Friday, August 28, 2015

The EHR Tipping point, HEDIS® Uncertainty Principle and the Hypoplastic Hypothesis

(From time to time, the Disease Management Care Blog welcomes commentary from its readers.  Here's an interesting thought.....)

As a long-term reader, I thought the erudite but contrarian and sometimes snarky DMCB might be the best venue to ask others of my ilk to comment on an observation of mine.

I am a primary care provider working at the quantum level of patient care.  I am in my second year of full fledged EHR use.  It is obvious to me from the consultation notes that I receive on an hourly basis that most of my colleagues are also on board.  Journal articles as well as my first-hand experience have convinced me that we have indeed reached the tipping point of electronic record use. 

Since this milestone passed, I have noticed a change in the focus of office notes and consults.  I am seeing neurosurgeons document conversations regarding the safety of patients relationships and whether or not they feel threatened.  Podiatrists routinely document the existence of living wills.  Dermatologists are now savvy about the sexual activity of octogenarians with actinic keratosis. Despite my consultants' thoroughness in their care (and conversations with health care students who have rotated through these specialties make me believe that some specialists are using telepathy to document things), I am not seeing traditional assessment and plans at the end of the encounter. 

What I usually see is the same generalized diagnosis code that I sent them with followed by a list of tests cluttered with a references to various quality metrics that are inspired by systems such as HEDIS®.  The old fashioned differential diagnoses or thoughtful prose concerning the evaluation is conspicuously absent. 

I call this my hypoplastic hypothesis.

As a primary care physician, when I consult a colleague, I am really asking the specialist “Hey, what do you think?” Prior to the advent of the EHR, much of my continuing medical education has come from the insights that I use to get from these consults. Now I'm reading about feeling threatened, living wills and sexual activity.
 
How did we get here?

When I was an undergrad in Biochemistry, during the dreaded Physical Chemistry course, we learned about the observer effect and the Heisenberg uncertainty principle. Wikipedia defines both as:

"In science, the term observer effect refers to changes that the act of observation will make on a phenomenon being observed. This is often the result of instruments that, by necessity, alter the state of what they measure in some manner. A commonplace example is checking the pressure in an automobile tire; this is difficult to do without letting out some of the air, thus changing the pressure. This effect can be observed in many domains of physics.....However in quantum mechanics, which deals with very small objects, it is not possible to observe a system without changing the system, so the observer must be considered part of the system being observed.

In quantum mechanics, the uncertainty principle is any of a variety of mathematical inequalities asserting a fundamental limit to the precision with which certain pairs of physical properties of a particle known as complementary variables, such as position and momentum, can be known simultaneously. For instance, the more precisely the position of some particle is determined, the less precisely its momentum can be known, and vice versa."

In my opinion we now have a new phenomena that parallel the laws of physical chemistry:  I call it the HEDIS uncertainty principle

The actual act of measuring HEDIS® scores and other similarly contrived quality metrics has fundamentally intruded into the quantum level of physician care.  Does this measurement change the behavior of the particles of the system and alter the ultimate structure of the encounter?  Are the data still reliable and the measurements still accurate?  Have the impressions and treatment recommendations indeed become hypoplastic, or has the encounter remained unchanged but the documentation is skewed to HEDIS®? Is the question asked of the consultant answered but not documented?  If not, what does this portend for disease management and health care quality?

I have my suspicions, but I would like to tap the wisdom of the DMCB readers for theirs.

Image from Wikipedia

On the Invisibility of Selection Bias and Regression to the Mean in Population Health Management

A DMCB Vacation....
While the Disease Management Care Blog is neglectfully vacationing at the New Jersey shore, the spouse is slathering it and the spawn with SPF 1003.  That's why the DMCB can't help but recall the recent advice of a media dermatologist: fear the sun.  Every melanoma patient he had ever cared for "recalled at least one severe sunburn!"

The population health management providers would be well advised to remember that skin doctor's silliness.  While every patient we recall "got better" also ask yourself the simple question that should have been posed by the radio-show host:

"What about the patients you didn't take care of?"

Talk to any telephonic-coach nurse or any medical home care manager, and he or she will likely be able to rattle off dozens of HIPAA-protected encounters that started with an expensive clueless patient and ended with a less-expensive empowered patient. They and their manager-supervisor-vice-presidents are sure they had an impact. They see little reason to believe otherwise and see no need for "proof."

They're wrong.

Unfortunately, for both dermatology and PHM, it cuts both ways.  Plenty of patients have had severe sunburns and never had to see a dermatologist.  And there are plenty of patients who go from high to low intensity without the benefit of care management.

Of course, don't credit the DMCB for this example of selection bias with regression to the mean.  Skeptic Francis Bacon commented on the invisibility of drowned worshippers centuries ago.

The DMCB won't mention that problem to the spouse when it enters the surf.

Image from Wikipedia

Thursday, August 27, 2015

Fee-for-Service Medicare Beneficiary Access to Care: The Truth May Be More Complicated

According to this just-released Health and Human Services Issue Brief, the percent of U.S. physicians "accepting new Medicare patients" increased from 87.9% in 2005 to 90.7% in 2015. What's more, this rate of uptake of new Medicare beneficiaries is tracking higher than the rate of "new privately insured patients."

The Issue also says there "may" have been a "very small increase" in the number of docs who have dropped out of the Medicare program. Those drop-outs appear to be greatest among psychiatrists (1.1%) and plastic surgeons (1.6%). In contrast, only 0.35% of primary care physicians have dropped out. These drop-outs have been more than compensated for by the new physicians entering the labor market.

Except for 2015, these data are from the in person interviews that comprise the National Ambulatory Medical Care Survey, The 2015 numbers are described as "interim," because they are based on a mail-in survey.

The Issue brief also quotes a separate MedPAC annual survey of thousands of Medicare beneficiaries. According to the brief, 77% reported they never experienced a delay in getting an appointment for routine care, compared with 76% in 2008.

Case closed, right?  The Disease Management Care Blog's dire warnings about a widespread provider exit from Medicare that was echoed years later by the Wall Street Journal have been overblown.

Not exactly, speculates the DMCB, for the following reasons:

1. The DMCB pulled a copy of the NAMCS survey and found the question that was apparently used to assess physician participation. The screen shot is above. It generically refers to "Medicare," not fee-for-service Medicare.  Because many physicians are members of insurance networks, an affirmative answer could be misinterpreted by the respondents as referring to Medicare Advantage. 

2. There is a difference between "accepting" new patients vs. welcoming new patients. In this seminal New England Journal study, many respondents "accepted" "new" Medicaid beneficiaries, but moved them to the back of the appointment queue.

