Tuesday, March 31, 2015

Obesity Surgery in Diabetes Mellitus: A Three Year Trial Shows High "Cure Rates." The Implications for Population Health

In case there is any doubt about the long-term efficacy of obesity surgery for diabetes, check out this three year study that was just published by the New England Journal of Medicine. 150 persons between the ages of 20 and 60 years with an A1c greater than the recommended target of 7% and a BMI greater than 27 were randomly assigned to either gastric bypass, sleeve gastrectomy or intensive medical therapy. 8 persons dropped out after being assigned to medical therapy and one patient had their surgery cancelled. Over the next 3 years, 4 persons were lost to follow up.

Of the remaining participants, two thirds were women and three quarters were white. The mean age was 48 years, the average BMI was a prodigious 36 and the mean A1c was a poor 9.3%, with an average duration of diabetes of just over 8 years. 

Of the 40 medical patients, 5% ended up with an A1c of 6%, versus 38% of the 48 bypass and 24% of the 49 sleeve patients.  The average weight loss was 4.3 kg in the medical patients vs. 26 and 21 kg in the bypass and sleeve patients. While only 2% of medically treated patients were able to stop their diabetes medications, 69% and 43% of the bypass and sleeve patients were able to do so. Only four patients in the surgery groups required additional surgery for the treatment of complications.  None died.

The Population Health Blog finds the results compelling enough to believe that the surgical option for obesity-related diabetes mellitus may be turning out to be a first line option.  The complication rate is acceptably low and the "cure" rate of up to 70% (if defined as not having to take medications) is likely to be welcomed by patients facing a lifetime of otherwise chronic illness.


Critics may worry that any long-term economic benefits at a population-based level may be cancelled by the cost of surgery.  The PHB understands that, but doesn't believe that obesity surgery should be viewed through a "return-on-investment" lens.  Rather, the value assessment of "outcome" (in terms of diabetes and obesity cure) per unit of cost (dollars spent) is a as good as an investment compared to, say, coronary artery bypass grafting or a knee replacement.

Critics may also worry that obesity surgery is more of a symptom of an overfed society and that our national treasure would be better spent on understanding our dietary dysfunctions.  The Population Health Blog cannot disagree, but doubts that our national health spending can be wired so that every dollar spent on the promotion of nutritional wisdom will reduce the near-term health care cost crisis from diabetes.  We need to be prepared to invest in both.

Implications for Population Health

It appears to the PHB that this was a single site "efficacy" study involving an academic medical center.  We don't know if the low complication rate observed here is typical of other hospitals that offer obesity surgery.  In addition, this study did not examine the impact of the more popular approach of banding surgery.  That being said, this three year trial suggests that bariatric surgery should be offered in the suite of options for persons meeting the criteria above.

The good news is that shared decision making has already been evaluated in this setting.  While the majority of participants are more likely to chose conservative treatment, the point is that a 40-70% chance of cure over three years should be raised in the course of patient-centric coaching.  Population health vendors in the diabetes-obesity "space" should be prepared to engage patients on this treatment option and help them decide if surgery is the right choice for them.

Image from Wikipedia

Sunday, March 29, 2015

The ACA SCOTUS Legal Lexicon

As it navigated the miasma of the Supreme Court hearings on the constitutionality of the Affordable  Care Act (ACA), the Disease Management Care Blog struggled with a host of unfamiliar acronyms, catch phrases, nostrums, euphemisms and tweetisms. Since the DMCB cannot let any novel verbiage go unexamined, it is pleased to offer readers this ACA legal lexicon. The DMCB plans on using each of these terms once a day in the coming days so that its colleagues and enemies alike recognize its health reform chops.
Now you can too:

"Boatload" - a description by one Justice of the amount of cash available to the states, assuming that they go along with the Washington's expansion of Medicaid eligibility. It seems a "bloodbath" is what the states fear if coming shortfalls prompt future administrations to cut budgets while simultaneously insisting that the eligibility rules remain.  Also see "unfunded mandate."

"Cruel and unusual" - the specter of the Supreme Court Justics and clerks having to do what most of Congress never did: read all of the ACA. This was brought up during arguments over "severability" and how to invalidate various provisions. See "crimes against humanity" caused by having to read all the regulations that are currently being promulgated under the ACA.

"SCOTUS" - stands for the Supreme Court of the United States.  Two other US examples include "POTUS" (President of the United States) and "DMCBSOTUS" (Disease Management Care Blog Spouse of the United States).

"Train wreck" - a television reporter's initial assessment of the Administration's efforts to defend the the ACA before SCOTUS.  While one U.S. Senator thought the term was extreme, the DMCB says Mr. Reid should be of good cheer: it could have been worse.

"Bipartisan" - a remarkable rebranding of the ACA by a Presidential spokesperson after the term "train wreck" (see above) was widely quoted in the mainstream media.

"Burial insurance" - a foil used by one Justice to neutralize the debate over whether the government can compel citizens to buy broccoli. Everyone will use health care and everyone will also die, so is it both "necessary and proper" for the Feds to mandate burial insurance?

"Salvage job or a wrecking operation" - the two broad alternatives for SCOTUS as they grappled with the ACA. For another example of "salvage job," see "bipartisan" above; for an example of the latter, see Fox News.

Happy Friday!

Image from Wikipedia

The Latest Health Wonk Review Is Up!

Now that the Surpremes have retreated to chambers, it's time to dial back on the constitutionality "stuff" and turn our attention to other health wonk stuff.  That's why you may want to check out David Williams' Health Business Blog and its hosted postings on topics like the EHR, SGR, DNR, FFS and much much more!


Saturday, March 28, 2015

Reflections on Why Mr. Obama Needs to Adjust

Time to adjust
When the Disease Management Care Blog recently visited Capitol Hill to advocate on behalf of tort reform, it couldn't help but notice that one Congressman's office wall was festooned with multiple pics of him with former Presidents Bush and Clinton. Their open-necked shirts and silly grins were quite the contrast with a single White House holiday portrait with a stiffly smiling Mr. and Mrs. Obama.

That particular photograph was hung off to the side.

Which is why the DMCB was not at all surprised by The New Yorker report about our President's remote and sterile governance style.   While we can take some comfort in his fact-driven decision making, the no-drama Obama methodology of coolly processing the underlying legal, policy and political strengths and weaknesses is quite a contrast from the messy, interpersonal, shifting, intuitive and maddening style of his two predecessors.

So it should also be little wonder that Mr. Obama's methodology can lead to remarkably legalistic decisions like trying Mr. Khalid in civil court, giving the EPA jurisdiction over CO2, signing the Dodd Frank legislation and embracing the Affordable Care Act (ACA). In each case, dissent was just a factor to be considered, disagreement a matter of misinterpretation and the decision the final product of reasoned judgment.

Which brings the DMCB to the Supreme Court's rude intrusion over the constitutionality of the ACA.  The DMCB thinks that a watershed moment in this POTUS-SCOTUS narrative was when the President berated the Supremes to their faces during the 2010 State of the Union address. While there may have been some political theater involved, it seems Mr. Obama was also genuinely annoyed that his manifest logic hadn't prevailed. After all, since his decision-making is so right, the judges must have been so wrong.

