Monday, June 30, 2008

Investment Advice from the Disease Management Care Blog

Check out this article from Healthways’ local newspaper. It an interesting summary of how the some of the bloom is off the company’s rose thanks to the Medicare Health Support announcement and some customer reluctance of to invest in population based care programs in the face of a struggling economy. Ouch – even layoffs.

Should investors bail?

Maybe not. Companies go through this sort of thing, especially as they mature. Decide for yourself if they are executing well and/or if a debt-laden stock buy-back is wise.

In addition, according to this report, PriceWaterhouseCoopers, predicts overall health care inflation will continue to rocket. While we can argue endlessly about the wisdom of (or evidence for) investing in programs that seek to avoid the a) development of chronic illness and b) occurrence of costly complications in those with chronic illness, the Disease Management Care Blog is still bullish on commercial disease and care management/coordination programs. They package and deliver simple-to-understand interventions that have far greater virtue to the average purchaser than building more wings on more hospitals, clustering more specialists in the suburbs or taking even more pictures and having no idea what to do with the information.

And then there is the obesity epidemic. According to the WSJ Blog, there is a Credit Suisse report that identifies Healthways as one company that stands to profit handsomely in this arena. In the opinion of the DMCB, the same is true for all of the industry – just about all the vendors offer some program in obesity management.

Short term? Treasuries n’ commodities. Long term, the DMCB thinks disease management is still a good bet.

better

I have a new post up at MyBreastCancerNetwork.Com.

I wrote about pulling myself out of the emotional funk, with the help and support of so many of you.

Sunday, June 29, 2008

Some quality is created more equal that others

Which of the following is backed by a robust level of literature demonstrating a consistently strong association between the intervention and an impact on morbidity and mortality? Is there a correlation between that impact and cost savings?
  • · Restricting sodium among persons with hypertension
  • · Influenza vaccination in persons with asthma
  • · Foot examination in persons with diabetes
  • · Weight measurement in heart failure

According to authors from the well-regarded Bridges to Excellence, Towers Perrin and the WDE the answer is none of the above and yes, their low impact means none reduce claims expense. You can read how they reached their conclusions here in the American Journal of Managed Care.

While much of their analysis is based on an unfamiliar rating point scale that simultaneously reconciles both clinical and economic value, it’s another good example of how a) all quality is not equal and b) many of assumptions about clinical and economic impact are not necessarily backed by the scientific literature. That doesn’t mean that a local market or consensus-based policy (absent an autonomous Health Fed) can’t choose one intervention over another based on other metrics. This is just another handy reminder of that reality.

Finally, it's an indication that purchasers, in their eternal quest for value, may demand that the disease management community focus on what they define as important.

Saturday, June 28, 2008

Run For the Hills, the Doctors Are Coming, the Doctors Are Coming!!!!

What is the one thing no human being should want to be next week?A Republican Senator at a Fourth of July Picnic.In the most amazing turn of events I have seen in 20 years of following health care policy in Washington, DC, the Democrats have the Republicans backed into an awful corner over the issue of the July 1st automatic 10.6% Medicare physician fee cut and corresponding private Medicare cuts

Friday, June 27, 2008

'Adopt' versus 'Release.' What AHIP Really Says About the Patient Centered Medical Home

Hat tip to Modern Health Care Online with their June 26 story that ‘AHIP adopts principles on patient centered medical home.’ Interestingly, the AHIP press release does not use the word ‘adopt,’ as in ‘accept,’ ‘support,’ ‘embrace,’ ‘desires,’ or ‘likes.’ Rather, the document itself is a carefully crafted and rather cautious outline of what the risk-bearing health insurers think about this topic at this time. Read it for yourself here and/or consider these quotes (bolding mine) and decide for yourself:

'The Patient centered Medical Home is a promising concept that would replace episodic care.'

'Even though many clinical setting can potentially constitute a patient centered medical home, we believe certain principles are crucial…'

'….ongoing market experimentation regarding designing and implementing the medical home, our community has made a commitment to work collaboratively with other stake holders…..'

'The medical home is not a concept designed to provide one standard of care process…..'

'Learning collaboratives, both physical and virtual, should be encouraged as a way to share early successes….'

'Clinicians…should commit to being accountable for improving clinical outcomes and patient experience, appropriate utilization… and ensuring transparency.'

'The benefits of a medical home only [sic] will be realized if both clinical practice and consumer behavior evolves….'

And what the DMCB thinks is a bottom line:

'Pilot testing…. should be completed before the patient centered medical home concept is broadly implemented to determine which approaches are most effective. Research is needed to determine a sustainable framework for improvement of clinical outcomes, ways to ensure long term affordability for patients and the best methods for implementation to ensure a stable infrastructure that prioritizes improved health outcomes.'

The verb used in the AHIP headline ‘releases.’ Sorry, PCMHitzens, you still have some work to do before the insurers will start cutting checks.

looking out at the world

My computer and my body are both still pretty sick.

I have been thinking though about my tendency to become a hermit when I get to feeling low, missing work and my old life (or give in to the fear, as cancer is still very real presence and I know that I have not escaped it).

Chemo weeks tend to be the worst but I will admit that I have been struggling a bit of late.

I have this friend who refuses to stop calling me, though, even when I don't call back. A friend who calls and leaves me messages that say, "Just checking in!"

A friend who refuses to let me turn completely inward.

I am very grateful.

Thursday, June 26, 2008

NewTalk's 'Reforming Chronic Care' Postings

Well, even after yesterday’s logorrheic post and feeling like this, the Disease Management Care Blog couldn’t let the week come to an end without a…..

Hat Tip to David Harlow over at the HealthBlawg, who discovered what can best be described as a fascinating series of expert board posts on reforming chronic care over at Common Good’s NewTalk. Letting these healthcare luminaries loose on this meandering tour of law, politics and policy helps the naïve Disease Management Care Blog better understand why terribly earnest and incredibly bright beltway insiders just can’t seem to land on implementing solutions to low quality and high costs in chronic illness. Don a scop patch, take a seat on this bus and you’ll see first-hand the complex mind-numbing interplay of options, finite resources, skepticism, self-promotion, statutes, perspectives, stakeholders, need for an SSRI (for one person in particular), dismissal of disease management, good ideas, needs, cynics, history, notions, reality checks, bad ideas, biases, anecdotes, research findings, fawning over the chronic care model, assumptions, egos, models, costs, benefit language and verbiage. It makes for interesting reading, but it’s a good thing these guys aren’t in charge. The DMCB is reminded of a quote from John LeCarre’s “Tinker Tailor Soldier Spy”: a committee like this is an animal with four back legs.

