Sunday, May 31, 2015

The DMCB Speaks

The Disease Management Care Blog is pleased to be among the faculty at the upcoming educational conference Star Ratings Congress for Medicare Advantage Plans.  The DMCB is always happy to hear itself speak, but what it really wants is to be in the audience and hear from the real experts on how to translate HEDIS and CAHPS scores into ACA mandated bonuses and rebates.

 The DMCB will address approaches to engaging primary care physicians in population health management (PHM).  While it's still fine-tuning its presentation, one of the points it intends to make is that physician engagement may be one of those areas where "variation" may not only be necessary but desirable.  Patient populations and physician cultures vary considerably and, as a result, state-of-the-art PHM must likewise be correspondingly adaptable.

The DMCB looks forward to gauging the audience's reaction to this brazen notion and describing it in a future post.

You can register for the Congress, which will be in Las Vegas July 12 and 13, here.

Saturday, May 30, 2015

The U.S. Health Care Debate in Five Bullet Points

"This message will self-destruct...."
The international arm of the Disease Management Care Blog is working on a presentation for the upcoming HauptstadtkongreƟ in Berlin Germany.  Its "Mission Impossible" is to explain the U.S. health care system to a group of German hospital executives in a half hour.

This, in a NuƟschale, is what the DMCB intends to say, using approximately eighteen PowerPoint slides:

1. While rising health care costs, as a percentage of U.S. GDP, has always been a problem, rising health care costs as a percentage of U.S. debt is widely viewed as a highly significant threat. We mean it this time.

2. The conservative vs. liberal debate over how to reduce health care costs for the U.S. government is ultimately about transferring its insurance risk.  The conservatives want to transfer risk to patients in the form of vouchers, while the liberals want to transfer risk to providers in the form of bundled payments and gain-sharing.  The liberals, so far, are handily winning the debate.

3. Risk is only half the health reform story.  The other half is quality. There is bipartisan consensus that a) U.S. health care quality could be better, and b) greater quality will mitigate insurance risk, resulting in fewer medical complications, emergency room visits and readmissions.
   
4. There is additional bipartisan consensus that a) insurance risk can be managed and b) quality can be increased when care is provided in large vertically integrated and regional provider systems.

5. If the twin exigencies of risk and quality are not addressed in the next 3-5 years, disappointment could lead to the unraveling of Obamacare and the introduction of a public payer option.

Image from Wikipedia

Where Did The 2010 Increase In Health Care Costs Come From and Who Is Paying?

Remember the last Health Wonk Review?  The Disease Management Care Blog recalls being impressed by the description of the "Health Care Cost Institute," a not-for-profit outfit that was established to store de-identified commercial insurance claims data for research purposes. The participating health insurers are Kaiser, Aetna, UnitedHealthcare and Humana. The database covers 33 million individuals less than age 65 years with employer-sponsored insurance. The DMCB suspects its personal Aetna claims information is in there, somewhere.

The DMCB is more impressed, because the HCCI has just released its first report on 2009 and 2010 health care cost trends. It's full of insights. 

To wit:

1) If you've wondered why your 2010 personal health insurance cost so much, it's because per capita spending was $4,255. This suggests insurers are not the only problem.

2) Costs in 2010 increased over baseline by 3.3% and was driven by an increase in unit prices (i.e., charges), not by greater utilization or overall mix of services.  This suggests providers are charging more for their services.

3) While costs increased, beneficiaries' out-of-pocket costs grew at a faster rate. In 2009, they paid 15.6% of their bill, while in 2010, they paid 16.2% - an increase of 3.8%.  This suggests that insurers are passing a small but painful amount of the additional 2010 provider charges to the consumer.

The DMCB says bravo to the four insurers for making this information available.  This and promised future reports should shed light on health care cost trends.

Image from Wikipedia

Friday, May 29, 2015

ACO Ver.2.0

Accountable care organization (ACO) enthusiasts may want to check out this article, "'New' Health Organizations Will Truly Manage Care" appearing in the latest issue of Managed Care Magazine. Based on a large provider survey and his own personal insights, author Richard Stefanacci points out that the current generation of Accountable Care Organizations(ACOs) is destined to fall short.

This is how the Disease Management Care Blog pieces together Dr. Stafanacci's narrative:

Hospitals and physicians will continue to pursue merged arrangements characterized by a) shared risk, b) less physician autonomy and c) greater efficiency. Yet, it's still too easy for these first generation ACOs to underestimate the downsides of risk contracting and it's even easier for them to under-invest in care management programs. Add to this the a) "dismal" track record of past physician-hospital collaborations, b) disappointing Physician Group Practice Demo results and c) disconnect between inferred savings and hard dollars, and there is every reason to be skeptical about the ACOs' future.

Even worse, there's a government-generated health care bubble. The looming budget crisis will force Washington DC to retrench.  Many large provider organizations and ACOs, caring for tens of thousands of patients with thousands of full-time employees, will be deemed "too big to fail."  That "popping" noise will announced the start of a very destabilized market.

Coming in the wake of all this underfunded wreckage will be second generation provider-led accountable organizations. They'll use the 2015-2015 time period to build a patient-centered culture, learn about insurance risk, invest in care management and prepare for the lean times ahead. They will focus on a) the 20% of patients who are responsible for 80% of the costs, and b) understand bundled payment arrangements.  That's when having strong physician leadership, fully aligned care management-medical homes and enterprise-wide medical decision support will mean the difference between merely surviving and thriving.

Medicare, Accountable Care Organizations & Medical Homes: Experimental, Potential or "Essential?"

Time to measure some
new Medicare office drapes?
One major and longstanding criticism of CMS' numerous innovation and demonstration projects is that they seldom lead to any meaningful reform of the core Medicare program.  In response, the Affordable Care Act created an "Innovation Center."  Despite legions of lobbyists, a 'third rail' dread afflicting our political class and a powerful Medicare voting bloc, the intrepid folks in the Center promise to deliver insights that will advance quality, lower costs, increase access and spare all sacred cows.

Naturally, the thousands of health care experts who regularly read the Disease Management Care Blog have their doubts.  As a result, they're unlikely to be moved by Karen Davis and colleagues' "Medicare Essential" proposal appearing in the May issue of Health Affairs.

Assuming that the most wildly optimistic Accountable Care Organization (ACO) and medical home pilot programs projections are fulfilled, Dr. Davis et al propose the creation of a new "Medicare Essential" program that would co-exist with standard Medicare and Medicare Advantage.

"Essential's" essential purpose would be to finance ACOs and medical homes.  Given the authors' enthusiasm, the DMCB is surprised that their Health Affairs paper isn't also recommending measuring drapes for the program's new offices.
 
