Monday, December 28, 2015

A Watershed Year: What 2015 Holds for the Patient Centered Medical Home (PCMH)

The savvy Jeff Levin-Scherz, who blogs over at Managing Healthcare Costs has responded to the Disease Management Care Blog's snarky "Prattling Pinheads of Pessimism" post on the topic of the Patient Centered Medical Home (PCMH). 

He's not a nattering nabob of negativity or a prattling pessimistic pinhead, says he.  He'd like to be thought of as a skeptic seeking substantiation.   The DMCB wholeheartedly approves of the agreeable alliterative appellation.

2015 may well turn out to be the watershed decision year for the PCMH:

If there's no published peer-reviewed proof that it reduces health care costs, nabobs, pinheads, skeptics and policymakers will need to decide if no evidence of an impact on costs is the same as evidence of no impact on costs.

If the answer is no, THEN we'll then have to decide if the traditional "X causes Y" mathematical approaches to derive proof (such as a comparison of averages using standard power calculations and/or impact on expected or observeed trend) are equal to the task in a very "statistically noisy" environment involving complicated human beings.

If that answer is no, THEN we'll have to decide if reasonable and informed assessments of potential cost reductions, used by countless other businesses every day in other sectors of the economy, are good enough,

If that answer is no, THEN we'll have to decide if there is face value to the PCMH. This involves a contrast of any patient benefit versus its incremental cost.  If the benefit is worth the cost.....

THEN we may have to decide if consumers are willing to pay for it, or if health care costs will need to be cut elsewhere to pay for it.

Stay tuned!


Sunday, December 27, 2015

Additional Ingredients for ACO Success: Communication Training, Support Tools and Culture

Pity the hospital CEOs, EVPs and Chairs and their "Accountable Care Organizations" (ACOs). They've lined up the doctors, invested in an electronic record, hired some care management nurses and signed the risk contracts.

And then Matthew Press and colleagues come along with this AJMC article on Care Coordination in Accountable Care Organizations: Moving Beyond Structure and Incentives.

Their message? You may have what's necessary, but it's not sufficient. Organization and incentives are not enough.

What's also needed are:

1. Training: physicians need education on coordination, collaboration communication and teamwork.  The education should be an organizational priority and typically involve course work, observation and feedback with continuous evaluation.  This cannot be accomplished in a one day workshop.  An example of what it might take can be found here.

2. Support tools: since efficient information transfer must to be built into ACOs' workflows, informal "situation" or "personality" dependent communication between docs and nurses need to be transformed.  An example of the kind of framework that Kaiser instituted can be found here.  While you're at it, think about HIPAA-compliant texting, wiki-enabled EHR records and patient activity streams.

3. Culture: if front line staff are going to support the delivery of high quality and optimum cost care, the organization will need to protect time for care coordination activities, multi-disciplinary meetings, forums to share best practices and incentives that recognize collaborative behaviors.

Looks like the work has only just begun.

Tuesday, December 22, 2015

Sunday, December 20, 2015

The Latest Health Wonk Review Is Up!

How can you reconcile all this seasonal merriment with your need to achieve one or two more days of productive learning?

Easy, says the Disease Management Care Blog.  Head on over to the Workers' Comp Insider's "Holiday Edition" of the Health Wonk Review.  Health insurers aren't following the ACA script, pharma's bad behavior shows no sign of abating, expert mandarins continue to plot transformizations, Medicaid continues to vex and stymie and Santa's workshop is in serious need of insurance.

And that's only a sample.  Much more can be found here.

Enjoy!

Saturday, December 19, 2015

Going Long on the Patient Centered Medical Home (PCMH) Despite the Prattling Pinheads of Pessimism


Is the Disease Management Care Blog worried about the prognosis of the Patient Centered Medical Home (PCMH)?

Not in the least.

It's simply marching from its "Peak of Inflated Expectations" through the "Trough of Disillusionment." Before you decide to short the PCMH, check out this very enlightening Bloomberg editorial, Lure More Doctors Into Primary Care With 'Medical Homes.'

Noting that many commercial insurers remain committed to the medical home model of careBloomberg's business-savvy editorial board also points out that the PCMH has the added quality of attracting physicians to careers in primary care. The Josia Macy Jr. Foundation has some preliminary data suggesting that experience in medical home settings increases medical students' enthusiasm for primary care.

It's a timely article.  While prattling pinheads of pessimism (examples here and here) glom onto imperfect research methodologies and findings that are unequal to the task at hand, top notch organizations like Sutter, University of Pittsburgh Medical Center and Horizon Blue Cross Blue Shield are going long on the PCMH.

These guys know something that the academics are missing.

Too bad there isn't a PCMH futures market; the DMCB could make some serious money.

Image from Wikipedia

The Latest Health Wonk Review Is Up!

His body mass index may still be too high, but let's face it: he can bring anything to anyone who knows how to ask nicely for it.  Case in point is the latest Health Wonk Review hosted by Julie Ferguson over at the Workers Comp Insider Blog.  If you're asking for health insights, pull up a chair, and get some holiday cookies and a beverage and enjoy.

Friday, December 18, 2015

The Relationship Between Discharging Patients From the Hospital Too Early and the Likelihood of a 30 Day Readmission: Treat, Street and Repeat.

I'm baaaaack!
When persons are admitted to a hospital, insurers' payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blog's physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  That's why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But that's all theoretical.  What's the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine

The authors used the U.S. Veterans Administration (VA) Hospital's "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  That's the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  That's the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears there's an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."

New Guidelines for Hypertension Care

If you or your company are in the business of population health management and your service portfolio includes high blood pressure, you need to download this report.  The JNC 8 Guidelines have been released on-line in JAMA.