If you don’t have a grande caffeinated beverage available and can’t read it all, the DMCB suggests you focus on the posts from Larry Casalino of the University of Chicago, who offers up a readable mix of primary care experience and academe. He astutely notes information technology alone is not up to the task of overcoming a fragmented health care system. He introduces us to the broader notion of ‘accountable care organizations’ that may be able to integrate otherwise independent hospitals and small physician groups. As the DMCB understands it, the idea is to harness the special advantages of independent small practices and still deploy larger economies of scale. He warns us to keep an eye out for an upcoming issue of JAMA, which will have an article on the topic. You read it here first.

Finally scroll through about half way and see what Susan Dentzer of Health Affairs has to offer in terms of a Big Bang Solution: Medicare Part E. She asks for comments. The DMCB offers this one: you go gurl!

Wednesday, June 25, 2008

Welcome to Health Wonk Review June 26 Edition

Mmmmm! The Disease Management Care Blog invites you to feast at this blog cornucopia of wonkery. No need to line up at this buffet table – visitors have instant access to a broad array of yummy intellectually stimulating and educational morsels. For your sampling pleasure:

Information Technology

Julie Ferguson of Worker’s Comp Insider posts about I.T. behemoth Google’s foray into the electronic medical-personal-health record ether with a tasty, succinct and link-laden summary of the good (many are the benefits), the bad (physician inertia) and ugly (privacy breaches).

If it’s links and more links about Google Health you are looking for, Jessica Merritt of NursingDegree provides a delicious stew of them here. Everything you want to know and more is just a click away.

If we are going to get ugly over privacy, Neil Versel of Healthcare IT asks if his unsolicited free offer for an allergy medicine had anything to do with his past purchases of pseudoephedrine containing medicines. Is this recipe of name & address-list selling, data mining, meth-addict backlash and over-zealous disease managing a dysguesic brew?

Let’s get even uglier with the InsureBlog’s H.G. Stern’s review of Fed Chairman Ben Bernanke’s pessimistic economic assessment of health care. It costs a lot. It’s going to cost more. Information tech doesn’t hold a candle to growing demand paired with the bitter availability of ever pricier treatment options. And we are all going to pay for it. The DMCB’s food for thought is that the government is going to tax us into the poorhouse and then print up money to make up the difference. Now is the time to convert all assets into gold bullion and bury it in the back yard.

But let’s end this part of the buffet table with some good news from Vince Kuraitis over at e-CareManagement. Health care-consumer Goldilocks had three porridge PHI liquidity options, but the one that belongs to the ‘Markle Foundation’s Common Framework for Personal Health Information’ is not only the right temperature, it’s PHI ambrosia. Find out why here.

Health Insurance

Spin the channel through C-SPAN and it’s likely you’ll see Michigan’s Representative John Conyers in action. He and Democratic gadfly Rep. Kucinich have cooked up legislation named ‘The United States National Insurance Act.’ Sidle up to the left side of the buffet and have a plateful thanks to Louise at the Colorado Health Insurance Insider, who gives a thumbs up/thumbs down synopsis of each of the Act’s provisions. This is not only your chance to see what a national plan would look like up close and personal, but how supporters of the concept process their way through the various benefit and policy options.

And on the right, load up over at the We Stand Firm blog. Paul Hseih dissects the recent NYT report that Japan’s Ministry of Health is introducing mandatory waist circumference measurement and mandatory education for individuals not meeting criteria. While you ponder whether Toledo should be concerned about the threat of creeping government infringements in Tokyo, the DMCB wonders if a) ‘metabo’ is cool new word for those in the know and b) if the portly and recalcitrant Kenzo Nagata should be extended honorary U.S. citizenship.

Anthony Wright over at Health Access rails against another example of the individual market’s dyspeptic failure to exceed customer expectations by explicitly factoring in gender (care to guess if males pay more or less?) and a past history of a caesarian section in its health insurance pricing. Should we all contribute equally to the risk pool or should each pay according to the underlying risk? If you support the latter, be wary of the (un)intended pernicious undercurrent of gender discrimination. And don't blame the actuaries for any of your tone deafness either.

Wonder just how single payer advocates seem to get so much traction? Brian Schwartz of the Patient Power blog (‘because your health care is too important to be left to politicians’) dishes up a fascinating examination of how government taps into to mankind’s deep desire to be members of a group. By muddling our innate tribalism with government’s natural tendency to take over, says he, our cooperation over national health insurance is a symptom, not a solution. The DMCB wants to join the group that is opposed to this. Watch out, Uwe, someone has your number.

Jane Hiebert-White notified the DMCB of Chris Fleming’s Health Affairs blog link to a Health Affairs Web exclusive by Ku and Broaddus that argues that public health insurance programs like SCHP and Medicaid have the twin advantages of low cost and low out of pocket expenses. So, like, what’s there not to admire about public health insurance? Take a full helping of this open-access article and decide for yourself.

Or decide not to, based on this hot pepper multi-alarm capsaicined alert from the pseudonymed ‘Zagreus Ammon,’ a physician executive over at, you guessed it, the Physician Executive Blog. Heard of the 'National Provider Identifier Number?' If you’re a doc, forget about getting any money from CMS unless the NPI info, such as the spelling of your name with or without the middle initial, periods and blanks exactly matches the IRS legal name. If you’re not a doc, here’s another reason why the 9 words ‘I’m from the government and I’m here to help’ can be so terrifying.

Ku and Broaddus in the Health Affairs article mentioned above would probably agree with the perspective of Richard Eskow over at the Sentinel Effect Blog, who alerts us to the California Medical Association’s assessment of the market performance of California’s HMOs. Assuming there are some market forces at work somewhere, why are premiums going up and up and up? He smells something sour. Read his blog and see if you can help him and fans of unfettered health care markets make any sense of it. And by the way, think insurers fear regulations or mandates that limit their administrative expense ratio to 15%? Think again. Richard points out the easiest way to meet such a requirement is to simply raise premiums.

Bridging the Payer/Fiduciary-Provider/Clinician Divide

Tom Emswiler of New Health Dialog Blog updates us on CMS’ Premier Hospital Quality Incentive Demonstration (and teaches us about a new acronym: 'HQID'). Readers may recall this CMS initiative is aimed at rewarding hospitals that do well in 30 care measures while penalizing those hospitals that fail. The penalties are now being assessed, but fear not. The penalty amount this year does not seem too high and it’s a small price to pay for the average 16% overall improvement. CMS especially likes this dish!

