Friday, October 30, 2015

More on Health Apps: Opportunities, Risks and the Implications for Population Health Management

It's called "mHealth" but others may call it "health apps." The FDA calls it a target rich regulatory opportunity. Others may call it hype.

The Disease Management Care Blog calls it inevitable.

Writing in JAMA, Drs. Steinhubl, Muse and Topol of Scripps agree and say that the future is bright for mHealth. Its adoption is being driven by the threefold convergence of:

1) the search for solutions that address otherwise unaffordable levels of healthcare spending,

2) the availability of broadband wireless connectivity, and

3) consumer demand for individualized care.

The DMCB suspects any one of the DMCB's 5000 regular readers could have written this article. Like Steinhubl et al, they already know that patients want self-diagnosis and condition monitoring. Health consumers want greater efficiencies and enhanced patient-physician collaboration.

Even tech-skeptics have to admit that it's possible that mHealth could lead to a utilization trifecta of fewer office visits, avoided emergency room visits and decreased hospitalizations. Imagine the handheld that can accurately catalog signs and symptoms that help the user discern between a simple self-limited cold vs. a more serious case of pneumonia, or benign skipped heart beats vs. a more worrisome arrythmia.

Handheld apps for chronic conditions are more available than realized. They are on the cusp of going mainstream with assisting hypertensives, diabetics and asthmatics monitor and act on their blood pressure, insulin dosing and inhalants.

If they work right, providers could review summary data and offer guidance via emails and texts in lieu of adding a patient on to the schedule at 5 PM. If done right, the background algorithms could liberate physicians to pay greater attention to the important stuff that requires their complex cognitive or procedural skills.

The authors point out that that doesn't mean it's going to be easy. Medicine is complex and getting paid for it is more so. There's also worry - warranted or not - about the decline of face-to-face doctor-patient relationship. mHealth can lead to overwhelming data gluts characterized by a lot of numbers with little actionable insight. Finally, there's the danger that an app can offer ineffective, inaccurate or dangerous guidance that leads to patient harm.

Bravo to the editors of JAMA for recognizing the importance of the topic and committing precious space to this manuscript.

That being said, however, this article fails to give a full accounting of all the opportunities as well as risks for "mHealth."

First off, as this Kaiser Health News article demonstrates, there are two additional opportunity dimensions that draw on the population health management business model:

1) Apps are not just for diagnosis and monitoring, but also for wellness, and

2) They're being principally sponsored by commercial health insurers who not only readily embrace innovation, but probably consider apps a "sticky" way to maintain customer loyalty. That is doubly true for engaged enrollees who ultimately represent a better insurance risk.  In fact, the DMCB suspects that value proposition is so compelling that insurers are willing to use apps as a "loss leader."

Oh, and while mHealth can be built, it's far more likely it's being bought. As in population health management vendors.

Risks?  You bet.....

1) The fit of mHealth with the electronic health record (EHR) remains an open question.  The DMCB is no coding geek, but it's safe to say that it's not automatic that two independently contrived technologies can automatically "speak" to each other or that the data from an app can by downloaded, summarized and coherently presented to a user at the point of care.

2)  As noted in this article on telemonitoring, it's also not necessarily true that mHealth can be equated with stand-alone technology. Depending on the condition and the need, mHealth will have to be often tethered to human support services.

3) As even casual observers are aware, allegations of "malpractice" are not unusual in health care.  Rather than comment on its friends who make a living off of contingency fees, the DMCB will only point out that mHealth may offer a target-rich rich environment for personal injury attorneys intent on using the legal theory of joint and several liability to maximum effect.  That threat may slow adoption of mHealth.

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The Health Wonk Review: An Example of the Facts, Education and Spin Behind the Lingering Debate on Obamacare and Health Reform

Modern political discourse
The Disease Management Care Blog had a Hurricane Sandy choice: either a) leave day before that early A.M. hospital procedure and stay with friends who live close by, or b) stay at home and make the long trip in the wind and the rain to the hospital that same morning.  The DMCB spouse turned to repetitive education to help the DMCB make the right choice.

Does that learning tactic underlie Obamacare supporter Maggie Mahar's approach to the latest Health Wonk Review?  That's what the DMCB thought when it read Maggie's posting.

To help the thousands of health reform realists who make up the DMCB readership, Hurricane Maggie repetitively retreads the cost-control talking points from reform architect Peter Orszag, surgeon Golden Boy Atul Gawande and the White House Office of Management and Budget  Rest assured, says Maggie, if you selectively counter the DMCB's fiction with facts, you'll realize Washington DC's solutions are the right choice.

The DMCB isn't too sure about that.

Maggie doesn't argue health care costs aren't rising, only that the increases are less than widely claimed.  She credits Obamacare.  The Disease Management Care Blog agrees that cost trends are moderating, but it also credits a lackluster economy.

Maggie says be of good cheer, because the increased costs are delivering correspondingly better value for the health care dollar. The DMCB says value remains an inexact science that is ill-suited to simplistic nostrums and blunt force laws and regulations. The latest examples of this conundrum include mammograms and annual check ups.  There are plenty of others like this.

Maggie points to Massachusetts's Atul Gawande's brimming optimism about Massachusetts leading the way with risk and performance contracting as a cost-control panacea.  The DMCB awaits the arrival of hard macroeconomic outcomes data that proves the experiment works.  It also points out that the Bay State's recently passed cost control legislation speaks volumes on what that state's leaders really think about the savings-success of Romneycare.

Last but not least, not everyone on the blue side of political spectrum shares Maggie's optimism.

By the way, the DMCB has received a cost estimate from the unnamed hospital mentioned above. That institution is the flagship part of a nationally recognized integrated delivery system that is a basis for much of Maggie Mahar's enthusiasm. The DMCB's planned procedure coupled with OR charges and an overnight stay will result in charges, prior to discounts and contracted rates, in excess of $100,000.

For those of us with a lingering doubt that our political class's health reform sound-bites, nostrums, talking points and pronouncements will cut through all those inconvenient facts, the DMCB recommends this catchy tune.  You'll feel a lot better:

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The Latest Cavalcade of Risk is Up

The latest Cavalcade of Risk is hosted by Jason Hull of Hull Financial Planning. Pointing out that this is more than just a board game, Jason summarizes and links a series of blogs dealing with the latest insights on managing and anticipating risk. The DMCB is included, so you know it's good stuff.


Thursday, October 29, 2015

Shared Decision Making: Population Health Management Bridging Academia and the Real World

In the prestigious medical journal JAMA, Georgetown University's William Novelli, Kaiser CEO George Halvorson and Consumer Reports' John Santa summarize the results of a patient survey and focus group results on the topic of shared decision making. The study was sponsored by the prestigious Institute of Medicine.

The results show that when it comes to treatment, patients want their doctors to present all relevant options, including the option of doing nothing.  Most also want to know each option's risk.  Once they have good understanding, the majority are comfortable with letting their physician lead on chosing the "best" decision.  This approach is likewise associated with greater patient satisfaction.

Yet, despite their preference on how to best reconcile competing treatment options, few can recall it actually happening that way.

While this may be newsworthy to JAMA readers, the results should be of no surprise to anyone working in the population health management (PHM) field.  PHM service providers have been advocating for shared decision making for years. They've also developed business models that bridge the gap between JAMA's academic ideals and the real world inhabited by flesh and blood patients with busy doctors who need help now.

