A Reality Check for Virtual Patient E-Mail Visits

As regular readers know, the Disease Management Care Blog is somewhat skeptical about the value of unbundled stand-alone technology in primary care, especially when it comes to chronic illness. So it was with a jaundiced eye that it read the Sunday Philadelphia Inquirer article on virtual visits. As far as the DMCB can tell, this is an email-like function that can be used to make appointments, obtain test results, get prescriptions or ask questions. According to the Inquirer (and the WSJ Health Blog) health insurers are overcoming their inertia, have seen the light and are finally “paying” for this service.

Good news you say? Using Pub Med as well as High Wire Press, the DMCB was unable to find any peer review research showing that this is quite the breakthrough the worshipers at the Health Information Technology Tabernacle would have you believe. While using email to get renewals or make appointments seem to be a no-brainer, can patients really can fire up their computer, author an email about a medical issue like interpreting abnormal test results or bothersome symptoms, hit 'send' and receive truly helpful communication back from Dr. M Welby? Do physicians embrace this technology and, now that they’re paid for it, they will come?

There is good scientific literature that shows email-based communication increases patient and physician satisfaction. Physicians are also not unfamiliar with the concept, and many are already using email gratis, especially in large multi-specialty practices. Interestingly, age and gender of the physician has no correlation with the likelihood of it being used.

That’s the good news. The bad news is that there is no solid evidence that this increases the quality or decreases the cost of care. The DMCB cannot find any prospectively randomized studies in which patients were allocated to usual care vs. email virtual visit care to determine if there is any impact on outcomes for any clinical condition. As far as cost goes, there is one retrospective report from Kaiser that shows that e-mail style virtual visits were associated with fewer clinic visits and phone calls. The DMCB is willing to bet that Kaiser still filled the clinic schedules with patients, didn’t downsize as a result of the better efficiency or decrease their insurance rates. In addition, email is better suited for self limited episodic problems anyway, which are not a large cost in the health care system. Last but not least, there is research showing this approach to care favors the socioeconomic group that already has the least problem accessing and paying for healthcare: white males.

It doesn’t end there. According to the Inquirer, payment rates for each interaction will range from approximately $25 to $35. The basis for this figure is not only unknown, but it can be argued this is simply one more example of the dysfunctional commoditized piecework payment system that must be endured by providers. Many may end up seeing this for what it's truly worth.

HIPAA and the health care system’s ceaseless talent for creating process is also likely to make this less user-friendly than many would anticipate. The DMCB anticipates password protected web clients and having to get through several pages of categorical questions (‘fever?, yes-no,’ and ‘list your medicines here’) along with many warnings and disclaimers before patients truly and finally get to 'send.'

And once it is sent, will physicians really be at the receiving end and waiting to reply? More likely many messages will be routed to same nurse triage system who will use new menu-driven responses that look and feel like the old menu driven responses ('take two aspirin and email us in the morning').

In the end, however, the DMCB is a fan of virtual visits. If a) physicians are fairly compensated, b) the fee meets cost plus margin, c) it is reasonably user friendly, d) doesn’t exacerbate health care disparities, e) the visits are linked to robust decision support, f) there is supervised teaming and oversight, g) there are links to a medical record h) there are ongoing studies to help us better understand its value and i) the value proposition is extended to chronic illness, it’s a good idea. It’ll be a great idea if it’s integrated in those other “systems” level initiatives that promise to redesign primary care. In the meantime, I don’t blame the commercial insurers for their reluctance and I’m not sure their enrollees realize what $25 worth of virtual care really entails.

By the way, in the spirit of getting real versus all that virtual hokum above, the DMCB points out that disease management vendors have used email visits in their systems of care with many of the ingredients described above for years. They provide it as part of their global fee for the global suite of services. The DMCB suspects patients are getting their money's worth.

Brian Klepper's recent post, "What Walgreens Surely Sees" got Health Beat's Maggie Mahar thinking and the result is one of her usually insightful comments. While Brian sees the for-profit model as a useful tool in making the primary care system more effective and vibrant, Maggie sees things differently.Their discussion represents the classic difference between those who believe the market needs

Pennsylvania's Health Care Reform Proposal Includes Primary Care

In a prior post, the Disease Management Care Blog had a brief report on Massachusetts’ health care reforms. If you are interested in learning even more about what’s going on in the Bay State, check out this well written article (subscription may be required) in the March 18 Annals of Internal Medicine.

Your trusty DMCB has the bottom line however. It was the description of that all important thing called "funding" that caught the DMCB’s eye. A pre-existing ‘free care pool,’ used to compensate hospitals for uninsured patients, was combined with matching Medicaid funds, additional state monies and employer (‘free rider’) and tax payer (kiss the deduction good bye) mandated penalty assessments. The DMCB agrees this multi-pronged approach aided the reform’s passage, along with three other factors. There was a manageable uninsured prevalence rate of 10% (versus 16% nationally). There was familiarity with the complicated issues at stake thanks to multiple prior attempts at reform. Finally, there was an appetite for bipartisan compromise.

As noted in that prior post, Massachusetts’ reform has been criticized from both the right and the left. According to the Annals, some physicians have also weighed in, pointing out that economically disadvantaged patients are now responsible for practically unaffordable insurance premiums and co-payments for care that had been previously covered by the free care pool. However, there is some consensus that many more health care consumers have been aided by access to health insurance than have been hurt.

Why is the DMCB thinking about this? Well, it believes the States and ERISA protected health insurers, in contrast to what's happening inside the beltway, may ultimately be the twin leaders in health care reform. It also believes any meaningful reform will need to include primary care.

The Annals article pointed out that Massachusetts’ reform is being hampered by the lack of any measures to meet a predictable increase in demand for primary care services. For example, in the year it was passed, the percent of internists not accepting new patients jumped 13% to 49%. Fewer are accepting Medicaid and wait times for new appointments have increased significantly. It seems there is some truth to the adage that providing health insurance doesn’t necessarily guarantee access to health care.

While all eyes are on Massachusetts, the DMCB points out that there is an instructive attempt at health care reform underway in Pennsylvania. Like Massachusetts, there is a separate pool of dollars that advocates of reform would like to tap. In addition, the State’s numbers of uninsured, as a percentage of the population, is not high. On the other hand, there is a distinct lack of bipartisanship. It remains to be seen if meaningful reform is ultimately achieved, or if the outcome is merely some increased familiarity for another try at some later date.

