The Disease Management Care Blog Explains What p < .05 Means, or Everthing You Want to Know about Statistical Significance But Were Afraid to Ask

The prior post on Obesity and Fitness made reference to ‘statistical significance.’

What? Just what does this ‘p < .05’ mean? More importantly, can it be explained without resorting to opaque concepts that are outside the reach of the numerically challenged? Flushed with prior success over intrepidly tackling QALYs, the ever-confident Disease Management Care Blog volunteers to give the nettlesome 'p value' a try. It figures that some DMCB readers, from time to time, may need to grasp this notion when struggling with the meaning of some result being reported in the scientific literature.

It wishes it could take credit for the explanation that follows below. Rather, it witnessed a rather famous statistician use a simple yet instructive parable at a conference long long ago.

Imagine you are in a shady casino in the Wild West that fortunately lacks a check-your-gun-at-the-door policy. One of the dealers bets you that he can flip a coin and accurately call heads or tails. With each bet, the jackpot doubles. If he calls it right, he wins. If he calls it wrong, you win. Double or nothing.

On the first flip, he calls ‘heads!’ Sure enough, that’s what happens. He collects the money and you lose.

On the second flip, ‘heads’ is called again. He’s right and again you lose.

Third flip. Same thing happens. He calls heads and again you lose.

Fourth flip. Uh oh.

This keeps going until you conclude that you are being bamboozled. The question is when do you take out ‘Ol Bessie’ and plug the laying polecat cheater?

The statistician asked for a show of hands for voting yes, shoot the guy on the 1^st flip of the coin. A few hands went up, enabling the rest of the audience to spot the NRA members who were against gun control.

2^nd flip? Few hands went up. 3^rd flip? Few hands went up. The vote for the 4^th flip prompted a lot more hands. Most voted to serve up some Texas-style street justice when the huckster got it right 5 times in a row. No numbers, just intuition.

Those voting to give the dealer an acute case of lead poisoning on the 1^st flip had little reason to do so, because the chance of correctly calling heads vs. tails is 50-50. Calling it right twice in a row is also intuitively possible, though less likely. By the way, the chance of doing that is 1 in 4, or 25%. We’ve all seen some lucky people call it right after three flips. The chance of doing that is 1 in 8 or about 12.5%. Four times in a row and we begin to think something’s wrong. The chance of doing that is 1 in 16 or about 6%. Five times in a row is very unlikely and that’s when most people stop playing. That’s 1 in 32 or 3%. If it’s that unlikely, we naturally conclude something is wrong. The line has been crossed and it’s time for Mr. Shady Dealer to be introduced to the business end of Mr. Smith and his buddy, Mr. Wesson.

P < .05 is that line on the casino floor. It summarizes and standardizes that intuition using statistical processes. 0.05 or 5% is between 6% and 3%, that watershed region of probabilities when we naturally begin to discount randomness and start smelling a rat. That’s when we raise our hands at the conference and vote yes on the motion to provide some through and through ventilation.

The .05 means that there is only a 5% chance that the dealer, or in the case of the medical literature, the study authors, got the results they got because they happened to be lucky and randomly have the coin flips go their way. That low ‘p’ or ‘probability’ (less than 5%) tells us that there was something else that 'un' randomly caused the data to fall the way it did. The numbers were ‘pushed’ by something. Shady Dealer had a loaded coin, while scientists have the intervention such as a drug, some sort of surgery or a disease management intervention.

the day after

I don't know why I always do this.

Ahead of time, I plan on being in bed the day after chemo (sure) but I also imagine all the things I will get done. In particular, I always seem to think the day after chemo will be a good day to get writing done.

And it always, turns out that, in reality, I can't concentrate long enough to read a book, knit on an easy project or even answer emails with any coherence.

And I am always disappointed in myself.

I know that some women work right through chemo treatments but I am not 'some women.' I am me.

And I have to stop beating myself up about it.

And I need to learn to lower my own expectations of myself. It's just so weird to remember, when I am feeling so well and healthy most of the time, that just a few hours of treatment will make me feel this crappy.

I did manage to read (and comment on) two great posts at BlogHer today. Check them out and let me know what you think:

I Want To Like Eckhart Tolle's Work. I just Can't Get There From Here by Mata H.

Paying The Price Of Vet Care - How Much Is Too Much? by lauriewrites

John McCain's Health Care Plan and the Uninsurable--There Are Better Fixes Than the Ones He's Proposed

John McCain spoke about health care in Tampa on Tuesday and tried to answer many of the questions that have been raised about his health care reform plan.The most pressing question is how would people with preexisting conditions get health care coverage in his plan? The worry is that his plan emphasizes tax incentives for consumers to purchase coverage in the individual health insurance market

Overweight, Obesity & Fitness: And Now for a Different Interpretation

The Disease Management Care Blog did not watch all of Reverend Wright’s sermons, because it preferred to take the time to read the original Archives paper on the interaction of obesity and exercise for heart disease risk in women. The DCMB suspects the Reverend would agree with the need to go past the dour headlines, which suggest overweight/obese women are doomed even if they work to remain active and fit. Intrigued by another possible example of the mainstream media once again being mistaken, unbalanced and muddled when it comes to journal reports, the DMCB thanked the Archives of Internal Medicine for keeping the manuscript accessible and waded in.

Based on data from the Women’s Health Study (WHS), Weinstein and colleagues used ‘hazard ratios’ to examine the impact of weight and exercise on the occurrence of heart disease over an average 11 years of follow-up. Hazard ratios are a tool that approximates ‘relative risk,’ which compares risk against a baseline rate. A ratio of ‘2’ implies the risk is doubled. In this instance, the baseline comparator was made up of non-overweight active women.

Over 38,000 women were followed and just under a 1000 were known to have developed a heart attack, need heart surgery or other procedure or have a stroke. Other concurrent conditions, like high blood pressure and diabetes were statistically accounted for/'neutralized.'

While being overweight (a BMI between 25 and 29.99) and inactive increased the hazard ratio (risk) by about 1.9 (i.e., almost doubled compared to being thin and active), being overweight and active had a hazard ratio that was less at 1.5 (the risk increased by 50%). Being obese (a BMI of 30 or greater) and inactive had a hazard ratio of 2.5, which decreased to 1.9 when women were active. Never mind the thin/active comparator. For both categories of overweight and obesity, going from active from inactive appeared to decrease the risk of heart attack, heart surgery and stroke by about 20% (and for the methodologists out there, that’s assuming there are no confounding variables and that the association is causal - and BTW that the differences are statistically significant).

But wait - it gets better. The authors described physical activity not in terms of formal ‘exercise’ but in terms of time spent walking; it appeared 30 minutes a day conferred protection.