They are the best summary that expert science has to offer on the state-of-the-art treatment for hypertension.  There are new thresholds for treatment, new targets that define success and new recommendations on which anti-hypertensives to try first. 

Stakeholders interested in promoting non-medication treatment options may come away disappointed.  After reading through this once, the Disease Management Care Blog found very little in the guidelines on "lifestyle"  The authors instead decided to briefly endorse a separate set of lifestyle guidelines that can be found here.  Good for them.

Unfortunately the JNC 8 guidelines are remarkably light on the well-recognized need to help patients overcome their reluctance to take their medications.  Patients are notorious for not taking their pills as prescribed, the causes for that are well known and better medication adherence translates into lower health care costs that, in studies like this, are statistically and financially significant. This is a whole other art and science that is the "secret sauce" for population health management, where team-based care managers with sophisticated coaching techniques can make a huge difference in key adherence outcomes.

Aside from a few nods to the topic, the JNC 8 authors just didn't have the time or take the effort.  Maybe the JAMA editors didn't have enough space in the journal to include a few paragraphs on the importance of promoting medication adherence.

Pity.

That's OK, though, because the millions of persons already involved in care management programs nationwide are already being cared for by professionals who are already aware of that need. 

Coda: A next step for JNC 8: getting docs to pay attention to them.  More on that here.

Image from Wikipedia

Thursday, December 17, 2015

The Medical Home News Question: The DMCB Answers "Other."


The Disease Management Care Blog is happy to serve on the National Advisory Board of Medical Home News.  MHN has important insights and updates on the implementation of Patient Centered Medical Home (PCMH).  It also regularly poises a "Thought Leader's Corner"question and prints answers from the PCMH community.

The December '12 issue question was:

What is the single most important issue to overcome in terms of widespread implementation of the medical home model?
A growing shortage of PCPs?
Lack of payer commitment to reimburse care coordination?
Lack of incentives to adopt/implement EHRs?
Lack of sufficient team culture being taught?
Other?


The Disease Management Care Blog naturally answered "other...."

"While I used to think the most important issue was finding generalizable approach to care (template) and an accompanying business model that has consistently been shown to reduce health care costs in a clinically and statistically significant manner, I’m changing my mind. 

The most important issue is the emerging link between accountable care organizations and the medical home to the exclusion of all other approaches to care.  The medical home has had its victories, but much of the published high quality research is from highly integrated settings and even then, it’s unclear if the avoided claims expense is greater than all the indirect and direct costs. We still don’t know if the medical home can succeed in the other kinds of networks being established by ACOs. 

As a result, if ACOs stumble and prove to be an unsuccessful reprise of the 1990s style physician-hospital initiatives, the medical home could be taken down before we know if it can work in non-academic, non-Medicaid community settings. 

This promising baby could be thrown out with the bathwater."

If, despite the DMCB's participation, you're interested in subscribing to MHN, getting your boss to pay for it or giving a year's worth of issues as a fitting holiday present, more information can be found here.

The Looming Credibility Trap of Obamacare?

While the young Disease Management Care Blog was first introduced to the concept of the "credibility gap" by Lyndon Johnson's Vietnam war, it wasn't until it started paying attention to blogs that it ran across the term "credibility trap." The former describes a disbelieving citizenry, while the latter describes a disbelieving government.

Enter this telling PolitcoMagazine article on the travails of being a Washington DC Cabinet Secretary.

In the modern course of our Republic, there are 23 talented overachievers who nominally preside over a huge federal bureaucracy. The DMCB thinks of that as the core machinery that lies at the heart of the liberal promise that Big 21st Century Government Can Accomplish Great Things.

If the Politico article is correct, successive White House Administrations have marginalized the Secretaries, letting the majority of Washington DC run like some side-show perpetual motion machine. As the DMCB understands it, that leaves the White House to insource the management of the really important stuff, like getting reelected or reversing rising ocean levels.

And so it was when it came to the implementation of the Affordable Care Act. Looking past the partisan cacophony, it appears the White House genuinely counted on HHS to smoothly implement the health care marketplace and its various mandates. What happened was a fumble of historic proportions that will continue in the weeks and months to come.

While conservative pundits are using the Obamacare imbroglio as another tiresome I-told-you-so lesson in government overreach, the DMCB is worried that the bright men and women who are responsible for implementing health reform are getting a crash course in the cynicism of the credibility trap.

Statutory deadlines are now meaningless. Regulations can be ignored. Being "on message" trumps the truth. Czars go into private equity so that lobbyists can become insiders. Political expediency is allowed to batter markets. Blowback begets stopgap crisis management by an insular political elite.

And as 2015 is threatened by death spirals, corrupted commercial enrollment data, unpleasant out-of-pocket surprises for consumers, small as well as large business market rate shocks, unpredictable legal challenges and further mischief by an emboldened Republican opposition, it becomes less a function of whose "fault" it is and more of a dreary exercise in keeping the Amtrak of health care from running off the rails.

The folks running the government bureaucracy are stuck with this lemon. Many are probably thinking that they deserve better.

Is the DMCB reading too much into the symptoms of C.T?

You be the judge.

The Horrific Newtown Shooting and the Inconvenient Facts About Gun Control, Mental Illness and How the Physician Community Should Respond


Like millions of other Americans, the Disease Management Care Blog was transfixed by Mr. Obama's comments at last night's Newtown vigil.  The President passionately spoke for and to the nation in a time of heartbreaking grief.  Well done, sir.

Then reality set in. 

Unfortunately, there are a number of inconvenient truths that are more than a match for President's considerable intelligence and persuasive rhetoric. 

