More on Medicare Health Support

While we wait for a better explanation from CMS, the Disease Management Blog has turned to popular culture for solace over the stealthy and what Vince Kuraitis eruditely describes as the bizarre Medicare Health Support Phase I announcement.

Werewolves from London played a big role in my formative years and there is a familiar chord progression that speaks to the topic - with posthumous apologies to eternal Warren Zevon:

Well we went and asked the Congress
Like everyone must do
How were we to know
If that five percent was true?

We gambled in the Beltway

We thought the law was passed
Send lawyers guns and money
Our lobbyists must act!

We're the innocent fee holderrrrr
And somehow we will pay
If not in a claw-back,
Then it's in the market cap
It's in the market cap
And it's in the market cap

Now we're hiding from investors
Medical Home has advanced!
Send lawyers guns and money
The **** has hit the fan!


I'm also a big fan of Dennis Hopper who reminds us that he doesn't really care, he's got his own point of view punctuated by bolding and hand gestures made famous from his counterculture Easy Rider biker days:

Fade in, play Spencer Davis Group, Gimme Some Lovin'
Dunda dunda duh, UNH, Dunda dunda duh UNH

Your healthcare attitudes are crazy.... they're impossible! They're not in this textbook. You're not some monthly fee, some guideline! (Toss book onto sand). Your generation is definitely not going to be told by some health provider how to manage anything. You're going to write your own book that's going to turn healthcare upside down. When I'm 62, I decide what pills. I decide which tests. Time to redefine outcomes, man.

(Voiceover) The best healthcare you'll get is your own. Your adviser can help you get it started and get to a degree of health defined by your dreams. Work with you one-on-one to make sure your health helps your dreams become a reality.

I just don't see you not being in charge. (Grin... nod).

(Fade out gimme gimme sum lovin... gimme gimme some lovin.....)

Ouch!







The Disease Management Blog remembers this is not the first time that the Medicare Program has "pulled the plug" and left its business partners feeling as if their expectations were not being exceeded. As a service to my colleagues at Healthways, I offer this link.


It's turning out to be a busy week for the disease management community. There's more news:






?Rumors about Matria here.











And XLHealth gets shaken.

California Health Reform Effort Fails--What Does It Mean?

With news that a California State Senate committee rejected Governor Schwarzenegger's plan by a vote of 7-1, efforts to achieve health care reform this year have all but ended in our biggest state.Governor Schwarzenegger and Assembly Speaker Nunez almost accomplished the impossible with a complexly balanced compromise that would have gone a long way toward solving that state's uninsured

Medicare Health Support Announcement

CMS has announced that Phase I of Medicare Health Support is unlikely to achieve budget neutrality and is not meeting the statutory requirements for demonstrated savings. In addition, it has concluded that there have been only nominal improvements in clinical quality and beneficiary satisfaction. As a result, Phase I will be allowed to end without any plan in place to begin Phase II. Phase I will end after three years of operations between July and December of 2008.

The Disease Management Blog expects there will be significant commentary about this in the coming days. It'll be "inside the beltway" over the next 24 hours and will spill over to the national arena in the days that follow. Given the coming cacophony, this blog can't resist adding its $.02................................................................

We're learning that legislating the conduct of randomized clinical trials is very cumbersome. While there may be no evidence of savings, the ability to discern the savings has been significantly compromised by several key methodological issues that are turning out to be insurmountable. Key word: bias.

In addition, what isn't true in the Medicare FFS population may still be true in other populations. Key word: generalizability.

Finally, the Ver. 1 model of disease management tested in MHS is becoming increasingly obsolete. In the opinion of the disease mangement blog, better predictive modeling with more robust and tailored behavioral approaches are continuing to transform the industry. Include better collaborative integration with the best elements of the Advanced Medical Home, pay for performance, electronic health records and flexible insurance benefit designs, the possibilities for real transformation of chronic illness care remain truly exciting. Key word: don'tthrowthebabyoutwiththebathwater.

A Clintonesque Examination of Quality in Disease Management

Everyone is aware that millions of Americans are being stymied by suboptimal healthcare quality, but the Disease Management Blog has been pondering just what “is” quality? Assuming it is expressed as a fraction of a group defined by a condition that achieves a desired outcome, the higher that fraction, the better. What’s more, with continued interventions, innovations and incentives we should be blessed with 100% quality. One example is NCQA, HEDIS and beta blockers.

But is that realistic in other sectors of chronic illness care?

Those of us who have worked in the trenches know the answer is sadly no. High blood pressure is a good example. As the heart squeezes down and pushes blood out into the arteries, the pressure goes up until the heart reaches its maximum degree of contraction. The maximum pressure in the arteries at that point in time is the “top number” (systolic pressure). As the heart relaxes or dilates (it needs to fill up with blood again), the pressure falls until the heart stops the relaxation and starts to squeeze again. That point of low pressure in the arteries is the bottom number (diastolic pressure). With the contraction and relaxation of the heart, the pressure in the arteries bounces between the systolic and diastolic, typically 120 millimeters of mercury on top and 80 mm of mercury on the bottom.

No one really knows what causes high blood pressure (usually defined as 140 or more systolic, or 90 or more diastolic) but whoever figures it out will likely deserve the Nobel Prize for Medicine, since that kind of discovery can lead to a cure. Absent that cure, we’re stuck with treatments consisting of weight loss, salt restriction, other lifestyle modifications and of course, drugs. Just how well do these treatments work?