That being said, the MedPAC survey suggests that isn't happening           - yet - to Medicare beneficiaries. And that's assuming a health care consumer's definition of "delay" hasn't been dumbed down since 2005.   

3. Last but not least, the NAMCS numbers represent a national average. Many areas of the country have seen consolidation of physician practices into larger groups. The DMCB suspects these entities are more willing to accommodate Medicare beneficiaries. It's very possible that the smaller physician-owned practices - many of whom practice in rural areas - are less likely to do so in 2015 than they were in 2008.

Coda:

In yesterday's post, the DMCB was introduced to "twerking." After additional inquiries of the DMCB spawn, it has learned more about this curious phenomenon. 

Which led to this insight:

Q: What is one key similarity between twerking and being an ACO?

A: You better be careful doing both, otherwise you could get screwed.



.

Wednesday, August 26, 2015

Time for Docs to Get Out of the Food Wars


In Food Fad Fantasyland, rotund patients can see their primary care physicians and discuss the merits of Atkins versus South Beach vs. [insert name here].  Armed with the latest nostrums, patients go forth and diet until the next twerk comes along.

Bleh.

While physicians and the for-profit care management vendors can disagree about many things, one thing they can agree on is the ability of their corpulent patients to swear by an endless number of diets.  Whether its "low carbs" or "Mediterranean" or "mini-fasts," docs and coaches alike are expected to not only endorse these fads, but deploy insider jargon like DMCB spawn watching the MTV Video Music Awards. Taylor Swift was crooning about... who?

Which is why, after reading this JAMA Viewpoint article, the Disease Management Care Blog agrees that it's time call a time-out.  It's also time for the DMCB primary care colleagues to exit.

The DMCB explains.

Drs. Pagoto and Appelhans point out that when it comes to weight loss and risk factor reduction, there is no research that convincingly proves that one dietary approach is superior to any other.  Outside of individual preference, the mix of nutrients makes no real difference.  Instead, say the authors, what's important is adherence.  In other words, once patients embark on their preferred diet, they have to stick to it.

Unfortunately, that message has been lost in the multi-billion dollar faddism that has come to dominate the food industry marketplace.

Skeptics will point out that getting persons to stick to a particular diet is a fool's errand.

Not so, say the JAMA authors. Pointing to the Finnish Diabetes Prevention Study, The Da Qing Diabetes Prevention Study and the Diabetes Prevention Program, they note that long-term behavior change that includes behavioral modification and lifestyle change is very possible. 

"Hear hear!" says the DMCB.

As most doctors are aware, most health insurers (including Medicare) don't really reimburse enough to meaningfully cover the true costs of life-style related counseling.  What's more, selective memory recall means that physicians generally remember just how often their counseling leads to their individual patients being as fat as ever.  Most of us physicians are not that good at coaching anyway.

Which is why the DMCB thinks dietary counseling should be outsourced outside of the doctors' offices.  The good news is that wellness and health promotion programs are becoming more adept at focusing on patients' adherence to lifestyle change, mostly by finding those with a willingness to change. It's then a matter supporting those individuals over the course of a year or more. 

This is just one example of the approach.  There are more to come.

The DMCB conclusion

1. Docs should be "agnostic" when it comes to one diet fad vs. another.  It's patient preference.  Next.

2. What really counts is adherence to long-term lifestyle change.  Since many physicians are not good at that kind of long-term coaching, better to let other programs offer their wares to insurers.  The key for these programs is to focus on lifestyle change for those patients who want it and can accomplish it.

Tuesday, August 25, 2015

CMS Succumbs to Disease Management Style Spin?

If, thanks to the medical home or disease management, you've witnessed the improvements in patients' care, you've also probably been frustrated by those silly skeptics' insistence on validation. But for traditional research designs, statistical significance, valid comparators and publication in obscure scientific journals, the face validity of nurse-led care management for high risk patients could have ushered in a new era in primary care.

Darn those academic-actuary-statistician-weenies! And double darn CMS for falling for them and not funding the medical home and disease management!

Which is why Population Health Blog readers may enjoy this bit of peer-review schadenfreude. It appears a recent CMS pronouncement that its own "Partnership for Patients Program" prevented early elective deliveries and reduced readmissions is highly suspect, thanks to "a weak design, a lack of valid metrics, and a lack of external peer review for its evaluation." 

Yikes.

It appears the amateurs at CMS used a pre-post design, selected start and stop evaluation points to gin up the outcomes, relied on imperfect administrative data and never bothered with having its outcomes validated by independent review. As a result, we really don't know if the billion of dollars that went into PPP did any good at all.

The PHB appreciates the point. Scientific discipline and peer review go a long way making sure that consumers are getting their money's worth. Now that CMS has gone from an agnostic payer to the centerpiece of health reform, there's a huge risk that its bureaucrats will succumb to shortcuts and spin.

Taxpayers deserve better.  And so do patients.

Image from Wikipedia

Monday, August 24, 2015

Friday Quips

Occasionally, I glimpse a truer Truth, hiding in imperfect simulacrums of itself, but as I approach, it bestirs itself and moves deeper into the thorny swamp of dissent.

from Cloud Atlas, by David Mitchell

plus......

From a short inteview with Jesse's Café Américain:

Q. If you could travel back in time and change something in the financial world that would benefit society, what would it be?

A. I would help Alan Greenspan achieve a wonderfully rewarding career as a professional clarinetist.

Saturday, August 22, 2015

More on the Corporatization of Health Care


In yesterday's post, the Disease Management Care Blog correlated an apparent White House policy preference for public-private health care "coporatization" (or corporate nationalism?) with the early death of government-run "public option," the conspicuously large role of large commercial insurers in Obamacare and the astonishing faith in unproven accountable care organizations (ACOs).

If the DMCB has it right, that:

1. ... might make Obama Administration officials think that they already have the tools they need to control coordinate health care costs. 

2. ....would explain Obamacare's myriad committees, councils, panels, offices and task forces staffed by bureaucrats, experts and insiders. Someone has to reconcile the numerous and complicated private and public dimensions of a top-down approach to health reform.

3. ....ironically risks, despite the greater involvement of a democratically elected government, less transparency. Think Congress delegating responsibility to consensus meetings populated by appointees who make the Big Decisions behind closed doors. Recent examples include mammography, Avastin, coverage of oral contraceptives and the EHR meaningful use criteria. More are on the way.

4. .... could lead to new versions of crony capitalism, where getting your way depends less on the merits of your idea or what patients want and more on how familiar you are with the decision-making process and the mandarins who are calling the shots. HIMSS may be an early example.

5. .... the states' role "as laboratories of democracy" is significantly diminished.

