Saturday, November 28, 2015

Whither Obamacare, Now That "It's the Law of the Land?"

While a roll-back of Obamacare now is about as likely as spotting gargoyle statuettes among the DMCB spouse's holiday decor, a recent New England Journal article points out that the Affordable Care Act (ACA) - even if it is the law of the land - still has a very bumpy road ahead.

That's because of four key issues:

1. The States can still knot things up by forcing Washington DC to run the Health Insurance Exchanges (HIEs).  It's very possible that Uncle Sam won't pull them off on time and, what's more, there's a credible Supreme Court challenge looming over Obamacare's potential lapse in extending tax credits to the federally-run HIEs.

2. States can refuse the Medicaid expansion. While their statewide hospital associations are very  unhappy about that, Governors are either ideologically opposed or just plain wary of additional downstream costs. This could result in additional millions of uninsured, especially in the conservative "red" states.

3. Health care cost inflation is likely continue its upward spiral.  Congress, no matter how CMS' payment innovations turn out and no matter how much it wants to curtail costs, is unlikely to withstand the lobbying from all corners of medical-industrial complex involving thousands of pages of rules and regulations.

4. Deep public ambivalence about the law will continue. That means that as Congress and the President look for ways to control the Federal deficit, Obamacare is especially vulnerable. Unlike Social Security or Medicare, the ACA's "patchwork" of insurance reforms is headed toward the fiscal cliff without a strong supportive constituency. Before Congress even touches Medicare, it's far more likely to cut Obamacare. The first hit could be those insurance tax subsidies mentioned above.

Friday, November 27, 2015

Another Study Shows Disease Management Works

Here's more evidence that disease management really works.

The study, Online Disease Management of Diabetes: Engaging and Motivating Patients Online With Enhanced Resources-Diabetes (EMPOWER-D), was a prospective randomized clinical trial that is posted online over at JAMIA.

The Disease Management Care Blog summary:

Researchers at the Palo Alto Medical Foundation used the electronic health record (EHR) to look for active (seen once in the last 12 months) patients over 18 years of age with  Type 2 diabetes and an A1c greater than 7.5%.  If the primary physician approved, patients were then asked to complete a questionnaire and keep an appointment with a research assistant for additional review and discussion. Once patients agreed, they were entered into the study.

6,907 potential study subjects were identified, 1,594 agreed to complete the questionnaire and see the research assistant, 768 met additional research criteria. 415 agreed to be enrolled in the study, and 379 completed most of the 12 months of follow-up.

Patients were randomly allocated into one of two treatment tracks and followed for 6 and 12 months. The usual care (UC) track provided reminders about preventive care in addition to their usual visits with their physicians.  The intervention (INT) track had the usual physician visits, plus:

1. access to a "nurse care manager" (NCM) who provided advice and protocol-based medication changes,
2. Wireless uploads of glucometer readings into the EHR,
3. an EHR-based patient-specific summary "dashboard," that included risk scores, preventive care updates and a care plan,
4. web-based insulin, exercise & nutrition logs,
5. secure EHR-based messaging with the physician and NCMs and
6. patient-specific text and video offerings targeted by the NCMs.

The principal outcome measure was the A1c test, which is an indicator of overall blood glucose control. A level of 7 or lower is considered to be satisfactory control. At 6 months, INT patients statistically significantly decreased their A1c by 1.3 vs. 0.7 in the UC group.

At 12 months, there was still a difference favoring the INT group, but it did not achieve statistical significance: 1.1 vs. 0.7. 

Once the study was completed, the authors went back and looked at the proportion of patients that had decreased their A1c by at least 0.5.  At 6 months, it was 70% vs. 53% for  at 6 months, and 70% vs. 55% at 12 months for the INT and UC groups, respectively.  Both differences were statistically significant. 

Patients in the INT group were also more likely to lower their cholesterol, go through a medication adjustment, experience lower "treatment distress," have greater knowledge of their diabetes and be more satisfied with their care.  There was no difference in blood pressure control or the number of physician visits.  Overall health care costs or insurance claims expense were not measured.

Disease Management Care Blog take-aways:

You Want Evidence? Thanks to this high quality randomized controlled clinical trial conducted in a real world setting, the evidence base supporting the use of remotely placed nurse care managers continues to build.   Kudos to Palo Alto for simultaneously taking good care of their patients and conducting impressive research.

Patients At Risk: The combination of a) a steady percent of INT patients keeping their A1c 0.5 at 6 and 12 months plus b) a simultaneous overall average decline in the A1c makes the DMCB think that there was a subcohort of patients that "back-slid" and affected the group mean.  Commercial population health management service providers are working hard at prospectively identifying these higher-risk individuals for additional interventions.

Doing something is better than nothing: While the modest A1c decrease in the UC patients could have been due to regression to the mean, the DMCB wonders if they also benefited from being identified and monitored. 

Can Finally Point to Something Good About the EHR: While the EHR continues to disappoint in terms of consistently improving quality or reducing costs, this study demonstrates an important upside: it can be used to efficiently recruit potential research subjects.  That's important because thousands of candidate patients are needed to find hundreds of study participants
Physician Utilization Did Not Decline: Unfortunately, this study did not address multiple measures of utilization, so the DMCB doesn't know what to make of any decrease in potential costs versus the cost of the the program.

ACOs Take Note: While the Palo Alto System is not representative of most health care settings in the U.S., it does hold important lessons for Accountable Care Organizations. Given their contractual responsibility to improve diabetes quality as well as managed insurance risk, this study says they ignore the potential of remotely-based and technology-backed nurse care managers at their peril

More on Al Lewis' Book "Why No One Believes the Numbers"

Remember the DMCB's reviews (here and here) of Al Lewis' book Why No One Believes the Numbers?  The DMCB can't either, which is why you may want to check out this review by Christobel Selecky over at the excellent DMCB sister blog, The Doctor Weighs In.  It's worthwhile reading, especially since Ms. Selecky was the CEO of the star crossed disease management company LifeMasters. She knows of what she speaks and has the scars to prove it.

The DMCB finds her 6th paragraph slightly off topic but worthy of further discussion. Say what you like about the "evidence" supporting disease management, but let's at least be consistent and apply the same high standard to the patient centered medical home, the electronic health record and accountable care organizations.  Patients deserve nothing less.

Thursday, November 26, 2015

A One-Size-Fits-All Approach to Determining Clinical Effectiveness Versus Shared Decision Making

The Disease Management Care Blog recently attended a physician meeting that keynoted a U.S. Senator.  In his prepared comments, he admitted that he knew little about controlling health care costs.  Unfortunately, that didn't stop him from humbly paraphrasing the testimony of a famous economist:

"Find out what works," said the expert, "and do that."

Maybe some of the physicians' silence that followed was an "aha!" reaction to the Senator's insightful nostrum.  Some of it may have also been out of respect. 

The DMCB is sure, however, that most of the docs in the room were quietly thinking "You must be kidding me."

Such is the approach of the mandarins leading our federal health care institutions.  "Science and existing literature" says HHS Secretary Sebelius.  "Effectiveness" is the mantra of the Center for Medicare and Medicaid Innovation.  "Improving health care" is now part and parcel of CMS. 

