every year is a gift

In a few days, I will turn 41.

I will be offline, hanging out at one of my favourite places in the world. I am not sure how peaceful it will be (we will be there with four adults, two kids, two puppies and a grown up dog) but I know it will be happy.

Last year my birthday was a very big deal. My friends and co-workers pooled their resources and sent me to BlogHer in Chicago. And there was a whole month of celebration leading up to the day itself. I was celebrating being alive, turning forty and my first clean scan after the metastasis.

This year I am happy to have things be much lower key. I am feeling pretty lucky these days.

In January, I acknowledged to myself that there were two things I really wanted this year, to attend BlogHer in San Francisco and a puppy. Thanks (again) to generosity from others (and the fact that I spoke at BlogHer this year), both of those things have been realized for me.

That’s a lot. And it’s enough.

Especially when I realize that every birthday marks another year that I have been alive in this beautiful world. Another year surrounded by people I love and in which I have the chance to learn and grow and become stronger.

I have been feeling a little off balance lately, tired and frustrated and somewhat overwhelmed. It’s good to have a birthday to remind me again how lucky I am. And with four clean scans now under my belt, I hope to have lots more chances to celebrate my birthday.

Now that’s not to say that I don’t want a little cake with a few candles and some home made cards from my kids (and I did treat myself to a facial before I left for SF). Even a low-key birthday needs to be celebrated.

I'll be back online on August 11th.

Cross-posted to Mothers With Cancer.

Will the Lobbyists Make Meaningful Health Care Reform Impossible?

Maggie Mahar joins us today. She responds to a recent post here by Brian Klepper. Brian argued that health care reform will be a very difficult thing to do in the near term. At the top of Brian's concerns is the the impact lobbying money has on the ability of the Congress to achieve real reform. While Maggie agrees that special interest money is a big factor, she argues there are other reasons to

A Role Model for Fitness. Or Rather, Thousands & Thousands of Role Models

The Disease Management Care Blog salutes Veronika Lusianoviaa* as a role model for fitness, wellness and prevention. Ms. L dotes on Nikolas (a canine of uncertain pedigree), cannot resist the lure of the make-up counters at Macy’s and dons nylons every day. She misses Richard Burton, prefers Vladimir Horowitz and has a working familiarity with Teilard de Chardin. She doesn’t use the TiVo, but only partly because of the GUI: there also little on TV that interests her. She finds email to be marvelous. She rarely queues and resists being rushed, but not because of the effort involved. She is not lazy. Rather, she has learned over her lifetime that there is little that is that important or cannot wait.

She recently decided to pay more attention to her health. At her discreet age, she has been to more than one funeral and knows that while death is fickle, it prefers the passive and the portly. She has also secretly concluded that her bottom should be of more modest proportions. She asked her nice doctor about getting exercise but the few minutes of worth of advice she received was about as helpful as her long deceased second husband’s plumbing skills.

Veronika is baffled by the modern ideals of elite athleticism, professional sport and freakish body builders. She wonders at her neighbor’s chubby son, who dreams of being a professional baseball player yet is partially immobilized by Grand Theft Auto. She has also read about silly persons older than her who jump out of planes, join karate classes, run marathons and other such nonsense. Despite widespread adoration of the famous and rich, she finds few lessons in their leisurely fitness regimes. Ignoring popular media’s cacophony, misinformation, disservice and fixation on rippled abs, Veronika has correctly concluded that more modest levels of exercise are suitable. For this alone she deserves an award.

Veronika had already joined the new Medicare plan because it was cheaper, she could see the same doctor, there is no intention of snowbirding to the strip malls and condos of Florida and the plan helps pay for some of her pills. She found out afterwards that the plan sponsored a once a week exercise program. She doesn’t care about the business model, but did care about having to forego the nylons. For this brave act also she deserves an award.

You go Veronika!

*Veronika is, of course a very fictional woman. However, a Google search on Silver Sneakers will generate hundreds of hits like this about many thousands of real persons much like Veronika who have something to teach the United States about the attainment of fitness.

A Blog about the Kaiser Family Foundation's Conference on Health Policy Blogging

The Kaiser Family Foundation sponsored a 1 ½ hr conference on the influence of health blogs on policy debates and journalism. While you can access the webcast here, the Disease Management Care Blog is pleased to post this blog about bloggers who talked about their blogging.

HHS Secretary Leavitt confesses to being an inveterate blogger. He got hooked because he’s been a long term fan of the web and recalled that as a former Governor, he found placing State services online turned out to be user-friendly, efficient and welcomed by his constituents, He also likes to write and uses writing to help clarify his thinking about issues and policy. He started blogging as a 6 week experiment and he’s still going strong. He can feel secure in blogging because as Secretary he is the official spokesperson for HHS. His twice-a-week posts consume about two hours a week while in trains, planes, automobiles and hotel rooms. There is no vetting’ by HHS staff, but he has a writer to help with grammar and punctuation. He is careful to solicit feedback prior to posting anything and has gotten advice to think again which sometimes leads him to withhold an article. Responses on the blog are moderated and other than three exceptions, all have been posted. Most are informed, many are insightful and some have even helped him change his thinking. His blog helps the staff at HHS who can use it as a library of ideas. He also believes his blog-based communications are more likely to be read than traditional print channels. Mr. Leavitt mentioned one person in HHS already has an official avatar in SecondLife. He has little doubt blogs will be a significant force in the formulation of public policy in the future.

At the conclusion of the Secretary’s remarks, there was a Panel Discussion moderated by Kaiser’s Vicky Rideout.

Michael Canon of the Cato Institute noted that he and his organization blog because their mission is to carry a torch for their libertarian ideas. They hope they educate interested readers about the finer points how they think government should operate. The ‘turnaround’ is also far quicker; when an issue comes up, there is no ginning up press releases or op eds. Yes, it’s easier in blogs to be vicious and half-cocked. Yet,talk radio or investigative reporters can be just as distasteful - so blogs are prone to being just as guilty but not more so. Blogging can change minds but he thinks that happens among the bloggers, thanks to ‘cross pollination.’ No mention of whether anyone is more libertarian if they subscribe. He also agreed that health policy blogs, despite the reputation for democratizing the public square, interact very little with other types of health blogs, for example, with persons with who write about their struggles with diabetes or docs that write about their experiences.