As testimony to the blurring between the theoretical and the possible, the Disease Management Care Blog has pasted 4 quotes below.  One is from a concluding paragraph of the JAMA paper, while the remainder are from the web sites associated some commercial care management vendors.

See if you can spot which is which:

physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health (link)

can ensure that in the trilogy of opinions, the patient's opinion and perspective are core, helping fulfill the promise of better health at lower cost (link)

constantly make decisions that impact their health and provides them with the tools they need to make the decisions that are right for them (link)

based on each individual's readiness-to-change and what health issues they want to address, personalized interventions connect the widest range of health management solutions, devices and diagnostic tests (link)

The Dreaded Strike Three for Obamacare: Corrupted Exchange Data and Inaccurate Insurance Policies

While the prescient Disease Management Care Blog was among the earliest to identify the threat of an Obamacare-induced insurance "death spiral," it missed spotting the potential fallout from a delay of the individual mandate.

As shrewdly pointed out in this Politico article, health insurance timelines require at least three months of claims experience to inform future rate setting.  Once that actuarial work is done, it then has to go through the states' Insurance Departments for approval.

In other words, if large numbers of Obamacare customers are allowed to sign up after March 31, 2015, insurance companies won't know what to charge their customers on January 1, 2015. 

While overcharging can be remedied by customer rebates, it remains to be seen how accommodating Washington DC will be if the insurers undercharge. That means negative cash flows, raiding surpluses and facing the ire of their investors and Boards of Directors.

It's baseball season, so think of the death spiral as a potential strike one, and inaccurate rate setting as a potential strike two.

Which brings the DMCB to a dreaded strike three. If it happens, the health reform brand could be irretrievably tarnished.  It could also and sink the current version of Obamacare.

Strike three would be a critical mass of inaccurate insurance policies.

If reports like this and this are even remotely representative of the back-end of Obamacare enrollment, the relative trickle of individuals who are successfully navigating the exchanges are getting commercial polices that depend on a very vulnerable reconciliation process involving many moving parts.  That includes information from the "hub" as well as user-based data entry. As noted in this report, commercial insurers are being forced to manually "clean up" the information prior to issuing their exchange-generated policies.

The DMCB suspects that a "garbage in, garbage out" adage may apply. Thanks to sheer number of inputs, clean-up mistakes are going to be inevitable.  And it will get a whole lot worse if the web site gets only partially fixed. 

While a few mistakes are acceptable in large risk pools, more than a few could be huge problem at three levels:

1. At a business level, where a core competency of insurance companies is to cover their enrollees and only their enrollees. Insurance companies are really good at knowing who is and who isn't insured for a covered or non-covered service with or without a variety of co-insurance arrangements.  It's more than just getting it right, it goes to the core of their business model. If enough policies are inaccurate, it could bring the finances of some smaller health insurers to their knees.

2. At national health policy-making level, where a critical mass of insured customers with premiums and subsidies mismatched to the risk could destabilize the market and distract our political leaders. Think about the customers who assume a service is covered, providers who expect to get paid accurately, balance sheets that don't reflect the truth about claims expense as well as IBNR and regulators who will need to sort it all out.

3. At an Obamacare "brand" level.  Think about all those unfriendly and anecdotal news reports about vulnerable patients who ended up legitimately - if mistakenly - paying more out of pocket for care, or persons mysteriously lacking insurance, or hospitals and doctors being unable to get paid. It could ultimately track back to the web site that everyone will loves to hate.

The worst part is that the White House has done such a masterful job of bullying the insurers that it's unlikely that they'll want to rock the boat by going public with any notification that their enrollment data is corrupted.  Mr. Obama will naturally claim that he wasn't in the loop and his loyal aides will deflect blame elsewhere.

Strike three, and we may not even see it coming.

Wednesday, October 28, 2015

Taking Patient Preferences Into Account When It Comes to Pursuing and Measuring Quality

Here's a thought: ask them what they want
One of the intellectual underpinnings of population health management is that the biopsychosocial dimensions of care is a huge determinant of real-world outcomes. As any doctor who takes care of flesh-and-blood patients knows, national treatment guidelines like these typically fall short of taking the human dimension into account. While there are plenty of good and bad reasons why docs are failing to take advantage of guidelines, one is their sterile one-size-fits-all approach that often fails to account for physician awareness of their patients' risk tolerances and economic circumstances. What's more, many widely promoted treatments only offer a small absolute benefit.

Fortunately, this disconnect is bubbling up into the mainstream scientific literature. The latest example is this Viewpoint that appears in the October 28 issue of JAMA. The authors point out that the perspectives of expert physicians who develop guidelines are typically different than the general public, caregivers or persons with a disease. For example, while the NCQA promotes an A1c threshold as a important measure of diabetes care quality, a compelling survey of patients with diabetes suggests that that emphasis may be displaced.

Where to from here? The JAMA authors offer three commonsense recommendations. Future guidelines should:

1. be developed with the input of patients and frontline clinicians.

2. encompass the full range of patient experiences, not outcomes. This means accounting for the  burden, impact on quality of life and role function dimensions of any treatment recommendations.

3. avoid strong recommendations when the best course of action depends on the patients' context, goals, values and preferences.. Lacking a clearly advantageous outcome with minimal side effects, guidelines should offer a conditional suggestions.

The DMCB modestly offers up three additional suggestions for the population health community and other stakeholders:

1) Absent a satisfactory guideline process from the usual national organizations, it would not be a bad idea to take this bull by the horns and develop a parallel set of guidelines that meet the principles outlined in this JAMA article.

2) Organizations like the NCQA and NQF need to be more flexible in promoting evidence-based guideline-based metrics by moving away from a reliance on their monodimensional clinical measures and toward more nuanced measures of meeting patient preferences.

3) Finally, while national variation in health care delivery is a huge challenge as we continue to build a coherent health system, it may be time to reconsider the notion that all variation is bad. Human beings are variation, and the likelihood of imposing local "best practices" across the U.S. will not be in the best interest of patients with different views of what it best for them.

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The Latest Health Wonk Review is Up!

Unrepentant Maggie Mahar takes the latest Health Wonk Review and puts it through a progressive-liberal centrifuge, emphasizing blog posts that she likes and tut-tuting anything she doesn't.  The Disease Management Care Blog loves it.  Dubbed a "Fact vs. Fiction" Pre-Election Edition, Ms. Mahar is certain to please those on the left, annoy those on the right and make everyone pay attention.

Is she angling for honorary membership in Doctors for Obama America?  You be the judge!


Monday, October 26, 2015

President Obama Addresses the Ebola Crisis

In this weekly address, President Obama addresses the Ebola crisis.  As we've come to expect from our Chief Executives, it's a perfectly crafted speech that addresses our major concerns. But the Population Health Blog doesn't think it goes far enough.  In its continuing quest to help Mr. Obama overcome his tanking approval ratings, the PHB changed a few words and modestly offers up a slightly edited version of the address.  It believe it speaks more forcefully to the issues at hand.....