To wit:

1) First some perspective: Schools are extraordinarily safe with a suicide/homicide rate of one death per 2.5 million (see page 6). All in all, a child is still far more likely to be injured on the way to school or in their home pool than on our nation's school grounds.

2) Been there, done that: according to this classic MMWR report, the evidence that restricting access firearms improves community-based outcomes is inconsistent.

3) Soft target: And then there is the disturbing possibility that armed killers, with little to fear from metal detectors or sign-in policies, purposely choose gun-free zones like schools. 

In the meantime, the DMB's physician colleagues are renewing calls for firearm ownership screening and education at the point of care.  To their credit there is good evidence that it helps....

But:

1) While there are two sides to every story, law abiding and constitutionally protected gun-owning parents may feel they are being unfairly bullied by a well-meaning physician.

2) When pediatricians are confronted by adults who are unwilling to consent to their child's immunization recommendations, the "difference in philosophy" may lead to a termination of the doctor-patient relationship. The same happened to this patient because of her weight. Are gun owners next?  And after them?

3) What happens if firearm-screening bubbles up into a 6th vital sign (the 5th one didn't work out so well) or physician pay-for-performance (with gaming could alienate the very patients it's designed to help?).

4) No corner of health care delivery is immune from the mischief of electronic health records (EHRs) and gun control is no exception.  Should gun owners be concerned that a) millions of unintended data breaches or b) government "background checks" of health information exchanges could increase their vulnerability?

And then there is the thorny issue of mental illness.

1. The majority of patients are still concerned about the release of any of their medical information.  Behavioral medicine providers are too.

2. We can not only use computer based algorithms to assess the quality of life for persons with mental illness, but predict a likelihood of community violence. Should either be made available to law enforcement?

3. Last but not least, us docs can issue and reissue impotent position statements all we like. but the mental health system is failing: we are all Adam Lanza's mother.

DMCB take-aways:

The DMCB has seen the President confidently direct his considerable rhetorical skills at topics like global warming and war in the Middle East.  While Mr. Obama is well-meaning, guns may similarly be beyond his political skills, especially because he's a 2nd termer with limited political capital. 

While Newtown has shocked the conscience of a nation, the DMCB is not holding its breath.

That doesn't mean America's docs can't be of assistance.  In addition to dusting off, recycling and renewing their current policies, physicians need to keep things in perspective and

a) lead the discussion on the use of predictive modeling to identify potentially violent patients. How do we reconcile the privacy rights of persons with mental illness with a constitutionally broad right to bear firearms?  If we remain silent on this, the lawyers will decide and it won't be pretty.

b) confront the possibility that the EHR is a threat to gunowners.  If not, explain why it wouldn't be cross-referenced with firearm licensing, pharmacy records or used to perform background checks?

c) advocate for fixing the mental health system so that parents who are struggling with a deeply disturbed child can get the help they need.

Image from Wikipedia

Wednesday, December 16, 2015

"Simulation Learning Experiences"

This is an engine. Now you're ready to drive!
Just when the Disease Management Care Blog thinks it has mastered the jargon of population health management, along comes another term that reminds it of how quickly the science is evolving.  "Simulation learning experiences" is a new addition to PHM parlance, thanks to this just-published JAMA article by the University of Colorado's Eric Coleman.

While the phrase may be new, the underlying science isn't. As DMCB readers are aware, it's one thing to transfer information to patients, it's another thing to transfer skills. 

Dr. Coleman points out that a patient with diabetes, heart failure or asthma is not unlike a person just learning to drive.  While some classroom work on how an internal combustion engine works is a good idea early-on in the process, it's not until the student takes "the wheel" of their glucometer, diuretic meds or peakflow meter that you can really know that they won't end up in a hospital (a.k.a. having an "avoidable admission").

Accordingly, individuals with chronic illnesses (and their layperson caregivers) need practice, rehearsal and role playing.  They need to test the care plan and make sure it comports, to any degree possible, with the home environment and the skills of the involved individuals.  Better to find out early about any obstacles, such as poor vision, low health literacy, cognitive impairment or low self-confidence.

Naturally, the traditional health system is ill-equipped to provide simulation learning experiences. There has to be dedicated space and the personnel who offer it to patients have to role-play, which can be very time consuming. Since each patient is ultimately unique with very different home circumstances, there is no one-size-fits-all approach

That being said, the DMCB suspects that as ACOs, integrated systems, provider networks, medical neighborhoods, managed care organizations and payers continue to evolve toward high value health systems, their hospital discharge planners, rehab-center case managers and transitions care managers will find that the "return on investment" from avoided re-hospitalizations, fewer unplanned ER visits and decreased redundant specialist visits will be more than enough to justify the cost.

And then there's the added bonus of the jargon that may warrant its own acronym of "SLE." The DMCB coyly suggests readers spring the term on an unsuspecting or clueless co-worker, boss, policymaker or doc who is all about "patient education."

Tuesday, December 15, 2015

The Latest Cavalcade of Risk Is Up!

As part of its continuing efforts to stay up to date on business risks and insurance, the Disease Management Care Blog participates in the Cavalcade of Risk.  The latest edition is hosted over at the Reduce Your Workers Comp Blog.  Topics include social media, the evolution of the San Francisco health market into the haves and have nots and the business lessons from Israel's "Iron Dome."

Enjoy!

Saturday, December 12, 2015

Of "Antifragile" and Accountable Care Organizations (ACOs)

Emboldened by yesterday's economics post on the U.S. "headwinds" that are marginalizing the "fiscal cliff" negotiations, the Disease Management Care Blog now turns it's attention to a magnificent new word:

"Antifragile."

