Tuesday, June 30, 2015

The Contraception Mandate: SCOTUS Quotes

Liberals are outraged and conservatives are overjoyed.  While the Population Health Blog is neither, it was interested enough to go to the Supreme Court's opinion page, read the majority opinion and and pull some of the more telling quotes:

Just where did the contraception mandate come from?

"....the Affordable Care Act requires ... health-insurance coverage to furnish “preventive care and screenings” for women without “any cost sharing requirements.” Congress itself, however, did not specify what types of preventive care must be covered. Instead, Congress authorized the Health Resources and Services Administration (HRSA), a component of HHS, to make that important and sensitive decision. The HRSA in turn consulted the Institute of Medicine, a nonprofit group of volunteer advisers, in determining which preventive services to require.
The [IOM]  Guidelines provide that nonexempt employers are generally required to provide “coverage, without cost sharing” for “[a]ll Food and Drug Administration [(FDA)] approved contraceptive methods, sterilization procedures, and patient education and counseling.”

Rights of corporations vs. the rights of individuals.

"A corporation is simply a form of organization used by human beings to achieve desired ends. An established body of law specifies the rights and obligations of the people (including shareholders, officers, and employees) who are associated with a corporation in one way or another. When rights, whether constitutional or statutory, are extended to corporations, the purpose is to protect the rights of these people. For example, extending Fourth Amendment protection to corporations protects the privacy interests of employees and others associated with the company. Protecting corporations from government seizure of their property without just compensation protects all those who have a stake in the corporations’ financial well-being. And protecting the free-exercise rights of corporations like Hobby Lobby, Conestoga, and Mardel protects the religious liberty."

Religious liberty?

"...we must next ask whether the HHS contraceptive mandate “substantially burden[s]” the exercise of religion. We have little trouble concluding that it does.  [The objecting parties] have a sincere religious belief that life begins at conception. They therefore object on religious grounds to providing health insurance that covers methods of birth control that, as HHS acknowledges may result in the destruction of an embryo. By requiring ... their companies to arrange for such coverage, the HHS mandate demands that they engage in conduct that seriously violates their religious beliefs."

Does this mean coverage of vaccines and blood transfusions are at risk of being litigated?

"HHS and the principal dissent argue that a ruling in favor of the objecting parties in these cases will lead to a flood of religious objections regarding a wide variety of medical procedures and drugs, such as vaccinations and blood transfusions, but HHS has made no effort to substantiate this prediction. HHS points to no evidence that insurance plans in existence prior to the enactment of ACA excluded coverage for such items. Nor has HHS provided evidence that any significant number of employers sought exemption, on religious grounds, from any of ACA’s coverage requirements other than the contraceptive mandate"

What is the way out?

"The most straightforward way ... would be for the Government to assume the cost of providing the ... contraceptives at issue to any women who are unable to obtain them under their health-insurance policies due to their employers’ religious objections. This would certainly be less restrictive of the plaintiffs’ religious liberty, and HHS has not shown that this is not a viable alternative."

Image from Wikipedia

Monday, June 29, 2015

Wecome to the Family, ACA

All big families go through this sooner or later. 

The upending of a familiar rhythm of behaviors, traditions, relationships and unspoken social rules by the unpleasant intrusion of one who is eumphemistically termed "a significant other." The disagreeable dolt who sleeps in.  The rude boyfriend who won't close his mouth when he chews. The unpleasant uncle who knows it all. In hushed whispers in the kitchen, the regulars wonder: just what in the world does she see in him?

Yet, even as families hope against hope that they'll break up, things settle into a new equilibrium. Loyalties evolve, the relatives adapt, newcomers behave and the traditions evolve. Yes, those were the good old days and he may be a horse's ass, but now he's our horse's ass.

Enter the Affordable Care Act. Whether we like it or not, the Supremes see something in this fat boy sitting in our living room and it looks like he's for keeps. The ACA may be unwieldly, expensive and prone to mischief, but it looks like he ain't going anywhere. Absent an unlikely Republican trifecta involving the Presidency, House and Senate (and that has to be filibuster proof) in the November elections, it looks like he'll be part of the family for years to come. 

Welcome to the family, ACA.

Friday, June 26, 2015

The Link Between Personalized Medicine and Worksite Wellness

Critics look at employee wellness
Only the Disease Management Care Blog can link population health, a JAMA "Viewpoint" article on personalized medicine and a Wall Street Journal editorial on the alleged futility of worksite wellness.

The DMCB explains.

The JAMA article, written by Drs. Goldberger and Buxton, illuminates the cognitive dissonance over guideline-based vs. personalized medicine

The former represents the best care advice for a condition based on a published body of evidence.  Makes sense, but that evidence is typically based on multiple research studies involving populations that are both broad (able to generate statistically significant data) and representative (similar to other patients with the same disease). 

The latter describes tailored medical treatment that is suited to the individual characteristics (and personal preferences) of each patient.  This suggests that within the flow of "populations" that form the basis of a generalized guideline, there are circumstances for some persons that might make a particular treatment of greater or lesser benefit.

While Goldberger and Buxton use a complicated example involving implantable cardioverter defibrillator therapy to illustrate the conundrum, the DMCB has a simpler example.  Current guidelines support yearly mammography in every woman over the age of 50 years. Does that apply for the terminally ill woman in hospice or for a woman who, despite the advice from her physician, decides to forgo the test?

Intellectually reconciling competing policies of guidelines, such as "best practice," "reducing variation," "benchmarks" and "pay-for performance" on one side vs. personalized "informed consent," "patient empowerment" and "clinical judgment" involves subpopulations.  In other words, within any population-based study that shows an intervention is of benefit (mammograms save lives) there are subpopulations where the intervention is of little to no benefit (exceptions to every rule).

Which brings the DMCB to this provocative Wall Street Journal editorial condemning the entire worksite wellness industry. It recycles a number of tiresome criticisms, including outcomes tainted by regression to the mean, over-reliance on process-based outcomes, selection bias, employee discrimination, savings vs. program costs and overdiagnosis.  

Another criticism of the industry is the need for workforce-level (total) savings vs. per-participant savings. Since wellness programs typically focus on subpopulations of employees at greatest risk who are most likely to benefit and willing to participate, the observed savings can be limited to a few patients.  Unless those savings are culled from the large pool of total health insurance claims, they are otherwise invisible and critics will unfairly pounce.

Worksite wellness offers personalized care for limited numbers of patients.  That is its essential value proposition and its curse.  Until we can reconcile the total care via standardized guidelines vs. a more nuanced approach using personal care, it will continue to be criticized.

Surprise, Surprise: The Patient Centered Medical Home Costs Money!

Alt for Norge!
The Disease Management Care Blog is decamping to Norway for a meet-the-family and see-the-sights vacation.  The good news is that Europe is 8 hours ahead, which means the DMCB will know about the Supreme's Thursday decision 8 hours before anyone else.  The bad news is that in the coming days, its posts will become infrequent at best.

