Thursday, April 30, 2015

AHIP Steps Up With Their Version of Health Reform

While HHS Secretary Sebelius reassures the House Republicans that the Fed's health insurance exchanges are on track, that the implementation of the Affordable Care Act will not be a "train wreck" and flies around the country touting Obamacare, Disease Management Care Blog readers may want to check out this 3 page article by the notorious anti-Sebelius a.k.a. AHIP's CEO Karen Ignagni.  In it, she mounts a vigorous defense of her trade association's commercial insurer members.

She points out:

1) Commercial insurers' versions of accountable care organizations include a variety of prospective payment approaches that are tailored to the provider's willingness to take on insurance risk.  What's more, commercial insurers can "calibrate" the benefit so that consumers', physicians' and hospitals' economic incentives are all aligned.

2) Health plans are quite able to share data and analytics support that translates into early identification of trends, accurate payment designs and the targeting of programs at patients who are at greatest risk.

3) AHIP's members are routinely providing health risk assessment tools, predictive modeling, medication compliance programs and care management services.

4) AHIP is well aware of the difference between true cost savings versus mere cost shifting.  As a result, they are asking for greater transparency on commercial and government fee schedules so that the potential impact of cost shifting can be better understood.

5) While Washington DC deserves a lot of credit for promoting a quality agenda, it could do a better job of working with all insurers to come up with a set of universally used quality measures.

6) While commercial plans are required to use uniform billing systems, providers are under no obligation to submit their claims electronically.  While this certainly helps physicians over the short term, the long term inefficiencies are not cheap.

7) Commercial insurers would rather cover treatments that have been shown to work. The "Patient-Centered Outcomes Research Institute" is not mentioned by name, but you get the idea.

8) AHIP supports letting non-physicians practice "to the top of their license."

9) State-based "laboratories of democracy" are a useful way to try out a variety of health reforms before they are adopted by Washington.

The DMCB's take?

AHIP and Karen Ignagni have been mostly out of the public eye.  Could this be a sign that they're less wary of the Administration's anti-insurer bluster?

While Medicare's Innovation Center continues to get high marks, the commercial insurers appear to be advantaged by having more leeway to test new payment and care management strategies.

AHIP's members are aware that many providers could fold if they mismanage the risk that underlies prospective payment systems.  Unike Washington's one-size fits all approach, they seem prepared to adapt their contracting accordingly.

Care and disease management programs?  The commercial insurers have rolled this into standard operating procedure.

Wishful Ideology About Integrated Delivery Systems

Kaiser Health News has posted a telling interview with former White House health adviser Ezekiel Emanuel MD. In it, Dr. Emanuel repeats a bold prediction about the end of health insurance companies:

Question: You also predict the end of insurance companies as we know them. Rather than continuing to function as the middleman between employers and health care providers, you say insurers may themselves contract with networks of doctors and hospitals, morphing into integrated health care delivery systems. But a one-stop shop isn’t always good for consumers. Networks are restrictive, and at least now, if your insurer turns you down for treatment, your doctor may go to bat for you.

Answer: I don't agree with you. In general, integrated systems do a pretty good job compared to lots of other ways care could be delivered. We like the adversarial system. We believe that’s the best. On the other hand, with integrated networks you can have better coordination of care. And people are mildly sticky. Once you pick an insurance network, you tend to stick with it. That's also good for the insurer. If someone selected you, year in and year out you'll be with them. That changes the dynamic. And to the extent people are long-term keepers, that’s going to be a better arrangement.

"Better arrangement?" The Population Health Blog isn't so sure:

1. As pointed out at the start of the interview, health insurance has been around for more than 200 years. Its staying power is testimony to the enduring value proposition of pooling and monetizing risk. We discard that our peril.

2. Assuming "integrated systems" will competently manage that risk is a stretch.

3. Part of competently managing that risk - even for provider groups - is utilization review.  While the interviewer unflatteringly portrays that as "your insurer turns you down for treatment," the truth is far more complicated mix of advantages and disadvantages that have been heavily regulated (an example here) for decades.

4. Can enlightened "coordination of care" make utilization review unnecessary?  The luxury of Dr. Emanuel's anti-health insurer ideology makes it easy for him to say yes.  So far, inconvenient facts about the ACO pilot program suggest a different story.

5. Plus, can restrictive networks also make utilization review unnecessary?  It remains to be seen whether consumers will appreciate the irony that this invention of managed care is now being embraced by Dr. Emanuel and other progressives, or agree that significant limits on provider choice will be a "better arrangement."

6. Last but not least, doctors like the PHB have been trained and acculturated to put the individual patient's interests before any other consideration, including the success of an integrated delivery system. Unable to say no, our loyalty will translate to the usual specialist referrals, sophisticated testing, the latest technology and the priciest drugs.  Culture trumps everything.

Like it says, the PHB isn't too sure.  Maybe with the right combination of patient incentives, decision support, shared decision making, risk stratification and tailored population health, integrated systems will ultimately prevail.  Time will tell.

Give credit, however, to Dr. Emanuel for being consistent over the last two years.

The same is true for the PHB.  Based on the emerging facts on the ground, the PHB still thinks the odds remain against Dr. Emanuel.

And the offer of a $1000 bet still stands.

Kids and Diabetes Control: The Today Study Provides a Benchmark Different Than Adults

If overweight adolescents between the age of 10 and 17 years with type 2 diabetes are enrolled in a population care program, what level of "successful" management can be expected? Will some, half or most of these adolescents achieve blood glucose control?

The depressing answer may be found in the just published "TODAY" study.  Youngsters with type 2 diabetes, a body mass index (BMI) at the 85th percentile and a committed adult caregiver were randomly assigned to one of three treatment protocols:  1) the first line drug metformin (up to 1000 mg twice a day) versus 2) metformin plus an individually delivered lifestyle program versus 3) metformin plus another diabetes drug rosiglitazone twice a day.  After a baseline 2-6 month "run in period" of basic diabetes education combined with the metformin, 699 kids were then randomly assigned to one of the three arms of the study.

Over an average of 3.8 years of follow up, 49% of the metformin group (N=232), 53% of the metformin plus lifestyle (N=234) and 62% of the of the metformin plus rosiglitazone group (N=233) managed to keep their HbA1c persistently below 8%.  When the three outcomes were compared, only the difference between metformin alone vs. metformin plus rosiglitazone was statistically significant.  What's more, the participants in all three treatment arms collectively experienced a slight increase in weight, though the metformin plus lifestyle experienced the least weight gain.  Race was inversely associated with glucose control: across all three groups. 48% of blacks vs. 55% of Hispanics vs 64% of whites stayed within the A1c range.

What are the implications for the population health management service providers?

1) Based on this rigorously conducted study, diabetic adolescents age 10-17 cannot be expected to achieve the same level of blood glucose control as similarly treated adults, who can expect success rates in the 80-85% range.  This should be factored into any peformance guarantees outside of research settings, especially if tighter A1c levels of 7% are used.

2) Ditto Patient Centered Medical Homes and any pay for performance (P4P) incentives that focus on diabetes care: kids are different.

3) Persons of color are more vulnerable and are at higher risk. 