While its prognosis is uncertain, the Pennsylvania plan is worth close examination because its plans for primary care contrasts with Massachusetts'. Elements include increased use of non-physician health care providers, expansion of federally qualified health centers, more nurse-managed care centers, providing funding for better evening and weekend coverage, expanding the primary care workforce, providing financial incentives, addressing the need for greater diversity and promoting the Chronic Care Model . Pennsylvania fee for service Medicaid also relies on a disease management company.

The Disease Management Vendor's Lament

...brought to you by Gabriel Garica Marquez in his magnificently written Love in the Time of Cholera. Frustrated by your customers' endless demands for customized interventions and data extracts?

"You have to know languages when you go to sell something," she said with mocking laughter. "But when you go to buy, everyone does what he must to understand you."

silly soothes the soul

I lost count of the number of times we watched this tonight.

My sister, if she hasn't already seen this, would love it.




Update: It turns out that there's a whole bunch of these on YouTube. The kids and I may have watched them all. These guys are awesome. And hilarious. I just wish I could understand the banter.

What Worksite and Retail Clinics Mean for the Primary Care Crisis

Today, Brian Klepper returns with one of the more intriguing posts we have seen from him.This time he looks at a relatively unnoticed acquisition of two worksite clinic firms in the broader context of the challenge primary care faces in out health care system.What Walgreens Surely Seesby Brian KlepperThough it probably went mostly unnoticed in the cacophony of health care stories, last week's

Physicians Support Medicare Health Support

Healthways is continuing to pull out all the stops in getting Medicare Health Support back on track. According to its press release, ‘more than 500 health care professionals’ and ‘400 family care givers’ have ‘appealed’ to members of Congress on behalf continuing the program. There is even a web site that hosts the scripting of personal emails.

The DMCB suspects Healthways had a hand in prompting the appeals but nonetheless, getting 500 health care professionals to do anything in unison is remarkable.

But then again, influencing health care providers is one of the things that the disease management industry strives to do. Maybe it's better at it than previously appreciated.

The Medicare Trust Fund: Problems and Non-Solutions

The Disease Management Care Blog has been reading about the Federal Government’s indolent cherry blossom-induced somnambulism over the downward spiral of the Medicare trust fund. But do not fret, present and future beneficiaries, because the same folks that brought you the Medicare Health Support imbroglio have ridden to the rescue with a press release outlining their recommendations for meaningful reform:

• ‘Basing payment levels on provider reports on quality and their ability to prevent costly and life-threatening hospital acquired infections’

Hospital acquired infections include but are not limited to line sepsis, ventilator associated pneumonia, pseudomembranous colitis and surgical incisions. The latter probably get the most attention. One good study found the rate of these could be reduced from just under 4% to 0.6% with the administration of properly timed antibiotics. Don’t get me wrong, any avoidable infection is one too many, but I’m not sure the economics of making 99.5% vs. 96 % is all that compelling in the big picture.

• ‘Providing transparent quality and cost information to beneficiaries and providers;’

With all this attention on evidence-based medicine, where is the evidence that this really works? Here's a report that casts doubt on the notion that patients use publicly available quality information in choosing one hospital versus another. As for the providers, skepticism abounds. I once presented a hospital’s Medicare data at a Grand Rounds at an academic medical center and was met with incredulity. I was also not invited back.

• ‘Developing and testing strategies to pay more for better results rather than more services;’

The hospital P4P data is still young, but what information exists in the peer review literature suggests that the gains are modest at best.

• ‘Implementing competitive bidding approaches to the delivery of care;’

The DMCB heard of this at a policy conference years ago and it makes sense. Note that the latest example of competitive programmatic bidding in the Medicare program was Medicare Health Support. If it’s good enough for Healthways, the DMCB figures it must be good enough for the nation’s hospitals.

• ‘Promoting the adoption of interoperable health information technology;’

The DMCB doubts this is as big a money saver as many seem to think. It is not alone.

• ‘Implementing reductions in market basket rates of growth, as proposed in the President’s 2009 Budget, including a proposed 0.4 percent reduction in the growth rate of Medicare payments if Congress does not pass a specific alternative proposal to achieve needed improvements in sustainability; ‘

Do not worry my fellow physicians. Pending the eventual discovery of MedPAC that there is a problem, other revenue opportunities include concierge medicine, botox parties, tattoo removal, depiliation, internet medication prescribing, personal wellness coaching, IT based virtual care, circuit riding around the country to testify in malpractice cases, and taxi driving.

• ‘Increasing the share of program costs paid by the highest-income beneficiaries, as proposed in the 2009 Budget.’

So in other words, we each pay different amounts for the same health insurance benefit. In the opinion of the DMCB, that’s not a problem if the lowest income beneficiaries get their money’s worth, let alone mine.

But the DMCB won’t stop there. Notably absent was any mention of increasing the role of primary care physicians, determining how the chronic care model may address the health care needs of the costliest Medicare beneficiaries and – of course – capitalizing on the latest generation disease management programs that are being relied on by the majority of nation’s commercial insurers. Last but not least, how about using the Medicare Health Support program to find what works - and what doesn't

too young too soon

I am grieving the death of an old friend today.

Ron Crawley, many people will miss you very, very much.

Instead of a regular post, I am linking to a post from BlogHer by Catherine Morgan. It's about the environmental causes of breast cancer but the information applies to other cancers as well.

The Gallup-Healthways Well Being Index

Want some more insight about the business model underlying the Gallup-Healthways “Well Being Index” venture? Check out this March 21 report that contrasts smoking vs. income by race.

They’ve calculated that there is a market for detailed information like this that will in turn enable businesses and governments to segment populations in multiple ways. This will allow precisely aimed health care interventions (oh, yes and marketing too) that are correlated to multiple dimensions such as income, place of employment, purchasing preferences or party-dude efficiency.

The Disease Management Care Blog heard Newt Gingrich salute this initiative, heralding it as another example of how our terabyte society will commercially coordinate itself into a state of maximum well being. But give this approach some credit. This is speedy, efficient and backed by an organization that knows how to do this. In my opinion, the data are methodologically close enough, confirms what we already know from prior studies in a highly granular fashion and points the way to designing interventions to reduce the burden of tobacco abuse where they are most needed.