So, based on this study, doctors, disease management programs, health educators, registered dietitians and other professionals can tell their women patients who are struggling with weight to be of good cheer: relatively modest levels of exercise are associated with a 20% improvement in the risk versus being inactive. The bad news is that overweight and obese women can’t exercise their way down the same level of cardiovascular risk as a thin active woman.

But it’s not even that bad. Note the data above were casted in terms of hazard ratios. A better question is what is the absolute risk? It’s not apparent in the Archives article above, but the DCMB had little trouble finding the answer in data from the Framingham Study. Having a BMI from 25 to 29.9 has a total yearly cardiac risk of 1.9 per thousand per year in women, while the risk among the obese is 2.4 per thousand per year. In other words the risks are 0.19% and 0.24% per year. The DMCB suspects that while being overweight/obese can ’double’ the risk versus thin persons, that doubling is at the margins. In other words, obese and overweight women have a 99% chance of NOT having a cardiovascular problem from year to year - with or without exercising.

This study is better thought of in these terms: if you are a woman with a high BMI, your less than 1% per year risk of heart attack and stroke may be decreased by a fifth if you walk 30 minutes a day. Doesn’t that sound better?

And finally, if you took the time to read that preceding 1000 word soliloquy-post on 'risk versus retail' (I apologize to readers about that, the DMCB got carried away), the above obesity numbers might lend some insight on why health insurers have been reluctant to include obesity programs as a covered benefit. Absent diabetes or heart disease (where the risk is considerable and weight loss can make a big difference in chronic disease control), obesity alone is probably not a big source of risk for the underwriters. They probably believe reducing the prevalence of obesity is unlikely to make a big difference in claims expense. Better to let it go retail.

Post script: we in the U.S. are not alone.

Post post script: slightly off topic, but while the DMCB agrees obesity is leading to epidemic levels of diabetes, hypertension and heart disease, it recalls seeing many otherwise well if chunky patients who were seeking 'treatment' because of how their girth appeared. Maybe the anti-fat bias activists have a point: our perception of health (as well as beauty) is also becoming distorted.

is that my ass?

Wow. I really need to lay off the cake.

And where did D. learn that pose? I have a whole bunch of photos of him doing that, now.

Chemo today.

I'll probably be back online tomorrow.

Risk Beats Retail for Disease Management, Medical Home, P4P and The Electronic Medical Record

The Disease Management Care Blog has been thinking about the two healthcare R’s, risk and retail, from the consumer’s and insurer’s point of view.

Quantifying and pricing ‘risk’ is what insurance is all about. This intellectual achievement is described in Peter Bernstein’s marvelously written Against the Gods, the Remarkable Story of Risk. He describes how the business of risk really took off in England in the 1600s when shippers were willing to pay for financial protection against the unlikely but real possibility that a storm or other mishap would result in the expensive loss of a ship and all its cargo. The individuals willing to write their signature under the contract terms (hence ‘under’ ‘writers’) were shrewd businessmen who made a tidy profit by ‘pooling’ the payments (otherwise known as premiums) for multiple risks across many shippers for a defined period of time. Pooling (known as the law of large numbers) made the average risk narrowly quantifiable (‘X’ ships were known to go down every Y months) and bearable (a larger number of shippers paying the underwriter resulted in a ‘pool’ of money that was available pay for the one or two ships that would go down and later be used as props for the movie the Little Mermaid).

In the 400 years since then, ship insurance has been expanded to cover practically anything, including the risk of becoming sick. This is a great concept for the average consumer because the premium we pay today is far more tolerable than the individual risk of bankruptcy from a tumor, ulcer or a heart attack. As an aside, it's a powerful social good that warrants the oversight of a Department of Insurance in every state in the U.S.

On the other hand, consumers may find notions of retail to be much simpler. In this system, the insurance middleman is cut out. Goods and services can be packaged according to the market-based laws of supply and demand. Shippers and patients can shop and barter for the best service at the best price. Yet, when illness strikes, the market fails: quality and price are not transparent and there often is no time to make a good decision.

Of course, it’s not all black and white. Risk and retail are often mixed. Insurers feel they are being victimized by retail-style demand, while valuable retail health care is getting tired of being viewed as a cost by the insurer. While the insurer wants the best value for their dollar once they have to pay on a loss, it is still a loss.

Why is this important? In the opinion of the DMCB, the policy debate over many of the thorny issues surrounding the delivery of primary care services for the chronically ill have muddled the notions of risk and retail. On one side, altering the delivery of primary care with disease management support, chronic care model re-engineering, pay for performance or information technology is supposed to “pay for itself” thanks to the downstream mitigation of risk. On the retail side, these same services are supposed to increase efficiency (lower the price) or quality (at the same or higher price) or both, leading to a great deal for the consumer (and, by the way, a retail-based resuscitation of primary care). But it doesn’t stop there: most supporters of each of these primary care initiatives argue their merits lay in both risk and retail. As will be seen below, the difference is in what gets emphasized.

Unfortunately, the DMCB agrees the peer-review evidence of risk mitigation is inconclusive, making many underwriters leery about reducing the premium they charge consumers for the risk just because there’s disease management, a medical home, P4P or an electronic medical record (EMR). That leeriness is particularly understandable, because when you think about it, underwriters aren’t being asked to reduce the premium, they’re being asked to keep the premium at the same level and give a percent of it to support disease management, a medical home, P4P or an EMR.

The DMCB points out that while the ‘return on investment’ evidence may be less than perfect, the case for retail has gone mostly ignored and is probably weaker. ‘Concierge medicine’ and ‘minute clinics’ outside of chronic illness may provide some lessons, but to my knowledge no one has tested whether consumers with diabetes or heart failure would be willing to personally pay for remote coaching, the medical home, a lower A1c or an EMR-enabled practice. In the experience of the DMCB, patients want it if someone else pays for it.

So why so much blog? Because the DMCB believes the risk-retail distinction is less important in chronic illness care because the United States has already decided that risk beats retail. Like it or not, the vehicle for managing the expense of chronic illness care is not a financing issue, it’s predominantly an insurance issue:

• Pooling risk remains a powerful if imperfect methodology for making all illness care affordable, including chronic illness.

• It’s unlikely that much of a ‘retail space’ will be carved out just for chronic illness.

• The three remaining candidates for U.S. president and their allies in Congress are emphasizing insurance-based mechanisms in their campaign promises.