PRESIDENT OBAMA: Hi everybody, this week, we remained focused on spinning a favorable White House narrative about Ebola. In Dallas, the natural history of the disease and basic isolation procedures limited spread of the disease to only two among the dozens of health care workers who had been in close contact with the first patient. Now, those two workers are two too many, which is why I've told the CDC that their calm and distant inertia is unacceptable.  As you know, that's my job.

The two nurses who contracted the disease in West Africa were thankfully released from the hospital. I was proud to welcome one of them to the Oval Office to give her a big hug and make sure plenty of photographs were taken.

And in Africa, the countries that did not wait for our help, Senegal and Nigeria, were declared free of Ebola.  Which is probably why New York City also decided to not wait on Washington DC. Local public health personnel there moved quickly to isolate the doctor who recently returned from West Africa. While we deployed one of our new CDC rapid response teams, I wonder what they'll learn from New York City's approach. Maybe a lot. And I’ve assured Governor Cuomo and Mayor de Blasio that they’ll have all the federal support they need as they go forward.  After all, I'm from big government and I'm here to help.

More broadly, this week we've continued to step up our use of words like "efforts" "outreach," "coordinate," and "integrate" across the country. New CDC outreach is helping hospitals coordinate and integrate training. The Defense Department’s new team of doctors, nurses and trainers will outreach, coordinate and integrate if called upon to help with coordination and integration and, you know, outreach and other efforts.

Now, rather than institute an unworkable travel ban, we now have a less unworkable travel measure that directs all travelers from the three affected countries in West Africa into five U.S. airports. Starting this week, these travelers will be required to report their temperatures and any symptoms on a daily basis—for 21 days until we’re mostly hopeful that they don’t have Ebola. Here at the White House, the lawyer I've appointed to coordinate and integrate the government's response will tell the doctors what to do and how to do it. And we have been examining the protocols for protecting our brave health care workers, and, guided by the science, we’ll continue to do everything we can to embarrass the Republican nutjobs who are also using Ebola for political gain.

In closing, I want to leave you with some basic facts. First, you cannot get Ebola easily through casual contact with someone. The only way you can get this disease is by coming into direct contact with the bodily fluids of someone with symptoms. But, if you do get it, your internal organs could liquefy. That’s why health workers must wear total body condoms. That's the science. Those are the facts.

Here’s the bottom line. We can beat this disease. But we at the White House have to stay on message by repeatedly saying that we have to work together at every level—federal, state and local. And we have to give the impression that we're leading a global response, because West Africa is in a world of hurt right now along with other global hot spots like Syria and Ukraine and Hong Kong and Russia.

And we have to be guided by the science—we have to be guided by the facts, not fear. Yesterday, New Yorkers showed us the way. Despite the mainstream media's alarmist reporting, they did what they do every day—jumping on buses, riding the subway, crowding into elevators, heading into work, gathering in parks, ignoring speeches like this and wondering why the Yankees aren't in the World Series.

That spirit—that determination to carry on—is part of what makes New York one of the great cities in the world. And that’s the spirit all of us can draw upon, as Americans, as we meet this challenge together.

Saturday, October 24, 2015

Does Hiring A "Care Coordinator" Assure Care Coordination?

Apparently not.

That's the Disease Management Care Blog's main take-away after reading the Care Continuum Alliance's "Population Health Management in Physician Practice: A Call to Action."

The CCA commissioned a survey that asked 105 primary care physician leaders about the implementation of population health-based care coordination in their clinics. The clinics were from all regions of the U.S. and ranged in size from 5 to 95 physicians (a total of 1,916 physicians with a mean of 18).  To be included in the survey, they had to be planning or had already implemented patient-centered care initiatives, many of which were modeled after the medical home. 93% already had an electronic record and10% reported being part of an Accountable Care Organization (ACO).
First the good news.

Over and beyond hiring non-physician providers (96% had at least one nurse practitioner and 70% had a physician assistant), 91% reported that they had hired a "care coordinator."  What's more,  85% said that population health was conceptually important in their practices and the majority 55% rated this as either a "4" or "5" on 1 to 5 scale.

But the bad news is that less than half were familiar enough with the concept to fully implement it in clinical practice.  The number one challenge in this area was the difficulty in making sure that roles and responsibilities of the care coordinators were appropriately defined. 

It should be noted that the practices surveyed in this report were not typical of primary care,  where experience with care coordination is even lower.  This was a elite group of innovators on the cutting edge of primary care who had committed precious resources and already were hiring care coordinators. Yet even these select clinics risk being operationally stymied by not knowing how to effectively implement it in their practice settings

The CCA report appropriately concludes with a call for education, tools and support to help physicians fully implement this in their clinics.  The DMCB wholeheartedly agrees.  Based on this report, hiring care coordinators is certainly necessary but isn't sufficient to attain high quality population health.

We still have our work cut out for us.

The President Says You Should Ignore This Health Wonk Review

Welcome to this October 2015 edition of the Health Wonk Review, hosted by your Disease Management Care Blog. The Review is a sampling of the best recent postings by thoughtful health policy bloggers who are offering insights about healthcare delivery, insurance and reform that are outside the media mainstream.

Or White House control. While Mr. Obama would like the bloggers to sit down, be quiet and let the Washington's expert political class get on with the people's work, the DMCB respectfully disagrees. It was the bloggers who were sounding the earliest alarms about the dysfunctions of the federal health insurance exchange. Despite the advice of our President, this edition of the HWR proudly offers readers some important insights, additional warnings and lessons learned.

One of those lessons is that the HWR bloggers should be read more, not less.

Of course, this Review is not just about the exchanges. If that bungled bit of bureaucracy doesn't pique your interest, read on and you'll find other great stuff on health reform, pharmaceutical costs, Medicare's well-meaning ability to impose silly regulations on docs and how that horrific Bangladesh garment factory fire didn't really lead to any meaningful worker safety reforms.

First up, the exchanges.....

Joe Paduda of Managed Care Matters says the Obama Administration's roll out of the exchanges failed at several levels. Let's face it, he says, the development process was politicized and, as a result, consumers were given the green light to use a flawed web site. They're now being forced to enter too much data before they can shop for insurance, server capacity is insufficient, links to participating insurers are dodgy and patients are unable to ascertain if their doctor is in a particular network. He believes the best way forward is to completely redo the web site and to never ever forget what happens when politics trumps common sense. It's so bad, says Paduda, that the only reason not to fire HHS Secretary Sebelius is the prospect of another partisan battle over her replacement. "Ouch!" says the DMCB.

For crying out loud, says Tim Jost in the Health Affairs blog notes, we're talking about a web site, not cold fusion. While all eyes are on the individual mandate, Jost isn't worried because that's assessed on a monthly basis and the ACA allows for "hardship" exemptions. He reminds us that the key deadline date of December 15 is months away. That's the last day that individuals can enroll in time for the subsidies that will be in place on January 1 2015. If deadline is not met, it's possible that millions of Americans will be unable to obtain affordable insurance. The good news is that the Feds have broad discretion to extend enrollment periods as well as provide commercial insurers with additional assistance. Jost is confident that with the right amount of creativity, health reform can continue. After reading this, the DMCB predicts HHS's creativity will include delaying the individual mandate without "delaying" the individual mandate.