Note that the Centers for Disease Control and Prevention have been collecting tobacco use data for many years. Unlike the Well Being Index, all their information is non-commercial and available on line. The DMCB doesn’t think the CDC information is quite as user friendly or as amenable to the wide range of possible sub-group analyses. Maybe Newt has a point about this area of the healthcare medical-industrial complex: there are new parts that work and then there are long-established parts that don’t work work less efficiently.

all at once

I was planning a post about cancer clusters today but I have decided to put that off until tomorrow.

Instead I will link you once again to Sara, who has left me furious, sad, scared, hopeful. inspired and even amused by a single post.

Cancer is a bitch.

Check Out What Aetna is Up To

If you’ve been reading Joe Paduda’s blog (it's a new blog link on the right), you may already be aware that Aetna’s stock avoided the recent market drubbing experienced by some other big health insurers. So, when a transcript from a recent Analyst Meeting became available, the Disease Management Care Blog donned the extra thick reading goggles, warmed up the coffee and read and searched for the ingredients behind Aetna’s recent success. Much of the presentation was all about underwriting, cost controls, market segmentation and exceeding customer expectations (and not using healthcare industry benchmarks by the way), but scroll on down through all that 6 point font and check out what CMO Troyen Brennan had to say.

Or, don’t read it and rely on this bulleted summary provided gratis by your ever faithful DMCB:

• They are converging disability, pharmacy, behavioral health, electronic medical, hospital, any clinical and its own claims data in algorithms to compare and contrast their providers’ care vs. best practices. They’re committed to continuing to use this information to influence patient and physician behaviors in many ways to reduce variation and increase quality.

• They are not worrying at all about the cost of an army of 2,500 health professionals who are responsible for interlocking wellness, disease management, pre-certification, concurrent review and case management laced with coaching and advocacy. They feel they and their customers are getting their money’s worth.

• Despite hostility from state Attorney Generals and organized physician groups, they are throttling full speed ahead on Centers of Excellence, preferred networks and patient steering. Transparency may help diminish the enmity, but from their customers’ point of view, the savings are just too compelling.

before i die

As part of an exercise I did last January, I wrote a list of things that I would like to do before I die.

Don't worry, I'm not being morbid nor have a received any bad news of late. It's an exercise that anybody could do, although it does feel more loaded now than it would have before I was diagnosed with cancer.

I re-read my list today and was surprised by it, even though I only wrote it two months ago.

The list contains things I feel I ought to do and things I fantasize about doing, things that are achievable (and that I will do) and things that probably fall under the category of pipe dream.

This is what I wrote, through stream of consciousness and completely uncensored:

Finish my queen-sized bed spread.

Write a novel.

Organize my house.

Travel with my kids.

Go back to school.

Run a marathon.

Participate in flyball or agility with a dog and my older son.

Get the message out re living long and well with metastatic cancer.

See the midnight sun again.

Go to Australia.

Become a soup-making expert.

Get more writing published.

What would be on your list?

Medicare Health Support - the DMAA Weighs In

Important article in the March 24 issue of Modern Healthcare:

The unsinkable Tracey Moorhead has penned an opinion on behalf of DMAA about the recent CMS decision to suspend Medicare Health Support.

Among her many points, the decision means:

• gains made to date will be jeopardized
  

• new initiatives will be difficult to re-start

• local alliances will be disrupted

• lessons learned will be lost

• beneficiaries who seem to like it so far will be denied an important service
  

• it's too early to tell

• flexibility is called for

• additional analyses may offer new insights

Match Day Results and the Implications for Chronic Illness Care

Ahhh… the Disease Management Care Blog remembers Match Day. That’s the process that matches medical students to their after-graduation specialty-based residency training programs. If you’re interested in seeing a video of the annual rite of senior med students getting their match results, check this out. Things haven’t changed.

After being alerted by the Wall Street Journal Health Blog’s telling description of the travails of one medical student navigating The Match, it kept its eye out for that other annual rite: a doom and gloom announcement by an organized primary care medicine group such as the American College of Physicians (ACP) or the American Academy of Family Practice (AAFP). It did not have long to wait.

According to ACPOnline, matching in internal medicine (primary care for adults) had another decline while family practice had a minuscule increase of 0.4%. According to their press release, there will not be an adequate supply of physicians to treat an aging population. That was also true in 2007, and 2006, and 2005 and… well you get the point.

While it is true that there is less variation and better utilization when there is access to primary care providers, the market (as dysfunctional as it is) preferentially values specialty care as measured by income and, to some extent, by the willingness of patients to bypass the local system. The DMCB asks this: if you or a family member had a really bad back ache, would you prefer to see your primary care and be reassured, or would you prefer to see a back specialist even if you had to travel and pay more out of pocket? The right answer is the former. A prevalent answer is the latter.

In addition, if you had a sore throat, would you prefer to call your primary care physician for an appointment or would you seek a walk-in nurse practitioner in the local pharmacy? The ultimate outcome may be pretty much the same, so the right answer often comes down to convenience.

Assuming market forces are allowed to persist in some fashion after the 2008 elections, the DMCB believes the ‘leak’ of patients above to specialists and the ‘grab’ from below of ‘episodic care’ patients (to entities like WalMart and Walgreens - including work sites) will leave the middle to primary care physicians. They will find their practices increasingly dominated by patients with chronic illness and multiple co-morbidities. Experts in the landscape of primary care seem to agree and have recommended primary care physicians prepare by radically rearranging their delivery of health care.

The DMCB agrees with the sage 2005 editorial by Dr. Lawrence. Rearranging things is not enough. One part of the answer is the chronic care model. It believes another is old fashioned disease management, which offers an under-recognized advantage of being able to “off-load” many of the more routine aspects of chronic illness follow-up and education. Both DM and CCM are associated with high levels of patient satisfaction and can command significant revenue. The chronic care model appropriately capitalizes on the special skills and roles of the physician. Unlike the chronic care model, however, disease management can increase the patient-primary care physician ratio. Assuming it can figure out how to integrate with physicians, it has the potential of enabling fewer docs to be available to more patients - all at a very competitive cost.