In the meantime, check out this just-published JAMA article on the PCMH. 669 primary care centers participated in a Harris survey commissioned by the Commonwealth Fund.  While the "Safety Net Medical Home Scale" was not based on the NCQA, it inquired about the familiar care domains.  The 0 to 100 scale was correlated with financial data from the Uniform Data System reports that reflected the clinics' operating costs.

Unsurprisingly, the authors found that as the medical home score increased, so did the operating costs. Moving from 60 points to 70 points increased the cost per patient per month by $2.26.  While the authors calculated that translated into more than half a million dollars of additional expense for the average clinic, the DMCB notes that kind of expense for an average physician panel of 1500 patients means more than $40,000 per year.

Readers familiar with the cost of disease and population health management will find that $2.26 PMPM statistic very significant because that's in the range of what is charged by many vendors.  What's more, the vendors' charges include a profit margin which was not necessarily included in the clinic's study data.


The PCMH is not necessarily "cheaper" than outsourced care management.

While the PCMH may (statistically significant proof remains elusive) "save money," it appears they have the same challenge faced by the disease management industry in the early days: savings net of fees doesn't necessarily equal profit or a financial gain for the health insurer or consumer.

Thursday, June 25, 2015

A Path Toward Further Health Reform Is Lined With the IRS?

As attention has shifted to phantom IRS emails, misbehaving Iraqis and our newfound national awareness of soccer's off-side rule, it's only natural for the Population Health Blog to wonder about the status of health reform.

Enter The New England Journal with a pair of perspectives on the coming prospects for the Affordable Care Act.

Over on the left, the Brooking Institution's Henry Aaron believes that, notwithstanding ascendant Republican hopes for the 2015 elections, Mr. Obama's veto power virtually guarantees the law's survival.  The only question is whether politics will get in the way of any adjustments.  Once we're into 2015 and beyond, these could include the mandate (weaken any penalties?), Medicaid (spending caps?), the states' roles (allow for local modifications?) and changing affordability standards (increasing income-based premium support for families).

Over on the right, the American Enterprise Institute's Joe Antos agrees there is no going back.  He offers up some potential conservative modifications for 2015 and beyond, such as shifting the insurance premium support to a defined contribution basis (versus a defined benefit), shielding mainstream health insurance by moving catastrophically ill persons to "high-risk" pools and requiring insurers (including Medicare) to leverage consumer education and incentives along with provider teaming to help steer beneficiaries toward lower-cost care options.

Drs. Aaron and Antos both agree that IRS-based enforcement rules may force significant changes.  Under current law, poor persons who underestimated future income for today's premium support calculations may be subject to claw-backs. According to Dr. Aaron, the IRS is responsible for administering that, and any payment would ultimately go to the insurer long after the fact.  Dr. Antos points out that the IRS's enforcement of the mandate could lead to the spectacle of tax refunds being withheld from low-income individuals and families.

The PHB is less sanguine.  While the PHB is no political pundit, the likely increase in the number of Republicans in Congress after 2015 combined with the kick-off of the 2016 Presidential race portends more of the same health reform gridlock. 

The only good news from Aaron and Antos is that growing antipathy toward the IRS may lead Congress to uncouple the IRS and it's enforcement mechanisms from the ACA. It may not be an example of pristine bipartisanship, but if it leads to necessary modifications of the ACA, that's not necessarily a bad thing.

Stay tuned!

Image from Wikipedia

The Important Look AHEAD (Action for Health in Diabetes) Study: No Benefit from Exercise and Weight Loss in Diabetes?

Diabetes? Exercise and then die just as soon.
It makes sense, doesn't it? If persons are overweight and have diabetes, diet and exercise-based "prevention" should translate into fewer heart attacks, strokes and deaths, right?


It turns out that a just-published and high quality research study shows it's not so simple.  What's more, the Disease Management Care Blog brazenly suggests that the disease management/population health vendors discovered this years ago.

The just-published study is here in the prestigious New England Journal of Medicine. The DMCB suspects that, thanks to the mainstream media's fixation on Snowden, SCOTUS, and Shakira possibly hawking Obamacare, this important research may not get the front-page attention it deserves.  Considering that it was ten-year, prospective, randomized multi-center academic study involving over 5000 patients, that'd be a shame.

Here's the DMCB's summary:

Eligibility: Participants had to be between 45 and 75 years of age with adequately controlled (A1c less than 11) "type 2" diabetes, an "overweight" body mass index (BMI) of 25 or more, blood pressure less than 160/100, an ability to exercise and access to a primary care provider. 

Recruitment: This went from August of 2001 through April of 2004. It was also tailored to keep insulin-using participants to less than 30% of the study group.

Interventions That Were Compared: Participants were randomly assigned to an "intensive lifestyle intervention" study arm or a "support and education" study arm.  The intensive group received weekly group and individual counseling for six months that subsequently tapered over the subsequent duration of the study. The counseling included a 1200-1800 calorie diet plus 175 minutes of moderate physical activity per week that was aimed at achieving a weight loss of at least 7% of body weight.  The support group got only three group sessions per year. Medicines and their doses were generally left to the primary care provider.

Outcomes Studied: Participants' waist circumference, weight, blood pressure, medications and exercise tolerance were assessed once a year. Hospital and other medical records were reviewed to assess the number of deaths and cardiovascular events, such has heart attack or stroke.

The Study Population: 5,124 persons were enrolled; 2570 were randomly assigned to the intensive group while 2575 were assigned to the support group. The average age was 59 years, 60% were women, the median duration of the diabetes diagnosis was 5 years and the average body mass index was a hefty 36. Only 4% were lost to follow-up.

Outcomes:  After a median of 9.6 years of follow-up......
  • patients assigned to the intensive group lost approximately three cm. from their waist and six kg. in weight vs. zero cm. and four kg., respectively, in the support group. This translated to a weight loss of 6% of body weight (vs. the target of 7%) in the intensive group vs. about 3.5% in the support group.
  • the A1c, which is a test of overall blood sugar control, was about two tenths of a point (7.4% vs. 7.2%) lower (i.e. better) in the intensive group. LDL cholesterol was also lower. Better control of the diabetes meant that the persons in the intensive group were taking fewer medicines at lower doses.
  • But it was all for naught.  During the course of the study, there were 403 cardiovascular deaths, non-fatal heart attacks or heart-related ("angina") hospitalizations in the intensive group, vs. 418 in the support group. The calculated rates of 1.8 vs. 1.9 events per 100 person years was too small to be statistically significant and was more likely the result of chance or randomness.
The Disease Management Care Blog's take?

The early painful lesson of the "disease management" industry was that a broad life-style intervention applied to a large group of diabetics was not going to meaningfully improve outcomes. Critics believed that while the interventions were conceptually sound (diet, exercise, weight loss), the delivery was flawed

This just published NEJM study would suggest the intervention itself is futile. If so, that is bad news.