In "Medicare Essential," Parts A (hospital), B (providers) and D (drugs) would be combined. There would be a single overall deductible, followed by low co-pays for primary care and higher co-pays for specialty and emergency room care Preventive care would have first dollar coverage. Pharmaceuticals would be governed by a single national formulary with low co-pays for generics as well as for preferred brands and condition-specific/value-based drugs. Persons in the "Essential" program who are receiving care in ACOs or medical homes (financed with capitation, bonuses, gain sharing and monthly fees) would naturally have even lower co-pays.
 
Using "modeling by the Actuarial Research Corporation" and, as the DMCB understands it, transferring all savings back to the beneficiary, monthly out-of-pocket costs for the average Medicare enrollee could be reduced from the currently level of $427 to $354.  As an added bonus, if the patient used an ACO/Medical Home, the out of pocket would be further reduced to $254.

Case closed, right?

The DMCB isn't too sure.

Don't Measure Those "Essential" Medicare Program Office Drapes Quite Yet: While Davis et al should be commended for sending the savings back to the patient instead of Uncle Sam, their optimistic actuarial "research" projections can't be based on any consistent, statistically significant and real-world published proof.  That's because there is no consistent, statistically significant and real-world published proof that ACOs and medical homes save money.  Come back, says the DMCB, when you have an analysis based on some real numbers.

Behavioral Economics: Furthermore, we don't know if monthly beneficiary savings of $73 to $173 are enough to move market share away from Medicare and Medicare Advantage to "Essential."  That's doubly true if ACOs and medical homes, despite their quality, are viewed by patients as another way to impose a restricted network.

Disease Management Playbook: Advocates for the earliest versions of disease management likewise used official sounding projections to confidently project huge benefits for the Medicare program. When reality rudely intruded, the industry's fall was spectacular and almost fatal.  With friends like Dr. Davis similarly doubling down with huge ACO and medical home promises, who needs enemies?

Reinventing A 3rd Wheel? Many Advantage plans have similar co-pay arrangements and are already investing in ACO-like and medical home programs in their networks. They are likewise more than able to leverage out-of-pocket expenses to incent beneficiary behavior.

Suppose You Gave An ACO Party and Nobody Came? The last time the DMCB looked, many parts of the country lacked fully functional ACOs and medical homes. Dr. Davis says beneficiaries will respond by demanding local access to the Essential program and therefore turbocharge additional health reform. The DMCB is unaware of any published data that supports that notion and, furthermore, wonders if the local lack of these programs will translate into even more variation in the U.S. health care system.

Thursday, May 28, 2015

Does ANYONE Really Know Projected Health Care Costs? Nope!

You sure about that?
According to the White House, the Affordable Care Act (ACA) is obviously responsible for the significant decrease in health care cost inflation over the last three years.
The respected health economist Victor Fuchs, writing in the New England Journal, disagrees.  He points out:

1) there is a strong relationship between growth in the U.S. gross domestic product (GDP) and growth in health care spending: for the last 60 years, when one goes up, the other follows suit.  While the prevalence of illness drives the consumption of health care, it turns out that the prevalence of illness plus a rising income is a stronger driver of health care consumption*.

It's far more likely that the lackluster economy has been responsible for the low rate of inflation.

2) Two to three years is not enough time to guage the impact of any single intervention on health care spending. In his NEJM article, Dr. Fuchs presents a graph showing the relationship between a two year period of spending and what follows over the next twenty years.  It turns out it's a very poor predictor.

So, even if the ACA could have an impact, it's far too early to tell.

In the meantime, skeptics like Bob Laszewski, are pointing to richer mandated insurance benefits and are confidently predicting that health care costs are destined to increase.  Former CBO Director Douglas Holtz-Eakin worries young healthy adults won't sign up, which could further fuel health insurance premium increases.

Who to believe?  A partisan White House?  Skeptics who want a return to market-based insurance?  The DMCB's solution is to believe Dr. Fuchs and confidently state it doesn't know which way things are going to go.

*The only exception to the association between GDP and health care costs was during the mid-1990's when managed care had its stranglehold on the delivery system

Image from Wikipedia

The Limits of the "Return on Investment" Measure in Population Health, Disease and Care Management Programs

But where's the money?
The Disease Management Care Blog has always been leery of the "return on investment" (ROI) metric in health care. It knows that there are precious few health care interventions that actually "save" money. Many prevention, wellness and disease management programs     - depending on the analysis -  can cost money since they a) add additional resources to a system with already high fixed costs with b) a short one-year time horizon.

Yet, the good news is even if a program isn't successful in slowing the rate of cost inflation (or "bending the curve," which represents the savings), it can still represent a great value.  That's because the additional benefit represents significant benefit for each additional dollar of spending.

That's the message in this recent JAMA Viewpoint editorial Assessing Value in Health Care Programs authored by Kevin Volpp, George Loewenstein and David Asch. They offer up a thought experiment. Consider, they say, a state-of-the-art medication compliance campaign for heart attack victims that avoids a number of costly hospitalizations.  The price tag at $2000 has a positive "ROI" because the investment is less than the avoided cost of the hospitalizations.  However, if the price tag is $3000 and the investment is now greater than the cost of the hospitalizations, the ROI is "negative" even though the same number of patients didn't have to be hospitalized.

The DMCB recommends readers keep this manuscript/link handy the next time some Finance weenie demands an "ROI calculation."

Speaking of readers, the DMCB is happy to announce that it just hit 500 Twitter followers.  That's in addition to more than 500 "RSS" subscribers, 461 Google Reader subscribers and thousands of return visitors per month.  The DMCB knows each was earned one person at a time.

Godzilla and VA Wait Times.

As predicted, the Veterans Administration (VA) waiting-list fracas is going from bad to worse.  Seeking refuge from all the bad news, the Population Health Blog naturally responded by inviting the spouse to go see the new Godzilla movie in IMAX 3D.

Mysteriously, she declined the invitation. 

Despite the two-plus hours of lonely and noisy cinematic excess, thoughts about the VA still intruded. As a result, the PHB has created another multiple choice test that tests readers' awareness of popular culture and this corner of health care policy. 

Good luck!

"Breaking Bad" actor Bryan Cranston is casted as scientist Joe Brady who barely survives a mysterious catastrophe at a Japanese nuclear plant. Years later, he (select the best answer):
 
1. is convinced that there is a cover-up
2. is still awaiting the report of the Nuclear Administration Inspector General who has yet to find any wrongdoing by anyone who is in charge
3. has an annoying level of anxiety that, in the opinion of the PHB, warrants industrial-strength doses of Xanax


At several key moments in the movie, there are sudden malfunctions of electronic equipment. That's because (select the best answer):

1. of monster-sized electromagnetic pulses
2. they're networked with the VA's computer system that manages wait lists
3. they're not, as the PHB spouse likes to frequently point out, Apple-based products


Godzilla's arch enemies are two large bugs that (select the best answer):

1. have unbalanced the natural order and must therefore be destroyed
2. the White House first learned of when they read the news reports
3. are a couple and - thankfully - were not filmed when the female's eggs were fertilized prior to their implantation in the ceiling of the San Francisco subway system.