6. ... means single payer "Medicare-for-all" has a far worse prognosis than generally appreciated by conservatives and progressives alike.  Someone should break the bad news to these guys.

7. ...that this is the medical-industrial complex on steroids.

Consider this front page Aug 22 Wall Street Journal article on the recent rescue of a Philadelphia oil refinery by the coordinated efforts of an Obama Administration official, a "well connected" D.C. private equity firm, a labor union and a Governor who leveraged personal relationships, subsidies, loosened environment regulations and union concessions to keep a failing business model afloat. The DMCB knows nothing about the petroleum business, but predicts the same kind of shenanigans are in store for health care big time.

You read it here first.

Friday, August 21, 2015

The "Coporatization" of U.S. Health Care: Why the Good Prognosis for Health Insurers & ACOs May Be Guaranteed

Corporatization
The Disease Management Care Blog is ashamed to admit it, but it's reading Edward Klein's The Amateur. While much of the book is a conservative-partisan rehash of Mr. Obama's alleged personal and political shortcomings, it did raise one issue that intrigued the DMCB:

"Corporatization."   It seems this White House likes it.

As the DMCB understands it, this is a policy agenda that favors the formation of huge corporate organizations that dominate the national business climate. Its argument is that, thanks to their size and scope, these gigantic private, public and not-for profit corporations are better able to marshal the resources it takes to launch transformative programs, achieve efficiencies, take risks and make profits that are beyond the normal reach of traditional commerce. Think about the hundreds of billions-of-dollars-approaches to housing, financial services, battery operated cars, high speed rail, solar power, privatized space travel and, last but not least, health care insurance and delivery.

A key ingredient of corporatization is "partnering" with government in a way that blurs the line between private enterprise and the public interest. Ingredients include government-backed financing, special tax breaks, loans, grants, mixed Boards of Directors and sovereign investment funds.  The downsides are quite familiar also: crony capitalism and too-big-to-fail status 

The best example of corporatization is China. Beijing centrally orchestrates many of its key economic sectors including finance, banking, housing, public transportation and heavy industry with an opaque mix of public and private companies. While political reforms and respect for human rights have been found wanting, the prospect that China could eclipse the United States in the next 25 years has prompted many in the U.S. to admire China and reexamine the merits of old fashioned capitalism and unfettered markets. For an interesting example of that thinking, see this editorial by Andy Stern that recently appeared in the Wall Street Journal.

What could this explain and what are the implications?

1. The abandonment of the government-run "public option" early in the course of creating the Affordable Care Act. Despite his hostile anti-insurer rhetoric, Mr. Obama's ultimate belief in large mega-insurance corporations, a) regulations and b) public subsidies that bind the behemoth insurers to D.C. won the day.  And it ain't going away anytime soon.

2. The near ideological support by this Administration for Accountable Care Organizations. Despite little track record that ACOs offer a viable business model, the notion of large regional providers partnering with and led by CMS is fully consistent with a belief in corporatization.  This makes the DMCB wonder if Mr. Obama's intent is to assure that ACOs succeed, no matter what.

Another Large Scale Research Study Confirms the Value of the Approach of Population Health Management

And here's another study, this time published in JAMA about Kaiser in Northern California that found that the following five components resulted in an increase of population-based blood pressure control

1. "Registry" (which the Disease Management Care Blog says is really a stand-alone database that is outside of the electronic health record);

2. "Control Rates" (which the DMCB figures is really an updated "dashboard" that displays key metrics to administrators and docs that provides feedback and helps keep everyone on the same page);

3. "Guideline" (in reality, it was a campaign to gain provider buy-in consisting of emails, publications, pocket cards, conferences, lectures and decision support);

4. "Medical assistant" follow-up operating under protocol to adjust medications (a.k.a population-based care management)

5. "Single" pill treatment (in other words, keep it simple by using pharmaceuticals that are combined in a single once a day prescription pill).

DMCB readers will not be surprised to know that the registry showed a progressive improvement in BP control (defined as less than 140/90 with the usual HEDIS® caveats) from 43.6% in 2001 to 80.4% in 2009.  Because everyone with hypertension at Kaiser was in the registry, there is no internal comparison group.  However, national and northern California HEDIS® rates for blood pressure control ranged from 55.4% to 69.4%.

While the results are 1) not necessarily generalizable outside of integrated systems like Kaiser (so we don't know for sure that this would work in a network of primary care clinics in Idaho), and 2) may have been influenced by an influx of patients with mild and easy-to-treat hypertension during the campaign), the DMCB is impressed

An 80% control rate for hypertension is damn good

The DMCB also figures that each of the interventions above are mutually supportive and even synergistic.  The whole is much greater than the sum of its parts.

How to translate this kind of success to networks of independent practices?  The answer, says the DMCB, is population health management: sponsored programs that can be owned by an insurer or a provider network that synergistically identify a population, maintain a data base, create a virtuous cycle of measurement and adjustment, get the doctors on board, deploy care managers and are smart about the pharmacy benefit.

If your a PHM service provider, vendor, consultant or stakeholder, the DMCB suggests this is one of those research papers you should bookmark, quote and aspire to.

Image from Wikipedia

Thursday, August 20, 2015

Why The Tipping Point for Health System Consolidation May Be Closer Than We Realize: Lessons from Airline Mergers

Ready for take off
From time to time, the Disease Management Care Blog and other pundits turn to the airline industry draw lessons on the evolution of health careIntegrated human-computer systems, safety check-lists, website-based Expedia-like price transparency, teaming and other such notions have infiltrated health policy PowerPoint presentations worse than Doritos bags in Seattle Hempfest crowd.

While the DMCB was mulling another lesson about the divide between coach (what vanilla insurance could turn out to be) versus business/first class (concierge-style direct pay), along came this interesting Wall Street Journal article by airline industry bad boy Robert Crandall about the American Airlines - US Airways merger.  He argues 1) mergers that lead to bigger are better (no surprise there) and 2) if some airlines are allowed to go big, the only way for others to compete is to go bigger also.

That latter argument is important, and may also hold lessons for health care. 

Mr. Crandall argues that once the furies are released and one or two regionally dominant service providers are allowed to populate the marketplace, smaller competitors are at a disadvantage.  As a result, they have no choice but to also seek alliances and mergers.  How well government reconciles consumer interests and business profitability will remain an open question involving lawyers, bureaucrats and politicians.

Ditto regional health care systems, accountable care organizations and integrated provider organizations. 

Once one of these behemoths is unleashed in a city or corner of a state, smaller neighboring provider systems will naturally circle the wagons and seek permission to consolidate so that, just like the airlines, they can compete. They make a good argument, because without the size, they could go bankrupt. 