To answer that question, the intrepid disease management blog blew tanks and dove into some of the peer review literature. Trials of hypertension therapy are a good window into the topic because in research settings, motivated volunteers agree to fully comply with treatment, have close follow-up by doctor and typically have a research assistant (such as a nurse) provide direction to the patient under protocol as part of a registry. It’s not too dissimilar from disease management or the chronic care model. That was also the approach used in the landmark HOT study.

In that study, patients with hypertension were randomly assigned to one of three targeted treatment protocols. While much has been made of the outcomes in the study, what is not widely appreciated is that only 85% of those assigned to a diastolic blood pressure less than 90 actually achieved it. In other words, even in high intensity research settings, the achievement of blood pressure control is not 100%.

How do I know this? Because I was one of the investigators in HOT and despite nuclear powered education and suitcase loads of pills, some of the participants in my clinic never got to target blood pressure.

And this phenomenon is not confined to high blood pressure. Outcomes less than “perfect” are typical in other clinical trial research reports involving chronic conditions like chronic heart failure, diabetes mellitus and high cholesterol. The HEDIS beta blocker success story will probably turn out to be the exception and not the rule.

Therefore, based on what the science is telling us, even with fully motivated patients who are carpet bombed with disease management (or the advanced medical home), ideal healthcare quality cannot be expressed as 100%. However, absent an adequate comparator, clinically reported clinical trials can yield up a “best of class” success rate of what can be accomplished under optimum conditions involving an optimum population. That puts a new perspective on press releases like this, where the results (compared to published trials) probably ain’t bad, but fail to tell us what is – and what isn’t – possible.

What President Bush Said in His 2008 State Of The Union Address About Health Care

See the prior post reviewing his 2007 speech. You won't be able to tell the difference between this year and last.President Bush's 2008 health care record will match his 2007 results--nothing was or will be accomplished.It is not surprising that a President in his last year would not launch any new health care initiatives. He also barely mentioned the need to deal with our giant entitlement

What President Bush Said in His 2007 State Of The Union Address About Health Care

Here is what President Bush had to say about health care in his January 2007 State of the Union Address:A future of hope and opportunity requires that all our citizens have affordable and available health care. When it comes to health care, government has an obligation to care for the elderly, the disabled, and poor children. We will meet those responsibilities. For all other Americans, private

not to worry

This may be a quiet week.

All is well. I am just spending some time with family and visiting friends. Posting may be sporadic to non-existent until early next week.

If you like, please post a link to your favourite blog in the comments and let me know why it's your fave.

Matria News!

Interesting!

acquire: \ə-ˈkwī(-ə)r\ from the Latin acquirere, from ad- + quaerere to seek, obtain to get as one's own: a: to come into possession or control of.

To find out more about Inverness.

While the glitterati have pointed out that the disease management industry is headed for more "consolidation," the intersection of personalized consumer "owned" self-management, über nutrition, genomics and remote physiologic monitoring may turn out to be an even bigger driver in this trend. I believe population-based care approaches are here to stay, but it's evolving rapidly. Those interested in "outcomes" and "proof" that disease management "works" are destined for even more disappointment, since by the time anything gets through peer review, it'll be obsolete anyway. The implications for the industry (and the design of Medicare Health Support) are huge!

A Detailed Analysis of the Romney Health Care Reform Plan

A Detailed Analysis of the Romney Health Care Reform PlanThis is a repost from October 22, 2007.Mitt Romney puts his faith in a reinvigorated health care market—not unlike his Republican rivals. But Romney puts a bit of a different spin on that by focusing on giving states the incentives to craft the solution that works best for them.The governor that signed the Massachusetts health reform law––

The Need for Chief Innovation Officers in DM, not.

The disease management blog spent the weekend catching up on a number of projects by day and getting reacquainted with a wonderful Chardonnay (Rombauer 2006 – while it can be criticized for an excess of oak, it’s a luscious buttery lass with a sublime finish) by night. So it was naturally by night that topic of healthcare title inflation recurred (see the Top Ten post below on Integrated Delivery Systems) and the crosshairs landed on “Chief Innovation Officer.”

And just what is it that these guys do? After a quick dose of some Google, I learned this species in the corporate healthcare fauna is mostly responsible for deciding whether to fund new internal or external ideas, sort of like an in-house venture capitalist, only minus a lot of the commas and zeros. Not only do many Fortune 500 companies have a CIO, but so does Humana, CDC and at least one Blues Plan. Apparently, one of the things many like to invest in is disease management.

Despite that moniker, two things emerged in my on-line tour of the topic. “Core” disease management companies don’t seem to have bothered with the position, despite the innovative froth in new behavioral approaches, increasingly accurate predictive modeling, novel contracting arrangements, more sophisticated cultural competency and the growth in international applications. Granted, it is a young industry not yet prone to excess administrative bloat, but I suspect the innovation is still too “distributed” to be corralled in some corner office. Secondly, there are a lot of “Chief” titles out there, including operations, technology, privacy, medical (what one friend described to me as a position akin to a “Golden Cage,” but that’s for another post), information, risk, quality, marketing and strategy just to name a few. Everyone knows it’s the chief executive officer that’s really in charge, but given the array of overlapping sub-corporate chiefdoms out there, the disease management blog asks if the title of chief chief officer (CCO) is more accurate.