4) While the twin drug approach of metformin plus rosiglitazone "beat" metformin plus lifestye instruction, the difference was not statistically significant.  This supports using metform plus lifestyle as an initial approach before additional (and potentially dangerous as well as expensive) drugs are added to the metformin.

5) A serious shortcoming of this study was not adding a fourth treatment arm for comparison: two drugs plus lifestyle instruction. It stands to reason that any lifestyle intervention plus any drugs should achieve better blood glucose control than either alone.

Image from the CDC website

The Latest Cavalcade of Risk Is Up!

Rebecca Shafer hosts the Cavalcade's round-up of risk-related posts. A wide variety of topics, including Wounded Warriors, venture capitalists, Aristotle, enterprise risk management and risk adjustment await your reading pleasure.


Wednesday, April 29, 2015

Three Models of Primary Care Teaming (TL, CC and ET): An Unexplored Feature of the Medical Home

What defines optimal outpatient primary care "teaming?"

The Disease Management Care Blog just assumed that if it took equal scoops of adaptable physicians, dedicated nurses and supportive culture and baked with a dollop of accountability, "teaming" would just.... happen.

It turns out that what may come out of that clinical practice oven is a lot more complicated than that. 

Which is why medical home advocates should pay attention to this article by George Washington University's Debra Goetz Goldberg and colleagues.  Interested in finding out more about primary care "teaming," they interviewed, reviewed and observed three different Virginia clinics that had embarked on transformative quality improvement programs.

Each clinic came up with a different version of "teaming":

1."Top of License" - nurses interviewed the patients, presented the problems to the docs and then documented the care plan.  They were also responsible for the patient education.  Thanks to using this model, the physicians almost doubled the number of patients they were seeing per day.

2. "Care Coordinator" - nurses focused on helping patients undergoing care "transitions" (typically out of the hospital) and provided self-management and health education to high-risk, high complexity patients.  Interestingly, unsatisfactory reimbursement levels forced the practice to cut back, but they still doubled mammography and blood pressure control rates among persons with diabetes mellitus.

3. "Enhanced Traditional" - the physicians still performed the bulk of the patient care but the researchers observed that the other clinic personnel benefited from increased trust, communication and hand-offs that translated into patient centered care, shared responsibility and heightened volunteerism.  The practice was unable to measure any outcomes.

"Very interesting!" says the DMCB. Authoritative web-sites like this or this and peer-reviewed articles like this refer to "teaming," but fail to precisely define it.  Assuming the three categories described by Goetz-Goldberg (in shorthand, "TL," "CC" and "ET") hold up in future studies, the DMCB looks forward to learning which approach results in the greatest quality or cost-savings.

Coda: As a reader bonus, the authors offer up a definition of "team-based care" that seems to span all three models and can be used for the DMCB readers' quoting pleasure:

"A group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients."

Handling HHS Secretary Nomination Questions

The Population Health Blog notes that HHS nominee Burwell has been scheduled to appear before the U.S. Senate Health, Education, Labor and Pensions Committee on May 8.  In all likelihood, the hearing will alternate between yawnfest softball and hyperparisan gotcha questions on the budget, ACA repeal, agencies and contraception.

The PHB plans on watching C-SPAN, hoping that some of the questions deal with its favorite blogging topics.

In the unlikely event that they do come up, the public-service minded PHB is pleased to prep Ms. Burwell with some "canned" and ready-to-go responses. The turnkey options below have been crafted to upend foes and friends alike.

When asked any question about "population health," respond by:

1. pointing out that you rely on the Population Health Blog's definition and, based on its author's many insights, believe that it is a promising feature of health reform, or....

2. affirming that "if you like your population health, you can keep it," or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of population health as an important option to derive high value care for Medicare beneficiaries!

When asked about the part of the Obamacare law that includes "shared decision making," respond by:

1. noting years of research on the topic have demonstrated that it is among the few interventions that can simultaneously reduce health care costs and increase beneficiary satisfaction, or...

2. reiterating that Congressional Republicans are not going to share in any decision making when it comes to any health care reform, or....

3. saying that HHS remains strongly committed to evaluating and further developing the future role of shared decision making as an important option to derive high value care for Medicare beneficiaries!

When asked about the Patient Centered Medical Home, respond by:

1. quoting extensively from the PCPCC web site, or...

2. announcing cautious support for the medical home, but confirm HHS' intention to name it something else, create alternate criteria, assess different outcomes and insist on budget neutrality, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of the Patient Centered Medical Home as an important option to derive high value care for Medicare beneficiaries!

When asked about care management, respond by:

1. pointing out that, for the right patients, studies like this show teaming between physicians and non-physicians can result in outcomes that are the result of more than the sum of its primary care parts, or...

2. announcing your intent to regulate the carbon footprint of all Medicare-participating acute-care hospitals, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of care management as an important option to derive high value care for Medicare beneficiaries!

When asked about primary care, respond by:

1. not saying that the 10% fee increase has resulted negligible changes in primary care physician satisfaction, or...

2. promising you're going to fix low primary care fee schedule rates faster than a Florida ophthalmologist submitting a $10,000 Medicare billing code, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of primary care as an important option to derive high value care for Medicare beneficiaries!

When asked about the sustainable growth rate, respond by:

1. Denying any White House responsibility, or....

2. Denying any White House responsibility, or...

3. Denying any White House responsibility

Image from Wikipedia

The Bombast of Health Care Funding and Student Loan Interest Support

The Disease Management Care Blog was shocked, shocked when it learned that Representative Pelosi's political opponents have conspired to fund federal student loan subsidies by "tak[ing] it from their favorite target: women's health" (italics DMCB). The White House has chimed in about this political evildoing, noting defunding women's health could result in "hundreds of thousands of women" losing access to cancer screenings.

Alarmed by this unfair disenfranchisement of half of the U.S. population, the DMCB spouse and a number of future Secret Service agents, the DMCB decided to investigate.

As the DMCB understands it, the House Republicans propose to pay for the loan subsidies by defunding all or some the Sec 4002 of Affordable Care Act's Prevention and Public Health Fund (PPHF). 

Here's the key wording from the ACA:

SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND be administered through HHS, to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs. FUNDING.—There are hereby authorized to be appropriated, and appropriated, to the Fund, out of any monies in the Treasury not otherwise appropriated—
(1) for fiscal year 2010, $500,000,000;
(2) for fiscal year 2011, $750,000,000;
(3) for fiscal year 2015, $1,000,000,000;
(4) for fiscal year 2015, $1,250,000,000;
(5) for fiscal year 2015, $1,500,000,000; and
(6) for fiscal year 2015, and each fiscal year thereafter, $2,000,000,000.
(c) USE OF FUND....for prevention, wellness, and public health activities including prevention research and health screenings, such as the Community Transformation grant program, the Education and Outreach Campaign for Preventive Benefits, and immunization programs.

Unable to find the words "women's health" in Sec. 4002 of the ACA, the DMCB next looked up the Community Transformation grant program and the Education and Outreach Campaign.  There is practically no mention of "women's health" there either.

With further research, the DMCB did find this insight on the mechanics of federal health grant funding in the unbiased and refereed policy journal Health Affairs.  According to Boston academic authors Mariana Arcaya and Xavier Briggs, the institutional complexity of overlapping committee and agency jurisdictions and budgets make it extremely difficult - absent innovation, reorganization and new support mechanisms - to coordinate grant programs like the PPHF and give the taxpayers their money's worth.