David Harlow at the HealthBlawg updates readers on the no pay for errors movement, describing the major Massachusetts insurers’ announcement that they’re going to follow the Leapfrog Group’s recommendations. He also points out that according to Leapfrog, ‘never events’ should also be paired with an ‘always apologize’ policy. Harkening back to the innocent days of the Lettermen, the DMCB asks if quality means you never have to say you’re sorry?

Dr. Roy Poses over at Health Care Renewal serves up a major dose of disappointment over the outsourcing-run-amok craze, typified by the still unresolved and unexplained Baxter-Heparin tragedy. While the DMCB still believes in coordinated/networked delivery systems, Dr. Poses makes an excellent point on how health care is ultimately not about über management, it’s ultimately about taking responsibility for it and always doing the right thing.

Annie at the Revolution Redux Home of the Brave Blog bakes up an alternative point of view over the thorny issue of nurse-patient ratios. She pleads for the return of nursing control and authority, not legislating inflexibility and mandates.

David Williams of the Health Business Blog weighs in on another example of Aetna’s nimbleness, this time in the arena of medication compliance. The insurer has agreed to accommodate a University of Pennsylvania-led clinical trial that tests a financial award lottery to incent enrollees to take their warfarin. David is a fan of spicing up the insurance benefit to Get-Enrollees-To-Do-The-Right-Thing and, assuming the trial is positive, offers up some other interesting recipes.

The ever perspicacious Maggie Mahar at Health Beat discusses in Post 1 and Post 2 the sorry state of business-as-usual end-of-life cancer care and introduces the readers to the notion of ‘palliative’ oncology care. Using liberal sprinklings and dashes of anecdotes and peer-review literature, Maggie asks if we need – or rather, should expect - oncology expert-teams who can assess prognosis, incorporate patient preferences, institute hospice, offer reasonable treatments and communicate well with patients AND families. After all, such experts are in the best position to develop the best menu of services. Compared to the draconian options of limiting therapy, she argues the expert-palliative approach is far more acceptable. The DMCB also learned again about some viable outcome measures in oncology: assuming the right answers are not 0% and not 100%, just what is the ‘right’ percent of cancer patients that should be a) receiving (new or old) chemotherapy within X days of death, and b) in hospice within ‘Y’ days of death?

Before we leave this section of the table, take a Bromo-Seltzer and heed this warning from David Hamilton of BNET, who uses (and visually depicts) a food-making allegory to describe a brazen marketing business initiative aimed at empowering getting the chronically ill to empower themselves with buy drugs and devices. To get a good sense of where they’re coming from, check out Omnicom’s view of ‘medical professionals.’

Medical Education

Not necessarily a frequent topic in our wonk circle, but the on-going education and professional development of physicians is a huge industry that has been whipsawed its longstanding reliance on pharma funding. Barbara Martin at Pathophilia ladles up a lesson in grammar, writing and being reasonable for the Accreditation Council for Continuing Medical Education (ACCME) at this very spicy post. Click around and you’ll see the debate doesn’t end there.

There you go! Something for everyone. It's been my pleasure. And make sure you mark your calendar for the next Wonk Review. You can find out more about it here.


A Flawed Defense of Medicare Advantage

If private Medicare is to be continued proponents had better make better arguments than Scott Gottlieb made on Tuesday's Wall Street Journal op-ed page.Gottlieb is a former Bush Administration CMS official and is currently at the American Enterprise Institute.The context of his arguments is that this week Congress is debating making cuts to the private Medicare Advantage program in order to pay

Tuesday, June 24, 2008

RUC Committee and Payment for the Medical Home

The Disease Management Care Blog is pleased to announce that it has been named to HCPro’s Disease Management Advisor editorial advisory board. It always thought the monthly Advisor was a great way to keep up to date with happenings in the industry and the July 2008 issue did not disappoint.

As readers may recall, the DMCB was one of several blogs (ably summarized by Vince Kuraitis over at e-caremanagement) that weighed in on the RVS Update Committee’s (RUC) recent payment recommendations for the Medical Home. According to the Advisor, the ‘healthcare bloggers’ were ‘particularly concerned about the suggested commitment and pay structure.’ The Chair of the Committee was interviewed about this and noted ‘my understanding is there are some bloggers who don’t understand financial implications…’ He then goes on to explain why the RUC payment recommendations, if adopted, will heap some serious coin on the nation’s primary care physicians.

Indeed. The DMCB accepts we are all entitled to our opinions, but is far more interested in the role of the blogs in this chapter of the Medical Home. It seems that, except for the bloggers, no one else pulled on the unhappy pants and went through the recommendations a) in detail, b) with the primary care physicians’ needs first and foremost, and c) unwilling to simply take the RUC’s word for it.

If the exercise helped the Chair of the RUC be a little more forthcoming for the Advisor, then I say hooray for us blogs.

Monday, June 23, 2008

Big JAMA Article on Chronic Care Model, er, no Disease Management, er... no wait, it's the Chronic Care Model

Suppose the Disease Management Care Blog announced that a famous medical journal had recently published a noteworthy lead article on the management of a chronic condition? That hundreds of patients with the condition were randomly assigned to either:

a) usual care, or

b) usual care plus home monitoring and web-access to a library plus secure email with their physician, or

c) the same usual care, home monitoring, web-access and email PLUS a remote non-physician using an action plan that included lifestyle goals and a guideline-driven treatment protocol? That the non-physicians used telephone and web-messaging with copies to the patients’ physicians?

And suppose a blinded assessment at one year showed a) 31% of those in usual care, versus b) 36% of those in home monitoring plus web, versus c) 56% with the addition of the non-physician achieved control of the condition?

It seems to the DMCB that the average reader with a working familiarity of disease management a.k.a population health improvement would hail the study as further evidence that this approach to care is an answer to the challenge of chronic illness care.

After all, the 3rd and most successful arm of the study had all the necessary elements: population identification (patients meeting clinical criteria were recruited into the study), comprehensive needs assessment (the action plan was tailored), increased patient awareness (detailed education about the condition), patient centric goals (that included patient selected lifestyle goals), self-management with behaviorally-based interventions (home-based monitoring and mutual decision making) and feedback loops (every two weeks).

But don’t break out the champagne disease management fans. In the article (not on-line yet) on hypertension control by Green and colleagues at Group Health that was published in the June 25 JAMA, the study design using pharmacists was based on…

care to guess?