Unfortunately, applying scientific evidence to the economics of health care delivery sounds easy enough until you get down into the weeds.  For a perfect example of that, consider the common condition of painful spinal stenosis among Medicare beneficiaries. According to this JAMA article, there were over 37,000 operations in this population at a national cost of $1.65 billion. 

Which begs the question: does spinal surgery "work," is "effective" and "improves health care?" Can the "science and existing literature" help us decide?

To get an idea of just how complicated the answer is, check out this Agency for Healthcare Research and Quality (AHRQ) research review on Spinal Fusion for Treating Painful Lumbar Degenerated Discs or Joints.  The conclusions from the abstract are:

Overall, limited evidence suggests that spinal fusion compared with physical therapy improves pain and function for adults undergoing fusion for low back pain due to disc degeneration. Because of insufficient reporting and variation in surgical methods used in the different studies, the incidence of adverse events (serious and minor) associated with fusion could not be determined conclusively. The evidence was insufficient to draw evidence-based conclusions for the benefits and harms of spinal fusion for patients with degenerative stenosis or degenerative spondylolisthesis of the lumbar spine. The evidence was also largely insufficient to draw conclusions about the benefits and harms of fusion compared with other invasive treatments or different fusion approaches or techniques.

In other words, there is some evidence that, compared to conservative treatment, surgery helps.  After that, it's the stuff of caveats, statistics, evolving technique and myriad study limitations.

In fact, it's so complicated that the only way it can be applied is by helping patients understand how the science applies to their unique circumstances and values.  Once the patient understands things, it's a matter of letting that patient and doctor jointly decide on the best course of action.

That approach - in contrast to U.S. Senators musing on how we need a one-size-fits-all approach to what works - is called shared decision making and it can be applied to back surgery with considerable cost savings.

"What works?" asks the Senator?  The answer is for you to consider staying out of the way.

Wednesday, November 25, 2015

Ten Rules for Health System Boards of Directors to Follow to Reduce the Risk of Fraudulent Outcomes Reporting and Scientific Misconduct

Enjoying a good spin
Are you on the Board of Directors for a large health service provider, population health vendor, integrated delivery system, managed care organization or other care corporation? 

If so, your company is likely collecting, analyzing and publicly reporting quality and cost data. Not only do superior results in journals, meetings, splashy web sites and glossy marketing materials present a competitive advantage, achieving superior outcomes is part and parcel of your organization's mission.

The Disease Management Care Blog reminds Board members that intentionally or unintentionally misrepresenting outcomes is an existential threat to health care organizations.  Having to retract a publication, correct a white paper, meet with grumpy regulators, confront claw backs, deal with a whistle-blower, respond to allegations of interpretation spin, uncover suppression of bad results or defend the integrity of your brand is something no Board wants to deal with.

To the DMCB's knowledge, this hasn't happened to any ACOs, risk contracting systems, managed care organizations or population health or wellness vendors.


It's just a matter of time.

While the risk of allegations of scientific misconduct can never be reduced to zero, the DMCB offers up ten best practices for Boards to follow:

Reduce opportunities by:

1. Exhibiting healthy skepticism regarding all outcomes reported by your management team, especially if the results seem to be too good to be true.

2. Insist that your management team has two persons with access to any data base, and that they have separate reporting relationships.

3. Insist that your management team has two persons independently involved in any data analysis, and that they have separate reporting relationships.

4. Be familiar with and insist that the rules on research on human subjects be followed.

5. Maintain a low threshold for conducting internal or external audits of any databases and any interpretations of those data.

Combat any rationalizations that fudging outcomes is OK by:

6. Recruiting Board members with research expertise.

7. Explicitly engage the Audit Committee and any other Board member or committee with oversight of risk to view "outcomes" with the same level of scrutiny as your company's financials.

8. Maintain an ethical "tone at the top" when it comes to research.

9. Have a disaster plan ready to go.  For starters, train your Board on how to deal with hostile media inquiries.

Reduce incentives by:

10.  Asking your CEO if any compensation plans including bonuses or unwittingly promoting unethical or fraudulent behavior.

Saturday, November 21, 2015

The Latest Health Wonk Review Is Up!

A festival of bright wonky bloggery awaits you, courtesy of Health Wonk Review host Hank Stern over at his InsureBlog.  In it, you'll find links to health policy insights and viewpoints that you simply can't find anywhere else.

Mazel tov!

Friday, November 20, 2015

The Curious Case of the Medical Device Tax

Some medical devices
The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

During the political maelstrom of the October government shutdown that enraged Americans and enraptured Tea Party alike, a curious proposal emerged as a possible eleventh-hour savior: a repeal of the medical device tax. 

The medical device tax, a substantial revenue source for ACA funding, was seen as a compelling political bargaining chip. Although not achieving a full “repeal” of the ACA, the vitiation of the tax would have given Republicans a symbolic victory (political cover) and the medical device industry a reprieve. Although the tax remained in force, it still serves as a potent symbol of how health care reform will need to align long-term financing mechanisms that also promote a more efficient health care system. 

A 2.3% excise tax on all medical devices was included in the ACA as a main financing stream for health care reform. Indeed, according to CBO estimates, the tax is estimated to bring in $29.1 billion in revenue from 2015-2022.  A repeal of the medical device tax would not cripple the ACA’s implementation; however, it would make it difficult to move forward, and perhaps more importantly, reopen the bill to legislative scrutiny (Note: President Obama’s announced  administrative fix for health insurance in the individual market assiduously avoided legislative action for similar reasons). 

Some supporters of the tax argue for the concept of “shared responsibility.” Building on the fiscal architecture of Massachusetts’ 2006 health reform legislation, proponents posited that stakeholders who potentially benefitted from health care reform should lend fiscal support.  The ACA followed a similar funding model: hospitals, insurers, and pharmaceutical companies all decided to participate; the medical device industry, although more obstinate, was ultimately written in the legislation.

More sophisticated repackaging of this argument has also emerged. Topher Spiro argued that the medical device tax served as a bulwark against the industry’s egregious pricing and anticompetitive practices. Although, to his credit, Spiro lays out more commonsense policies to increase transparency and address monopolistic concerns besides taxation, he ultimately adopts an odd “the ends justify the means” policy prescription.

Opponents of the medical device tax adopt a well-known line of reasoning: taxation on medical devices will hurt domestic innovation, eliminate jobs in research and development, and have a negative economic impact. This is textbook economic analysis. While some of these points are apposite, much like pharmaceutical companies, medical device companies could arguably make up lost revenue through discriminatory pricing abroad, although this may be (increasingly) difficult in areas such as “austere” Europe. 

Overall, one may be agnostic regarding the substantive points of both supporters and detractors and still be dismayed at the misalignment between the medical device tax and its intended purpose. Granted, medical device providers are leveraging the opportunity to lobby and maximize the industry’s interests in the ACA tumult. However, the tax is not ultimately intended to discourage purchase of medical devices, many of which have substantially improved quality of life for patients. Rather, it functions as a defacto “windfall” tax clawing back excess profits from an industry seen as anticompetitive and opaque with oligopolistic pricing power. 

