Iron Healthcare America!

Welcome to Iron Healthcare America. Yes, few dare enter the Kitchen Stadium in which population-based interventions battle for the supremacy in taste, acceptance and coverage by Medicare. But there is one more ingredient to this week’s battle, the secret ingredient:

(Dunka dunka music. Martial arts flourish). Cost savings!

This week’s battle pins the challenger, Disease Management against Iron Chef Medical Home. Disease Management has robustly embraced population-based care for over ten years, serving as both a Wall Street darling and a medical continuum of care Mephistopheles. Now hawking its wares in commercial and self insured settings, its interventions have been hailed as far as Brazil and Singapore, which are the only places hailing its interventions. Facing off is Iron Chef Medical Home, most famous for its inventive fusion of patient centeredness and the chronic care model. It’s knocking on Medicare’s door and daring diners to go ahead, don’t pay for this and make my day.

And meet our judges:

Dilweed Flabbersham, Lead Chef of Chez Blinders, a leading hip bistro located in hip Washington, DC;

Percy Aliquot, Editor in Chief of Dysgeusia, the not infrequently cited gastronomic and policy journal, headquartered in Boston and;

Hugh G. LeMorose, MD, a physician gourmand, physician advocate and physician provocateur.

Iron Chef Medical Home opened with a pressure cooked cocktail of Grande Moneyier, cost savings extract and blenderized ‘justgivemtome’ shekels. A team-infused crepe sautéed with a scrumptious blend of cost savings puree, bulbous doubtplant and primary care followed. The main course consisted of a half-baked loaf of boeuf served over a base of sympathy, policy mash and fillet of cost-savings ‘sans data’ style. The dessert was custard crème compote of tart indignation and inefficiency syrup drizzled with an acidic blend of monetary woe.

Challenger Disease Management began with a sans les physicians style zoupe of laid egg white, standard recycled stock and cost savings ‘chowder-style.’ Our judges next turned to la salade of select data greens, ripened data gourds, specially chosen participants and caramelized bon-bons sprinkled with avoided expense. The main course was a brisket served ‘controls au invisible,’ with a peer reviewed reduction and spiced trendalot. Dessert finished this fete with a trend-based pudding of mirage like diced claims, spiked assertions served over mirror smoked savings.

As you know, judges had to score each contestant on acceptability (5 points), originality (5 points) and taste (10 points).

And how did the judges score this gastronomic duel?

(Dunka dunka music. Martial arts flourish).

Chef Flabbersham:
Medical Home 14 points, Disease Management 15 points

Editor Aliquot:
Medical Home 14 points, Disease Management 15 points

Dr. LeMorose:
Medical Home 0 points. Disease management 0 points.

This week’s winner? (Dunka dunka music. Martial arts flourish).

Iron Chef Medical Home!

Tune in next week when Medical Home takes on Value Based Purchasing……

drops in the water

Today, is the Jewish New Year.

My spouse is Jewish but I am not.

Neither of us is even remotely religious.

But I love the idea of fall renewal, of having the chance to start a brand new year, in this time of harvest and change.

Nonlinear Girl has a post on this subject today and on having the chance to "cast off" the things that hold us back:

"In the Jewish religion, today is the ceremony Tashlich, which is Hebrew for "casting off." As part of the start of a new year, this is a chance to symbolically cast off the sins of the past year. Jews go to a natural body of flowing water and throw in pieces of bread to symbolize the shedding of these old errors. The idea is to get rid of things you do not want to take with you into the new year. While traditionalists focus on specific errors made in the past year, right now I am thinking more about the ways I make life unnecessarily harder for myself. By tossing away some of these I hope I will feel lighter about whatever happens in the next year."

You can read more of this post here and leave a comment, if you like, about the things you would toss away to help you move forward.

I wrote:

Toss in my insecurities about my inability to be an artist, my shame about having cancer and the fears that keep me from 'doing.'

writing my way through breast cancer

I have a new post up at MyBreastCancerNetwork.Com:

"When I was first diagnosed with breast cancer, in January 2006, I was given an envelope full of information, pamphlets about available resources, a calendar (to track all the appointments) and a journal for chronicling, “my breast cancer journey.”

While I had kept a journal for brief periods of my life in the past (and most actively while travelling), I set this one aside. I was far too overwhelmed with absorbing information and trying not to feel overwhelmed to contemplate keeping a personal diary of my feelings.

I did however, choose to start a blog. For most of my professional life, I did some form of communications or public relations work. I was strongly motivated to control the “message” around my breast cancer. I wanted to be the one to determine the Who, What, Where and When (if not the Why) of my cancer and its treatment. I also saw writing, as a way to process my experiences, as an important side benefit.

I could never have predicted how important my blog would come to my survival. I thrived on the connections I made, the community to whom I connected and, in opening myself up to others, I began to feel much stronger and more confident."

You can read the rest of this post here.

With Little Hope for Reform, What Can Congress and CMS Do?

After today’s market meltdown, the Disease Management Care Blog once again pondered the moribund prognosis for any new money being approved by Congress for health care reform in the near future. Main Street is clearly balking over a bailout for Wall Street. Given the bad news for their 401Ks or home values, who thinks the folks on Main Street will be willing to dig into their pockets for their uninsured neighbors, underpaid Lexus-driving physicians or overfilled hospitals?

