The Link Between Personalized Medicine and Worksite Wellness

Critics look at employee wellness

Only the Disease Management Care Blog can link population health, a JAMA "Viewpoint" article on personalized medicine and a Wall Street Journal editorial on the alleged futility of worksite wellness.

The DMCB explains.

The JAMA article, written by Drs. Goldberger and Buxton, illuminates the cognitive dissonance over guideline-based vs. personalized medicine. 

The former represents the best care advice for a condition based on a published body of evidence.  Makes sense, but that evidence is typically based on multiple research studies involving populations that are both broad (able to generate statistically significant data) and representative (similar to other patients with the same disease). 

The latter describes tailored medical treatment that is suited to the individual characteristics (and personal preferences) of each patient.  This suggests that within the flow of "populations" that form the basis of a generalized guideline, there are circumstances for some persons that might make a particular treatment of greater or lesser benefit.

While Goldberger and Buxton use a complicated example involving implantable cardioverter defibrillator therapy to illustrate the conundrum, the DMCB has a simpler example.  Current guidelines support yearly mammography in every woman over the age of 50 years. Does that apply for the terminally ill woman in hospice or for a woman who, despite the advice from her physician, decides to forgo the test?

Intellectually reconciling competing policies of guidelines, such as "best practice," "reducing variation," "benchmarks" and "pay-for performance" on one side vs. personalized "informed consent," "patient empowerment" and "clinical judgment" involves subpopulations.  In other words, within any population-based study that shows an intervention is of benefit (mammograms save lives) there are subpopulations where the intervention is of little to no benefit (exceptions to every rule).

Which brings the DMCB to this provocative Wall Street Journal editorial condemning the entire worksite wellness industry. It recycles a number of tiresome criticisms, including outcomes tainted by regression to the mean, over-reliance on process-based outcomes, selection bias, employee discrimination, savings vs. program costs and overdiagnosis.  

Another criticism of the industry is the need for workforce-level (total) savings vs. per-participant savings. Since wellness programs typically focus on subpopulations of employees at greatest risk who are most likely to benefit and willing to participate, the observed savings can be limited to a few patients.  Unless those savings are culled from the large pool of total health insurance claims, they are otherwise invisible and critics will unfairly pounce.

Worksite wellness offers personalized care for limited numbers of patients.  That is its essential value proposition and its curse.  Until we can reconcile the total care via standardized guidelines vs. a more nuanced approach using personal care, it will continue to be criticized.

Patient Perceptions of Risk, Media Innumeracy and The Enduring Futility of the Annual Check Up

Today the DMCB caught up on some reading of the medical literature. 

The first article is an example of how researchers' risk thresholds don't match patient perceptions.

The second article is an example of media innumeracy. 

The third article is likely to be ignored by everyone.

1. Should Cardiac Telemetry Not Be Used for Patients with Only a Three Percent Chance of a Problem?

Suppose, asks the Disease Management Care Blog, your elder family member mysteriously passed out and was seriously injured?  You would wonder if a cardiac problem could be the cause. While the likelihood of that is typically low, even the small chance of something being "wrong with the heart" is enough to make patients and their families worry.

But suppose the chance of a heart problem was only.... 10%?  Or 5%? Or 1%?    

Once a decision is made to admit a patient with loss of consciousness to a hospital, doctors typically arrange for "cardiac telemetry." That broadcasts the electrocardiogram on an ongoing basis to a monitoring unit.  Unfortunately, however, the demand for a hospital telemetry "slots" is high and the monitoring requires additional personnel.

As a result, clinical guidelines like these have been developed.  They define high risk patients who warrant telemetry and low risk patients who don't.  For example, patients who have had a recent heart attack are vulnerable to unstable heart rhythms, while patients with stable atrial fibrillation can probably be safely managed off telemetry. Patients who have passed out and are stable on telemetry after 3 days are considered low risk.

Enter Evan Benjamin and colleagues who applied the guidelines to a retrospective audit of how telemetry was used for 501 consecutive patients at four Massachusetts medical centers.  Since patients could transition from high to low risk as the days passed, the unit of measure was "patient-days" (if two patients were each on telemetry for 4 days, that yielded eight "patient-days"). 

38% of the total 1559 patient-days were low risk. Among the high risk patients, a heart problem was detected in 21 out of 100 patient-days.  In the low risk patients, a problem was detected in 3 out of 100 patient days. 

The authors argue that these data show that better enforcement of guidelines that restrict access to telemetry would result in more cost-effective care.  The DMCB isn't so sure, because it intuitively thinks most patients and doctors would consider a 3% (3 out of 100 patient-days) a low enough threshold to warrant monitoring.

Good luck, says the DMCB, enforcing that. 

2. Just How Bad is the Link Between Red Meat and Diabetes?

"Yikes!" said the DMCB after listening to this NPR broadcast and reading this WSJ article.  It appears that increasing red meat consumption increased the risk of diabetes among previously healthy people "by 50%!"  While its first impulse was to throw away those frozen strip steaks, the DMCB took a deep breath and did something the reporters neglected to do: read the article.  It turns out that the approximate risks went from approximately 0.2% to 0.3%.  More than 99% of the carnivores did fine.  Once again, the reporters failed to discern that while the relative risk was high, while the absolute risk was vanishingly low.