Unfortunately, many of Mr. Obama's supporters have taken that attitude to a whole new style of hubris. When the ACA passed and the Tea Partiers registered their initial objections over notions of constitutional liberty, they were dismissed as either wacky radicals or dullards incapable of understanding the enlightenment of a supremely rational system. Even when conservative lawyers began to swarm in the lower federal courts, the consensus was that theirs was poorly conceived long-shot that was motivated by bad ideology.  Even when the contrary lower court opinions began to accumulate, The Obama Posse et al showed no second thoughts.

What a difference three days makes. If the SCOTUS observers' reports are any guide, the ACA opponents are within credible striking distance of overturning the mandate and gutting the entire law.

Which leads the DMCB back to Mr. Obama's holiday photograph.  As the SCOTUS imbroglio plays out, it is times like this when Presidents pause, reflect, reconsider and adjust.  This is a time when doubt, second-guessing and 'what-did-I-get-wrong' steps in.  Smart people learn from it and become better decision-makers.

While a gauge of that will not necessarily be a new informality portrayed in pictures on Capitol Hill office walls, the DMCB and other voters will be watching to see what the President and his supporters have learned from this. The DMCB will be on the look-out for a more flexible and nuanced accommodation of contrary points of view that may not fit with a scrubbed lawyerly and political calculus.

The DMCB thinks that will be the true measure of our 44th President. What's more, that'll be how many other messy, interpersonal, shifting, intuitive and maddening Americans decide to vote for or against him this fall.

Friday, March 27, 2015

How Can Care Management Respond to Patients' Spiritual Concerns?

The Disease Management Care Blog remembers her well.

She knew it was not going to be good news.  That gnawing pain in the pit of the stomach was getting worse and, when the whites of her eyes turned yellow (for example), she knew she had to see the doctor.  The CAT scan confirmed what the DMCB already knew: it was cancer and it was going to kill her in a matter of months.

In the months of DMCB follow-up, the patient talked about her pain, other docs, family, regrets, treatments, comforts, side effects, new limitations, waning appetite, getting skinny, numerous fears, dying and, yes, religion.  Aside from taking a few seconds to drag a stethoscope across her chest or poke at her scarred abdomen, the DMCB mostly listened.

It sat still and listened.

In retrospect, the DMCB was using a long-used strategy of  patient centered empathy.  As a nonegoic counselor, it was enabling the patient to think aloud with a non-judgmental listener and "process" a new reality.  While economists can only speculate on the "impact on claims expense" or the "return on investment," this is a low-cost and high value health care intervention.  It's also a way to accommodate, use and even share in patients' religious and spiritual needs.

Unfortunately, this kind of counseling is also time consuming.  While surveys show that mainstream providers believe in active listening and being engaged in patients' spirituality, perceptions over "professional role conflicts" make actually doing it in a busy clinic another matter.

The DMCB suspects the same ambivalence is present in the care management provider industry.  The DMCB has seen vendor nurses in action, and while their counseling protocols include "readiness for enhanced spiritual well-being," the ability of a telephonic nurse-counselor to meaningfully provide high impact and spiritual listening probably varies from individual to individual.  Long telephone queues make actually doing it another matter.

And the same is true in patient-centered medical homes, where non-physician professional team members are assigned the task of patient counseling in their day-to-day care and case management.

Which is why the DMCB likes community-based organizations like Someone To Tell It To.* When patients are facing a life-altering disease or complication, they often seek guidance that not only falls outside the narrow evidence-based protocols that drive care management, but the interests, ability or beliefs of an individual counselor to offer it.  In a classic "build or buy" decision, companies can develop this resource on their own (perhaps by designating an in-house provider with special skills or interest in this sort of counseling) or "outsource" and referring the patient. 

While it may seem awkward to "outsource" this kind of counseling, the DMCB has examined the rise of health care outsourcing here and here.  If Someone To Tell It To can help patients being followed by care management providers, medical homes or ACOs, why not refer them? 

Why should this important facet of patient care be any different?

*Disclaimer: the non-salaried DMCB spouse serves on STTIT's Board of Directors.

Bariatric Surgery to Cure Diabetes: Two Compelling Studies But There Are Still Four Reasons for Healthy Skepticism

A cure for diabetes?
Mrs. Jones (name changed) was obese. Her weight remained persistently high despite education and entreaties about diet and exercise. She hated taking all those medications. She dreaded bathing suits.

And then.... she had bariatric surgery. She shed pounds faster than Supreme Court justices spanking a health insurance mandate. Instead of having a corpulent and unhealthy patient, the Disease Management Care Blog had a svelte and healthy patient.

Based on witnessing first hand patient transformations like this, the DMCB knows that bariatric surgery for obesity works.

Despite clinical anecdotes, however, obesity surgery skeptics have pointed out that the evidence has been marred by the lack of any prospective randomized clinical trials. Looking backwards at outcomes data can't rule out the possibility that something else was going on to account for the surgery's apparent success. Most of all, this includes self-selection bias where patients, who are destined to independently do well, select surgery. By leaving assignment to chance, docs and patients are out of the decision-making. This randomization helps researchers be more confident that the surgery, and nothing else, accounts for any observed outcomes.

Enter the New England Journal of Medicine, which published the results from two landmark prospective and randomized trials that compared obesity surgery to conservative medical management:

1. Geltrude Mingrone and colleagues screened 72 and then randomly assigned 60 diabetic persons with a BMI of 35 to either a) conventional medical therapy (targeting an A1c of 7% using a multidisciplinary team with visits every 3 months for a year and then one additional visit at two years) or b) gastric bypass or c) biliopancreatic diversion.  The study occurred at Rome's Catholic University. Follow-up lasted two years. At the end of the study, 56 patients' data were available for analysis. 15 of the 20 patients who had gastric bypass, 19 of the 20 patients who had the diversion and zero of the medically treated patients were off diabetes medications and had normal blood glucoses. As expected, surgery resulted in a whopping decrease in the BMI down to approximately 29.  In contrast the mean BMI was 43 in the medically treated group. Two patients had the surgical complications of hernia and obstruction

2. Philip Schauer and colleagues screened 218 patients and randomly assigned 150 diabetic obese persons with BMIs ranging from 27 to 43 to either a) medical therapy (life style counseling, weight management home glucose monitoring and medications with diabetes specialist clinic visits every three months that targeted an A1c of 6%) or b) "Roux en Y" bypass or c) sleeve gastrectomy. The study occurred at Cleveland Clinic. Follow-up lasted one year and 140 patients' data were available for analysis. 5 of 41 patients in the medical therapy group vs. 21 in the 50 assigned to gastric bypass and 18 of 49 who had the sleeve achieved the A1c of 6%. What's more, most of the surgery patients who achieved the targeted A1c were off all diabetes medications.  As expected, the surgery groups decreased their BMI down to the 26-27 range, while the medically treated patients' BMI remained essentially unchanged.  In contrast to Rome, there was a wider range of complications that included 4 reoperations and 1 patient that developed a gastrointestinal leak with peritonitis.