The DMCB accepts the claims of success from both the chronic care model and the disease management industry. However, it doesn’t believe either alone is up to the task of addressing the perpetually dismal primary care match results and the growing needs of persons with chronic illness. The "chronic care" market will be looking for better approaches to care and isn’t paying much attention to the ACP’s gloom and doom. We need to understand how the "chronic illness market" and its worsening manpower shortage will respond to best-of-both combinations of disease management and the chronic care model.

Open Sourcing - Help (and possibly make some money), Follow or Get Out of the Way

Regular readers may recall this blog’s prior posts on the option of ‘Open Sourcing’ by the disease management industry. Advantages include the good will generated by transparency and the likelihood that others will be able to glean additional insights from the data. I also pointed out that the asymmetric patient-physician information gap could dissipate, leading to emnuclear powered patient-amateur scientists and profound changes for the medical profession.

Here’s a glimpse of the open sourcing that is already possible, courtesy of the New York Times. The Disease Management Care Blog thinks this makes for astonishing reading. In truest web fashion, individuals are not just “self-aggregating” into an anecdote-sharing and support community, they’ve gone open source and are using their own subgroup analyses to come up with measures of central tendency that takes “translational research” to a whole new level. There is some needed discussion about managing the privacy trade-offs and the expected tut-tutting from physicians – none of which is insurmountable. What goes unmentioned is how users are also bypassing the traditional peer-review/scientific publication process.

How will health insurers, health/electronic medical record vendors, on-line personal health record “aggregators,” scientific journals and the disease management industry respond? The DMCB is only distantly aware of that science known as “marketing,” but it knows that where there is demand for disruptive technology, there is also opportunity.

Sven Updates the Disease Management Care Blog

Ok people time to rock and roll. It is the Sven video again and I am back to tell you that I can no longer remain your personal Sven. You never seem to have enough lefse, pickled herring, linie aquavit, lutefisk or Ingmar Bergman DVDs on hand. But the real reason I must depart is because I must help the Disease Management Care Blog update itself. I have installed a list of labels on the right side of the page that helps readers retrieve past DMCB entries by topic, such as 'humor,' 'medical home' or 'industry trends.'

But do not be unhappy. While your blood sugar is high and your blood pressure is down, I have arranged for disease management nurses who will remind you to adjust your insulin, while for you the doctor will be alerted. There are five emails on healthy living for each of you. Now that your SF-36 scores are up, you can handle your own skeduules, cook your own breakfast and fetch your own sweaters. By the way, your daughter’s interest in Kung Fu has less to do with self defense and more with a classmate by the name of Adam. Uff da.

how aware are you?

This blew me away:


Awareness Test - Watch more free videos

I think I'm going to be very nervous next time I'm on my bike.

What Angels Teach Us About Announcements from the Disease Management Industry

The season reminds the Disease Management Care Blog that healthcare is more than just outcomes or trend. It’s also about the Fat Lady and not living on bread alone. Consider that Jesus’ life-story was bracketed by angels announcing His birth and resurrection to persons subsisting at the lowest socioeconomic rungs of the day: shepherds and women. I leave it to the reader to interpret the significance of what happened between the angels’ visits. Whatever the conclusion, it should remind our industry to always consider the relevance of our multiple announcements for those struggling at the margins of today’s modern society.

in defense of universal health care

My friend Sara has just written the most beautiful, moving and utterly persuasive post in favour of universal health care that I have ever read.

Healthways Tells Us About the State of the Disease Management Industry

Ben Leedle, Healthways’ CEO, recently completed that quarterly ritual known as the Earnings Call. The Disease Management Care Blog looked past the nascent optimism and went for the story behind the transcript – it makes for interesting reading because it tells us a lot about the disease management industry in general. I’ve culled telling (if sometimes awkwardly worded) parts of the transcript below and paired them with my industry insights. See if you agree:

The DM market is more than just outsourcing vs. not outsourcing by individual insurers - insurers are seeking to do both:

‘we believe the best in class solutions for health plans will always be a combination of in-source and out-sourced capabilities that are well-knit together.’

The U.S. business environment for DM is good:

‘continuing success in g rowing [sic] our domestic business can be found in the more than 200 contracts signed year-to-date.’

One reason it’s good is because there is demand for wellness intertwined DM:

‘we are seeing is a very strong shift and a rapid move for disease management and wellness programs to be integrated.’

Another reason why it’s good is because health plans want to use DM to avoid becoming commoditized and just paying claims:

‘pressure on the health plans to show their relevancy to do just that. So I think it is going to press them, as we’ve said for a long, long time, that at the end of the day it will be about outcome and that the market will pursue at a higher rate of expectation that you can deliver and improve those outcomes.’

And international markets too:

‘Our second central growth initiative is to expand our addressable market beyond our domestic business. One way we are doing this is through our international initiative…with DAK, the second largest statutory insurer in Germany….Brazil became our latest new addressable market with the signing of a ten year disease management services agreement with Fleury FA'

As far as we’re concerned, the debate about the science is over:

‘Twenty-one significant publications, nearly one-third of all the published peer reviewed outcome studies in our industry over the past ten years have evaluated our solutions and proven the value of the work that we do with our customers. Sixteen of these studies evaluated our disease management outcomes. Five evaluated results of health improvement solutions.’

Turning terabytes of data to information and information to insight are an emerging and important part of the business model:

'Gallup will make at least 365,000+ annual surveys for the next 25 years. Coupled with the deep clinical, behavior change and claims data Healthways will provide, the Gallup Healthways Well-being Index will…measure the health and well being of population(s) to guide strategies for improvement and to evaluate the effectiveness of selected solutions….We leverage one of the largest and diverse databases for health improvement on the planet. We maintain more than 200 terabytes of consumer data across claims, clinical, utilization and intervention support categories.'

What was not said:

Chronic care model, medical home.

We’re from the government and we’re here to help you with timely access to data, following the intent of Congress and complete transparency, not:

'What we don’t know any more than you do is where that data came from or have the opportunity for CMS to share with us how they came to those conclusions…we went public with a statement about request for that clarification….I think the one thing to keep in mind is the difference between any kind of financial reconciliation related to the Cooperative Agreement and the construct and concept and work that will be done to evaluate the performance of these pilots consistent with the way that the Statute was written. I think there is still confusion in the marketplace around the difference in those two things and it is going to be really important that you keep that in mind….I can’t draw any conclusion around it until I understand directly from CMS how they arrived at those numbers and for what time periods they arrived for it and what was their work done in being able to calculate relative trend lines and the rate of change that has to occur with remaining months.'