That's the term invented by Nassim Taleb in his latest book. In it, he counterintuitively suggests that political, business and economic systems can benefit from recurring and unexpected mishaps. The sucess of antifragile systems is based on their fragile constituents that rise and fall on their own merits. One "antifragile" example is the local restaurant industry in many large cities. It may be beset by recurring single unit bankruptcies but it ultimately provides the marketplace with a dependable set of gustatory options every Saturday night. 

The converse are "fragile" systems that are ironically made up of highly stable individual units. An example is the highly regulated U.S. banking industry, which amply demonstrated its collective vulnerabilities in the 2008 crash.

The terms "antifragile" and "fragile" speak to the threat of unknown and potentially catastrophic "Black Swan" risks, such as torrential superstorms and toxic mortgage assets.  Many New York restaurants rebounded (by candlelight), while the banking industry almost took down the entire U.S. economy.

The erudite Dr. Taleb often turns to mythology, molecular biology, physics, history and more to make his points, but the DMCB is naturally thinking cinema.

In The Godfather, after the Corleone family goes to the mattresses, Clemenza explains periodic war between the New York families is a good thing because it gets rid of a lot of "bad blood" (the Mafia is antifragile).

In the silly Underworld vampire movies, chief bloodsucker Viktor condemns the successful liaison between his race and the werewolf "Lycans" as an "abomination" that upsets centuries of rigidly enforced stability (vamps are fragile).

In one of the Star Trek movies, engineer Montgomery Scott deftly disables a new star ship after pointing out "that the more they overthink the plumbing, the easier it is to stop up the drain" (warp drive-enabled space ships are fragile). 

And finally, Pandora's ecosystem in the movie Avatar may be teeming with all manner of scary survival of the fittest, but its antfragility is what ultimately prevails against the despicably avaricious humans.

Which makes the DMCB naturally worry about fragility of accountable care organizations, which are arguably comprised of highly stable hospitals and clinics in an intensely regulated environment.    While you may be tempted to tut-tut the DMCB's antifragile infatuations, recall AHERF's spectacular failure and the Medicare Health Support Demonstration disaster.  When they started out, both were the darlings of health policy makers and both were torpedoed by large and unexpected catastrophes that were only identified in retrospect.

What Black Swans could take some ACOs down?

Many savvy DMCB readers may disagree about ACOs, but you have to admit, "antifragile" will be a great word guaranteed to impress colleagues, co-workers and bosses.  For example

"Broadening our provider network to those three new counties may be risky, but it'll make our managed care organization more antifragile!"

"Buying a single source electronic record will reduce our health system's antifragile competitive advantage!"

"By limiting my access to modern electronic gadgetry, the DMCB spouse is risking a system-wide entertainment failure of epic antifragile proportions!"

And so it goes......



 

Friday, December 11, 2015

Will A Negotiated Agreement on the Fiscal Cliff Fix Things?

While the dysfunction of the "fiscal cliff" negotiation crawls along like a slow-motion Titanic movie dubbed in some obscure foreign language, vaguely interested readers may want to check out this PIMCO analysis. PIMCO is a leading global bond trading firm and when its sages talk, people listen.

Bill Gross, PIMCO's CIO, offers a remarkably readable Beatle-esque analysis of the macroeconomic "headwinds" that are bedeviling the U.S. economy. While Mr. Gross' observations have important implications for the DMCB readers living on Main Street, they are particularly scary for the insurers on Wall Street (as well as their cousins on Not-For-Profit street).  That's because insurers rely on investments to supplement income. Sputtering bond returns in the insurers' portfolios could ultimately translate into even higher premium costs for their beneficiaries.

According to Mr. Gross:

1. Developed countries like the U.S are reducing their considerable debt and, like it or not, austerity will be part of the solution. In the meantime, there are compelling data that show that when a country's debt exceeds 90% of gross domestic product, it slows economic growth. The U.S. is now at 100%, which means the likelihood of using tax revenues to fix the debt will be blunted by years of a lackluster economy. Even if President Obama gets his way with the House Republicans, fixing the debt problem will take many years.

2. The fall of the Iron Curtain and the entry of China to the global economy added billions of consumers to the world market.  That impact is now waning.

3. "Technological unemployment" means machines, robotics and software are cheaper than full-time-equivalents (FTEs) on an assembly line. It's possible that that will lead to a "new normal" unemployment equilibrium of 7%

4. It's the 20 to 55 year age group that grows families, buys houses and grows companies. The U.S. population is aging, which means there will be greater savings and less consumption leading to lower economic growth.

The good news is that hydrocarbon energy will be getting cheaper, housing may finally be turning the corner and who knows when the "Next Big Thing" (think handhelds) will hit.

Depressing stuff, eh? The DMCB isn't the only one that's dismayed at all the doom and gloom.  Rather than turn to the Beatles for inspiration, the DMCB wonders if the current situation is being best summed up by the still-rockin' Rolling Stones. 




(By the way, the DMCB declines to link the actual music video. It's a horrid, misogynistic and antifeminist display of modern vulgarity that unnecessarily detracts from 1) a nifty chord progression and 2) the miracle that Keith Richards is still alive. Look no further for another window into the war on women.)

Guidelines for Guidelines

"Guidelines" (like these) drive health leaders, policymakers, politicians and caregivers crazy. They're supposed to describe "evidence-based" "best practices" for diagnosis, treatment and overall management for hundreds of medical problems. Yet, it's been known for years they often go ignored by many practicing physicians who are unaware of them, would rather rely on their individual independent judgment and experience, doubt their validity or would rather continue with what they've done for years.

What's the problem? Is it the guidelines or is it the docs?