Based on these data plus less pristine studies, its clinical experience and common sense, the DMCB is convinced that bariatric surgery works. These two studies are an important step forward in building the case for the use of this approach in persons with obesity and diabetes.

That being said, there is still room for some skepticism. That lingering doubt could be enough for a commercial insurer to limit coverage. It may be enough to prompt a PCP to recommend that an obese patient with diabetes should still hold off on surgery a bit longer. It may be enough for patients and families to wait another year until there are more confirmatory studies.

Here's why:

1. The studies were not "blinded." The purpose of "blinding" is to keep patients and doctors from being swayed by a "placebo effect." While that's intuitively silly, there is a possibility that having abdominal surgery made those patients believe they were going to lose weight and be cured of diabetes. After all, sham surgery has been known to help angina chest pains.

2. The studies are not necessarily "generalizable." Both studies were conducted by teams of surgeons from single institutions. While we can take Rome and Cleveland's word for it, we don't know if obesity surgery done at Bumkinville's Our Mother of Holy Deficit Hospital will have the same success and low rates of complications.

3. Speaking of complications, both studies were not adequately "powered" to fully assess mishap rates. While there were small single digit differences in the rates of complications, the small numbers may not tell the whole story. Having more patients enrolled in these studies would have increased the ability to meaningfully quantify all the possible bad outcomes.  That was one of the lessons of the Vioxx catastrophe.

4. Last but not least, the success of the surgery may have been inflated by the relatively poor performance of the non-surgical comparison groups. We know very little about the "intensity" of the medical treatment, other than they had the benefit of accessing a multidisciplinary clinic every three months. Population health management experts know that lifestyle change requires an intense program that includes engagement in a personalized and multidimensional care plan that includes far more frequent in-person and telephonic coaching. We don't know if the medical therapy group achieved this level of excellence.

Despite these limitations, however, the DMCB is more convinced that, for patients in whom nothing else works, bariatric surgery can reverse diabetes.

Thursday, March 26, 2015

ACO Market Dominance: What's Happening At the Local Level?

ACOs and insurers discuss terms
The Disease Management Care Blog likes to think of itself as having achieved "critical mass." Now that its readership has climbed into the thousands (and Twitter is now well beyond 600), medical meeting organizers want to issue press credentials, medical journals are sending it embargoed previews and spammers are working particularly hard at getting maliciously-linked comments posted. The best upside for the DMCB, however, is its email correspondence with smart professionals who have insights that run contrary to the mainstream's confirmation bias.

Here's a gently edited email from one astute observer that the DMCB wanted to share:
While policymakers extoll the clinical integration virtues of ACOs and the PCMH, what goes unmentioned is that these vehicles often involve provider consolidation. While coordination of care and wasteful utilization might improve, does this mean that those entities could also amass considerable market leverage or become quasi-monopolies? Could that drive up costs?

I was at an specialty provider conference in early March where it was cited (in an admittedly unscientific member poll) that 25% of institutions surveyed had themselves been part of a consolidation or site of service change, mostly from community private practice to hospital-based setting. If physicians are not being employed outright, they're entering into professional services agreements (PSAs).  Since this has to increase negotiating clout with insurers, the other locally competing providers are responding with an in-kind physician arms race.

Given this dynamic, what will happen when a system has a become a very efficient ACO and controls primary care with a locally dominant medical home network? Even if they fail to show any cost savings, will their ability to command favorable contracts be the key to economically surviving? Darwin would be proud of these long-beaked birds.

Are our federal and state governments prepared to reconcile the twin needs of integration and competition? I can’t help but think that regulators will be outmaneuvered by these increasingly powerful health care entities and that an unintended consequence of reform will be the increasing price points and the return of sticker-shock health care inflation.

Need an example of what is going on at the local level? Check out St. Luke's in Idaho and their ongoing battle with Trinity. St. Luke’s is a CMS designated ACO (on page 33) and is buying up assets left and right, employing physicians, and doing so in almost a direct anticompetitive way. I think that currently St. Luke's is doing a lot of forward thinking things, but if St. Luke prevails and Trinity does indeed go out of business as they state they will, it will leave a monopoly in that mostly rural state. When that happens, St. Luke's can set the price point.  Will they use that power to coordinate care or maximize revenue?

Believers in ACOs and the PCMH would do well to take a look at the Trinity perspective.

You Have A Great Population Health Program. Time to Tell the World About it. Here's How.

The Population Health Blog feels your pain.

You're the co-leader of a population health initiative.  It may involve an mHealth app, a new decision support tool, a novel care management nurse training program, a community-based intervention, a new type of telephonic outreach, a web-based messaging system, a new way of engaging high risk patients, relying on lay-persons for patient education, a different approach to predictive modeling, a better way to support the patient centered medical home or a report on the benefits of "big data."

You have outcomes.  They may be decreased costs, increased quality, higher levels of consumer satisfaction, lower absenteeism, better presenteeism, medication compliance, enhanced experience of care, lower utilization, better accuracy or something else.

You want to tell the world about it.  That's because it will help like-minded colleagues take better care of patients, convince policymakers that population health is beneficial, differentiate your company against the competition, generate some contructive feedback or get you an excuse to travel to a warmer climate.

And now you can. If any of the above applies to you, or even if it doesn't, you may want to check out The Population Health Alliance Forum.  In addition to its usual tradeshow networking, learning, dinners and fun, the PHA Forum is the place were programs get to strut their stuff.  As an added bonus, it's possible that you'll get to meet the PHB!

The Forum meets Dec. 10-12 in warm sunny Scottsdale AZ.
The link that leads that gives you the information you need is here

You have until April 8.

Mandates, Pink Slime and Surreptitious Patient Recruitment for Disease Management

The opening Supreme Court Affordable Care Act (ACA) deliberations focused on the obscure 1867 Anti-Injunction Act and whether the mandate is a "tax." It's not until the day two of arguments that The Nine Lawyers will take on the "individual mandate."

While the Disease Management Care Blog delights in the mandate's constitutional dilemmas, it also knows that the provision does nothing about the United States' health care cost dilemma.

That day of reckoning yet awaits.

Obliging more health persons into the insurance "risk" pools is fundamentally an exercise in spreading the same risk and health care costs over a larger population. While individuals may see their health insurance premium decline thanks to more persons paying into the system, the total consumption of health care services has no reason to slow down. A mandate by itself will not reduce costs.*

Speaking of saving money, the omnivorous DMCB, spent some of its teenage years living on a country farm. The family did its own butchering and, never leaving anything to waste, did everything it could to use every scrap of meat. As far as the DMCB is concerned, "pink slime" a.k.a. "boneless meat trimmings" is a virtuous confluence of that same thrift on an industrial scale combined with centrifuges and ammonia. Talk about a slaughter.