"Not so fast!" says the DMCB.

In addition to renaming itself (now "population health"), the industry responded to the science and the critics by retooling.  It learned to channel tailored interventions at population sub-segments who are most likely to experience a specific benefit. Instead of an "intensive" weight loss intervention for all overweight diabetics, population health can use baseline survey, insurance or clinical data to spot (risk stratify) those diabetics who are most likely to achieve a specific benefit that could range from (for example) a sustained 7% weight loss to reduced readmissions.

This NEJM study tried to benefit all diabetics.  A better approach is to find which diabetics will benefit.

As an aside there were some other issues with the study to bring up when debating the study with colleagues and foes:

The BMI of 36 suggests this was a very obese study population that lost only 6% of their body weight during the course of the study.  Since weight was still a health risk at the end of the study, the DMCB wonders if the intervention would have shown more benefit with a less heavy population.

The support group also lost weight and lowered their A1c, which could have obscured the clinically significant benefit in the intervention group. 

This accompanying editorial points out that lower statin and ACE drug use in the intervention group could have paradoxically increased their risk, since these drugs are known to lower the incidence of stroke and heart attack.

The editorial also points out that spin-off studies have already shown that the intervention group benefitted from higher quality of life.

Stacking the Deck in Health Care Policy

If no poster, a statue maybe?
The Disease Management Care Blog is always on the lookout for wall decor for its fashionable world headquarters and all but decided on this framed poster picture. The alarmed DMCB spouse inappropriately intervened, citing a host of silly concerns*.

The politically shrewd DMCB countered the spouse's raw power play by appealing for the input from a stacked deck of friends and family. They appreciatiate the similarities between the bon vivant DMCB and The King, and they also have a sense of humor.  Thusly armed with the support of its handpicked cadre, the DMCB thought the day was won.

Why not?  The DMCB is only copying from the White House's playbook.  Check out this HHS press release.

Dare: June 20, 2015 11:30 AM PDT
Subject: External Affairs Welcomes Dr. Mandy Cohen
Dear Stakeholders,
I am pleased to announce that Dr. Mandy Cohen has joined our team in the HHS Office of Intergovernmental and External Affairs (IEA) as Senior Policy Advisor and Director of Provider Engagement. In her new role, she will focus on the Department’s work to transform the delivery system and oversee the Department’s outreach and engagement with clinicians, health professionals and other providers.

For the past two years, Dr. Cohen has been the Director of Stakeholder Engagement at the CMS Innovation Center, working with the Center’s many constituencies to develop and test new payment and delivery models. Prior to joining CMS she was the Executive Director of Doctors for America. Dr. Cohen received her medical degree from the Yale University School of Medicine and trained in internal medicine at Massachusetts General Hospital. (bolding DMCB)

Dr. Cohen and I both look forward to working with you as we improve the health care system together. 
The DMCB was first introduced to "Doctors for America" thanks to this HuffPo posting describing a mutual-admiration health reform meeting at the White House. Having never heard of Doctors for America, the DMCB naturally turned to Wikipedia, where it all became clear

The DFA used to be known as DFO, i.e., Doctors for Obama during the 2008 elections. While the White House also gets to conflate the "A" and the "O," it's real purpose is the portrayal of getting seemingly neutral input from an impressively named physician organization that is not the AMA.

Unfortunately, it doesn't look like the DMCB will get its way on the hanging the picture.  Unsurprisingly, the White House's stacking the deck with political backers doesn't mean they're necessary going to get their way on health care either. 

(In all fairness, however, it should be pointed out that CMS is working with former AMA President Nielson).

Statue image from Wikipedia

*The controversial poster shot  was taken during rehearsals for the filming of Captain EO in 1986.

Wednesday, June 24, 2015

A "Penny Dreadful" Take on Health Reform

To the spouse's enduring disappointment, the Population Health Blog has been ensnared by the Showtime horror series Penny Dreadful.  Set in the 1890'sVictorian England, viewers can follow the derring-do of Dr. Frankenstein, Sir Malcolm Murray and Vanessa Ives as they quote Shelley and hunt for vampires.

The good news that even this corner of vacuous TV media, the PHB can find some lessons in health reform.

For example.....

Young Dr. Frankenstein creates a monster.  While that's what you get for stitching miscellaneous body parts together and zapping the corpse with life-giving electricity, Dr. Frankenstein should also know......

1) things would have been worse if he had installed electronic health record in his laboratory, and
2) that's what happens when docs are too morose and wear far too much mascara.
When a ship hailing from Egypt has been quarantined by the London authorities because of supposed plague, the intrepid Sir Malcolm shrewdly deduces it is ultimate source of all the recent "chicanery."  Since the ship is infested with lusty, blond and bloodthirsty vampire-vixens, his conclusion is correct. But, he should also be aware that....

1) the Veterans Administration has conducted an internal investigation and has found that no evidence that any patient has been harmed and,
2) he has given the PHB a reminder to use the word "chicanery" in a future blog post.
Dorian Gray is able to continue his dissolute libidinous lifestyle by standing in front of a painting and instantaneously curing his claw marks and, while he's at it, his probable sexually transmitted diseases.  The PHB wonders if this is the key to harnessing the life-prolonging potential of telomerases, but it also cautions....

1) that this should be ignored by the medical community until it has been subjected to repeated randomized clinical trials and approved by the FDA, and
2) the U.S. government's deficit won't be helped by subjecting the painting to a medical device tax.

Dr. Van Helsing quotes from a lurid penny novel to prove that vampires do exist.  This is an inspirational example of how early hematologists used disparate clues to arrive at obscure diagnoses. It is also....

1) a telling example of how doctors can quote from faux authoritative texts to support any predetermined medical conclusion.

After a long stay in a mental asylum for a "psychosexual disorder," Vanessa Ives is still prone to fits where her eyes turn white, she channels demons and she floats around the room.  This is evidence that she needs to return to the asylum stat, but is also

1) obviously why thorazine-loaded blow darts were invented
2) better than the any of her battle scenes from the movie 300 Rise of an Empire

Europe Likes U.S. Disease Management

Listen to public radio, read the national newspapers, surf the standard cable channels or listen to the mainstream commentariat and the message is the same: if only the U.S. would import the best of European-style health care, life-expectancy rates would increase, health care costs would decline and physicians like the Disease Management Care Blog would bask in the benevolent and enlightened management of the U.S. Department of Health and Human Services.

As the DMCB has pointed out before, comparative national data are not a slam-dunk, untangling unique non-medical cultural and economic impacts on population the U.S. is complicated and the U.S. in some instances, is getting its money's worth.  What's more, rising health care costs are a global phenomenon and there is no evidence that dropping European-style health care on the U.S. will blunt its overall cost inflation. As for the enlightened benevolence of HHS, just remember that their Board of Directors is Congress and that Taxmageddon promises that the SGR fix won't be pretty.