John Goodman is less optimistic. He uses his eponymously named blog to remind us that if only the sickest and most persistent Americans successfully use the exchanges, Obamacare may precipitate numerous insurer death spirals. State risk pools are closing, employer-based plans are closing, and individuals can now exit their "job lock." John predicts the sickest of these individuals will find the exchange's "gold" and "platinum" insurance plans to be relative bargains. Goodman offers some potential solutions, including flattening the subsidies, prohibiting dumping of the sickest members by insurers, requiring COBRA benefits to be exhausted first and stopping enrollees from gaming the system by enrolling at the last minute. It's the risk pools stupid!

Sean McGuire of Health Reform Explained coins the new catchphrase "nerd herd" to describe the exchange's "tech surge" repair. Despite the impressive-sounding term, he doubts the website code will be successfully rewritten any time soon. He wonders if the Feds shouldn't completely outsource to the states, because they have the track record and, with sufficient financial support, the resources to fix this problem. Code woes prompt geek fleet.

Hank Stern of the Insure Blog builds off another blogger's observation that one reason why the exchanges are not performing well is because HHS wanted to shield users from seeing the cost of their insurance prior to the calculation of the income-indexed subsidy. For us wannabe techies, this is known as a "no wrong door" approach to web portals. What HWR review is complete without a catch phrase you can use to impress your friends and stymie your enemies. And you're welcome.

So, how's health reform going?

Louse Norris, writing in Colorado Health Insurance Insider blogs with first-hand knowledge about a wrinkle in the ACA that allows for early renewal of existing insurance policies. As the DMCB understands it, this pushes back the day of reckoning when persons have to "buy up" to standard insurance benefit packages that may be more expensive than the "skinnier" policies that have lower out-of-pocket expenses. While some unnamed policy makers think that's a loophole, Louise thinks it's a good idea because, for her family - and many other Americans - that translates into hundreds of dollars a month in savings for 2015. What other loopholes are there?

Maggie Mahar of the Health Beat Blog points out that the commercial insurers were at the table when the final details of the Affordable Care Act were hammered out. They agreed to shelling out new
fees and taxes to help fund the legislation. Despite that, however, skeptics were suspicious that Mr. Obama had been too accommodating to the insurers. According to Maggie, we now can say with certainty that the skeptics were wrong. The commercial insurers' stock prices are now tanking because the investors are only now discovering, among other things, that pre-existing conditions cannot be used against patients, administrative costs are limited, preventive care now has first dollar coverage, lifetime caps no long exist, that they have to cover a standard benefit and state regulators are finally "getting some spine." She thinks the investors made two mistakes that she perceptively avoided: along with Ms. Pelosi, they didn't read the bill and they were confident that Mr. Obama wouldn't be re-elected. The DMCB wonders if investors are also worried about the commercial for-profits being battered by death spirals.

Never mind high tech, how about payment reform leading to high touch? David Harlow of The Health Blawg argues that the evidence that transformed primary care can save money is reaching critical mass. Primary care clinics that invest in systems of care may cost more in the short run, but the downstream cost savings are considerable. As fee-for-service continues to unravel, Harlow predicts these preventive and care coordination business models will become even more compelling. Which prompts the DMCB to provocatively ask if this could this also be an argument for the monthly fees commanded by the "concierge" practices?

For those of us who think there may be market solutions that can reinvigorate medical education, Roy Poses of the Healthcare Renewal blog says it's time to think again. Roy looks at some of the "outcomes" from one off-shore for-profit medical school that caters to U.S. students, including the entry of venture capitalists, the creation of shady tax shelters, deans with jet-setting lifestyles, Swiss bank accounts, laundering money and the mysterious disappearance of school Presidents once the indictments start to roll. As Roy has pointed out, however, on-shore and not-for-profit medical enterprises are not immune from bad behavior either. Health care bubble, anyone? 

Brad Flansbaum of The Hospital Leader blog examines the impact of the Medicare regulation that post-hospital home health services can only be prescribed during the course of a "face-to-face" visit. For doctors getting their patients out of the hospital, this has resulted in one more form that needs to be completed (typically by someone other than the doctor) and then signed (by the doctor).When added to the press of other things that have to happen, the result is a discharge of a thousand cuts. The DMCB's colleagues have lived with these and other unpleasantness that comes from being on the business end of Medicare.  And people wonder why docs are leery about a single payer system?


Jason Shafrin of the Healthcare Economist blog describes how the Italian city of Naples recently saved 20 million euros in pharmaceutical costs. There was no single solution, but a combination approaches that may hold lessons for the United States. They include direct purchasing of drugs by patients, providing a supply of necessary medicines when patients leave the hospital, accepting generic drug names for prescriptions and making patients pay the difference when they insist on a brand-name drug. That doesn't mean that Italy's cost problems are automatically solved. New agents are constantly coming on line and the Italians do recognize that manufacturers need to recoup their development costs. That's OK, however, because Italy uses multiple administrative levels of review for efficacy, a rigorous "pay for performance evaluation process and "soft" spending global limits. In the end, if a drug is worth it, they'll pay for it. U.S. drug company executives may end up taking some of their own products if this system gets adopted here.

If reports are true, David Williams of the Health Business Blog points out that the Food and Drug Administration's public service mission is being undercut by the "invitation-only" meddling of pharmaceutical companies in the Agency's pain management evaluation meeting panels. Either pharma should get out, says Williams, or other legitimate stakeholders, like patients, payers, academics, advocacy groups and other government agencies should also be in the room. So, with news like this, why is bloggery a bad thing?

And last but certainly not least.....

We all remember that horrendous garment factory fire in Bangladesh that killed over a thousand workers. If you still enjoy wearing that name-brand clothing, you won't want to read Julie Ferguson's summary and review of a multi-part series of articles on the topic appearing in Workers Comp Insider. If you do, you'll either want to go naked or start paying attention to which retailers have truly committed to international worker safety. Unfortunately, it appears that most continue to put low-cost fashion as their number one priority, even if it means putting more lives at risk. Behold the health implications of our throw-away clothing life style.  Maybe it's time to reward clothing manufacturers that offer products made in the U.S.A. 

Friday, October 23, 2015

Access, Affordability and Quality: Only A Third of the Work Is Done

Access, affordability, quality
Did you know that the taxpayer costs of some versions of public transportation have proven so expensive, that it would have been cheaper to provide each rider with their own BMW

Which is why the Disease Management Care Blog, which always uses public transportation in and out of the SFO, ORD, ATL, PHL airports, ascertained that it was time for it to make its coupe selection. Unknown to the DMCB spouse, it has started to examine the trade-offs between bimmer cost, speed and comfort.

Which reminds the DMCB of the parallel universe of health care.

In its travels around Washington DC, the Disease Management Care Blog has repeatedly heard that the health reform likewise involves trade-offs between the three similar goals of 1) access, 2) affordability or 3) quality. Historically, most health reform proposals have managed to secure two out of three. A good summary of the historical travails of this "iron triangle" can be found here.

Which is why conservative-leaning Gail Wilensky's examination of Obamacare in the Oct 18 issue of the New England Journal makes for good reading. She finds the President's signature achievement wanting because it only delivers on on the single goal of access. 

Thanks to the law, 30 million Americans will soon be able to get coverage.  Approximately half will obtain subsidized private insurance  and the other half will be able to qualify for Medicaid. 

