How Can Care Management Programs Manage Physician Incentives?

One ingredient for physician cooperation?

Years ago, when the Disease Management Care Blog was helping to lead a care management program, it was paired up with a nurse-administrator who was troubled by the notion that docs should get paid to sign-off on a disease management care plan. Why, it was asked, should docs get any extra compensation to do something that's a fundamental part of caring for patients?

It listened politely to its colleague's input.  After a careful review of all the issues, risks, benefits and alternatives, the physician-DMCB decided to compromise by paying the docs to sign-off on the care plans.

Drs. Nikola Biller-Andorno and Thomas H. Lee, writing in the March 14 New England Journal, point out that that physician enticements are far more complicated than shekels for signatures. They think economic incentives in health care are a complex mix of "traditional," (social status) "self-interest, (one example is money) "affective" (being appreciated) and "shared purpose" (for the greater good) motives.  They also suggest that they are unavoidable.

A nurse care management administrator might as well join 'em rather than fight 'em.

Armed with that insight, it's easier to contrast the underlying cultures of a non-for-profit community health center versus a for-profit hospital chain. It's also easier to understand that performance measures can not only appeal to self-interest (as in pay for performance) but to the "affective" reward of being given an excellent rating by a community of colleagues.  The authors also point out that a sense of shared purpose cannot be underestimated, since it speaks to the "core principles of the medical profession."

The DMCB's insight here is that there is no single incentive "lever" that can change physician behavior.  Rather, the best approach to incentives is to capitalize on all four incentive domains.  What's more, if "shared purpose" is undervalued, physicians are more likely to feel dissed and ignore the best laid incentive plan.

It turns out paying the docs was the right thing to do as well as appealing to their sense of shared purpose.  What the DMCB and nurse administrator should have done was to also look for some way to leverage the other domains of social status (perhaps a recognition program) and being appreciated (asking a lead physician to express appreciation for the extra work.

Image from Wikipedia

A Reprise of the Infamous CBO Report on Disease Management and the De-linking of Health Insurance and Wellness

Two things "heard on the street" at today's Medical Home Summit:

1) The recent JAMA article on the failure of the medical home to reduce health costs is provoking the same defensiveness as the infamous 2004 CBO report on "disease management."  PCMH advocates are using the same arguments that were used by the old DM vendors to defend their business model back in 2004.

Two of the more common ones heard by the Population Health Blog are that 1) today's model is far improved over the Ver. 1.0 reported in the JAMA article and 2) the improved health status of populations is not correlated with reduced insurance claims expense.
 
2) The bad news is that employers have given up on health insurance and many are prepared to push their workforce into the health insurance exchanges.  The good news is that they are continuing to invest in wellness and health promotion programs for their employees - not because they believe it saves money, but because it increases productivity.

In other words, commercial health insurance and wellness are being de-linked.

The Latest Health Wonk Review Is Up!

Want to get ready for St. Patrick's Day?  The Disease Management Care Blog prefers May 17 and aquavit instead of Guiness and blarney, it may change its mind after reading Boston Health News' Health Wonk Review.  This is an assortment of blog-wisdom loaded with perspectives on health reform that you won't read anywhere else.  Check it out and reward your new insights with an extra beverage!

Use of Quasi-Experimental Designs By Employers to Assess Population Health and Disease Management

If you were an employer with tens of thousands of employees and dependents and had launched a health promotion, disease management and care management program, how would you assess its impact? If you answered you wouldn't bother with measuring outcomes, you'd flying blind.  If you answered that you'd call up an academic institution to fashion a comparative clinical research trial, you'd be using a lot of your time and money. 

But if you answered you'd use a quasi-experimental design, you'd be eligible or a Disease Management Care Blog Gold Star.  That's because business owes it to its employees and investors to not only understand the value of these programs, but also make reasonable compromises on the detail, speed and accuracy of these kinds of analyses.

That's why this paper by Serxner and colleagues appearing in the American Journal of Health Promotion is a good template for companies that want understand if their health management programs are doing any good.  This analysis involved an unnamed company with over 120,000 insurance beneficiaries. 

The authors decided to focus on 75,475 active employees and COBRA participants who were eligible for the programs.  They included a health risk assessment, lifestyle management, telephonic disease management, a health information nurseline, and health awareness initiatives.  The analysis itself put limitations on the age inclusion (18 to 64 years) as well as continuous enrollment, which further limited the research to 49,237 individuals.

The baseline comparison period extended from January 2003 through December 2004, while the intervention period extended went from 2005 through 2007.  When the programs were rolled out in 2005, participation among the insured beneficiaries grew.  Since not all of the employees participated at once, the authors took advantage of what turned out to be a staggered implementation with concurrent parallel cohorts made up of participants and non-participants. This allowed for the "quasi-experimental" comparison.  Regression modeling was used to isolate and account for the impact of age, gender and the type of medical plan.

In year one, the company spent over $2.5 million, followed by $4.6 million in year two and 5.0 million in year 3 for its programs (including $2 pmpm for the disease management). 

What happened to the company's health care costs?  While they increased for everyone over time, the persons who had enrolled in the program experienced less of an increase in their health care costs. The total gross savings for each of the years were $1.5 million, $15.4 million and $13 million in years one, two and three, respectively. When the savings were netted against the program costs,the first year had an unfavorable return on investment (ROI) of .59:1.  This turned positive once persons were in the program for two and three years, with ROIs of 3.33 and 2.59, respectively.

While studies like this can not rule out the possibility of "self-selection bias" (i.e. persons destined for lower health care costs were naturally drawn to the programs), the analysis passes muster for a large business that needs a reasonable degree of assurance that it is getting its money's worth.  While the analysis itself may seem daunting, the DMCB suggests that that cost, when compared the millions already being spent, is comparatively reasonable and should be rolled into the price of doing business.

The DMCB suspects dozens of studies like this are being done by employers and insurers, most of which are being used for internal consumption.  Sexner et al's study is one that made it into the public domain. 

Heads up, corporate America: your competition is not only investing in their employees health, but using quasi-experimental analytics to understand the return on investment. It's another factor in achieving a competitive advantage.