Yet, while DMCB readers may have a reason to be skeptical about the wisdom of of europhilism, what about the possibility that our beret-wearing, cobblestone-hopping, Audi-driving and cafe-sipping cousins across the Atlantic admire the U.S. system?  Impossible you say?

Think again.  The DMCB has personally been to Europe to share the good news about U.S. approaches to disease and management. The Care Continuum Alliance has an impressive international presence made up of organizations using elements of  disease management and population-based care. Many of the vendors sell millions of dollars' worth of services in Europe. 

To drive the point home, here's recent and telling opening quote from a internationally published paper in Health Expectations on the topic of disease management:

Inspired by American examples, several European countries are now developing disease management programmes (DMPs) to improve the quality of care for patients with chronic diseases.

It Costs How Much to Launch a Patient Centered Medical Home?

HOW much for the PCMH?!*
According to Drs. Gill and Bagley, writing in the Annals of Family Medicine, the costs of transforming a primary care practice to a Patient Centered Medical Home should be generously borne by "payers."

While wishful thinking about payers' deep pockets is not new, the article has some eye-opening data (with Disease Management Care Blog provided links) on just how much some or all of the elements of a PCMH cost:

a) $1850 per month per practice or $17,000 per physician,

b) $5,600 start-up then $2,200 per year related to the costs of reporting outcomes,

c) $117,000 per physician per year, and

d) up to approximately $15,000 per practice per year for a management facilitator

No wonder the DMCB's friends in academia want someone else to pay for it.

In the meantime, companies like this continue to offer a different business model. Instead of rebuilding and equipping an entire primary care practice for a croup-to-guts "transformation," population health (definition here) service providers focus on those patients who are at highest risk and provide a modular combination of in as well as outsourced services. While there is no head-to-head cost comparison of PH vs. PCMH, it would appear that the per patient approach of PH has a competitive pricing advantage.

Stocking up for
allergy season
And speaking of outsourced services, the DMCB joins its other colleagues in looking forward to EHR's "meaningful use" criteria go from being meaningless to being truly meaningful.

For an under-recognized example of just how meaningful things will become, check out this interesting blog posting that describes the use of cloud-based EHR-data to follow U.S. allergy statistics.

While the information is interesting on its own merits, think how these data could be used by savvy providers to match allergy "market demand" by "stocking" a "just-in-time" "inventory" of allergy-care services such as patient reminder campaigns (for those with allergy-provoked asthma, "be sure to use your peak flow meter!") extra condition-specific appointments ("your provider with allergy expertise can see you this morning!"), treatments slots (nebulizers and immunotherapy ready to go) and medications (OTCs and prescription meds for the in-house pharmacy).

*Image from Wikipedia

The Majority of Medicare Spending Variation Is Unexplained

From time to time, the Population Health Blog spouse finds that her husband is insufficiently attentive.  During a recent conversation about that very topic, things stopped when the PHB pointed out the window and exclaimed "Look! A squirrel!"

Naturally, the spouse is curious about the PHB's erratic attentiveness.  Is it how its brain is hardwired?  Too much sugar? Substandard parenting?  And of all those possibilities, how much do each contribute?

That introduction should help the PHB and its readers check out this just-published Health Affairs paper on Medicare's erratic spending habits.

As PHB readers know, Medicare's patient costs patient vary from one locale to another by thousands of dollars, with no discernible impact on survivorship or quality. One narrative is that the health system is being consciously or unconsciously manipulated by doctors and hospitals at a regional level.  Another is that poverty is causing patients in some areas of the country to have have more than their fair share of health problems.

Enter Laurence Baker et al, who wanted to know if patients' preferences are playing a role.

The answer is that it does. But, compared to hospitals and patient income, not that much.

The authors obtained Medicare claims data from 2005 and sorted it by Medicare Hospital Referral Region (or "HRRs," which can span several counties). They wanted to know if HRR costs correlated with 1) county and zip code-level median income, 2) self-reported health status, 3) the availability of doctors and hospital beds and 4) a six question survey that ascertained respondents' preferences for care based on scenarios like chest pain or cough.

The results?

The HRRs were grouped and sorted into low to high spending quintiles.  As the quintiles increased, so did the number of hospital beds per thousand (2.2 low to 2.5 high), which suggested that the supply of services increases health care utilization. Doctors were negatively correlated (the more docs, the lower the spending, 214 per 100K low vs. 193 per 100K high). 

Income was not correlated.

Patient preferences were correlated but only by a small amount (just over $100 across the quintiles).

It's one thing, however to have a correlation, it's another to know the strength of the correlation.  Using regression analytics, the authors found that the availability of hospital beds and doctors could independently account for 23% of the low to high variation across the quintiles. Health status and income seemed to drive another 12%. Patient preferences explained another 5%.

While that explains approximately 40% of the low to high variation across the quintiles, that means 60% remains a mystery. 

In other words, if hospital services, patient economic disparities and patient preferences were completely neutralized by very enlightened central planning, wholly just income redistribution and perfect patient education, only 40% of the cost variation across the United States would go away.  Boston would still cost more than Boise.
The PHB's take:

1) Squirrels abound: there is still a lot that we don't understand about the national swings in Medicare's costs.  Some areas are cheap, others aren't and the majority of that has little to do with the availability of hospital services, poverty or beneficiary preferences.

2) Any wonk, policymaker, politician, academic or blogger who offers "a solution" to Medicare's variation is kidding themselves.  The majority remains outside the reach of laws, regulations or payment reforms.

3) Compared to Medicare, PHB's variable attention span is a comparatively modest problem.  The spouse should take some comfort in that.

Image from Wikipedia

Sunday, June 21, 2015

A Health Care Anthem of Optimism

Our understanding of the ACA?
If Disease Management Care Blog's bold prediction holds up and the Supreme Court splits the health care baby by letting the Affordable Care Act (ACA) stand while striking down the "individual mandate," progressives will announce the world is ending, while conservatives will announce Obamacare is ending.

The DMCB argues neither will be true.  When the sun rises the next day, Ms. Pelosi's health care "constitutionality" sputterings will not cease, crafty U.S. House Republicans won't stop their devilish attempts to gut what remains of the ACA and CMS' vast bureaucracy will continue to "innovate" with long-used approaches from the commercial health insurance markets.

The DMCB also predicts that there'll be an emerging consensus that a stumbling White House somehow botched the media-public opionion-wars. According to that narrative, manipulating an unsuspecting "Jersey Shore" addled public with news conferences, speeches, town halls, favorable coverage, framing, biased polling, talking points, press releases, The Daily Show appearances, bloggery, tweets, negative ads, spin, messaging, appeals to "the base," and targeted air-time can convert uninformed numbskulls into opinionated numbskulls.  Talking heads on both sides of the partisan divide would have us believe that but for Americans being educated about the merits of one position vs. another, they'd not only make the correct judgement, it'd be our judgement.