The DMCB's conclusions?

1. Given the size of the U.S. government's deficit, it's Congress' job to make tough choices. Cancelling one program to fund another is one of them. The DMCB wishes that happened more often.

2. Trading a costly and questionably effective PPHF for a national investment in college education doesn't sound like a bad idea to the DMCB.

3. This is only the beginning. Those of us in the health care industry can look forward to the threat of funding cuts in other federally supported programs.

4. Even in this time of political discontent, Speaker Boehner has a point. Shame on Ms. Pelosi and her allies for their bombast and for the mainstream news media for failing to recognize it.

Image from Wikipedia

Tuesday, April 28, 2015

Commitment Devices, Behavior Change and Population Health

A new addition to the
behavior change tool box
Whenever the Population Health Blog encountered a tobacco user in its clinic, it would gauge the patient's readiness to quit. For those patients who were ready, it then established a future "quit date" (to facilitate planning), a "contract" (a jointly signed prescription for display on the home fridge) and advice to use any money savings (tobacco is expensive) for a nice reward once seven days of success (for example, a restaurant dinner) was achieved.

The PHB didn't know it at the time, but that seven-day reward was a variation of a "commitment device."  That's what it learned after reading this just-published JAMA manuscript by Todd Rogers and colleagues.

Commitment devices are a way that "present" persons can commit their "future selves" to a sufficient level of needed behavior change.  The threat of a penalty, such as the loss of a night out on the town, imposes a limit on future choices and makes success more likely. 

Other examples of commitment devices described by the authors include applying cash to a success contract (for example, employers could link a bonus to participation in a exercise program that would otherwise be lost), "temptation" bundling that limits access to a gratifying experience in exchange for "consistent" behaviors (used with repeated success by the crafty PHB spouse), limiting bad choices to small packages (smaller portion sizes) and partnering (to avoid disappointing a buddy who shares the commitment).

In retrospect, "commitment devices" have been used in population health for decades.  As Rogers et al point out, however, despite some good research on how effective this approach is, they're generally underused by providers and patients.  One potential way to overcome that is to offer them routinely on an "opt-out" basis, 401k savings-plan style.  The authors also point out that a series of commitment devices on a longitudinal basis could be used to blunt drop outs and maintain long-term behavior change. Last but not least, leveraging social networks with or without handheld "apps" remains an area ripe for future research.

As medical homes spread and shared-risk payment reforms gain traction, the art and science of commitment devices will likely grow. Not only is it a cool piece of insider jargon ("Hey, Mary, I like this care management proposal, but have you any plans to develop commitment devices?"), but any addition to the behavior-change tool box can only help.

Image from Wikipedia

Sunday, April 26, 2015

Money Power and... Health Care!

Morbidly fascinated by the 2008 financial meltdown that destroyed Bear Sterns, bankrupted Lehman, brought AIG to its knees, froze the credit markets and destroyed gazillions of dollars of real estate worth?

Even if you aren't, Frontline's report Money Power and Wall Street may still be worth your time.  Insightful nuggets abound.  For example, the Disease Management Care Blog learned that "collateralized debt obligations" (CDOs) were the clever weekend invention of a small cabal of 20-something financial brainiacs.  They had discovered an unregulated way to uncouple and transfer risk from a host of otherwise capital intensive loan instruments that freed up their customers' balance sheets. The DMCB also found out that that the crafty candidate Obama had an "insider" feeding him key intelligence during the frenzied Treasury attempts to restore order to the U.S. markets. 

Most telling of all was the astonishing inability of very sophisticated investors to understand what they were getting into. Not only did a huge secondary trading "market" for CDOs spring up, synthetic CDOs fueled the feeding frenzy. Once the risk materialized, it all achieved critical mass and invaded the financial system's "blood stream." Too-big-to-fail titans of industry had no choice but to grab ahold of Uncle Sam's Troubled Asset Relief Program (TARP) lifeline.

All of which prompted the DMCB to wonder if the titans of the health care industry really understand all of the dimensions of risk transfer collectively referred to a shared savings. After looking at this New England Journal of Medicine article several times, many of the assumptions underlying Medicare's version of accountable care organizations (ACOs) are way out of the DMCB's depth. This table only makes things more scary.  Will bad mistakes lead some too-big-to-fail health systems having to be rescued?  Are there other young brainiacs out there, figuring out how to mischieviously move nebulous health insurance claims and risk around?

Maybe the DMCB is getting too paranoid thanks to watching too much Frontline. Time will tell if the financial markets are all that different from health care. 

The DMCB says stay tuned.

The Latest Health Wonk Review Is Up!

Please join the Disease Management Care Blog in welcoming Wing of Zock to the pantheon of bloggers that have hosted the Health Wonk Review.  They must be really happy to have joined that elite group, because they've dubbed their just posted collection of wise bloggery links as the "Shiny Happy (Mostly) Edition."


Saturday, April 25, 2015

"Cappers" vs. "Skinners" in the Struggle to Control Costs

The Disease Management Care Blog agrees that if you want a peek at a potential future scenario for health care reform, look at what has happened in Massachusetts since 2006. That's when the Bay State passed a law that, just like its cousin the Affordable Care Act (ACA), emphasized insurance reforms that included exchanges, subsidies and changes in Medicaid eligibility.

According to this recent New England Journal of Medicine article, the reforms resulted in both good and bad news. The good news is that 98% of Massachusetts' citizens have insurance coverage; the bad news is that health care now consumes a whopping 54% of the state's total budget. 

In response, the state is now pursuing cost reforms. As the DMCB understands it, Massachusetts is banking on the principle of "global payment" to incent health care providers to work within a budget. If it works out, the providers will embrace "value" by delivering needed services and cutting waste. If it doesn't work out, the providers could end up putting savings before patients by withholding medical care.

It remains to be seen what the ultimate mix of value vs. withholding will be.  Undoubtedly, Massachusetts' regulators will be vigilant for any abuses and continue to pressure the providers to prove that they're also achieving quality. The state will also undoubtedly be interested in scrutinizing the providers' overhead costs and trying to keep the industry's profits in the single digits. Expect a combination of increased transparency and intrusiveness, says the DMCB.

All well and good but the Massachusetts experience only tells half the story. For the rest of the nation and Washington DC, the potential scenarios ultimately come down to two competing world views on how to temper health care costs. On one side are the "cappers" i.e., those who believe in using Massachusetts's euphemistically named version of capitation to force providers to moderate the consumption of health care services.

On the other are the "skinners" i.e., those who want patients' "skin in the game" to harness markets by forcing consumers to share part of the cost of health care. To the DMCB's knowledge, no state has actually tried that on a Massachusetts-style scale.

Which will win out?  We don't know yet, but we'll learn how the "capper" version works in Massachusetts years before we know how the ACA is performing.

The DMCB will stay tuned.