In the opinion of the DMCB, this landscape is why disease management has achieved much of its success. While there are retail virtues, its supporters have emphasized its ability to mitigate risk in the commercial insurance sector by: 1) presenting credible if imperfect evidence of risk reduction not only in the peer review literature but in its proprietary business dealings, and 2) has been willing to accept financial performance guarantees (a.k.a risk transfer), in essence rebating a portion of its fees if too many 'ships' end up in the emergency room. In contrast, supporters of the medical home, P4P or EMR have even less to show in terms of proof of savings and are unlikely to even give the money back if things don’t work out.

This has important lessons for supporters of the medical home, physician P4P and office-based EMR. Among the reasons why uptake has not been as widespread as disease management is because in an insurance dominated world where risk beats retail, their emphasis on the ‘retail’ dimensions represents cost to the insurer and hasn’t gained much retail support from consumers.

The DMCB asks if they will be come to terms with the world of insurance and the risk-based 'coin of the realm?' Be able to demonstrate a beneficial impact on insuring the risk of persons with chronic illness? Provide performance guarantees? They will, once the struggle to define their role begins with understanding the role of risk in caring for persons with chronic illness.

HMO Executive Earnings Are the Subject of Criticism--37 Execs Paid $277 Million in 2007

I have had two different emails today on the subject of health plan executive compensation.The first cited a link to an article in the Baltimore Sun that reports the $17.65 million severance settlement with the former CEO of CareFirst (Maryland Blue Cross) is under scrutiny by the State of Maryland.The second was a reference to an Industry Radar post that compares HMO executive compensation from

why we do what we do

Yesterday, we had my young son's birthday party at the noisiest place on earth.

Why? Because we love him and that is what he really, really wanted.

I cannot express how wiped out we all were when it was over.

But as I was towelling D. off after his bath last night (and boy did he need it. We all did!), I asked him if his birthday party had been everything he'd hoped for.

He nodded vigorously.

And then he said, "Actually, it was even better!"

So, I'd have to say that it was worth it.

And that I would do it again.

But I am really, really glad that birthdays come only once a year.

The Genetic Discrimination Bill Shows Us Just How Hard Health Care Reform Can Be

About 1990, I was a member of something called the Task Force on Genetic Testing at the then Health Insurance Association of America (HIAA). The health insurance industry realized that, with the Human Genome Project in its early stages, we weren't far away from genetics being a part of everyday health care and the Orwellian implications on us as insurance underwriters were not lost.The task was

Boeing Assembles the Ambulatory Intensive Care Unit - aka Medical Home

The Disease Management Care Blog has one more noteworthy plateful from last week’s World Health Care Conference Buffet Table. A representative from Boeing Corporation brought us up to date on one way to address a yearly $1.9 billion health care bill. Dissatisfied with the pace of incremental change, this company decided to pilot an “Ambulatory Intensive Care Unit.” Boeing was content with its disease management programs, but it decided more action was necessary. It targeted its sickest and costliest patients with a version of the medical home. Mercer was involved, but it was Renaissance Health’s predictive modeling program that found the approximately 700 patients that were destined to remain or become high cost. Three large clinics in the Seattle area agreed to participate in the program with 120 ‘opt-in’ patients. The clinics had to pass muster by developing the team-based support infrastructure and agreeing to develop a ‘Shared Care Plan’ for each of the participating patients.

It’s only just started, so stay tuned on the clinical and financial outcomes. The comparator group will be drawn from the non-participating patients.

But there were some interesting highlights:

• The patient encounters continue to be paid using the established fee schedule, but there is an additional monthly adjusted case rate that ranges from $25 to $100.

• The clinics have salaried physicians and there is no guarantee that the docs will personally share in the case-rate revenue. Boeing had some anecdotes suggesting the participating physicians were still very supportive.

• Multiple enrollee incentives were necessary and even then, only 20% of the eligible patients opted-in, even with a waiver of the co-pay for the medical home - AICU intake exam. What seemed to work best was a recruitment letter signed by the patients’ existing physicians.

• This is another example of the co-existence of the medical home and disease management in the same network.

what we did in london (part 3)

Wednesday, April 16th

My friend K., S. and I set out reasonably early (thanks to K. arriving at the hotel with good, strong coffee) to visit the Tower of London on Wednesday morning. I had skipped it on previous visits to London in favour of less touristy destinations but S. provided me with the excuse to make this historic site a priority (K. had been before but she happily joined us).

We took a little tour and did some wandering around on our own. The Bloody Tower and the Crown Jewels (which we visited twice!) made the biggest impression. I am never sure, on these occasions, how much my son is taking in. But yesterday, I was in his class for knitting club and the kids were asking about our visit to London and the Tower, in particular. One of the kids asked, "Which king was it who had his nephews killed?". I couldn't remember. But S. replied, without missing a beat, "Richard the Third."

I checked. He's right.

After a couple of hours at the Tower, the three of us found a heated patio where we could have lunch outside. Then we reluctantly said goodbye to K., who needed to return home to work and family. The visit went by so quickly!

S. and I were both sad to see her go but he perked up pretty quickly when I offered to take him shopping (back to Oxford Street) for cds (he had some cash from Grammy and Granddad to spend and he was pretty keen to do so. After he had managed to procure a Rolling Stones DVD set and some Doctor Who audio cds (read by David Tennant, the good Doctor, in his most recent incarnation) and I had found a Spike Milligan compilation for T., a very happy boy and I met Grandpa at the Statue of Anteros.

After we all had dinner, Grandpa took us to see the Thirty-Nine Steps (a comical adaptation of the Hitchcock movie, itself based on the novel by one-time Canadian Governor-General John Buchan). I love live theatre and it was a real joy to see S. get swept up. In fact, in a week full of wonderful experiences, S. consistently says that the play was his absolute favourite.

Thursday, April 17th

Thursday was the day we had set aside for the Doctor Who Exhibition. Expectations were very, very high as we arrived at Earl's Court but I have to say that they were met and perhaps exceeded.

I enjoyed myself far more than I might have without my excellent tour guide (the young S.), whose detailed knowledge of every episode of Doctor Who since the series was revived in 2005 is truly impressive.

That afternoon, it was time for something a little more highbrow. S. wanted to go to an art gallery and, based on Grandpa's recommendation, we chose to visit the National Portrait Gallery. I highly recommend this gallery, as much as a lesson in history as for the beautiful artwork. I especially loved the portraits of Mary Wollstonecraft (an early feminist, she wrote The Vindication of the Rights of Women in 1792) her daughter Mary Shelley (who wrote Frankenstein) and Lord Byron (check out the portrait. Doesn't it explain both his reputation and why he made women swoon?).

The Karsh collection is also truly wonderful (especially the famous photo of Winston Churchill, taken just after Karsh had yanked a cigar from out of the Churchill's mouth). It was also neat to see the photo of John Buchan, since we'd just seen the theatrical adaptation of his novel the previous evening.