The Disease Management Blog has Industry Sponsors

The Disease Management Care Blog has been circumnavigating the blogsphere and noticed some of sites apparently have paying “sponsors.” It made the mistake of pointing these out to the spouse, and she wants to know when the DMCB is going to have them flashing/java-ing on its site.

That is obviously going to take awhile, but in the meantime the DCMB has generously created the Gratis Sponsors List of Honorees from our industry. It thanks these individuals and companies for their generous support:

Individuals

Platinum Diamond Sponsor:

Robin DeSurplus

Gold Sponsor:

Maximillion Hipparules

Silver Sponsor:

Anita Moreoutcomes

Paul Tredata

Ivana Savemoney

Companies

Creative Conclusions Inc.

Shake It, Bake It and Take It Predictive Modeling, LLP

Wholesome Wonderful Betterness Wellness R Us, Inc

By the way, Health Wonk Review is up. The DMCB missed the deadline for submission but it still makes for great reading at Joe Paduda's site. Check it out.

boiling blood

I can't stop thinking about this story.

This should never, ever have happened. And so many medical professionals contributed to the problem.

It makes me furious.

Beverly Green, who is featured in this article (and was on the front page of the Globe and Mail last week end) is 45 years old and dying of liver metastasis. She found out way too late that she should have been given Tamoxifen.

I know that the government review being conducted will not lay criminal responsibility but I would really like to see some heads roll.

Hospitals, P4P, Non-Payment of Medical Errors, Performance Guarantees and Disease Management

While the disease management care blog has been aghast at Dancing Priscilla’s botox overdose and egregiously bummed over Robert Plant’s decision to tour with Alison in lieu of Jimmy, at least it has a 2008 Yes Tour to look forward to. In the meantime, it will make do with CBS’ on-line streaming of March Madness, which includes a video player with “boss button.” Click it and a spreadsheet will cover your screen.

The DMCB thinks bosses should be pleased if their employees regularly log onto this web page, so no boss button is necessary. Read on, leave it up and be proud. In fact, forward the link to the big guy: you'll be thanked.

Speaking of CBS, it has another interesting bit of news video that describes a medication error involving the newborn Quaid twins. While the pharma's tone deafness in a separate video makes for creepy viewing, readers may be more interested the implications of what CBS offers up as one solution: hospital package pricing with “performance guarantees” for an the episode of care that extends beyond the initial hospitalization. If the patient needs to be readmitted, that cost is generally covered. For those readers interested in methodology, this has been described in one publication using a pre-post study design in a setting of dubious generalizability.

What’s more, the lack of detail makes the DMCB suspect performance guarantee contracting is actuarially neutral, i.e., priced to account for an expected rate of complications. That may be one reason there hasn’t been a stampede among health insurers to adopt the guarantee approach. Rather, they seem to prefer sticking to their pre-existing fee schedules and turning up the heat with more blunt approaches of carrots (P4P bonuses) and sticks (non-payment for medical errors).

The DMCB asks: who cares? Hospitals will need to improve their in-house care processes but that alone is not sufficient. There is considerable literature showing better patient preparation prior to an elective admission is important and that post-discharge planning often goes awry. Enter the disease management companies which can add value across a wide number of inpatient conditions and their associated episodes of care. For example, they have resources that may be of use prior to surgery in helping patients choose their best treatment options ahead of time, and they have a track record of reducing readmissions once patients are discharged. This may not apply to all conditions treated all ways in all hospitals in all settings, but there is some merit to this approach.

As the pressure grows to increase quality and avoid errors, hospitals may soon turn out to be another customer of disease management companies. In other words, in the opinion of the DMCB, these companies may be able to help secure the bonus, avoid the unnecessary readmission or fulfill the guarantee.

feeling well. and irony noted.

I had my regular oncologist appointment today.

The thought occurred to me, as I readied myself to go, that I am feeling healthier these days than I did before my diagnosis.

It took cancer to get me to take care of myself.

Obesity & Disease Management: Why the Industry is Happy to Fill a Vacuum

So just what is going on with obesity and disease management?

While persons with obesity have greater claims expense, insurers and the actuaries that advise them are unsure if programs aimed at reducing the severity and prevalence of obesity in a covered population truly result in savings. Accordingly, they fear that if they cover obesity treatment, medical costs will not only remain high, they’ll have to bear the cost of a richer benefit.

Health insurers' customers don’t want to hear that. CEOs and human resource leaders have looked at their insurance premiums and the body habitus of the employees in their cafeterias, assembly lines and cubicles and have concluded that there is a causal relationship between obesity and the rising cost of health care. They have decided that addressing the former will mitigate the latter. They also believe that preventive and conservative obesity treatment programs will reduce the looming and unaffordable cost of bariatric surgery.

They don’t find much comfort in the argument that expensive up-front coverage of bariatric surgery will ultimately result in cost savings in the long run. They would rather avoid having to choose between the up versus downstream costs of obesity. Many employers have also not given up on the belief that their human capital is worth the investment in high value, cost effective and preventive health insurance. One market judgment beats five evidence-based medicines. It also beats five actuaries.

Whether they like it or not, health insurers are under pressure to do something. For employers who are self insured, they’re also prepared to do something.

And how has the traditional health care system responded? Except for a few successes, the silence has been deafening. While physicians can use a wide range of diagnosis codes (making the DMCB doubt the contention that obesity treatment is not “paid for”), their training and the traditional one-on-one care approach to care has been ill-equipped to provide lifestyle counseling. It has also been simply out-numbered by the sheer volume of persons with obesity. Other resources, such as registered dieticians or nutritionists, are too few or hospital-based.

In the meantime, obesity has long been addressed as a co-morbidity by disease management programs; contrary to popular opinion, it’s been years since they confined their care protocols to single disease treatment. They have been including weight management as part of their approach to chronic illness for years. Given their pre-existing treatment protocols, infrastructure and willingness to sell population based approaches for any condition at the right price, they have been more than willing to fill the vacuum created by the growing prevalence of obesity, the demand for affordable treatment as well as the inertia of the traditional health care system. They have been more than happy to respond to the “do something” described above.

