The Remarkable Consensus Over the Next Steps for Health Reform, Including the Role of Population Health Management

Let's fix it!

While noisy media leprechauns dispense blame and declare winners in the government shutdown imbroglio, the Disease Management Care Blog remains focused on the next steps for meaningful health reform. So are JAMA authors Jack Lewin, Lawrence Atkins and Larry McNeely who, other than one lapse in their editorial, get it mostly right.

Their important insight is that the Bipartisan Policy Center, Brookings Institution, Commonwealth Fund, Kaiser Family Foundation, the National Coalition on Health Care, Partnership for Sustainable Health Care and Urban Institute all have a remarkable degree of overlap in their recommendations for the next phases of health reform. 

Most of these expert organizations agree on the merits of value-based payment as well as insurance reform (pay for quality), information technology, competition, tort reform, evidence-based benefit design (paying when there's evidence that it works), workforce changes (greater efficiency), reforming Medicare, changing tax policy (the exemption for health insurance) and instituting regional or local caps (stick to a budget or there's consequences).

The DMCB wholeheartedly agrees and hopes that the bipartisan consensus evident among these think-tank institutions leads Congress (if not this one, the next) and the President (if not this one....) to use these ingredients to build on the successes and correct the many deficiencies of the Affordable Care Act.

And the lapse? 

Jack Lewin et al were missing one thing. The DMCB looked in each of these organizations' web sites and found that there was also considerable support for population health management.

To wit:

The Bipartisan Policy Center - while the emphasis of this report is on health information technology, the real dividends are pretty clear when it mentions "population health" 14 times:

This plan should address the development and adoption of policies and standards needed for the delivery of care, the empowerment of individuals, and improvements in population health based on national health and health care priorities.

The Commonwealth Fund:

 Effective population health management requires fundamental change in care delivery that must be supported by changes in payment.

National Coalition

Real reform means engaging consumers in their own health and health care choices. In both Medicare and too many private plans today, benefit design neither supports self-management of chronic disease nor distinguishes between care that is effective and care that is not.

Partnership for Sustainable Health Care - see page 22:

Federal nurse education funding should be refocused to equip registered nurses to assume the roles of case manager and population health coordinator.

The Urban Institute - see page 17 on the topic of Medicaid reform:

States can start in select geographic areas or specific population groups (adults and children or specific chronic conditions), and then incrementally expand them after learning from experience and making program improvements and adjustments. Broader efforts typically mean additional stakeholders, increased collaboration and communication.

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

YOU are in last place!

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

Ugh.

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

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

Here's the complete report. 

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

Quality:

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

Preventive Care:

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

Effective Care:

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

Safety:

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

Care Coordination:

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

Patient Centeredness:

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

Engagement and patient preferences:

"The United States did well on most indicators."

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

Again, some quotes:

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

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

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

Plus this tidbit.....

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

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

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

2.  The United States suffers from high overall costs. 

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

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

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

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

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

The Persistence of Disease Management: It's Not Going Away......

We're all aware of the past criticisms of "disease management." According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of "outcomes" were based on flawed research that was never intended to be science; it was really intended to market their wares.  

But suppose the Disease Management Care Blog alerted you to:

1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.

If you think that sounds like typical vendor-driven telephonic disease management, you'd be right.  You'd also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses.  When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.

Or how about.......

2. A major insurer that decided to use its claims data to identify its own "best practices" without waiting for any published evidence-based studies?  Since "strict experimental conditions cannot always be met," shortcuts like time-series analyses" and "propensity score approaches" will be used to "blur" the lines between feedback and evaluation, as well as the lines between provider and insurer?

If you think that sounds like an commercial insurer muscling into health care delivery while using quasi-experimental research shortcuts, you'd be right.  You'd also be describing how Medicare's Innovation Center is borrowing from the disease management industry's approach.  It's all here.

Lastly, there's......

3. A major insurer that decided to NOT to pay primary care sites enough fee-for-service or capitation, preventing them from hiring nurses who could provide coordinated care.  The insurer instead hired its own nurses and "embedded" them in the primary care sites while linking additional monthly payments of approximately $5 to pay-for-performance metrics.

If you think that sounds like a step away from the usual Patient Centered Medical Home, you'd be wrong.  In this instance, having the embedded nurses did not get in the way of the sites achieving PPC-PCMH recognition. What's more, compared to usual care in a prospective randomized study that was underwritten by the medical-home fans at the Commonwealth Fund, the embedded nurse approach resulted in better hypertension care, breast cancer screening and fewer emergency room visits.

Alas, disease management: to paraphrase The Bard, a rose still smells as sweet by any other name, especially if it's used by Group Health, CMS and the Commonwealth Fund.