As health reform continues, geographically large systems that can access capital, achieve economies of scale, become accountable and take insurance risk will grow in number and complexity. That will only fuel the further consolidation of small local hospitals and smaller physician practices.

In other words, the lesson from the airlines may be that that "tipping point" for nationwide health system consolidation may be much closer than we realize.

Image from Wikipedia

Are Rising Health Care Costs As Bad As We Think They Are?

When pundits claim that health care spending is out of control, what do they mean?

Does it mean that Massachusetts' outlawing of hospitals' excessive price increases is a good thing? That rolling back the Affordable Care Act will automatically usher in a new round of price gouging? That when the DMCB generates another medical co-pay, the DMCB spouse is right to wave a copy of the bill around and demand that the DMCB do something now to reform the U.S. health care system?

As the Disease Management Care Blog understands it, what the pundits, Massachusetts legislators, patient advocates and the DMCB spouse mean is that more and more of our nation's gross domestic product (GDP) is being spent on health care services.

That assumes we'd all be better off if the U.S. were spending its national treasure on stuff like manufacturing, technology, education and innovation. So, instead of committing just under 18% of our output on hospital care, physician services, nursing homes, medical devices and drugs, we'd all be better off if we spent it on the production of solar panels, Facebook, public school vouchers and iPhone apps.

That way we wouldn't be struggling with the prospect of another 1% gain on GDP (to 19%) and the looming possibility that we'll soon be spending a whopping fifth of our economy on health care.

But is the spending on health care really that bad?  As noted here, the DMCB pointed out that non-government-insured health care costs have been moderating for years.  What's more, recent year-to-year increases in health care spending in the U.S. are actually lower than much of the developed world.

And now there's one more reason to doubt the prevailing wisdom about rising health care costs. Charles Roehrig, Ani Turner, Paul Hughes-Cromwick and George Miller of the curiously name Altarum Institute point out that the normally rising and falling GDP associated with routine economic cycles can make steady health care costs look relatively worse or better than they appear.

To dampen the impact of a cyclic economy on the assessment of health care spending, the authors compared health spending to U.S. "potential GDP." Apparently, this obscure economic metric has been used by economists to portray what GDP would be if the economy were operating at full employment of the current population and without any idle production capacity.  This metric has the advantage of "smoothing out" many of the peaks and valleys of the normally measured GDP.

Using potential GDP as the comparative baseline, the authors found that health care spending growth gained less than 1% of the economy starting in July of 2005, well before the onset of the Great Recession of 2008In other words, during that time, the health care industry grew pretty much at the same rate as the "potential" GDP. 

What's more, in June of 2009, health care cost growth gained an additional 1% of potential GDP, only to fall back below 1% again in May of 2011.  Most of the increases seemed to be accounted for by Medicare Part D spending; if that particular cost is backed out, excess growth would have been 1% or less throughout the measurement period.

The authors can only hypothesize on why health care costs didn't outstrip the U.S. economy. While it could be partially accounted for by the rising numbers of uninsured (who would have avoided going to hospitals or seeing doctors), the authors point out that other trends could have played a role: changing physician practice standards, increasing numbers of salaried physicians, market pressures pushing down on fee schedules, increases in patients' out-of-pocket expenses making them less likely to access the care system, new care models (including disease management?), the increasing use of generics, previously expensive drugs going off patent and the drop-off in the number of "blockbuster" pharmaceuticals.

This means when the economy bounces back and/or Obamacare results in more insured Americans, there is no guarantee that underlying health care inflation will return.

Just What Is "Patient Engagement" in Health Care?

According to this paper by Barello et al in the Journal of Participatory Medicine, the muddled answer depends on when it was used as well as your professional background.

Using a densely written "lexicographic qualitative analysis" to dive into over 250 scientific papers, the authors found that the term has evolved and may still be in its infancy. When it first began to regularly appear about 15 years ago, the term "patient engagement" was used in behavioral and nursing contexts to describe a dimension of established one-on-one provider-patient care.  Since then, it's been used in a biomedical sense to portray a new relationship between a system and a patient.

The authors point out that how "engagement" is achieved depends on a spectrum of patient perspectives that range from unaware to really motivated.  The Population Health Blog suggests that one way to think about it may be the transtheoretical "readiness to change" model.

The one thing that has been missing in the scientific papers is the patients' perspective.  Ironically, no one has asked and cataloged their answers in any systemic manner.

Last but not least, it's unclear if real purpose of achieving patient "engagement" is greater autonomy, relationship-building, making health care more responsive, reducing costs, or improving public health.  As a result, it's a catchphrase has become all things to all people.

While this lacks the all-important input of folks like this and may also be an exercise in tautology, the Population Health Blog managed to extract something of a definition for the term: a span of cognitive processes that seeks participation, compliance, learning  and self-management in health care, including disease, prevention and health.

Image from Wikipedia

  

Wednesday, August 19, 2015

More on Penn State's Wellness Woes and The Evolving Science of Evaluating Health Promotion Program Outcomes: There Is No Gold Standard

Aside from keeping up to date with work buddies, the Disease Management Care Blog doesn't really use LinkedIn all that much. But when "Support our Penn State Colleagues in their Fight to Prevent Coercive Junk-Science Wellness Programs" postings began to appear in a Discussions board, the DMCB couldn't resist. It rose in support of its alma mater (College of Medicine, '77) faster than a med-mal attorney can calculate a contingency fee.

 As noted in this prior DMCB posting, Penn State University launched a rather routine health promotion program that prompted some nasty and very public teaching faculty resentment. Calls for "civil disobedience" and sinister references to "eugenics" made the DMCB wonder how much of the reported push-back was mainstream employee opinion vs. mainstream media's biased reporting. That distinction didn't stop the LinkedIn board from running a mostly one-sided dialogue on the matter.

So, undeterred by the unfairness of so many vs. just one, the contrarian DMCB naturally jumped right in.  Among the issues raised:

The RAND Study on wellness casts doubts on the merits of employer sponsored wellness programs:

Actually, RAND found employer-sponsored programs lead to statistically significant increases in exercise levels as well as reductions in tobacco abuse and body weight.  To the disappointment of wellness vendors everywhere, however, these programs did not lead to statistically significant reductions in health insurance claims expense.  The ever-optimistic DMCB points out that that means that these health improvements occurred without an increase in health care costs.

While cost neutrality alone is good news, the DMCB also believes that an emerging generation of wellness programs will do a far better job of identifying persons with 1) actionable risk and 2) who are willing to take action.  By husbanding wellness resources for subpopulations where it will have the greatest "bang," program costs will go down and claims savings will achieve statistical significance.

The author of the widely quoted Health Affairs paper on the merits of employer sponsored wellness programs has back-pedaled away ("too early to tell") from her study's original conclusions.