All well and good, except a substantial proportion of Americans remain philosophically skeptical of the law's merits. Whether you agree with the skeptics or not, it's still feeding a lingering partisan divide that continues to chew up precious political capital.

And, according to Ms. Wilensky, that was the easy part. Affordability and quality remain serious challenges.

That's because, despite some promising (but ultimately still unproven) innovations involving bundled payments and shared risk, Obamacare leaves Medicare's fee-for service reimbursement very much intact for years to come.  That means quality will continue to disappoint and costs (i.e. affordability) will take a greater and greater share of America's gross domestic product.

Disagree?  While Ms. Wilensky may be criticized by partisans as a market-oriented Republican shill, the DMCB has seen her up close, in-person and in action: she's smart, always makes good points and when she speaks about the Affordable Care Act, the rest of us should listen:

1) Some of the anticipated savings of Obamacare that went into budget planning included a curious item called "productivity adjustments."  This was based on the assumption that the health system would achieve greater efficiencies long before any of the Affordable Care Acts payment innovations are a) proven and b) imposed on the majority of providers.

2) The Relative Based Value Scale is fundamentally untouched and continues to reward physicians for high margin services instead of efficiency.

3) The much ballyhooed value-based payment bonuses are quite modest and an unlikely to significantly alter hospitals' approach to doing business.

4) Congress' past vulnerability to special interests and the low likelihood that the Independent Payment Advisory Board will change physician behavior does not inspire confidence.

5) While supporters believe the law will incent value-driven market behaviors, it's ultimately Washington DC - not consumers and certainly not markets - that will reward the winners and losers.

6)  The prospects surrounding the looming fiscal cliff and SGR remind us that cutting fees are not the same as cutting costs.

One third full versus two thirds empty?  Perhaps.  Depressing?  Maybe.  An accurate portrayal of bad times to come?  Maybe not.  Better, says the DMCB to know what we're potentially up against and the hard choices we still have to make between affordability, quality and access.

Addendum:  If you got here thanks to Maggie Mahar's Health Wonk Review, a friendly rebuttal to her partisan spin can be found here.  The DMCB linked that up on the Reply part of the HWR posting but it's gone missing.

Thursday, October 22, 2015

The Progressives' Point of View When It Comes to Health Reform

While the Disease Management Care Blog tries to be an equal opportunity cynic and generally sides with policy underdogs and lost causes, it supposes that its conservative leanings sometimes comes through in its writing. 

That was enough to prompt a series of well-written email exchanges with Greg Brown, a retired educator from the Kansas City area. He did a great job of compactly summarizing the views of supporters of the current version of health reform. 

It seems to boil down to five main arguments:

1. Medicare and Social Security: While passage of these landmark safety net programs was likewise met with deep concerns about the erosion of liberty, their ultimate success cannot be denied.  Most of the persons who are against the Affordable Care Act are ironically happy to have the feds appropriate a portion of their income in exchange for economic security in their old age. They can't have it both ways.

2. This is not buying shoes:  One role of the federal government is to step in when markets fail, and that has been amply demonstrated when it comes to health insurance. While it's difficult enough to remember to even buy a product that you may not need, shopping for the best value in commercial insurance is practically impossible.  Proposals to expand this unworkable solution are a pipedream.

3. The public good: Keeping people from going bankrupt in the course of an unexpected illness is everyone's interest.  It's ultimately a better bargain for society to proactively manage this with near-universal insurance than to deal with poverty after the fact.

4. Purchasing power: To date, Washington DC has chosen to not flex its purchasing power with providers.  Think of how much cheaper drugs would be if Medicare leveraged this for Part D.  Just wait until the happens in the rest of health care system and how much all of us will all benefit. 

4. Status quo: Even if you don't accept the track record of Medicare, the realities of buying insurance, the merits of a public good and the advantages of purchasing power, the status quo has led the U.S., compared to the rest of the developed world, to be a unsustainable per-capita cost outlier.  Something has to change. and theACA is doing just that.

I am not an expert by any stretch. I am just an interested layman. I really wish Obama had pushed for a single payer or at least a strong government alternative delivery system. But here we are and as imperfect as it is, it is the best thing I see on the horizon right now. It does at least attempt some cost controls, it broadens access, and it may lead to better quality with a focus on health outcomes rather than billable procedures. At least it attempts to address all three.

Image from Wikipedia

The Underestimated Power of Online Relationships and the Implications for Population Health Management

Health care in a box?
Maci's very upset.  Dopey Kyle, who otherwise seems like a nice guy, has been hot-chatting it up with online girlfriends.  Good thing pop psychologist Dr. Drew can come to the emotional rescue on MTV's "Teen Mom."

The Disease Management Care Blog's response?  Mute and quickly change the channel before the DMCB spouse has one more reason to doubt the intelligence of the male species.

Yet, only the perspicacious DMCB can use this sordid tale to extract an important lesson for the population health management (PHM) community.

That's because it listened carefully to TedMed's Jay Walker, who spoke at the closing plenary session at the Care Continuum Alliance's Forum12.  Mr. Walker observed that handheld devices with texting are blurring the lines that separate in-person and virtual relationships.  While 3-D, face-to-face "analog" interactions still count, people are also going online to achieve an astonishing level of digital familiarity and even intimacy with each other.

While regular readers already know that persons turn to trusted in-person as well as virtual "friends" and "communities" for health care advice (past DMCB posts on the topic are here and here), the DMCB may have underestimated the full implications of just how real and behavior-changing an on-line relationship can be. 

No, the DMCB is not suggesting that PHM vendors start hot chatting with clients. 

But it is saying that vendors as well as buyers who discount "remote" web-enabled and text coaching versus in-person services may need to take another look at their future business plans and underlying value propositions. Maci and Kyle's dysfunction are teaching us that remote texting has far more "connectedness" potential than generally appreciated. If a social-media-based relationship's downsides can capture Maci and Kyle's attention, why can't the upsides also be harnessed to change behavior?

We have a lot more to learn about the determinants of on-line relationship building.  Companies that figure it out will win.

Image from Wikipedia

Wednesday, October 21, 2015

The High Price of High Deductible Plans and the Potential Role of Population Health Management

Your bronze plan ticket to health care?
Should patients be forced to reach a spending threshold before their insurance kicks in? At first glance, it makes sense, because health consumers' "skin in the game" forces them to think twice before going to the emergency room for a sore throat, or an orthopedic surgeon for simple back pain.

Wharam and colleagues examine the science behind high deductible insurance in this just-written article in the New England Journal.

And the science says there is a lot we do not know.

Once insurance risk is monetized into premiums, policymakers as well as insurers are operating in the dark about calculating the right deduction for a given income level. One example is Cover Oregon's $5000 deductible for persons who are at 200% to 400% of the federal poverty level. That means a family with a yearly income as low as $47,000 would have to spend more than 10% of their income on health care before seeing a dime of insurance coverage.

"Egads," says the DMCB.

Given that stark reality, the challenge is to figure out how an up-front deductible influences "buying behavior" once persons get sick. Unfortunately, most of the research out there is on the impact of relatively "small" amounts of out-of-pocket expenses on health care utilization, especially in low-income populations. The bad news is that lay-persons - who are unable to discern the difference between a simple headache vs. a brain tumor - tend to "indiscriminately" lower all utilization as their cost sharing goes up.