Coda: Unfortunately, the NEJM article fails to point out that Massachusetts already had access to a large funding source called the "Uncompensated Care Pool." They also started out with a high baseline of insurance enrollment among its citizens.  What's more, having insurance doesn't necessarily mean having health care access and there is evidence that many docs in Massachusetts see little reason to accept low payment rates and are closing their practices to new patients.  Whether that continues will be the ultimate test of Massachusetts's reforms and represents a real danger for the ACA as it unfolds.

Friday, April 24, 2015

Bullying Health Insurance Actuaries

Years ago, the Disease Management Care Blog proudly showed the consulting health insurance actuaries published data like these and these. It naively expected the actuaries to agree that disease management had resulted in cost reductions and that the programs should be favorably factored into the managed care insurance plan's premium pricing for the coming year.

The response of the actuaries was "no."

Disease management not only did not factor into their trend analysis, they decreed that the programs' costs needed to be loaded as an additional administrative cost. The worst part of dealing with their obstreperous math was that the health insurance plan was actually paying them to deliver this bad news.

Which is why the DMCB believes that anyone who believes that actuaries' relationships with health insurers are riddled with conflicts of interest is amateurishly misinformed.  To wit, Senator Franken (D-MN) recently scored a political "gotcha"against the Society of Actuaries when they had the temerity to predict that health insurance costs in the individual market could go up by 32%. While it is true that their consulting services generate fees that are paid by their insurers, their hard-nosed recommendations are hardly ever welcome in the industry, their fees are not linked to health plan profitability, states have regulated actuarial consulting input for decades and, to add insult to injury, customers like the DMCB have to pay their fees for unwanted news.

At one level, the DMCB welcomes members of the U.S. Congress to its world.  The job of the independent actuaries is to present inconvenient truths about future health care trends and premium pricing.  At another level, the DMCB is concerned that Frankenesque-style bluster and bullying could force health insurance actuaries to underprice insurance and destabilize the market just when Obamacare is getting out of the blocks.  We deserve better.

It's Team Based Care, Not More Experts!

Oh oh. 

A nurse asks about falls
Another study  that shows how awful physicians are ("Doctors Fall Short") and, according to the press release, "why expert geriatric care is needed." 

According to the John A. Harford Foundation, a poll of over a thousand elders revealed that physicians aren't performing an annual review of their medications, asking them whether they're prone to falling, screening them for the presence of depression, providing them with referrals to community-based health resources or assessing their ability to perform activities of daily living (ADLs).  The depressing poll results are here.  Combine these data with this infamous 2003 NEJM study and it's easy to conclude that primary care quality is declining faster than a U.S. secret service agent can say "let's party!"

The contrarian Disease Management Care Blog is:

1. Unsurprised that, once again, disconnected academics who know little about the realities of clinical medicine failed to appreciate what the literature is also telling us: the provision of all recommended care services to all eligible patients seen in the course of a typical clinic day would crowd out everything else.  Real world clinical medicine is the art of priorities and compromises.

2. Disappointed that the sophisticated Hartford Foundation staff would be stuck on a physician-centric notion that "expert geriatric care" is the answer to a systems failure.  Hogwash: assessing medications, screening for falls, depression, ADL limitations and referring to community resources doesn't take expertise.  It takes team-enabled primary care that includes nurse-led population health management. 

Too bad the Hartford didn't ask the survey respondents about that option and/or submit their report for peer-reviewed publication; if they had, the reviewers could have turned this second rate press release into something with greater discipline.

3. Hopeful that this survey, as bad as it is, will prompt others to recognize what DMCB readers already know: geriatric screening and prevention can be practically "outsourced" to non-physicians who, in turn, can use the principles of population health management with information technology (such as links, protocols and standing orders) to get the right care to the right patients at the right time.

You'll be able to learn more about this if you listen in on this upcoming webcast.

The Latest Health Wonk Review Is Up

Louise Norris hosts a wide ranging Health Wonk Review at her smartly-written Colorado Health Insurance Insider. Like prior HWRs, Louise summarizes and links the best health policy bloggers on topics like the high price of Hepatitis C treatment (follow the money), Medicaid (does it really save lives), how the competition in Mexico is taking a bite out dentists' fees... and so much more.


Physician Specialty and Intelligence

What makes medical students select one specialty career path over another? 

While academics and economists tell us it boils down to lifestyle and income, the Disease Management Care Blog thinks there's more to it. As its medical education progressed, the DMCB noticed that students who enjoyed the company of others pursued careers in primary care, while the not-so-sociably-inclined preferred the company of unconscious patients by entering anesthesia. Those with hand dexterity seemed to gravitate toward surgery and the brainiest, naturally, chose internal medicine.

The classic stereotype has been that students with an athletic background, especially if they had less intellectual "heft," tend to go into that field of applied human carpentry known as orthopedics. But is that true? In a small tongue-in-cheek-study published in the British Medical Journal that was designed to shed more light on the link between native ability and specialty, Dr. Subramanian and colleagues performed intelligence (IQ, as measured by the Mensa test) and strength (by testing grip with a calibrated dynanometer) on 36 orthopedists and compared them to 40 anesthesiologists - who went through the same tests.

The orthopedists beat the anesthesiologists by small and statistically significant amounts in both measures. What's more, the IQ and the grip strength, compared to the normal population, clustered around average.

The authors, who are orthopedists, naturally find the data redeeming and take comfort in their favorable specialty comparison. While the study was performed in England and excluded women (both of which have important and decidedly divergent implications for the IQ measures), the DMCB looks forward to using this study to remind its non-internist colleagues of the existence of published science that confirms their average abilities.

Last but not least, it's important to note that confidence may also play a role in specialty selection.  That's displayed by an old joke of two docs - an internist and an orthopedist - who had never seen wild ducks but decided to go duck hunting anyway.  Spying two of the apparent waterfowl headed their way, they both made successful shots.  Upon retrieving hapless birds, the internist looked at his and remarked that the bill, webbed feet and feathers certainly suggested it was a duck, but that he'd confirm it by comparing it to some pictures when he got home. The orthopedist's conclusion: "I shot it, so it must be a duck."

Image from Wikipedia

Thursday, April 23, 2015

Questions That Should Be Asked in the Upcoming HHS Secretary Nomination Process

As a public service, the Population Health Blog is pleased to offer up some questions that may or should arise in the course of Senate confirmation process for HHS nominee Ms. Burwell. 

If she can address the inquiries in these key categories, the PHB suggests she'll be more than prepared for the job:

The Clinton years: Supporters of the Affordable Care Act say "it is now the law of the land."  Based on your extensive experience in the Clinton White House, how would you define "is?"

Signing up young people: Do you credit the last-minute surge in sign-ups on the individual exchanges to Mr. Obama, Mr. Galifianakis or to the Two Ferns?  How will you use that insight to increase individual enrollments in 2015?

Use of social media: Since the Population Health Blog began on-line publication more than 5 years ago, health care cost inflation has moderated significantly. Please explain how Medicare's actuaries will factor this into their future projections.

Doing your part for the 2015 mid-term elections: Will you advocate that the "essential health benefit" be broadened to include coverage for global warming?

To test your awareness of the employer mandate: If Peter Baelish hires 47 part-time seasonal service employees in KIng's Landing for more than 120 continuous days in the first quarter of 2015 without a profit sharing provision, what is the number of FTEs and what would the "4980H penalty" be if it were calculated in Gold Dragons?