Godzilla's rampage results in numerous American military injuries.  That's (select the best answer):

1. because the monster has very big feet
2. OK, because the injured will be able to get care outside of the Veterans Administration health care system
3. the result of the generals failing to heed the lessons of the 1960s Godzilla movies that repeatedly demonstrated tanks and machine guns are to no avail.


At the end of the movie, Godzilla appears to be taking a dirt nap. He (select the best answer):

1. is merely tired and has decided to rest
2. is providing us with a useful reminder us that even prehistoric creatures had to deal with wait-times.
3. awakens when a San Francisco veterinarian ill-advisedly attempts to obtain a nasal biopsy.


The Latest Health Wonk Review is Up!

There's right and wrong, but when it comes to health policy wonkery, you can also be Wright.  As in Wright on Health, which is hosting the latest Health Wonk Review.  This is a linked summary of the brightest bloggery for your reading pleasure.

Enjoy!

Wednesday, May 27, 2015

Big Data, Definitions and Population Health

What's the likelihood of diabetes?
Utter the term "big data" at any ACO, care management or managed care meeting, and one of two things will happen:

1) Your colleagues will admire your population health chops and your boss will be reminded that you deserve a raise, or

2) Your colleagues will tire of your faddism and your boss will wonder, once again, just what "big data" means

Either way, you may want to refer your colleagues and boss to this readable "on-line first" article appearing in JAMA.

Here's a handy PHB summary:

"Big data" can be defined as the linking of disparate large data sets to provide insight at the individual level.

It's been used by political campaigns (swing voters), business (expectant mothers) and the NSA (potential terrorists). Once they are identified, amenable voters can be individually lobbied, expectant mothers can be sent personalized coupons and evil-doers can be visited by Jack Bauer.

According to Weber and his co-authors, how should health care providers approach big data?

1) Inventory the available data sets.  Traditional examples include electronic health records, insurance claims and pharmacy data.  Big data architects should also be aware of non-traditional examples including social media, census records and credit card purchases (such as grocery store purchases, fitness club memberships or over-the-counter meds).

2) Anticipate "probabilistic matching," since two or more individuals may fulfill criteria.  This will involve trade-offs between accuracy and feasibility, since two individuals matching "John Smith" in a single zip code may appear to have the same risk. 

3) Worry about HIPAA. Unfortunately, while medical data sets are disparate, they're also walled off by privacy concerns and special regulations that govern genetic and mental health data. It's not insurmountable. The health care industry should also participate in the public square to and help shape evolving societal and legislative standards over privacy.

Fortunately, the population health industry (here's a modest example) is already engaged. They understand that big data can be used to estimate individual risk which can, in turn, guide outreach to individual patients.

Image from Wikipedia

More On The Politicizing of Preventive Health Care: Keeping the Feds Out of the Way

Guideline experts at work
Max Levin of the Health Diplomat Blog isn't sure about the DMCB's suggestion that guideline interpretation for health care coverage decisions (including preventive care)be decentralized.  While pushing responsibility down to the local health plans and provider organizations would certainly defang the powerful special interests, Max points out that without a nationally recognized guideline "Good Housekeeping" seal of approval, charlatans and hucksters will be able to foist their pseudo-clinical recommendations on an unsophisticated and unsuspecting public.

Max has a point, but the DMCB isn't changing it's mind:

1. When one big national guideline gets it wrong, the damage involving thousands of patients can be considerable. Examples include years of supporting preventive estrogen for post-menopausal women and aggressive blood glucose control among persons with diabetes.

2. While advocates and lobbyists are just as able to swindle unsuspecting managed care and ACO leaders, they'd need to do so among hundreds of provider organizations.  When power is concentrated in Washington DC, all they have to do is convince one Congressman.

3. In the DMCB's experience, health insurers and ACOs are not only highly expert, but more skeptical when it comes to interpreting clinical trial data and deciding the fit in coverage decisions. For an example of their first-do-no-harm conservatism, recall how managed care refused to cover bone marrow transplants for breast cancer.

4. Last but not least, even Atul Gawande pointed out how "local" health care is.  It's up to communities to create working systems out of the complex fragments of health care that best fits the local population.

The Feds should assure guidelines are incorporated in coverage decision-making.  They can accomplish that through the regulatory process, periodic audits and during the appeals process.  Otherwise, says the DMCB, they should stay out of the way.

Tuesday, May 26, 2015

The Two-Sided Iron Triangle of Cost and Access and What It Means for Health Reform in 2015

From time to time, the Population Health Blog likes to refer to this article on the "iron triangle" of health care reform. Using classic project management theory, it suggests health care planning is:

a) bound by 1) cost, 2) quality and 3) access, and

b) if there are limited resources, health system planners can only optimize two out of three.

Want to decrease costs?  Either quality will go down or access to care will decline. 

Want to increase access?  Docs and operating rooms will spend less time with patients (quality will suffer) or costs will go up, because you have to hire more docs or build more operating rooms.

Suppose you want to increase quality?  Because most interventions that increase quality are not free, it'll cost you.  Alternatively, fixed budgets and resources will have to be tasked to additional needs, so access will suffer.

It's admittedly simplistic, but this framework can be used even by the amateurs in the White House to better define the Veteran Affairs scandal. As the PHB understands it, VA administrators wanted to increase quality (more primary care, better mental health services), but they didn't have the budget to match it. Access declined and, voila, waiting lists developed.

Which brings the PHB to the insurers' dilemma.  The generous narrative is that commercial and government insurers can leverage "quality" and somehow increase access for more persons with insurance and/or "bend the curve" of cost inflation.  The "iron triangle" says that's not true and the PHB agrees.

That's because:

1) while it's possible to statistically assess outcomes in primary care settings, there is a shortage of primary care providers.

2) it's far more difficult to statistically assess outcomes in specialty settings, where there are limited numbers of patients, fewer commonly accepted outcomes and a greater impact of patient variation.

In other words, quality is neutralized. That means health care is a two sided triangle.

Assuming quality is now constant, the PHB now has another reason to predict that insurers will have only two options in 2015:

1) increase access to care for more persons, but that means increasing, not decreasing costs. That means higher out-of-pocket costs for patients, or lower reimbursement for providers.

2) lower costs, but that means decreased access to care. Providers will refuse to contract or more restricted provider networks be created.

Image from Wikipedia

Sunday, May 24, 2015

Why Population-Based Care and Disease Management Can Increase Access to Primary Care

If the population health management (PHM) service industry needed just one evidence-based medical journal article to justify its existence, it couldn't do better than this. Writing in the New England Journal of Medicine, Amireh Ghorob and Thomas Bodenheimer advocate for Sharing the Care to Improve Access to Primary Care.

The authors argue there can be only one solution to the twin challenges of dwindling primary care physician (PCP) numbers and the increasing burden of chronic illness : reallocating clinical responsibilities away from PCPs to empowered non-physician team members. These responsibilities include, but are not limited to a) prescription drug monitoring, titration and renewals, b) scheduling and processing of routine blood testing (like cholesterol) and imaging studies (like mammography), and c) counseling patients about lifestyle changes, medication adherence and their preferences, priorities and goals for their chronic conditions.