Johns Hopkins' Peter Pronovost, writing in the Dec. 5 JAMA wonders if both can be helped with some common sense guidelines for guidelines:

1. Any guideline should prioritize its recommendations (based on patient benefit) and explicitly link them to "time and space" of a specific point in the course of an episode of care  The author points out that it's not uncommon for guidelines to be more than a hundred pages and simply list all the recommendations.

2. Guidelines should identify the barriers to their adoption and recommend strategies for their successful implementation.  Naturally, the developers of these guidelines would need to climb down from their ivory towers and actually think (and maybe perform research) on getting the guideline into the front lines of real-world health care.

3. Guidelines need to contemplate co-existing conditions and stop focusing on single diseases or risks.  In a hospital, it's not unusual for safety checklists to deal with single issues, resulting in dozens of lists.

4. Automate automate automate and use "systems" of care instead of relying on the memory and best intentions of human beings.  Robotics can do a lot of routine monitoring, patient work flows can incorporate safety and docs and nurses should be freed to be..... docs and nurses!

5. Develop "practice strategies" that integrate multi-disciplinary teaming and pools expertise in the related sciences of epidemiology, implementation and engineering.

The DMCB agrees with the ideas and wonders if these recommendations can't also be used by Accountable Care Organizations, health care systems and population-based service providers as they seek to disseminate best practices for the care. It's one thing to "post" or "link" a standard guideline in an intranet or an electronic health record "prompt," it's another to make it useful at the point of care.

Thursday, December 10, 2015

Some Medicare Stars Program Updates and the Overlap with Population-Based Care and Disease Management


The Disease Management Care Blog is back from grandly named "Healthcare Education Associates' and the Risk Adjustment Initiative And Society for Education's (RISE)" CMS Star Ratings Master Class conference. The day-long Miami meeting was all about succeeding in the CMS quality-based bonus program called "Stars."

The DMCB listened closely to one speaker.  First are its notes, which are followed by three take-aways.

The notes:

CMS had tried posting Medicare Advantage (MA) Plans' quality measures online, but they were generally ignored by consumers.  That's when CMS decided to change course and use its Demonstration authority to launch the current Stars program. It incents the MA as well as other contracting plans with bonus payments based on a complex weighted formula that includes satisfaction, quality of life and clinical outcomes.  The latter measures are dominated by chronic conditions.

While the measures' minimum payment thresholds are constantly changing, In 2015, 11 MA plans achieved the coveted "5 Star" our of 5 rating, while 127 achieved a respectable rating of 4 or better our of 5. Success appears to be associated with:

1. HMO-type physician network structure,
2. Not for profit status,
3. An enrollment of more than 90,000,
4. An established marketplace presence,
5. A track record of pursuing quality,
6. A track record of physician integration and
7. Advanced informatics including a data dashboard (tracking outcomes), physician level tracking and providing care gap information at the point of care

While the calculation and translation of a particular Stars rating to a particular bonus amount surpasseth the DMCB's understanding, the big picture is impressive.  In 2015, health plans with government contracts spent over $1 billion on their quality programs, while CMS is projected to award $3.1 billion in bonus payments.  This works out to a payment of $281 per beneficiary, or approximately $23 per member per month (PMPM).

The DMCB take-ways:

1. You call it "Stars" but the DMCB calls it population health management: CMS is basically paying its contracted health plans $23 PMPM to develop or outsource programs targeting chronic illness, quality of life and satisfaction, much of which is old fashioned PHM. The DMCB confidently assumes a lot of that $23 PMPM is paying salary and benefits for non-physicians (such as nurses), who are engaging members and doctors using risk stratification and outreach that includes the old fashioned telephone.

2. How generous: Compared to many population health management vendor fees, $23 PMPM seems high. What's more, an industry-wide return on investment of approximately 3:1 ($3.1 billion in payments vs. a cost of $1 billion) is lavish, especially because the DMCB suspects most MA plans were already willing to spend a billion to reduce their claims expense by even more.

3. We've changed our minds: An emerging Medicare "whisper" "fiscal cliff" savings target is $250 billion, which may be partially attained by cutting back on the Stars bonus payments.  While it could be argued that the MA plans have been amply rewarded by the program, the Fed's fickleness remains a considerable business risk, especially for the smaller not-for-profit MA plans 

How Does the Office of the National Coordinator for Health Information Technology (ONC) Think About EHR Portals?

EHR portals at work?
The Disease Management Care Blog had this thoughtful reply logged onto its "Follow-Up" post on the topic of EHR patient portals. Logged by Rebecca M Coelius MD, Medical Officer for Innovation at HHS/ONC, the DMCB recognized that this was important enough to warrant its own separate page.

While we wish that the results were more conclusive and positive, the Office of the National Coordinator for Health Information Technology (ONC) applauds the meta-analysis and the recent upswing in articles on patient portals and other patient-facing technologies. The number of patients and caregivers who desire greater participation and transparency in their healthcare makes continued research in this area vital. Yet, in a close read of the full Annals of Internal Medicine meta-analysis article and in many of the studies it cites, there were unquestionably statistically significant positive clinical outcomes, as well as positive patient experiences, associated with certain patient portal functions.

The ONC does not believe that Health IT alone is a panacea, or that meeting the form of Meaningful Use, while not embracing the new functions the technologies it enables, is likely to result in measurable improvements. The study authors caution that it was case management that tipped the utility of portals from unclear or small to more substantial, but it is important to note that the case management activities happened via the portal itself. This is a perfect example of Health IT as an enabler of new ways of reaching and caring for patients; we would not separate the two concepts.

