

The study isn't perfect, because there could be hidden biases.  As the authors point out, even propensity matching can't guarantee that the two populations were truly similar; since participation was voluntary, it's possible that the participants were more health conscious and that characteristic - not the disease management - is what's responsible for the observed savings.


The Centers for Medicare & Medicaid Services (CMS) Gets Nudged to Do Something About Shared Decision Making (SDM)

Medicare tackles the shared decision
making requirement in the ACA
In a recent New England Journal of Medicine article, Emily Lee and Ezekiel Emanuel point out that it's high time for the Centers for Medicare and Medicaid Services (CMS) to wake up and do something about Section 3506 of the Affordable Care Act.

That's the section of the law that deals with "shared decision making" (SDM):

"The Secretary shall establish a program to provide for the phased-in development, implementation, and evaluation of shared decision making using patient decision aids to meet the objective of improving the understanding of patients of their medical treatment options...."

In particular, they argue that CMS should expedite the creation of an independent entity that would certify and implement patient decision aids and begin piloting SDM among Medicare beneficiaries who are contemplating having one of the 20 most frequently performed procedures (a list can be found on page 3).

And they don't stop there. 

They recommend that Medicare's coverage for the "top 20" should be made contingent on the documented delivery of SDM to the beneficiary

"To give such a requirement teeth, full Medicare reimbursement could be made contingent on having documentation in the patient's file of the proper use of a decision aid for these 20 procedures. Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."

In contrast to the NEJM readership, the thousands of regular visitors to the Disease Management Care Blog aren't surprised. They've known all along that "shared decision making was an important if unknown part of the Affordable Care Act.  To them it's not news that SDM is an evidence based approach that combines patient engagement with physician participation to optimize the utilization of potentially harmful therapies.

Pity that CMS leadership isn't regularly reading the DMCB.  Whether a NEJM article by one of D.C. health care mandarins spurs CMS to action remains to be seen.

Stay tuned!

Tuesday, January 6, 2015

A Runaway Steetcar Named Contraception Mandate

Here's comes the contraception mandate!
Consider the classic "trolley car" thought experiment:

There is a runaway trolley barreling down the railway tracks. Ahead, on the tracks, there are five people tied up and unable to move. The trolley is headed straight for them. You are standing some distance off in the train yard, next to a lever. If you pull this lever, the trolley will switch to a different set of tracks. Unfortunately, you notice that there is one person on the side track. You do not have the ability to operate the lever in a way that would cause the trolley to derail without loss of life (for example, holding the lever in an intermediate position so that the trolley goes between the two sets of tracks, or pulling the lever after the front wheels pass the switch, but before the rear wheels do). You have two options:

 (1) Do nothing, and the trolley kills the five people on the main track,

 (2) Pull the lever, diverting the trolley onto the side track where it will kill one person.

Which is the correct choice?

While this thought experiment has lived on through countless variations and even more debate, the Disease Management Care Blog was taught in a long bygone ethics class that the choices boil down to a utilitarian argument (pull the switch because five lost lives is worse than one lost life) vs. the moral argument (don't pull the switch because, in a situation for which you bear no responsibility, you have a personal duty to not sin by taking a life).

While the DMCB could ruminate on what the Fat Lady would advise, that's not the point here. Rather, the DMCB points out that philosophical choices are unsettled and that there is plenty of room for intelligent argument on both sides.

Which brings us to the Little Sisters of the Poor and their appeal over the Obamacare contraception mandate. 

As the DMCB understands it, this Catholic religious order wants to be exempted from the exemption process that requires the completion of a one-page "self certifying" form. The purpose of the self-certifying form is to allow organizations like Little Sisters to exclude birth control pills (the moral arguments on why it's regarded as sinful can be found here) as a covered benefit for its insured employees.

Completing that form would oblige the insurer, not the buyer, to provide access to contraception services that are mandated by the Affordable Care Act. After checking out pages 39877 and 39878 of the Federal Register, DMCB understands that Washington DC defends this "accommodation" as a cost-neutral solution (fewer pregnancies underwrite the cost of the contraceptives) and as a "administrative" cost that is spread across the risk pool. Accordingly, neither arguably obliges a Catholic organization to meaningfully participate in (pay for) what it regards as a moral sin.

But, says the DMCB, signing the self-certifying form triggers the accommodation which, in turn, leads to coverage of contraceptives. The Little Sisters of the Poor are, in effect, being asked to pull the enabling trolley switch.  Sure, it's not the death of innocents or the trading of lives, but the underlying parallels to the thought experiment still apply. These nuns are being asked to choose the lesser of what they regard as two sins and trigger the contraception coverage.

 In simplistic terms, these nuns are instead choosing a classic moral answer.

From an ethics standpoint, the contraception mandate is far more murky than it appears.

Two additional thoughts:

1.  The contraceptive mandate is a trolley car conundrum of the government's making. They're the ones that built the tracks and put the nuns - and other persons of conscience -  at the switch.

2. In that long bygone ethics class, the DMCB was confronted by a variation in the trolley care thought experiment. Supposed you were held at gunpoint and non-compliance also meant your death in addition to the death of five innocents?  The moral answer would be that your personal duty to do no harm to extends to yourself and you would need to take the bullet. 

That's why the DMCB fears that the Sisters are not going to cooperate even if the government legally prevails in overcoming their objections. They probably mean it and will go out of business.  To make a statement in the best tradition of civil disobedience, they could continue to provide services, refuse to pay the fines and go to jail. 

Yikes.

CODA: It turns out that the particular insurer is also exempt from the contraception mandate. That makes much of the Little Sisters' objections legally moot, but that's not the moral point.