Ezra Klein of the American Prospect blogs because his organization knows media is changing. As mainstream media become increasingly shallow thanks to collapsing news cycles and attention spans, his blog offers considerable liberal depth for the interested news consumer. After all, in blogs, there is no scarcity of space, only content. Accordingly, Ezra can not only write insightful long articles but set them up as ongoing conversations that create relationships between the writer and the readers. He estimates his site gets about 50,000 unique hits a week and believes his readership consists of persons between 30-40 years of age, probably office workers who complete their morning tasks and use the late morning or lunch hour to read his posts. He also finds his posts are the gifts that keep on giving, because they often continue to get quoted long after they are posted or the news cycle has runs its course. He thinks his readership ‘tilts’ male and white which may be someone ironic for the supposedly diverse blogsphere. Yet, he also notes that it is too easy for persons from diverse backgrounds to become sorted into bloggycubbyholes based on race and gender. To him, the blog coin of the realm is feedback. He also notes that people cannot resist Googling their own names and that writing about or quoting people in blogs invariably draws them to your site – which not only increases traffic but enhances your visibility among opinion leaders. Blogs also get considerable media attention and, depending on the topic or circumstances, can generate embarrassing partisan feeding frenzies. Ultimately, once key difference from traditional media is that blogs speak not from ‘authority’ but ‘sourcing.’ He’s also not worried about any negative impact from blogging on public discourse because it can’t get any worse.

Jacob Goldstein of WSJ blogs because it fits with the Journal’s newsprint mission: explain the world clearly and insightfully. Someone else could do it, but this blog would prefer to be the one doing it. Blogs serve to aggregate content for both readers of the Journal as well as nonsubscribers. The Wall Street Journal doesn’t disclose traffic statistics, but it’s enough to meet the Journal’s ’desires.’ Its preferred style is to write as ‘an insider’ and he thinks that’s more effective than the what-where-when-why and how of traditional reporting.

John McDonough of Healthcare For All (in Massachusetts) blogs to overcome the superficial treatment of healthcare by the media and to communicate an important point of view about access to insurance. He described his site as a ‘diary’ of health care reform in Massachusetts that aggregates or ‘stitches things’ or links things together, such as documents and op-eds. He also hopes he has created a ‘community’ of about 1000 like-minded readers a day. Conversations on his site can turn into ‘pie throwing,’ but even that’s an opportunity to correct misimpressions. He notes blogging may not change minds but he derives some satisfaction by drawing attention to topics that are relevant. As a blogger, he finds anonymous posts are annoying but that’s not necessarily different from talk radio where persons can also talk anonymously. He believes blogging has helped changed some Massachusetts’ insurers’ minds. Finally, he thinks blogs accelerate the political process because legislators are reading about themselves.

Tom Rosenstiel is a media expert who described blogs as ‘muffins,’ distinguished more by their shape than content. He notes bloggers typically think of themselves as activists, much like soldiers in an army. Blogs have big implications for mainstream journalism, which is slowly moving online anyway. He’s not sure what media will look like in 25 years and he’s not confident that print will continue to exist at all. For example, many newspapers nowadays have ½ of their readership on line. There are 30 million unique visitors a month for these newspaper sites and the numbers are growing. He suggests blog readers are heavy news consumers who use blogs to extend the news they consume. In surveys, 50% of blog readers say they read a blog once a day and 80% say monthly. Despite those impressive numbers, however, keep in mind that 90% view daily TV news. In his mind blogs are distinguished by opinion and aggregation. They are typically conversational not observational, but there are there some exceptions such as pharma and politics where blogs have broken new news. Yes, blogs skew to a young, male and educated and are therefore open to being elitist. Blogs won’t necessarily help inform the public, because ‘more’ isn’t necessary ‘better.’ One factor that may distinguish policy blogs from personal diary blogs is whether there is appreciable advertising revenue.

a very good man

On my first full day in San Francisco, I spent the early part of the day playing tourist. A highlight was a visit to City Lights Book Store. When I am away on my own, my kids and my spouse are never very far from my mind and this wonderful and historic book store seemed like as good a place as any to buy them some presents.

And so I did. I bought an armload of stories that I had never seen anywhere else and put them all in canvas bag with the store's name on it. I left the store feeling very pleased with myself.

I schlepped those books from North Beach to Union Square, for the orientation session for BlogHer speakers. But before going out for dinner and on to the various BlogHer welcome receptions, I stowed all my stuff in Babz's room in the hotel, so that I wouldn't have to carry them or risk losing them. Again, I felt very pleased with myself.

I had a lovely evening. I don't handle crowds of new people very well but there is something to be said for hitching yourself to an extrovert and just enjoying the experiences. And so I basked in Babz's glow and met some wonderful people at the Speakers' reception. I even won the door prize, a Nintendo DS.

As that party wound down, we headed up to the Newbie party for BlogHer first-timers. I demurred, as I was not a newbie but someone convinced me that I could play a role in welcoming the newbies. It sounded good to me, and besides it was in a rooftop bar with a beautiful view. I had expected to make the evening a short one, as I was jet-lagged and feeling the three hour time difference. I also had to commute out to friends' place where I was staying in Oakland. But it wasn't until we arrived at our third party of the evening (in yet another part of the hotel) that I realized that I had hit a wall (and that the room was just too packed for me). I left that party as quickly as I had entered it and headed back up to Babz's room to get my stuff.

Babz walked me down to the taxi stand (it was too late for me to feel safe walking home from the BART in Oakland) and saw me get off safely.

It was at that point that I realized that I was more than a little drunk. As I had been busy socializing all evening, the bar had been open and my glass was always full. And somehow it hadn't occurred to me to get someone to fill my glass with water.

I managed to slur out the address in Oakland to my cab driver, a young man who was really very nice. When I couldn't tell him how to get to my destination, he first called a friend and then used his Blackberry to call up a map. He had to use it again when I couldn't tell him where to exit off the freeway (something I could not have done even if I were sober. I am a terrible navigator).

While he drove, we chatted a little bit. I told him about the conference. He told me that he didn't usually like to drive to Oakland but that he was doing it for me because I "seem like a nice person."

"I am a nice person," I enthusiastically replied.

We were both relieved and happy when he dropped me off in front of my friends' building and we wished each other well.

In the middle of the night (skipping over the part where I locked myself out and had to wake my hosts who I had only met the day before so that they could let me in), I woke with a start and registered the fact that I no longer had the City Lights bag.

I tip-toed down the hall and back out to the street to see if I had left the bag on the front stoop (where I had sat while I had been trying to sober up), to no avail. Nor did Babz find the bag in her room. My receipt didn't have the name of the taxi company (and I couldn't remember). I checked twice with hotel security (in case it had been found and dropped off there) and with the lost and found table for BlogHer. By Saturday, I had given up and was trying to decide if I should return to City Lights and attempt to replace the presents I'd bought.