Actually, the original Health Affairs paper said that the finding of a $3.27 return on every dollar spent is subject to:

 "(f)urther study.... to elucidate the time path of return on investment.... The assumption of a linear trend in savings from the beginning to the end of program evaluation may not reflect the reality of behavior change within organizations."

The point is that nuanced and calibrated conservatism is typical of excellent peer-reviewed research and, taken in context, the authors are being quite consistent in-print and on-air.  Academics will always say more research is needed.  Skeptics will over read that.

There are powerful arguments against the common wisdom that "wellness saves money," suggesting that the health promotion industry has been intentionally ripping employers off.

Actually, when it comes to wellness outcomes, there is no agreement on "the" measurement "gold standard." Without any consensus on which assessment approach (for e.g., this vs. this) is truly "better," only one thing is certain: much like the Betamax vs. VHS wars, the future owner of "the" standard stands to reap a consultant's bonanza. Until we declare a winner, assessing the truth will be a messy mix of triangulating on means, medians, confidence intervals, imperfect reference controls, suspect generalizability, human judgment, moving targets and evolving interventions.

What about [insert name of wellness program here] that is an obvious sham?

There have been women who have had mammograms with missed cancer, victims of car crashes who have died despite seat belts and times when the DMCB did something really dumb despite the advice of the DMCB spouse.  That doesn't mean mammogram, seat belts or advice are worthless.  The plural of anecdotes is not data.

Coda: By the way, the statistically significant "value of  0.05" is more of a consensus than a gold standard.  Why is a 5% chance that an observed result is not the result of randomness wiser than a 6% chance or a 4% chance?

Foot Biden Mouth Disease

Disease Management Vendors Offer Treatment for Dreaded Foot Biden Mouth Disease

From Naaj Vorodis, DMCB
Updated 17:00 Sun August 19, 2015

Washington DC (DMCB) -- A consortium of disease management service providers have announced a new product offering for "Foot Biden Mouth Disease." 

Characterized by a microphone-induced symptom triad of pseudodementia, confabulation and tone deafness, this chronic and incurable condition is associated with pandemics of spinning punditosis and chronic voter fatigue. Statistics gathered by the CDC and the Boston Globe show that, while this pestilence is uncommon, a multiplier effect over news media, websites and social networks makes it appear as bad as it really is.

In response, the consortium is now offering a bluetooth-enabled monitoring device that analyzes the wearer's speech and, when doltish utterances are detected, sends a SMS text message to a responsible adult. This patented and proprietary technology uses a voice activated political information exchange network that mines the user's phrases and compares them to quotes from Mel Brooks, Donald Trump, SuperPAC Ads, The Simpsons and Bane. When a match is detected, not only is the text message is generated, but the wearer is also prompted to apply a cork.

"Our background in enabling behavior change to reduce the rate of complications in conditions such as diabetes and high blood pressure makes disease management a perfect answer to this disabling condition of political buffoonery," said  disease management industry expert Bill Alot. "Our technology can adapt itself to the consumer's level of insight and result in beneficial outcomes, even if the patient has zero insight," he added.

Unnamed sources in the White House have stated that this may reduce the recurring episodes of panic in the Situation Room.  "We sure hope this works," said one source, "otherwise its back to the teleprompters for all of us."

Tuesday, August 18, 2015

Doubling Down on Accountable Care Organizations and Health Information Networks

Want to achieve effective health care, reduced costs, increased quality, population health, widespread prevention and seamless health information access? 

It's easy, says  this article in Population Health Management: mix one part PHO with one part HRB to create a HAPPI.

The Population Health Blog was confused too, but that's what's proposed by three smart academics from Johns Hopkins, Arizona State University and UC Berkeley.

As the PHB understands it, Population Health Organizations (PHOs) would be responsible for all medical, public health, community and social services in a defined geographic area and coordinate them with local education, housing and labor. Much of it would be paid for by a pooled risk-adjusted global or capitated payment (budget) from all insurers.

Each organization would be paired with a Health Record Bank (HRB), which would act as a huge data warehouse that not only stores all medical information, but any other publically available information on every individual enrolled in the PHO. The HRBs would be owned and operated by "trusted custodial organizations." Data access would be ultimately controlled by each patient.

The authors believe that patient payments would be a source of additional revenue for their PHOs. Examples include buying "apps" that are tailored to their individual health needs, or selling their personal health information, especially if it means helping physicians buy an electronic health record or access cutting edge research.

Combine a PHO and HRB and you have a Health and Prevention Promotion Initiative (HAPPI). Its size and scale would warrant contributions from community and provider organizations "without the need for additional reimbursement or outside funding." It would efficiently "align incentives" for insurers, hospitals and ACOs - with money left over for prevention, care coordination, decision support and a learning health system.

Breathtaking, isn't it?  If any PHB readers thought accountable care organizations (ACOs) and health information networks (HINs) weren't big enough, along comes Tyrannosaurus rex-sized PHOs, HRBs and HAPPIs. 

The PHB worries that while we'd want to see how pint-sized ACOs (not a slam dunk) and HINs (likewise not a slam dunk) perform before we apply the massive steroid doses, the opposite could happen: their messy failure could be just the justification for doubling down and going even bigger

As pointed out in a recent Wall Street Journal Notable and Quotable:

Economist Michael Munger writing in the Freeman, Aug. 11:

When I am discussing the state with my [academic] colleagues, it's not long before I realize that, for them, almost without exception, the State is a unicorn. I come from the Public Choice tradition, which tends to emphasize consequentialist arguments more than natural rights, and so the distinction is particularly important for me. My friends generally dislike politicians, find democracy messy and distasteful, and object to the brutality and coercive excesses of foreign wars, the war on drugs, and the spying of the NSA.
 
But their solution is, without exception, to expand the power of "the State." That seems literally insane to me—a non sequitur of such monstrous proportions that I had trouble taking it seriously.
 
Then I realized that they want a kind of unicorn, a State that has the properties, motivations, knowledge, and abilities that they can imagine for it. When I finally realized that we were talking past each other, I felt kind of dumb. Because essentially this very realization—that people who favor expansion of government imagine a State different from the one possible in the physical world—has been a core part of the argument made by classical liberals for at least three hundred years.

Image from Wikipedia

Sunday, August 16, 2015

What You May - or May Not - See at the Care Continuum Alliance's Forum12 Annual Meeting in Atlanta

Along with many readers, the Disease Management Care Blog is looking forward to the Care Continuum Alliance's annual meeting, Forum12, two months from now in Atlanta. Not only will the DMCB get to make new friendships, the plenary presentations and smaller educational sessions are great way to learn how to apply the theoretical underpinnings of wellness, prevention and care management to the real world.