Last but not least, the DMCB got one more population health management insight from Charles Duhigg's book The Power of Habit. In it, Mr. Duhigg describes how Target's brainiacs discovered an association between the emergence of new buying habits in young women and early pregnancy. While that classic exercise in predictive modeling is not new, what happened next was insightful: creeped out Target customers pushed back when they unexpectedly started getting maternity and baby product coupons. In response, Target learned to camouflage its recruitment efforts by disseminating its coupons with random and unrelated product offers. The DMCB wonders if the same surreptitious approach could somehow be adapted to recruit high risk patients into population health management.  $5 toward text messaging if we can ask you some questions about your wellness.... and diabetes.

*Assume for a moment that 90 persons have health insurance which costs $500 a year.  That "pools" 90 x $500 or $45,000 in resources that are available pay for persons that need to be in a hospital.

Then assume 4 persons get sick - one gets appendicitis, one is involved in a car accident, one gets gets an infected paper cut  and the last one neglects to follow a DMCB spouse preventive health recommendation and gets what he deserves.  If the average cost per hospitalization is $10,000, the total cost is $40,000.  That leaves $5000 left over.

Cost of the insurance for each of the 90 persons: $500.
Cost of the illness for each of the 90 persons : $444.
Total amount of money going to the insurance company: $45,000.
Total cost of the illness: $40,000.
Amount that goes to the insurance company's bottom line: $5000

One year later, the 90 persons realize that there are ten persons living in their community who are not buying insurance.  Assume these freeloaders are healthy.  The 90 persons have a majority and pass an ACA with a mandate.  Over the next year, four other persons get sick again.

Cost of the insurance for each of the 100 persons: $500.
Cost of the illness for each of the 100 persons : $400.
Total amount of money going to the insurance company: $50,000.
Total cost of the illness: $40,000
Amount that goes to the insurance company's bottom line: $10,000

Of course, it's more complicated than that.  Of the ten forced to buy insurance, some have preexisting conditions and the cost of a hospitalization rises year after year, but that doesn't change the basic math underlying a mandate: total health care costs are the same, but they're spread over a larger base population.

Patient Centered Primary Care Collaborative Webinar: Care Coordination & the Patient's Role in Shared Decision Making and Team Communication

Mark your calendar!

If you're interested , click here.

Wednesday, March 25, 2015

More JAMA Drama: The Medical Home Reduces Costs, But Only For High Risk Patients

A medical home
Just when the Population Health Blog decided to take a break from all the JAMA drama, along comes this study "Medical Homes and Cost and Utilization Among High-Risk Patients" that was just published in American Journal of Managed Care (AJMC).

It cannot resist.

As readers will recall, the offending JAMA article described how a large three year-long Patient Centered Medical Home (PCMH) multi-payer pilot involving approximately 64,000 patients failed to reduce health care costs or increase quality. The pilot program was called the "Chronic Care Initiative" (CCI), and was the brainchild of then Governor Rendell's reform-minded "Prescription for Pennsylvania."

In the AMJC study, 6940 "intervention" patients with a) at least 3 months of primary care physician follow-up, plus b) at least 6 months of assignment to one of the medical home practices were retrospectively compared to 6940 similar "control" patients from a single non-participating practice. The control patients were matched using "DxCG" risk adjustment software* that was combined with propensity matching.

Pediatric practices were excluded, as were outlier patients with more than $100,000 in medical expenses.

In addition to looking at those patients, the top 10% of risk DxCG patients from the medical home (654 patients) were compared to matched high-risk non-medical home practices (734 patients). 

The analysis was complicated by the later attainment of NCQA medical home recognition among some clinics that were taking some of the control patients.  This limited the pool of patients in the 3rd year to just over a thousand in both arms, and just over 100 patients in the high risk groups.


There was no difference in the evolution of health care costs among all patients included in the analysis.  This confirmed the JAMA drama.


For the top 10% high-risk patients, there were reductions of 61, 48 and 94 hospitalizations per thousand over each of the three years study. This was accompanied by a difference of the per member per month (PMPM) inpatient costs of $115 and $62 in years 1 and 2.  While there was also an increase in outpatient specialist visits, the downward change in inpatient utilization drove the difference in combined overall costs in years 1 and 2 of $107 and $75 PMPM. 

All these differences were statistically significant.  The 3rd year was not because there were too few patients to achieve statistical significance.

While the study was retrospective, the matching methodology is credible enough for the peer reviewers of AJMC and for the PHB. Using control patients from just one clinic is problematic, but no study is perfect. 

Which brings us to the punchlines:

1. Two years ago, the prescient Population Health Blog described how modern Ver. 2.0 "disease" (better described as "population") health management can financially succeed.  It said that one key ingredient is risk segmenting the population and targeting services at the highest risk patients. This AJMC article says it was right.  Most patients won't benefit, but vulnerable patients will.  They are the PCMH's customer.

2. The AMJC article also comports with an accompanying JAMA editorial that is discussed here.  As the PHB quoted, the JAMA drama....

".... has done a great service for the advocates of the Patient Centered Medical Home by effectively ending promotion of this care model as a generic, low-level, unselective approach to health care delivery for all.  The next critical phase of PCMH development should focus on its strategic deployment for the care of high-utilization patients...."

* This uses "linear additive formulas obtained from ordinary least squares regression to combine expenses associated with clinical groups and demographic factors to generate predictions." Wasn't that easy?

Showdown at the SCOTUS Corral

Past decisions have been reviewed. The briefs have been filed. The mock practice sessions are over.

It's time.

March 26 will kick off an epic three days of Supreme Court hearings that will not only examine the fate of a sweeping once-in-a-lifetime health reform bill, but tackle far larger constitutional questions about states' rights and the role of government.  And nine lawyers, who have never taken care of a patient, had a bill rejected by Medicare, got paid pennies on the dollar by Medicaid or listened to an insurer's on-hold muzak will vote yea or nay on a badly crafted and complicated law that is stubbornly resented by half of all Americans.

Disappointed?  So is the Disease Management Care Blog. 

But that doesn't mean we Americans won't eventually work something out.  Former HCFA Administrator Gail Wilensky seems to agree with that perspective in this recent article.  As health reform continues to evolve with or without an intact Affordable Care Act, it is apparent that four broad areas of bipartisan consensus are emerging over how to address Medicare's looming insolvency:  

Sorry, Millennials, slowly increase the Medicare eligibility age up from age 65 to age 67 or beyond. While this ultimately transfers the cost of health insurance from the Feds to private insurance, it'll help the deficit.

Soak the Rich by tying the amount of out-of-pocket expenses such as the premium, co-pay and deductibles to income.  We're going to do that in other areas of the tax code, so why should Medicare by any different?

Double Down on SGREven though the SGR has been a colossal exercise in political fecklessness, that doesn't mean that Medicare's overall budget can't continue to be tied to economic targets like GDP.  One factor that's been driving this is the realization that, thanks to a tepid economy, Medicare's per capita growth over the last few years has been paralleling the GDP quite nicely. Why not pass a law and make it so.... forever?