This narrative works only so far: Medicare, a publicly funded entity, is one of the largest purchasers of medical devices.  However, Medicare is not able (or is politically prevented) from exercising greater pressure on medical device providers through conducting cost-effectiveness analysis or lowering payments on devices that have a suboptimal cost-quality profile. It is true that Medicare is developing bundled payments that will subsume the cost of the device as part of the total procedure; this move away from fee-for-service charges may reduce the “economic rents” (profits) of medical device firms over the long-term. Until then, however, the misalignment between financing mechanisms and policy incentives will likely continue, along with the distortions of second and third-best policies in an already bloated system. 

Medical image from Wikipedia

The Electronic Health Record (EHR) On-Line Portal Increases Hospitalization Rates

"Hi doc! I used my on-line
portal to make an appointment!"
Hey there Accountable Care Organization executive.

You're probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal.  That's because you've been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospital's lobby.

Well, after you've read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist.

The article's title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.

How the study was done:

Kaiser Permanente Colorado added "MyHealthManager" (MHM) to their EHR in May 2006. MHM allows patients to view tests, records, problem lists as well as care plans, schedule appointments, request refills and message their doctors. By June of 2009, over 375,000 Kaiser patients had signed up for MHM. Of those, about 45% had used the system at least once.  Of this number, Kaiser researchers pulled the records of 44,321 persons who had been continuously enrolled in the Kaiser system for at least two years. 

This group was retrospectively matched to a control group of Kaiser patients who had not signed up for MHM.  The authors did this through "propensity matching." This found a similar number of patients, based on age, gender, race, number of chronic illnesses and baseline office visits who, using logistic regression analytics, appeared to be the type of patient who would otherwise sign up for MHM.

The results:

Compared to non-MHM patients, the MHM experienced an increase in hospitalization rates (20 per thousand patients) and emergency room visits (11 per thousand).  In other words, for every hundred patients, the on-line portal seemed to lead to 2 extra hospitalizations and 1 extra ER visit. Both differences were statistically significant.

There were also increases in the number of office visits (.7 per patient per year), telephone calls (.3 per patient per year) and after-hour clinic visits (18.7 per thousand patients per year).


The authors correctly point out that this study is not perfect.  Retrospective propensity matching is not as good as a randomized clinical trial; it's possible that the patients who self-selected for MHM were already realtively more interested in or likely to increase their use of health care services.  Results at Kaiser may not apply elsewhere.


Despite the limitations, this study should be a wake-up call for those who believe EHR portals is a savings panacea.  By increasing access to on-line services, physicians and patients may paradoxically use the system to address concerns that otherwise wouldn't come to medical attention.  In other words, the EHR portal exacerbates the classic health care economics problem of supplier-induced demand.

Image from Wikipedia

Thursday, November 19, 2015

March of Dimes Says the PREEMIE Act Saves Lives. Does It?

Saving children's lives. Nothing could be nobler right?

According to a November 15 March of Dimes press release:

The PREEMIE Reauthorization Act will save infants’ lives," said Dr. Jennifer L. Howse, President of the March of Dimes. “Tonight the Senate took a vital step toward ensuring a healthy start for our nation’s infants."

The release goes on to say:

Our efforts are bearing fruit,” Dr. Howse added. “Preterm birth rates have now dropped for five consecutive years after rising steadily for three decades. The PREEMIE Reauthorization Act will continue to fuel our progress by supporting federal research and promoting known interventions and community initiatives."

"Really?" asks the Disease Management Care Blog.  What about the dozens of lecturers, professors and colleagues that have told the DMCB that preterm birth rates have remained stubbornly unchanged for decades? 

It's a significant problem because the delivery of a child prior to 37 weeks gestation (vs. the usual 39 weeks) is associated with many complications for both the mother and child.

Wanting to learn more about this life-saving legislative miracle courtesy of Uncle Sam, the DMCB decided to take a look for itself.

It turns out the original "Prematurity Research Expansion and Education for Mothers who deliver Infants Early Act" (or PREEMIE) Act was passed and signed into law by then President Bush in 2006.  The statute provided for a number of interventions, including millions of dollars worth of research funding, provider education and nationwide monitoring. The funding was due to run out in 2011. 

Enter the PREEMIE Reauthorization Act that was just passed by the U.S. Senate.  It doesn't appear to authorize any funding, but it essentially continues the activities contained in the original 2006 legislation by striking out the term "2011" and replacing it with "2017."

Based on the March of Dimes press release quotes above, it appears that the organization is crediting the 2006 PREEMIE with the nationwide drop in preterm birth rates. The basis for this is March of Dimes data that can be found here. If you look at the upper right hand corner, you can see that the prematurity rate went from 12.8% in 2006 (when the law was passed) to a preliminary measure of 11.7% in 2011.

Unfortunately, these data do not tell the entire story. For that, the DMCB went to the "" website and discovered that overall prematurity rates have remained stubbornly fixed in the 10.6% to 12.8% range for over two decades.  The rate peaked in 2006 and has been drifting back down to the baseline historical average.   To the DMCB it looks like normal year-to-year variation.  What's more, DMCB readers are well aware of the phenomenon of regression to the mean.

Next step for PREEMIE is the House of Representatives.  The DMCB isn't advocating for or against PREEMIE, but it hopes a second look in our bicameral legislative process prompts a more rigorous and complete examination of the outcomes associated with this piece of legislation.

Editorial Comment: The DMCB is all for research to discover what works, but it would like to point out that there is a considerable body of published literature on the topic.  Do we really need more research, or do we need to figure out how to provide these services using the principles of population health management? 

You be the judge: it's your money.  

Image from Wikipedia.

Dr. Berwick Discovers Toxic Politics Too Late

Dr. Berwick listens to Ms. Sebelius
If you're interested in a post-mortem of Dr. Donald Berwick's failure to be confirmed as CMS Administrator, check out his November 13 JAMA article on "The Toxic Politics of Health Care." 

He identifies six causes of our national discontent, which the social media-minded Disease Management Care Blog has boiled down into 140 character or less tweetable summaries:

Money: there are too many entities making too much money to give up on the status quo. "Reducing costs" means cutting into someone's income.

Unorganized majority latent interests: the majority of Americans can't see or translate their interests into effective political action.

The Silence of Professions: Organized medicine has been all about the SGR and tort reform.  They should advocate for health reform.

Suspicion of Science: public trust in science is eroding because of its elitism. That, in turn, feeds into fear of rationing.

Duality of self interest: a lot of people work in the health care industry. Cutting costs will add to U.S. unemployment woes.

Ambivalence about Federalism: it's difficult to develop a coherent national health policy when power is shared with the states.

Ambivalence about the poor: it's difficult to convince the U.S. electorate that disadvantaged populations deserve public support.

For the record, the DMCB openly supported Dr. Berwick's nomination and still feels that he would have ably served his country as CMS Administrator.  That being said, one cause for his undoing was his failure identify these issues before he was forced to leave Administration. 

Docs like Dr. Berwick - and that includes the DMCB - unfortunately think that all they need are the facts to win the day. Not so: they need to address the money, catalyze coalitions, nudge stakeholders, reconcile multiple interests, cut deals and still do what's right.

He was the wrong guy at the wrong time.