S. and I both also enjoyed the Vanity Fair Portraits. We disagreed over the amount of time we wanted to spend in front of each portrait (a couple of minutes versus ten seconds or so) but he waited for me with tremendous patience. I was very proud of him.

One of the best things about travelling with S. is that we were both quite content to wrap our day up in late afternoon and head back to the hotel to lounge around for the evening.

And so we did.

How Do Keith and the Rolling Stones Do It?

Assuming this is osteoarthritis, maybe part of the apparently successful Stones' version of disease management for Keith Richards' hands is the music! Amazing.

what we did in london (part 2)

Tuesday, April 15th

My friend K. flew all the way from Holland to be with us! We were college room-mates almost twenty-four years ago and became close friends within minutes of meeting (I have very fond memories of being silly together and confiding in each other. She also went to great lengths to help me get over a broken heart. Our adventures included her taking me out on a sail boat so I could scream far away from human ears and to Vancouver, where we stayed at a seedy hotel and pretended we were all grown up).

We'd met up only three times since she graduated. She came to my home town for a few days that first summer and back to visit a couple of years later. Then we lost touch until 2005, when she came to Montreal for a conference and I took the train to meet her for dinner out and a pajama party. Every time we've re-connected, we've picked up the thread of our friendship as though it had never been dropped.

K. is a doctor now, with two beautiful daughters and a spouse who sounds like a great guy. We had a fantastic time together, talking, laughing and playing tourists in London.

That Tuesday morning, S. and I met K. at her hotel, which was just around the corner from ours. It was a beautiful day, so we decided to walk through Kensington Gardens towards Buckingham Palace, stopping for lunch on the way. We hung for a while outside the palace, went into the palace shop to get some souvenir baubles and then toured the Royal Mews. I have to admit that I would have skipped the mews if it weren't for K.'s suggestion that we go. And it really was fun. We saw the queen's horses,


and carriages (the most impressive of which was the one last used for the coronation in 1953).


I am not a monarchist but I was fascinated by the palace and its trappings. It's hard to imagine that these things and all that staff (most of whom actually live in flats on the palace grounds or in the mews themselves) actually belong to real people. How bizarre.

Once we were done with the palace, we crossed the street to buy a teapot. I know this is very cliche of me but this will be my third from this particular London store (the previous two were broken. I bought the first when I first went to London in 2000 and the second was a chemo present I ordered through the mail) and that use a particular kind of filter for loose tea. The three of us decided that I should spurn the more tasteful teapot for it's more garish counterpart.




Teapot in hand, we made our way back to the hotel, where we had curry, dessert and wine, courtesy of Marks and Spencer.

A potpourri of news: Wellpoint, American Well, Physician Travails, Inverness, SHPS and Nationwide Maternity Health

Commenting on the economics behind Wellpoint’s recent announcement that its last quarter’s positive earnings were lower than the first quarter of 2007 is outside the Disease Management Care Blog’s comfort zone. Nonetheless, the DCMB is smart enough to discern that the drop in earnings was largely due to an increase in claims expense sprinkled with some hits in investment (known as the ‘float’) income.

Wellpoint apparently intends to fix this by increasing premiums, riding the underwriting cycle and ramping up its ‘medical management’ activities. That presumably includes its subsidiary HMC. As further evidence of Wellpoint’s belief in the role of population-based care solutions to managing the business, the DMCB points to WellPoint’s recent acquisition of Resolution Health.

At the other end of the care spectrum, check out a ‘webilicious’ individual health care ‘solution’ called American Well. It achieved something of a starry-eyed rushing-the-stage rock star status at the last HMCC and Health 2.0. This privately held company will offer up a stable of primary care and specialist physicians who can provide fee-for-service virtual visits by phone, video-conferencing, telephone, chat, messaging and voicemail. The Disease Management Care Blog suspects the participating physicians won’t be ‘owned’ by AW, which means they’ll probably be paid FFS while AW keeps a cut. Other sources of revenue will include licensing and install/maintenance fees for entities like health insurers. The DMCB believes AW will ask its contracted health insurers to make its claims data available, so the physicians can access some version of past medical history during the encounter. [Yawn]. One more grab at a marginal piece of the broken one-on-one system of health care. Those of us who believe in population-based care solutions will probably fail to see how this will meaningfully address The Pressing Health Care Issues Of Our Time. What’s more, the DMCB suggests docs aren’t dumb and will quickly figure out how to cut out the middle man with their own IT access solutions.

That doesn’t mean docs are necessarily able to spot the bigger threats to their profession. Check out this interesting perspective at the Patient’s Doctor Blog. Physicians are consummate personal consultants who haven’t been given the skills to come up for air and look at the needs of the community or society. [Sigh].

Readers may recall that Inverness was pummeled by Wall Street following the announcement that it was acquiring Matria. Guess what: it’s alive and well. The DMCB continues look forward to seeing how this alliance of gadgets and disease management works out.

Forget about wondering just what ‘S’ ‘H’ ‘P’ and ‘S” actually stood for. You can start referring to it as ‘Carewise Health.’

And last but not least, Nationwide has a press release announcing a tripling of NICU savings with a maternity management program. When the DMCB went to the press release, it was unable to find the materials and methods behind the conclusion. There was also a “Get the Facts Scientology Video Channel” click ad in the middle of the web page when it loaded.

What Good Has Private Medicare Done for Shareholders?

Wall Street seems to have lost faith in publicly traded HMOs.When the Medicare Modernization Act was passed in late 2003, it was seen as a major boon to the health plan business. Without a doubt the revenue and profits that have accrued from the privatization of Medicare have been more than substantial.But what good has Medicare privatization done for shareholders?The first week of January 2005,

Diabetes and the Government Sponsored Disease Registry of New York City

Registries. Everybody loves ‘em. These data bases promise sorting, insight, planning, action and improvement, right? Government should not only support them, but maybe even sponsor them, right? Use them to create documents with maps, hm?

Not so fast. The April 28 edition of the Archives of Internal Medicine (not online at the time of this posting) has a well written pro vs. con debate on the topic. Specifically, New York City (that's a map displaying the burden of disease in the 5 boroughs) is requiring that all its laboratories forward A1c results and demographic data on all persons with a diagnosis of diabetes mellitus to the NYC Department of Health and Mental Hygiene. Once patients are in the data base, they will be given the ability to ‘opt-out’ of being contacted. If there is no opt-out, patients with an A1c greater than 8% will be alerted by letter and sent education materials. The ordering physicians will also receive alerts along with treatment recommendations.

This is a slight twist on a familiar subject for readers of the Disease Management Care Blog. This debate centers around government sponsored registries. There are still some important lessons.