And finally, tort reform:  Suppose Iva Pannus buys taxpayer subsidized insurance but also participates in a workplace weight reduction program. If Iva's girth paradoxically increases and she develops sore knees, should she sue in state court to recover her out-of-pocket "bronze" plan expenses and should HHS assert a lien if there is a jury award?

Image from Wikipedia

Wednesday, April 22, 2015

Discovering What We Don't' Know About Risk-Adjustment for Hospital Readmission Rates in Medicare

Something like this?
When the Population Health Blog agreed with the spouse that it was time to replace the living-room gas fireplace insert with something more sleek and modern, it then turned its attention to changing the surrounding mantle. The PHB favored something heraldic, featuring partially-garbed warrior babes, sporting shields and sandals. Cherubs too.  Preferably oak.

After some counseling from the PHB spouse, it came to realize that its wayward tastes in interior design may be a function of going sans helmet during its childhood bicycle riding, its deepening appreciation of bourbon's mysteries and pausing too frequently on Fox News' The Kelly Files

Naturally, the PHB wants to know the relative influence of each. Increasing exposure will help it propose some ideas for the unfinished basement.

Hospital administrators are dealing with a similar problem when it comes to readmissions.

Approximately 20% of discharged Medicare beneficiaries come back within 30 days. In response, CMS financially penalizes hospitals with high readmission rates for heart attack, heart failure and pneumonia. To reduce that penalty, hospitals have asked about the quality of their care, discharge planning and follow-up outpatient care. 

But, what is the relative impact of each? Where should administrators focus their corrective actions? 

Or, like the PHB and interior design, are readmissions ominously outside of anyone's control?

According to some interesting research, it turns out that more than half of the variation in readmissions may be outside of hospitals' control.  What's worse, CMS doesn't account for that in its calculation of the penalty that uses patient factors, such as age, gender and illness burden.

That's the conclusion of this recent article appearing in HSR Health Services Research.

Herrin and colleagues correlated CMS's Hospital Compare readmission data with each hospital county's socioeconomic data (rural vs. urban, persons living alone, employment status and educational level), access to care (the per capita density of primary care and specialist physicians as well as hospital beds) and nursing home number and quality (the number beds and the number of high-risk, long-term patients with bed sores).

Based on risk-adjusted rates from 4,079 hospitals in 2,254 counties, the authors found that more half of the variation in hospital readmissions was statistically explained by the counties' data.  That included persons living alone, low educational attainment, urban setting, a higher number of Medicare beneficiaries, fewer primary care physicians, fewer nursing home beds, higher numbers of nursing home patients with bed sores.  More beds and more specialist physicians were also independently associated with higher readmission rates.

The Population Health Blog's take?

As it noted previously, much of the vituperation around the unexplained variation in health care has been less a function of an inefficient health care system and more a function of our inability to identify the underlying drivers of utilization.

And now we're getting better. The HSR article shows that when it comes to readmissions, much of that variation is a reflection of the poverty in our neighbors' homes as well as the strength of the primary care network and the ability of nursing homes to act as a cushion.

Hopefully the mandarins at CMS will take these findings into account as they continue to financially sanction hospitals for readmissions. A more sophisticated approach to risk adjustment could help lessen the budgetary impact of county-level factors that are outside the hospital administrators' control. 

And since hospitals' bottom lines typically reflect the populations they serve, better risk adjustment could also lessen the disparate impact on the nation's poorest hospitals.

Image from Wikipedia

Telemonitoring's Evolution (and why it's tough to keep up with it)

Is that a fish eye or an EKG monitor?
While the sputtering skeptics in medical academia continue to demonstrate what doesn't work, the telemonitoring industry continues to evolve at a furious pace.

To wit:

Publishing in the Archives of Internal Medicine, Mayo Clinic researcher Paul Takahashi and colleagues examined the impact of telemonitoring by randomly assigning high risk and community dwelling elderly patients to either:

1) daily use of a multifunctional blood sugar, breathing airflow, blood pressure, blood oxygen and weight monitoring device. The devices' data feeds were "overseen" by a nurse who communicated with the patients as necessary and alerted the patients' physicians.


2) to usual care. 

Over 500 persons were screened for study participation. Ultimately 102 were assigned to the device and 103 were assigned to usual care.  The average age of the participants was just over 80 years and the mean SF-36 quality of life score was 35.

During the twelve months of follow-up, 89% of the planned telemonitoring was completed.
Compared to the usual care group, the persons assigned to the telemoniting had an increased rate of having had at least one hospitalization or an emergency room visit: 64% vs. 57%. This difference, however, failed to achieve statistical significance. Looking at the individual measures that made up the composite index likewise showed no meaningful outcomes differences between telemonitoring or usual care.  The only thing that was statistically different was the death rate, which was increased in the telemonitoring group: 15% vs. 4% (p=0.008).

The authors concluded that telemonitoring did not work.

The authors also pointed out that their study had limitations. It wasn't blinded, the results may not be applicable outside the Mayo system and the outcomes were based on billing, not medical, records. They also recognize that the difference in death rates could indicate that, despite randomization, there may have been a preponderance of "healthier" persons in the control group. That could have biased the results.

The Disease Management Care Blog agrees that those are limitations, but it also also offer three additional observations:

1. The mean SF-36 score of 35 and age of 80 suggests this was a very sick group of patients.  As the DMCB has pointed out before, telemonitoring-backed population health management is better suited for those patients who are in the "sweet middle" between the catastrophically ill on one side and those who are stable on the other.  Persons in their 80's with a low SF score are frail elderly who warrant a more intensive case management program. In other words, they are probably destined to be high consumers of health care resources no matter what you do.

2. The study was performed at Mayo, where health care utilization is notoriously low. So, while the study population was sick, they were already in a system and a Minnesota culture configured to only use the hospital and emergency room when it was really necessary.

3. Just because the data is given to the patients' physicians, it doesn't follow that they can act on it. Raw telemonitoring is notorious for not fitting into a physicians' office workflows.

In other words, telemonitoring is not a panacea for any sick patient anywhere in the United States. The DMCB thinks it's an excellent option in areas of the U.S. where baseline utilization is high. It should be offered to patients who are most likely to benefit: those with moderate levels of risk that can be mitigated.

As an aside, the DMCB notes that 10% of the telemonitoring was never completed. Enter mc10's "stretchable silicon technology" that can apparently be stretched and wrapped over a patient's skin in a fashion that makes it resemble a tattoo. Given its ease of use, the DMCB suspects that once it's ready for prime time, a) 100% compliance b) use by the right patients and c) being adapted to clinical workflows, it will represent a high value proposition. That's where the population health management service providers and vendors will come in.

Of course, by the time the academic community passes judgement on that, the industry will have moved on.

Image from Wikipedia

Reducing Health Care Labor Costs In the United States: Lessons from Overseas

Now that the Affordable Care Act has increased access to health insurance, progressive-minded policymakers are now turning their attention to increasing access to care.  Costs are going up and there isn't enough to meet demand.

Unfortunately, as Disease Management Care Blog readers are well aware, a host of inconvenient truths are getting in the way.  They include population growth, increasing age, insatiable yuppie expectations, underlying inflation, supply-induced demand, administrative costs, pricey new drugs and technology, misaligned provider incentives and unrelenting labor costs.