The Latest Cavalcade of Risk Is Up

.... and it's been up for a while.  The tardy DMCB was mentioned in Louse Norris' excellent rendition of the Cav back on November 14.  Even now, however, the Colorado Health Insurer Insider page is still worth a visit for anyone interested in the some great writing on the economics of enterprise, business and insurance risk.


Wednesday, November 18, 2015

Stuff Their Mouths with Gold

The Disease Management Care Blog uncovered this confidential memo, presumably authored by a health insurance CEO to the company's senior management team. Any resemblance to reality or perception is purely intentional.

DATE: November 18, 2015

TO: Senior Management

FROM: The Office of the CEO

RE: Our recent White House meeting on the individual mandate

As many of you are aware, I and other commercial insurance CEOs visited White House to barnstorm over ways to help President Obama out of his latest political pickle.  While, like you, I was caught off-guard by the President's "I hear you loud and clear" proclamation, our trade association CEO, Karen Ignagni, was once again masterful in helping us understand the big picture.  I wish to share that information with you.

1. Remember that the Affordable Care Act (ACA) is a commercial insurance gold-laying goose. Millions of Americans are being forced to buy our products, and a lot of them will be subsidized by the faith and credit of the Federal government. While the President will use every opportunity to deflect any blame on us, we must remember: eye on the prize, people!

2. While we would naturally prefer that, effective January 1 2015, our customers move from the skimpy lower margin individual plans to the richer and more profitable "essential health benefit" plans, Ms. Ignagni anticipated that the amateurs advising the President would lead to him to having to make stuff up on the fly.  Think of this as the price of doing business.
3. While many of you will be working long hours through the upcoming holidays to un-disenroll the hundreds of thousands of insureds that got our cancellation nastygrams, let me assure you that getting it right most, not all of the time is our new business mantra.  Sure, thousands of persons will allege that that they thought they were covered with X deductible for Y condition, but we can clean that up after the fact through the standard appeal process.  Hey, it's right there on the White House web site.

4. It's no accident that Ms. Ignagni described our White House meeting as "very productive."  While the details cannot be shared with you, as many of you know, the ACA allows for certain "risk corridor offsets" to be made if there are early death spirals in the mandated minimum benefit plans.  While opponents of the ACA will attempt to undermine those costly offsets in the upcoming government budget battles, we're hopeful that politicians on both sides of the aisle will ultimately recognize that it's not our fault that the White House's insights on health insurance is about as deep as Toronto Mayor Rob Ford's awareness of the perils of crack.

5. We must remain quiet and outside the public eye. While all of us are appalled at the Administration's blunders, the last thing we want to do is to remind our Democratic allies about the "public option."  If we are approached by the media, let's recall that Aneurin Bevan, the founder of the National Health Service, neutralized the opposition of Britain's doctors by "stuff[ing] their mouths with gold." The ACA is our gold and let's keep our dismay out of sight and our mouths silent. 

Saturday, November 14, 2015

Patient "Skin in the Game" Has Its Limits: The Assymetry of Patient Cost-Sharing Incentives

The Disease Management Care Blog always thought that the upsides and downsides of patient "skin in the game" was "symmetrical."  Writing in the Oct 24 issue of JAMA, Kevin Volpp and colleagues point out that that may not be true and that patient economic incentives may not necessarily work as intended when it comes to Choosing Wisely

Rather, economic incentives can be asymmetrical.

In other words, it's commonly thought that if increasing patient out-of-pocket cost for a drug (for e.g., an unproven brand-name drug) or unnecessary health care service (for e.g., antibiotics for uncomplicated sinusitis) decreases utilization in a population by a certain amount, it should stand to reason that decreasing the cost (for e.g., for a cholesterol drug) by the same amount would correspondingly increase utilization (for e.g., among heart attack patients). 
According to Dr. Volpp and colleagues, it doesn't work out that way.  Research has shown that increasing out-of-pocket costs can readily prompt patients to defer testing or treatment.  However, the converse is less true: decreasing out of pocket costs has limited impact on incenting patients to embrace testing or treatment.

Reasons include:

1) persons are generally more sensitive to financial losses than to gains (especially when those gains are intangible savings).

2) when it comes to drugs, a decreased or absent co-pays every 30 or 90 days has little impact on the daily decision to take a pill

3) increases in cost dissuade patients that already want a service or medication; decreases target a different population of patients who are not engaged and are already paying nothing.

Implications for the population health management industry and the patient centered medical home: coaching patients to take their medications or to pursue needed testing may require significantly different approaches depending on out-of-pocket co-pay arrangement.   Patients are more likely to view cost sharing as a barrier, while those with little cost-sharing may benefit from additional incentives.

Friday, November 13, 2015

More On Why The Prognosis of Accountable Care Organizations (ACOs) Is Guarded and How Should Population Health Management Providers Position Themselves

For a long time, the more than 5000 regular visitors to the Disease Management Care Blog have been aware of the gap separating the promise and reality of Accountable Care Organizations (ACOs). That's why the DMCB salutes the editors of Health Affairs, who have decided it's time to extend the same courtesy to its readership with a well written article by Lawton Burns and Mark Pauly titled "Accountable Care Organizations May Have Difficulty Avoiding The Failures Of Integrated Delivery Networks Of The 1990s."

Remember the 1990's style integrated physician-hospital delivery systems? The DMCB sure does. Like the modern ACOs, these systems' business model were also based on care coordination, incentives alignment, risk bearing, salaried physicians and horizontal and vertical organization.

According to Drs. Burns and Pauly, they flamed out because they paid physicians too much for their practices, lacked adequate information technology, failed to achieve economies of scale, couldn't coordinate care and entered into "piecemeal" capitated contracts.  Last but not least, the typical 1990's style integrated system was never really "integrated" at all: it was made up of multiple provider entities that were simply bolted together.

ACO advocates argue it's going to be really different this time. Information technology is cheaper and more robust, new payment approaches (such as upside risk and bundled payments) are more user friendly, health care administrators are more adept at squeezing costs from the system and purchasers are demanding value over volume.  Toss in patient-centeredness, accountability, transparency, paying zero for physicians' practices and the momentum of federal payment reform, and it's easy to see why ACO-skeptics like the DMCB readers are being viewed as paper-medical record-loving party-pooping pinheads who pine for fee-for-service.

For the record, the DMCB categorically denies being a pinhead. But it and Drs. Burns and Pauly agree there are plenty of reasons to be skeptical.  Among the article's points that resonated with the DMCB are:

1) Most attempts at hospital-physician integration have not ended well, thanks to conflicting goals have not achieved quality, cost, cooperation or integration. Will economics and information technology finally trump culture?  We'll see.

2) Care coordination is no less difficult compared to the 1990s because it not only relies on timely information, but patient self management and nurse coordinators. The parallel flame-out of early versions of disease management also taught us that it is not a panacea for all patients with all chronic conditions being cared for by multiple providers in open networks. It works best when it is targeted at persons with a high burden of disease with readiness to change.

3) Medical homes take years to develop, thanks to years of transformative change management. Just because you're an ACO doesn't mean you're good at it and, what's more, you don't have years.

4) Clinically-based health information technology such as point-of-care decision support, electronic records and computerized physician entry have been inconsistently successful. And that's being generous.