The ‘pro’ article by Drs. Littenberg and MacLean of the University of Vermont has the all the usual arguments and then some. Registries have been used to conquer other scourges of mankind. They track incidence and prevalence. They enable program budgeting, planning and refinement. They provide insight about the quality of care by geography. They’re part of the Chronic Care Model, and that’s good, right? They also enable the follow-up of individuals. The reason why other registries have a single digit opt-out dropout rate is because patients are good citizens. Registries are expensive and government funding guarantees success.

Dr. Trief and Mr. Ellison rise in opposition to the motion. They note that public health registries were created to help combat communicable infectious disease, not chronic illness. They looked for studies that examined the link between A1c self-awareness and diabetes control and could only find one - and it apparently demonstrated no link existed. Another study is quoted that failed to find an association between the use of a registry and health care utilization among persons with diabetes. What’s more, other studies that gave alerts (for example, fax) to physicians for other conditions failed to show much improvement. They also feel the downside risks also cannot be discounted. The appearance of government intrusion could prompt patients to stay away from their physicians, the New York City registry could be ‘hacked’ and patients may be justified in worrying about how their data could be used against them in the future. While not so clearly stated, they indicate a registry is helpful when it is integrated with other quality enhancing initiatives – which are lacking here.

The DMCB is inclined to agree with the ‘con’ perspective, especially the patient dimensions – and not just because the 'pro' authors are from the People’s Democratic Swedish Republic of Vermont. Being a blog, however, it can’t help adding some other 'con' POVs by opining that while this is a well-meaning initiative, physicians are becoming saturated with prompts, nudges, reminders, alerts, warnings, cautions and alarms from well meaning good-doers using faxes, screen prompts, emails, calls and letters containing guidelines, lists, recommendations, contact information, disclaimers, bar graphs and HIPAA boilerplate. New York City’s foray may provoke registry-fatigue or even blow-back from the docs and what’s worse, give the government sponsored population-care a bad name – not only because stand-alone registries don’t work very well, but because they also annoy docs with false positives.

The DMCB can't tell if the NYC Department of Health understands notions of private-public partnerships, which would allow it to use this otherwise good idea to enable a number of other population-based care options. Does anyone have any insights to share?

In the meantime, the Archives invites readers to submit their own 250 word, clearly labeled “pro” or “con” abstract to their journal. If selected, you’ll be invited to author a full manuscript on the topic for peer review consideration.

Addendum to my post on quotes from the WHCC: My physician colleagues from internal medicine will enjoy a learned description from a surgeon who, during a presentation on the topic of medical devices, shared his insight about a key feature of nanotechnology: ‘it’s really really small.’ Yup.

Health Care Reform Will Be a Long Shot in 2009

Many people, me included, have compared the recent resurgence in calls for health care reform with the big debate we had in 1993 and 1994 and the expectation back then that we would see major health care reform. Of course, all of that focus on the issue ended with the failed Clinton Health Care Plan derailing health reform for at least 15 years--and counting.Each of the remaining candidates for

what we did in london (part 1)

I can't believe it but I am still jet-lagged. I have been in bed by nine every night this week and I could be sleeping the day away as well, if I'd let myself.

It was a really great week, though, and totally worth it. For those who've been asking, here is a more detailed account of how we spent our days:

Sunday, April 13th

We arrived in London early in the morning (but two hours later than scheduled) and took the Heathrow Express to Paddington Station and walked the two minutes to our hotel.

Happily, we were able to check in early and our room was a pleasant surprise (other than the overwhelming smell of bleach). It was much bigger than I had expected, and bright, with windows that opened and laminate flooring instead of carpet.

We both crashed for a couple of hours (and I witnessed my son sleep-walking for the first time that I can remember) and then set out to meet my father-in-law who was in town on business. We had a late lunch and strolled from Regent's Park to Oxford Street where we went to Hamley's (truly the most marvelous toy store I have ever visited).

That night, we had Indian curry at a little hole in the wall that was a favourite haunt of Ghandi's when he was a law student. We got home on the tube (after a couple of false starts), despite the fact that we were both hysterical with exhaustion.

Monday, April 14th

We took the a double decker bus from Paddington to St. Paul's Cathedral (a lovely way to get a better sense of Central London).

We walked across the Thames to the waterfront (I couldn't convince S. to get on the London Eye) and toured the Movieum (movies are my son's latest obsession). At twenty pounds for both of us (I had to stop converting to Canadian dollars every time I paid for something. London is expensive), this place this place was a bit of a rip off. Some neat stuff from sets but far two many cardboard cut outs and movie posters.

S. loved it, though.



I thought the animation wing was the best thing, with a comic book illustrator at work in his studio, taking time out to give lessons to the kids who dropped by. We both thought that was pretty cool.

After the Movieum, we went to the movies. After watching the Rolling Stones do their thing (and directed by Martin Scorsese) on a giant screen, I now, finally understand their appeal.

After the credits rolled, we headed home (on the tube again, we didn't take a taxi once the whole week), after stopping to pick up dinner at Marks and Spencer Simply Food (we did this almost every night. S. loved it. We would walk into the store and I would say, "Pick yourself some dinner." We would each get what we wanted, with dessert for him and wine for me and take it back to the hotel to heat up and eat).

S. did some impressive air guitar back in our hotel that evening.

Employer-based Tobacco Control: Scotts Declares War

On its way out of World Health Care Congress meeting, the Disease Management Care Blog listened in on the last plenary session with Jim Hagedorn, CEO of Scotts Miracle-Gro, Inc. He has a reputation for being a straight-talking former F-16 fighter pilot and he did not disappoint. Once again, the topic was on how the employer-based health-insurance sector isn’t going to hold its breath while government and policy makers slog along.

Want to work at this company? Well, you better not use tobacco, or at least figure out a way to beat the screening test. You can read all about it here. Mr. Hagedorn didn’t offer any particularly new information but the DMCB came away with some impressions:

This isn’t principally about the money: Persons with a military background aren’t necessarily predisposed to subtle distinctions. Tobacco is a preventable and treatable behavior that leads to disease and death among employees. Scott’s CEO has declared war.

CEOs are becoming health-industry experts: It was pretty obvious that Mr. Hagedorn was familiar with the science of nicotine addiction. He seemed to have more than a passing familiarity with much of the lingo that has heretofore been confined to us medical types. And why not? Health care costs chewing into cash flows. The days of assigning this to some cubicle down in the Human Resources department are coming to an end.