…. not disease management, but the Chronic Care Model (CCM), because of ‘self management support, clinical information systems, delivery system redesign, decision support, health care reorganization and community resources.’ In fact, the authors go on to state that this was 'the 1st randomized controlled trial that has applied the CCM to hypertension….' and 'adding pharmacist care allowed the CCM to be integrated…..'

The DMCB will agree that the approach, as described in the publication, may certainly be consistent with the CCM. However, based on the information presented, it is also quite reminiscent of the approach taken by disease management. In fact, the DMCB will speculate (and if any readers know different, please speak up) that the remotely located pharmacists in this study were not physically assigned to any particular clinic or were dedicated one team. Rather, they were virtual, supplying their services from afar and letting the physician know after the fact.

DM or CCM? You be the judge.

Oh wait, the DMCB thinks it knows how to tell the difference between DM and CCM in the literature. It's figured out what to do when overlapping principles from both are used in an integrated approach for the care of persons with a chronic condition. If it’s successful, call it “the chronic care model” or “medical home” and neglect any mention of disease management. If the same approach turns out to be unsuccessful, THEN call it “disease management.” Your mainstream journal editors, peer reviewers and academic readers will thank you for it.

The DMCB has already burned up too much rant, but it thanks Jones and Peterson in the accompanying editorial in the same issue. This is not only an excellent review of the article but they include this salient observation:

the “use of the internet by these investigators was certainly novel, yet their interventions share commonalities with many disease management strategies.”

The DMCB won’t cancel its JAMA subscription.

paradox


I am afflicted with my usual pre-chemo malaise.

And something else. I made it a goal this year to write as much as I could about cancer and living with mets and yet, today I am sick of being a cancer patient, sick of cancer and everything about it.

Achieving balance has always been a challenge for me.

My computer is sick today. The fan has died and it will only work for a few minutes at a time. Tomorrow it will go unto the shop (how realistic is it to think that I will get it back on the same day?).

Hopefully, by Wednesday, my computer and I will both be up to writing again.

Sunday, June 22, 2008

The Integration of Disease Management & the Patient Centered Medical Home

The Disease Management Care Blog has made no secret of its prediction (or maybe it's a preference, but, hey, it's my blog) that the 'patient centered medical home' and 'disease management/population health' will become integrated.

While the PCMH is many things to many people, in the opinion of the DMCB, its best features are a) the new version primary care physician and b) a team of hands-on providers. By 'new version,' it means a PCP with a commitment to chronic illness and population-based clinical and economic outcomes. By 'team of hands-on providers,' it means nurses (usually) who can help particularly ill patients navigate an increasingly complex and unending episode of care.

While disease management is the Anti-Christ to many people, in the opinion of the DMCB, it brings a remarkably sophisticated high-volume low-cost outreach/communications/coaching ability that simply cannot be matched by most primary care networks in most geographies. This seems well suited to patients with a chronic condition who need to be engaged in self care, but who do not need much hands-on care.

In order for integration to occur, three things will need to happen:

1) the PCMH pilots will go through the same cycle as DM of inconsistent findings about savings versus usual care. Think MCCD, which was more about the Medical Home. This will diminish some of the hubris and prompt recognition that a wider population reach is necessary.

2) a formula about who is "in charge" will emerge. It will reconcile the PCMH's central clinical role and DM's insurance-risk mitigation role.

3) a successful pilot/demo/clinical trial that passes muster.

The DMCB doesn't think it needs to happen in that order either.

And what does the DMCB do at times like this when it's pondering this stuff?

Why, it breaks into song! Click on the YouTube window and test drive the lyrics below. With apologies to Canned Heat.



Together we'll stand
Divided we'll fall
we need more data
the… cash flows will stall
let’s work together
Come on, come on
let’s work together
Now now people….
Because together we will stand
Every doc, all the vendors and Plans!

D M, your fees - they suck
and the.... costs still rise
n’ your …results are luck
a …roll of the dice
You can do better
You know, you know
You should do better
Ohhhh…
So says CBO and RAND,
Every blog, doc, buyer and Plan!

Ohhh, M H, you’ve got your share
there’s too much doubt
and no one cares, what
about… the docs
they want the money
they think, they think
it’s just the money
Now now people….
and the pilots may tank
you’ll be the topic of RAND!

Ahhh, come on now...
(RIFF time, dance in front of your computer)
Ahhh, come on, let's work together! (Woo hoo!)

Now…, don’t wait too long
Until it’s too late….
Let’s mix together and just integrate
It’s more efficient
the trend, the trend
the Fund’s deficient
Now now people…
Because we can’t afford
The usual for the elders of the land!

Oh well now come on you doctors
Do a group hug
With all those vendors, they are beggin for love
To work together
C’mon c’mon
please work together
Now now doctors
Because together we can share
Every fee that’ll be for Medi--care
Ahhh, yes!

(RIFF #2 time, time to dance in front of your computer again)

Because together we can care
For all those elders yes, woman and man!

Friday, June 20, 2008

cancer is a chronic illness

My father-in-law, himself a cancer survivor, sent me a terrific article from the New York Times:

"Cancer as a Disease, Not a Death Sentence"

That about sums it up, for me.

I particularly enjoyed the following anecdote, so reflective of my own experience (the drugs are different, except for the Herceptin):

''Dr. Esteva described a breast cancer patient first treated with a mastectomy and the antiestrogen tamoxifen in 1995. Five years later, cancer had spread to her lungs, prompting treatment with a newer anticancer drug, an aromatase inhibitor. When that no longer worked, her cancer was found to possess a molecular factor, HER-2, and she began treatment with Herceptin, a designer drug tailor made to attack HER-2-positive breast cancer.

Herceptin therapy was able to stabilize her metastases for years, “something we had not seen before,” Dr. Esteva said.

The patient now receives a combination of Herceptin and another drug and enjoys a relatively normal quality of life, the doctor reported.''

The article describes beautifully the approach of my oncologist. First treatment A is tried until that stops working, then treatment B and so on. Ideally, treatment would continue in this way until a cure is found . For the time, being, though many of us are living longer than anyone thought we would and with a pretty good quality of life.

Cross-posted to Mothers with Cancer.

Thursday, June 19, 2008

Disease Management: Return on Investment or Value?

In yesterday’s post, the Disease Management Care Blog ended with an observation that maybe, just maybe, ‘disease management’ may not save money. That apostasy is the bad news. The good news is that disease management may represent a great deal for the average health care dollar.