As for me, I’m tempted to use what one former CEO acquaintance used to get to the Captain’s Table on a cruise. Even though she was a CEO for a large insurer, she confidently described herself as an “MEP.” She held out until crème brûlée before noting the title stood for “most exalted person.”

The Lifetime Benefits Cap on Health Insurance Policies Often Needs Updating

In today's Washington Post, Chris Lee has a story about lifetime maximums in health insurance policies. Sometimes, these caps are as little as $1 million--particularly for individual health insurance polices.As health care policy goes, this is not a widespread issue. The number of people who incur medical costs over $1 million or $2 million is quite small and most health insurance coverage is at

41 reasons I’m glad he’s mine

1. I have a weakness for big brown eyes.
2. He makes me laugh.
3. He laughs at my jokes.
4. The values we share.
5. He calls me on my ‘meshuggahs’ (a lovely Yiddish word that means something like ‘crazy stuff’).
6. He has taught me a whole bunch of nifty Yiddish words.
7. His family.
8. He’s the smartest person I know.
9. He loves me.
10. He can show affection (to his family, his friends and to me).
11. The cute face he makes when he’s feeling a little sheepish (and the same face I see reflected on my oldest son).
12. His unwavering support, throughout the worst and the best of my life as a cancer patient.
13. He’s an amazing father.
14. He still manages to surprise me, even after almost seventeen years together.
15. He chooses good friends.
16. He has kept his hair longer, even though it bugs him because I think it’s hot.
17. He is a sexy beast (and will be mortified that I wrote this).
18. He is beautiful. Inside and out.
19. He has shown me that being angry with me and loving me are not mutually exclusive.
20. We have fun together.
21. He knows me better than anyone (and loves me anyway).
22. He is a really good cook.
23. He tells me that I’m beautiful.
24. He thinks the most casual of clothes are the sexiest.
25. He puts up with the fact that I do not drive.
26. He is incredibly supportive of my writing.
27. He understands that ‘taking care of myself’ can mean yet another ball of wool or a pedicure, even if he doesn’t totally get it.
28. The way we can communicate with a glance and a raised eyebrow.
29. The way he can wax eloquent about hot sauce.
30. I feel like I’m still getting to know him.
31. His calves.
32. He is very kind.
33. He can apologize when he’s wrong.
34. He reads.
35. He lets me talk to him about knitting (and I talk about knitting a lot).
36. He doesn’t knit but he can talk knowledgeably about getting gauge and blocking.
37. He has his own interests and his own friends.
38. He encourages my separate interests and friendships.
39. I can recognize his walk from a distance (and my boys walk the same way).
40. He makes writing this list incredibly easy. I’m confident that I could go on for 100 more birthdays.
41. I love him more than I can say.

the days are getting longer

Have you noticed?

LifeMasters News

Update on leadership changes here.

"Strategies To Overcome and Prevent Obesity"--Important Policy Proposals

Taking the point in the effort to deal with obesity in America is the, "Strategies to Overcome and Prevent Obesity Alliannce." It is a broad-based coalition doing good works on this front.They recently sent me the following update on their activities and links to their work:As you know, America’s struggle with its weight is affecting much more than just the shape of the union…it’s actually

.... and now for a word from the New England Journal of Medicine

Salient commentary that resonates with Victor Fuch's perspective (see below).

Those who read history are condemned to repeat it!

book review: the south beach diet

I've been doing a bit of research, as part of my plan to take control of my diet, feel healthier and STOP GAINING WEIGHT. Oh, and I'd like to fend off cancer, too.

The South Beach Diet was written by cardiologist, Arthur Agatson, "in order to reverse the myriad of heart and vascular problems that stem from obesity" (p.7). Web MD describes South Beach as "a heart-friendly version of the Atkins Diet."

The premise of the diet is that we feel better and lose weight when our insulin levels are regulated and that the way to do this is by consuming mostly foods with with a lower glycemic index (because I am lazy, I am going to let Wiki fill you in on the details).

The book promises that you will lose eight to thirteen pounds in the first two weeks of the diet (I think the idea is that a quick success will get you motivated), known as Phase 1. And the cover of the edition that I borrowed from the library offered the added bonus, "Lose Belly Fat First!"

Who wouldn't love a diet that offered quick results (although Dr. Agatson is very careful to say that weight loss does slow down in the second phase of the diet, when some previously forbidden foods are reintroduced) and that promised to trim fat from what for many of us (especially those of us who've had babies) is a source of considerable angst? And there is lots in this diet that does make sense.

I know that lean protein makes me feel more full and that, if I get too hungry and let my blood sugar drop, I become a little hysterical (my youngest son is very like me in this. If he gets too hungry, he becomes a little terror. The transformation once he is fed is truly remarkable). I also know that I feel much better when I avoid white sugar.

But I have to say that I am a little leery of a diet that prescribes bacon and eggs for breakfast most mornings and that frowns on whole grain bread (although Agatson does say that whole grains are much better than their refined counterparts).

And I know all to well what a bad idea it can be to try any diet that makes you feel deprived of foods you love.