In order for all this to happen, Mr. Ghorob and Dr. Bodenheimer suggest two ingredients will be necessary: 1) payment reforms that make teaming profitable and 2) physician compromise over their long-cherished notions of control.

That's precisely the approach that has been used by the PHM vendors for decades.

They have nurses, they rely on the teaming, they can manage routine prescriptions, testing and counseling and they can do it for a relatively small monthly fee. They've also learned their lesson: the vendors are doing a much better job of navigating through the doctor-patient relationship and discerning the important differences between clinical responsibility and busy-work control.

A far less important issue is the location or level of service provided by the non-physicians. 

The Disease Management Care Blog argues that sorting that out is a local decision based on physician preferences, pre-existing clinical infrastructure, history and organizational culture. Highly integrated systems may prefer to achieve teaming by transforming their primary care sites into medical homes. Less integrated networks may prefer a shared services model that in or outsources the teams. 

The point is that there is no one-size-fits-all approach to relying on teaming to increase access to primary care. Dr. Bodenheimer has confirmed which are the basic ingredients.  Now it's time for the rest of the system to figure out the details.

Saturday, May 23, 2015

The Health Wonk Review, Come Back, We'll Leave The Light On For You Edition

The Disease Management Care Blog (DMCB) welcomes readers to this edition of the Health Wonk Review. The DMCB is a physician-writer with knowledge and experience in primary care, health insurance, population health and health information technology. That's why it's delighted to host this compendium of recent writings from the best health policy bloggers offering insights you won't find anywhere else. Read this and the DMCB assures your Huff Po addled colleagues will admire you and your USA Today reading opponents will envy you.

For example, this HWR has a conservative who actually likes health insurance exchanges and a progressive who is disappointed with a key aspect of the Affordable Care Act. There's also a unique description of an important collaboration among competing commercial health insurers and a thoughtful discussion of the downsides of preventing HIV infection.  You'll also find a detailed report on how the evening news blew the coverage of an important cancer screening guideline update.

And don't be put off by the wide ranging number of posts.  Read what captures your interest, follow the links and come back as often as you like.   The DMCB will leave the light on for ya.

HOSPITALS

Hospital Quality

Most readers of this Health Wonk Review are undoubtedly sophisticated and dispassionate experts on hospital quality, consumerism, patient satisfaction and outcomes.  Well, Neil Versel of the Meaningful Health IT News blog shows us how that learning contrasts with watching a terminally ill loved one with Multiple System Atrophy struggle with distant physicians, medication errors, incomplete care planning, lack of basic health services, ignored advance directives and occasional Keystone Kops style encounters with health workers who should know better.  And we wonder why Americans are so fed up with the U.S. health care (non) system?  Egads, says the DMCB.

A Medicare Hospital Measure Called "MSPB"

Speaking of hospitals and quality, CMS has started to publicly report peri-hospitalization health care costs using a metric called the Medicare Spending Per Beneficiary (MSPB). According to Jason Shafrin of the Healthcare Economist Blog in this post titled "Measuring Hospital Efficiency," Medicare is now reporting a roll-up of all payments made to docs and the facility three days prior, during and 30 days after a hospital stay. Non-surprisingly, some areas of the country have much higher MSPBs than others. Yet, despite its merits, Jason reports that the measure is not without controversy because we don't know enough about the link between the MSPB and outcomes (does more spending result in high quality?) or if reported higher costs were the the result of waste (for example, unnecessary or redundant testing) versus additional necessary care (perhaps extra days in a rehab facility after discharge were worth it).   The one thing the DMCB does know is how necessary it will be to use the acronym "MSPB" the next time it steps up to a microphone at a health policy confab.  It can't wait.

"Observational Status"

When is an admission to the hospital not an admission?  That's the conundrum tackled by Dr. Brad Flansbaum of The Hospitalist Leader blog, who helps the reader understand how hospitals use their inpatient facilities to treat outpatients. The key distinguishing factor is a limited 24-48 hour course of care that is aimed at returning the patient home.  Unfortunately, outpatient care is covered with an outpatient insurance benefit that can include significant out-of-pocket expenses.  Medicare has policies that require providers to inform beneficiaries of the financial impact of being in "observation status" but as the line that separates inpatient and outpatient care continues to be blurred, it's likely we'll have to wait for global payments or shared risk arrangements to reconcile patient coverage expectations and billing systems.  Until that happens, Brad has quotes a Medicare official who assures us that CMS is "considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system."  Right.

HEALTH SYSTEMS

Accountable Care Organizations

While the mainstream focuses on Medicare's ACOs (for example), Blue Shield of California, CalPERS, Hill Physicians Medical Group and Dignity Health quietly partnered back in 2007 on a shared savings program that apparently resulted in a noisy $20 million in savings.  Glenn Melnick and Lois Gree over that the Health Affairs Blog have authored an interesting interview-narrative about this initiative that is full of interesting lessons. These lessons include the importance of physician buy-in and participation, a system-wide working familiarity with old-fashioned capitation, a supportive pre-existing provider culture, an emphasis on reducing readmissions, using wellness to reduce use of pricey bariatric surgery services, data liquidity, increasing use of evidence-based guidelines at the point of care, patient "repatriation" from non-participating care settings, data dashboards and empowering non-physicians to engage patients in self-care.  The California HealthCare Foundation has committed to completing a full evaluation of the outcomes next year. The DMCB commits to using some new health policy jargon it discovered in reading this post: "actualize" and "head in a bed."

"Charismatic Leaders"

Roy Poses of Health Care Renewal continues to expose the folly running rampant in the U.S. health care system, this time by looking at the "CEO as False Messiah." Dr. Poses cautions readers to pause any time they run into local or national leaders who are uncritically hailed as "visionary."  It's far more likely that their fawning admirers have been seduced by a toxic level of charisma that often leads to catastrophe.  Get real, advises Roy, and admire such folks for being smart while keeping a skeptical eye on their ability to produce results.

PROVIDERS

The Doctor-Patient Relationship

David Williams of the Health Business Blog uses a Health Affairs article on "shared decision making" to reflect on the upsides of being labelled a "difficult patient."  Researchers found that an important barrier to forming a doctor-patient relationship is the fear among health care consumers that expressing a preference will annoy their doctor.  David argues that's not such a bad thing, especially since modern consumers now have the option of seeking a second opinion, getting another doctor and ultimately refusing a questionable treatment. The DMCB really agrees with David's perspective because it wants to be liked by him.

DRUGS

HIV Prevention Is Good News, Right?