3. A Reminder that the Annual Check Up is a Waste of Time and Money

After reviewing 16 studies involving over 180,000 participants, the authors in this JAMA study concluded:

.... general health checks were not associated with lower rates of mortality or morbidity.  However, general health check may increase the number of diagnoses and the use of medications.

The irony is that The White House and CMS profess to being evidence-based while remaining simultaneously committed to "wellness checks."

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The Failure of "The Coming Failure of Accountable Care"

An alternative to ACOs?

Anyone remotely interested in Accountable Care Organizations (ACOs), should be aware of this Wall Street Journal article by economist-savant Clayton Christensen on The Coming Failure of  'Accountable Care.' 

Dr. Christensen argues that just because they're in ACOs, a) physicians aren't going to change their money-spending ways, b) without any corresponding "skin in the game," patients will continue to demand high-end services  and c) the rosiest savings assumptions will still be minuscule compared to the total federal health budget.

If true transformation is needed, argues Dr. Christensen, health policymakers should embrace alternative care venues ("Minute Clinics"), downjobbing (let generalists provide specialty care services), non-physician providers (nurse practitioners) and telehealth.

The Disease Management Care Blog thinks Dr. Christensen has it mostly right about ACOs but has less confidence in his alternative solutions.

Minute Clinics: in classic health insurance 101, alternative care settings are not substitutive, they're additive.  Classic economic supply and demand does not apply because most health care services create their own demand.

Downjobbing: in any health care system, the economics are push and pull: costs are avoided, while revenue is pursued.  While the luster of a rich procedure code is enough to drive patients toward specialists, another factor in patient referral patterns is the associated cost.  To put it bluntly, the ultimate value of primary care physicians is the savings that they achieve for patients who represent a cost.

Non-physicians: there are arguments on both sides, but health care ultimately remains a labor-intense environment.  The main argument unaddressed by Dr. Christensen is that playing concertos, flying fighter jets and getting diagnoses and treatment right more than 99% of the time requires 10,000 hours' worth of expertise.

Telehealth: the same Minute Clinic logic applies: typical telehealth could end up being additive, not substitutive.

A Definition of "Big Data" for Health Care Providers and Five Useful Caveats

And you thought its only
function was to be an EHR?

Regular readers of the Wall Street Journal probably saw the Monday March 11 "big data" section that was filled with articles like this.

Written from a "business intelligence" perspective, there were precious few insights for the population and care management community. We're aware of the concept, but how, asks the Disease Management Care Blog, does it apply to our corner of the health care delivery system?

Unable to resist, the DMCB donned its snorkle and flippers and took a deep dive at the topic.

First off, when the DMCB performed a classic medical literature search using the key words "big data," it found that that the term has not entered the health care lexicon in a big way. Academics instead prefer to write about "registries," "data warehousing" and "predictive modeling." The DMCB also looked for a standard health care definition of "big data" and could find none in the published medical literature.

So, the DMCB offers up its own definition, culled from papers like this and this:

Health care "big data" is a branch of health care informatics that pools large and disparate data sets and applies a suite of mathematical approaches that derives associations, facilitates comparisons and generates insights that are otherwise not possible using standard mono-source analytics. It includes, but is not limited to, reporting, dashboards, ad-hoc queries, graphical displays, scorecards, predictive modeling, data mining and business intelligence. The data sets can be comprised of EHR data, insurance claims, pharmacy utilization, care management systems, consumer as well as government information, public health, surveys, point-of-contact information and web-usage.

The DMCB's simplistic off-the-cuff examples of big data queries include examining 1) the association between "hits" from a cluster of ISPs on an emergency room's web page and ER utilization, 2) complaints about a hospital's food service from family and the likelihood of being named in a malpractice suit, 3) looking for rare side effects among persons with a cluster of medical diagnoses who are using a just-released drug and 4) whether the number of household flat screens is a useful predictor of obesity.

Five DMCB caveats:

1. One data integrity trumps five Ph.Ds: The chief challenge is not the mathematics but combining and aligning the various databases.  Once the information is teed up, it's amazing how much can be done by a masters-level statistician and a desktop PC.

2. Associations, not causality. Whether a web page leads to ER visits or whether bad food fuels dissatisfaction is a different question.  It's possible that ER visits prompt web usage or that already dissatisfied patients find overcooked string beans icky. All the possibilities are still useful insights.

3. Not a panacea: It's "a" tool, not "the" tool.  Users will still need to also invest in faster, better and cheaper mundane data tasks (like admissions per thousand) while they simultaneously understand how big data's associations, comparisons and insights generate additional patient value.

4. Journey, not destination: There's a potent mix of art, science and wizardry in the evolving science of "big data."  There are no standard methodologies or best practices.  Get used to it.

5. Skepticism abounds: Data stakeholders who are used to standard analytics will refer, as the DMCB found out, to "big data" as "voodoo," and resist buy-in.  If a critical mass of an organization's leadership comes to believe it's useful, the rest will follow... eventually.