What I am taking from this diet:

• A good reminder to follow my naturopathic doctor's advice and avoid refined sugar.
• Eat smaller meals and avoid getting too hungry.
• Have snacks with good, healthy proteins.
• Avoid refined carbohydrates (I seldom bother with a bun when I have a burger and I don't have bread with dinner, usually. Avoiding carb-centred snacks, especially when we can't have nuts in the house, is more of a challenge).
  

I am keen to learn more about the glycemic index and how it affects metabolism, so expect more from me on this subject in the future.

I would also love to hear from any of you have successfully (or unsuccessfully) followed the South Beach Diet. What was your experience like? Does the diet work as a long-term lifestyle? Did all the saturated fats send your cholesterol through the roof?

I have been surprised by how much interest my posts on diet have generated. It seems that some of you actually are not bored when I write about what I've been eating.

This week, I made another small change based on setting S.M.A.R.T. goals: I eliminated the bedtime snack and stopped eating two hours before bedtime (food eaten late at night doesn't get burned off and I feel better when I wake up hungry).

Next week, I will eat fish at least once.

The Tale of Two Simpsons

The relationship between resources used and the benefit obtained has been seen in many pockets of the healthcare industry. In general, the more money you put in, the more you get until you reach a point of diminishing returns. In fact, there is some evidence that overdoing it will cause the curve (way over on the right) to dip down thanks, in part, to patient harm. For example, lots of CAT scans means big doses of ionizing radiation, lots of biotech means flakey off-label use and lots of plastic surgeons means funny looking celebs.

The Disease Management Blog wonders if much of the same phenomenon is true in the disease management part of the industry. Consider the case of the two Simpsons.

Jessica, may not deserve it but let’s face it: she does not have a reputation for high intelligence. However, she is an earnest and well meaning person (Dallas fans may disagree). If Jessica were tasked with some remote patient behavior change, I suspect that, despite her low healthcare skill set, she’d have some success even if all she did was call, leave a message and remind the “client” to regularly check the blood glucose or remind the physician about this study. Jessica is on the lower part of the curve.

On the other hand, Lisa is remarkably talented and insightful and she would undoubtedly be able to adjust her interactions with patients and deploy just the right input of insight, coaching and good cheer necessary to convince even the most unmotivated person to comply with the most complex of Care Plans. Lisa is higher up on the curve.

While the value of disease management is more than a function of telephony, it’s still fun to think about. There may be a role for Jessica, depending on the needs and health status of the population - as well as the negotiated price. Lisa is important also, but having too much of her can lead to diminishing returns. I also think Jessica or Lisa can overdo it and prompt some patients to seek additional high-cost, low-value or unnecessary care. I suspect finding the right balance of “Jessica” and “Lisa” is what distinguishes the high performing disease management companies from the others.

Health Wonk Review is up!

Check it out! The latest edition of the Health Wonk Review is up at Vince Kuraitis' e-CareManagement blog, with lots of thought provoking carefully considered insights and commentary from a host of healthcare savants. Enjoy.

Where's the Fat Lady?

Fans of J.D. Salinger may remember the Catcher in the Rye, but the Disease Management Blog thinks Franny and Zooey was J.D.’s finest work. In it, the college-attending, 1950’s heroine, Franny, becomes disillusioned by her meaningless life. Lacking access to the answers offered by our more modern age, like attending a rave or the joys of body art, she turns to repetitive prayer. It’s up to her elder brother and precocious radio-star Zooey to get her to snap out of it. After giving the reader a literary bus tour of the Upanishads, Zen Buddhism and Christian mysticism, Zooey finally hits pay dirt when he reminds his sister about the Fat Lady. Franny’s anxieties are eclipsed by the satori-provoking metaphor of lifelong service to this least-of-us child of/symbol of God.

Heavy stuff indeed. So what does this have to do with anything? Well, my blog, my posts. But seriously, the Disease Management Blog recently had the pleasure of touring a disease management call center, which was an industrial-strength, football-field sized, white-noised cubicle farm of nurses telephonically “engaging” persons of chronic illness. When I was invited to sit in on an HIPAA compliant “outbound,” the nurse took the time to show me a simple hand-made present and a handwritten thank-you letter sent to her by one of her diabetic patients. While she appreciated the small gift, it was gratitude in that note that was memorable for the two of us. Its value will never be captured in a per diseased member per month transaction.

There are several lessons here. The first is that Franny and Zooey is a good read if you're a JD fan and like that sort of book. It’s an option for that next plane trip. The second is that the sheer scale and complexity of these call centers is remarkable. Don’t turn down an opportunity to see one. Third, the remote coaching telephony from a good nurse to an interested patient is not automatically the Vytorin of health care: it can make a remarkable difference in individual patients’ lives. Fourth, the nurses that work these centers are good. Really good. And finally, while it’s fun to cross swords over what to do about the national cost and quality of chronic illness care, the Fat Lady not only appreciates the disease management nurses. She also writes to us from the center of our healthcare policy debate.

making music, taking action

As I have written before, I am a big fan of singer-songwriter Eve Goldberg. Her voice is pure and clear and her songs always move me. Her most recent album, A Kinder Season, recorded in the months after her mother passed away from breast cancer, was the balm and inspiration that helped me get through the initial shock and pain of my own cancer diagnosis.

You can listen to audio clips from each of her albums on her web site. Go check her out (and buy her music. You won't regret it).