A new form of vilification: "fee-for-service."  Like the terms "axis of evil," "WMD" or "Celine Dion," the FFS moniker is quickly turning into a payment methodology uniformly loathed by both sides of the aisle.  Expect expansion of other payment methodologies such as bundled payments and modified capitation.  This is good news for the population health and disease management vendors, which are typically funded through these types of arrangements.

In other words whatever SCOTUS does and no matter who the President is and who controls Congress, it's very possible that consensus could arise over one or more of the four policy areas described above.

It's far from over.

Image from Wikipedia

Physician Survey Shows Docs Prefer ACOs for Their Market Clout, Not Quality

Physicians climb aboard the ACOs
Talk about spin.

Deloitte has released its 2015 Survey of U.S. Physicians that examines attitudes about health reform and the current practice environment. A random sample of 20,472 physicians from the AMA's master file of physicians were invited to participate.  While only 613 (a 3% response rate) surveys were returned, the DMCB thinks the results are intuitively credible. 

What was interesting was how the Deloitte writers chose to report the data.

Most interesting was the description of physician attitudes about accountable care organizations (ACOs).

Here's Deloitte's word-for-word reporting:

"Physicians report that accountable care organizations (ACOs) will be successful to some extent in achieving improved quality (introduction of performance reporting and benchmarking, 37% better identification and closer management of high-risk patients, 28% and improved population health, 21%) and reduced costs (use of lower-cost treatment settings and providers, 21%)."

Exsqueeze me, but this makes the DMCB believe that a majority of respondent physicians do not believe ACOs will be successful in performance reporting and benchmarking (63%), better high risk patient identification and management (72%) or population health (79%). A similar large majority (79%) do not believe cost savings will be be achieved.

So, asks the DMCB, if the numbers are so dreary, why are physicians apparently flocking to work in ACO settings?

Says Deloitte:

"However, physicians currently working in ACOs diverge from those not in ACOs in their views on capitation bundled payments and Medicaid reimbursements. Three in 10 physicians currently working in ACOs chose to work in an ACO environment with high-quality, evidence based care standards."

So only a minority (30%) of physicians are attracted to ACOs' claims that they offer high quality and evidence-based care settings?

That's right.  Read on.....

"Physicians identify the trade-offs between larger (e.g., large medical groups, health systems, hospitals, and health insurance plans) versus solo practices. Larger practices are perceived to be better placed to secure superior third-party payer contracts and offer the greatest financial success potential, whereas solo practices are perceived to offer greater clinical autonomy. Larger work settings offer better conditions for contracting with third-party payers (89 percent of all physicians feel this way) whereas clinical autonomy was a valued feature of and more likely to be a feature of solo practices (81 percent of all physicians)."

In other words, when it comes to the grand convergence of physicians and ACOs, it's not about quality and efficiency.  It's all about giving up clinical autonomy in exchange for income preservation and the market dominance that leads to local negotiating clout.  

The finding - albeit in an imperfect survey - that few docs who work in these settings have faith in the promise of increased quality or efficiency does not bode well for ACOs.

Stay tuned! 

Tuesday, March 24, 2015

Ten Things to Know About the mHealth App Ecosystem.

A mHealth app walled garden:
enter at your own risk?
If, like the Population Health Blog, you're interested in the hand-held mHealth app ecosystem, you may want to check out this just published JAMA review article "In Search of a Few Good Apps." 

Naturally, for time-pressed readers who'd rather not read it all, your PHB is happy to provide this ten point summary.

1) There are more than 40,000 of mHealth apps and the industry is still in its infancy.

2) Despite their faddish sexiness, there is very little hard evidence that many of the commercially available apps to lead to measurable improvements in clinical or economic outcomes. However, some of the underlying technology (such as pedometers) does provide a benefit.

3) The Food and Drug Administration (FDA) will assert its regulatory authority if the app "acts" like a "medical device" or as an accessory to a "medical device." Logging data, retrieving content or communicating won't be regulated, but medication dosing guides or the provision of diagnostic information will be.

4) 3) Little is known about the physician prescribing patterns for apps.  We also haven't figured out if or how a patient's access to an app should depend on a licensed professional's approval/prescription.

5) There is a possibility that many currently available apps are putting users' privacy at risk.

6) Little is known about apps' compatibility with electronic health records (EHRs).  This may be less of an "ecosystem" and more a bunch of isolated "walled gardens."

7) One vulnerability to any app's usefulness is data overload. Hundreds of food entries, for example, may do little to increase user insight about his or her diet.

8) Other than the FDA and its fussing over apps' medical "deviceness", there is no agency or entity that provides certification for apps. Consumers are on their own, based largely on on-line reviews and word of mouth.  One organization tried to do it and conspicuously failed.

9) The time is right to create "guidelines" for app developers, such as how to provide useful data summaries as well as visual displays, maximize patient safety, ensure information accuracy and protect consumer privacy.

10) The time is also right for funding agencies to support research on apps, especially for persons with chronic illness.

Naturally, the PHB offers commentary:

It remains to be seen if the FDA can keep up, especially with apps that are in the "grey zone" between offering advice/possibilities vs. diagnosis/treatment. That shortcoming is vulnerable to overlawyering and regulatory overreach. That means prolonged time to market, increased uncertainty, hampered innovation and the threat of retroactive and potentially capricious reviews.

As you are reading this, many apps are undoubtedly being developed by the population health service providers.  It may be time for entities like the Population Health Alliance or stakeholder organized medicine organizations to take the lead in establishing app benchmarks, best practices and guidelines.  If they don't lead on this, someone will do it to them. 

While vendors that offer apps along with their coaching may be inclined to regard them as proprietary and shield them from the scrutiny of peer review research, apps that are proven to improve outcomes will ultimately rise to the top.  It's not just the funding agencies but the companies that offer these apps that have a stake in "proving it," while also advancing medical knowledge for the betterment of all of us.

Finally, wouldn't it be neat if there was a generic mHealth app that could be used by medical homes to facilitate nurse-patient coaching, link the patient to the EHR and enhance communication with providers?  If there is one that the PHB isn't aware of, it wants to know about it.

Image from Wikipedia

Sunday, March 22, 2015

A Law That Won't Get No Respect

Talk about a law that won't get no respect. The President is quietly ignoring the Affordable Care Act's two year anniversary while leaving it to the controversial Ms. Pelosi to apply her unique rhetorical style to its defense. To add insult to injury, the U.S. House has just voted to repeal a signature feature of the law, the Independent Payment Review Commission (IAPB). If the repeal weren't linked to HR 5's medical malpractice reforms, there's a chance that enough of Mr. Obama's Democratic Senate would abandon him and force a Presidential veto.

The late Rodney Dangerfield would have a lot to say.....

"When ACA supporters talk about the ACA, they have to wear two paper bags over their heads... in case one falls off!"

"When the ACA passed, critics said it was unaffordable.  It's supporters wanted a second opinion, so that's when the critics said it's unconstitutional too!" 

"One ACA supporter told his psychologist that ever since he voted for the ACA, everyone he knows hates him!  He said he was being ridculous - not everyone knows that he voted for it!"