 Nate Ogden of the InsureBlog walks readers through a fascinating exercise on the costs and ethics surrounding the FDA's approval of HIV-prevention drug called "Travuda." While readers may initially want to hail this medical breakthrough, Nate suggests it's not so simple: 1) the retail cost of the drug is $11,000 a year, which a) contrasts with the $30 a month cost of equally effective condoms and b) would be enough to treat 20 HIV positive patients, 2) persons taking the drug may misuse their new found protection and paradoxically engage in increased risk-taking sexual behaviors and 3) coverage may be mandated as an insurance benefit, which means there'll be one more driver of health care costs for all of us.  Another silk purse turned into a sow's ear, says the DMCB.

Would You Like Some Drug Monitoring Along With That Refill?

Never at a loss for words, Joe Paduda of Managed Care Matters takes umbrage with Missouri State Senator Robert Schaaf's opposition to the state's "Prescription Drug Monitoring Program Act." Joe argues that the act would reduce the incidence of drug-drug interactions and lessen prescription drug abuse through doctor shopping.  Without passage of the bill, says Joe, kids will lose their moms, Scout troops will have to meet without their den mothers and schools will have teacherless classrooms.Dr. Schaff, who by the way is a family physician and leads a prominent physician liability insurance carrier, has a different perspective. The DMCB predicts the Senator will not find Joe's disapproval very compelling.

HEALTH INFORMATION ANALYTICS

Health Insurer Data Mining

If it's one thing that Medicare has done better than the commercial insurers, it's making its claims data available to health services researchers.  The DMCB suspects that the commercial insurers have been reluctant to do so because of the considerable effort involved, concerns about inadvertently running afoul of HIPAA's unwieldy confidentiality provisions, giving their competition otherwise confidential information about payment rates and the lack any relevant value propositions. According to Martin Gaynor at the curiously named Wing of Zock Blog, those barriers have finally been overcome. Aetna, Human, Kaiser and United have all agreed to ship billions of lines of claims data to the not-for-profit Health Care Cost Institute which will make the deidentified data available to researchers.  The DMCB agrees that this is a significant development that will allow researchers to mine insights that, thanks to relatively low numbers of patients, non-generalizable health care settings and limited imagination, have been out of reach. The DMCB hopes the data will be made democratically available on as close to an "open source" basis as possible.

HEALTH INSURANCE

 Group and Individual Insurance Markets

Need a quick lesson on the fundamental differences between group and individual health insurance policies?  Louise over at Colorado Health Insider has a terrific "101" on health insurance guaranteed issue, mandates, underwriting, the role of high risk pools and the impact of Affordable Care Act. The DMCB recommends that everyone - except the White House - bookmark this page just in case we're forced by the Supreme Court into a health insurance reform do-over. The White House is being given a pass by the DMCB because if that happens, no one will really care what they think.

Speaking of the Individual Market....

In case you think all progressives uncritically support the Affordable Care Act, Maggie Mahar at the healthinsurance blog inconveniently points out that a big part of the individual health insurance market will remain broken come 2015. Maggie's post offers up some compelling statistics that demonstrate that many middle aged boomers (yikes, including the DMCB) who are between ages 50 and 64 years won't meet income thresholds for subsidies.  As a result, they're looking at the prospect that health insurance premiums could reach an unaffordable average of $7500 a year. Combine that with a lackluster job market, declining incomes and substantial out-of-pocket costs and it is clear that health reform will remain a contentious, time-consuming and difficult work in progress for years to come. In the meantime, the DMCB will wonder about the affordability of essential benefits, the merits of value-based insurance designs, how population health-based care management can help blunt the impact of chronic illness and the wisdom of  using limits on age rating to shift costs to the DMCB spawn.

STATES

One State's Perspective on Federal Health Reform

While California's budget slides into the sea thanks to an unending budgetary earthquake, every dollar counts. That's why Anthony Wright of the Health Access Blog points out that in addition to the patently obvious merits of assuring access, lowering costs and protecting consumers, the Affordable Care Act is also a windfall for the Golden State.  He quotes and links a California-based Bay Area Council Economic Institute report that calculates that the ACA will add close to a 100,000 new California-based jobs and $4.4 billion in additional state output.  Alas, says the DMCB, between the U.S. Supreme Court and less-than-expected taxable income from the disappointing Facebook IPO, it looks like fixing Sacramento''s budget woes may need a Plan C.

How Should States Respond to Health Insurance Exchanges?

Conservatives hate those ACA-mandate insurance exchanges, while progressives love them, right?  And any Republican Governor that sets up an exchange under the terms of the ACA is a hypocritical closet-supporter of Obamacare? Is that so?  John Goodman's Health Policy Blog point-counterpoint posting teaches us that it's not so simple.  It turns out that states 1) may fare better with or without the ACA if they maintain control over exchanges, 2) could use the flexibility that comes with control to make insurance exchanges more effective and fair, and 3) with that control will also have a say over the commercial insurance subsidies that will add up to gazillions of dollars.  Just in case you think John's post is just a lot of hot air, check out this telling Pennsylvania-based Op-Ed.

WORKERS COMP

Links Between Worker's Comp and Health Promotion

Many health care providers regard "worker's comp" as something as a policy sideshow, but Worker's Comp Insider Jon Coppelman shows us that this multi-billion dollar industry is not only a big deal but also not immune to the growing costs of our sedentary lifestyle. When a 50 year old fat ambulance worker's stroke was blamed on a lower extremity paradoxical embolism resulting from hours of sitting, the lifelong care costs were ruled "compensible." Next stops are the diabetes-causing donuts on our way to work and the hypertension from those generously salted fries in the company cafeteria. Mr. Coppleman recommends early adjuster involvement in the claims adjudication. The DMCB wonders if the Workers Comp insurance industry should think about being more proactive, including using risk stratification and advocating for common sense health promotion.

WELNESS AND HEALTH PROMOTION

Wellness!  Gotta Have It!

No Health Wonk Review would be complete without one enthusiastic endorsement of all things wellness. Kat Haselkorn of Corporate Wellness Insights steps into that role with copious praise of all the benefits of health promotion, including positive culture change, huge returns on investment, enriched social networks and accelerating employee productivity.  Kat suggests that if just one person buys into wellness, the effect can ripple through the company faster than spandex-clad yuppies swarming at an after-work Zumba class.

Wellness!  Gotta Keep Funding It!

New blogger Tracey Moorhead of the Care Continuum Alliance writes in the Voice On Population Health Blog about the ill-advised willingness of the U.S. House to steal from the ACA's Prevention and Public Health Fund to extend coverage of student load interest subsidies. Tracey passionately argues the fund has already led to important behavioral health screenings, data infrastructure development and expansion of wellness services in multiple states. Whoa, says the DMCB, which isn't surprised at the Care Continuum Alliance's advocacy on behalf of prevention and population health.  Good for them.

And Here's An Added Benefit of Being Fit?