But the authors don't stop there.  They describe four ACO "Achilles heels":

1) If PCPs are truly the linchpin to ACOs' success, it should also be pointed out that they are in short supply. It remains to be seen if they'll welcome a loss of professional autonomy or be willing to accept compensation that remains a fraction of their specialist colleagues;

2) Assuming large integrated systems comprised of a hundred or more physicians are truly able to achieve economies of scale, they won't spontaneously appear.  They take years to develop and mature.  See medical homes above.

3) Utilization of health care services outside an ACO's network not only outside their control but is very expensive, and

4) Maybe ACOs are a "disruptive technology" but the ultimate judge will be consumers.  They have yet to weigh in.

Implications for the population health management (PHM) service providers:

1. As ACOs struggle with their primary care providers and scramble for medical home and large health system-style care coordination services, "outsourced" nurse-based coaching will be very much in demand. But you already know this.

2. Given their national footprint, PHM providers may be in the best position to assist with those out of network or out of state ACO enrollees.  That's a new thought.

3. Keep a Plan B available just in case, and despite your help, ACOs collapse of their own weight.

Three Population Health Management Principles for Reconciling Quality-Based Pay for Performance and the Doctor-Patient Relationship

Writing in the New England Journal, Robert Berenson and Deborah Kay of the Urban Institute say a linchpin of Washington DC's pursuit of quality is a "policy overreach [that] could undermine the quest for higher-value health care."

Yikes.  The Disease Management Care Blog turns to population health management to ponder their unhappiness.

The authors' concern is over Medicare's "Physician Quality Reporting System" or "PQRS."  As the DMCB understands it, PQRS rewards (and penalizes) physicians for outcomes that are calculated from a set of quality "modifiers" that are submitted as part of the Medicare billing statement (an example can be found here).  The amount of money at stake is in the range of 1%-2% of the Medicare reimbursements.

Berensen and Kay point out that while the system has been ramping up over 6 years, 70% of Medicare participating physicians do not submit any modifiers.  In their opinion, that's because:

1) the loss of 1% of any payment is practically meaningless,

2) physicians distrust the metrics and

3) there is a fundamental disconnect between the modifiers and the complex world of clinical practice. 

As examples, radiologists are being dinged for total x-ray exposure while surgeons are being held accountable for pre-op antibiotic administration. While these and other quality measures are important, they fall far short of recognizing what keeps docs up at night, like reading the x-ray correctly and getting a patient through surgery and out of the hospital.

"Hear hear!" says the Disease Management Care Blog.  In the course of a normal day, it is job of doctors to do "doctor stuff" involving one patient at a time. 

But, you ask, isn't that contrary to being accountable to the health of populations? 

The DMCB doesn't think so, because state-of-the-art population health management (PHM) agrees that:

A. Physicians need to be immunized from disruptions their "customer facing" (i.e., the patient) activities.  Otherwise known as the doctor-patient relationship, that's the part of the health care system that relies on the seven or more years of undergraduate and graduate training that turns smart people into exquisitely trained physicians.  Let the doctors be doctors, says the DMCB, and let them worry about their patients.

B. High performing systems - as much as possible - need to be configured around those customer-facing activities, further enabling the doc to focus on the patient who is right here and right now. 

From time to time, PHM might have to intrude.  When it does, the DMCB suggests policymakers recognize that they should proceed:

1) only when it's really important

2) only infrequently and

3) whenever possible, when it reduces physician work by outsourcing (an example in primary care can be found here) those things that don't require the personal involvement of a doc.

It would seem that Medicare's PQRS failed to recognize the fundamentals.

Image fromWikipedia

Thursday, November 12, 2015

The Dilemma of Medicare Coverage of "Reasonable and Necessary" Care and Why It's Important

If you get sick, health insurance should cover all the "stuff" necessary to make you better, right?

While that sounds good in principle, Uncle Sam has made it a lot more complicated than that.  As we continue to struggle with health reform, this New England Journal article on "Medicare's Enduring Struggle to Define Reasonable and Necessary Care" is very timely.

According to Drs. Neumann and Chambers, Medicare has always covered medical services that are "reasonable and necessary." As new approaches, drugs and medical technologies have been released, you'd think coverage would be based on an objective analysis of outcomes and cost effectiveness.

You'd be wrong.

Years of differing interpretations, patient advocacy, Congressional meddling, regulatory carve-outs and case law have generated a miasma of bureaucratic complexity that will guarantee the incomes of thousands of lawyers for years to come.

Not that CMS hasn't tried to be reasonable about "reasonable and necessary." According to the article, in 1989 CMS specifically proposed that the words "cost effective" could be used to assess new technology. That proved too controversial. It later tried "least costly alternative language" for coverage of durable medical equipment and Part B medications.  This too was dismantled by the courts when plaintiffs argued that the term "reasonable and necessary" could only be applied to medical services, not to the costs of those services.

How ironic. Even though CMS is making "value-based purchasing" judgements for hospital payments and costs can be factored in the coverage of preventive services, that still doesn't apply to new technologies and drugs.

The latest dysfunction is CMS' pretzel logic of "coverage with evidence  development" approach to medical devices, essentially agreeing to coverage that is conditional on CMS' evaluation of additional outcomes data.  Unfortunately, CMS' ability to collect and interpret these kinds of data in the current political environment remains an open question.

Outside of Medicare's cost travails, why is all of this important?

1) Medicare's price tag was $509 billion in 2010, taking 12% of the federal budget. While there are other drivers of cost, such as aging, coverage arrangements, income, pricing, administrative costs and defensive medicine, technology could account from 38% to more than 65% of the current growth (inflation) in spending.  Medicare's historic inability to control this does not bode well for future cost projections.

2) This is not a partisan issue and there are no partisan solutions.

3) Commercial insurers generally use Medicare's coverage criteria to define their own benefit structure.  Medicare's problems are everyone else's.

4) This is another reason why Medicare is banking on ACOs.  By delegating management and the associated risk of all these thorny coverage issues, they're hoping ACOs can do within three years what CMS couldn't do in three decades. We'll see.

"Down Jobbing" to Primary Care Technicians?

Heard of "down-jobbing?"
Your PCT will see you now.....

The Disease Management Care Blog first became aware of the term years ago when it was pointed out that primary care docs can take on some specialty care responsibilities, while nurses can take on primary care roles, while office assistants can take on nursing roles. A parallel phenomenon is the movement of surgeries and other medical procedures from the inpatient to the outpatient surgi-center to the physician's office.

Naturally, the ultimate down-jobbing target is the patient. Examples include the reasonable innovation of self-service kiosks as well as emergency or wacky "self surgery."

Which naturally prompts the DMCB to offer it's own definition of down-jobbing: the historical movement of medical treatment from higher to lower levels or locations of health care services.

Of course, the major driver of down-jobbing is economics. DMCB readers are well aware of our national obsession with transitioning from "fee-for-service" (FFS) to more "value-based" reimbursement arrangements. These include pay-for-performance as well as shared-risk, global or other capitated approaches.