Then, on Saturday, as I was being miked for the session at which I was speaking, I heard my name being called. "I was your taxi driver," he said. And on his arm was a bag full of books.

"How did you find me?"

He made typing motions with his fingers. "Your name was on your credit card slip."

I was euphoric.

I asked him if I could hug him.

I offered him money (he refused).

Babz took his picture (which I won't post here because it doesn't do him justice).

And everyone made a big fuss.

"I was in the neighbourhood," he said, modestly.

But I know that he went to great lengths to track me down. He googled my name to find my blog. My last post had said that I was going to the BlogHer conference. I had linked to the BlogHer agenda, so he must have read it to find my name and the title of my session (I had told him that I was speaking). He then came to the hotel, checked the directory and followed the labyrinthine corridors to find me.

I am so touched by what he did. I wish that there had been something I could have done (I could have insisted on giving him money but I felt like it would embarrass him). His name is Eduardo and he is a lovely man.

The next time I have the chance to something nice for a stranger, I will think of Eduardo. I encourage all of you to do the same. If you do, please let me know in the comments (or if something like this has ever happened to you, please share that as well).

And yes, I really did behave myself for the rest of the conference.

Chantix vs. Nicotine Patch for Tobacco Cessation & What About Disease Management?

The Disease Management Care Blog was struck by Wall Street Journal Health Blog’s (WSJHB) coverage of another varenicline (Chantix) peer review publication. Reported in Thorax, study participants were randomly assigned to Chantix or to a nicotine patch. While early abstinence rates favored Chantix, the one year quit rates (26% vs. 20%) failed to achieve statistical difference (p=.056). Unsurprisingly, it wasn’t Pfizer that alerted the WSJHB but GlaxoSmithKline. It makes the competing nicotine patch.

WSJHB writes the borderline p value suggests that Chantix was ‘a little bit’ more effective. As in, um, the results were a little bit statistically significant. Sorry guys, the interpretation is that the Chantix vs. patch rates did not achieve the conventionally accepted threshold that distinguishes random chance from a real effect.

This is bad news for Chantix’s manufacturer, Pfizer. Looks like the Mayo Clinic won’t need to change its on line information all that much. Many managed care organizations provide access to nicotine patches via vouchers or discount programs. Since the patch arguably works as well as Chantix, these patch promotion programs will continue and Chantix will continue to be subject to preauthorization that is often dependent on trying the patch 1st.

The DMCB took some additional time to review some other publications on Chantix here, here and here. What was striking about these studies was that Chantix’s success was always accompanied by multiple follow-up 10 minute tobacco cessation office visits. The DMCB interprets this as showing that Chantix’s quit rates are intertwined with a significant degree of ongoing counseling. In fact, we really don’t know how well Chantix works without counseling. What’s more, tobacco cessation guidelines echo the necessity of prescribing tobacco cessation medications in conjunction with close follow-up:

'There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (ie, via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (eg, the number of minutes of contact). If the patient agrees to attempt cessation, the clinician should then assist in making a quit attempt and should arrange for follow-up contacts to prevent a relapse. The treatment of tobacco dependence, like the treatment of other chronic diseases, requires the use of multiple modalities. '

This is echoed in the Chantix web site and the package insert. Yet, despite the evidence, it’s unlikely that the market or insurance regulators will tolerate making access to Chantix contingent on the availability or use of counseling.

Other options include:

Paying the physicians: In contrast to other preventive care services, tobacco counseling is already covered by many insurers, including Medicare. The problem is that physicians are not taking advantage of it. Maybe it’s not enough money. Alternatives include linking the payment to presence of a Patient Centered Medicial home, pay for performance, a global fee for an episode of care or compensation referring Chantix users to another entity (hint, there's one in each state) that can provide the counseling.

Deploy disease management: Note that the counseling doesn’t necessarily have to be personally provided by a physician or in person. This is an opportunity for the Pharmacy Benefit Managers to provide the service or to partner with a disease management organization that can provide the counseling. Given the scalability and expertise of existing disease management programs, the DMCB suspects this is a more available and cost-effective option.

more than my cancer

I really do have an amazing story to share with all of you and I meant to post it before now. Parenting, however, has proven an impediment. I will tell you my terrific story (how is that for a build up?) tomorrow but for today, here are some thoughts on the BlogHer conference:

When I meet someone new, I don’t usually introduce myself by saying, “I’m Laurie and I have cancer.”

In fact, there are many people I know only casually who have no idea that I have ever been through cancer treatment, let alone that I live with metastasis. People tell me all the time how healthy I look and I take pride (somewhat irrationally, I admit) in the fact that I don’t look like a typical “cancer patient.”

Entire days often go by when the word “cancer” does not cross my lips (I would like to say that there are days when it does not cross my mind but that would be a lie). I write about living with cancer but cancer is not my life. And I like it that way.

This year, for the second time, I attended BlogHer, a conference for women bloggers (last year it was in Chicago and this year in San Francisco). The conference sold out this year and there were more than 1,000 women in attendance. For someone who spends a lot of time by myself by choice, this is both an exciting and scary concept.

Meeting that many new people at the same time is always overwhelming. However, this is compounded for me because, at BlogHer, when I introduce myself, I have to lead with the fact that I have cancer.

“I’m Laurie and I blog at Not Just About Cancer. And Mothers With Cancer. And MyBreastCancerNetwork.Com.”

You get the idea.

You can read the rest of this post at MyBreastCancerNetwork.Com.

State High Risk Pools For the Uninsured--Who Would Want To Be In Them?

What do we do with people who are uninsurable because they have a pre-existing medical condition?That is a particularly important question as both McCain and Obama propose reforming American health care by building on the private health insurance system.One of the solutions being discussed--by McCain among others--is to use state-based risk pools. Under McCain's plan heavily dependent on an

Sound Off to the Republican Platform Committee

Want to share your good ideas on healthcare reform and chronic care improvement with the Republican National Platform Committee? Here's your chance.

The Housing and Economic Recovery Act Teaches the DMCB What It Will Take to Achieve Healthcare Reform

When the Disease Management Care Blog watched the closing U.S. Senate debate on the Housing and Economic Recovery Act, it wondered if advocates for federal healthcare reform aren’t lusting for the same Congressional bipartisanship and alacrity. While all political hands were on deck for the mortgage crisis, healthcare languishes. How so?

While not having the information and experience of the insightful denizens of Healthpolicyland, the DMCB drew some lessons from watching C-Span’s broadcast of Senator Dodd’s speech on the Act. It gave good insight into what it takes for him and his colleagues to come into work on a summer Saturday morning:

Follow the money: when both Wall Street and Main Street are economically threatened by a pressing crisis, Government acts.