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The Concentration of Naiveté

The Population Health Blog's car garage is not the size of a football field. 

So, when the PHB spouse parks our car inside, she tends to err on the side of safety.  She pulls far forward so that the rear bumper doesn't get "dinged" by automatic closure of the garage door.  That obliges the Population Health Blog to inconveniently squeeze past and climb over the front bumper when it wants to use the PHBmobile.

The win-win fix to our travails arrived last Christmas when the perspicacious PHB gave the spouse a positionally adjustable ceiling-mounted laser. It blinks a ruby red light through the windshield onto the dashboard when the car is in optimum position.  Pull too far forward, and the beam will be directed on the floor or a front seat. 

Since it's been installed, the PHB spouse has ignored it.  The laser beam is effectively pointing at the back seat.

The good news is that the PHB's naiveté was limited to parking habits, one house's garage and a spend of $19. 

Not so for Ezekiel Emanuel's work in health reform in the White House and a spend of far more money. 

According to this article in this weekend's Wall Street Journal, the well-meaning Dr. Emmanuel couldn't change the habits of Medicare's vast bureaucracy or of Mr. Obama's formidable political advisors.  As a result, bundled payments remained the stuff of demonstration projects, while the closure of tax exclusions for employer sponsored health insurance was limited to "Cadillac" plans.

What's more, professional liability reform died in the crib thanks to the White House chief of staff Rahm Emanuel's unwillingness to stir the political pot:

He immediately cut me off: "Shut the f— up! We are not doing malpractice. Period. Every time the AMA comes in here, they don't talk about malpractice." Their first, second and third priority, he said, was the formula used by Medicare to determine doctors' pay. "We don't need to do malpractice for the doctors, and I am not alienating the president's base for nothing," he barked. "Stop it."

Rahm's reaction told me everything that I needed to know about the politics of the issue. Democrats would accept malpractice reform under two circumstances: if they needed it to keep the AMA's support for the bill, or if they needed it to attract Republican support. Neither was true. In backroom negotiations, the AMA was solely focused on securing higher physician payments—not on malpractice. And not a single Republican in Congress would even negotiate.

The president had already aggravated liberals by forgoing a "public option." He'd offended unions by limiting the tax exclusion. He wasn't going to antagonize trial lawyers, another core Democratic constituency, for no gain.(from the WSJ, March 7 "Inside the Making of Obamacare.")

In its own small way, the PHB called attention to the AMA's narrow-minded focus on the SGR five years ago.  But the AMA's blunder and PHB's prescience are not the point.  Or, rather, points:

1. The health reform that eventually passed was a curious mix of White House naiveté and Washington inside-the-beltway politics. The result was the Affordable Care Act which continues to spawn quick-fix delays and throw sand in the gears of government.  We deserved better.

2. By concentrating risky decision making in Washington DC, the upside gains in big government may be undercut by the downside of unintended consequences and half-baked decision-making in all 50 states.  It's scary to think that the likes of Dr. Emanuel had such power.

Lessons learned.

How Small Business Is Helped By Obamacare... and Large Businesses Will Be Less Able to Compete Against Them

Small business points at its competitor

It wasn't until the Disease Management Care Blog had read this Jan. 30 Wall Street Journal opinion piece that it realized that its "nano" corporate" status was packed with such futuristic potential. According to the editorialist, American companies should follow the DMCB's lead and be "protean" by dropping old fashioned W-2 employees and substituting 1099 contract relationships.  That way, everyone - including a single person "nano" - can enjoy the upsides of being a corporation and stay below Obamacare's 50 employee pay-or-play $2000 penalty threshold.

Since the DMCB formed it's own corporation more than 5 years ago, it has certainly participated in "protean" business relationships. Once things get underway, the DMCB often discovers that of the many prominent organizations that it does business with really consist of a small core office populated by a few owner-founders, a single administrative aide and one or two payroll folks who oversee the outsourcing of everything else.  While the term "protean" is certainly novel, the DMCB thinks distributed, adaptable and organic business networks have been around for years.

But the WSJ editorial opens a window into an underappreciated consequence of Obamacare and the underlying assumptions of the central planners who run Washington DC.  The DMCB doesn't necessarily think it's bad, but it sure is interesting.

Read on.

While the Affordable Care Act (ACA) was intended to link employment and health insurance, what it has really done is handed many small nimble interlocked businesses another leg-up against their large traditional mainframe competitors. For example, one colleague pointed out to the DMCB that "new" pharma companies are really marketing departments that outsource manufacturing that, in turn, outsources supply management that outsources I.T. that outsources its cloud services. It's the only way they can compete. 

The new economics of health insurance will only accelerate similar trends in other manufacturing and service sectors of the economy.  Toss in the ability of people and capital to move and work across borders and the picture becomes even more dynamic. And in the meantime, Washington DC continues to implement the ACA with a legacy of large companies buying comprehensive health insurance for its employees.

Little did anyone anticipate that the ACA would hamper the success of American big business.

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