Just how does one dollar-ize the value of one point drop in A1c versus coronary artery stenting versus a mammogram? Like it or not, it comes down to the gain of additional years of life and the quality of life in those years, both of which can be reconciled and combined in a single measure called ‘quality adjusted life years’ or ‘QALYs. The DMCB recognizes that getting a brain wrapped around the concept of a QALY can be mind numbing for average purchasers, politicians, consumers, providers, practitioners, but it can be really handy once you get the hang of it.

And readers of the DMCB may want to get the hang of it. That’s because of interest in an autonomous ‘federal health board’ by the U.S. Senate Finance Committee and Congressional Budget Office as well as by the Federal Reserve. While the details of how such a politically insulated body would function is still unknown and if the concept survives Congressional and Presidential scrutiny, it is possible that it would use some measure of longevity and quality of life metrics to recommend and/or adjudicate health care coverage options for the Medicare and Medicaid programs. Commercial insurers would probably fall in line.

For an example of how QALYs can be used to prioritize the use of health care resources, check out this article that shows hypertension control among persons with diabetes saves money, while blood glucose control results in better quality/longevity but at an increasing cost that depends on age. The DMCB is aware that ridding the system of unwarranted variation, waste, defensive medicine and fraud could help pay for hypertension AND blood glucose control, but that’s not the point. The point is that BP control, blood glucose control and cholesterol control among persons with diabetes costs, on average, between –negative $1959/QALY to $51,000/QALY – which represents great value whether there is or isn’t variation, waste or fraud. If versions of disease management can deliver those outcomes at these or even lower prices, its future under a 'Health Fed' will be assured – even if it doesn’t save money.

Coronary artery stents may represent another particularly attractive deal in terms of the money spent per unit of life and quality, but also note no one is arguing that coronary artery stents ‘save’ money. They deliver value. In contrast, check out the value of admittedly more accurate but also pricey digital mammography. It does a better job of detecting cancer but is the price worth it?

Bob Stone of Healthways has it right in this recent editorial appearing in Disease Management. His recommended third approach of assuring access to optimized evidence-based care makes a lot of sense, assuming the evidence not only points to effectiveness but cost-effectiveness. If a Health Fed comes to pass, the population health industry can be confident that the outcomes it delivers at its prevailing fees for A1c and BP control in chronic illness will pass muster without having to contend with notions of ‘return on investment.’

If the DMCB was developing strategy on behalf of the disease management vendors with paid lobbyists, it'd be pushing an independent federal agency that aggressively and objectively evaluates the cost-effectiveness of health care interventions. And if 'Health Fed' legislation actually gained momentum, the DMCB would advise investors to go long on the industry.


Coventry Health--Another Reminder That This Isn't an Easy Business

Here are some comments from a first quarter earnings call Coventry management would sure like to take back.Yesterday, Coventry reported that its Medicare private fee-for-service business will miss its second quarter medical cost ratio projections by more than 300 basis points and that it will miss its prior second quarter estimates for its commercial medial cost ratio by a whopping 200 basis

Wednesday, June 18, 2008

A Compressed Summary of the Debate over the Value of Disease Management

Check out this timeline summary of a series of publications in the American Journal of Managed Care (AJMC) focusing on the topic of disease management. This is a good encapsulation of much of the current debate on what we know and don't know about its value.

December 2007: The AJMC publishes a review article by Mattke, Seid and Ma of RAND that provocatively asks if there is "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" After reviewing the available medical literature, they conclude that there is ample evidence of improvement in processes of care across multiple chronic disease states, but "no conclusive evidence that disease management leads to a net reduction of direct medical costs."

January 2008: AJMC publishes a response letter from Gordon Norman of Alere and Chair-Elect of the DMAA. He argues disease management has considerable face validity, sponsors have been unwilling to subject patients to serving as 'controls,' the industry is not in the business of conducting research, positive internal and non-published evaluations by industry are just as rigorous but not as publicly available as peer review studies, a critical mass of randomized prospective trials may be lacking but other methodologies have shown positive results, other accepted medical interventions have unfairly not been subjected to similar scrutiny and, finally, evidence is slowly accumulating. The DMAA issues a news release about Dr. Norman's letter.

May 2008: AJMC publishes another response letter from Robert Stone of Healthways, noting that there is considerable variation in what comprises disease management in the literature. As a result, a pooled analysis may include spurious results from faux-disease management programs. He argues a pooled analysis using more restrictive inclusion criteria, especially using programs that execute well, would show reductions in costs.

May 2008: The Disease Management Care Blog posts a discussion in reference to the above, arguing that if the disease management industry is going to gain advantage from publishing positive results in the peer review medical literature, it will also have to get used to the downside of critical scientific scrutiny. It also notes there are other approaches to better understanding the value of disease management.

June 2008: Dr. Mattke writes an editorial in AJMC, provocatively titled "Is There a Disease Management Backlash?" While the jumping off point is a discussion of negative outcomes associated with a disease management program aimed at pharmacologic treatment following myocardial infarction, he goes on to discuss the generally small limited studies that make up much of the disease management literature in general. He argues more studies are needed, that the industry should submit more of its results for peer review and that, in the meantime, purchasers would be well advised to heed the principle of caveat emptor. Dr. Mattke also makes another excellent point: instead of claiming disease management 'saves' money, perhaps the industry should examine the comparative benefit it delivers per unit of additional cost.

Coventry Health Care--What the Heck Is Going On?

When WellPoint, Humana, United, and others had earnings warnings this spring I pointed out their issues were largely unrelated and amounted to more rounding errors as the helpful five year deceleration in health care trend came to an end and the business just wasn't as easy.But today, Coventry hit us with a 300 - 340 basis point adjustment in their expected Medicare Advantage medical loss ratio

book review: the deceived*

Holey moley! I was in the mood for a page turner and with Brett Battles’ The Deceived, I got that in spades. This book sucked me in and swept me along in the way only a good, action-filled suspense novel really can.

The book’s central character is a mercenary with the alias Jonathan Quinn. Quinn is a ‘cleaner’, hired by government and crime bosses alike to go in and eliminate evidence (and remove bodies) after the violence is over.

In this, the second novel in a series, Quinn is hired to clean out a shipping container, only to find that it contains the body of a man who once saved his life. The man, a former CIA agent, was badly beaten and left to slowly die in the shipping container. He did, however, manage to scrawl a message (in blood, of course), consisting of a series of letters and numbers, on the container wall. And he died clutching a photo of his girlfriend - one that had been taken by Quinn himself when all three had been on a fishing vacation.