To help attendees better prepare for the meeting, the DMCB is pleased to offer this Lettermanesque "Top Ten" of things you may, or may not, see at the Forum12:

10. Someone genuflects upon hearing the term "CMS Innovation Center."

9. Only healthful fruit is served at one of the meeting breaks; in response, attendees riot.

8. A DMCB YouTube video is embedded in session PowerPoint (hey, it's happened).

7. Three quarters of the attendees sitting in on a session are from the presenting faculty's company.

6. Someone shows up at an early morning pre-meeting yoga class dressed in business attire, thinking it was a presentation on the return on investment from an employee yoga program.

5. The term "engagement" is used 20 times by a presenter in the course of ten minutes.

4. One faculty member hits a "presenter's trifecta": 1) arrival flight lands on time 1/2 hour prior to the presentation, 2) he or she finds the meeting room within minutes and 3) catches the departure flight 1/2 hour after the end of the presentation.

3. The imposing booming disembodied voice asking you to take your seat at a plenary session is that of a female. With attitude.

2. The competition between the exhibitors for your attention becomes so intense, one offers free beer. Others follow suit.

1. The DMCB spouse "crowdsurfs" one of the plenary sessions.

Saturday, August 15, 2015

A Brainy Health Wonk Review on Health Reform, the Affordable Care Act and Lots More!

Welcome to the Disease Management Care Blog, your host for this edition of the Health Wonk Review. This is a linked summary of the latest and best postings from an informal community of health policy bloggers with informed insights that readers, business leaders, academics and policymakers won't find anywhere else. We invite you to sit back, get a beverage, enjoy a snack and feed your brain as you join thousands of your colleagues and competitors in gaining a deeper understanding of the U.S. health care system.

When when when (of a miscellaneous nature)

When researchers act like politicians: The falsification, fabrication and plagiarism that comprises research misconduct is the topic of a post by Donald Kornfled over at the delightfully named Wing of Zock. Causes include the fear of failure, perfectionism, ethical lapses, grandiosity and psychopathy. Dr. Kornfield reviews potential fixes, including training courses, better mentorship with monitoring and protections for whistleblowers.

When for-profits run amok: Roy Poses at Health Care Renewal scrutinizes one health care system's latest branding campaign and acquisitions, pointing out that the lack of any specificity seems to confirm that this is all about profits, not patients; commoditization, not caring; and corporatization, not community.  Unfortunately, this is not an isolated incident.  You've been warned.

When outcomes are based on flawed research: David Williams of the Health Business Blog asks Al Lewis why no one believes the numbers that underlie the reported effectiveness of population health management, the medical home and wellness. It's easy, says Al: the math has been unnecessarily complicated, actuaries make mistakes and there's selection bias, regression to the mean, confounders. pressure to show success and, most of all, a widespread and regrettable under-recognition of Al's vast expertise.

No Health Wonk Review is Complete Without the Affordable Care Act

Will it never end? If you're interested in even more obscure legal theorizing over the constitutional legitimacy of the Affordable Care Act, then head on over to the Health Affairs Blog. It appears the ACA may only authorize consumer subsidy tax credits in "state" run exchanges. The failure to include federal exchanges in the legislation could be a pesky wording oversight (argued here by Timothy Jost) that is overcome by a common sense understanding of Congress' original intent, or a craftily worded way of giving the states one more incentive to open their own exchanges (argued here by Michael Canon and Jonathan Adler) that could backfire and conveniently hobble the roll-out of the exchanges.

If you had to pick one good thing about the ACA, would this be it? Have you heard about the ACA's insurance co-ops? Think of these as smaller regional not-for-profit health insurance plans that are sponsored by consumer-based organizations. Jay of the Colorado Health Insurance Insider describes how, thanks to a loan from Uncle Sam, a new rural co-op is being launched in Colorado. It plans to open its doors in 2015 with a target of 10,000 enrollees.

And if you wanted to convince skeptical voters about the rest of the ACA, Anthony Wright of the Health Access Blog reminds us that the Brits proudly featured their National Health Service (NHS) in the Olympic Opening Ceremony for lots of good reasons.  The conservative DMCB not only wonders what marketing lessons CMS can learn from this (hint: opening ceremony at the World Series) but it has had its wacky closet Tea Party fears confirmed: "ACA" spelled backwards is "NHS" and its Maximum Kommissar will be First Citizen Don Berwick.

Massachusets reminds of what could follow the ACA: David Harlow of the HealthBlawg looks at what the Bay State is doing now that Romneycare's reforms neglected to tame health care cost inflation: Regulations that prohibit excessive provider price increases,promotion of the medical home and ACOs, greater market transparency, more public financing and physician liability reforms.

And what do the brokers think of the ACA? Hank Stern of the InsureBlog describes a blow back on the insurance provision that excess administrative costs must be rebated back to the beneficiaries.  Not only is it very burdensome to calculate in group policies with individual underwriting, but the tax implications are best considered in a "Michelob teaching moment" (that'll make more sense when you read the entire post, but trust the DMCB: it's not good).

Accountable Care Organizations?  Amazingly, only one HWR submission!

Is the DMCB really a DmCB?  DMCb?  Kerry Willis of the Health Talent Transformation blog calls on docs to resist the siren call of the ACOs' easy money. Look closely, he says, and you'll notice a strong resemblance the 1990s-style PHOs that were long on hospitals' interests and short on physicians' needs. He suggests that a better name would have been pHO. That's why he says unless ACOs use the physician-led patient centered medical home or concierge practices, a better name for them would be AcO.

Of Budgets, Priorities (and their evil architects)

In the taxpayers-get-what-they-pay-for-department, Liz Borkowsi of ScienceBlogs reviews a Health Affairs study on physicians' willingness to care for coming wave of new Medicaid beneficiaries. Based on a representative sample of docs, 69% are currently accepting such patients, but the numbers vary by geography (the rate is only 40% in New Jersey, for example).  The researchers estimate increasing payment rates to match Medicare's fee schedule would likely increase acceptance by an average of 10 points. One solution is expanding the nation's 8000 community health centers with the $11 billion allocated by the ACA. Unfortunately, that money has been a tempting target for budget-deficit minded politicians.

...and here's more on the taxpayers-get what-they-pay-for: Jason Shafrin of the Healthcare Economist blog looks at Medicare's reimbursement for for Alaskan physicians and finds evidence that new and established Medicare beneficiaries are having trouble finding a primary care physician. It seems the physicians would rather fill their clinics with better paying commercially insured patients.  If that income stream ever gets cut off, thinks the DMCB, the docs could always turn to the remunerative world of blogging.