To the study’s described limitations, we offer two significant additions. First, the definition of a patient portal remains loosely specified, so it is difficult to make conclusive statements about the entire category. The meta-analysis did attempt to list which functions were present for each study, but half of the studies that looked at patient outcomes gave only a partial description of portal features, and a deeper assessment of the quality of functions and their relevance to the outcomes measured was not present for any study.

A more illustrative future approach would be to evaluate individual functions of portals for impact on patient participation in their care and specific health outcomes, and then ask what design principles and organizational contexts were necessary to make that function successful. For example, the impressive OpenNotes project demonstrated that patients with access to provider notes had a better understanding of their health and condition, improved recall of their care plan, and increased likelihood of taking medications as prescribed. In a New England Journal of Medicine study on weight loss interventions, over twice the number of patients in the remote support intervention groups (telephone, website access, and e-mail support) lost more than 5% of their weight versus the control group. Secure messaging and the ability to view personal health information are two cornerstones of portal functionality within Meaningful Use.

Second, more than 10% of these studies are ten years old, and over a third were published five or more years ago. We understand the necessity of adequate numbers for meta-analyses, but statistical significance does not necessarily confer relevant insights. Technology, and patient preferences and capabilities for using technology have fundamentally changed over the study time periods included, not to mention the maturation among health-care organizations themselves and the expectations of patients.

The very premise of the patient portal is a rapidly ageing one. As the ONC articulated in a 2015 Health Affairs article, there are shifting attitudes related to the traditional roles of patients and providers, and exploding demand and penetration of smartphones, health and wellness apps, and connected devices. We are moving the conversation from engaging people with our existing healthcare system through “portals”, to using technology to move outside our system to reach them every day where health truly happens. What we need to measure and incentivize in the future is not the value of portals, but the value of delivering the right information and intervention to the right person, at the right time, through the right interface based on an individual user’s context.

Wednesday, December 9, 2015

Follow-Up on Electronic Health Record Portals: We're Asking the Wrong Question (and the DMCB is guilty)

Researchers pondering the EHR portal
Thanks to Twitter, the @DisMgtCareBlog had a highly rewarding tweetologue with tweetociates @Paulflevy (with an insightful bit of bloggery here), @granitehead and @subatomicdoc about a recent DMCB post on the topic of electronic health record (EHR) patient portals. As readers will recall, yet another notion of the Lilliputian Order of Unquestioning EHR Believers failed to pass scientific muster when The Annals published a negative review on patient portals. Tweeples took note with a series of tweets that simultaneously advanced the DMCB's social media chops and the antipathy of the how-does-this-make-money? DMCB spouse.

To tell the truth, however, the skeptical DMCB took unfair advantage of this latest EHR kerfuffle. It confesses that it couldn't resist this latest addition to the target-rich environment of HIT disappointments in quality, cost and governmental overreach.

So, upon further reflection, just because almost 15 years of high quality research failed to establish any lasting value doesn't mean portals should go the way of the Dodo, low-cost medical malpractice insurance or Mr. Obama's credibility.

In other words, the DMCB does think that portals have a role to play in the health care reform landscape, and it said so in front of a huge audience at the recent Star Ratings Conference in Fort Lauderdale.

Portals, thinks the DMCB, have little value as stand-alone interventions. Just dropping it into a clinic's patient population is unlikely to significantly increase communication and shift behaviors enough to produce enough of a "signal" that cost or quality outcomes are better compared to usual care.

But when EHR portals are part of a multi-channel outreach strategy that includes (but is not limited to) mailings, interactive voice response-based calls, secure messaging, emails, social media, "anniversary" time-for-your-appointment cards, live telephony as well as home visits that are all backed by predictive modeling (who is at greatest risk) that informs "impactability" (how they're at greatest risk) that's all tethered to care management that is also closely aligned with marketing and builds brand, then portals mostly likely do add value.

Unfortunately, traditional health services research cannot assesses the multiple simultaneous interventions described above.  As Dr. Donald Berwick presciently noted in this classic JAMA article:

Experimentalists have pursued too single-mindedly the question of whether a [social] program works at the expense of knowing why it works. Thus, although [traditional research] seeks generalizable knowledge...it relies on removing most of the local details about “how” something works and about the “what” of contexts. It therefore reveals little about mechanisms or about factors that affect generalizability. Studying a few covariates, or using stratified designs, or probing for interactions can mitigate this loss, but these are inadequate tools for studying complex, unstable, nonlinear social change.

As the DMCB has noted before, absence of any proof is not the same as proof of absence.  The studies that the DMCB ultimately quoted were based on traditional research, which is simply not up to the task of the non-linear intervention of patient-doc-team communications.

Don Berwick recommends a more insightful approach:

Health care researchers who believe that their main role is to ride the brakes on change—to weigh evidence with impoverished tools, ill-fit for use—are not being as helpful as they need to be. “Where is the randomized trial?” is, for many purposes, the right question, but for many others it is the wrong question, a myopic one. A better one is broader: “What is everyone learning?” Asking the question that way will help clinicians and researchers see further in navigating toward improvement.

When it comes to EHR portals, it's time we ask just what are we learning.

Sunday, December 6, 2015

The Latest Health Wonk Review Is Up!

A Festival of Lights and Insights awaits you at the latest Health Wonk Review.

This edition is hosted by the unsinkable Hank Stern over at the InsureBlog. You can learn about latke, the IOM, dreidls, cuts to graduate medical education, chanukiahs, premium taxes, sufganyot, deductibles, fried chickpeas and whether "Oy Vey!" is a good toast if you're drinking Aquavit.

Enjoy!