Michael Gavin of the Evidence-Based blog notes that a recently published article in the medical journal Pain shows that athletes have a higher pain threshold.  From his point of view, this is why exercise should not only be promoted as an alternative to using dangerous drugs to control pain but as an added overall benefit from achieving maximum fitness.  The contrarian DMCB took a look at the abstract and wonders if persons who are naturally blessed with higher pain thresholds are attracted to exercise (or at the very least, find it less unpleasant).  While readers are figuring out which is cause and which is effect, they can also show their health knowledge chops by not only referring to exercise related "endorpins" but "endocannabinoids" as the basis for the runner's "high."

SPECIAL POPULATIONS

Prisoners

Talk about a disenfranchised population. Suffering with highly prevalent rates of Hepatitis C, HIV and mental illness, huge numbers of released prisoners were being left to fend on their own. Harold Pollack, also of the healthinsurance blog describes how thanks to recently passed federal legislation, hundreds of thousands of these individuals will be able to qualify for Medicaid, obtain tax credits that can defray the cost of private insurance and access basic community-based health care services. While health reform is all about the single mom waitress with two kids, the middle America steel worker and the kid with end stage cancer, Dr. Pollack says we all benefit when ex-prisoners are also staying away from crowded emergency rooms, avoiding unnecessary hospitalizations and not burdening over-stretched safety net programs.

Geriatrics

IF you believe geriatric care is important, THEN you should read this post BECAUSE you'll get to learn about the "ACOVE" framework. That's the message the DMCB got after reading Chris Langston's post on the Quality of Geriatric Care over at the John A Hartford Foundation. It turns out that the Assessing Care of Vulnerable Elders is a handy IF-THEN-BECAUSE tool that identifies the specific health issues afflicting the elderly and targets geriatriccare planning. Chris argues wider use of ACOVE would increase quality of care in geriatrics and clarify the important differences between general medical versus geriatric conditions.

CODING

Hate ICD-10?

Here's another anti-ICD-10 rant, courtesy of a post by TBD Consulting's Jonena Relth at the Healthcare Talent Transformation Blog.  She argues that veteran front-line health care workers are deeply skeptical about the ultimate value of the insurance billing system's astonishingly complicated specificity and detail. Jonena is concerned that the new coding will paradoxically lead to billing errors and enable greater health insurer mischief. Too bad there wasn't any credit given to the AMA for CMS' decision to delay implementation of ICD-10 as well as the organization's continuing advocacy on the issue. As for the health insurers, the DMCB thinks that given the circumstances of a very hostile Administration and the luster of an ACA-driven enrollment windfall, they quietly came as close as they could to expressing concerns over the wisdom of ICD-10.

and last but not least.....THE NEWS DISAPPOINTS...AGAIN

Prostate Cancer Screening and the News Media

As risks, benefits and alternatives to cancer screening move into the public square, Gary Schwitzer's HealthNewsReview blog offers up this balanced scientific review on the merits of prostate cancer screening by Richard Hoffman and this insightful description on how the mainstream news media made a mess of things. It turns out that the U.S. Preventive Task Force's recommendations weren't really all that new, that a substantial number of physicians have been PSA skeptics for years and that early detection of prostate cancer - whatever its merits - is hugely remunerative to providers. As testimony to the news elites'  selective inattention, ask yourself if you should thank Diane Sawyer et al for avoiding this new wrinkle on the topic of lung cancer screening.

Image from Wikipedia


A Cavalcade of Risk Is Up!

Better late than never, so the DMCB wants to alert readers to the May 16 edition of the Cavalcade of Risk that is ably hosted at the "Insurance Claims And Issues" blog.  The Cav is a rotating assortment of the best writings on a topic of insurance and business risk topics.

Enjoy!

Friday, May 22, 2015

Maintenance of Certification in Internal Medicine: What the Population Health Community Needs to Know

Since population health provider organizations work closely with physicians, they're aware that "board certification" is an important credential.  Being "boarded" in family practice, pediatrics or internal medicine is widely regarded as evidence of extensive training.

They may not be aware of the controversy brewing over board certification in the internal medicine physician community.

The American Board of Internal Medicine (ABIM) is the certifying Board for the nation's internists.  After meeting training requirements involving years of training after medical school graduation, candidates have to pass an examination.  Once physicians do that, they have the credential that documents their expertise. 

It used to be that once you did the training and passed the test, you were credentialed as a "board certified" internist.... forever.  With increasing recognition that skills can grow stale with time, in 1990 the ABIM decided to require recredentialing on a periodic basis. 

That process has evolved under the umbrella term "maintenance of certification" ("MOC").  You can read more about that here and here, but it basically involves earning "points" through activities such as documentation of learning, participation in quality improvement, chart audits and taking a repeat test.

Unfortunately, MOC and the ABIM have become a focus of physician ire.  While the academics and organized medical societies' leaders believe in the process, many rank and file practicing physicians disagree

Among their concerns that are nicely documented here and here:

1. It takes a considerable amount of time, documentation, and paperwork to complete the 10 years' worth of continued training/chart audits and to prepare for the repeat examination.  (That's especially true thanks to the difficulty at extracting electronic records data; it also puts smaller practices at a disadvantage, since they may not have the support personnel to help with all those tasks).

2. It's also expensive.

3. If a physician doesn't pass the test, it needs to be taken again at additional cost.  Over the past five years, the failure rate has increased from 10% to 22%.  Since it's unlikely that the pool of docs entering the MOC process are dumber, that suggests the test is getting unnecessarily harder. Some physicians wonder if ABIM has a financial incentive to increase the failure rate. 

4. Unlike the initial process of board certification, there is little hard evidence that MOC-credentialed physicians  attain better patient outcomes compared to non-MOC physicians.

5. Physicians are unhappy that the MOC process does not recognize the practical wisdom that comes with decades of patient care.  It is "one size fits all" and can't be tailored to account for different practice settings.

6. There is a possibility that MOC could evolve from a voluntary exercise in professionalism to a mandatory condition of licensure, hospital/insurer participation or employment.

7. ABIM not only has a monopoly, it has no oversight. Whatever the merits, the ABIM's MOC actions are seen by some as capricious, arbitrary, disconnected to the real world and only adding to physicians' low morale.  One survey suggests a majority of practicing physicians are skeptical about the MOC.

 The Population Health Blog suspects this is a controversy that is not going away anytime soon.  Population health service providers will always be interested in helping their "orphan" patients without a PCP become engaged with a physician, and may use "board" status as one criterion for referral.  It remains to be seen if "MOC" participation should be part of that calculus.

Stay tuned!

A Thursday Three-fer: Diabetes Predictive Modeling, The Threat of Ambulatory Care Write Offs and It's the National Debt, Stupid!

At Risk?
Diabetes Predictive Modeling: Evidence Based, Peer Reviewed and Open Domain:

As Accountable Care Organizations, Patient Centered Medical Homes, care management vendors and managed care organizations continue to grapple with health care costs, they want to know who is at greatest risk in the coming months.  When it comes to diabetes mellitus, John McAna and colleagues (one of whom is the Disease Management Care Blog) is riding to the rescue with their American Journal of Managed Care paper "A Predictive Model of Hospitalization Risk Among Disabled Medicaid Enrollees." 