"Bunk!" says the DMCB.

It thinks that by now most Americans "get" the broad outlines of the Affordable Care Act: expanded, mandated and regulated private as well as government-sponsored health insurance that is paid for by the Feds and therefore the taxpayer. Knowing the facts, it's not unreasonable for thinking persons on either side of the political spectrum to agree or disagree with the ACA.  Call the DMCB naive, but it thinks that the general poll trending against the ACA has less to do with media and more to do with the informed judgement and native intelligence of a messy democracy that is underestimated by a cynical partisan elite.

The DMCB is not arguing that the news cycle and media don't have an impact. They do. Yet, when it comes to the ACA, both sides have had an ample opportunity to use all the powers of persuasion to nudge public opinion.  The fact that the ACA has failed to achieve a convincing level of support speaks less to competing messages than the underlying content. In other musical words, it's not the arrangement, but the underlying chord progression.

What to make of all this wreckage?

The ACA's unfavorability, despite a generally supportive news media, suggests Congressional leadership cannot govern from the left.  This is a cautionary lesson for the emboldened Republicans, who may calculate that when their turn comes, they'll be able to govern from the right.

There's good news for health reform.  President Obama's allies forced the issue and, sooner or later, Americans, after trying every alternative, will finally do the right thing. The Supremes and public opinion seem to be telling us that the ACA is not necessarily that right thing. We're still working on it and a plan that can be supported by most Americans will eventually emerge.

Saturday, June 20, 2015

"Hovering" - A New Term for Disease Management?


That's the term used by Drs. Asch, Muller and Volpp in a New England Journal article on care management that gets it mostly right for the wrong reasons.

Noting a few hours of face-to-face visit time with a doctor over the course of a year doesn't come close to meeting the full-time needs of patients with chronic illness, the authors describe how wellness, medication compliance, transitional care and telemonitoring programs have stepped in, especially for 'hot spotter' patients.

Sounds good, say the authors, but they argue that these "conventional" disease management programs have "not fulfilled their promise" because of 1) unjustifiable personnel expenses and 2) the difficulty of maintaining patient engagement.

They feel things will change for the better. That's because

1) payment mechanisms are now demanding "accountability,

2) the science of behavioral economics allows for a better understanding of what motivates patients and

3) the price of wireless and internet-enabled devices is dropping.

So, when all three of these ingredients are optimally combined for the right kinds of patients, they say the resulting "hovering" will drop health care costs and increase quality. They describe an example of an automatic pill-bottle reminder system that is linked to patient lottery reward that has been shown to increase medication compliance and reduce hospitalizations (which, by the way, was described four years ago by the DMCB here).

Dr. Asch et al are technically correct but unfairly portray the disease and population health management service providers as behind the times. They couldn't be more wrong.

The vendors have been working on an "accountable" risk-basis with health insurers for over a decade, have led the way in the use of behavioral economics in their programs, have been closely aligned with telemonitoring services and regularly use the technology of predictive modeling to identify those patients who are mostly likely to benefit.

One thing the vendors have not done, however, is use the term "hovering" in their marketing materials, peer-reviewed publications or national meeting presentations. 

Which begs the question: how about changing from the DMCB to "Hovering Care Blog?"


The Latest Health Wonk Review is Up!

The bloggers are really swarming in the latest Health Wonk Review.  While the mainstream news pasteurizes the progress of health care reform, Sarah Sonies and Jennifer Salopek of Wing of Zock brings insights and occasionally contrarian perspectives from around the web: aging immigrants, medical device gamesmanship, insurance rate (non)sticker shock, the insurance subsidy miasma, the real IRS problem and the possible unintended consequences from messing with solid organ transplant rules.  Hey, if no one else is going to look at these issues, why not us bloggers?


Friday, June 19, 2015

France Says Affordable Care Act Is Seeking Asylum

En guarde for the ACA
Washington DC (DMCB) - The Affordable Care Act (ACA) sought refuge in the French Embassy today and has applied for political asylum, said U.S. officials.  France's Foreign Minister, Philipe deBird announced that the Act is now under the protection of the French government while it considers its obligations under international law.

The ACA has been appealing its numerous death sentences in U.S. courts and a final ruling is expected any day now from the U.S. Supreme Court. Many legal experts expect the Court to uphold many of the Appeal Courts' decisions, which could spell certain doom for the ACA.

Various members of Congress have denounced the Act as a threat to national security and have advocated for a remote drone attack.  "The dark references to 'severability' in speeches on the floor of the House of Representatives probably pushed the ACA over the edge" said DMCB legal expert Dawn Tzume.  "It's also no accident that the ACA chose the French Embassy, since they not only support free health care but smartly sport berets and stylishly drape their jackets over their shoulders, even when they are in Afghanistan" added Ms. Tzume.
Former State Department spokesperson Wanda Ostomy charged that France may use this incident to influence U.S. monetary policy.  "The French could easily deny asylum, putting the U.S. budget back in the dumpster," said Ms. Ostomy. "They'll probably 'suggest' that we convert to the Euro and use it to finance California's 2015 deficit," she added.

The DMCB contacted the White House for comment and was referred to Nancy Pelosi's office.  "We are studying the situation and let the President know what the next steps will be," said an unnamed person in Ms. Pelosi's office. 

"The ACA is at this moment enjoying some cheese, croissants and pear slices, courtesy of the French people," said Embassy spokesperson, Jean Claude deRash. "Many of our citizens are on holiday at this time of year and we wished to extend the same courtesy to our unexpected guest," he added.

The Disease Management Care Blog will continue to follow this developing story

Image from Wikipedia

Do Employer-Based Wellness Programs Work?

Reuters tackles worksite wellness outcomes
Mrs. Smith (name changed) was overweight.  She knew it and her physician, the Disease Management Care Blog, knew that she knew it.  Since the DMCB was one of the two persons on the planet who knew her true weight, she could talk to it behind closed doors about diet, exercise, fads, over the counter meds, prescription appetite suppressants and even bariatric surgery. 

What the DMCB quickly discovered was that Mrs. Smith's weight-loss goals were not only unrealistic but, like many women struggling with weight, driven more by the prospect of how she'd look in a bathing suit than any real health benefit.

Mrs. Smith wasn't alone. This seminal study demonstrated just how unrealistic women's weight loss goals (in the range of 50 lbs.) can be.  Think of the popularity of The Biggest Loser and it's easy to see why persons think thinness is just a matter of a few months of dieting and exercise, and that being skinny leads to health and happiness, 

Easy, right?

DMCB readers know otherwise. That's why they're not going to be impressed by the tone of this May 24 Reuters article on worksite wellness.  RAND, in a not-quite released report to Congress, examined the impact of several employee based programs and found, in the words of the Reuters reporter, only a "modest effect."  Average weight loss was "only" three lbs., tobacco cessation rates were significant but "short term," average cholesterol levels were unchanged and reductions in health insurance claims expense failed to achieve statistical significance.