Saturday, December 5, 2015

Some Follow-Up

Remember the Atul Gawande and McAllen Texas fracas?  That New Yorker article captured the national spotlight and put a harsh glare on areas of the United States that had unexplained high rates of health care utilization.  Dr. Gawande blamed the local culture of fee-for-service private practice, while the Disease Management Care Blog wondered if it was a statistical fluke and/or the burdens of a chronically ill population

It turns out that there might be another factor at play.

The DMCB recently received this rather stunning (and lightly edited) email:

Here is a little story I thought I would share.  As you know, Atul Gawande wrote about McAllen TX over 3 years ago. You would think having the spotlight on them would make people scramble to clean up their act. On a recent flight, I sat next to a medical sales representative. His company has a number sales personnel covering the state of Texas, but none of them are assigned to the McAllen territory. That's because it is known that you have to “pay to play.”  In one example, a physician asked the company to send a check to his charity…so they did some research and found the address for the charity was located at a corn field.  Reportedly there are dozens of medical companies that service Texas but only 3 or 4 bother to sell in that market. Sounds like old habits die hard!  

The Latest Health Wonk Review Is Up!

The Healthcare Economist Blog has a summary of the latest and best wonky health policy insights in the latest Health Wonk Review.  Dubbed The Health Wonk Review takes on Healthcare.gov, host Jason Shafrin offers users a two-fer: 1) information you can't find any where else and 2) a web site that actually works as advertised.

Friday, December 4, 2015

12 Reasons Why Every Physician Should Have A Twitter Account


The Disease Management Care Blog really likes Twitter. Its scrolling 140-character tableau of news nuggets fit perfectly on the DMCB's hand held device, lap top and home personal computer.  It's easy to glance at between tasks and the advertising is blessedly minimal. The DMCB controls the content by following and unfollowing other Twitter accounts with a simple click or a touch.

But why, physician-skeptics may ask, is Twitter any better than traditional web browsing, email, list-servs and handheld apps?  Your DMCB thought about that and is pleased to offer its Top Twelve reasons why every doc should include Twitter in their informatics medical bag.

1. Lit Headlines: The major medical journals use Twitter to efficiently describe their latest content with links. For example.

2. Fame: Traditional print authors are publishing more and more about less and less. Getting peers to follow your original and insightful tweets is the new route to attaining status as an expert.  The DMCB has more than 500 daily followers vs. how many actually read the average peer-reviewed article?

3. News Junkies: Some of your like-minded peers are freely aggregating and retweeting relevant headlines with links for your perusing efficiency. They can be indefatigable.

4. Kool-Aid Immunity: Did you know your Chief, Chair, VP, lead administrator or Dean wants to control all your communication?  Twitter is an easy way to step out of the information bubble and monitor contrary news about that EHR, medical device, performance standards, your institution's business partners, the competition and more. For example.

5. Efficiency: Twitter trains you to be both brainy and brief. If you can't fit it into 140 characters or less, you're wasting your readers' time.

6. Messaging: The "@" allows you to interact with established and potential colleagues outside of your institution's email system. Thanks to this function, DMCB has met some wonderful colleagues.

7. Medical Conference Tweets: View formal and informal updates and insights about that conference you're attending from not only the meeting organizers but other attendees.

8. Community: Like-minded colleagues are not only clustering in listservs but in Twitter.

9. Room for Diversions: Efficiency makes it guilt-free to include non-medical content.

10. Speed: It's astonishing how quickly Twitter users spot and link just-released reports that take days to appear on the web and weeks to appear on print.

11. Searches: Yes, traditional literature searches and Google have their advantages, but the "#" function can find links to information resources that you might otherwise miss.

12. The Disease Management Care Blog is on Twitter.

The Office Manager: A Member of the Patient Centered Medical Home Team You Never Heard Of

Which one is the practice manager?
Ask the average primary health care policy wonk about the make-up of the Patient Centered Medical Home team and you're likely to get an elevator speech that includes some or all of the key words "pharmacists,"" social workers," "nurse care managers," "nurse practitioners," "physician assistants," "dieticians," "health educators," "respiratory therapists," "psychologists" or "navigators." 

If that's all you hear, tell that wonk they only know part of the story.

That's what the Disease Management Care Blog discovered when it was preparing for its talk at the upcoming CME Start Ratings Master Class Conference that will be held Dec 9-10 in Fort Lauderdale.

It turns out that every primary care office ultimately has one person charged with making sure that the office "workflows" are running smoothly.  When patients register, use the waiting room, have their vital signs and medications reviewed, are asked about pain, are prompted to share other concerns, are moved to the examining room and subsequently get checked out with a follow-up appointments or referrals, there is a maestro in the background charged with making sure the trains run on time.

Meet the office practice manager, the hidden part of the health care team who you never heard of.

In case you think they don't matter, think again.  They have their own trade association and are making their opinions known when it comes to health reform. If a health insurer or practice association needs the primary care clinic to implement a "medical home," you can be sure that it will be up to the practice manager to make it happen.  You ignore that person at your care-coordination peril.

The message for insurers, delivery systems and population health service providers is that physician buy-in is very necessary, but may not be sufficient.  After the doc says OK, medical home advocates would be well advised to find the practice manager and work closely with that individual.

Electronic Health Record Portals: So What Is the Evidence That Supports Their Use?

Talk about a compelling story that went ignored.

In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch. 

In particular, any impact on diabetes care was short-lived or nonexistent, patients with heart failure had no meaningful improvement, blood pressure control did not improve and adherence to prevention recommendations were marginal.  One observational study found persons with heart failure were more likely to use the emergency room.  The only study that found any benefit involved a single randomized control trial that examined the impact of portals in the co-management of depression.

After looking at this review, depressed advocates of EHR portals may have to personally use their own portals to communicate with their docs health care medical neighborhood.