While the data were based on two states' Medicaid claims data sets, the research may be generalizable to other populations.  Factors that most strongly predicted a future hospitalization were increasing age (especially more than 65 years), a prior pattern of repeated hospitalizations (especially 3 or more) and the Charlson Comorbidity Index. The good news is that all the independent variables and their odds ratios are not-only evidence based, they're available for use by your actuaries and statisticians as quick as you can download the paper (after signing in) at the bottom of page 4.

Rumored Ambulatory Care Write-Offs: An Achilles Heel of Integrated Delivery Systems and ACOs?

In its recent travels, the DMCB was informed by two credible and astute physician-leaders that hospitals that have recently acquired outpatient physician practices are typically "writing off" ambulatory care bills because a) contesting small fee disputes are relatively costly and b) the threat of Medicare "overcharge" or RAC audits is existential.  That's significant because those small charges add up into millions and can mean the difference between a profitable outpatient clinic system and a loss leader.

It's Not the Economy, It's Not the GDP, It's the National Debt, Stupid:

The DMCB also recalls repeatedly hearing that it was President Nixon who first called attention to the growing fraction of the nation's gross domestic product going toward health care. The problem was that no one knew what was the "right" percent of GDP.  Mr. Nixon thought 7% was too high. If 7% isn't, in retrospect, bad, why is the current level of about 18% so bad?  What's so different?

The answer: it really is different this time.  What's bad is that health care is responsible for the lion's share of the separate problem of the growing national debt, which has been directly linked to national security.  Yikes.

Outcome Measures for Both the Patient Centered Medical Home (PCMH) and Population Health Management (PHM)

The Disease Management Care Blog remembers years ago when it watched several captains of the disease management (DM) agree in a meeting that "third party" organizations were in the best position to evaluate the industry's outcomes.  The good news is that that approach minimized the industry's conflicts of interest.  The bad news is that it also led many companies to effectively "outsource" what should have been a core competency of rigorously conducted self-evaluation.  Years later, when the Congressional Budget Office (CBO) could find no evidence supporting DM, the result was an industry-wide near death experience.  

Good thing the Patient Centered Medical Home (PCMH) isn't making the same mistake. In addition to relying on third parties like the National Committee for Quality Assurance (NCQA) to set recognition standards, PCMH advocates have committed considerable time and energy into conducting their own detailed outcomes studies. While the published results haven't been a slam dunk, they have informed the PCMH's continuing evolution.

Enter the Commonwealth Fund with this 12 page "Data Brief" on Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality. The Fund assembled 75 experienced health services researchers who, after numerous meetings, two publications, presentations at national scientific meetings and close collaboration with the NCQA and AHRQ, developed a standard set of PCMH clinical and economic measures. As you might expect, there was agreement about the need for transparency and validated algorithms.  There was less certainty over the approach to standardized pricing and risk adjustment.

Because the document does a nice job of compactly summarizing the recommended outcome metrics in easy-to-read tables, this handy brief could turn out to be a widely used reference document. Unfortunately, while HEDIS®, PQRI, AQA and CAHPS are prominently mentioned, the authors neglected to take advantage of the additional insights provided by the Care Continuum Alliance's Outcomes Report

That'll be important in networks where the PCMH and population health management (PHM) are converging in combined arrangements that use the best of both approaches to care, including measurement.  That's probably one reason why the PCMH's own Patient Centered Primary Care Collaborative links the CCA's document here.

Thursday, May 21, 2015

What Population Health and Care Management Needs to Know About Getting People to Take Their Pills

Suspecting that the poorly controlled [insert name of chronic condition here] is the result of not taking the medication as prescribed, the doctor says: "Remember to take the [insert name of pharmaceutical here]!"

After silently concluding that the benefit of the medicine is less than the cost, hassles, side effects and long-term risks, the patient thinks "Like hell!"

That scenario has probably been played out thousands of times today in clinics across the United States.  According to Zachary Marcum and colleagues writing in the May 22 JAMA, that's costing $100 billion a year. 

Doctors like the Disease Management Care Blog have responded to "medication nonadherence" with entreaties to take the pills as prescribed. When docs take the time to address the issue with patients, research shows it can make a positive difference.

Marcum et al believe physicians can do better if they understand the six types of behaviors that lead to medicines going unused:

1. Insufficient understanding of the link to health and well-being

2. A decision that the benefit is exceeded by the costs.

3. Complexity of the medication management overwhelms the patient

4. Inattention (or what the authors describe as low vigilance)

5. Irrational or conflicting beliefs about medicine

6. Perceived lack of efficacy

What does the population health management service provider community need to know about this?

1. There are a variety of screening surveys that can be used to identify each of the patterns above; unfortunately for DMCB readers, however, there is no single survey that can do it all. 

2. There is also no single intervention that has been shown to consistently increase medication compliance.  Instead, multiple concurrent supports are needed, including education and behavioral support.  This paper by Ho et al echoes that assessment, pointing out that there is ample evidence that other valuable supports include reducing the number of pills, use of special containers, telemonitoring with interactive voice response, non-physician (nurse or pharmacist) one-on-one involvement and regular clinical follow-up with reminders.  Last but not least this paper in the Annals points out that reducing out of pocket patient costs can also make a difference.

Image from Wikipedia

Combine Chronic Conditions and Facebook: A New Start Up Called "Woebook"

It's the Disease Management Care Blog's 31st wedding anniversary. To celebrate, the happy couple is at hideaway that offers what the DMCB spouse refers to as "chaise lounges." She patted one next to her's and asked the DMCB sit, relax and "converse."

That's when the DMCB excitedly pointed out that Facebook's launch has many lessons, including the overlaps between hype and greed, the wackiness of giving money to a 28 year old hoodie-wearing oddball and the certainty that if everyone could only "friend" everyone, cheap solar power would finally prevail.  Inspired by the luster of a multi-billion dollar IPO, it thinks now is the time to cash out the retirement funds, leverage the DMCB's brand and launch its own social media offering called "Woebook."

The User Profile: This will list any and all medical conditions that may reflect a user's, family member's or friend's medical history, or a professional interest or a passing hobby. If you don't know your condition, a partnership with IBM's "Watson" will assign one to you. If you have no condition, a bank of specialists will be on call to make one up for you.

Friends: Communities of the Diseased will spring up, share symptoms and insights and give special meaning to the term "poked."

Marketing: Instead of relying of some claptrap on how targeted and intrusive ads somehow "enrich" the users' "experience," Woebook will be honest and announce its intent to bludgeon users with what they really want: information on pricey brand name drugs and the latest and most expensive medical devices.

Privacy Settings: While the default is HIPAA-level privacy and the threat of unending visits by U.S. Department of Justice bullies, Woebook will maintain a jumbotron in Silicon Valley that will rotate the pages of users who have selected the "maximally voyeur" privacy setting. Banner ads scrolling across the bottom will generate tons of advertising revenue. Best of all, those annoying Millennials in their BMWs will be reminded that something incurable is waiting them just a few years away.