While each represent a significant challenge, the DMCB suspects the most vexing has been labor costs. That's because health care remains a retail and "high touch" business.

Which is why this Health Affairs article on the merits of "frugal" labor-saving innovations that are being used outside of the U.S. is interesting.  Can they overcome the short comings of a "labor stagnant" economic sector being afflicted with Baumol's "cost-disease?"

Authors Michael Macdonnell and Ara Darzi describe four areas ripe for innovation:
Telephony: in Mexico, "Medicall Home" provides advices and referrals to over one million households for about $5 a month.  It's charged right to the cell phone bill. In India, a similar service costs about fifty cents a call.

Work flow process innovations: While hospitals in India can do many more heart catheterizations with the same number of personnel and square feet, how about performing multiple eye surgeries in the Aravind Eye Care System in same operating room, conveyor-belt style? 

Task shifting to paraprofessionals: In India, a 3 1/2 year training program is enough to qualify as a primary care provider.  In other settings, nurses and pharmacists can do some of the tasks previously relegated to physicians only.  In Brazil, teams under the direction of a general practitioner provide primary care semi-autonomously to defined geographic areas.

Self care: patients can be taught to take care of their own diabetes, asthma, COPD and other chronic conditions.

While the DMCB has been well aware of the innovations, what it didn't appreciate was the extent of their uptake outside of the United States.  Brazil, India and Mexico's solutions may not fully apply to Boise, Indiana or Manhattan, but our labor costs are considerable. Perhaps there are lessons that we can apply here. 

While the prognosis of conveyor-belt surgery in the U.S. is unknown, the labor costs problem bodes well for the telephone-based and face-to-face care management industry. It may also speak to the inevitability of expanded reliance on non-physicians.

Tuesday, April 21, 2015

I'm From CMS and I'm Here to Help

Writing in JAMA "online first," CMS Administrator Tavenner and colleagues offer a payment reform "framework" that includes "multipayer collaboration."  The article is wonky, so the Population Health Blog dons its universal adminispeak translator so us normal humans can better understand what CMS is up to.

According to the writers, CMS has a history of innovatively implementing reforms that were later adapted by other insurers. The most famous example is the hospital "DRG" system that, starting in 1983, paid for a diagnosis in lieu of a daily room rate.  Suddenly, hospitals had an incentive to shorten hospital stays, which is precisely what happened in the years that followed.

Buoyed by this success, the authors describe the merits of championing Medicare's transition from "category 1" fee-for-service without any link to quality to "category 4" population-based payments that are linked to quality. And, as CMS embarks on this excellent payment journey toward accountable care, they'll get other commercial insurers to mirror their efforts by:

"Being conveners" as in "working with" other insurers in a region or a state to implement large payment reforms.  Working with may include grants;

"Incentivizing," as in requiring the participation of other payers prior to funding any large pilot programs.

"Working with states" to implement additional reforms, when the state has sufficient influence over the health insurance or delivery system.

The Population Health Blog's take:

"Category 4 population-based payments" are a form of capitation that are ultimately designed to transfer insurance risk from CMS to providers. The PHB hopes the bureaucrats at CMS are aware of the risk re-introducing some 1990s-style managed care abuses. 
What also goes unmentioned by the JAMA article are examples of CMS payment reform unintentionally gone awry, including RVUs, regional payment variation and the SGR with lingering fraud. While CMS has had its successes, it's also had more than its share of problems.  Time will tell which track record will apply to population-based payments.

Convening was an art developed by Medicaid programs.

Ms. Tavenner implies that population-based payments (a form of capitation) are intrinsically linked to quality.  Nothing could be further from the truth, since it's possible to reward quality while also relying on a FFS methodology

Accountable population-based care remains a large experiment.  Ms. Tavenner implies that there is an aura of inevitability.  The PHB learned long ago that the sign of a good plan is an exit strategy in case things go south.  The PHB didn't read that here.

When It Comes to Nurse Care Managers in Primary Care Settings, It's Not "Build or Buy," It's INVENT or Buy

Seen one of these lately?
The Passenger Pigeon. The Dodo bird.  The primary care clinic nurse.  All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they've last seen these species and you're likely to get the same baffled look that the of DMCB spouse gives when she's asked about her compliant husband who does what he's told.

Yet, the Disease Management Care Blog wasn't aware of the primary care nurses' total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs.  "There are no 'nurses'" she said. "They've all been replaced by office assistants and the docs are trying to get them to do the patient education."

Which makes sense. While articles like this have been lauding health care "teams" made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms.  True, some of the larger health systems with a stake in primary care have kept nurses in the mix, the DMCB thinks that's merely part of a market-preserving loss-leader strategy.

The DMCB looked for medical literature on the topic.  It can't find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape.  If it's wrong, it wants to hear from its readers.

If true, what are the implications?

  • In large swaths of the primary care landscape, there is no "build or buy."  It's invent or buy.

  • What's more, younger PCP's are even less familiar with the notion of an office-based nurse, let alone partnering with one.  Physician knowledge may have gone extinct too.

  • No wonder the Patient Centered Medical Home hasn't caught on.

  • I Waited Patiently... He Inclined Unto Me, and Heard My Cry

    Along with millions of other Americans, the Disease Management Care Blog spent a Friday night in front of the TV, transfixed by the unfolding Boston Marathon manhunt. If it had been on the streets of Watertown, it too would have applauded the fine work of the law enforcement personnel when they successfully nabbed Mr. Tsarnaev.

    But there is little to celebrate here. Two more young men were caught up in a sociopathic ideology, their victims have months of healing in front of them and America's been reminded of just how vulnerable and tough we are.

    We live in an imperfect world and will be figuratively singing this hymn a long, long time.


    Sunday, April 19, 2015

    Expert Jargon Run Amok: Doesn't Work for United Airlines or Primary Care

    During a recent plane trip, the Disease Management Care Blog was shown a pre-flight video that featured the airline's CEO extolling the coming improvements of the "on board product." Inspired by this precise terminology, DMCB announced when it got home that it would like to be called a "spousal support service provider" and that henceforth, household chores would be better referred to as "domiciliary task units." The spouse responded by observing her husband was being an "oxygen deprived moronic nitwit" thanks to the stress of too many hours at 35,000 feet. After a chilled beverage close to sea level, the DMCB returned to its senses.

    Behold what happens when experts pickled by the jargon of their closed information loops are exposed to an unprepared lay public. And our health care industry leaders are no exception. Listen to them, and you'll no longer believe patients see their doctors to get better.  Instead, they're "health care consumers" who interact with their "patient centered medical homes" in "episodes of care."

    While there isn't anything wrong with the phrases, the DMCB's point is that when it spills into the public space, the overinterpretation doesn't inspire much confidence. Better to leave that kind of terminology in the corporate planning suites, along with all those other unpleasant terms like "primary care loss leader," and "market competitive CEO compensation."

    How about telling the DMCB that the airline is working to "upgrade" its "flying experience" with improvements in the "cabin design?" Or that "persons" can now "count on" their "health care team" to be there "from start to finish?"

    Image from Wikipedia

    A Special One-Hour Webcast That Includes the Disease Management Care Blog!