Very recently, though, Eve has released a new song, one with a very important message. The following is from her website:

This month marks the launch of my new song "The Streets of Burma." I wrote this song after watching the TV news last fall and seeing the powerful images of monks and nuns in Burma peacefully taking to the streets to protest against the military dictatorship. Their protests were brutally suppressed. Watching these events unfold from half a world away, I was outraged, and concerned for the people of Burma. The TV news has moved on to other, more "exciting" events, but what has happened to the monks and nuns? What has happened to the ordinary citizens in Burma who long for peace and democracy? That's where my song "The Streets of Burma" was born.

And I'm proud to announce that Amnesty International has decided to use the song as part of its campaign to help free U Gambira, one of the monks arrested following the protests. You can listen to and download the song by clicking on the link above left, and you can find out more about the campaign at www.amnesty.ca/streetsofburma/

Please support Amnesty International's important work in this area.

The song is lovely and haunting. You can download at the Amnesty site or on Eve's own website (where you can also make make a donation to the Amnesty campaign).

Readers of the disease management blog may have begun to suspect a bias in favor of the industry. That may be true, especially since I've assembled another Top Ten List that mostly has nice things to say about it. It was certainly more fun thinking about a new list than trying to decipher today's credit crunch, yield spreads and interest rate brouhaha. So here is my list of reasons why we're comforted by the stable employment prospects of this corner of the healthcare industry.

10 Performance guarantees were around long before it occurred to the folks at CMS that they should stop paying for mistakes.

9 Access to capital.

8 Life prolonging exercise! Flatter stomach! Conditioning! Sign me up.

7 Nurses have a choice: work that professionally rewarding evening shift in the local, low margin, high volume hospital or work mostly 8-5 and maybe even from home. Duh.

6 Upside growth potential.

5 Never mind the dysfunctional Feds, it's the States that may be the next successful staging ground.

4 Plenty of room for more creativity in program design. My friend, Vince Kuraitis over at the e-caremanagement blog, has an excellent discussion on the many forces of change that have big implications for the industry.

3 There is lots of competition over both price and quality. The industry is a long way from becoming commoditized.

2 More transparency means even better competition.

1 What do those Captains of Industry, those Wall Street Titans and the no-nonsense folks on the Boards of Directors know that the peer reviewed literature seems to have missed?

Double standard? You be the judge.....

Isn’t a shame that this personalized care engagement strategy doesn’t get more respect? Advocates have pointed out that participants benefit from six key components:

• identification processes that identify important clinical conditions
• application of evidence-based clinical guidelines
• the participation of other skilled healthcare providers
• high quality, personalized patient education
• ongoing data storage for use in outcomes evaluation and
• performance feedback

Thought I was talking about disease management? Not exactly.

The summary above is also about the annual physical examination, which is supposed to 1) uncover treatable conditions, 2) apply only the best science for prevention and treatment of those conditions, 3) initiate and coordinate appropriate care with other healthcare providers, 4) inform patients about their best care options, 5) establish a complete and retrievable record and 6) create a baseline against which future health can be measured.

If we fairly applied the tone of many reviews about disease management to the time-honored yearly check-up, it might read something like this:

Skeptics have raised doubts about the annual physical exam in the medical literature. There have also been reports from highly respected sources that have extensively reviewed the available evidence and concluded it has failed to demonstrate that it has any consistent value. While other studies indicate it may or may not actually increase quality, its cost amounts to billions and the absence of any good studies on a return on investment makes one wonder if the physical examination industry is intentionally misleading us. Market demand for the annual examination is high however, which has been forcing many commercial health insurers to ignore their actuaries’ advice and pay for it.

Physicians have their unbiased perspective on the topic. Good thing the U.S. Congress and CMS routinely, uniformly and fairly apply a scientifically rigorous process to controversies like this before covering it under the standard benefit.

they like me!

The following email was waiting in my inbox when I got back from yoga this afternoon:

"Dear Not Just About Cancer Blog Author,

Our editors recently reviewed your blog and have given it a 9.5 score out of (10). Your blog is currently ranked in the top 3 in the Conditions and Diseases category of Blogged.com. This is quite an achievement!

http://www.blogged.com/directory/health/conditions-and-diseases

We evaluated your blog based on the following criteria: Frequency of Updates, Relevance of Content, Site Design, and Writing Style. After carefully reviewing each of these criteria, your site was given its 9.5 score.

Please accept my congratulations on a blog well-done!"

How cool am I? OK, so I don't think I've ever heard of Blogged.com (although I will pay attention to them, now!) and I don't remember submitting my blog to them (although I may well have). And the "Conditions and Diseases" category cracks me up (although I'm pleased to say that you can find me near the top of their Health section, not just in the "Diseases").

But still. Some people who read lots of blogs reviewed mine and thought it deserved 9.5 out of 10.

I'll accept the compliment, happily.

And that part of me that remains in Mme. Delorme's Grade Four class (Madame Delorme was really tough. And I worshipped her)? That part of me's wondering what happened to the other 0.5.

my champions

I've been working my way through week one of The Artist's Way and thoroughly enjoying myself.

I thought it would be difficult to write three pages of longhand every day but, for the last couple of days, my words have spilled over beyond that third page.

Today I wrote four pages.