Implications for healthcare reform: while both Wall and Main Street don’t like it, the price of health care is still a burden, not a crisis. It’s also relatively slow moving, versus the nightly news spectacle of overnight bankruptcies and waves of foreclosures. It’s unclear what it will take to turn the health care burden into a threat.

Follow the voter: middle class persons and retirees, making up the bulk of registered voters, were not only watching their real estate values decline, but the contagion was hitting their 401Ks. They were not happy 100 days before the November elections.

Implications for healthcare reform: until the middle class and retirees really care about all those uninsured, they’ll have trouble remembering just how many million there are, let alone what to do about it. Sure, they know health insurance is expensive, but so is everything else. Next.

Everyone wins: Wall Street gets federal guarantees while distressed homeowners get a chance to refinance. The aura of government involvement is intended to inject confidence back into the markets, stopping the slide in real estate and equities. The politicians can claim there was action, even if things continue to slide.

Implications for healthcare reform: what proposal promises premium relief for business, a margin for insurers, choice for consumers, buy-in from the physicians, viability for the hospitals, cover for the politicians and breathing room for pharma?

No big money: as the DMCB understands it, Block Grants provide some requisite pork, but it appears the Federales have little appetite for big-bang spending. Instead, they like increased Government oversight, regulation and bureaucracy.

Implications for healthcare reform: does anyone seriously think the U.S. Congress has the stomach to pass a large spending bill?

The DMCB was also struck by the decline in rhetoric over who to blame in the week leading up to passage of the Act - such as lobbyists, big mortgage lenders, housing speculators and unwise consumers. The DMCB will use this as a prognostic sign in the coming health care debates. If the volume over ‘special interest lobbyists,’ ‘greedy insurers’ or ‘evil pharma’ is high, serious reform is probably far away.

Consider this cold dose of reality from Victor Fuchs this Health Affairs piece. Using his logic, mortgage reform benefited from the three-fold alignment of special interests, the pain of continued inertia and increasing unity. In contrast, healthcare reform is still currently batting zero out of three. The election of a new President and the creation of a Senate supermajority In November are unlikely to change that.

Toss in preoccupation with the economy, the environment, Iran, Iraq and Afghanistan. Mix thoroughly, place in a pan, bake in a pre-warmed oven at 350° and decide for yourself how likely health care reform is in the short term.

+++++++++++++++++++

In a prior post, the DMCB mentioned 'The Black Swan.' This is an extremely interesting book about the underappreciated role of remotely possible and unforeseen events in a world that operates as if everything can be arrayed around a mean with a standard deviation. 'The Black Knight,' the very successful ‘Batman’ movie not only possesses eye candy and displays the late Heath Ledger’s considerable acting skills. It also showcases the contrast between the coin-flipping reliance on choosing between two known alternatives (by Two-Face, a former district attorney from Mediocrestan) and the catastrophes possible when the unmanageable unforeseen happen (thanks to the Joker, who was raised in a dysfunctional household in Extremestan). To top things off, there is even a display of the Prisoners’ Dilemma.

Definitely worth seeing.

Required Reading for Health Care Analysts and Coventry Health's "Sort of" Informative Conference Call

Joe Paduda, writing over at Managed Care Matters, has a post any health plan investor should read.He laments that the analysts just weren't asking the right questions and weren't tough enough during last week's Coventry Health earnings call.With my 35 years in the health insurance business, I have to agree with him. He's dead on.Beyond Joe's comments, I noted that management used the precise term

amazing encounters (part 1)

I met Grover! Sesame Street had a suite at the hotel that was hosting the BlogHer conference. They were promoting their new web site, which my son loves. The real Grover and the real Abby (she came after my Sesame Street time but she's really nice) were present and anyone who signed up could take home a DVD of herself on Sesame Street!

The atmosphere in the room was absolutely giddy. And I lost count of the number of moms who laughed as they insisted, "I'm telling them that I'm doing this for my kids."

Which is exactly why I did it. I swear.

I have to say that I am struck by this photo. Can you tell how happy I was right at that moment? Seriously, meeting Grover turned me into a giggling groupie.

I need to tell you all about two other amazing folks I met when I was in San Francisco. And neither had anything to do with blogging or the conference.

I arrived in SF on Wednesday evening. I didn't have my first meeting (an orientation for BlogHer speakers) until 3pm on Thursday, so I spent the earlier part of that day playing tourist.

On my walk back from North Beach to the hotel, my eye was caught by a store with some funky looking clothes and purses in the window. I am really not much of a shopper but there was something about this place that just spoke to me. Inside, I met Megan the designer, who was working away at her table as I browsed.

I tried on a gorgeous jacket (which looked great on me. The online photo doesn't do it justice. And the in store price was cheaper, too) and decided to justify it as a birthday present to myself (August 4th is not that far away...).

Martha and I chatted away as I browsed. Now, I have no idea how this came up but at some point she mentioned menopause. I told her that I had gone through menopause at 38, due to chemotherapy (not the kind of thing I generally tell a complete stranger).

Then Martha told me that she has had Stage 4 thyroid cancer that she has been living and working with for many years (I not absolutely certain about the thyroid or the number of years. I was just so stunned by this revelation).

I told her that I am Stage 4, too.

We hugged. And we looked at each other, a little in awe.

You wouldn't guess that either of us had cancer. We both look pretty damn healthy. Better than healthy.

I floated out of the store, so buoyed was I from this encounter.

And I will always think of Martha, hope and inspiration when I wear my beautiful jacket.

I'll tell you about another amazing encounter tomorrow.

If McCain Picks Romney He Will Never Again Be Able to Criticize Obama's Health Plan

Mitt Romney seems to be at the top of the list when it comes to speculation over who John McCain will pick for his vice presidential running mate. I am not sure if that is what John McCain is thinking as much as the Romney people, trying to boost their guy, want us to think.But if McCain picks Romney, it will make for an interesting health care debate this fall.The Obama Health Plan is a virtual

Feed Your Head at this World Research Group Webinar

The World Research Group, the Disease Management Care Blog and Grace would like to point out Vince Kuraitis and the DMCB will be conducting a webinar:

Patient-Centered Medical Home Model: Overview and Update.

The webinar takes place next Monday, July 28 at 12 Eastern. Click here for details. We hope you can join us.