There has also been no research on the impact of high deductible plans on mortality or chronic condition control.

Concluding that the U.S. is "poorly prepared" for what will happen under Obamacare's bronze high deductible plans, Wharam et al recommend there be more research on the topic.  Pending that, they suggest consumers be educated about their insurance purchases and be encouraged to chose low-deductible plans. They note that the star-crossed insurance exchanges (once they're fixed) can be configured to help do that. When there is employer-based insurance, employers could be encouraged to make the deductibles more proportional to income. In addition, health savings accounts could also help.

While the authors don't use the words "population health management," they tap this discipline as one solution to this Obamacare problem. They point out that predictive modeling/risk stratification can be used to create "personalized" insurance designs that optimize high-risk patients' access to care. Patients in these plans could have access to decision-aids and coaching that help them figure out when it's a simple headache and then they should seek medical care.

Sunday, October 18, 2015

Pearls from the Care Continuum Alliance Forum12

The Disease Management Care Blog is recovering from a case of post-oratory exhaustion following today's Care Continuum Alliance Forum12 sermon.  Happily, it delivered the session payload without any impolitic gaffs, wardrobe malfunctions, unsightly hives or gastrointestinal afflictions.

It's also grateful for all the pre-event PowerPoint advice that it got (you know who you are).

Nonetheless, the DMCB steeled itself and attended a host of educational follow-up sessions over the remainder of the day and scribbled down some of the better pearls of wisdom:

Americans, without exception, distrust all large institutions.  That prompted the DMCB to wonder again about the prognosis of the ACO business model.

People trust persons like themselves.  This used to mean just friends, neighbors and family, but now includes social media circles.  Health providers ignore the implications of that at their peril.

Consumers do not equate healthcare information with healthcare solutions.

A goal of old age is to live with inevitable chronic illness without being sick.

HIPAA compliant on-line authentication is moving away from entering an email address to entering a cell phone number.  Email accounts change, but people tend to keep the same cell number even if they change phones or carriers.

Ideal clinical work flows from a Patient Centered Medical Home is circuitous: the patient never exits.

Friday, October 16, 2015

Health Worker Nonchalance About Ebola?

The Ebola virus
Recent reports of two nurses becoming infected with Ebola begs the question of whether they were lax in following infection-control protocols. Even if that's true (and it may not be) the bigger mystery is healthcare community's apparent nonchalance. TV's talking heads are generally not alarmed. NBC medical correspondent Nancy Snyderman reportedly snuck out to get some take-out food. Experts at the CDC apparently okayed one mildly feverish nurse's request that she be allowed to travel.

What gives?

First off, how does Ebola spread?

 Ebola is "filovirus" (so named because it has a uniquely filamentous appearance) that, once introduced into the body, can attach to and invade numerous types of human cells. Getting into the human body occurs from the injection of infected blood (such as a inadvertent needle stick from a person with Ebola) or hand-borne "self-inoculation" of a patient's body fluids into the mucus membranes. That's typically the mouth, nose or eyes. 

"Self-inoculation" of a virus by rubbing the eyes or touching the nose/mouth has been a long-known means of spreading infection. Because humans unconsciously touch their facial mucous membranes frequently during the course of a day, eye goggles and facemasks are not only a barrier to airborne virus (such as regular cold viruses), but also act as a reminder to keep your fingers away from your face and eyes (which is more important with the Ebola virus, which is not airborne). 

After the inoculation and during the initial stages of invasion and replication, there aren't enough viral particles to pose a significant person-to-person transmission risk. It's only when the infection becomes overwhelming (which is heralded by a fever) that the virus makes its appearance in body fluids, including blood, tears, saliva, sweat, diarrhea and vomit. Healthcare workers cannot avoid handling the sick patient or their bedclothes, and that's when accidental needle sticks and unconscious touching of their face - i.e. mucus membranes - leads to transmission of the virus to a new victim.

What are healthcare workers' attitudes about infections?

Getting health care workers to pay attention to the inadvertent spread of infection in the course of patient care has been a topic of research for decades.  It's not like they don't know how viruses move from person to person.  Rather, failure to act on that knowledge is a result of poor adherence, insufficient resources, staffing problems, lack of culture change, no impetus to change, and issues related to staff and patient education.  Even with intense education, attitudes may shift by a only a few percentage points. It's not uncommon for up to a quarter of health care workers to not follow basic infection control protocols after a teaching intervention.

How well do health care workers educate lay-persons?

Even when patients are in contact isolation for other reasons, healthcare workers do a bad job of dealing with the concerns of family members or educating their patients about its importance. And it doesn't help that nurse "burnout" can be an independent risk factor for the inadvertent transmission of infection to patients.

While reports like this portray the importance of public education, it's fair to say that the gap between the "stay calm" Ebola expertise of organizations like the CDC and the growing alarm of the lay public is significant.

The Population Health Blog's take?

Healthcare providers have cared for patients with other serious infectious diseases, and their attitudes to dealing with Ebola are not new. While the PHB is unaware of the details of how the two nurses described above contracted the disease, it was just a matter of time until someone got infected. 

If more primary Ebola cases occur in the U.S., we can expect more healthcare workers to contract the disease. A nonchalance toward infectious disease has been a part of the medical landscape for decades.  While the risks associated with Ebola are higher (a purported mortality rate as high as 70%), this is another virus bumping into decades-long patterns of imperfect human behaviors.

While the public is extremely concerned about the specter of Ebola, expert infectious disease talking-heads are well-acquainted with the above data.  They are not surprised that nurses are coming down with Ebola.  Unfortunately, that unsurprised expertise combined with a legacy of poor lay-public education is coming across as incompetence. That's especially true when clinical judgment about a fever leads to a plane-load of passengers being exposed to a sick patient's body fluids. The public deserves better.

An Evil Downside of "Disease Management" (Humor)

Did you know that there is published research that demonstrates that every time a person was signed up for the early versions of commercial disease management, a kitten somewhere in Washington D.C. died?  No wonder health policy makers and academics were so opposed to these programs!
The Disease Management Care Blog will explore the issue in greater detail during its presentation at the Care Continuum Alliance Forum12 meeting.
See you there!

(If you want a PowerPoint slide, let me know)

On Death Marches and Lost Causes

As of this writing, it appears the U.S. Senate has achieved a bipartisan compromise over the shutdown and the debt ceiling. It is highly likely the House will agree and a funding bill will reach the President's desk in time to avoid a default. 

As the Disease Management Care Blog understands it, the contentious issues of the size of government and debt will have to be revisited in a matter of weeks.  That practically guarantees another round of brinksmanship and frothy bloggery in December.

So what has the DMCB learned from this imbroglio?

It is of two minds.......

While a critical mass of Congressional Republicans have embarrassed their party with a forced death march to nowhere, there's something to be said for sticking to your principles. Nice try. After all, advocates of the quintessentially liberal cause of gun control vow to inconveniently bring the topic up again and again. While their odds are long, the DMCB is reminded that that was a tactic that may have ultimately turned the tide on same sex marriage. The DMCB hopes the "nagging and haranguing" strategy ultimately prevails on behalf of reasonable tort reforms nationally and getting the DMCB spouse to yield her HGTV tuning locally.

As Mr. Smith points out, the only things worth fighting for are "lost causes."