It's all stream of consciousness and some much most of it is just words I put down to keep going ("I'm thirsty" "Coffee tastes good" "The dog is getting a little smelly"). Every day, though, there are at least a couple of flashes of insight and I always feel energized when I'm done. It's not great writing but we aren't even supposed to re-read for at least the first six weeks of this twelve week programme.

I have never done anything like this before (and followed, through, anyway).

It's making me happy.

One of the tasks for this week was to make a list of people who have championed my writing throughout my life.

This is my list (in no particular order):

• Each of the teachers (and there were several) who not only praised my writing but pushed me to do more. They went out of their way to give me creative writing assignments that would challenge me and give me the chance to grow as a writer. In particular, Mr. D., my high school drama teacher, was very special. He not only got me to write but encouraged me to apply to to Pearson College and coached me through the whole application and interview process.

• My father, who was one of my very harshest critics but who taught me to value intelligence, reading and the beauty of language.

• My spouse, who is almost always the first person to read this blog before it goes 'live.' His support has been unwavering. He knows me better than anyone and I value his feedback more than I can say.

• My sister, herself an enormously talented writer, who has been one of my most vocal supporters since we were kids. I wrote for her when I was a child and I often still find myself writing with her in mind. Her absolute belief in me has kept me writing when I wanted to stop and helped to push me past my own doubts. Conversations with her continue to be the springboard for much of what I write. Of the two of us, she is the more lyrical writer, a poet who uses language in a way that inspires me.

• And you, the readers of this blog. I started Not Just About Cancer as a place to process my experience with breast cancer and share some it with my friends and family. It has grown into so much more. Whether I know you IRL ('in real life'!) or not, I am so honoured by the fact that you keep coming reading (and that you take the time to provide feedback, through the comments, in person or via email).

Re-reading this, I am reminded why I consider myself to be a lucky person, despite having metastatic breast cancer.

It's good to count one's blessings every once in a while.

The 15% Medicare Doc Cut and Medicare Advantage Payments--The Battle Has Begun Again

Key players in the Congress are voicing some optimism that they can fix the 10% reduction in Medicare physician fees that will occur on July 1 and the further 5% reduction that is on track to follow on January 1, 2009.It is not surprising that Democrats would be sounding optimistic this early in the new session, but what is interesting is that we are hearing some willingness to compromise on the

buckets of sh*t

Don't you just love scathing movie reviews?

Jeanne, the Assertive Cancer Patient turned me on to a terrific review of the Bucket List by Roger Ebert, who as a veteran movie critic and recent cancer survivor is doubly qualified to review this awful-sounding movie.

And Ebert does not mince words, in panning this flick:

'"The Bucket List" is a movie about two old codgers who are nothing like people, both suffering from cancer that is nothing like cancer, and setting off on adventures that are nothing like possible. I urgently advise hospitals: Do not make the DVD available to your patients; there may be an outbreak of bedpans thrown at TV screens.'

As Jeanne says in her post about the movie review, "Don't see this film but do read Ebert's review."

A second review, of Katherine Heigl's new vehicle, 27 Dresses, also landed in my inbox yesterday. By Ottawa Xpress reviewer Isa Tousignant, it was called, "Dressed Down" and subtitled, "Katherine Heigl loses her charm in chick-flick shit-brick 27 Dresses."

Try saying that ten times, quickly.

Tousignant condemns the movie for it's "complete and utter lack of chemistry between [Heigl] and James Marsden" as well as the "ineptitude of its premise."

The critic concludes by summing up the movie as follows:

'...107 long minutes of insulting, sexist, predictable, morally offensive schlock that made me want to jump off this planet for shame of sharing it with anyone who may find this cute.'

I don't think she liked it very much.

Remember Nancy Johnson?

The Disease Management Blog has been on the road, making a living, personally washing the hotel room glass ware and taking advantage of some free internet access. And guess who I ran into in my travels: none other than the Honorable Nancy Johnson, former member of Congress who represented the 5th District of Connecticut. Her 24 year term included being Chair of Subcommittee on Health for the very powerful House Ways and Mean Committee. Veteran disease managemenites will readily recognize her as a principle architect of the historical Medicare Modernization Act that launched what eventually came to be known as Medicare Health Support

It may be my imagination, but the way she talks about her career makes me think she misses being a member of Congress. She also seems disappointed by how her record was framed by her opposition and the tone of many of the attacks against her. I don’t presume to get into the difference between being biased versus being balanced in matters of the Beltway (at least not on this blog) but I think this is another example of the coarsening and polarization of our nation’s political discourse. Our Republic is worse off for it and lessens the prospect (as discussed below) of meaningful health care reform.

It’s a good thing I didn’t read the vituperative links before I ran into her, because I was charmed by this energetic, bespeckled, talkative bundle of energy with an astonishing depth of knowledge in topics including but not limited to Middle East, small business, information technology, South American trade and, of course, health care. She remains very interested in the progress of MHS, was concerned about the 5% savings requirement and agrees the non-equivalence of the intervention and control patients that emerged after randomization but before the intervention could be having a significant impact on the results.

She now ably advises clients of the Baker Donelson law firm as a senior public policy advisor and tells me she loves her work.

Asked how she feels about no longer being in Congress, Ms. Johnson gave me a big smile and said “It’s freeing. I can pay attention to topics for more than three minutes at a time.”

click, please!