The disease management care blog is unaware of any studies that describe the number of persons in or the revenue from commercial disease management obesity programs, but it suspects the numbers are considerable. Surprised? Don’t be, because they have an understandable product at a reasonable price that promises an alternative to hidebound traditional medical care, high cost pharmaceuticals and even higher cost bariatric surgery.

Oh, and last but not least, it’s ironic that weight loss medications and bariatric surgery are most effective if they are paired with ongoing counseling and follow-up. Care to guess if the disease management industry is ready to get paid for this too?

dreams

I have recurring dreams.

And while I don't remember all of my dreams, there are some that stay with me very vividly. I don't believe that all of my dreams have great meaning (and some make so little sense when I wake up that I don't even try to ascribe meaning to them) but sometimes, I really feel that my dreams relay messages from my sub-conscious.

I still occasionally have a dream that I am back in university. It's time to write exams, only I haven't been to class (OK some of this did actually happen in real life). In fact, I had no idea that I had even signed up for that particular course.

It's very stressful.

In a recent version of the dream (and I have had this one more than once), I have had to quit my job and go live with my parents, since I have just found out that I did not complete high school. In this dream, I can't even find the school office to get a copy of the class schedule. As the end of the school year approaches and exams loom, I realize that I have not attended a single math class (I don't even know where the classroom is).

At the most stressful periods of my working life, I found myself back in grade school (it is not fun being the only adult in Grade 4).

When I was pregnant with my first child, I dreamed that I gave birth to a chicken. I was horrified. I knew that I was supposed to love that chicken and I was wracked with guilt that, instead, I was repulsed by it. I was especially terrified at the prospect of breast-feeding the chicken.

Several months later, I dreamed that I gave birth to a golden retriever. I took that as a sign that I was making progress in my mental preparation for motherhood. I still didn't know how I would breastfeed a puppy but at least the creature in the crib was mammalian (and the thought of cuddling with it did not freak me out. I have never really liked birds).

In the year before my cancer diagnosis (my last year of working crazy hours), I dreamed that I had inherited a house. After living in it for some time, I would always discover that the house had another floor to it, one I had not known existed. This attic didn't always look the same but it was always beautifully furnished, dusty and fairly vast. My feeling upon discovering it was always wonder, mixed with a lot of fear and some excitement.

I took that one to mean that there was some aspect of my past that needed exploring. Perhaps I was also telling myself that I was neglecting some part of who I was.

More recently, I have been having a dream that is likely related to the unexplored house. In this one, I am staying at a large hotel. It always looks different and the location and reason for travel also vary. But in every dream, I get locked out of my room and I can't find my keys (this is something that happens to me almost every time I travel. And I lose keys all the time). I spend the rest of the dream wandering the halls, trying to find the front desk or, if I succeed in getting a new key, I can no longer find my room. All the hallways and every floor look exactly the same. Or the numbers have disappeared from the doors. Or I get my key to work in a lock, only to find that door opens to an empty room (or one with someone else in it. I have had this happen in real life, except that in the dream, I am the only one who seems to be bothered).

It's not a panicky dream (like the school ones), just a frustrating one. Perhaps I am just feeling stuck and not sure how to get to where I want to go (and unsure of what the destination should be).

I think dreams can tell us a great deal about ourselves, if we can actually figure them out.

Thoughts? Feel free to psychoanalyze me or share dreams of your own in the commments.

A version of this was cross-posted to Mommybloggers.

Update on Medicare Health Support - Democracy in Action

Modern Healthcare Online (free subscription required for full access) is first out with an interesting story describing the letter sent by four U.S. Senators to CMS about the halting of Medicare Health Support. They are "concerned." Hints about which Senators are here and here.

More Background Facts on Obesity.

Yesterday’s posting on obesity prompted the Disease Management Care Blog to take a stroll through the obesity information market. The following factoids made it into the DMCB posting check-out basket. Here you are, in the order in which I pulled them out of the bags when I got home:

Here’s a good book on how U.S became one of the fattest nations in the history of the planet. Check out the economics behind high fructose corn syrup, cheap palm oil, supersized value meals and the demise of school based physical education.

And speaking of economics, it really does cost more to eat healthy.

According to Business Week, the estimate of U.S. obesity prevalence can be thought of as thirds: one third are obese, one third are overweight and one third are normal. Among the obese there is a category with a BMI of 40 or greater known as the extreme obese. This group comprises approximately 5% of the U.S. population. The 2/3 of the U.S that are overweight or obese represents a huge potential market for weight loss drugs, and the race is on to be the first to market with one that is safe and effective.

This report used NHANES data to show that medical expenses in the United States for being overweight (BMI 25–29.9) and obese (BMI greater than 30) added up to $92.6 billion in 2002. Prescription drugs currently are only $200 million.

There is a difference between “central” (where fat storage predominates in the abdomen) and “peripheral” (where fat storage is subcutaneous, often resulting in what has been described as a “pear look”) adiposity. Abdominal obesity is associated with a higher rate of disease burden, which may make measuring waist circumference a better disease-preventing screening tool.

The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline.

Bariatric surgery is a growth industry thanks to a 400% increase from 1997 to 2002. And yet, as of 2002, only 0.6 percent of the 11.5 million eligible persons had bariatric surgery. Partly to promote excellence, partly to protect market share and partly to preempt the creation of managed care networks, bariatric surgery centers can achieve status as centers of excellence.

For the managed care perspective on bariatric surgery, see this link. It comes down to safety and cost, in that order.

Unable to find much good news here, the DMCB is thinking of starting an 501(c)(3) advocacy group, named along the lines of “We Battle Obesity – So Are You.” We pledge to only accept pharmaceutical company sponsorship if its weight loss drug has an acceptable mortality rate. We will accept Bariatric Center of Excellence sponsorship if they agree to remit a portion of their surgical fee to the hapless primary care physicians that are supposed to provide follow-up for all these patients.

The DMCB anticipates a zero budget for the foreseeable future. I'll use some of that budget to review the implications for the disease management industry in an upcoming post.

a change is as good as a rest

And a rest is as good as a rest, too.