    Disease Management Care Blog readers can become smarter than they already are and be among the first to learn about a new Care Continuum Alliance (CCA) "road map" for population health management (PHM) in primary care and how embedded PHM strategies can support and complement the patient-physician visit in a special one hour CCA webcast!

    CCA member research leader Jaan Sidorov, MD, MHSA, FACP, will present the CCA's new Population Health Management Road Map for Primary Care, and MedAssurant community-based chronic care experts Ashwini Davison, MD and Toni Kfuri, MD will discuss:

    • The value of using face-to-face nursing assessments and coaching.
    • How face-to-face coordinates and collaborates with physician care.
    • Ways to coordinate with local community resources.
    • Examples of chronic care support in community settings.

    CCA makes this valuable presentation available for only $39 (members) and $59 (non-members).  The DMCB says that's a bargain.

    You can register here

    Saturday, April 18, 2015

    Hewlett Packard and the Disease Management Care Blog Part Company

    Most DMCB friends, colleagues and enemies are aware that it had a half-time job at HP as a Medical Director of Analytics.  Two days ago, as part of reduction in force involving over a 100 individuals, its position was eliminated.

    First and foremost, the DMCB is very grateful for having gotten to know so many smart and dedicated information technology professionals. They are a credit to HP and are the very definition of high worth human capital.  They also taught the DMCB about the value of relationships underlying countless emails and conference calls that form the living fabric of a world class IT company. 

    Some of the very smart ones even read this blog.  The DMCB hopes they stay in touch.

    Working for HP was also a DMCB eye-opening educational experience.  Among the more important lessons learned:

    The Cultural Crosswalk: While many of the DMCB physician colleagues work in small business settings, our health care culture - despite its imperfections - is imbued with a commitment to social mission and patient service. That contrasts with HP's culture of maximizing shareholder value and the customer always being right.  That mix of non and for profit incentives accounts for much of what is both very good and not so good about the U.S. health care system.  That being said, some health care providers could learn a lot from from HP's approach to "customer facing" interactions.

    The Gold Rush: The DMCB has come to believe that, just like and mortgages, there is a health care bubble underway. While that's been obscured by a moribund economy, a perfect storm of boomer demographics, consumer demand and government largess continue to fuel increasing employment and capital investment in the health care sector. When that kind of gold rush builds, success has less to do with "prospecting" and more to do with selling shovels.  While ACOs are taking considerable risk and medical home advocates think $3 per patient per month is a good deal, companies like HP are selling network architecture and servers at a very tidy profit.

    Sales: There is no underestimating the days of strategizing, worry and planning that go into a seemingly innocuous customer sales meeting.  In the past, when the DMCB was on the "buy-side," it thought of vendor meetings as a one hour pitch.  It has since learned that the "sell-side" is an expertly crafted event designed to define the problems, present the solutions, forge relationships and land a maximally profitable contract. The DMCB will never underestimate a sales representative again.

    The Social Contract? While the DMCB grew up in an era of employment being a lifelong commitment to a company that ended in a gold watch and a retirement party, those days are long gone. Employment is now a mutual agreement to exchange a work product for compensation. The DMCB witnessed the transaction being unilaterlly cancelled by co-workers as well as by the company many times. While the DMCB was on the receiving end this time, it knows that its exit from HP is just business.


    The Latest Cavalcade of Risk Is Up!

    The latest Cavalcade of Risk is up at Jason Shafrin's Healthcare Economist.  As usual, the contributing writer-bloggers have done an outstanding job of examining the latest thinking surrounding the art and science of business and insurance risk.

    Jason has an additional insight to share:

    According to, in 2015, there were 658 marathons in the U.S. and Canada.  Thus, the probability of a bombing of a randomly selected marathon in the U.S. or Canada is about 0.2% if one assumes one bombing per year.

    The Chicago Tribune reports that 100 people were injured and 3 people died.  In 2015, 528,375 individuals finished a marathon.  Thus, the probability of being injured at a marathon due to a bombing is 0.02% and the probability of being killed is 0.0006% or fewer than 1 in every 150,000 individuals.

    About 1 in 100,000 marathon finishers die during or in the 24 hours immediately after a marathon, according to The New York Times.  Thus, marathoners are at higher risk of dying of a heart attack after a marathon than from a terrorist attack. 

    Friday, April 17, 2015

    Cavalcade of Risk #155

    Welcome to the Disease Management Care Blog's hosting of this 155th Edition of the Cavalcade of Risk.

    If this is your first visit to a Cavalcade, think of it as a linked collection of the latest observations from a variety of blog authors on the broad topics of insurance and business risk. Since the DMCB frequently examines health insurance, it couldn't turn down the chance to be this edition's host.

    And without further ado......

    Are you interested in the intersection between insurance concepts and actuarial mathematics? Here's you chance to find out if that's just a passing fancy or the real thing when you read the Healthcare Economist Blog's review of an academic paper on the pernicious asymmetry of "private information" in the individual health insurance market.  While the MIT analysis may explain the uninsurability of some persons, the DMCB has gotten a new appreciation of the unreadability of the actuarial literature.

    In contrast, the PT Money Blog provides a very readable posting on an informal survey conducted by the PTMB of some other finance-writer-bloggers about the wisdom of buying long term disability insurance. It turns out that cheap disability insurance is typically available through employer arrangements or trade associations, while individual policies are unaffordable. Yet, those who are lucky to get the insurance would be well advised to read the small print to determine if the long-term pay-outs are indexed to inflation. The DMCB was interested to see that some of the survey respondents were interested in insuring their blogging income.  In response, the DMCB spouse points out that it's time to reconsider the DMCB's resistance to revenue-producing ads, pop-ups, faux surveys, endorsements, product placements and promotions.

    What happens when an insurance expert's house burns down? Well, one thing Marcus Cree does is write about it in the Risk Management Monitor Blog. It turns out that managing a home fire involves risk assessment prior, using the contingency planning during and mitigating the effects after the tragedy. It also involves blogging about risk assessment, contingency planning and mitigation and then making the DMCB blog about the blogging about risk assessment, contingency planning and mitigation instead of checking its smoke detectors. Ironic? You be the judge, because instead of reading this, you could be checking....

    And what happens when a smart blogger reads about health status and smart phones?  David Williams over at the Health Business Blog shows that readers should be creeped out by the ability of advertisers to correlate their location and network use to come up with some surprising insights about their personal behaviors.  The DMCB asks if advertisers can do this, what could happen when health insurers offer free cell phones to their insureds? What's more, if you're reading this on your hand held device, should nosey third parties conclude that you are uncommonly smart and send you a Groupon offer for half off on a subscription to an actuarial journal? The DMCB says the answer is yes.

    And what happens when a finance professional reads about the awful long term effects of repeated head trauma?  Well, it seems they blog about that too.  My Wealth Builder played high school and college football for eight years and blogs about his worry that some underlying brain damage may eventually catch up with him. The DMCB is happy to report that its approach to avoiding football-related head injuries has been to give the football during any game to whoever wanted it.  In retrospect, that was a savvy risk mitigation strategy,  even if it meant being banished to the chess club.