Since traditional FFS is notoriously linked to medical necessity as well as provider credentialing (examples are not hard to find), physicians have had little incentive to go along with down-jobbing. As FFS allegedly goes the way of the dinosaurs (a perspective likewise not hard to find), health care providers in these new value-based payment systems are looking for cost-effective ways to service their patients within a fixed budget or fixed payment system. One way to do that is to down-job.

So it was only a matter of time until someone thought of the option of "primary care technicians" ("PCTs") as a value-based and down-jobbed solution to the nation's physician shortage. As Kellermann et al point out in the November 2015 issue of Health Affairs, the pipeline for primary care docs, physician assistants, nurse practitioners is not only expensive, it's unlikely to meet future demand.  They argue that PCTs can be to primary care providers like emergency medical technicians (EMTs) are to emergency care rooms.  Like EMTs, PCT training to handle preventive care, treatment of minor illnesses and monitoring chronic conditions needn't be extensive. That's especially true if PCTs are armed with a health IT safety net that provides tablet-based decision-support algorithms that are ultimately tethered to (or teamed with?) a primary care physician.

So there you go: a few questions, a cursory exam and a recommended treatment plan for millions of healthcare hungry Americans is well within reach.  All it takes is some additional down-jobbing.

The DMCB thinks that, on paper, it's not a bad idea and no accident that it would appear in the academic health policy literature.  Whether this could gain any traction in the real world of patients remains to be seen.  Perhaps the next step is a randomized controlled clinical trial comparing the outcomes of patients seeing newly minted PCTs to those receiving usual care.

The DMCB has two additional concerns:

1. The promise of the expansion of access to health insurance under the current iteration of health reform was that patients would be able to access the current health care system, including doctors and hospitals.  Even if this system of primary care meet outcome expectations, this will hardly burnish American's ambivalent views of Obamacare.

2. Liability concerns are significant. Allegations of malpractice are inevitable with PCTs and their supervising docs will naturally worry about being ensnared in even more lawsuits by a very nimble plaintiffs' bar.

Image from Wikipedia

Wednesday, November 11, 2015

Rising Healthcare Costs: Delayed or Defeated?

Ready, set......
According to this just-published New England Journal article, analysts are still waiting for the twin forces of 1) an improving U.S. economy and 2) higher numbers of newly insured Americans to reignite healthcare inflation.  While the latest data from the Bureau of Economic Analysis (BEA) are conflicting, data from the early part of 2015 suggests that health costs are remaining tame.

What gives?
While many Obamacare supporters say this is more evidence of Washington's central-planning genius, author Charles Roehrig notes other factors be at play, namely:

1. The 9 million of 2015's newly insured amounts to 3% of the U.S. population. Their baseline spending was probably half of normal, so the resulting increase would expand the nation's spending by a modest additional 1.5%.  Since this group is younger, it'll likely be less than that.  Their contribution to increasing costs will be harder to detect.

2. What's more, insurance enrollments were finalized relatively late in the year, so these newly insured haven't had much of a chance to give their new benefits an early test-drive.

3. The first quarter of 2015 was an unusually cold winter. The Population Health Blog recalls how freezing temps, wind and snow made for a relaxed day at the clinic. Multiply that across millions of newly as well as long-term insured people, and it adds up.

4. Yes, stupid, it is the economy, which has a strong correlation with healthcare spending. Loss of health insurance thanks to unemployment, declining tax revenues that pressure government insurance programs to limit eligibility as well as benefits, employers' unwillingness to go along with otherwise automatic benefit increases and a general unwillingness of consumers to open their wallets in recessionary times has also added up.

5. Thanks to the expiration of some patents, prescription drug spending moderated.

Bottom line: all of the above are one-time impacts.  The economy's impact and new access to insurance are lasting fundamentals that will not go away. It's too soon to tell what is really going on.
The PHB will stay tuned.

Health Information Technology and the Patient Centered Medical Home: Seven Additional Caveats

The Disease Management Care Blog is scheduled to participate in a November 12 PCPCC webinar on the timely topic of population health management (PHM).  We'll be focusing on the October 2015 PCPCC report "Managing Populations, Maximizing Technology." Readers can download it here and refer to page 2 where the DMCB, among other luminaries, is acknowledged for its thoughtful review.

The PCPCC report effectively reminds health system architects and policymakers that the electronic health record (EHR) is necessary - but nowhere near sufficient - for a high performing patient-centered medical neighborhood.  Other information technology (IT) components include intelligent shared decision making, registries, health information exchanges, analytics, referral tracking, telemonitoring, automated outreach, patient communications, mobile apps, decision support and risk stratification.

And that's just for starters. 

The good news here is that while Washington DC's EHR weenies remain focused on the dreary stages "meaningful use," innovative health systems with medical homes and neighborhoods are really using IT to make a thousand PHM flowers bloom.   

Naturally, during the PCPCC webinar, the DMCB isn't going to stop there. If given a chance, it will also point out:

1. Build vs. buy: While health systems generally believe that PHM - with or without its IT  trappings - can be built using local resources, a better answer may be to buy it from a vendor.  Why own it when you can rent it?

2. And speaking of outsourcing: While its physician-colleagues prize the stature that comes from "quarterbacking" a medical home team, what is less appreciated is the distinct possibility that a quarterback is often not the most important position.  Get out of the way and let the IT-empowered and enabled non-physicians do their thing.

3. The EHR gone wrong: "Portals" are preferred by EHR vendors because they push patients toward their products, often run by lawyers who fear HIPAA and typically programmed by IT geeks who only think about code. It's time to put patients first.

4. "This is not my patient!": While predictive modeling generates lists of patients that annoy physicians with multiple inaccuracies, the science is getting better.  That being said, many other tests like EKGs and chest x-rays are notorious for false negative and false positive results.  It's all part of being a doctor.

5. Apply a filter.... please!: The biggest threat from health IT is a data glut of numbers, labs, tests, surveys, messages, alerts, prompts, readings, alarms, vitals and figures that overwhelm medical home team members. That's going to involve setting thresholds and priorities.

6. It's not about the revenue: Forget about using health IT to justify additional payment. In a health system without anymore money, the purpose of health IT is to generate savings.  That means it has to pay for itself.

7. Watch out! The under-appreciated health IT event that is going to change the relationship between insurers and providers: the move from using paid insurance claims to submitted EHR claims to assess population outcomes.

Image from Wikipedia

Saturday, November 7, 2015

DMCB Election Insights with Help From the Queen of Rock and Roll

The Disease Management Care Blog spent a better part of the day on the Pennsylvania Turnpike scanning the radio dial for insights on yesterday's national elections.  As the DMCB understands it, we've gone from a Democratic Prez, a U.S. House Republican majority and a U.S. Senate Democratic majority to a Democratic Prez, a U.S. House Republican majority and a U.S. Senate Democratic majority.

Among the lessons:

(Re)Electing a President has parallels to the experience of losing your virginity: after a lot of anticipation and excitement, what's left is a dawning realization: "Is that all there is to it?"

If God truly loved national Republican politicians, She would strike any who publicly utter the word "rape" with a thunderbolt.

Job One for the Republican Party: figuring out which Mitt lost.

The race for the 2016 Presidential election is underway and first up for the Dems: heir-apparent Joe Biden!