Happy Friday!

Saturday, March 21, 2015

Electronic Health Records, Cue Destruction, Reordering of Habits and Medical Quality: A Look at Charles Duhigg's Book on "The Power of Habit"

Habit destruction
While the peer-reviewed medical literature on the electronic health record (EHR) continues to be populated with lukewarm articles like this, the Disease Management Care Blog has been reading Charles Duhigg's interesting book on "habits."

According to Mr. Duhigg, it's the basal ganglia that warehouse the complex behaviors that allow the DMCB to brush its teeth, back a car out of the garage and nod at the DMCB spouse without really "thinking" about it. All it takes is a "cue" that signals that a behavioral sequence can begin that, when it is completed, results in a "reward."

The DMCB thinks of it as a labor-saving device for its grey matter. It "outsources" activity that would otherwise take a lot of effort, like figuring out every time it time it encounters a door that the secret to managing that nob involves firmly grasping it and then rotating it.

Such "habits" can be either good or bad.  Cues (such as walking in the door at 5 PM) can prompt humans to unthinkingly respond by donning jogging sneakers or opening a can of Pringles that in turn lead to either to endorphin rush or resolution of the munchies.  And it is this link between seemingly innocuous cues and habits the forms the central theme of Mr. Duhigg's book:

If you, your spouse, or your employer wants to alter your behaviors, the answer may lie in finding those underlying cues and replacing them.

Which brings the DMCB back to the EHR. Talk to any physician who has made the transition from a paper record to an electronic record and he or she will tell you that it is an ordeal. Patient throughputs decline, clinic work flows are reordered and doctor-patient interactions have to adapt to the intrusion of a keyboard and monitor.

In other words, it is a perfect environment for upsetting the baseline "cue" applecart that drives a clinic's good and bad habits. Silent but all important prompts that lead to and guide previously established clinical "routines" like medication list reviews, assessing allergies, performing a physical exam or ordering imaging studies are blown away and replaced with a new equilibrium. Providers, aware that they need to increase quality, develop new cues and habits in response to the chaos of an EHR installation.  It's not the EHR itself.

The DMCB wonders if the "cue destruction" may be one explanation for some of the EHR's successes. As noted here, a "successful" EHR install involves a "redesign of clinical processes" that likely forces providers to relearn countless hidden habits.  Since cue destruction is not an explicit and conscious part of the typical transition from paper to computer, EHR installs are likely to vary in terms of their impact. Some are easier and less intrusive than others.

Two conclusions:

1.While the EHR itself with its reminder prompts, decision support and quality improvement routines may lead to increases in quality, another basis for its success may be in its ability to force "cue" replacement and the alteration of old physician habits.That's not necessarily bad, but it is very unintentional. This could explain why the EHR's impact on clinical quality performance has been decidedly spotty.

2. This may warrant additional research. While a prospective randomized clinical trial examining the impact on quality or habits would be daunting, the design could include an EHR install in one arm and a totally rearranged paper record in the other. Alternatively, regression analytics could be used to assess whether the level of chaos associated with a new EHR purchase is an independent predictor of downstream quality.

The Latest Cavalcade of Risk is Up

While we ponder Wisconsin's chances against Syracuse in the Sweet 16, Jason Shafrin of the Health Care Economist Blog has won with the latest version of the Cavalcade of Risk.  The DMCB is pleased that its amateur posting made it past Jason's scrutiny. 

You'll be pleased with all the links to insights and news about business-related risk that you wont' get anywhere else.

Friday, March 20, 2015

A Seven Step Recipe for Making Money With Modern Disease Management

The Disease Management Care Blog, based on vast experience, occasional consulting gigs, the peer-reviewed literature, informed opinion and late-night beverage-fueled conversations is pleased to offer this seven-step Recipe for Making Money With Disease Management:

1. First off, notify the physicians about your plans using a variety of communication channels such as meetings (food helps), memos emails and announcements. Establish an physician advisory committee and reward them for their effort. Most importantly, never ever ask any physician anywhere to alter his or her clinical work flows. Set aside.

2. Next, identify the population. This may be all persons in a service area, employees plus dependents, those being served by a clinic, having a particular diagnosis or assigned to an Accountable Care Organization.

3. Obtain one nurse for between every 800 to 1500 patients in your population. Leaven with primary care experience, top of license, connectivity, protocols, mobility, telephonic as well as face-to-face patient coaching and a full time dedication to the task at hand. Avoid hiring refugees fleeing the ICU 11-7 shift. Set aside.

4. Knowing that as a covered entity that you will protect personal health information, obtain, array and organize all available clinical and/or insurance claims data on that population. This may involve mining an EHR, extracting insurance claims information or conducting a health risk survey. Place on a server or a cloud.

5. Applying a variety of statistical methodologies to the data, risk segment the population for an outcome of interest such as (but not limited to) hospital admission, high expense or high primary care use.  Mix thoroughly.  This will allow you to identify those individuals at greatest future risk.

6. Return to the nurses. Assign one nurse to one or more physicians (or clinics) and have the nurses contact and assess the patients in those clinics who are highest risk.  For those with modifiable risk, engage, educate, coach and collaborate.  For those without modifiable risk, discharge, refer and move on.

7. Nurse-physician collaboration should achieve physician buy-in and patient betterment.  Physicians with constructive input should be referred to the committee in described Step 1 above. Nurses should also experience an appreciable case-load turn over as patients graduate and more are recruited to take their place.

This recipe should lead to the following return-on-investment (ROI) curve:

Since there are high up-front fixed costs, early enrollment savings will not match start-up costs.  As the highest risk opportunities are realized, the ROI will turn positive.  However, as nurses continue to enroll patients at progressively lower risk, the likelihood of modifying future costs, hospitalizations or utilization will diminish and eventually result in a negative ROI.  The idea is to limit the program to the patients at greatest need and stop while you're ahead.

Let the DMCB know if you want the graphic on a PowerPoint slide.

Exorcising the Ghost of Cost Shifting: Why the Alternative May Be Worse

The cost-shifting ghost!
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.

Of all the mythologies in the arcane world of health economics, cost shifting holds a hallowed place. First conjured up by commercial insurers in the 1970s to warn against catastrophic Medicaid cuts on hospitals’ financial positions, the rhetorical phantasm of cost shifting continues to rise from the dead to haunt the public sphere, particularly when politicians propose to reform public insurance reimbursement levels or undertake large-scale reforms.

The theory of cost shifting is fairly straight forward: hospitals raise prices on private insurance customers when public payments are cut in order to make up for lost revenue. For all the importance afforded to cost shifting, however, there still remains a (highly) inconvenient truth: Numerous academic studies over the past 20 years have failed to find systematic evidence of its existence.