Researchers have known for years that conservative dietary and lifestyle therapy typically results in weight loss in the range described above. In addition, cholesterol reduction as a primary prevention intervention is low yield when it comes to health. On the other hand, even short term tobacco cessation is a good thing. When it comes to the ability of wellness to reduce health care costs, weight reduction is unlikely to drive claims expense for a health insurer within two to three years, the impact of obesity on overall mortality rates is not as large as you'd think and "prevention" rarely saves money.

What's more, these programs were able to achieve their "modest" outcomes without increasing claims expense.  Participants lost weight and stopped smoking at no additional cost to the system.  Now that is something.

Mrs. Smith and Reuters are very similar.  Both are struggling with nrealistic expectations thanks to dubious fashion trends, media misinformation and scientific ignorance.  Fortunately, Mrs. Smith had access to a resource that could help her better manage her weight.  The DMCB can only hope that Reuters has access to a resource that can help it manage its lack of background knowledge.

Thursday, June 18, 2015

Psycopathy In Health Care Organizations

Years ago, the Disease Management Care Blog tagged along as a minor player to a high level strategic meeting involving a pharmaceutical company and a provider organization. The senior leadership egos on display barely competed with the meeting room's spacious view of the Manhattan skyline as our group was hosted over yummy pastries and coffee by a good looking, gregarious, gracious, intelligent and obviously "connected" pharma executive.

The meeting progressed quite nicely until a coffee break supervened and the DMCB found itself alone in an anteroom with the host. Caught up in the enthusiasm of the moment, the DMCB parroted one of the meeting's nostrums about the internet. The executive turned and hissed at the DMCB's stupidity with dripping contempt, turned and walked out. Minutes later, the meeting restarted as if nothing happened.

That was just one of the DMCB's many encounters with an organizational psychopath. Unable to have experience any interpersonal "connection" with anyone, these soulless persons use the people around them to pursue the more tangible rewards of power, financial gain or amusement.  Excluded from the social web of human relationships, psychopaths can't access a moral compass.  As a result, they turn to social mimicry to charm, shame or bully anyone in the pursuit of their goals.  Everyone that surrounds them is a either a means to an end or,in the case of the DMCB, dirt.

While the more famous psychopaths are sadistic murderers, they're the exception.  Most of them coldly calculate that they don't need violence to achieve their ends. Deceit, predation and manipulation are more than enough while they pursue their goals in the cubicles down the hall and the offices upstairs.  And as they click along, these Sandusky-esque time bombs are often recognized too late.

Here's the DMCB's four  rules on how deal with organizational psychopath:

1.  That ill-defined "feeling" that you have that something's wrong with that person? You wonder if it's bad parenting, drugs, mental illness, curious flattery or an inflated egoTrust your instincts and include psychopathy among the possibilities.

2. Don't be surprised when you uncover the extent of the dysfunction.  The prevalence is at least 1% and their toxicity can bring a team, a department and even an organization to its knees before you realize what's happening.

3. The infamous Milgram experiments found that persons in positions of power can lead decent people to do awful thingsQuestioning authority is a good thing. If you do it, you deserve credit. If one of your reports does it, they deserve protection.

4. Stay away, contain and remove, preferably the latter - even if it means you.  Warnings and counseling will not change their underlying motivation in any appreciable manner.

The DMCB is happy to report that the meeting didn't lead anywhere and that it was wiser for the experience. 

That's why, years later, its skin crawled in a medical meeting hotel bar. 

Following a standing ovation for a plenary session presentation by the charismatic CEO of a very successful health care organization on the merits population health, the electronic record and systems integration, the DMCB found itself behind him and one of his minions trying to get a cappuccino. English was not the hapless server's primary language and she struggled with the barista's brewing details. The CEO's cold scorn and hateful disdain were radioactive while his companion's nervous silence signalled that more than just impatience was at work.  The guy on stage just minutes before was an impostor.

Yes, it really did happen and yes, he's still out there.

The Cost-Saving Elevator-Pitch for the Patient Centered Medical Home

Ready, set, elevator, go!
Over the last year, several colleagues have asked the Population Health Blog to compactly summarize the economic return for the Patient Centered Medical Home (PCMH).

Here's the PHB's elevator speech: 

The PCMH comes down to two distinct - and separate - propositions:

1. "Reduce avoidable costs" by only applying the team-based care management and coordination to persons with all three of the following: a) chronic illness who b) are at high risk for future claims and c) are amenable to change.*  All three must be present. This cohort typically represents a small, but "high return potential" fraction of a population.
The temptation is to blanket all patients with medical home resources, which increases program as well as claims costs and does little to bend the total cost curve.  The "disease management" industry learned about "care creep" the hard way.

2. "Increase value" by enhancing quality and/or the experience of care with a modest - and relatively affordable - increases in costs. The relative increase in quality/experience is greater than the corresponding increase in program and claims costs, and represents a good deal for the health care dollar.

The temptation is to believe that quality/experience improvements lead to lower costs.  Once again, the "disease management" industry learned about this the hard way. 

* By the way, if the elevator ride is long, the PHB recommends pointing out that 1) predictive modeling/risk stratification can find the high risk persons and that 2) "change" includes modifying patient behaviors.

Image from Wikipedia

Patient Perceptions of Risk, Media Innumeracy and The Enduring Futility of the Annual Check Up

Today the DMCB caught up on some reading of the medical literature. 

The first article is an example of how researchers' risk thresholds don't match patient perceptions.

The second article is an example of media innumeracy

The third article is likely to be ignored by everyone.

1. Should Cardiac Telemetry Not Be Used for Patients with Only a Three Percent Chance of a Problem?

Suppose, asks the Disease Management Care Blog, your elder family member mysteriously passed out and was seriously injured?  You would wonder if a cardiac problem could be the cause. While the likelihood of that is typically low, even the small chance of something being "wrong with the heart" is enough to make patients and their families worry.

But suppose the chance of a heart problem was only.... 10%?  Or 5%? Or 1%?    

Once a decision is made to admit a patient with loss of consciousness to a hospital, doctors typically arrange for "cardiac telemetry." That broadcasts the electrocardiogram on an ongoing basis to a monitoring unit.  Unfortunately, however, the demand for a hospital telemetry "slots" is high and the monitoring requires additional personnel.

As a result, clinical guidelines like these have been developed.  They define high risk patients who warrant telemetry and low risk patients who don't.  For example, patients who have had a recent heart attack are vulnerable to unstable heart rhythms, while patients with stable atrial fibrillation can probably be safely managed off telemetry. Patients who have passed out and are stable on telemetry after 3 days are considered low risk.