It's times like this that the DMCB turns to song for inspiration, and who better than the Queen of Rock and Roll? Congratulations to all the politicians on your election, says Ms. Turner, but like many a constituent, she's had enough of false promises and lies. "You Better Be Good To Me."

The Latest Health Wonk Review is Up!

Wright on Health is hosting the latest Health Wonk Review with an interesting line up of bloggers on either side of the President's assurances about keeping your health plan.  Given the spectrum of insights and opinion, the Disease Management Care Blog declares this latest Review .....a keeper!


Friday, November 6, 2015

Texting to Promote Weight Loss and in Population Health Management

Anyone who regularly attends a house of worship is certainly aware of how preachers make a point of regularly visiting parishioners while they're in a hospital. Since the Disease Management Care Blog's recent hospitalization involved an inconvenient distance (hour and a half drive) and time (6:30 AM), the DMCB pastor adapted by texting a prayer message. The DMCB took some comfort in what its colleagues euphemistically refer to as "faith healing."

Which is one reason why the DMCB paid attention to this interesting peer-reviewed abstract. 170 obese persons were randomly assigned to either monthly emails or daily "personally relevant and interactive" text messages. There was no difference in weight loss at 6 and 12 months of follow-up, but persons who were "adherent" to the text messages had statistically significant greater weight loss and greater activity levels.  Satisfaction levels were also high in the text message group.

And then there's this other study that randomly assigned obese college students to text messaging plus Facebook, Facebook alone and a "waiting list" control group.  In the limited follow-up of 8 weeks, the text messaging group lost a significantly greater amount of weight (2.4 kg.) vs. the other two groups.

Is texting an option for weight loss in particular and for population health management (PHM) in general?  These two studies would indicate the answer for both is "perhaps."  A better answer may be that texting plus other PHM interventions is better and that texting for persons who prefer it is best. 

The DMCB's Fat Lady might also approve of texting. If it's good enough for the prayerful among us, who can argue against it?

Image from Wikipedia

A Medical Education Bubble Portends Lower Health Care Cost Inflation?

The Disease Management Care Blog spent part of its day in front of its internet enabled World Headquarters' computer screens. As a result, it was able to tune into todays dreary Sebelius Senate Finance Committee testimony.

It wish it hadn't. Between the spin, gotcha's and speechifying, it's obvious that the political rancor is here to stay. And in the end, it makes little difference who is "wrong" or "right" about Presidential reinterpretations of the history about "keeping your plan" or some regulation about "grandfathering." What is more disconcerting is how the partisan divide is gumming up the gears of a well-intentioned if flawed piece of legislation that is now hitting one fifth of the U.S. economy.

Which makes this New England Journal article on the possibility of a "medical education bubble" so timely. According to David Asch et al, "bubbles" occur when a product (in this case the training to be a practicing physician) far outstrips the underlying economic demand (i.e., physician services). Based on this chart that trends medical educational debt to income, student debt has gone up, while future income potential is stalling. In other words, there is a growing disconnect between what physicians can charge patients and what medical schools are charging their students.

The DMCB was not surprised at the rising cost of medical school and financial sacrifices necessary to do a residency, but it was less aware of how slowing health care costs are playing out in our nation's medical schools.

The good news is that this bubble is another indication of slowing health care inflation.

Most agree that the individual insurance market was broken, Medicare's expenses remain ultimately unsustainable and Obamacare will continue a long-established trend of making consumers assume a greater share of health care costs thanks to significant out-of-pocket expenses. The bubble phenomenon suggests we may be getting a handle on that.

Bad for medical schools, but good for the country - especially since the tenor of today's hearing suggest Congress is unlikely to come up with any new solutions in the near term.

Thursday, November 5, 2015

Hospitals Push Back Against "RAC" Audits. They Should.

One of the Disease Management Care Blog's local hospitals has jumped into a lawsuit against Medicare. 

According to this article, the dreaded 2003 Medicare Modernization Act's RAC audits have gummed up Part B as well as Part A payments.  That's important because Part B includes physician services, which outside of hospital-physician alliances like Accountable Care Organizations, is typically completely separate. Hitting A as well as B not only represents a potential double hit to hospitals' bottom lines.

Could that give hospitals a reason to think again about hiring physicians?

Even if the DMCB is wrong about the scope of the lawsuit, the article's paragraph on this hospital's costs in dealing with the RAC audits are eye opening: 6 staff members and additional hundreds of thousands of dollars to cover medical record requests, consultants and appeals.  If other hospitals are being forced to follow suit, the cost to the health care system is considerable.

And those are Medicare administrative costs. These are borne not by the feds, but by hospitals, which must comply with thousands of pages of complex rules and regulations.  While it's mathematically true that Medicare has "low administrative costs," that's because the Agency's principal means of enforcement are cudgels like RAC audits with clawbacks with interest, penalties and other sanctions. 

While there is no shortage of hospital bad behavior, DMCB suspects most hospitals are honest and, despite that, have had no choice: add additional administrative expenses that are ultimately passed through to the patient and the nation's fisc.

Does Diet and Exercise Prevent Diabetes or Help Persons with Diabetes Live Longer?

It's such a no-brainer, right?  If persons at risk for diabetes would only eat right and exercise more, they'd avoid the disease.  And for those who develop diabetes, diet and exercise will reduce death rates and complications.

Yes and no, say Elizabeth Sumamo Schellenberg and colleagues at the University of Alberta.  Their review of the mixed published scientific evidence on the topic appears in the October 15 issue of the Annals of Internal Medicine.  The purpose of their study was to ascertain the impact of diet and exercise on the prevention of "Type 2 diabetes," as well as lowering complications among persons with who had established Type 2 diabetes. 

To be included, studies had to be prospective and compare the outcomes from an intervention versus a randomly selected control group. The study could only be included if it examined the impact of exercise plus diet and "one other component," such as "counseling, smoking cessation and behavior modification."  The outcomes had to include the development of Type 2 diabetes (in the prevention trials) or complications (in the treatment trials).

1289 candidate studies were found but only 20 made the grade. Nine were prevention trials and 11 were treatment trials.

For the prevention trials:

The interventions lasted from 6 to 72 months, with follow-up going for 3 to 20 years for between 39 to 3234 participants.  The counseling varied and included group and/or individual with or without tobacco cessation, telephony, goal setting, cooking classes or pills involving a range of physician and non-physician professionals.


Seven of the nine studies showed that diabetes can be delayed. When the results were pooled, compared to the control patients, the risk of developing diabetes over 10 years was only a third and the difference was statistically significant.

But, there was no detectable impact on cardiovascular disease events or on eye, kidney or nerve damage. That may have been due to not all the studies including these outcomes as well as the time it takes for these complications to occur once diabetes develops.  With more patients or more time, a difference could have become apparent.
For the treatment trials:

The interventions lasted from 6 to 48 months with follow-up for 6 to 93 months. The counseling was as varied as the prevention trials but included glucose and blood pressure monitoring as well as stress management and, in one instance, a three day residential retreat. There was likewise the range of professionals who provided the interventions.


Compared to the control patients, there was no statistically significant difference in all-cause mortality.  Some individual studies had beneficial outcomes involving cardiovascular events or diabetes complications, but they included the aggressive use of medications.  There were no sustained impacts on weight or dietary intake.  And if pills were not included, there was also no real improvement in measures of blood glucose control.