S. and I had a great time in Toronto. I really didn't do a lot of parenting, as S. and Grandma were pretty much inseparable. They saw a lot of movies, ate food that we can't keep in the house (nuts, peanuts and sesame, due to D.'s allergies) and just generally enjoyed each other's company.

S. also discovered bitstrips. How could a kid who loves comics and the internet resist?

And, as his proud Mama, I have to crow that he created comic strip embedded above, all by himself (yes, I swear he really is nine). "Susan" is a nom de plume (or rather the name of the adult whose account he was using).

And as for me, I slept a fair bit, did a bit (a very little bit after the first couple of days) of writing and spent time with really good friends.

I also did lots of walking. On Saturday, I walked the length of Queen Street from Coxwell to Crawford (and then up, almost to Bloor), about 10km (more than 6 miles). It was a really fun way to see a real cross-section of Toronto life.

I played tourist, too.

If you're ever in Toronto, you really should check out the following:

• go here, if you are a knitter
• eat here, if you like good, cheap food and a really relaxed atmosphere
• hang out here, if you like to take in a bit of history, enjoy artists studios or just like to drink locally brewed beer
• get take out from here if you like Caribbean food (you can't get good roti in Ottawa).

And there's more. I saved the best part for last. We drove (T. and D. had come to join us) home in record time. And no one puked.

JAMA Article about Obesity Disease Management

The publication of the Weight Loss Maintenance (WLM) trial in JAMA caught the attention of the Disease Management Care Blog. It’s one thing for patients to achieve weight loss. It’s another for that weight loss to be maintained.

The WLM trial is worth a close read because it a) rigorously tested state-of-the-art weight maintenance approaches that are typically used in disease management programs and b) provided an usually long period of follow-up.

The full study is available on line here. As a service to readers of the DMCB, I've provided a summary. To skip forward to lessons for the disease management community, scroll down to the bold text below.

In order to qualify for inclusion, persons had to have a BMI between 25 and 45 and have either high blood pressure or high blood cholesterol (heart disease and diabetes patients were excluded). Participants then went through 6 months of weekly group sessions consisting of diet (‘Approaches to Stop Hypertension’) and exercise advice. Persons who had lost at least 4 kilograms (about 9 lbs.) were then randomly assigned to one of three types of weight maintenance follow-up over 30 months: 1) personal contact (monthly 10-15 minute phone calls), 2) interactive technology (consisting of a personalized password protected web site) or self-directed care (some printed materials and goodbye). The study centers were Duke, Johns Hopkins, Pennington Biomedical Research Center and Kaiser Permanente.

The average starting BMI in the study participants was a generous 34.1. 1685 persons started the trial and 1032 (61%) managed to lose the approximately 9 or more lbs to qualify for the rest of study. The average weight loss was over those 6 months was 8.5 kg (18.7 lbs).

Over the 30 months of the study, the persons assigned to the personal contact did better than the web site or self care. Weight regain was 5.5 kg. (12 lbs) in the self directed group, 5.2 kg. (11.4 lbs) in the web-based group and 4 kg. (9 lbs) in the personal contact group. In other words, the personal contact patients avoided an average of 3.3 lbs weight gain. 42% in the personal contact group vs. 35% and 34% in the web site and self directed groups respectively stayed at least 5% below the entry weight. The impact on the programs on blood pressure and blood cholesterol went unreported.

Kudos to the authors for gauging the success of this program among a group of persons with special health care needs: African Americans. The subgroup analysis for these individuals revealed their program results were no different.

What are the lessons for the disease management organizations that offer weight loss programs?

First off, this study could have been titled “A study on the value of two already widely used disease management strategies vs. usual care for sustaining weight loss.” The researchers in this study saluted themselves for establishing the value of an “efficient and practical mode of delivery” but failed to mention that the personal contact phone call is in already place and available to millions of commercially insured persons who have access to disease management programs.

Personalized phone calls appear to work better than web-based interventions. I tried to get into the WLS web site to take it for a test drive but was unable to do so. It may or may not be as “rich” as commercially based programs’ web sites, which are constantly being updated and modified. Nonetheless, this is consistent with what disease management programs have known all along: high touch beats high tech. In other words, purchasers of disease management programs aka weight loss/maintenance programs get what they pay for.

Since the industry is constantly improving their web-based approaches to patient care, it’s hard to know if all commercially available web-based approaches to weight loss maintenance can be painted with the same WLS brush. In the estimation of the DMCB, that misses the point. In any population, there are persons who prefer web-based approaches. Persons with such a preference may be very successful in maintaining weight loss. That was not evaluated in this study. In addition, both web-based approaches and telephoney probably work better than either alone.

The disease management industry has a useful benchmark. Personalized weight maintenance follow-up can be expected to result in keeping about 10 lbs off among persons who initially lose 20 lbs.

National guidelines on the topic of weight loss recommend that one measure of the success of weight loss among persons with obesity is 10% of body weight. Using that very hard-to-reach threshold, this study was a complete failure. It’s depressing isn’t it? After all that time and trouble and state of the art treatment, persons with a BMI in the 30s lost about 10 lbs over the 2-3 years of the study. Reality check!

Last but not least, it appears that physicians were not involved. This may strike some as a threat to the profession, but a) physicians are typically not well trained in ongoing counseling for weight loss maintenance and b) the DMCB doesn’t think most primary care physicians are very interested in that kind of work anyway. That being said, it’s notable that the authors failed to note that one stumbling block to this “efficient and practical mode of delivery” may be a lack of physician buy-in in many usual care settings. The disease management industry knows this very well, but probably finds it ironic that this study was published in this journal named for the parent organization: the American Medical Association.

Notes from the Avalere Conference, Part 2

More notes from the Avalere Diabetes / Broaden Your View Conference in Washington DC:

New number to remember: Just out.... diabetes mellitus cost the U.S. $172 billion in combined direct and indirect costs in 2007. Compared to 2002, that’s a greater than 30% increase.

Be of good cheer, the peoples’ business goes on: Diabetes, of all the chronic conditions, is a high-visibility opportunity for Congress to experiment with Medicare and Medicaid coverage. Starting in ’09, look for a flurry of diabetes-specific ‘cost and/or coverage and/or quality’ legislative proposals, including new types of reimbursement approaches (including ‘care coordination’), support for HIT (including electronic records and registries) and redefining the term ‘health care provider.’ Absent fundamental reform, expect a majority of this to be “demonstrations.” Depressed at the thought of even more demos? Me too and during an question and answer session I griped about that. I was reminded that demos have a good track record of helping to inform public policy and building consensus. What's more, sometimes you need a demo to prove something really works as well as its advocates think it works, "MHS being a case in point."

