Another ICD-10 Delay

Buried in the U.S. Congress's just-passed sustainable growth rate extension patch is a little known provision that would further delay the HIPAA-mandated implementation of ICD-10. As reviewed years ago by the PHB ("Rough Seas Ahead"), ICD-10's benefit of precise medical billing accuracy was threatened by the considerable provider costs of having to retool their information systems without much impact on patient care or revenue. 

This was going to be an uphill climb under the best of circumstances.

While CMS had previously delayed the implementation of ICD-10 from 2015 to October of 2015, continued hospital and physician alarm apparently convinced a majority of U.S. Senators to delay the implementation by another year to 2015.  While many in the health care industry are undoubtedly breathing a sigh of relief, that's small comfort to others who have been diligently working hard and investing a lot of money to be in compliance with the law.

Is this democracy in action, or further evidence of Washington DC's fickle inability to be a responsible and consistent steward of the health care system?  While readers ponder that, the Population Health Blog was naturally struck by some similarities between the tragic loss of Malaysian flight 370 and the star-crossed travails of ICD-10 roll out:

Response to heartbroken families and overworked programmers?

Malaysia 370:   Sorry!               
ICD-10 Delay:  Sorry!
                        
Remains only big news only to:

Malaysia 370:  CNN viewers                
ICD-10 Delay:  Commercial insurers
                                            
One underlying problem:                   

Malaysia 370:   Transponding               
ICD-10 Delay:  Squandering         

Involving tends of thousands of:

Malaysia 370:   Square miles               
ICD-10 Delay:  Diagnosis codes

How should the public respond?

Malaysia 370:    Fly less?              
ICD-10 Delay:   Couldn't care less
                               
Who really seems to be in charge?

Malaysia 370:   Astrologers               
ICD-10 Delay: Senators
                 
Outcome?

Malaysia 370:   Flotsam         
ICD-10 Delay:  Bedlam

The Patient Centered Medical Home's Return On Investment (not?)

Read this lead American Journal of Managed Care article on Geisinger's approach to the patient centered medical home (PCMH), and you may agree that the major findings are:

1) the longer patients with chronic conditions are exposed to care coordination, the greater the impact on claims expense, and

2) while insurance claims went down, the savings weren't enough to generate a return on investment, i.e., the program itself cost too much.

The DMCB also agreed but mined the article to find out more.

Geisinger has a ""Proven Health Navigator" system of primary care sites with "embedded" nurse case managers who serve medically complex patients. As more primary care sites were recruited into the system and as more Medicare Advantage patients were enrolled by the nurses, it became possible to contrast the duration of exposure to Navigator with the amount of savings. Based on over one million member-months in 43 primary care sites over four years, the authors found that from one to twelve months of exposure, patients' claims expenses were not statistically significantly less than expected. However, once more than twelve months elapsed, the percent savings ranged from 4.3% to 6.7%. Yet, while the savings per member per month ranged from approximately $70 to $120, that was still not enough to exceed "the actual dollar amount invested in implementing" Navigator.

What else can the DMCB conclude?

1) When it comes to reducing claims expense, it'll take more than 12 months to see a reduction in claims expense, i.e., "to bend the curve."  According to these data, it'll take 2 years or more.  That means starting a care coordination program is a two to three year commitment.

2) The authors point out that with more time or more patients, they may have been able to achieve enough observations to achieve a statistically significant return on investment. Unfortunately, close reading shows there is little information in the manuscript on the program costs which led to the authors' conclusions.

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.

What GM's Ignition Switch Travails Can Teach About Concentration of Risk: Implications for Large Integrated Delivery Systems

CEO Barra not having a
good day at a Congressional hearing

Today, the motoring Population Health Blog used its C-SPAN enabled car radio to listen in on the U.S. House Energy and Commerce Subcommittee's grilling of General Motor's CEO Mary Barra.  As the PHB understands it, GM allowed millions of its cars to stay on the road despite awareness among some of its executives of a faulty ignition switch that failed to "meet specifications."  It was deployed in seven GM models for over a decade.

The PHB can assure readers that when it comes to using "gotcha" yes or no questions on a humbled CEO to plumb the meaning of "specifications," Congressional bipartisanship is alive and well.

While GM is completing its internal investigation and the PHB is speculating, it's possible that GM's travails are ultimately the result of concentrated risk.  While standardization across automobile manufacturing is a no-brainer, it all came down to a weeny metal spring's inability to hold a plunger in place. That led to a loss in power in moving cars with a catastrophic failure of steering, brakes and airbags.

Which naturally brings the PHB to health care.

In a recent chat with a well-connected and savvy colleague, it was pointed out that some health leaders are predicting that, in the years to come, health care in the United States will be delivered by a network of dominant regional integrated delivery systems.  Many policymakers naturally welcome the prospect of "postindustrial care" that is replacing a highly variable and unmeasured cottage industry with guideline-driven science and standardized protocols.  Part of that standardization will almost certainly include uniform treatment pathways and medical devices.

The problem? 

Never mind that some guidelines may not work as well as intended.  They can actually cause harm. Medical devices, just like ignition switches, are also not perfect and can lead to (for example) broken pacemaker wires or premature artificial joint failures.  While guideline and device mishaps are infrequent, the rise of "systems" means they're more likely to involve many more people when they inevitably do happen.

That's because these large regional delivery systems will be favoring single processes and products across all patients and all settings.  Instead of a flawed ignition switch in seven models, think of flawed pacemaker in all seven hospitals serving three states.

What's more, it's possible that GM decided that a low rate of failure (ultimately only 31 accidents with 13 fatalities) represented an acceptable cost-risk ratio.  The PHB recalls GM was financially ailing during the period in question; could it have decided that retooling a manufacturing process was too expensive?  If future integrated delivery systems also turn out to be financially stressed, will they likewise be tempted to stick with an old pacemaker or metal joint, despite early indications of problems?

Oh, and if you think it's just a matter of better government oversight, tell that to Acting Administrator of National Highway Traffic Administration, David Friedman .  He was seated next to Ms. Barra and was asked about his decision not to act on switch complaints as far back as 2007.

Risk is unavoidable.  It's just a matter of anticipating it in all it's many forms.  Assuming these big regional systems turn out to have traction, this concentration of risk will be a feature of them. 

The PHB leaves it to its readers to decide if it's worth it.