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!

What Happened To "Disease Management?"

Early Disease Management

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

And that's just for starters.

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

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

What a difference 20 years makes.

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

Big Data and the Coming New Value Proposition for Disease, Care and Wellness Management Providers

Disease Management Care Blog readers know that the its latest interest is "Big Data." While the researcher-DMCB has played in the sandbox of some insurance claims data sets, the idea of combining and combing through multiple terrabytes of clinical and public data remains a topic of endless fascination. It knows it's not alone.

So, it was only a matter of time until one of the major clinical journals published an article on the topic. JAMA has stepped forward, and not a moment too soon.

It's "must reading" for the disease and care management provider community.

Drs. Murdoch and Detsky point out that Big Data offers four value propositions:

1. Observational correlations may generate insights that cannot be found using standard research approaches. Scanning text for key words in electronic record systems involving hundreds of thousands of patients may find associations or trigger early warnings faster, quicker and cheaper than any formal scientific protocol or clinical trial.

2. Those insights, especially since they can be tailored to fit the circumstances of an otherwise unique patient, can be used to guide diagnosis or treatment. Physician judgement cannot be replaced, but if Big Data points out that there were other patients with a similar pattern of illness who responded best to one treatment versus another, patient outcomes could improve.

3. A Big Data approach to genomics can correlate genetic information with outcomes and further guide therapy. While the DMCB still wonders if "genomics," outside some narrow anecdotes, will always remain the science of the future, Big Data may turn out to be the key to finally unlocking its potential.

4. Since Big Data, by its very nature, can combine clinical information to other personal data (the foods you've bought or your driving history), Big Data will necessarily tilt toward the patient-consumer and away from the health care system. Not only does permission for access lie with the patient, but the insights will be less about sickness and more about wellness.

The authors do a good job of pointing out that there are plenty of challenges. Most doctors don't get it, privacy laws could be over-interpreted or enforced, it remains to be seen who will pay for it and Big Data is still in its infancy.  The DMCB also points out that while Medicare has just discovered that alternative research innovations are possible, Big Data promises to eclipse those approaches (like traditional time series analysis, propensity matching), again making CMS a day late and another dollar over budget.

The implications for the care management and population health community are considerable. The industry has amassed years of intellectual capital in the science of predictive modeling and Big Data is it's next step. Many care management vendors have multiple clinical partners and already have access to terrabytes of data involving millions of persons. Not only is the math and the informatics well within reach, they also "get" the tilt toward wellness and consumer empowerment. Last but not least, if anyone can monetize a value proposition like this and turn insights into revenue (or "shared savings"), these nimble vendors can.

A DMCB prediction: while academics will write about Big Data in scientific journals, the care management industry will be doing it.  In fact, they probably already are.

Two particularly good quotes to use to impress your CEO and stymie your competitors:

"Data has gone from refuse to riches."

and

Economic theory describes the quantitative conversion of 3 kinds of inputs (capital, labor, and raw materials) into outputs (goods and services)...The current revolution in data management makes it clear that a fourth kind of input, information, will become just as important as these other inputs in the future of many industries.

Telephonic Nurse-Led Disease Management Saves Money .... Again

They did it again!

Before too long, the Disease Management Care Blog will start getting bored with the accumulating evidence (for example, here, here and here) that telephonic disease management (DM) reduces medical claims expense in excess of program costs.  There's only one thing that's more tiring, and that is the lingering ideological assumption among many academics that the Medicare program's inability to save money with DM means there's a problem with DM and not with Medicare.

Enter this study on diabetes telephonic care management that was just published in the American Journal of Managed Care.  This was about as real world as you can get.

The Denver Health's Westside Family Health Center, a federally funded community health center, randomly assigned 381 patients with diabetes to a 20-month telephone outreach program and another 381 to usual physician care.  In the intervention arm, patients not only saw their physicians, but had the involvement of 3 nurses sharing a ".75 full time equivalent" position.  The nurses used motivational interviewing and clinical protocols to guide these patients in self-care.  The nurses also independently ordered labs, initiated and titrated medications (with the use of pre-signed prescriptions as necessary), arranged vaccinations and facilitated physician appointments.  The nurses focused on control of lipids, blood glucose control and treatment of high blood pressure.