The ‘automobile insurance’ analogy was raised again: Just about everyone has a car and understands how premiums are tied to the imperfectly fair co-morbidities (lots of chrome or excess of horse-power) and excess utilization (accidents). There are important differences compared to health insurance, but the DMCB wonders if this analogy will flavor future national debates or local purchasing decisions when the employers are involved.

phoning it in

I had an appointment with my oncologist today.

When we arrived at the cancer centre there was a line-up for the registration desk, which appeared to be staffed by someone who was new at the job (I actually muttered to the woman behind me,"It looks like they have the B team on today." Don't judge me. The cancer centre makes me cranky). I stood in line for twenty minutes, only to be informed that my oncologist was running an hour behind.

The waiting room was absolutely packed with grumpy people. At one point, I turned to T. and said, "I loathe this place. I don't just dislike it a little. I really and truly loathe it."

Then I saw my oncologist. It was a very strange appointment. I had no concerns about my health to discuss and neither did he. He told me that I look great. We chatted about our families. He also said that it's silly that I have to come into the cancer centre and wait around for him when we have nothing to talk about. He asked me if I wanted to start doing my appointments over the phone.

I jumped all over that offer.

I still need to go and see him in person every three months or so ("when it's convenient" or when I feel the need to see him). I will continue to have regular tests and scans and to have treatment once a month. But no more waiting for hours to see the oncologist, "just to say hello."

I love that man (and so does my spouse. I am so glad that he was there with me today because my oncologist is so reassuring. I think it might have freaked him out a little if I had come home today and announced, "I don't have to go and see Dr. G. in person any more!").

Dr. G. mentioned again today that cancer is a chronic illness ("like diabetes") that needs to be monitored, treated and managed over the long term. If we see any spots, we will deal with them. And when we need to, we will begin a more aggressive course of treatment.

He also said that there are so many new drugs to treat cancer now that he can barely keep track of them all. He also said that "it's a very exciting time."

This really does make me very hopeful. I am very glad to know that when the time comes to ramp things up again I will have so many options. And that a doctor who is smart, compassionate and really good at his job will be helping me to make treatment choices.

But until that time comes, I am very happy to just phone in my appointments.

Wall Street Continues to Be Disappointed in Managed Care--Just Where Did They Think It Was Headed in the First Place?

United Health's earnings and revenue grew by 7% this quarter year over year and the stock fell by almost 10% yesterday.I'd hate to see them really screw up.United is the first to admit that they have some service and persistency issues but the fundamentals of their business continue on track.Wellpoint followed with another disappointing report today.Wall Street finally seems to be figuring out

Secretary Leavitt, Secretary of Health and Human Services, Speaks at the World Health Care Congress

Michael Leavitt, Secretary, Department of Health and Human Services spoke at the April 23 session of the World Health Care Congress on the topic of the value driven health care system.

He noted a study from Harvard has just been released showing that life expectancy is decreasing. This gives greater urgency to the topic of reform. Health care must change and while it may take a decade, the success or failure of pulling this off may define the success of this generation.

This value-based movement is underway and is made up of a broad spectrum of stakeholders who represent a chance at ‘real reform’ for a system that was built on volume. Secretary Leavitt thinks of advancing value as a function of the “Four Cornerstones.”

Standard Measures of Quality – there has been a large increase in the number of measures but the methodologies remain fragmented among the multi-participant quality enterprise. He believes we need national standards, hopefully that are sufficiently endorsed. He implied that if they are not available, CMS is prepared to ‘push the envelope.’

Standardized Cost Comparisons – best done if performed using ‘grouper’ methodologies, but it’s also hampered by a lack of speed and opaqueness. Secretary Leavitt gave kudos to the Robert Wood Johnson Foundation for helping to accelerate this process. He’d like consumers to be able to scrutinize bundled knee surgeries with the same ease of checking a potential car purchase. If methodologies are not available, CMS is prepared to ‘not let the excellent be the enemy of the good.’

Interoperable Electronic Medical Records – we’re not there yet, but we are getting closer. CCHIT process is a good step forward and has been applied to 75% of the EMR products out there. He finds the uptake of EMR among hospitals and large practice groups gratifying and knows that small practices cannot afford it. CMS is piloting “Personal Health Records” and is confident that consumer involvement is destined to increase. ‘Payments at the highest level for providers should be linked to physicians who interact with CMS at the highest level.’ One ingredient of the highest level is electronic connectivity.

Incentives to Seek Value – aka eliminate duplicative services and low value services with ‘carrots and sticks.’ This includes using financial incentives to encourage patients seek out high quality lower cost physicians. This will need to be transitioned in multiple markets over time, but according to Secretary Leavitt, it’s got to happen and it’s going to happen.

Fourteen Chartered Value Exchange (CVE)’brands’ have been awarded by CMS on the basis of adherence to the Four Cornerstones, acceptance of national standards and local provider buy in. He hopes more will be awarded and the system will eventually become self-sustaining.

Question and answers:

There are two competing philosophies when it comes to reforms: government ‘owns’ the system vs. government ‘organizes’ the system. He favors the latter as a force in the health care sector (he distinguished that from the inaccurate term ‘system.’)

Insurers are destined to not only pool risk but deliver information to their enrollees.

Who pays? The answer lies in the transition problem. Between ‘here’ and ‘there,’ the costs of transformation will increase but the pay off will more than make up for it. (comment from the DMCB: not everyone who bears the cost in the transition period will be the beneficiaries of that return on investment).

The American Medical Association Point of View at the WHCC

Question: So what is the perspective of the American Medical Association on the critical issues confronting health care today, such as transparency, pay for performance, health information technology, value-based purchasing, chronic care enhancements, employer based reforms, consumer cost sharing, patient accountability, bundling payments, single payer systems, European models of care, cost effectiveness studies, predictive modeling, disease management or the patient centered medical home?

Answer: We are opposed to Medicare’s planned 10% reduction in physician reimbursement.

The Top Three Approaches to Health Care Reform from Three Points of View

So here’s something that sounds like an old joke: a businessman, a physician and an economist walk onto a wired-for-sound dais and are asked to list their top three elements for health care reform. From an afternoon session of the April 22 World Health Care Congress:

Webber of the National Business Coalition on Health:

Payment Reform: stop paying for volumes of units, pay less for specialty care, more for primary care, go with pay for performance, increase the role of market forces, decrease fee for service and increase bundling.

Consumer Activation: leverage this and help them choose high performing options

Total Quality Management: promote process engineering, technology, metrics and tracking.

Tooker of the American College of Physicians:

Primary Care Base: it needs to be strengthened with the Patient Centered Medical Home

Patients First: to do this, adopt the primary care physicians’ proposal for the Patient Centered Medical Home.

Financing Reform: uncouple physicians from financial incentives that lead physicians to do more by paying for the Patient Centered Medical Home.