4th Tier Drugging

In today’s July 24 New England Journal of Medicine Perspective, Thomas Lee (a physician executive at Partners Health System) and Ezekiel Emanuel (a physician ethicist at the NIH) tackle how health insurers are resorting to 'tiering' to manage the high cost of biologic drugs.

Their opinion piece points out that biologic drugs (other than vaccines) can cost from $50,00 to $100,000 per year. The average health insurer is contending with a rising number of biologics and an increasing number of indications. As a result, plans are turning to placing biologics on a “4^th Tier,” which may require the enrollee to pay a percent of the total cost of the drug. If the co-pay on a $100,000 drug is 33%, the financial burden could be considerable and put potentially life-saving treatment out of reach.

Drs. Lee and Ezekiel then go on to note that this approach is a blunt two pronged method of cost control that is divorced from quality and that 1) incents consumers to not take advantage of potentially lifesaving therapy and b) for those who accept the therapy, transfers cost from the insurer to the patient. They report that 86% of Medicare drug plans and 10% of private commercial plans use a Tier 4. Furthermore, since the number of enrollees is small and the total health spend (compared to other big ticket items in the overall health care budget) is relatively small, their plight is unlikely to garner much attention.

So far so good, but Drs. Lee and Emanuel’s solutions simply fail to pass muster. They suggest society needs to get smarter about which biologics are given to which patients. Those smarts can be achieved though evidence and consensus based guidelines. We should expert health insurers to administer/enforce the guidelines. If a treatment option is questionable, patients should only be allowed to access a biologic by participating in a clinical trial. If this is done right, they encourage the physician community to support this approach instead of undermining it.

[Sigh]

The Disease Management Care Blog suggests these eminent academics spend one day in the shoes of an average HMO Medical director. Managed care organizations and their medical directors already rely on guidelines to enforce the pharmacy benefit for high cost drugs. It’s because that approach doesn’t work very well they have been forced to rely on the beneficiary-patient to act as a “speed bump” in the decision making process.

Guidelines don’t work well because a) they are often out of date thanks to new – and often substandard - research and b) they are authored in such a way to give physicians interpretive leeway. Physicians will use any new data and leeway when they believe is in the best interest of their individual patient. Their loyalty to the patient will always supersede any prior agreement over guidelines and insurance coverage. Insures have little hope that they would be trusted by the very physicians Drs. Lee and Ezekiel claim to represent.

The DMCB offers up five other suggestions which are hardly original and go unexamined in the Journal piece:

Take the biologics out of the pharmacy benefit and place them in the medical benefit: One reason why biologics are such a tempting target is because their cost represents an appreciable fraction of the total pharmacy spend. The medical spend is much larger and unlikely to be whipsawed by these agents, many of which have been in the medical benefit anyway. One could argue these agents belong in the medical benefit because the line that separates the inpatient and outpatient treatment settings are becoming increasingly blurred.

Cap the exposure to the beneficiary: Since biologics may be used for years, it’s reasonable to limit the out of pocket to some amount after some period of time. This may require the use of publicly funded risk pools. However, the beneficiary still has some ‘skin in the game.’

Make continuing coverage contingent on a clinical response: if there is an insufficient benefit, measured by objective criteria, coverage past a defined period of time is denied. This doesn’t necessarily mean any clinical response. There’d have to be an appreciable clinical response that matches the value of the biologic.

Deploy disease management: unless the physician is already doing this, remote monitoring can assure compliance, assess response, address untoward reactions and help patients and their physicians achieve maximum value for the dollar.

Create drug registries: short of the expensive and time consuming prospective clinical trials favored by our friends in academia, we need a database that allows us to track outcomes in these populations. As the outcomes become apparent, we’ll better understand the value of what we’re paying for.

safe, sound, happy and tired

I had a wonderful time at BlogHer '08.

I had chemo the day after my return, though and am still recovering. Some longer posts are owed to you all very soon.

Meanwhile, here is a pic of me, BlogHer co-founder Lisa Stone and wonderful Babz (Babz and I, who had never met in person, took to each other like two old friends).


I had to snag this photo from Babz, since I took exactly one photo all week end. It's of me and an international celebrity and I will post that tomorrow.

The latest Health Wonk Review is Up!

The latest Health Wonk Review is up over at the Health Business Blog. Take a look for the best and brightest of the health policy blog.

The DMCB Comments About Comparative Effectiveness Research, Payment for Quality, Measuring Resource Use & Physician Payment

The Disease Management Care Blog participated in an interview about some of The Big Medical Questions Of Our Time and, in typical media fashion, adhered to a superficial‘ drive-by shooting’ approach in its responses. This is less about accuracy or thoroughness but more about covering as wide an area as possible and then exiting quickly. So here’s the short and sweet of it:

What is the role of Comparative Effectiveness Research?

It’s suitable for drugs, devices and relatively circumscribed medical interventions. In the CER universe, an academic/research medical-industrial complex approach of head-to-head randomized clinical trials will be a virtue. That’s fine, but the DMCB doubts complex ‘packages’ of interventions that are interdependent and synergistic (like the Medical Home or Disease Management) lend themselves too well to prospective trials because they are hard to randomize, hard to blind, difficult to shield from other sources of bias and certainly hard to pay for.

The key question for readers of the DMCB: If CER determines there is no evidence that an intervention “works,” should that result in 1) no payment, because there is no evidence, or 2) payment until there is evidence that something else works better?

What is the role of Linking Payment to Quality?

While this has yet to really be applied to physicians, in order to discern levels of clinical quality ('high,' warranting payment, versus 'low,' warranting non-payment), the ‘law of large numbers’ requires that a valid statistical sample be used. Most individual physicians in most practice settings don’t have sufficient numbers of patients with a condition in which quality can be confidently assessed. This is an insurmountable problem, unless the solution is “close” is good enough. By the way, even if a sufficiently large sample becomes available, a p value of .05, means 5% of the payments are probably in error.

The key question for readers of the DMCB: A common solution is to aggregate physicians’ data and let the physicians distribute the payment. Is this a conscious or unconscious early step in the aggregation of physicians into groups, PHOs, accountable health systems or integrated health systems – and the demise of the small independent practice?

What is the role of Measuring Resource Use?

Since the subsequent use of resources (back imaging studies and a visit to a specialist or hospital) following an index encounter (the first visit for back pain) is part of the resource consumption, most measures of resource use rely on ‘episodes of care,” which the DMCB thinks of as a packaged timeline with a start (index visit) and a finish (resolution of the condition). The good news is that otherwise independent providers involved in the episode of care can have a stake in optimizing resource use. The measures, if done right, can get them to cooperate and integrate.