On the other hand, it can be argued that the rancorous and bitter fruits of the Affordable Care Act are likewise the result of a Democratic majority's unwillingness to compromise. While supporters of Obamacare correctly point out that its provisions were interdependent and based on Republican ideas, there is some truth to the perspective that the process was a blunt force exercise in partisan political jujitsu and an historical lesson in how not to pass and implement a big law.  In other words, Mr. Smith makes for good Hollywood but makes for lousy governance.

Aetna Talks Exchanges

One of the stories behind the story of Affordable Care Act's successful passage and survival to date has been the silence of the commercial insurers. It's not a good political or technical sign for the health insurance exchanges when Aetna's CEO goes public like this.....

Thursday, October 15, 2015

Associations. Correlations. Inferences. Signals. Yes, That's Big Data

America's corporate Directors
celebrate big data
The Population Health Blog's recent travels recently included a speaking gig at the just concluded National Association of Corporate Directors ("NACD") annual conference meeting.  It was part of a panel discussion focusing on health care innovation that was ably moderated by tech guru John Hotta.

The PHB's educational mission was to enable the persons who serve on Boards of Directors understand how "big data" is going to change health care.  After giving its standard definition (the use of large, disparate and unrelated data sets to find correlations and draw inferences that are actionable at the individual level), it turned to the following example:

"Imagine standing at the top of the Empire State Building and analyzing the noise from below to find out what's most likely happening down on Fifth Avenue."

In other words, its the use of computational analytics to separate the noise from the signals, and using those signals to ascertain a probability.

An informed guess.  Or, a probabilistic choice.

Folks in the audience seemed to get it, especially when the PHB noted that insurance (ICD-9 250), electronic record ("diabetes") pharmacy (insulin), public health (obesity prevalence data by zip code), survey ("have you ever been told you have diabetes?"), government (car registration; overweight persons prefer minivans), web-usage (recent interest in low calorie foods?) and purchasing (grocery purchases) data could be marshalled to assign a risk that diabetes is present, and if it's present, the risk of complications, and if there is a high risk, whether it's actionable.

The value proposition? 

By understanding the risk and being able to array it from high to low, precious health care resources can be scaled to the burden of illness in the population.  So, instead of "carpet bombing" all persons with a diagnosis of diabetes with one-size-fits-all reminders to see their doctor along with mass mailings of educational materials, personalized outreach can be targeted on those persons most likely to be hospitalized (and there are big data signals that can predict it) in the next year.

Bottom line: it can save money by rationalizing health care.

The PHB wanted to point out some other need-to-knows, which it did with variable success:

1. Quantum jumps in processing power and server capacity have put this within reach of desk-top personal computers.  As an added bonus, you don't need an army of mathematicians.

2. "Actionable" also means that the information is meaningfully available at the point of care, i.e. in the doctor's office where 80% of the decisions that drive health care spending occur.

3. Big data can also point to way toward more accurate diagnoses (imagine if all the risk factors for an Ebola infection had been rolled up into a single score in that Texas ER) as well as treatment (deciding on the "best" cancer treatment program after knowing the relative influences of genetics, lifestyle and past medical history).

Demanding Medical Excellence: How Do Things Stand?

Disease Management Care Blog colleague Michael Millenson has written a book called Demanding Medical Excellence. Like many other insightful observers, he wrote that only a minority of care interventions are evidence-based and that it can take years for proven therapies to be mainstreamed in clinical practice. Practice variation is rampant, avoidable errors occur too often, patients are passive bystanders in their own care and the U.S. health care system is spending money like trial attorneys at an anti-tort reform political fundraiser.

What few realize is that Millenson was among the first to recognize these issues when he wrote his groundbreaking book over 15 years ago

And, you ask, how have things fared since then?

Millenson answers the question in this Health Affairs article with some good as well as some bad news.

The bad news is that the U.S. health care system pays little attention to the prescient insights of smart people like Michael Millenson. The DMCB shares his pain because many of the things it has blogged about have likewise been ignored by the health care system.  The DMCB spouse and most persons working inside the health care system are not surprised.
The good news is that, while it may have taken 15 years to address these issues, things, according to Mr. Millensen, are finally beginning to get better.

In his view, the long delay was due to the commercial insurers' unwillingness to give up on their misaligned payment systems that continued to reward preventable complications, prolonged hospitalizations and readmissions. 

This was finally overcome by the twin forces of public insurer activism and patient consumerism. . 

The former imposed no-pay for "never events," required computerized physician order entry (CPOE), promoted accountable care, introduced bundled payments, made physician quality reporting a reality, and reduced payment for hospital acquired conditions. The latter is now represented by internet-enabled consumers who can use their lap tops and handhelds to compare symptoms with other patients, assess treatment options and compare provider outcomes.

The result? According to Millenson, we're finally seeing a long-due "paradigm shift" that is leading to transparent measurement and meaningful rewarding of quality improvement, accountability, safety, quality and value. Providers who are unwilling or unable to participate are seeing their services commoditized.

The DMCB agrees and is reminded that, from time to time, government can be a force for good.
That being said, it was the managed care backlash of the 1990s that scuttled the commercial insurers' ability to implement many of their ideas that were eventually adopted by Medicare and Medicaid. 

What's more, federal policy doesn't necessarily automatically translate into win-win, higher quality, lower costs and no unintended consequences for never events (here), CPOE (here), accountable care (here), bundled payments (here) or physician quality reporting (here). 

It may take a few more years before we can know if Millenson can write a follow-on book titled Achieving Medical Excellence.

Image from Wikipedia

What Happened To "Disease Management?"

Early Disease Management
The Disease Management Care Blog is hard at work rehearsing its Care Continuum Alliance Forum12 Plenary Session that's scheduled later this week. Right now there are 22 slides and they have something for everyone: Laurel and Hardy, Keystone Kops, kittens, witches, Ingmar Bergman and Bill Clinton. 

And that's just for starters.

One of the topics that the DMCB will tackle is how much "disease management" (DM) has changed over the past two decades.

When DM first started, many believed it was "the" solution.  It focused solely on chronic illness.  It promoted patient consumerism. While there was some shared risk, the business model was ultimately based on fee-for-service payment mechanisms that pursued a "return on investment."  It sought 100% patient outreach. It alienated many physicians.  It didn't invest in research. The industry suffered from hubris. Many believed it was a silver bullet.  It used nurses.

What a difference 20 years makes.

Now, the population health management service providers view themselves as part of the solution. It spans the full continuum of care, including case management, prevention and wellness. It promotes patient-centric collaborative teaming.  Instead of FFS, its business model is one of value and efficiency that reduces avoidable claims and optimizes trend.  It uses risk stratification to selectively enroll persons who will benefit the most. It is achieving physician buy in. It has invested in rigorous research and a host of studies since then demonstrate increases in quality and savings.  It has sought out partnerships and collaborations.  Many regard it as a key strategy. Its nurses practice behavioral medicine.

Wednesday, October 14, 2015

The Exchangeacillin Package Insert: Black Box Warnings and Adverse Reactions

The Disease Management Care Blog is pleased to assist the U.S. Department of Health and Human Services with this FDA-inspired "medication package insert" that is designed to help consumer-shoppers grapple with the star-crossed health insurance exchanges.