So...see that ad on the right side of this page? Every time someone clicks on it, I get a little bit of money (just about $100 dollars since September, so not a lot, but every little bit helps). It's all going into a new bank account in the hopes that I will be able to go to the BlogHer conference this year and then onto the conference for cancer bloggers that Jeanne is organizing (or perhaps I will only go to one event or maybe I'll just pay the mortgage).

So take a second and click on through. You don't even have to buy anything (but don't tell anyone I said that, OK?)

Matria

Some links speak for themselves. I asked and was told "even if I knew, and I don't, I couldn't and tell you." Which is the right thing to say.

i resolve part 3: get organized

I had chemo and herceptin yesterday, along with a serious dose of Demerol to keep weird reactions at bay (apparently, I am "special". There are a handful of other women who get the herceptin over 90 minutes or an hour, instead of 30 minutes but I am the only one who gets a regular dose of a heavy duty narcotic to go along with it). I did do some pretty weird twitching, though, so I doubt we will be eliminating the Demerol any time soon.

The third part of my S.M.A.R.T resolutions involves getting my life organized, a subject that tends to make me want to dive for the covers. We have more clutter in our house than anyone I know. Than anyone I have ever visited. There are piles everywhere and one room we can't even go into because there is so much junk. And all too often, we end up buying things (does anyone have any idea what happened to the electric pencil sharpener?) to replace things that have gone missing, only to find them a week later (um...why are there pencil shavings in the bottom of the laundry basket?).

I've had enough (and no, this is not the first time I've said this).

But I have decided, in order to actually get anything done, I need to keep my goals modest. I also need to get a sense of accomplishment, the chance to throw some stuff out and the feeling that we can maintain the order I manage to create (she begins to laugh hysterically at the mere thought of this).

So. My goal for January? Clean out the fridge, freezers and cupboards. I have already done the fridge (Sort of. We still have many, many condiments of uncertain vintage that I was not permitted to throw out). I have fifteen days left and some of those will be slowed down by chemo, which means that next week, I've really got to roll up my sleeves.

I'll let you know how it goes.

Four Big Trends Toward Better Health Care Cost and Quality

Brian Klepper joins us again today and calls attention to four key trends in the marketplace, all targeted on improving both the cost and quality of care.Four Big Trendsby Brian KlepperSeveral events and trends emerged over the last year that will reverberate throughout the health care marketplace in 2008 and going forward. While none of these dominated the trade press like some other issues--

The Prospects for Health Reform and Disease Management

Fed up with the media primary frenzy, my wife has temporarily banished TV election coverage from our house. So, in response, the Disease Management Blog retreated to the office and nosed around some of the candidates' web sites, press releases and press reports and copied some telling quotes:

…will require that providers that participating in the new public plan, Medicare or the Federal Employee Health Benefits Program use proven disease management programs.
.

…will ensure higher quality and better coordination of care by using state of the art chronic care coordination models with federally funded programs to provid care for Americans afflicted with the costly multi-faceted illnesses.

...infuse incentives in insurance markets that promote wellness and better outcomes for chronic diseases. Health insurance must be redefined to cover wellness and well as sickness.

...give states more flexibility in how to use federal Medicaid dollars, making it easier for states to develop innovative programs - such as one in Utah that helps people managed chronic illness, keeping them healthier and reducing costs.

...any health care proposal must first focus on containing spending. To accomplish that, the emphasis should be on better treating chronic disease, like diabetes and heart disease....

('nuff said)

Issues of election rhetoric aside, it's remarkable how much apparent agreement there is across the political spectrum on the need to develop "programs" for persons with chronic illness. While the details have yet to be worked out and then there is the matter of Congressional buy-in, it seems that no health care reform proposal will be complete without some type of "disease management" in it. That's the good news.

Want some bad news? Check out Victor Fuch's Perspective piece in Health Affairs, where he points out that the coming Congress and administration will be hobbled by an inability to marshal enough of a reform-minded coalition, fear of change outweighing its attractiveness and the disproportionate political power of special interests. Then there is the distraction of some very important foreign policy issues, including withdrawal from Iraq & Afghanistan and dealing with the nuclear ambitions of North Korea and Iran. While the long term prospects are ultimately good, the chances of something happening in the next 5-10 years is "50-50" and "the executive and legislative branch will have little time or political capital to spend on major health care reform for the rest of this decade."

(Sigh).

The Disease Management Blog will be on the road for the next 3 days. I hope to stay in a cheap hotel which means free internet access but doesn't mean a lot of time to post material. We'll see.

An Analysis of Senator Hillary Clinton's Health Plan Proposal

A Detailed Point by Point Analysis of Senator Clinton's Health Reform PlanThis is a repost of my October analysis of Senator Clinton's health care reform plan.This is nothing like the Clinton Health Plan from 1993.Senator Clinton has so far been running a smart campaign for President and her health care reform strategy is no exception.She waited until after all of the leading Democratic, and most

Are Integrated Delivery Systems really all that?

Speaking of population-based health care, how about those Integrated Delivery Systems (IDS)? Their fans fawn over IDS’ aggregation of healthcare services in an efficient, social-mission minded, mutually supportive panoply of consumer-friendly, one-stop primary, secondary, tertiary and quaternary and insurance for the cure and coverage of whatever ails all persons or populations. They do have a lot going for them.