Enter Evan Benjamin and colleagues who applied the guidelines to a retrospective audit of how telemetry was used for 501 consecutive patients at four Massachusetts medical centers.  Since patients could transition from high to low risk as the days passed, the unit of measure was "patient-days" (if two patients were each on telemetry for 4 days, that yielded eight "patient-days"). 

38% of the total 1559 patient-days were low risk. Among the high risk patients, a heart problem was detected in 21 out of 100 patient-days.  In the low risk patients, a problem was detected in 3 out of 100 patient days. 

The authors argue that these data show that better enforcement of guidelines that restrict access to telemetry would result in more cost-effective care.  The DMCB isn't so sure, because it intuitively thinks most patients and doctors would consider a 3% (3 out of 100 patient-days) a low enough threshold to warrant monitoring.

Good luck, says the DMCB, enforcing that. 

2. Just How Bad is the Link Between Red Meat and Diabetes?

"Yikes!" said the DMCB after listening to this NPR broadcast and reading this WSJ article.  It appears that increasing red meat consumption increased the risk of diabetes among previously healthy people "by 50%!"  While its first impulse was to throw away those frozen strip steaks, the DMCB took a deep breath and did something the reporters neglected to do: read the article.  It turns out that the approximate risks went from approximately 0.2% to 0.3%.  More than 99% of the carnivores did fine.  Once again, the reporters failed to discern that while the relative risk was high, while the absolute risk was vanishingly low.

3. A Reminder that the Annual Check Up is a Waste of Time and Money

After reviewing 16 studies involving over 180,000 participants, the authors in this JAMA study concluded:

.... general health checks were not associated with lower rates of mortality or morbidity.  However, general health check may increase the number of diagnoses and the use of medications.

The irony is that The White House and CMS profess to being evidence-based while remaining simultaneously committed to "wellness checks."

Image from Wikipedia

Wednesday, June 17, 2015

Bring On The Coupons!

Most persons with insurance that includes a pharmacy benefit are probably very familiar with co-pays.  Those out-of-pocket expenses not only reduce the insurers' costs, but are a powerful tool that can incentivize the choice of a month's supply of an otherwise equivalent generic (for $5) versus an expensive brand medicine (for $30).

But suppose the brand drug manufacturer fights back with a $30 coupon?

That's the topic of this JAMA paper by David Grande. While the coupons could be prohibited as "kickbacks," can be suddenly stopped and are often given on-line in exchange for otherwise private patient information, the main argument against them is that they substantially increase insurer costs.  As a result, Dr. Grande recommends that physicians resist the allure of giving their patients any coupons and that pharmaceutical companies find other ways to reduce patients' out of pocket costs.

The DMCB has another idea that is going unmentioned by JAMA.  Why not suggest that insurers compete should against the manufacturers' coupons with their own coupons?  Competition may eat into the insurers' bottom lines but the patients will win.

Patient interests: That's the point, right?

The Commonwealth Fund Keeps Score on U.S. Healthcare: Less Here Than Meets the Eye

YOU are in last place!
According to news reports on the Commonwealth Fund's comparison of the United States' healthcare to other developed countries, we are the sick man, on a losing streak and dead last


Just when the U.S. prevailed against Ghana in the World Cup, we have to deal with being called a loser.

Naturally, the Population Health Blog decided to investigate.  It discovered that the Commonwealth Fund ranked the U.S. against 10 other countries using a combination of multiple outcome measures. 

Here's the complete report

What does it actually say?  Rather than attempt to summarize the report's findings, the PHB provides some telling quotes:


"The United Kingdom ranks first and Norway last on quality, based on averages of the scores in these four areas. The U.S. falls in the midrange on this domain of performance."

Preventive Care:

"The U.S. does well in providing preventive care for its population. Respondents in the U.S. were more likely than those in most other countries to receive preventive care reminders and advice from their doctors on diet and exercise."

Effective Care:

"The U.S. is third on effective care overall, performing relatively well on prevention but average in comparison to other industrialized nations on quality of chronic care management."


"These findings indicate that the United States has improved on safety indicators.... For example, the U.S. now leads all nations with a relatively low number of sicker patients reporting an infection during a hospital stay or shortly after."

Care Coordination:

"Eighty-three percent of American patients had arrangements for follow-up visits with a doctor or other health care professional made for them when leaving the hospital, second only to the United Kingdom."

Patient Centeredness:

"The U.S. ranks fourth. All countries could improve substantially in this area."

Engagement and patient preferences:

"The United States did well on most indicators."

So, since the United States is doing well on quality, preventive care, effective care, safety, care coordination, patient centeredness as well as engagement and patient preferences, what's the problem? 

Again, some quotes:

Americans .... reported negative insurance surprises and the highest rates of serious problems paying medical bills.... On indicators of efficiency, the U.S. scores last overall with poor performance on the two measures of national health expenditures, as well as on measures of administrative hassles, timely access to records and test results, duplicative tests, and rehospitalization.

Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs.

The U.S. ranks last on mortality amenable to health care, last on infant mortality, and second-to-last on healthy life expectancy at age 60.

Plus this tidbit.....

Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home.

The PHB's take?  There is less to this than meets the eye:

1.  The United States performs well on a majority of overall quality measures.

2.  The United States suffers from high overall costs

3.  The Commonwealth Fund's ranking system faults the U.S. on two levels:  value (our high quality comes at a very high price) and equity (persons with lower incomes cannot afford to access our high quality system).  Add up the points in this scoring system, and the U.S. is last.

4.  The Commonwealth Fund uses data from prior to the 2015 implementation of Obamacare, which was specifically designed to address the United States' shortfalls by subsidizing commercial insurance and increasing Medicaid enrollment.

5. By the way, despite little evidence in the report that cost, value or access are necessarily increased by the U. S. version of the medical home, the Commonwealth Fund included it anyway.

How well will all those high out-of-pocket "bronze plans," Medicaid, Accountable Care Organizations and the medical home truly reduce cost inflation, enhance value and increase access? 

Stay tuned.  The PHB is looking forward to seeing how they'll rank Obamacare's impact in 2015.

The MIddle Class Bubble and the Long Term Implications for Care Management & Health Care

According to this 2011 article in The Atlantic, the middle class is in trouble.  The Disease Management Care Blog agrees and wonders if they are ultimately doomed. Either way, there are important implications for health care in general and the care management industry in particular.

The amateur DMCB explains.

With the advent of the Gilded Age in the 1870s, the industrial revolution ushered in more than a century of heavy industry, railroads, mining, commercial farming and manufacturing that were powered by millions of skilled and unskilled workers. Wealth and power remained concentrated in an elite 1% plutocracy that had prevailed throughout most of human history, but a newly emergent "middle class" benefited from high wages and became an accepted part of the American political and cultural landscape.  Thanks to their labor, the quality of goods and services increased while simultaneously becoming cheaper.