(online bunglecide)

Virtual Suspension

Prescribing Information

**Black Box Warning**
Health insurance exchanges increase the risk compared to placebo of wishful behavior in adults and politicians in recent short term studies. Anyone considering the use of EXHANGEACILLIN must balance the risk of unintended consequences involving a federal bureaucracy unfamiliar with fundamental principles of insurance 101. There are no studies that assess the success of online exchanges, and persons of all ages who use Exchangeacillin should be closely observed for hours-long vacant staring at computer screens.  Long term use may lead to loss of confidence in big government and unpredictable election cycles. (See WARNINGS: Insurance Markets and Bureaucratic Meddling: Information for Consumers, PRECAUTIONS: Information for navigators)

Exchangeacillin (online bunglecide) is a virtually administered insurance platform with approximately one billion lines of unstable computer code. It has a melting point range that falls within room temperature and zero resemblance to modern web-based architectures.

The efficacy of exchangeacillin in the treatment of underinsurance, access to care or life expectancy remains an open question.  Preliminary studies in humans have demonstrated accelerated partisan animus, selective interpretations and media spin, leading to one of the largest live social experiments in modern history. In vitro and binding studies may demonstrate that persons at risk for near-term insurance claims expense are preferentially attracted to Exchangeacillin. The impact on Millenials, Generation X'ers, Slackers and Dudes is speculative.

Exchangeacillin is unpredictably absorbed and has been shown to lead to one or more commercial insurance accounts with an elimination half life for redundant applications that may extend for six months or more. Nonlinear kinetics can lead to botched income estimations, claw backs and opaque tax consequences. 

Exchangeacillin is indicated for the treatment of underinsurance, being uninsured, high co-pays, unwanted co-insurance, double-digit co-pays, skinny insurance benefits, benefit exclusions, windfall profits, high administrative costs, coverage denials, not having birth control and showing the health insurers a thing or two.

Post-marketing surveillance studies have shown an increased risk of buttock decubiti, White House embarrassment, yawning, consumer disappointment, carpal tunnel syndrome, insomina, gridlock, hypersomnia, digit calluses, onychophagia, boredom, bluescreenosis, resentment, death spiraling, employer mandate delays, government shutdowns, war memorial posturing, bombast, biased reporting, deficits, speechifying, inflation, carve-outs, administrative exceptions, skepticism, income non-verification, disbelief, distrust, bickering, hyperpartisanship, multiple-accounts, insurance death spirals, closed national parks, can kicked down the roadedness, comparisons to Medicare, comparisons to Medicaid, tiresome pundits, nausea, bloggery, anecdotes, generalizations, wealth transfer, increased federal deficits, decreased federal deficits, higher taxes, government savings, higher for-profit health insurance stock prices, elevated media ratings, anxiety, confusion, dizziness, breathlessness, wordiness, emotional lability, dubious claims, confident predictions, foolishness, restlessness, cancelled WH meetings and DMCB spouse exasperation.

Use of Exchangeacillin may interfere with budgets, debt limits, sequester agreements and elections.

While Exchangeacillin should be administered following months of testing and debugging, the FDA has approved its administration in a let-'er-rip "big bang" fashion with ad hoc adjustments and unpredictable shut-downs.

On-line with "Apply Now" code that prompts "we have a lot of visitors on the site right now. Please stay on this page.... Thanks for your patience!"

Sunday, October 11, 2015

The Latest Health Wonk Review Is Up!

The Disease Management Care Blog votes for David Williams' latest version of the Health Wonk Review at his election themed "October Surprise Edition."  His Health Business Blog has lots of links to both sides of the health reform debate plus some other timely bloggy insights.


Saturday, October 10, 2015

If the Patient Centered Outcomes Research Institute's (PCORI) Findings Are Incorporated into Shared Decision Making, It'll Succeed.

Dr. Smith* was well known among the hospital's medical directors. Thanks to his superb training and busy clinical practice, this busy physician was convinced, thank you very much, that he had all the knowledge necessary to manage his patient population.

Summary quality reports, feedback and best practice advice he did not need.  He also loved pointing out that he wasn't being adequately reimbursed to deal with administrative hassles, many national Clinical Guidelines were based on faulty research, his patients were not "average," and his duty to his patients was to "first do no harm."  He believed in patient education but resented administrators' meddling.

The medical directors weren't about to use a "stick" and "de"credential Dr. Smith and kick him out of the network. The "carrot" financial P4P incentives they offered for quality measures were modest and comprised a only a small percentage of the physician's income.  They. Were. Stuck.

Enter the Affordable Care Act's Patient Centered Outcomes Research Institute (PCORI). Writing in the latest issue of Health Affairs, RAND researchers Justin Timble, Eric Schneider, Kristin Van Busum and Steven Fox reassure frustrated medical directors everywhere that PCORI will come to their rescue by ushering in a new dawn of clinical trial research.  The studies will be so good that Dr. Smith will change his passive-aggressive ways.

Dr. Timble et al point out that the reluctance of physicians like Dr. Smith to change their clinical practice is not surprising.  Payment mechanisms incent questionable treatments, much of the published medical science is riddled with ambiguities, even expert scientists succumb to a host of biases when they interpret study results and doctors are more interested in avoiding the risky downsides versus the upside benefit of new medical advances.  Last but not least, clinic-based electronic record decision support never fails to disappoint.

Fortunately, says these RAND authors, the PCORI is on it. Its sponsored research will transparently solicit stakeholder input and investigate all meaningful outcomes, including side effects.  When this high octane knowledge is combined with a dollop of rigorous guideline development, more gigabytes of information tech decision support and the luster of Obamacare's payment reforms, uncooperative Dr. Smith will be transformed into compliant Dr. Smith.

Sounds good, but the DMCB doubts that sprinkling PCORI pixie dust on docs is the cure to what ails the health care system. In its estimation, the RAND authors and the editors of Health Affairs are only telling half the story.

The DMCB to the rescue.

Despite the authors' enthusiasm, PCORI's well-meaning stakeholders will have to make real-world compromises on study scope, data collection and completeness. Their research methods and findings will never be completely immunized against healthy skepticism.  And while RAND scientists and the readers of Health Affairs are professionally invested in PCORI, how well it competes for the attention of practicing docs like Dr. Smith remains to be seen.

Financial carrots and sticks can be used to change physician behavior, but Dr. Smith will ultimately stay in the driver's seat thanks to a) a looming physician shortage and b) the prospect that total physician reimbursement will go down, leaving no room for incentives. While integrated delivery systems, accountable care organizations and physician-hospital alliances may (or maybe not) wring some dollars out of PCORI-based efficiency and quality studies, it remains to be seen how these big capital-intense organizations will share any precious leftover dollars with their docs.

The population health management (PHM) service community has a better answer.

While high quality research conducted under the supervision of an expert professional class has its place, they know it's ultimately up to the informed patient to make decision.  A considerable body of research, much of which would pass PCORI muster, has shown that shared decision making using a personal physician's advice is remarkably adept at reconciling imperfect research with patient values and preferences.  This, in turn, increases quality and reduces unnecessary costs.

The DMCB has seen countless physicians like Dr. Smith welcome the help of team-based nurses who can help his patients. He may call it "education," but they're engaging patients in science based decision-making and taking a lot of work off of Dr. Smith's hands.