Hm. Are they really all that?

So, knowing that a crippling writers’ strike is on the verge of turning much of our popular media from eye-candy to a yawnfest, I’ve decided try to help out. Here is my “Top-Ten” list of why IDS’ could always remain the health care solution of the future:

10 Indisputably better patient safety and health care quality at the same or lower price?

9 Liberal policy wonks like them.

8 Stultifying miasmic bloats of overlapping mid-level Assistant, Associate, Senior and Executive VPs, Directors and Managers. Check out this redacted/altered press release from a household-name IDS

“….has been named (title) for hospital operations and support services across the (institution) campus and outlying medical office buildings with responsibilities including working closely with (others) in the planning, coordination and execution of operational strategies to improve quality, service and financial performance at (Name) in (Region). ….will be the senior administrative officer responsible for materials management, facilities, radiology, anesthesiology, laboratory, perioperative/surgery, patient care services, and ambulatory care.”

7 Go ahead, try to close that stand-alone, major employer, community-based Hugh G. Deficit Memorial Hospital.

6 Um, what does IDS stand for again? A lot of my physician friends have idea none.

5 Its share of black eyes. Oops!

4 And just how are they different than the for-profits?

3 Reverting back to “eat what you kill” physician compensation means "why not keep what you kill" physician compensation.

2 “We discussed management’s preference vs. the doc’s preference and decided to compromise. We’ll do it management’s way.”

1 And the majority of exciting, cutting edge innovations in P4P, insurance benefit design, disease management, the Medical Home and the EHR are mostly coming from where?

change is a-foot

I am reading the Artist's Way by Julia Cameron.

I actually signed a little contract to myself (as suggested) by the author, to do the exercises in the book, make an 'artist's date' every week (which could mean just sitting with my knitting) and to write every day.

I am very excited.

And a little scared.

I promise to elaborate more on this in the future, but I'm not ready yet.

Disease management’s pushing drugs!

I really like this study that was published in the latest edition of Health Affairs (full citation below).

Briefly, this was a quasi-experimental “differences in (pre-post) differences” study of the impact of a pharmacy benefit co-pay reduction versus no reduction in two self-insured employer groups, both of whom relied on the same ActiveHealth disease management organization (DMO). One employer reduced the co-pays across all tiers for some key drugs that have been indisputably shown to improve clinical outcomes in asthma, diabetes, heart disease and other conditions, while the other employer did not.

The result? Medication adherence (based on the statistically adjusted “Medication Possession Ratio” or MPR) increased approximately 2 to 4% when co-pays were reduced versus no change in the comparison employer. Except for the asthma inhaler, all the differences observed were statistically significant.

Why is this important?

While the effect size may seem modest, these changes in typical insurance settings are not only hard to achieve but could make a big difference between first and second place in a local market’s HEDIS® measures. Insurer Quality Improvement/Assurance VPs, Managers and Directors take note!

The authors are being modest when they describe this as a study of the impact of a pharmacy co-pay reduction while holding disease management (and other sources of bias) neutral. While technically correct and consistent with righteous health services research, it appears ActiveHealth notified its participants about the co-pay reduction. In other words, ActiveHealth’s remote telephony promoted the drug bargains among the patients that needed them, suggesting to me that the change in the MPR was the result of a pharmacy benefit design change combined with the DMO's services. That’s unique. True, there are other excellent studies (for example) that have shown patient coaching can increase medication use, but this was a mainstream commercial vendor program meeting the DMAA definition that was simultaneously caring for a total of 32 chronic conditions.

It’s pretty obvious that disease management and pharmacy should be coordinated, but silos predominate in this corner of health insurance “with pharmacy budgets that result in shifting of expenses from the pharmacy side to the medical side.” Seems to me that an industry with a reputation for not exceeding its customers’ expectations could use all the help it can get.

This is also a great example of the type of rigorous, transparent peer-reviewed research required of the disease management organizations if they are going to convince skeptics (ouch!) that they bring real value to the health care consumer. Quasi-experimental studies using an adequate comparator are well within their reach and they too can survive the rarefied, peer-reviewed academisphere - and in Health Affairs no less!

The authors also deserve credit for being honest about the study’s shortcomings, including the difference in the baseline MPRs between the two groups as well as other demographic differences, the possibility that other unmeasured factors accounted for the observed changes and that an increase in MPR doesn’t necessarily guarantee better clinical and financial outcomes. Kudos to ActiveHealth and may they be blessed with increased market share for better truth in advertising.

Some captains of the managed care industry may disagree with a “reduced co-pay for some patients” approach, arguing that an equal insurance premium should provide equal coverage. I think most State Departments of Insurance would agree. On the other hand, if all health insurance enrollees have a stake in not only pooling but mitigating risk, I don’t think cross-subsidization of the right drugs for the right people is all that bad, especially when generics are not budget busting in the zero sum game. Thank goodness for flexibility afforded by ERISA and the willingness of some employers to test some important concepts.

I got to be reminded about Steppenwolf’s classic tune, The Pusher. I’m showing my age!
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Citation: Chernew ME, Shah, MR, Wegh A, Rosenberg SN, Juster IA, Bosen AB, Sokol MC, Yu-Isenberg K, Fendrick AM Impact of decreasing copayment on medication adherence with a disease management environment. Health Affairs 2008;27;103-112