The only good news is that there were some data that suggested that a substantial number of consumers liked using the portals.  But the DMCB likes channel surfing too, but that doesn't mean that the spouse agrees that its television-watching quality has improved or that the cost of all those premium channels is moderating.

The authors pointed out that it was difficult to isolate the impact of a portal vs. a portal plus care management.  To the DMCB, that means that portals are at best a means-to-an-end of enabling care managers to better communicate with their enrollees. 

To the thousands of DMCB readers, that is not a surprise.

In the meantime, the Feds and the NCQA have one more reason to re-examine their many cherished assumptions about health information technology and the stand-alone electronic record. The last time the DMCB looked, the federal government continues to extoll portal's stand-alone virtues. The National Committee on Quality Assurance (NCQA) still includes two way communication for appointments, referrals and prescription referrals as a standard for the medical home.  Finally, the Fed's promotion of the electronic health record (EHR) approves of portals as an option in meeting meaningful use criteria.

Image from Wikipedia

Thursday, December 3, 2015

Being Bullish on the Patient Centered Medical Home, Despite What the Annals of Internal Medicine Has To Say


The Disease Management Care Blog recently received a curious email from the Patient Centered Primary Care Collaborative.  As readers may recall, this is the Washington DC-based coalition that advocates on behalf of the Patient Centered Medical Home(PCMH). 

The content of that rather defensive communication can be found here.

What provoked this? The premier internal medicine specialty journal, the Annals of Internal Medicine, published a comprehensive review of the peer-reviewed literature on the PCMH, and its authors skeptically concluded:

The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes

Ouch. No "economic outcomes" means that there is no proof that the PCMH saves money.

Unlike the PCPCC membership, regular DMCB readers aren't surprised.  For example, the DMCB pointed out months ago that the U.S. government's Agency for Healthcare Research and Quality ("AHRQ") had concluded the same thing.  Countless other DMCB posts on the medical home have pointed out that there were problems with the published PCMH literature (for example, here and here).

Thanks to a past Congressional Budget Office report, the DMCB feels the PCPCC pain. It also knows that a) finding statistically significant cost savings in health insurance data bases are notoriously difficult, b) successful medical home initiatives that are outside the academisphere are the least likely to be reported it in the peer-reviewed literature, c) "savings" isn't the only measure of patient value and d) journals like the Annals of Internal Medicine are being sidelined by innovators who are more astute judges of what works for their patients.

What's changed for the medical home and the PCPCC after this unpleasant dust-up?  Ultimately nothing. Pairing nurses and physicians in team-based care, whether it's done remote telephonic "disease management" style or in the clinic "medical home" style is ultimately a good idea with obvious face validity. The Annals' problem is that we don't have pristine scientific methodologies that can identify, capture and measure the benefit.

The good news is that the science is getting better. Until it catches up, the population health and disease management service providers will remain in business and the medical home will continue to have a bright future.

Exercise Doesn't Have To Be Hard Work

With some creativity, it can be made downright fun.

C'est vrai, n'est pas?


Wednesday, December 2, 2015

The Oval Office Tone At the Top and the Temptation for Consumers to Lie About Income on the Health Insurance Exchanges

According to this CNN article, it's na├»ve for the Disease Management Care Blog to expect U.S. Presidents to never lie. From time to time, political realities force occupants of the Oval Office to use falsehoods to advance a greater good and/or protect the integrity of their office.  What's more, when they're found out, voters tend to be remarkably forgiving. So, When Mr. Obama repeatedly reassured Americans that "you can keep your health insurance," the DMCB should conclude that this was business-as-usual statecraft and that it will all work out.

But even if many Americans sign up for health insurance and the President rebuilds his approval ratings, the contrarian DMCB has a deeper concern.

It thinks a dishonest "tone at the top" can have a corrosive effect on how Americans will access their premium subsidies. 

In the business world, it is well known that the misbehavior of corporate boards and C-suite leaders can infect an entire company. The Board Chair's or the CEO's dubious financials, revenue schemes, stock manipulation, predatory behavior or just plain arrogance can roll right through the managerial ranks and destroy a company in a matter of months. When leaders lie to serve some other business need, you can be sure that others in the company will also lie.

The same may be true for the government of the United States. It's one thing to lie about Japan's military might (Roosevelt), trading arms for hostages (Reagan) or Iraq's weapons of mass destruction (Bush), it's quite another to lie about buying health insurance. The DMCB suspects that "tone of the Oval Office" is subtly signaling to regulators, insurers and ultimately consumers that it's OK to manipulate the truth when it comes to buying health insurance.

Recall that as part of health reform, the health insurance exchanges prompt applicants to estimate future income. It's also temptingly easy to misrepresent projected 2015 income.  A mild "fudge" that lowballs income can make the difference of thousands of dollars in subsidies.

Long before the President landed in hot water over his "you can keep it" promise, Americans had a huge incentive to lie about their income. That has been especially true for low income earners who really need the insurance. Now that everyone - including Mr. Obama - has admitted that he stretched the truth, the DMCB suspects Americans now have one more reason to do the same when it comes to getting health insurance subsidies. Once that pattern of insurance fraud becomes established in the marketplace, the DMCB thinks it will never go away and hundreds of millions of dollars will go to where it's not intended year after year after year.

The DMCB predicts tens of thousands of Americans who purchase insurance on the exchanges will succumb to lying in 2015.

You read it here first. 

Coda: The good news is that when it comes to the health insurers who are responsible for signing up the millions of Americans, there's no evidence that they're helping enrollees lie.  The DMCB suspects that in the battle to capture market share, it's just a matter of time until one of them has a renegade employee or two who channel the President and likewise help prospective customers to lie. We'll see.