The Disease Management Care Blog's take?

The good news is that there is good evidence that exercise and diet can prevent diabetes.  The bad news is that it takes years for that "return on investment" to declare itself and typically involves interventions that fall outside the traditional health care delivery system.  It's unlikely, thinks the DMCB, that current iterations of payment reform (value based purchasing, bundled payments or upside risk) can be marshaled to make this a reality.  That being said, population health management (PHM) companies like Omada Health are making their evidence-based services available to, for example, employers who have a longer term commitment to the well being of their "human capital" outside of the traditional insurance market.

The bad news is that once diabetes declares itself, diet and exercise don't result in life extension, and control of complications as well as overall blood sugar levels is more a function of pills than lifestyle. Accordingly, expectations need to be realisitically shared with patients and PHM should emphasize taking the pills as prescribed.

Image from Wikipedia

Wednesday, November 4, 2015

The Magnificent Carnac Again Speaks to Health Care Reform!

Visitated once again by the astral, magnificent, all-knowing and soothsaying Carnac, the Disease Management Care Blog has divined his answers to the questions swirling around the roll-out debacle.

As Tonight Show Johnny Carson fans know, the prescient Carnac can foretell answers before the questions have even been asked by Congress and its allies in the punditosphere! By merely holding an hermetically sealed envelope containing the question, the mighty Carnac would provide astounded observers with the answer.

Behold the wisdom of Carnac's answers:


That is NOT the number of individuals securing insurance on the first day of the website! Rather, it is the answer to the question:

"How many million lines of computer code need to be changed to fix the web site?"

"Healthcare dot gov and the DMCB spouse"....

The question: "Name one thing that won't work and one person who won't twerk."

"Grits, Glitz and Glitch"....

The question: "Name an excuse for breakfast, zirconium and a government sponsored website."

"Burger King, Viagra dot com and the misstatements surrounding the Affordable Care Act"....

The question: "Name three homes for "The Whopper."

"Zero Dark Thirty"....

The question: "Name three descriptions of what happened to President Obama's approval ratings following the roll out of"

More information on the image can be found here.

Health Care Cost Insights and Capitation for the Patient Centered Medical Home (PCMH)

The Population Health Blog finally caught up with the Oct 22/29 "Price, Cost and Competition" issue of JAMA

One of the more interesting articles was a Viewpoint editorial on the Patient Centered Medical Home (PCMH). After tut-tuting fee-for-service payment as antithetical to meaningful payment reform, the author admits what the PHB has been saying all along: a global payment that covers all the medical, coordinating as well as non-physician services of the PCMH is tantamount to old fashioned "capitation." As we learned in the 1990s, capitation's unintended consequences are a) signing up too many patients, b) limiting access to primary care and c) over-referring to specialists.  To counter that, the editorial's author suggests the PCMH movement seeks "accountability." 

We'll see about that.

In the meantime, some other interesting articles:

Are "for-profit" hospitals evil?  Not necessarily.....

237 hospitals that converted from not-for-profit to for-profit anytime between 2003 and 2010 were compared to 631 hospitals that had not converted.  Converting hospitals improved their financial margins (practically all were in the red and subsequently became break-even) vs. the comparison group, and did so without increased utilization, restricting access to care, higher death rates or declines in quality for their Medicare patients. Their path to profitability may have been lined by renegotiated commercial insurance contracts, cutting costs or moving non-performing assets off the balance sheet.

Can physician groups become monopolistic? In a word, yes.

Commercial insurance preferred provider organization (PPO) charges for ten types of physician office visits in ten different specialties across 50 states were correlated with a measure of local market dominance dubbed the "Hirschman-Herfindahl Index" (more on that here).  As the HHI index increased, payments also increased, suggesting that as much as additional $3 to $12 in fees for the same services were the result of monopolistic contracting.

Monopolies aside, if docs are in charge vs. the hospitals, can they reduce health care costs?  Also yes.

This study compared average "per-patient expenditures" of physician-owned versus hospital-owned integrated medical groups and independent practice associations in California from 2009 to 2015. Among the 158 groups, 118 were owned by docs; their expenditures were over a thousand dollars less compared to hospital owned groups.  Larger physician groups had higher expenditures than the smaller ones.  More on that in a future post.

Does price transparency help patients chose to spend less?

Over 500,000 insurance plan enrollees had special on-line access to prices for medical services prior to using them.  There were over 250,000 households and of these, approximately 7500 accessed the information. Compared to households that didn't check the information, the price-shoppers seemed to choose cheaper labs (a few dollars per test) and imaging options (about a hundred dollars per test).  In looking at the data, the DMCB suspects some may have also deferred testing by choosing to use them less frequently or not at all.

Tuesday, November 3, 2015

State of the Art Obesity Management - Keep It Away from Primary Care

In the course of the Population Health Blog's last primary care encounter, a measurement of its height and weight determined that it was overweight.  On the way to the examination room, the nurse apologetically provided a patient education leaflet. The physician let the topic go unmentioned.

These health care professionals clearly were not "into" managing weight issues in their patient population.

After reading this paper, who can blame them?  A review of fifteen randomized clinical trials involving over 4500 patients showed that while primary care-based "behavior change for weight loss" results in statistically significant weight loss, the average amount was a clinically insignificant 3 lbs.

While web sites such as this provide useful pointers on engaging patients on the topic of weight loss, the U.S. Preventive Services Task Force (PSPSTF) recommends that persons with obesity be referred to a care setting that specializes in intensive multi-component behavioral interventions.

The primary care PHB agrees: these frontline clinics can screen for obesity using height and weight, but that's where their responsibility arguably ends.  Until there is research that shows otherwise, the primary care setting is no place for management of weight issues.

The PHB's care was state-of-the-art.

Monday, November 2, 2015

The Latest Cavalcade of Risk is Up!

The latest Cavalcade of Risk is up, hosted by Ray at the Excess Return blog.  This is a compendium of blog posts about enterprise, insurance and business-related risk.


Physician Assisted Suicide: The Need for a Registry with Ongoing "Big Data" Surveillance

The means for escape......
While the Disease Management Care Blog was pondering a Final Exit methodology to escape the glut of repugnant political ads, it came across this "Not So Fast" editorial in the Halloween New York Times.  Author Ben Matlin gives pause to the notion that death with dignity is an open and shut issue. "Thin and porous" is how Mr. Matlin describes the border between coercion and choice.

In the meantime, policy is dominated by articles like this that reassure readers that physician-assisted suicide will remain reasonably appropriate, palliative care will be available to those who choose to struggle on, "vulnerable" patients will not be disproportionately impacted and that the slippery slope that leads to euthanasia will be prevented by solid safeguards. Ethics and organized medical opposition aside, the argument is that all that remains is the need for a "federal" mechanism with safeguards, transparency and non-physicians.

The DMCB has idea none where this will lead.  It suggests, however, given the significant estate tax considerations that surround the timing of a death, that this is an issue that calls for a registry with ongoing "Big Data" style surveillance.  If nationwide trends show a significant association between assisted suicide events and the various and shifting local, state or federal tax deadlines, we'll know that we've made a terrible mistake.

Image from Wikepedia