 Since many of these patients had no insurance, linear regression models were used to evaluate costs "from the perspective of the health care system" with "cost to charge ratios."  Patients with no primary care visit in the year preceding the end of the study were excluded from the analysis and the use of health care services outside of the Center was not counted. 

Aside from a slight gender imbalance (64% vs. 57% female in the intervention and control groups, respectively) as well as different rates of cerebrovascular disease (14% vs. 9%) and use of insulin (24% vs. 38%), the two patient populations were mostly similar in multiple baseline labs and co-morbid conditions.  In terms of the baseline costs, the control group had higher baseline hospitalization rates and total costs.

At the end of the study, 58% vs. 47% had achieved a target cholesterol LDL, but there was no difference in blood glucose or blood pressure control. 65 patients were lost to follow-up. The remainder were contacted an average of three times over the course of the study.

There was a significant drop in costs in the intervention group.  Over 18 months, their costs decreased from a baseline of $6390 per patient to $6217, while the control group went up from $7694 to $9033.
When the cost of the program was rolled in, the intervention resulted in $60,902 in total savings, which included the costs of $134,750 for the nurse-based intervention.  The savings appeared to be due to fewer hospitalizations.

While this study didn't use remotely positioned telephonic disease management and instead used nurses that were on-site, the DMCB points out that many telephonic programs use the same playbook. If the nurses have a good working relationship with the clinic physicians, they can do great things by telephone.  Last but not least, while the nurses pursued lipids, blood sugar and blood pressure, the DMCB suspects the real secret sauce was the countless and immeasurable other pieces of advice and help that were provided to the intervention patients.

A Money Back Guarantee in Health Care? You Bet!

Who cares about the color, so
long as it catches mice?

Talk about disruptive.

While an unholy alliance of CMS mandarins, fawning think-tank supporters and earnest academics continue to promote their top-down "mainframe" health care ideology, along comes AMCHealth and their money back guarantee.

While the Disease Management Care Blog can only speculate on the how the contracting details would work, AMC's fundamental value proposition is pretty compelling: it promises it will reduce a client's hospital readmissions by "at least 10% within 90 days of deployment" or your money back. AMC is confident it can use interactive voice response (IVR) technology and nurse case managers to identify and then help at-risk patients who might otherwise have to be rehospitalized when things are not going well.

In the meantime, the prevailing Washington DC health reform ideology is that hospitals, doctors, nursing homes and community organizations large and small should pool and sort existing resources under the twin banners of integration and coordination. Mix the solar power of CMS' innovations, the fiscal wisdom of the White House's insurance experts, the academisphere's eternally funded prospective research studies and politically targeted community grants and, if the Feds have their way, the nation's health care non-system will morph into large regional and regulated utilities. Twenty percent of the national GDP will be under the firm control of CMS.

Maybe the DMCB is being overly suspicious. That being said, many of the academics, regulators and government long-timers who are presiding over the medical-industrial complex have made no secret of their disdain of outsider-run care management to the DMCB in meetings and conversations. Using Deng Xiaoping's famous observation, they want their cats to be only one color.

The entrepreneurial AMCs of the health care world are a threat to that vision.  Not only are they a viable business option for impressive organizations like this, they've backed up their claims in the peer-reviewed literature.

If these for-profits succeed, the mainframe healthcare ideology could go the way of dinosaurs, FEMA and Amtrak. By offering solutions that are faster, cheaper and guaranteed, the ultimate success for health care institutions won't lay securing local monopolies but the decentralized and organic business approaches with a mix of build or buy being used in other sectors of the economy.

Image from Wikipedia

Harnessing Market Forces to Achieve Quality and Promote Innovation

Maybe they'll put up a
plaque honoring Mr. Obama?

The health care newsie Disease Management Care Blog thought it had seen it all.  Now this.......