The key question for readers of the DMCB: Is measuring resource use around an episode of care the first step in a road that will lead to paying for episodes of care, using a payment mechanism similar to capitation?

What is the role of Medicare Payment Updates from the RUC?

Mainstream primary care physicians are confused by the RVU methodologies, disenchanted with the competing specialties in the process, distrustful of the politics surrounding them and disdainful with the RVU conversion to dollars and payment. While policy, economic and physician experts are grappling over tenths of an RVU, the street level PCPs have become disengaged.

The key question for readers of the DMCB: While us do-gooders in the population-health biz have GREAT ideas on how to make life better for physicians and their patients, why should docs, given their experience with RVUs (and capitation and P4P) believe that we aren’t offering more disappointment?

+++++++++++++++++++++++++

Off topic, but DMCB is having an 'egads, what were you thinking!?' moment over the bad Gator behavior of young and future physicians. A study from the Journal of General Internal Medicine:

Abstract

Aim To measure the frequency and content of online social networking among medical students and residents.

Methods Using the online network Facebook, we evaluated online profiles of all medical students (n = 501) and residents (n = 312) at the University of Florida, Gainesville. Objective measures included the existence of a profile, whether it was made private, and any personally identifiable information. Subjective outcomes included photographic content, affiliated social groups, and personal information not generally disclosed in a doctor–patient encounter.

Results Social networking with Facebook is common among medical trainees, with 44.5% having an account. Medical students used it frequently (64.3%) and residents less frequently (12.8%, p < .0001). The majority of accounts (83.3%) listed at least 1 form of personally identifiable information, only a third (37.5%) were made private, and some accounts displayed potentially unprofessional material. There was a significant decline in utilization of Facebook as trainees approached medical or residency graduation (first year as referent, years 3 and 4, p < .05).

Discussion While social networking in medical trainees is common in the current culture of emerging professionals, a majority of users allow anyone to view their profile. With a significant proportion having subjectively inappropriate content, ACGME competencies in professionalism must include instruction on the intersection of personal and professional identities.

According to MSNBC:

'Erick W. Black, one of the researchers, said he found pictures of students grabbing their breasts and crotches, posing with a dead raccoon and multiple photos of residents and medical students drinking heavily.

Many students had joined Facebook groups that could be considered sexist, racist or downright nasty, with many using vulgar language. Some of the tamer groups included 'Physicians looking for trophy wives in training' and 'PIMP' (Party of Important Male Physicians).''

The DMCB asks if instruction in the use of common sense might also be in order. DMCB spouse opines 'they should not be allowed to graduate!'

The End of Medicare Private Fee-For-Service--the Questions to Ask the Health Plans During Earnings Season

Now that we know private fee-for-service (PFFS) is dead on January 1, 2011 in all but the most rural markets, how will the health plans who have significant PFFS business respond?UnitedHealth is the first health plan to report earnings this quarter and I thought they had the right answer. From their earnings call transcript (Ovations CEO commenting):We have had a strategy of deliberately

Vytorin and SEAS: Here's An Alternative Point of View

There's been something of a feeding frenzy over reports of ! CANCER ! in the latest Vytorin trial. The study was acronymed 'SEAS' for the ‘Simvastatin and Ezetimibe in Aortic Stenosis Study,’ which randomly assigned over 1800 persons with ‘aortic stenosis’ to a placebo or to Vytorin. Different than coronary artery disease (in which the arteries feeding the heart muscle get blocked), aortic stenosis is scarring and thickening of a major heart valve. It usually evolves over decades and can lead to chest pain, shortness of breath and passing out. If the progression can be slowed with drugs, persons with mild stenosis may avoid severe stenosis and die of natural causes before the only known cure becomes necessary: major heart surgery.

The trial showed no difference in aortic valve outcomes. However, what the trial did show is an increase in cancer rates among subjects assigned to Vytorin:

‘In the subsidiary safety analyses, a total of 158 patients were recorded with a serious adverse event attributed to cancer. More of these events were observed among patients assigned the combination of simvastatin and ezetimibe than among those assigned placebo (93 (9.9%) versus 65 (7.0%); unadjusted p=0.03), and there were also slightly more cancer deaths (39 (4.1%) versus 23 (2.5%); unadjusted p=0.05). These apparent differences were not related to any particular type of cancer and did not become significantly larger with more prolonged treatment.’

Shocking you say? While the mainstream print media’s alarmist framing (see here and here) can be forgiven (and let’s face it, they are also being distracted by the scourge of Mexican hot pepper Salmonella poisoning), some bloggers are really piling on: ‘this combination pill, still taken by millions of people, raises the risk of cancer,’ and it ‘unexpectedly suggests an increase in cancer…. disturbing finding…’ and cancer fears are putting stocks ‘in a tailspin.’

The Disease Management Care Blog advises folks to take a deep breath, calm down and look at the facts.

First off, fears that there are links between cholesterol lowering as well as cholesterol lowering drugs and cancer are not new. Reports as far back as the 1990s raised that possibility. Other studies have cast doubt on the association while other studies suggest lowering cholesterol may protect against cancer. When all the science is considered, the SEAS news is not surprising, not shocking and certainly not conclusive.

Secondly, there is the difference between causality and association. Just because two things happen at the same time doesn’t mean one directly causes the other. Between and surrounding Vytorin and cancer may be other events that drive the association. What’s more, even if there is a causal relationship, we don’t know the direction: it’s possible that developing cancer can cause a decrease in blood cholesterol levels, long before the cancer becomes apparent. The SEAS study may not have evenly randomized patients at risk for cancer.

Thirdly, if multiple studies are done, statistical significance – when none exists – is more likely to occur. The all important ‘p value’ of .05 means there is a 5% chance that the observation could have happened as result of random error. If multiple studies are done, the .05 for each study is additive. In other words, if there is a one in twenty chance that something will happen, by the time you get past ten chances (or you conduct ten studies), there is a reasonable expectation that that error (a spurious association) will happen. It was possible this was SEAS' bad luck.

Unfortunately, SEAS was unable to demonstrate that Vytorin can slow the progression of aortic stenosis. Based on prior studies, we still don't know about the cancer risk from cholesterol lowering medicines, but in general they suggest there isn't an association. The DMCB thinks the statistical/methodological issues above are more likely explanation for what happened.

Patient Centered Medical Care and Disease Management Both Let Doctors Be... Doctors

The Disease Management Care Blog doesn’t remember too much about its 7 years of medical school or residency (thank goodness) but it remembers when it left Preventastan and crossed into Acuteastan. It was close to midnight and one of my fellow interns was drawing up a gram of Solumedrol for an I.V. ‘push’ dose for an unfortunate with Lupus nephritis. I thought, how cool.