    If you have mortgage life insurance, you may want to rethink the wisdom of paying that premium, says the Boomer and Echo Blog.  That's because that class of insurers has a reputation for denying claims and continue to charge the same premium even as the mortgage amount declines.  B&E points out that simple term insurance can cover the mortgage and more for a smaller premium.  Which makes the DMCB ask: Where was this sense of responsibility before the mortgage meltdown?

    Are you eating your veggies? Louise of the Colorado Health Insurance Insider ponders the risks of not having a proper produce stand close by and wonders if our calorie dense lifestyle is the real culprit behind our spiraling health care costs.  Be forewarned, however, because the answer may involve a veggie with awfulness that is only exceeded by the turnip: brussel sprouts.  Now that is risk that the DMCB would willingly pay to have transferred.

    Russell Hutchinson of the Chatswood Moneyblog writes on how good direct channels can help to increase the total size of the market by reducing barriers to entry for buyers that need low prices points, ease of access, and channels they can control. This increases access to entry level products that they then trade-up when they subsequently consult financial advisers.

    Many readers have heard about the Jet Blue pilot who loudly and bizarrely acted out after his alarmed co-pilots barricaded the cockpit.  Jon Coppelman of the Workers Comp Insider Blog examines the policy implications of trying to minimize the impact of mental illness, meeting the expectations of a flying public and doing right by the individual patient.  The DMCB will be flying tomorrow and will also try to do right by resisting the temptation to roll its eyes at passengers with no hope of fitting their large bag in that small overhead space or jab that annoying neighbor who is hogging the arm rest.  Otherwise it might also act out.  You've been warned.

    Last but not least, for an example of the DMCB's bloggery, check out this post on the hazards for small physician practices that enter into risk contracts.  Without a sufficiently large base of patients, they can run afoul of the "law of large numbers."  Insurers know this and are understandably reluctant to let a small practice become financially crippled, even if it is a medical home.

    The next Cav of Risk host will be the Free Money Finance Blog.

    Electronic Health Records Not Only Don't Save Money.... They Increase Health Care Costs?

    One outcome of the Disease Management Care Blog's authorship of this manuscript that questioned the merits of the electronic health record (EHR) was an enduring belief that these systems didn't save money. The DMCB doubted that it would increase provider efficiency, decrease avoidable complications, reduce duplicative testing or increase quality. Its best educated guess was that the impact on overall health care costs was neutral.

    According to six members of the United States Senate, the DMCB was wrong. They say the EHR may waste money and increase health care costs.

    That's among the conclusions of Senators Thune (R-S.D), Alexander (R-TN), Roberts (R-KAN), Burr (R-NC), Coburn (R-OK) and Enzi (R-WY) in their just-released report "Reboot: Re-examining the Strategies Needed to Successfully Adopt Health IT."

    They point to the phenomenon of "code creep," which can result from using EHRs to document more extensive patient histories and physical examinations that, in turn, are used to justify an "upcoded" and therefore richer bill with a higher payment.  In addition, the Senators point to research that suggests code creep can be linked to an increased ordering of clinical testing and services.  Last but not least, they point out that once an incorrect diagnosis enters the EHR, it is practically impossible to delete it, leading subsequent providers to mistakenly believe it is still active.

    And to add insult to injury, Reboot describes the response of a "CMS official" who was asked about the above concerns.  The answer was that it would take years for the Agency to better understand the phenomenon.

    The DMCB's take?

    Closer examination of the Senators' report shows that much of the cost concerns are based on lay media reporting instead of any peer reviewed studies.  That being said, there may be merit to the idea that EHRs can game billing systems.  It warrants further research.

    Is partisanship playing a role?  The DMCB can't deny it's a factor, but the same underlying motivation may be underlying CMS's unwillingness to do anything to diminish the Democrats' health reform "branding."

    Last but not least, the Agency's guess that it would take "years" to examine the concern is overly optimistic.  There are outside analytic/research outfits that can do a faster, better and cheaper job of coming up with an answer. 

    The Senators and the U.S. taxpaying public deserve to know if this is true.

    When It Comes to Cancer, Hope at the Margins of Success is Medically Necessary

    Disease Management Care Blog readers saw it here first.

    Months ago, the DMCB presciently argued that cancer patients' appetite for high expense and low yield treatments was based on more than desperation.  It said it was also based on doctors' and patients' quite rational realization that these treatments could rarely result in meaningful life prolongation.  In other words, while an "average" life expectancy from a particular treatment might be reported to be "only" six months, knowing that some persons make it to 12 or more months while others died immediately (zero months) could prompt a reasonable cancer patient to choose a shot at getting the twelve months.

    The prestigious medical journal Health Affairs has finally caught up the the DMCB.  In the latest issue, Darius Lakdawalla and colleagues surveyed 150 persons with either breast cancer (N=47, 20 of whom had advanced disease), melanoma (N=20) or other types of cancer (N=83). 

    There were two surveys dealing with breast cancer and melanoma that presented two nominally equal chemotherapy treatment scenarios.  One used a "hypothetical" survival outcome based on the usual kind of "average survival" statistics.  The other presented a "hopeful" survival outcome that reported a "spread" of survival statistics that included the small number of persons with shortened as well as prolonged lifespans.  The surveys were conducted face-to-face using interviews on representative patients drawn from multiple cancer treatment centers nationwide.

    According to the authors, the survey was designed to test the appetite for risk among cancer patients. Behavioral economists have long known that persons generally prefer the "sure bets" ($100 now) over equivalently valued "hopeful gambles" (a coin flip to win $200 or lose it all).

    It's also known that persons who are not well-off have a greater appetite for the hopeful gamble.  Betting a relatively small amount with a large upside explains the luster of low odds state lotteries for socioeconomically disadvantaged persons. It could also account for the willingness of very sick cancer patients - who have little to lose - to demand long shot treatments, even if they're toxic and experimental. 

    The results showed that 77% of the survey participants preferred the hopeful gamble scenario. 71% of the patients with the melanoma scenario were prepared to "bet" two years of life in return for a 20% chance of living 4½ years. Among the patients with the breast cancer scenario, 83% were willing to bet 1½ years for a 10% chance of living 4 years. 

    These preferences were also accompanied by a willingness to spend a lot of money to access the bet. On average, the melanoma patients were willing to pay at least $45,000, while the breast cancer scenario patients were willing to pay at least $90,000.  Persons with higher income levels were willing to pay even more.

    While the authors correctly note that more research is needed, the DMCB suspects this could explain the decision-making that's leading many cancer patients to demand insurance coverage of experimental, high cost and low yield treatments.  Not only does it make intuitive sense, but popular media extolls the intrepid hero who prevails and gets the girl, wins the talent show or defeats the aliens despite little chance of winning.  We're a culture inculcated with high stakes gambles,especially if there is little to lose.

    The DMCB recalls one of its middle aged patients with colon cancer that had spread to his liver.  After multiple rounds of surgery (half his liver was removed), chemo and radiation, he was swollen, sickly, tired, gaunt and moribund.  He agreed the treatments were pretty bad - until he considered the alternative.

    Assuming IPAB survives, do we really think their pronouncements based on the usual approaches to comparative outcomes will really convince cancer patients to not seek hope?  Will they really determine that hope is not medically necessary?