In a striking policy about-face, the Obama Administration has adopted a market-based approach to setting prices and controlling utilization. Everyone agrees that letting prices rise in response to demand disproportionately harms lower income Americans. We also know it's another drag on an already fragile economy. Last but not least, it's vexing the President's political base. 

Nonetheless, the Administration is being resolute. Putting political expediency aside, the White House has courageously put their faith in an unabashed conservative philosophy by arguing that long-term benefits of higher prices will ultimately pay dividends in wise consumerism, innovation and quality.

Wow.

As a result, the White will House forgo any "demand" or "supply" side interventions.  There will be no price regulation based on prevailing costs and projected outcomes. They'll spurn the suggestions of myriad legal, economic and regulatory expert panels.  They'll resist activist calls to expand the role of the Federal government. 

Politics?  Sure, but the machinery in West Wing knows how to manage that. They know a normally friendly news media will report some inflammatory anecdotes about how low income Americans are being forced chose among life's other basic necessities. They'll just ride out the news cycle and counter with populist attacks about "profits" and "fat cats" and "corporate jets."  While the messy politics sort themselves out, Mr. Obama has faith: supply, demand and the marketplace will take us where we need to be.

Is this about health care you ask?  Hardly.  Education?  Nope.  Housing? Negative. The Disease Management Care Blog points out that this is the Administration posture on an arguably equally important part of our collective national well-being: transportation and energy prices.  Mileage standards and Detroit bail-outs aside, The DMCB thinks this is quite a reversal.

A harbinger of things to come?  We can only hope. 

Image from Wikipedia

Disease Management Has Moderated U.S. Health Care Cost Inflation

Thanks to years of unapologetically quoting, citing, linking and blogging in over 1300 posts that disease management saves money, the Disease Management Care Blog has earned approbation, fear, respect and disdain nationwide.

But its audacity is mere child's play compared to this Wall Street Journal Opinion by J.D. Kleinke.

His claim? That "disease management" was one factor in the slowing of national health care costs.

Mr. Kleinke, as you can see here, is no lightweight. He not only has experience as a real-world health care entrepreneur and executive, he's the author of the groundbreaking book, The Bleeding Edge.  When he published it ten years ago, Mr. Kleinke predicted the rise of "Emerging Healthcare Organizations" (EHOs) that would harness the forces of risk-assumption, consumerism, consolidation, integration, and industrialization and transform the health care system. If you believe ACOs will succeed, you may want to thank JD for thinking of them first - even if he got two of the initials wrong.

But is he wrong about disease management?

Mr. Kleinke uses a copyrighted bar graph in the article but the image below (lifted by the DMCB from the White House's web site) shows the same data. After an uptick in 2000, the nation's annual percentage change in total health care spending has progressively declined and is the lowest it's been since the 1980s.

Mr. Kleinke asserts that when HMOs were defanged after their '90's decade of bad behavior, insurers not only rolled out deductibles, co-payments, health savings accounts, tiered drug plans and urgent care center coverage, but they were subjected to public performance measures and started "the still emerging science of disease management." The result was an historical decrease in cost inflation.

He makes the point that it's impossible to know the relative contribution of each of the initiatives described above. Assuming that they collectively had some impact, Mr. Kleinke calls for a doubling down and change the regulations and tax code that still is preventing insurers from building on their success and finding other ways to innovate.

The DMCB agrees that he makes a good point. But it also brings up several caveats:

Just because two things happen at the same time doesn't mean one causes the other.  That being said, Mr. Kleinke's hypothesis is intriguing.

Depending on how you compare Medicare fee-for-service (FFS) (where there is no disease management) and commercial insurance costs (where there is), the rate of increase Medicare may be even lower.  It's comparing apples and oranges, but it's still an important point that deserves further analysis.  There's more discussion on why the comparison is not so simple here.

The remarkable drop in health care costs over the last two years may be result of a bad economy and not the advances described by Mr. Kleinke.  We'll find out more when the economy picks up steam.

Last but not least, a smaller rate increase on top of an ever expanding fraction of the economy is still an big increase.  We're now committing a whopping 17% of gross domestic product to health care.