A recent National Bureau of Economic Research paper by Dranove, Garthwaite, and Ody examines the phenomenon of cost shifting in a new light. While scholars traditionally have examined hospitals’ pricing responses to planned changes in Medicare and Medicaid reimbursement levels, the financial crisis of 2007 provided a unique opportunity to analyze how they responded to a one-time loss in wealth. That crisis had a substantive impact on most hospitals; Not only did consumer demand for services decline, but many hospitals lost a substantial portion of their endowments due to the ensuing market turmoil. Dranove and his co-authors wanted to explore if hospitals that lost a significant proportion of their endowment would “cost shift” in order to make up for lost wealth, compared to hospitals that did not suffer similar losses.

What the authors found was disconcerting. Only a small sample of hospitals raised prices in the aftermath of the crisis. Many more responded with another strategy: cutting costs. Hospitals axed planned and ongoing capital expenditure projects (e.g.,  electronic health records) and shut down low-profit centers, including resource-intensive trauma and psychiatric centers.

Although the paper’s results cannot necessarily be generalized to all health care markets, it does suggest that hospitals can and will respond to financial downturns by cutting vital services.
Since the concept of cost shifting offends widely held notions of fairness, the further subsidization of baby boomers’ Medicare benefits in the purported era of austerity might not be politically palatable. The paper by Dranove et al, however, shows that a far worse scenario is possible if Medicare payment rates are slashed: cuts to costly but high value clinical programs. That’s ironic, because many of the benefits ascribed to the Affordable Care Act were predicated on increasing access to crucial medical services, particularly in underserved areas.

The only good news is that if hospitals react to changes in reimbursement levels and wealth loss by cutting important services, policy makers will be unable to summon forth the spirit of cost shifting.  While skeptical economists everywhere may rejoice, that will be small comfort to communities that find that their local hospitals are cutting basic services.

Thursday, March 19, 2015

A Generic Keyword "Pitch" to Better Sell the Medical Home

While the just concluded 2015 Medical Home Summit was a wonderful learning and networking confab, it did have it's moments of jargon-laced salesmanship.

Think mixing two parts suspect data with one part dubious claims and a helping of preordained conclusions, bake with PowerPoint and serve to a fawning audience with a garnish of sweeping generalizations. And the dessert?  Applause.

Naturally, some of the Population Health Blog's evidence-based colleagues fussed over the occasional spills of snake oil. The PHB isn't at all concerned, because it was taught years ago by the old disease management industry that even the most pristine research in the most elite journals gets spun.

And let's face it: we collectively crossed that Rubicon when the Mr. Obama sold us a health insurance reform program that promised we could keep our doctors.

Since we all gotta make a living, the PHB is pleased to offer a free service to its more honest, non-for-profit and spin-challenged colleagues. It has combined its trove of disease management nostrums with a list of medical home keywords (underlined) that appeared in many of the Summit's presentations and huckstered over cheese and wine during the Exhibit Hall receptions:

Our (insert name of your medical home program) is a transformative and population-based initiative that shifts health care delivery from volume to value that proves that that JAMA article (link here) was wrong. Our transparency is only matched by our EHR registry and teaming of physicians, nurse practitioners, social workers, office staff, clerks, temps and janitorial service workers and we (pick one: have been, will be or should be) the subject of a (pick one: grant or report) by (pick one or more: PCPCC, the Commonwealth Fund, AHRQ, Medical Home News) that further shows why JAMA was woefully mistaken.

By proactively focusing on impactful care coordination and reducing care gaps, engagement of both patients and primary care providers drives triple-aim outcomes that include (insert percent numbers here without p values), which further demonstrates the JAMA article is a despicable outlier.

Our savings, enhanced clinical outcomes, decreases in readmissions, improved patient care experience and betterment of the community show that (name of medical home program) is foundational to the success of accountable care, which is why JAMA sucks.

As a result, we conclude that (pick one or more: politicians, employers) (pick one: wisely have or definitely should) require commercial and government insurers to pay (pick one or more: millions, specialists less, or through the nose) to save primary care despite what JAMA says.

The Constitutionality of the Affordable Care Act: From Twitter to the Supremes

In a hyperconnected fit of participatory democracy, the White House's Deputy Chief of Staff Nancy-Ann DeParle hosted a Twitter health reform Q and A under the hashtag "WHChat." "Tweeps" poised questions using 140 characters or less and Nancy responded in 140 characters or less. The sanitized White house version extolling the virtues and constitutionality of the Affordable Care Act (ACA) is here, but if you look at what actually happened in Twitter, most questions ranged from rhetorical to outright obnoxious. That being said, there were some deliciously irreverent flamers like:

#WHChat Give me a motorcycle helmet! I could be hospitalized if I don't get one for free

#WHChat My Best Buy extended cell phone warranty won't cover my wife's birth control. Why does Best Buy hate women

#WHChat Can you look at this mole and let me know what you think? Oh, not those kind of questions

#WHChat what's the official twitter hash tag for his "take over" executive order?

If all this Twittering has prompted a renewed interest in the upcoming SCOTUS arguments next week on the constitutionality of the ACA, you may want to check out this article examining the merits and the "severability" of the individual mandate. If the mandate is separated from the Court, it's possible that the ACA will be ruled constitutional, but the mandate itself will be struck down.

Drs. Sessions and Detsky note that the Court has historically tilted in favor of preserving as much legislation as possible. That makes it more likely that it will consider the Affordable Care Act separately from its mandate provisions.

If that's the case, the Administration will have a difficult time arguing that the ACA will collapse without it. If the mandate is struck down, insurers could still impose open enrollment windows or waiting periods (which would lessen the phenomenon of persons only buying insurance when they discover they are ill). In addition, the combinations of subsidies, employer penalties, Medicaid expansion and the exchanges make it much easier for consumers to buy insurance as intended.  When these are combined with weak penalties (signalling a belief that the law didn't really need a "mandate") and the pretzel legal logic of "partial severability," it would appear that the Supremes' threshold to "severing" the mandate and declaring it unconstitutional is quite low.

The DMCB shared a delicious California red with a smart lawyer last week and heard an interesting prediction: given the law's historical importance, the Justices are going to seek a strong numerical majority one way or another.  One way to do that would be to support the ACA and duck the issue of the mandate by forcing Congress to rewrite those provisions that are legally problematic. That way out for both sides may be another reason to doubt the mandate's constitutional prognosis.

Last but not least, there's always the prediction markets and public opinion. According to intrade, the individual mandate's odds of not surviving are 45%.  In the meantime, 51% of Americans believe the mandate is unconstitutional, while 53% predict it will be struck down.

Accountable Care Organizations Can Improve Population Health If They Use The Correct Definition

The right definition was there all along!
Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over "population health."

The Disease Management Care Blog says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing "population health" for an entire geography

Between the here of "improving chronic care" and the there of "population health," Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term "population health" in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

In short, they don't believe ACOs, as currently configured, are up to the new task.  That's because ACOs would need to collaborate with social service organizations, be responsible for a geographically defined service area and improve long term public health outcomes.  According to the authors' subtitle, the answer to the question "should they try" is "no."