Speaking of Ads: You'll have to give permission to have them appear on your pages. If you accept that option, the DMCB's Woebook will share its vast ad income with you. Users will also have the option of sanctioning spurious, malicious or uncool ads and, if enough votes are collected, the ad and the sponsoring company will be banned. That includes for profits, not-for-profits, government agencies and candidates for U.S President.

Photo sharing: You bet, including but not limited to that unsightly and tough-to-diagnose rash or non-healing sore, x-ray images and scans of the mysterious "this is not a bill" documentation.

The DMCB spouse is unsurprisingly not ready to cash out and commit the 401K. Angel investors are free to call for a copy of the Woebook business plan.

Wednesday, May 20, 2015

Facebook and ACO's Similarities

Investors just ponied up well over $100 billion for a piece of the social media giant Facebook. While Mr. Zuckerberg and his co-founders deserve a hearty congratulations, the Disease Management Care Blog finds some eerie parallels between Facebook and accountable care organizations.  The similarity does not bode well for either business model.

1. The users are not the customers: Facebook sells its users to marketeers.  ACOs sells its patients' health care utilization to insurers. 

2. It's the data and it's not yours: Facebook's targeted ads are constructed off of prior usage patterns. ACO's shared savings calculations are built off off actuarially determined health care utilization patterns.

3. Sovereign hostility: Washington DC views information technology and health care as distractions from the true task at hand: restoring the U.S. manufacturing base.

4. Do you care, really? Now that the wunderkids in charge of Facebook have made their millions, it remains to be seen if they'll work as hard in delivering value to its users.  Ditto for all the salaried docs working for ACOs, who no longer have to arrive early, skip lunch and stay late.

5. The long term: Yahoo once was the darling of internet investors.  Even if ACOs have initial success, is a better care model being developed as you are reading this?

Medical Marijuana and Population Health

Many population health providers may deal with the chronic conditions of HIV, Alzheimer disease, multiple sclerosis cancer, epilepsy, inflammatory bowel disease and mental illness. For those who do, it's only a matter of time until they have to deal with medical marijuana.

Here's a good summary that provides some useful insights:

1) There is precious little peer-reviewed clinical trial data.  Much of the political and regulatory support is based on patient testimonials and the luster of tax revenue. 

2) Dosing is highly variable and dependent on a mix of over a hundred active ingredients, some of which are intentionally manipulated to develop different plant strains.

3) A marijuana pill has been approved by the FDA, but typically goes unmentioned by advocates. Small wonder, since smoking weed allows the user to not only titrate any medical effects, but the euphoria that goes along with them.

4) Absent clinical trial data, short and long term harms are also largely unknown.  There are worrisome reports of structural brain changes, decline in IQ, mental illness and respiratory disease.  Legalization would further increase the public's perception of safety.

5) FDA involvement is minimal.  If contamination occurs (pesticides, herbicides or fungal infestation), there is little hope of a recall.

The authors conclude with the usual academic call for more research.  The Population Health Blog wholeheartedly agrees.

The PHB also predicts the population health vendors and their outcomes registries may become an important factor in better understanding the role of medical marijuana in the management of chronic illness.  In the meantime, an evidence-based approach would suggest that until we have better data, informed skepticism should prevail in the course of patient coaching and decision-making.

Image from Wikipedia

The Limits of Airline Safety When It Comes to Healthcare Quality

Readers of the Disease Management Care Blog are probably familiar with its past references to the airline industry's multiple lessons for health care.

The modern jumbo jet has become an inspiring model of human-systems work-flow engineering and information technology that, in turn, has led to unparalleled flying safety. The narrative used by the DMCB - as well as by the New York Times and Agency Healthcare Research and Quality - has been that if providers would embrace cockpit science, the U.S. health care system wouldn't kill the equivalent of four jets' worth of people every week.

The DMCB still agrees with the peer review literature that tells us there is much to be gained by the adoption of aviation safety principles. With further research and experience, it will likely continue to improve patient safety and save lives.

But it also thinks the lessons from the airline industry are not a safety panacea.  There are limits.

As pointed out by economist William Baumol, many parts of health care are still dominated by "personal" or "handicraft" services that remain very labor intensive. Human beings are more complicated than jumbo jets, which means both diagnosis and treatment have to be tailored to each person's unique anatomy, genetics, metabolism, psychology, culture and social supports, one person at a time.

Instead of a jumbo jet, think about a quartet made up of musicians with violins, violas and cellos playing a complicated musical score.:



Unlike the check lists, information inputs and back-up systems of a modern cockpit, each note has to be executed just right in concert with others. The likelihood of one note being off key or out of sequence is considerable. Fortunately, for the musicians and their audience, all an error leads to is an unsatisfactory concert experience.

For a patient with diabetes and heart failure who has been discharged from the hospital who cannot afford his medicines, who is having drug side effects and relying on an overwhelmed family, the likelihood of one note being off-key is very high. Unfortunately for patients and insurers, a single error can lead to a cascading series of interdependent events that will lead back to the hospital.

For the patient with a new diagnosis of cancer who has a chance at cure with the approach of more radical surgery combined with multiple chemotherapy drugs plus radiation therapy who is a healthy 88 year old, the likelihood of one note being off-key and ending up in the ICU is very high.

For the patient with clinical depression who dislikes taking drugs and tells his physician that he will take his medicine and has no intention of doing so, the likelihood of one note being off-key is very high.

For much of health care, one-on-one care involving docs, non-physicians and other professionals with their patients sweating each and every individual detail will still be necessary for the foreseeable future.

Tuesday, May 19, 2015

The Veterans Administration Scandal: Implications for Health Reform and A Call for Clinical Research Into the Reported Death Rate

As the Population Health Blog understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital.  Approximately 1500 vets were assigned to an "off-the-books" waiting list that made the clinics' official waiting times appear shorter than they really were. Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command.  If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.

And the scandal is flourishing.  Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain.  A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General's investigation prejudgment is that none of the deaths can be attributed to delays in care. You can't make this stuff up.

"Good grief!" says the PHB.  Numerous articles like this, this and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.

Not any more.

That's why the implications of this extend far beyond a huge stain on the VA's reputation.  Once again, taxpayers are witnessing another failure of big government. While this has nothing to do with Obamacare, voters have another reason to doubt Washington's ability to competently deliver on its health care promises.

In the meantime, the PHB offers the VA plutocrats one approach to figuring out if the waiting lists were associated with higher death rates.  It's possible, thinks the PHB, to use propensity score matching within the VA's much-admired electronic health record system to retrospectively create a cohort of patients that were similar in every way except for being on the wait list.  A similar death rate in that group - demonstrated by unbiased scientists outside the control of the VA - would go a long way toward reassuring all of us that this debacle was limited to customer service.      

Image from Wikipedia