It is difficult to overestimate the mostly good and sometimes bad influence of medical training on attitude, values and career choices. One of the most pervasive outcomes of med school and residency however, is the enculturation of young trainees toward an acute care focus. We become addicted to the thrill of spotting a diagnosis and tailoring a successful treatment. That’s not necessarily bad: physicians are needed first and foremost to care for sick patients. After many rewarding years of helping patients in extremis, prevention - the art and science of non-events - is, well, so boring.

This contrast between chronic care ennui and acute care excitement has gone unexamined as one cause of the widespread lapses in health care quality. But the DMCB thinks it is out there.

By ‘prevention,’ the DMCB includes not only the avoidance of disease but the complications of established chronic disease. Getting docs to enter Preventastan is hard work. There have been unsuccessful efforts to advance prevention with quality improvement (QI), the electronic medical/health record and pay for performance (P4P). There is literature that suggests these interventions have a spotty record in changing the approach of hardened professionals. They are openly skeptical about QI, willing to ignore electronic on-screen prompts and resist P4P.

The DMCB appreciates there are other forces at play. Physicians lack time, trust in the system, training, incentives and support. On the other hand, when physicians really want to effect change, it appears they have the means to do so.

This is why the DMCB likes the Patient Centered Medical Home (PCMH) and Disease Management (DM). Both approaches explicitly recognize the physician doesn’t need to be personally responsible for preventive care. PCMH delegates chronic care to members of the clinic’s team while DM outsources it to remote nurses. Some combination of both probably works best.

What’s more both PCMH and CM approaches can be helped by quality improvement, rely on the electronic record and can generate payment for performance.

And finally, both let doctors be …. doctors.

Is Meaningful Health Care (Or Any Other Kind Of) Reform Possible?

Our good friend Brian Klepper joins us after a bit of a summer break. This time he examines the dynamics of health care reform and questions just how optimistic we should be that progress will be made.Is Meaningful Health Care (Or Any Other Kind Of) Reform Possible?By Brian KlepperThose who wait, ever hopefully, for real health reform might want to take a deep breath and take stock of a few

Why Are Such High ROIs Possible in Disease Management?

The Disease Management Care Blog appreciates that in the business world, a return on investment of 1-6% is quite respectable. Contrast that with claims of ROIs of 200% percent or range or more (literally doubling the money) in disease management. Is this evidence of the disease management industry’s incredulous and sloppy methodology?

Maybe it's not that simple. Wanting to boil this area of controversy down to it’s simplest terms, the DMCB offers up a non-financial expert's, non-economist’s simplistic 7 point explanation on why such ROIs are possible:

1) Decades of research on worksite wellness programs, which also address chronic disease in addition to prevention, use many of the same approaches in disease management and have demonstrated reductions in claims expense.

2) Advocates of the Medical Home suggest this approach also reduces claims expense. Maybe it does, but much of the literature is based on interventions not dissimilar from the approach used in disease management. Just like worksite wellness, what’s different is the location, not its effectiveness in saving money.

3) Disease management is all about avoidable medical cost in the form of insurance claims. Avoided claims expense in health insurance is distinctly different from top line revenue, which is a function of premiums. Revenue increases are smaller but are easier to discern and are attributable. Measuring what doesn’t happen – such as emergency room visits or hospitalizations - in the flow of a health insurer's claims is subject to unavoidable variations in measurement and interpretation that can favor disease management programs.

4) In health insurance, changes in the top line reflect real dollars being spent for the real service of risk transfer. There are also real dollars being spent for disease management. In contrast, inflated charges for the medical services that comprise claims expense has little to do with their real costs. Comparing the real fees for disease management against the inflated fees for medical services increases the ROI.

5) Claims typically have a non-Gaussian (skewed) distribution and a very wide distribution. While this can cut both ways, a small reduction in high cost outlier claims in a measurement period can favor the ROI significantly.

6) One averted hospitalization can mean (for the sake of argument) $10,000 in claims expense. Disease management may charge $30 per person per month. If there are 100 persons with a chronic illness, that’s $3000/month or $36,000 per year. It's not unreasonable to believe that avoiding 4 or more hospitalizations may well be within reach of an aggressive program.

7) Then there are the competing countries of 'Mediocrestan' vs 'Extremistan.' The DMCB picked up these terms from Nassim Taleb’s book, “The Black Swan,” which examines the growing impact of ‘low probability’ yet ‘high damage” Extremistan events,’ in a Mediocrestan world engineered to operate around an average. Dr. Taleb doesn’t discuss health care very much in his book, but the DMCB thinks clinical medicine is more Extremistan: slight changes in imperfect tests and even less perfect treatment combined with natural patient variation can result in huge unpredictable swings in outcomes. Despite an aura of science, the real art of caring for patients can be somewhat akin to Chaos Theory. Accordingly, the beating of disease management’s butterfly wings may be enough to avert a sufficient number of high cost storms.

Catch Up Friday

It's Friday! What better day to catch up on some random pre-weekend observations and thoughts:

As further evidence of how passé the term ‘disease management’ is becoming, the journal formerly known as ‘Disease Management’ will henceforth refer to itself as ‘Population Health Management.’

++++++++++++++++++++++

Wonder why you are reading this blog? So is the Kaiser Family Foundation, which will be sponsoring a July 29 1 PM discussion on the growing illumination of bloglight on news reporting and policy debates. Attend in person in Washington DC if you like but for those of us of the virtual persuasion, a webcast will be available here. Mark your calendar.

++++++++++++++++++++++

Here’s one way to conduct participant satisfaction surveys. Here’s another. You decide which is a more credible approach.

++++++++++++++++++++++

Brriiiingggg!

ADT: 'Just calling m’am. We’ve received an alert and wanted to make sure everything is OK.'

[Strobe lights flashing. Alarm sounding bong... bong.... bong.... whoop whoop whoop!]

Woman: 'Oh thank goodness you called, yes we’re alright!

ADT: Should I have the medication compliance police come over and make sure you take your pill?

++++++++++++++++++++++

And completely off topic, but this is my blog. While watching the July 17 PBS NewsHour, the DMCB wasn’t quite sure it heard right. It did:

'And Joseph, who was an eccentric man -- I mean, he was a nudist, he was a wild morris dancer (ph), he was an accordion player. People say, being a nudist, at least he wasn't a cymbals player.'

Indeed!

What Are the Top Ten Features of Cost-Saving Employer Sponsored Wellness Programs?