How about what patients don't want to pay for? Medical student Justin Jones examines end-of-life care and finds doctors who forgo aggressive treatment of their incurable cancers may be role models for the rest of us.  Yet, despite some compelling anecdotes and the disdain for death panels and cost considerations, the provocative DMCB still wonders how insurers and their risk-bearing providers will reconcile an obvious conflict of interest over death with dignity and reducing claims expense with upside gain sharing.

In the physicians get annoyed-on-how-they're-monitored department, everyone agrees we need to measure health care quality and make providers more accountable.  Unfortunately, making that happen in the real world is proving difficult. Brad Flansbaum of the Hospitalist Leader blog offers a quick primer on CMS' early efforts at physician report cards in Kansas, Iowa, Missouri and Nebraska and explores the pros and cons of measurement at the individual, group or hospital level.

Tough Choices: Chris Langston, the Program Director at the John A Hartford Foundation blog points out that the dysfunctional economics of Medicare and Medicaid are ethically troubling. Decreased payments for geriatric services are part of a troubling pattern of discriminating against the poor and elderly. He asks if it's time to recast the political debate over the current scope of government insurance as a beneficiary rights issue.

I knew it! Is Republican VP candidate Paul Ryan a real budget hawk, or is his record in Congress marred by the realpolitik of partisanship and party loyalty? Joe Paduda finds compelling evidence of the latter.

Want more dirt on Paul Ryan? Harold Pollack over at healthinsurance.org says he's "extreme," a "pampered millionaire known to purchase $350 wine" with proposals "opposed by huge middle class constituencies" that would lead "between 14 and 27 million low-income Americans to lose health coverage" and cause "deep" cuts in highway repair, K-12 education, environmental protection, public health and law enforcement."

Heroes vs. affordability: While the U.S. military has increased the visibility of post traumatic stress disorder (PTSD), Lynch Ryan of Workers Comp Insider blog reminds us that our nation's police force members are not immune. Cops are far more likely to die by their own hand than be killed in the line of duty, and their rate of suicide per 100,000 matches the U.S. army. Lynch explores the workman's compensation implications: should treatment of the disabling stress of witnessing violence be covered, or is this part of the job?

Your next host for the Health Wonk Review will be Louise Norris of the Colorado Health Insurance Insider Blog.

Friday, August 14, 2015

Penn State's Wellness Woes: Seven Lessons Learned About Launching a Worksite Employer-Based Health Promotion Program

Penn State's mascot goes on the
prowl for a good wellness program
Listen to this NPR report and it's easy to conclude that another employer-based health promotion program has gone amok. Reporter Jeff Brady implies rising health care costs have led Penn State University to force its employees into an intrusive wellness initiative, pitting David-like faculty members against the Goliath-Administration.

What can wellness architects and service providers learn from this imbroglio?

Here's the facts:

Penn State provides health benefits to over 45,000 employees and dependents. It's self-insured (administered by Highmark), which means the University, not some remote insurer, is on the hook for any unanticipated health care costs. 

Those costs have led to a whopping $217 million health care budget for 2015-2015 and a long term $3 billion pension liability. In response to the threat of budgetary "crowd out," the University made some important changes to the insurance benefit that included a high deductible option and value-based benefits.

It also hatched a health promotion initiative. It checked in with the Faculty Benefits Committee in the early spring of 2015 and then used the summer to unveil a "comprehensive wellness-focused strategy."  This included the "Take Care of Your Health" program that packaged biometric screening (some labs, weight blood pressure), an on-line WebMD wellness survey and preventive health exam. Failure to complete that screening, survey and exam will result in a $100 per month payroll deduction in 2015.

The plan didn't sit well with everyone. Faculty members Matthew Woessner fretted about privacy and penned a "call for action and civil resistance," Barry Ickes doubted the economics and Larry Backer invoked eugenics, human dignity and sinister profit-motives.  Brian Curran used the Change.Org website to post an anti-wellness petition for "employees, alumni and friends" that has reached 2000 signatories.  Naturally, wellness gadflies Vik Khanna and Al Lewis were unable to resist and used The Health Care Blog to pile on any wellness program with the temerity to not use their consulting services.

The Disease Management Care Blog speculates on lessons learned......

  • While worksite wellness programs have a reputation for increasing employee morale, it stands to reason for that any stressed organization (and here's why that may be true here), it runs both ways: low employee morale can hinder acceptance of a wellness program. The faculty backlash may be as much of a symptom as a problem.

  • Lesson: Health promotion programs should tread lightly in times of organization turmoil.  This is no time for "big bang" multidimensional interventions, especially if they involve a $100 per month penalty.

  • There is good evidence that employer-sponsored wellness programs save money, but it's unlikely that any health promotion will be enough to tame a $217 million budget.  To Penn State's credit, they simultaneously made some health insurance benefit changes, but that's been lost in this controversy.

  • Lesson: If you're fighting high health care cost trends, don't let the positive return on investment (ROI) from health promotion take the lead. It won't work that well, and employees will think this about reducing your costs, not about increasing their well-being.

  • Similar on-line WebMD wellness assessments for Pittsburgh city employees and the Mennonite Church have gone without any substantial privacy concerns.

  • Lesson: If there are two employee groups with a special talent for indignant paranoiac outrage over any employer-sponsored health initiative, it's medical providers and university faculty. There are plenty of reasons, but the DMCB suspects both are victims of the decades-long twin cultures of 1) autonomy and 2) abundance in health care and higher education.  Stopping by a Faculty Benefits Committee is not enough to secure buy-in.

  • Interestingly, Penn State's College of Medicine has a long standing agreement with Highmark that includes the joint development of evidence-based health, wellness and prevention programs.  Unless that's been cancelled, the medical science faculty's silence is deafening.

    Lesson: Search for and engage employee subgroups that can be your allies in launching a health promotion initiative. Their advocacy may really help.

  • There are wellness service providers like this and this with established records of performance that can successfully reconcile employee and employer needs.

  • Lesson: There's nothing wrong with preferring to "build" over "buy," but only if both options are carefully considered at the outset.  External wellness providers are often subject to financial performance and recruitment standards. If the petition gains traction, the latter would sure come in handy here.

  • Critics of wellness programs in general and this one in particular say that they lead to unnecessary testing.

  • Lesson: The science is still evolving, but here is one answer to that criticism: it's not wellness per se but our society's love of technology.  Wellness programs can use initiatives like Choosing Wisely to develop even better programs.

  • As a self-insured entity, Penn State technically already has access to all the employees' insurance and claims information.  The WebMD privacy concern is silly.

  • Lesson: Now would not be a good time for Penn State's administration to point that out.