Reinhardt of Princeton:

Health Information Technology: Data is already retrievable on every doc’s orders, which means payors and purchasers already have the resources to compare physicians and hold them accountable.

Comparative Effectiveness: And don’t let the U.S. government ‘house’ this. Rather, use an endowment mechanism to set up one or more independent entities that use open source data. The market will know what to do with its non-binding insights.

Payment Reform: bundle payments by paying per treatment episode, and be willing to include health (not just sickness) management as well as sticks and carrots that incent the right kind of patient behaviors.

World Health Care Congress Quotes for Your Reading Pleasure

Quotable paraphrases heard at the World Health Care Congress:

'Wonder if you need an online personal health record? No? Well... did you wonder if you needed a BlackBerry?'

New title for mothers: 'Family Health Managers' or 'FHMs.'

'It’s not the best hospital, it’s the hospital [or doctor] that best matches the preferences and values of each patient.'

Have high deductable plans interfered with disease management program enrollment? Answer from a disease management vendor: 'No.'

Following a four presenter lengthy one hour nostrum-filled, earnest, wordy, complicated, disorganized and biased PowerPoint session on a multi-party disease management initiative attacking diabetic eye disease for a major Blues Plan, the DCMB asked if there was any impact on HEDIS rates: “Don’t know.”


'How many of the persons in this audience WALKED to school?' Vast majority of hands went up. 'How many of your CHILDREN walked to to school?' Very few hands went up.

Obesity and Smoking--One Step Forward and Two Steps Back

Young Americans risk being the first generation whose health status will be worse off then the last.I have repeated that prediction many times but today it looks like tomorrow is here.A study by the Harvard School of Public Health and the University of Washington and published in the journal PLoS Medicine now tells us that the overall of life expectancy of many Americans has actually been in

Is the Bush Administration in Favor of Provider Transparency and Accountability or Aren't They?

Brian Klepper has shared an open letter he and Michael Millenson have written to HHS Secretary Leavitt regarding the issue of provider information transparency and the Department of HHS's apparent contradiction with its own policies.An Open Response To HHS Secretary Michael Leavittby Brian Klepper and Michael MillensonA few months ago, the two of us – both long-time advocates for transparency and

What is Minnesota BCBS Up To?

The Disease Management Care Blog attended a session describing what Minnesota Blue Cross Blue Shield has been up to in the ‘medical home’ arena. As regular readers will recall, this particular Blue was one of the reasons why Healthway’s stock experienced a recent price decline following the announcement that it may withdraw from its contract.

It appears that Minnesota BCBS was petitioned by a number of provider organizations to support a ‘medical home’ in lieu of traditional disease management. The experience with one 400 physician medical group was very telling. This particular group had an electronic health record with registry support as well as physician-led teams staffed with non-physician practitioners. Minnesota BCBS agreed to give it a try and turned off the disease management for the patients assigned to this clinic. Over time, there was a meaningful improvement in clinical outcomes. Minnesota BCBS took the next step and compared the medical home-enabled clinic’s outcomes data to another similar clinic that still had live disease management. They found that the improvement in outcomes not only appeared to be significantly better compared to the convenience control clinic, but that there was also a meaningful difference in per member per month cost favoring the medical home.

Based on what the DMCB heard, this doesn’t mean Minnesota BCBS is prepared to cover all versions of the medical home throughout its network starting tomorrow. For example, the pilot above did not include any changes in reimbursement. However, other clinics have expressed an interest offering this and there are efforts underway to develop a payment mechanism. “It’s worth our time to work with clinics that have medical homes.”

Without being prompted to do so, the speaker pointed out that he believes the “call center” function works better in a central location that is supervised by the insurer. The intrepid DMCB asked about this, and the reply was interesting but unsurprising: a “distributed” call center function spread out among multiple clinics is destined to be higher cost: ‘we found one nurse can cover a thousand patients with CAD.’ The speaker suggested one way to approach this would be to allow the medical homes to individually or collectively “outsource” its telephonic remote support. To further support this, BCBS has had some positive experience in which remote disease management nurses were able to enter, interact with and document in the electronic health record for review by the care team.

Interesting stuff. The DMCB doesn't know if what is true in Minnesota is necessarily transferable to the rest of the United States, especially smaller clinics. However, it can't blame Minnesota BCBS for thinking about using its network for population based care while integrating the more scalable support functions from a central location.

my baby is five

For my darling D., on his fifth birthday:

You crawled into my bed this morning, and as you cuddled up with me, I lay there remembering the day you were born.

You came into the world in a real hurry (less than an hour of hard labour) and I remember your plump little body, your lusty cries and the pride on your father's face. When our midwife told us we had a little boy (a surprise, as you were uncooperative during the ultrasound), we knew right away that you would be our D. Your name is one I have loved since I was a little girl but the deal was sealed when S. declared it the perfect choice for his little brother.

We had to stay in the hospital for a couple of days (your little lungs experienced a bit of shock at the rapidity with which you came into the world). I remember how much I missed your big brother (this was during the height of the SARS crisis and only Papa was allowed to visit) but I treasured those first days alone with my new baby.

We had a fabulous maternity leave together (and I lost 48 pounds between your nursing and all the walking I did with you in the stroller). You were, from your first days, the social, engaged, loving, headstrong, mercurial child that you are today.

You are smart, funny, enormously charismatic, and full of wonderful insight into the world around you. It is a privilege to be your mother.

And to quote your own words back at you, "I love you as much as all the days."

More.




Cross-posted to Mommybloggers.

Employer-Based Health Care Cost Control: Lessons from Safeway

The opening session of Tuesday’s World Health Care Congress hosted Steven Burd, CEO of Safeway. In 2005, this company launched a 4-pronged, in-house health management program for its employees consisting of 1) financially incented behavior change, 2) cost transparency with increased out of pocket costs beyond reasonable charges, 3) a special emphasis on prevention and 4) not being shy about increased ‘personal responsibility.’ They’ve reduced their health care costs from $1 billion to just over $800 million despite a countervailing 10% inflation rate. He credits the success to application a Willie Sutton rule: focus on 4 chronic conditions by focusing on the circumscribed principles of behavior change (estimated to about a third of the savings) and transparency (about a half of the savings).

Take-aways:

While there is a societal good to the notion of pooled risk, Safeway is embracing the automobile-insurance’ish model: want a flashy car or have a lot of accidents, be prepared to pay a higher premium. It reminds the Disease Management Care Blog of an old adage: help the wounded, shoot the laggards.

'Shooting' may sound harsh, but Safeway is a high volume, low volume business with little room for escalating health care costs. Insurers and government aren’t moving fast enough for the Safeways of this world.