Patient education is necessary but not sufficient: A speaker asked 'how many of you know you should floss?’ Many hands went up in the conference room. ‘How many of you flossed this morning?’ Far fewer hands went up.

New acronym that makes you sound smart: GWAS aka ‘genome wide association studies’ are surveys of genetic variations in persons with an illness that compare those variations to persons without an illness. If the variation appears comparatively more frequently among persons with the disease, it can be used to not only predict the risk of future occurrence, it can point to an underlying cause. The disease causing genetic variations that are treated by drugs like metformin and TZDs have been identified, and other genetic variations that may ultimately be amenable to yet-to-be-developed drugs are in the chute. Thanks to GWAS, we ain’t seen nothing yet when it comes to diabetes treatment options.

In addition to ‘CER,’ see how many other acronyms and first names you recognize: Federally supported Comparative Effectiveness Research (CER) has attracted the support of AHIP, the BCBSA, MedPAC, CBO, IOM, Hillary, Barack and Gail. Everyone agrees that ‘evidence’ in health care is poorly defined and inconsistent. Think the answer is more gold standard randomized clinical trials? Too bad, because they are unaffordable, too time-consuming and utterly unrealistic. Let the games begin.

Got graphs? Check out this treasure box from the CDC for your next PowerPoint presentation

Do the math: Wal-Mart has come to realize that persons with Type 2 diabetes are an important market segment. Wal-Mart offers meters n’ strips, all kinds of food, $4 medications, eye centers, and walk-in clinics. It doesn’t hurt that all those persons with diabetes need to walk past other yellow-smiley consumer goods and, while they’re at it, may also decide to use the Wal-Mart pharmacy to also purchase their higher-margin non-generics.

Once a week exenatide (Byetta shot)? You heard it here first. Speaking of the incretins, they are associated with weight loss and less hypoglycemia. One speaker predicted that formulary placement of this class of drugs may ultimately be driven not only by patient demand, but by the threat of a suit over a preventable episode of hypoglycemia.

And now for a word from a ringside seat in Massachusetts’ health reform: Adults that are a) working, b) childless and c) young have been the greatest winners in this initiative; elders, children, their parents and the poor had coverage options all along. Worshipers at the Single Payor Shrine of the Left and Supplicants of the Free Market Goddess of the Right continue to loathe this program, but contrary to headlines in the Boston Globe and editorials in the Wall Street Journal, the center is holding. Yes, the budget has been exceeded, but that’s because a surprising number of persons have signed up. The insurance premiums themselves are turning out to be on target.

Dr. Google: Think it’s just EHRs, registries and decision support? Think again, because in any given day, more people go online for health care information than see a doctor. Yet, the information is still hard to find, understand and contextualize. Healthcare entities that combine the provider and the online information in a consumer friendly format is destined to win.

After hearing about continuous glucose monitors, the Disease Management Care Blog believes their coverage should be contingent on participation in an accredited disease management program. Ditto pumps. And what if an endocrinologist is involved? DM companies should get out of their way outsource the care and pay the endocrinologist (and their CDE) a majority of the disease management fee received for that patient.

Notes from the Avalere Washington DC Diabetes Conference

Notes from the Avalere Dabetes / Broaden Your View Conference in Washington DC:

Newt Gingrich, former Speaker of the US House of Representatives and shy-not commentator on the failings of medical care: served as the dinner speaker and revealed that he and a colleague from Congress have penned a soon-to-appear editorial recommending the creation of the Office of the “National Diabetes Coordinator.” Big problems warrant big solutions. He also had countless and worn anecdotes that contrasted the “world that works” vs. the “world that doesn’t work” but a fav of the DMCB was the observation that during the time a UPS driver makes a delivery to an average physician’s office, the computing power in that office is temporarily doubled.

Dan Mendelson, President Avalere Health: Republicans, Democrats and policy makers have merged into a perfect storm on the need for 1) coverage expansion, 2) cost containment, 3) quality improvement and 4) health information technology. This will probably kick off the national dialog on diabetes and chronic illness care in January 2009. Nationally sanctioned “comparative effectiveness research” (CER) is being supported by a counter-intuitive coalition of policy makers and managed care organizations: they believe it will help rationalize coverage decisions. Device manufacturers and pharma are opposed because CER can be used to deny coverage for worthwhile or innovative treatments.

Other insights from other speakers:

The ABCs: Access to a healthcare service = adequate payment. Payment in turn depends on coverage, which in turn depends on demonstrable and meaningful increases in quality. This is best demonstrated in randomized controlled clinical trails (RCTs). “RCTs don’t necessarily need to be published, you just need to know the results.” A national office for “comparative effectiveness research” will help.

Woeful physicians: Much of diabetes care for physicians is an intellectual pursuit, not a money maker. Office surveys have shown that endocrinologists consistently underbill for their services, using the Level 4 E&M code an average 53% of the time, versus oncologists using Level 5 E&M 51% of the time. Billing for group visits, diabetes self management training and continuous glucose monitoring may improve patient care and endocrinologists’ cash flow.

Medicare Coverage of medical devices is more complicated than you thought: Absent a “National Coverage Decision” (NCD) from the Medicare program, “Local Coverage Decisions” (LCDs) are used regionally at a State level to adjudicate coverage of medical devices. LCDs can be determined by evaluation (literature reviews), regulatory considerations (which may hamper a LCD) and collaboration (new device manufacturers are encouraged to enter the LCD process as early as possible).

Are we worrying about the right things? Glycemic control does not substantially increase life span in older Type 1 diabetes and does not prevent the slow progression of cardiovascular disease in Type 2 diabetes. Only 33% of vision loss in Type 2 diabetes is due to diabetic retinopathy and 90% of the retinopathy that does occur can be successfully treated despite a high A1c level. Only 10% of persons with type 2 diabetes develop kidney complications and blood pressure control is more important than the A1c.

The Disease Management Care Blog also heard about insulin pumps. It wonders if coverage of pumps should contingent on participation in an accredited disease management program.