     

    Medicare Readmissions Equals Revenue Cuts Equals Hospital Consolidation. Here's Why

    This way to consolidation....
    Disease Management Care Blog readers may recall that Medicare's Hospital Readmissions Reduction Program was among the many provisions of the Affordable Care Act. 

    According to the finalized regulations, if a hospital's readmission rate within 30 days for heart attack, heart failure or pneumonia exceeds an established norm (using three years of data based on a minimum of 25 patients with a statistical risk adjustment to account for co-morbid conditions), that hospital's Medicare payment rates will be reduced for all discharges in the following year. The reduction, depending on the excess rate, can go from zero (readmissions meet the norm) to a maximum of 1% (the hospital penalty results in payment of only 99% of the applicable fee schedule).

    Now, Kaiser Health News has just looked at the numbers and calculates that, thanks to the HRRP,over 2000 hospitals will forgo close to $300 million. According to KHN, 278 hospitals - including some household names - will achieve the dubious distinction of a full 1% reduction.  You can check out how your local hospital will likely fare here.

    While readmissions themselves are a significant problem, the approach used by the HRRP has its own set of under-appreciated methodologic challenges (as noted here and here). Now that hospitals are about to get battered by a well-meaning if flawed payment system, your DMCB raises one more red flag:

    This will drive hospital consolidation.

    That may well be one intent of the law. Cheesecake Factory logic tells us that large hospital systems have the intellectual and capital resources to systematize care, apply best practices, reduce variation and maximize outcomes.  Rather than weep for those hospitals that are losing income, Washington's policymakers are probably hoping that the losers have one more reason to join forces with the bigger, smarter and more efficient hospitals or systems nearby or in the next state (especially the ones with a smartly run disease management program).

    Yet, whether or not hospital consolidation alone would make a palpable difference in cost or quality remains to be seen (as indicated here and here). What could happen instead is the rise of too-big-to-fail, politically connected and market-dominant health care systems.

    We'll see.

    Image from NIHSeniorHealth

    17 Reasons Why Care Management Is Probably Not Going To Be in a Clinic Near You Anytime Soon

    Here's a good review of all the reasons why care management has not become a routine part of patient care. 

    As policymakers, reformists, consultants and architects plan for a population and outcomes-based future, they'd be wise to think about the review's 17-point reality check.

    1) Start-up costs are considerable;

    2) Costly to maintain;

    3) Multi-year time horizon for any return on investment;

    4) Any success undercuts future traditional fee-for-service revenue;

    5) Can't be broken down into discreet 'reimbursible" units for fee-for-service payments;

    6) It's paid for with still-novel-experimental capitated payments and/or shared savings;

    7) The link between increased quality today and downstream savings tomorrow is still tenuous;

    8) Complicates primary care by introducing more uncertainty;

    9) Non-physician manager training is time-consuming and costly;

    10) It's a resource that is best reserved for high risk patients, not all patients;

    11) Doesn't fit into long-standing clinical workflows in established clinics;

    12) Primary care already has enough challenges and implementing care management is not a priority;

    13) Most EHRs are not configured to document or support non-physician care;

    14) Decision-makers need additional information on expected net savings;

    15) It relies on a lot of outside-the-doc-comfort zone behavioral, vs. "medical" health interventions;

    16) It requires considerable data support;

    17) It's often balkanized by multiple payers.

    But be of good cheer. Jimmy Cliff reminds us that half the battle is knowing what you're up against.


    Thursday, August 13, 2015

    The Just Right "Sweet Middle" of Care Management

    Finding the "just right" middle
    If you're interested in care management (definition here), there's a supportive case report in the August 7 edition of the New England Journal.

    But it also makes a important point that appears to have been missed by the Editors.

    The Population Health Blog explains.

    The case revolves around a fragile cancer patient with abnormal blood chemistries and distributed locations of care. The author describes how care management successfully improved the patient's safety, required a lot of physician-to-physician communication and relied on care management's "reach" outside the four walls of the primary care clinic.

    All good points.

    However, what's also true is that prior to the cancer diagnosis, this was an otherwise well patient with post-discharge needs that were amenable to care management intervention.  In other words, this patient was "high risk, high impact." These individuals make up the narrow middle in the span of patients who range from otherwise well (destined to do OK) to disastrously complicated (destined to do poorly no matter what). 

    The Population Health Blog doubts the case would have been so meaningful or successful with a routine surgery patient (stable and OK) or someone with metastatic spread of the cancer (a disaster).

    The Population Health Blog is all for patient safety, doc-to-doc communication and distributed care management.  However, they're not going to be of equal benefit for every patient.  If the intent is to "save money" by reducing avoidable health care utilization, it's best aimed at the patients in the middle.

    Like this one.

    Suggestions for Managing Health Reform in 2015

    Unfortunately for Mr. Obama, the spotlight on the some of the more unsavory aspects of the NSA's surveillance programs has forced him to call for "changes." In doing so, he turned to every rhetorical trick at his command, including minimizing Snowden's role, obfuscating the original intentions of the Patriot Act's authors and countering with largely cosmetic tweaks.

    Good thing that Obamacare has avoided a similar fate. Despite similar levels of public skepticism further compounded by the steady drip of implementation delays with other unintended consequences, the President can hang tough by resisting any and all statutory changes to the Affordable Care Act. Signaling any willingness to alter the legislation could embolden his foes, dismay his allies and prompt countless poison pill amendments.

    The obvious political calculus:  silence, veto threats and burying any changes in web site legalese.

    Yet, the ever-prepared Disease Management Care Blog wants to help.  In the unlikely event that Mr. Obama has to compromise on health care reform without really compromising, it offers up this teleprompter-ready statement that incorporates condescension, selected truths and confusion:

    "Despite my calls for bipartisan dialogue on how to further vilify fat-cat insurance executives, the debate on how to best implement Obamacare has proceeded in a not-always civil way. Like the DMCB's mother, I'm not angry, I'm disappointed. [applause] 

    While I'm annoyed at the failure of my supporters and opponents to grasp the obvious, I'm also reassured that 20% of our nation's GDP is being expertly managed by our superbly trained White House health economists. [applause]  You should be too.  [applause]

    I also know that continued unmanaged debate could complicate health care reform faster than one of my lawyer-friends suing an ACO for withholding care. That's why, effective today, I'm changing the subject by announcing that I will meet with hand-picked members of Congress.  I'll seek to improve the public's confidence in Obamacare by creating legislation that establishes the Commission of Official Managerial Assessment (COMA).  This will be a special office within the IRS. This expert commission will monitor, report, assess, analyze, examine, subpoena, audit, interpret, leak, manage, spin and regulate key aspects of Affordable Care Act's implementation.

    Image from Wikipedia