Given the stakes involved, U.S. CEOs are fast becoming de-facto health care executives with a depth of knowledge rivaling the best of the best in the traditional health insurance industry.

The mainstream principles of successful population-based behavior change seem far removed from traditional clinical medicine. That gap is remarkable and getting wider.

The tinkering continues and the program is continuing to evolve. Mr. Burd admitted that he surfs Google Health monthly looking for good ideas. This is very much a moving target. The DMCB wonders about the merits of companies moving their parking lots back from the workplace and limiting-slowing up the elevators/escalators.

Worried about employer-based health police? Maybe, but Mr. Burd said he and his HR department can’t access individual data and they’ve stopped short of firing obese smokers.

Presidential Candidates Healthcare Insights, Medicare's P4P and a Glimpse of Collaborative Care Systems

The Disease Management Care Blog offers some additional reportage on the April 21 World Health Care Congress:

A Panel Discussion involving advisors from the presidential candidates’ camps impressed Kaiser CEO George Halvorson. The DMCB agrees the depth of knowledge and amount of analysis was considerable, especially since each speaker only had ten minutes to speak. There truly was little sound-byte laden posturing. What was remarkable to the DMCB, however, was the novelty of the Republicans. While it appears the Democrats want to expand the current business-government based health insurance model, their opponents want to develop an individual purchase model designed to force market-based competition, possibly backed up by vouchers. Just who is being radical?

Another separate session taught the DMCB that unless Congress steps in with wacky steps to protect its constituent hospitals, we can expect CMS to get really REALLY serious about ‘value-based purchasing.’ They appear to really like the results of their Premier Pilot that hit the trifecta of increased quality, diminished variation and lower cost. Flushed with that success, more preventable conditions are being added to their P4P list. And what about the observation that patient complications and mishaps can occur despite the best of care? Tough, because a) ‘we’re not even close!’ meaning the majority of complications and mishaps are happening because of shoddy care and b) CMS has the statutory authority to go after ‘reasonably preventable’ conditions, not perfectly preventable conditions. In the opinion of the DMCB, CMS is in the hunt for some more badly-needed successes, even if it means using some very blunt tools.

The biggest disappointment was a panel discussion anchored on Clayton Christensen of the Harvard Business School. An intensely intelligent and earnest professor, Dr. Christensen forayed into the virtues of a thoroughly coordinated regional health care system. Maybe, but the DMCB is more excited by jargon that uses “collaborative” instead of “integrated” and “ecosystem” instead of “top-down system.” Silly and naïve you say? Maybe, but Boeing doesn’t own much of its manufacturing anymore; it uses a network of outsourced customers that are constantly shifting/improving their processes in an intensely supported IT environment that leads to the planes’ final lower-cost, higher-quality modular assembly. More on the implications of this for a later post.


And an addendum on Deep Dive (see below). If you accept that usual disease management is no better than a placebo/sham intervention or usual care, the lesson of Deep Dive is that the secret sauce of targeted enhanced care management is truly cost-saving compared to usual care.

Health Dialog takes the World Health Care Congress on a Deep Dive and We Liked It

A thoroughly caffeinated and excited-to-learn Disease Management Care Blog attended the first day of the World Health Care Congress. While there were a host of sessions presided over by the lesser and greater gods of the health care cosmos, the most interesting was hosted by Susan Dentzer (soon-to-be Editor in Chief, Health Affairs) on the “Deep Dive” clinical trial. The two presenters were David Wennberg MD, MPH of Health Dialog and Lance Lang MD of Health Net, Inc. Almost 190,000 (not a mistake, that’s 190 thousand) commercially insured patients from Highmark Blue Cross Blue Shield (east coast) Health Net (west coast) were randomly assigned to 'usual' care management (serving as the control group) versus “enhanced” care management (the intervention group).

What difference in between the two groups? According to Dr. Wennberg, the intevention group was the subject of 'analytics on steroids.' As the DMCB understands it, this consisted of a later-generation predictive modeling capability that was hypothesized to do a better job of identifying which patients would benefit from Health Dialog’s remote patient coaching.

As many in the population-care ‘business’ already intuitively know, not all patients with a chronic condition necessarily benefit from disease management. For example, many patients implacably prefer not to be called, many have already achieved maximum self-care, others are not ready to make any life-style changes, many are victims of other random illness, many have severe disease that may not benefit from remote coaching and many have other concurrent conditions that are not amenable to any intervention. The DMCB suspects that Heath Dialog used its prior experience in the art and science of patient engagement to develop a predictive modeling tool that culled subjects who would be most a) open to and b) likely to benefit from its care programs. By targeting the “health coaching” at the ‘optimum’ patients in the intervention group, the researchers suspected total health care costs would be lower versus a control group that received the relatively untargeted health coaching.

The content of the health coaching was not different in the two groups; what was different is that the Health Dialog nurses received different lists of patients to call. The patient randomization occurred at a household level. Following randomization, the control and intervention groups were statistically similar by mean age, male-female ratio, disease burden and baseline costs. In classic Health Dialog style, the two groups were also similar according to the proportion of persons with the a) ‘big 5’ diseases, b) ‘preference sensitive conditions’ (examples include heart disease amenable to surgery, hip and knee arthritis, back problems and uterine disorders) and c) ‘coachable’ conditions (examples include obesity, hyperlipidemia, migraine and abdominal pain).

Bottom line: compared to the control group, costs were significantly lower in the intervention group. The majority of savings appeared to be due to lower inpatient utilization, but this was also true across the board including emergency room visits and outpatient visits. The savings weren’t huge, but enough to cover the cost of the program and then some. What’s more, Lance Lang presented evidence from Health Net showing a compelling impact on overall trend. As a result of these data, Health Net and Highmark have moved their control patients into the ‘analytics on steroids.’

While the DMCB and its readers will need to await release of the detailed information in a public peer review setting, this preview is interesting at several levels. First of all, Health Dialog and its partners are showing “applied” health services research is possible in the business setting. Secondly, while critics of disease management fault the industry for failing to show any 'return on investment,” that criticism is really being directed at Ver. 1 programs that are long gone. The industry has already moved beyond those early approaches with new programs. Third, modern strategies for persons with chronic illness may need to rely more on ‘market segmentation’ than on finding new remote engagement strategies. Fourth, there is no good news here on how this might work in Medicare population: this information doesn’t appear to be generalizable to that group.

Last but not least, Drs. Wennberg and Lang noted the success in this trial is not the “magic bullet,” but is an important consideration in a broader multi-pronged strategy aimed at controlling health care costs. I am pleased to report that Ms. Dentzer and the audience did not appear to disagree.