The Disease Management humbly disagrees.  That's because Drs Noble and Casalino, the editors of JAMA and the manuscript's peer reviewers seem to be ignorant of the the correct definition of population health. It's right there on the Care Continuum Alliance's web site, in this longstanding page that describes the "population health model of care."  When the DMCB did a simple Google search on "population health definition," it had little difficulty finding the link.

The CCA helpfully describes population health as:

a delivery model characterized as a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.

Was that so hard?

And how is that accomplished?  According to the CCA, the ingredients to that make for population health include:

• Population identification strategies and processes;

• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;

• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;

• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;

• Self-management interventions aimed at influencing the targeted population to make behavioral changes;

• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;

• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health

Accordingly, if an CMS-contracted ACO can identify its assigned Medicare population, perform needs assessments, promote awareness of health risks, offer education as well as support, increase self management, use data feedback and evaluate outcomes, it's offering "population health."  By using that playbook, an ACO will capitalizing on the experience of a community of population health service providers that have been doing precisely this for over a decade.

This vision is far more compact than the overreaching, misinformed and muddled definition of "population health" offered in JAMA.  It is also, if ACOs invest in the right resources and partnerships, well within reach.

The DMCB's answer to the question "Should they try?" is "yes."

Wednesday, March 18, 2015

Noise to Signal Ratio in the Assessment of the Medical Home

From time to time, the Population Health Blog's consulting business generates supplemental income.  When that happens, it gets dropped into the PHB's cash flow and life goes on.

Months later, is the PHB household better off?  On one hand, every little bit helps.  On the other, total income is the result of many jobs and total well-being is only partially a function of the PHB's bank account.  In other words, it's difficult to gauge the one time contribution of a consulting gig to the "outcome" of total income.

It's a classic "noise" (total income) to "signal" (the gig) conundrum.

That's how the PHB addressed the problem of this disappointing JAMA article in its conversations with colleagues at today's Medical Home Summit meeting.  As readers will recall, this JAMA research showed no statistically significant impact on claims expense for all patients who were attributed to a medical home clinic compared to a parallel population of patients attributed to non-medical home clinics.
To the PHB, "total claims expense" is akin to total income, while the impact on a smaller subpopulation segment of patients with chronic conditions who were at special risk is the "gig."  Because of the overwhelming "noise" of insurance claims involving tens of thousands of patients, it's practically impossible to discern the benefit of the medical home for the smaller number of vulnerable patients.

The lesson?  While all patients assigned to a medical home clinic won't benefit, some could.  Until we understand that, we won't really know the return on investment of this approach to care. 

Your Tricorder Will See You Now

What happens when a tricorder's
batteries go dead
Heads-up displays in cars. Apps that can remotely open garage doors. Cable TV embedded in bathroom mirrors. The techie Disease Management Care Blog lusts after all of them and understands when advances like these cross from being mere conveniences to vital necessities.  While it waits for an unenthusiastic DMCB spouse to catch up, it looks forward to the arrival of other lifestyle enhancements like internet-enabled goggles, ear hair curing nanotechnolgy and Star Trek styled tricorders, preferably with lots of blinka blinka diodes.      
Good thing that the X-Prize Foundation agrees on the latter, though without the blinka blinka.  According to this web page, it will award $10 million to any outfit that can cram "artificial intelligence, wireless sensing, imaging diagnostics, lab-on-a-chip and molecular biology" in a single home-based "tool" that is safe, weighs no more than five pounds and has internet connectivity. Competitors for this "Qualcomm Tricorder X PRIZE" are expected to make trade-offs between audio, visual displays, imaging technology, portability, bandwidth-use, power requirements, and sensors.

The Foundation antcipates that the device will enable consumers to "incoporate health knowledge and decision-making into their daily lives." The ultimate goal is to allow end-user "direct care" for "15 diseases" that trumps "science" over the "art of medicine," bypasses the monopolistic "bottleneck" created by the traditional doctor, clinic or hospital and places diagnosis and measurement under the control of the patient.

Gosh. It wasn't too long ago that credentialled physicians totally owned the health care space. Thanks to their brute force learning, a rigorous apprenticeship and 10,000 hours' worth of experiential heuristics, patient-consumers could be be highly confident of getting a correct diagnosis and treatment.

While that's still true, that space is changing: networked e-Patient communities can harness the wisdom of crowds, IBM's "Watson" can strip-mine the world's medical knowledge to answer a single question for anyone anytime, computers are aiding the interpretation of imaging studies, non-physician clinicans can monitor as well as coach personalized self-care for thousands of consumers from afar and elite surgeons can remotely project their expertise worldwide with stereotaxic robotics.  While skeptics may doubt the short-term prognosis for this particular X-PRIZE, there can be no doubt that the concept is ultimately sound.

Big changes are in store for medical practice.

The impact will be greatest for care for persons with chronic conditions.  This not only represents another threat to the viability of primary care but undercuts a major value proposition for ACOs.

Providers and health insurers that adapt will survive; those that adopt or co-opt will thrive.
Depite the vision of a fully self-sufficent health care consumer, the DMCB doubts physicians will go extinct. They will  adopt and co-opt because high tech plus high touch trumps high tech with low touch.  The sum of a tricorder plus a provider will be far more than the sum of its parts. 

Even the Enterprise needed a Dr. McCoy on board.

How Can Care Management Programs Manage Physician Incentives?

One ingredient for physician cooperation?
Years ago, when the Disease Management Care Blog was helping to lead a care management program, it was paired up with a nurse-administrator who was troubled by the notion that docs should get paid to sign-off on a disease management care plan. Why, it was asked, should docs get any extra compensation to do something that's a fundamental part of caring for patients?

It listened politely to its colleague's input.  After a careful review of all the issues, risks, benefits and alternatives, the physician-DMCB decided to compromise by paying the docs to sign-off on the care plans.

Drs. Nikola Biller-Andorno and Thomas H. Lee, writing in the March 14 New England Journal, point out that that physician enticements are far more complicated than shekels for signatures. They think economic incentives in health care are a complex mix of "traditional," (social status) "self-interest, (one example is money) "affective" (being appreciated) and "shared purpose" (for the greater good) motives.  They also suggest that they are unavoidable.

A nurse care management administrator might as well join 'em rather than fight 'em.

Armed with that insight, it's easier to contrast the underlying cultures of a non-for-profit community health center versus a for-profit hospital chain. It's also easier to understand that performance measures can not only appeal to self-interest (as in pay for performance) but to the "affective" reward of being given an excellent rating by a community of colleagues.  The authors also point out that a sense of shared purpose cannot be underestimated, since it speaks to the "core principles of the medical profession."

The DMCB's insight here is that there is no single incentive "lever" that can change physician behavior.  Rather, the best approach to incentives is to capitalize on all four incentive domains.  What's more, if "shared purpose" is undervalued, physicians are more likely to feel dissed and ignore the best laid incentive plan.

It turns out paying the docs was the right thing to do as well as appealing to their sense of shared purpose.  What the DMCB and nurse administrator should have done was to also look for some way to leverage the other domains of social status (perhaps a recognition program) and being appreciated (asking a lead physician to express appreciation for the extra work.

Image from Wikipedia