While the middle class was in retreat at the turn of the millennium, The Great Recession suggests that their century-long party may be truly over. Global competition with the free movement of labor and capital combined with automation have made the costs of industry even cheaper. The plutocracy that has always been there can shrug off the effects of a recession, but the intrinsic value of traditional labor has popped, bubble fashion

In the last decade, persons in the nominal middle class with less than $90,000 a year in income have had flat wages and have been unable to increase their spending. Since 2000, American manufacturing - which has not only lost ground to China but become more mechanized - has lost about a third of its jobs. This has played itself out in geographic terms, where the elite hubs around Washington DC, San Francisco and Boston have high wage job listings, while cities like Detroit and Miami have been in the dumpster. In other words, much of the middle class is being hollowed out and being forced to downjob into personal services, retail and food preparation - while leading lives that are at risk for financial stress, partner conflicts, single parenting and troubled children.

In the meantime, the DMCB suspects that the "fat cat" billionaires so reviled by progressives are not any more numerous or fantastically wealthy.  The DMCB thinks that they're only more visible.  It remains to be seen if government will be successful in moving wealth from that top 1% to the struggling 99%.  History suggests otherwise.

Long term implications for the health and care management industry:

Health care will sort into 1) high end, high touch, personalized care for a small elite that can not only afford it, but will be responsible for profitable top line revenue and 2) a strained publicly underfunded system with thin margins for the rest.  Care management providers will likewise sort into these two camps.  The first involves high margin value, the second involves low margin volume.  Given the disparate business models, it's unlikely that single companies will be able to do both.

While universal access to affordable health insurance remains a bipartisan goal, high out-of-pocket costs combined with limited provider access for persons outside of the 1% will increase the popularity of cheap "DIY" care involving eHealth. This is a natural fit for the care management industry.

Lacking factory work, more workers than anticipated may be available as the U.S. population ages and the demand for personal health care attendants increases.

Classic health care "knowledge workers" may not be immune, since information tech and automation may enable machines to generate a differential diagnosis and read an x-ray, while cheap and highly trained remote labor may be able to deply robotics to perform routine surgeries.  For the care management industry, an on-line script that prompts a nominally-trained health educator may be able to replace nurse care managers.

Image from Wikipedia

Tuesday, June 16, 2015

The Evidence Supporting Heart Failure Care Management

In the earliest days of the national trade association "disease management" meetings, the Population Health Blog encountered so many sessions and abstracts on heart failure rehospitalization-reduction programs, that it was almost boring

They all involved some version of risk stratification and a combination of telephonic and in-person nurse-based care management. 

And they all worked.

Which is why the Annals of Internal Medicine could have saved itself a lot of time and effort by simply asking the PHB for a summary.  Instead, it did the next best thing and published this meta-analysis by Feltner et al.  The authors pooled the data from 47 randomized clinical trials and found that both in-person and telephonic nurse-led disease care management reduced readmissions to a statistically significant degree.


1. This is another example of old news not making reaching the elite ruling classes of Academikstan until well after the fact.

2. For my colleagues in the medical home movement, take note: achieving financially relevant outcomes will depend on focusing care management where it will have greatest impact. Instead of managing all patients with heart failure (for example), start by managing the patients at risk of (re) hospitalization.  That's where the return-on-investment gold can be mined.

Image from Wikipedia

Sunday, June 14, 2015

From P4P to Pay Patients for Performance (P4PP)?

Joanne Wu, writing in the Annals of Family Medicine, suggests that we dismantle the health insurers' "pay for performance" ("P4P") programs in favor of "pay patients for performance" (PP4P).  As blood pressure control, cholesterol treatment, cancer screening rates or fitness rates increase, she proposes that patients receive "health care credits" in the form of lower co-pays, discounts or premium reductions.

Good idea, says the  Disease Management Care Blog, but:

1) Long standing regulations stand in the way. Health insurance regulators generally frown on programs that compromise community-rated risk pooling that gives everyone the same benefit for the same price.  ERISA-protected plans, on the other hand, have greater latitude in flexing their insurance benefits. 

2) Politics stand in the way. Opponents argue that persons less well off will be unfairly disadvantaged by wellness incentives.  You can read more about that here

3) Doctors stand in the way. Last but not least, insurers generally fund P4P by diverting the money from the providers' inflation-adjusted or market-driven fee schedule increases.  In other words, taking P4P money from the docs and giving P4PP to the patients ain't gonna easily happen.

That being said, the DMCB thinks Dr. Wu may be onto something.  She recommends a pilot be tried in a small community.  Given the downstream savings, we'd be foolish to not take every advantage we can to achieve patient buy-in, and a pilot sounds like a grand idea.

Saturday, June 13, 2015

We Need to Leave the Complex Legacy EHR Systems for Something Better. Here's How

Years ago, when the physician Disease Management Care Blog was first grappling with an electronic health record (EHR) system, it couldn't:

  • manage any text with basic word processing tools;

  • review a patient's summary data (like all cancer screening tests over time);

  • review its patients' summary data (like blood pressure control among all persons with a diagnosis of hypertension);

  • communicate with patients outside of an unwieldy messaging system;

  • perform outcomes research (based on a look-back, which approach worked better?).

  • support key elements of population health management, like risk stratification or facilitating nurse-physician care plan work flows.

  • What it could do was continue to see patients one-at-a-time, type (not write) a clinic note, click (not mark) the tests it ordered and bill a lot more for its services.  And what the DMCB's clinic could do was spend a lot of money on health information technology that was siloed (unable to communicate in any fashion with any area hospital) and complicated (the health IT department was enormous).

    According to the New England Journal's Drs. Mandl and Kohane, the DMCB is not alone. Too many docs today are trapped in legacy systems that don't come close to the home technology they and their patients have, like Twitter, smartphone apps, Facebook, Google search and iTunes.

    They argue that the solution is to reject the  EHR vendors' argument that health care IT has to be complicated.  We can transition from those horrid meaningful-use addled single systems to a flexible modular approach based on cheap and existing technology that is available today.  We need EHR systems that can not only document, order and bill, but:

    1. Reasonably securely store retrievable patient data on the "cloud"

    2. Enable providers to securely share information seamlessly using open source formatting

    3. Apply project management software to patient documentation to record extended interactions over an episode of care

    4. Use public domain analytics to identify, manage and follow population-based care needs

    The DMCB agrees and sees an opportunity that parallels what happened when electricity was introduced to U.S. manufacturing.  According to Drs. Jones, Heaton, Rudin and Schneider writing in the same issue of the Journal, swapping electric motors for steam powered engines during the Industrial Revolution didn't result in any productivity gains. Rather, it was the follow-up distribution of small motors throughout the factory floor that transformed American industry. 

    The same principle may apply to health care. We have yet to intelligently "distribute" information technology in a modular fashion throughout the clinical factory floor and adapt our old one-patient-at-a-time workflows to really take advantage of it.

    Image from Wikipedia