Quinn sets out to find out what happened to his friend and soon learns that the man’s girlfriend, Jenny, has disappeared. The reader travels with Quinn to several American cities and, eventually, to Singapore, as he begins to put the pieces of the puzzle together and very quickly puts himself in the line of fire.

The book is well-written (a real necessity for me to enjoy any book. Even with a great plot, badly written prose is like nails on a chalk board), with great dialogue between likeable characters, who manage to be believable despite their existence among the world of “secrets.” And the action scenes are great fun (they certainly got my heart racing).

The book did start to drag near the end (the part that takes place in Singapore), as it took a little too long to build to the climax. And there was one plot twist that I saw coming a mile away. However, there was a terrific ending and a few subsequent plot twists that did surprise, so I consider these to be minor quibbles.

I don’t know if I’ll remember The Deceived in a few weeks’ time but I certainly had fun reading it. If you are looking for some enjoyable summer reading and mysteries are your thing (and you don’t mind a little violent action), then get yourself a copy of The Deceived. I have already ordered the first book in the series from the library.

*This is a review of a book that was sent to me via Library Thing's Early Reviewer Program.

Tuesday, June 17, 2008

Open Access and the Patient Centered Medical Home: Uh-Oh!

If you know about the ‘patient centered medical home,’ you know that one of its underlying ‘joint principles’ is ‘enhanced access’ or making ‘care… available through systems such as open scheduling [bolding mine], expanded hours and new options for communication between patients, their personal physician, and practice staff.’ ‘Open scheduling’ has been the topic of an extensive body of peer review literature, much of which has been authored by the same folks that have championed the chronic care model.

Open scheduling or open access is based on principles of just-in-time engineering, queuing theory and other industrial process improvement approaches that rearrange the availability of primary care appointments, including for the same day that patients request it. Tired of being told that your primary care doctor can’t see you for that check up for 6 months? Have you already read all those National Geographics in the waiting room an hour or more after your scheduled appointment? Have you had to choose between being seen late today by an unknown provider versus having to go to the emergency room now for an urgent problem? Open access could be the answer you and your hapless doctor have been looking for.

Or is it?

In the latest Annals of Internal Medicine, Mehrotra, Keehl-Markowitz and Ayanian describe the (pre-post) outcomes associated with a state-of-the-art implementation of an open access scheduling system in six primary care sites in Massachusetts. One practice dropped out. For the remaining five, there was an initial dip in patient waiting times for an appointment, but a) no practice was able to achieve consistent same day access and b) over two years, the gains in waiting times eventually vanished for four of the clinics. In fact, two of them ‘became worse than what we observed before implementation.’ Four of the five clinics were able to complete patient surveys: patient perception of their primary care sites’ access did not change.

The authors point out that the open access was undermined by physician turnover, lack of economic incentives, difficulty in assessing the physicians’ panel sizes and provider skepticism about the ultimate value of same day access. They also noted that the advent of greater availability of health insurance in Massachusetts combined with briefly shorter waiting times paradoxically increased demand from new patients, which exacerbated availability.

The authors deserve a lot of credit for pointing out the limitations of their study, including the lack of concurrent control practices, sample size limitations and incomplete data sets. Interestingly, they also discuss other peer-reviewed publications on open access and note:

'Nearly all the studies have important methodological limitations (many of which our study shares), including no statistical testing, limited access-to-care measures, lack of concurrent control groups, small sample size, and inconsistent methods. Among the few studies that assessed outcomes beyond access to care, open access had mixed effects on patient satisfaction (2 of 5 studies reported improvement) staff satisfaction (1 of 2 reported improvement), and no-show rates (3 of 6 reported improvement). Our results add to this literature and raise the question of whether open-access scheduling truly leads to the ancillary benefits that advocates have proposed.'

Is open scheduling a big, really big promising solution for broadening primary care access under the patient centered medical home? Readers of the Disease Management Care Blog will need to judge for themselves. However, it is at times like this, when so many patients are competing for a limited number of appointments with an even more limited numbers of doctors, that the DMCB turns to the time-tested wisdom of its father.

Years ago, when he critically appraised a new-fangled bathing suit for one of the DMCB’s sisters, his comment was prescient: “It’s like trying to put 30 lbs of potatoes in a 20 lb bag.”

Transparency and Accountability: The Door Swings Both Ways--AMA Releases Its "National Health Insurer Report Card"

You have to wonder what they're thinking about over at AHP--the health insurance trade association that called for more transparency and accountability for the provider community a few days ago--now that the American Medical Association's (AMA) detailed report card on insurer claim processing performance is out.And, it's a fascinating read.How often do health plans pay at the contracted payment

what inspires you?

I have been feeling kind of burned out lately and completely uninspired.

Perhaps I have been over-extending myself. And as much as I need and want to write about my experiences as a cancer patient, mining that particular vein can be draining (and I am trying really hard not to repeat myself too much in the different venues in which I am writing).

I did my morning pages today, for the first time in a while and I found it to be a tough slog. I started to list the things that inspire me and I realized that I have not really been making a lot of space in my life to do these things. My days have been focused on being productive and, perhaps, when I have had down time, I have not been engaging in the kind of activities that fill me up.

I think this needs to change. Yes, I have deadlines (and the house is a mess) but I think that I might spend less time staring at a blank computer screen, struggling over every word (or surfing the net to avoid writing) if I let myself spend a little time getting inspired.

Here's my list. What would be on yours?

Reading books.

Knitting.

Going for long walks.

Spending time in the arboretum and other beautiful places.

Taking in other people's art.

Listening to music.

Laughing.

Hanging out with friends and family.

Being silly with my kids.

Spending time with my spouse.

Monday, June 16, 2008

Obesity, Increased Risk and Decreased Risk of Disease

Obesity is associated with hypertension, osteoarthritis, high cholesterol, diabetes mellitus, heart attacks, stroke, gallbladder disease, sleep apnea, uterine or breast or kidney or colon cancer, liver disease, infertility, birth defects, carpal tunnel syndrome, venous insufficiency, deep vein thrombosis, poor wound healing, gout, kidney stones, gastroesophageal reflux, psoriasis, dementia, rhinoliquorrhea (what ever THAT is), atrial fibrillation, asthma and big butts.

But (no pun intended) you knew that already. Can you name two conditions for which obesity may LOWER the risk? Answers here and here.

Extra credit: name a cancer for which tobacco use may lower the risk. Answer here.

i've been here before

Yesterday, we had puppy class.