In the second day and concluding day of the WRG Conference, we heard from WebMD’s Larry Chapman. He echoed yesterday’s comments from Emory University: there is no doubt that employer sponsored wellness programs (many of which resemble classic disease management) have a return on investment (ROI). There are multiple positive studies from disparate settings including NORTEL, Duke University, the City of Birmingham and DuPont.

What are the lessons from such successful wellness programs you ask? Good thing the Disease Management Care Blog kept notes:

1. Don’t limit ROI economic measures to just claims expense. Include turnover, absenteeism, disability, workman’s compensation and presenteeism. That may inflate the ROI, but these domains are also important to employers and they want to know,

2. Enhance risk reduction and mitigation by promoting employee awareness, increasing motivation and helping them develop new skills,

3. Use a total population health model that is ‘results oriented,’

4. Include employees’ spouses,

5. Require employee participation in an annual health risk assessment (HRA). Think about making it part of open enrollment,

6. Let the employees fund most if not all of wellness incentives through premium differential. Don’t be shy about ‘play or pay’ and ‘getting everyone on the wellness bus,’

7. Coordinate wellness with the insurance benefit, particularly with consumer directed health plans (CDHPs) and any other cost sharing approaches,

8. Promote self care. An example is promoting WebMD’s ‘symptom checker,’

9. Promote consumer education that includes not only condition but benefit management. In fact, consider requiring CDHP participants attend a ‘how to’ workshop. Furthermore, emphasize injury prevention (an example is seat belts) and provide aggressive intervention programs for enrollees with multiple health risks,

10. Offer a tiered wellness incentive with real money based on explicitly defined criteria.

Update on the WRG Conference - A Sampling of Some Interesting Stuff

What an interesting WRG conference. For your reading pleasure, below are summaries of some of the presentations that really caught the ear of the Disease Management Care Blog. More to follow tomorrow…..

Blue Cross Blue Shield of Michigan is finding that offering wellness is an increasingly critical ingredient in winning accounts. Their approach is to offer a suite of wellness and disease management options that, depending on the buyer, can be ‘dialed up’ or ‘dialed down.’ They are developing their own assessment methodology that not only calculates savings vs. costs (i.e., return on investment) but changes in ‘net savings.’

Most interesting message: As outreach progresses from high to low risk, Michigan's modeling suggests that increasing the outreach to more persons with chronic illness eventually leads to a ‘tipping point’ decline in ROI and net savings.

StayWell believes best practice elements for company wellness programs include: strong organizational commitment, identification of wellness champions, linkage to business objectives, effective communications, having fulltime dedicated staff/vendors, making employee spouses eligible, offering comprehensiveness, raising awareness company-wide, targeting special interventions for high-risk persons, maximizing accessibility, providing incentives and utilizing biometric screening.

Most interesting message: Want to incent employees to fill out that health risk assessment or show up at a wellness program offering? Employee premium differentials beat cash rewards, which beat non cash rewards. Premium differentials not only increase participation rates, the non-participants subsidize the participants – which payers/purchasers like.

Emory University says there is a rich body of occupational health literature that has been around for years that conclusively shows wellness programs have a positive return on investment. There is a methodology using a health risk assessment that can assign a ‘Risk Profile’ to an employee-participant. This profile correlates with insurance claims expense. The ready availability of ‘propensity scoring’ makes a parallel control group readily available. Between the Risk Profile and the propensity scoring, analysts can approximate return on investment without having to conduct a randomized clinical trail.

Most interesting message: It is not uncommon for ROIs to exceed 3 to 1. And we shouldn’t be embarrassed to say so.

Highmark thinks that if you’re going to offer wellness, you might as well lead with your employees. That’s what Highmark did with an in-house wellness program. Read all about it at the February 2008 issue of the Journal of Occupational and Environmental Medicine.

Most interesting message: The ROI for a wellness program may not become apparent for three years.

Aetna was mentioned in a prior DMCB post, which discussed a blog post describing the insurer’s use of a lottery with a financial award to increase medication compliance. It turns out this is more sophisticated than just a simple lottery. There is a considerable body of research that shows humans tend to overestimate their chances in such games of chance. The medication-compliance lottery is a conscious exercise in “asymmetric paternalism,” in which the insurer harnesses their enrollees’ tendency to exercise poor judgment.

Most interesting message: Persons can be incented to make the right decision using bad decision logic. We can simultaneously harness and respect a person’s right to choose - wrongly.

Health Insurance Industry Stupidity—It’s a Rout From Here On Out

Why the health insurance industry allowed itself to be put in the place they were put by the Democrats yesterday is beyond me.With the Senate voting 70-26, and the House 383-41, to override President Bush’s veto of the bill to erase the 10.6% Medicare physician fee cut and pay for it with changes that will end the Medicare private fee-for-service program in 2011, the health insurance industry’s

Return on Investment, Disease Management and Wellness

The Disease Management Care Blog is coming to you from Washington DC, where it is attending (and speaking at) a World Research Group conference focused on wellness. It intends to share the highlights of the other speakers from other settings who are embarking on new programs in future posts, so stay tuned.

One of the major themes of this confab is the perennially difficult topic of ‘return on investment.’

Some of the DMCB’s planned – and simplistic - comments for tomorrow:

If we must use the term ‘return on investment,’ its measure is generally done one of five ways. These are:

1. Compare the claims expense of either the population or a representative part of the population to a matched control. Using the population at baseline and comparing it to itself (pre-post) after the intervention is a variation on this theme. It’s better to use a parallel control. This has the advantage of being conceptually easy to understand. This may partially explain why this approach still appears, in the experience of the DMCB, to dominate the market place.

2. Examine the trend (change over time or the slope) in claims expense for the population and compare it to a control or what the expected trend should be. Trend can be more difficult to understand but it has the advantage of also being used in other health insurance calculations. As such, it is probably destined to be the ‘coin of the realm.’

3. Use ‘Other Weird Calculations’ such as measuring the relative impact of the program on the observed trend. In other words, as the claims expense goes down (or up), is there any correlation with the amount of the intervention, and if so, how much? For example, do more coaching calls translate to correspondingly fewer admissions?

4. Use anecdotes. Don’t underestimate the impact of positive or negative personal testimonials shared at an all-employee meeting or given to the head of Human Resources.

5. Rely on Quality Adjusted Life Years (QALYs), which captures the possibility that there isn’t a reduction in claims expense. If there aren’t, what gains in quality are there, and for each ‘unit’ of quality what is the cost?

The DMCB will be looking forward to hearing how others at the Conference tackle this. More to follow.