I have been working really hard with little Lucy, doing our homework and practicing, practicing, practicing. We have 'sit' and 'down' nailed.

Or so I thought.

We didn't walk her before class, as we had been busy with Father's Day activities in the morning and we hadn't wanted to make her too tired. As a result, she was excited and wild from the moment we entered the class.

Despite this, I was pretty confident when the trainer asked if Lucy would be the 'demo dog.' However, although the trainer had a juicy piece of hot dog in her hand, Lucy would not sit or lie down, after several minutes of encouragement.

The trainer passed her back to me and moved on to another dog. I casually signalled to Lucy to sit. She sat. I signalled for her to lie down. She lay down.

Sigh.

Lucy is a very smart dog and in her quieter moments is very obedient. But when she is wild (usually in the evenings, unfortunately for the kids) she is defiant, intransigent and a little bit out of control.

And when she is sweet, she is very sweet indeed.

Reminds me of someone else I know and love.

When D., my youngest son, was a toddler, I wanted to knit a hat for a friend's baby. I tried to measure D.'s head. He refused to cooperate. I kept trying for weeks. I would ask nicely, try sneaking up on him when he was distracted or firmly tell him to sit still. I begged and pleaded. All to no avail.

A few months later, when the hat was finished (I guessed at the size) and mailed off to the recipient, I pulled out my tape measure to check my progress on another project. D. approached me and sweetly asked, "Mama, do you want to measure my head?"

To this day, he wants me to measure his head whenever I am using a tape measure.

Sunday, June 15, 2008

Tim Russert Teaches Us We Still Have Work To Do

Which news is worse: that a) there is atherosclerotic disease in your coronary arteries that has led to a ‘lot’ of blockage or b) similar disease that has resulted in 'minimal' blockage? While neither option is particularly attractive, if you chose to have minimal blockage, you may have also selected sharing Tim Russert’s fate.

Even though the heart is a muscle that pumps blood, it does not receive its blood supply from the blood going through the heart. Rather, there are a separate set of arteries that wrap around the outside of the heart muscle. When those arteries start becoming blocked by cholesterol plaque, the result is coronary artery disease. While having a big bulky blockage results in decreased blood flow to the heart muscle, it turns out that the composition of the plague also matters a lot.

It turns out large 'hard' plagues that result in gradually severe narrowing of the coronary arteries rarely cause the kind of abrupt blockage leading to a sudden stoppage of blood flow with the death of heart tissue a.k.a. heart attack. Instead, most large heart attacks are the result of 'soft' plaques that are only mildly obstructive. It turns out these kind of 'thin' plaques are filled with a mix of cholesterol and other substances that expand outward. This expansion can vary and be unpredictable. Local inflammation seems to play a key role (aspirin may do more than just thin blood). If the expansion reaches a point where there is a large rupture, an exposed flap of tissue can block the artery. Shut down of blood flow is further aided by the accumulation of clots around that exposed flap.

Plague rupture probably accounts for two thirds of death from acute coronary artery disease. Identifying plaques that are prone to rupture ahead of time is very difficult. Since they are not causing any blockages prior to rupture, patients may have no symptoms. Like Tim Russert, they can go through stress tests with flying colors one day and collapse the next.

Unfortunately, the types of interventions promoted by disease management, such as exercising regularly, eating 'right,' taking aspirin, using cholesterol lowering medicines and treating high blood pressure all only imperfectly lower the risk of death from coronary artery disease. Those of us in health care still have a lot of work to do.

Friday, June 13, 2008

otherwise engaged

Today's blog has been pre-empted by an afternoon with my sister, a run in the sun with my son (and my sister), an evening at the park and a really good book.

Update: I have a new post up at MyBreastCancerNetwork.Com.

Wall Street Relieved Democrats Unable to Cut Private Medicare Advantage Payments This Week--Why?

Congressional Democrats tried to take a big bite out of private Medicare this past week in an attempt to pay for an 18 month fix to the upcoming July 1st 10.6% reduction in Medicare physician payments.The effort, led by Senate Finance Chair Max Baucus (D-MT) got only 54 of the 60 votes he needed to end debate and move the issue to a floor vote. While getting that floor vote would almost have

"I Hear the Train a Comin"--What Does That Johnny Cash Refrain and the Employer-Based Health Care System Have in Common?

OK, maybe it's a stretch but bear with me.I heard a senior exec from a big health plan say the other day that it's hard to believe we will ever see the end of health insurance distributed primarily through the workplace in favor of an individual-based health insurance system. In fact, much of the health insurance industry is lining up behind staying with the system we know best and the one who

Thursday, June 12, 2008

Chronic Non-Chronic Blended Trending? A Word from Milliman about Medicare & Disease Management

Check out this interesting and highly readable report from Milliman and their health care actuaries. According to this analysis of Medicare fee-for-service claims from ’03 to ’06, the rate of increase (otherwise known as the ‘trend’) for persons with heart disease, diabetes, chronic obstructive pulmonary disease, chronic heart failure and asthma was lower than the trend for persons without those conditions.

That’s important because trend is arguably a more important metric for the success of disease management than cost. While it would be nice to ‘lower’ the cost of care for persons with chronic conditions, that begs the question of lower cost compared to what. Thanks to forces driving the overall cost of health care (for example, people are getting older, inflation is accelerating, technology is expanding), a successful disease management program may diminish the costs that are proportionally directly due to the chronic condition but still ‘look bad,’ thanks to the general cost drivers. Since costs are constantly increasing across the board, looking at the rate of increase is a good way to reconcile expected vs. observed costs. At least that's how the non-actuarially inclined Disease Management Care Blog thinks about it when its brain isn't getting full.

The art and science of separating costs/trends that are due to the chronic illness versus overall costs not only turns otherwise brainy, stoic, placid and mute health care actuaries into brainy, stoic, placid and murmuring actuaries but is also the stuff on which millions and millions dollars of disease management company performance guarantees depend. Guarantees may depend on comparison of observed trend to a calculated trend that ‘blends’ the non-chronic and chronic trends. If the ‘non-chronic’ general trend is higher than expected and the ‘chronic’ trend is already low without any disease management, the guarantees could be miscalculated. Big time.

This is all based on Medicare fee-for-service data, which doesn’t necessarily apply to the commercial insurance sector, which is where most disease management companies live. In fact, Medicare fee-for-service has no disease management programs to speak of. Milliman's analysis would need to be performed outside of Medicare to determine if it's generalizable.

However, the observation that rate of cost increases is higher for persons without chronic illness has big implications for health care policy. The Milliman report points out that wellness, preventive care, diagnostic services and elective procedures may be the more important drivers of health care costs in 2008. The folks at the Dartmouth Atlas, thanks to their perspective on variation and preference sensitive conditions, would probably agree. The report also asks if the current evidence-based medicine and quality improvement efforts that have been focused on chronic disease is paying off.

The report didn’t bring this up, but it begs another question: does Medicare FFS really need disease management? The answer may still be yes, but if this is all about the scary likelihood of depleting the Trust Fund by 2019, chronic illness may not be where President Willie Obama McCain Sutton should want to go. Maybe some parts of the current Demos directed at chronic illness were unable to show an impact because chronic illness trends were already down....

Food for thought. In the meantime, if you want to learn more about this chronic-non-chronic trend stuff, look here. The DMCB is going to read its copy one more time.

my efficient heart

I spent the better part of today at the hospital getting an echo cardiogram and seeing the oncologist.

The good news is that my heart is functioning just fine. It is most likely that there was never a problem and that the echo just gives a clearer picture.

Health Wonk Review is Up

This time Jane Hiebert-White does a great job of selecting some of the most thoughtful posts from the world of health blogs over at the Health Affairs Blog.Topics include federal health reform, health information technology, consumer and patient rights, the business of health care, research-based policymaking, and others.

Latest Health Wonk Review is Up!


Add one shot wonk'resso to steamed bloggery.

Sprinkle with Health Affairs.

Sip slowly.

Enjoy!

Wednesday, June 11, 2008

Call 9-1-1 and Get.... Emergency Disease Management?

Hat tip to the FierceHealthcare site for this story on how nurse-coaches are being paired up with 911 emergency dispatchers in Houston. While this appears to be a not-for-profit community-minded service that is designed to not only help persons with emergencies but lessen the load of unnecessary ambulance calls, the Disease Management Care Blog wonders if this isn’t an untapped market for the disease management industry.

In this instance, the service is being subcontracted to ‘CareNet,’ which appears to be a Care Management service provided courtesy of the CHRISTUS Health Care System. Among its offerings is disease management, which presumably accounts for its nurse-coaching expertise.

The DMCB is no expert on the logistics of setting up an emergency network, but it did ride ambulance years back and for a time was certified as some sort of EMT. That experience plus lots of hours in the emergency room confirmed that many persons use the 911 system for nonurgent problems. Helping callers cope instead of dispatching costly on-site personnel seems to be tailor made for nurses who understand self-efficacy, coaching, education level and possess clinical wisdom and on-the-spot common sense. And talk about win-win: the callers themselves think they are in trouble but many don’t necessarily want to go to an E.R., the taxpayers don’t like paying for avoidable E.R. visits, the E.R. itself is busy enough, the 911 personnel probably want to lighten up their call queue and the disease management service provider is happy to take the revenue that would otherwise be spent elsewhere. The approach is also not without literature to back it up.

The DMCB recalls there is an adage in the business world along the line of growing your business through the creation of new markets. Perhaps this is one potential market the industry hasn’t thought of in a big way, but should.

As an aside.....

And check out this version of community mindedness. If you had a business, wouldn’t you be more than happy to testify that you think everyone should be required to buy your product, that the American taxpayer should help pay for it and at the same time refer to it 'reform?' The DMCB thinks they oughtta pass a law making blog reading mandatory and is waiting for the invitation to say so to the Senate Committee on Finance.

Too bad having health insurance or reading the Disease Management Care Blog doesn’t necessarily translate into access to health care, but at least the latter does make you smarter.


connected

The hardest thing about membership in my community of cancer bloggers and activists is that we face more than our share of sadness, fear and loss. My friend Jacqueline once remarked that we have not been brought together "by our shared interest in quilting."

Two members of my community got bad news this week and I have been thinking about them a lot. I am struck by Rebecca's humourous description of her recurrence (which involves both potato and spaceship analogies) and Andrea's strength and grace as she choses between more treatment or hospice care.

But I am sad.

And a little bit scared.

I think I am going to go sit outside in the sun with the doggies now.

Tuesday, June 10, 2008

What is the Role of Physicians as Leaders in Disease Management (and the Medical Home)?

So, a physician and a psychologist are in a local watering hole, and the bartender tells them a local disease management company is looking for a Chief Medical Officer. Both want the job. Who should get it?

Readers of the Disease Management Care Blog may think selecting the physician is a no-brainer, but don’t be so sure. The DMCB wonders if the key ingredient of success in the management of chronic illness for persons with chronic illness is ‘self efficacy,’ defined as the level of confidence about achieving a desired level of performance. After all, once patients are outside their physician’s office, it’s up to them to meet the hour by hour, day by day challenges of their condition. In the case of disease management, the patient’s confidence in optimal use of a peak-flow meter, avoiding an emergency room visit or asking the physician the right questions lays at the core of quality and cost. Sound psychological? Sure does.

In addition to self efficacy, a prevailing theory of disease management is ‘readiness to change.’ Described in the Transtheoretical Model of Behavior Change, the point is that assessing patients’ willingness to alter life-choices is a critical 1st step in the delivery of illness-changing interventions. Sound psychological? Yup.

Once self efficacy, readiness to change and countless other approaches to molding patient behavior is reconciled, who is best equipped to assess the integrity and impact of the patient outreach programs themselves? Think physicians are taught about this in medical school or residency programs? Not so sure about that.

And how about analyzing the outcomes? The DMCB has run into many qualified statisticians with backgrounds in psychology. Maybe it has to do with all those mazes, questionnaires and measures of physiologic responses from their days in post-graduate training programs, but these social scientists seem to have a special affinity for t-tests, regression equations and minimizing sources of bias.

On the other hand, the DMCB has met many physician-Chief Medical Officers of disease management organizations, the majority of whom appreciate the psychological dimensions of their business and have the extra added bonus of knowing the difference between an A1c and an ACE. Most seem to have backgrounds in primary care medicine, which seems to attract persons with an innate interest in reconciling the medical and psychological. The DMCB thinks they are more the latter than the former.

Which raises another point. The Medical Home is predicated on the physician leadership of a team of health care providers who provide the full spectrum of participatory support and clinical services for persons with chronic illness. As you may have gathered from the watering hole scenario above, the DMCB thinks docs who embrace the non-medical dimensions of self-care are not as common as we’d like: they’ve all become disease management medical directors or are in bars debating things with psychologists. As the Medical Home continues to evolve, it will be interesting to see how this potential Achilles Heel plays out.

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