That doesn’t mean Congress and CMS won’t search for something, anything that will give their constituents the impression that they’re concerned – deeply concerned – about healthcare quality or cost savings. Here are four process-rich areas that will give the Feds the cover they need in mainstream FFS Medicare. The DMCB fully expects these concerns to move to center stage, pushing disease management, population-based care strategies, new provider reimbursement or consumerism off to the side for the foreseeable future.

Attacking fraud. A perennial bipartisan favorite that is a never ending source of blustering indignation. Given the whack-a-mole complexity of the Medicare regulations, enterprising criminals will always exploit a loophole. In exchange, the Feds get to always exploit the appearance of accomplishing stuff.

Exposing administrative incompetence. While Medicare is a huge bureaucracy, there are simply not enough people to monitor inappropriate utilization, especially when CMS relies on the threat of a retrospective audit to get its way. That doesn’t mean there isn’t political advantage to be gained by finding examples like this. A closely related area is high cost radiology.

Not paying for errors (and paying for quality). No, not all mishaps are unavoidable and not all quality is measurable, but that’s not the point. It tastes great and is less costly.

Pursuing physician self-referrals. The rules that govern ‘safe harbors’ between physicians and imaging facilities are a mind-numbing morass. Perfectly suited for our political process, which can use untold months pulling it all apart and then putting it back together again.

so many lovely people

I left for Toronto early Thursday morning and got back late last night.

I spent time with friends and family that I love very much.

I didn't get enough time with anyone but I enjoyed every moment.

And I ate. And ate. And ate.

I am tired today.

But I am happy.

Hazardous Surgical Approaches to the Patient Centered Medical Home

Remember that Edward Jones commercial where the surgeon uses the telephone to instruct the hapless patient on how to perform abdominal surgery? My colleague Vince Kuraitis over at the e-CareManagement Blog suggests the same may be going on between the expert Chronic Care Model (CCM) intelligentsia over at the AHRQ and the amateur episodic-care focused primary care physicians. Given the richness of the CCM and the complexity of redesigning a primary care clinic, he may have a good point. This is very complicated stuff.

Despite Vince’s admonitions, however, the average primary care physician could decide that the-do-it-yourself “insert peg A into hole B” CCM AHRQ manual is worth a try. In Disease Management Care Blog’s prior post on the topic, it assumed that a physician could do the install. Maybe physicians can, but the DMCB argued that once the new clinical CCM Ver. 1 operating system was booted up, it would bear insufficient resemblance to that Golden-Boy darling of the doctors, that lusty pick of the policy makers, that most admired of the academics, the Patient Centered Medical Home (PCMH). There is significant overlap between the CCM and PCMH, but the two are distinctly different. Accordingly, even if successful, the physician and patients would be stuck with yesterday’s care model. As a matter of fact, it would be far removed from the model that is more likely to succeed: a combined disease management - PCMH approach to care.

e-CareManagement makes another point about the CCM, and that is that the surgery would be partially or completely unsuccessful. The DMCB agrees and believes there are important implications for the PCMH. As I point out in my article on the topic in Health Affairs, the track record of implementation of the complicated multi-faceted CCM in practice settings often results in partial installs that depend more on the local physicians’ preferences and biases rather than a commitment to replicating what is reported in the evidence-based literature.

The same could happen to the PCMH.

What else could account for the tiered 100 point scoring system used by the NCQA’s PCC-PCMH recognition program? As the DMCB understands it, installing ‘half’ of a PCMH is enough to get 50% of the points. Does this mean that this 'Ver. 0.5' install would a) take care of half of the needs of a population, or b) achieve half of the potential savings, or c) warrant half of the case management fee, or d) that 50% fewer patients can be assigned to a practice?

Rhetoric aside, the DMCB does not know if a partial version of PCMH results in any, some or all of the potential improvement that a PCMH is supposed to achieve. Think getting only part of the neurosurgery done or taking out only half of an appendix. The DMCB believes there is no peer reviewed, evidence based literature that examines the outcomes from a partially implemented PCMH.

Coda: When criticized by Gail Wilensky, Harvard economist David Cutler has agreed that the individual elements of tort and payment reform, health IT and comparative effectiveness studies aren’t necessarily associated with cost savings. He argued however, that their simultaneous use is the critical ingredient for success. Is the same true for the elements that make up the PCMH?

What I'm Telling the Health Care Business About the Future

Last week I did a post, The Chance for Major Health Care Reform in Either 2009 or 2010 Is Now Zero.I made the point that the bailout the Congress is now voting on is on top of a 2009 projected federal budget deficit that the White House has already estimated to be $500 billion. Add to that the $300 billion in deals the feds have done for the likes of Freddie, Fannie, and AIG. Then we have the

Health 2.0 in San Francisco October 22-23

Matt Holt is getting ready for his upcoming Health 2.0 conference and asked that I pass along his personal invitation:The next Health 2.0 conference will be held in San Francisco, California from October 22nd - 23rd at the San Francisco Marriott. The theme will be a return to the focus that made our first conference a resounding success: Web 2.0 technologies, healthcare and all points between.

AHRQ Posts a Tool Kit for Yesterday's Care Advances

The Disease Management Care Blog found this on-line AHRQ "Tool Kit" that provides a detailed tailored step-by-step guide for primary care practices' switch to a 'Chronic Care Model.' The roadmap has decision points that account for prevalent payment streams (fee for service versus capitation) and the ability to bill for ancillary services. It focuses on how to create your leadership team, establish data streams, set performance targets, engineer the necessary measurement infrastructure, redesign the practice with clinical teams, understand which patients 'belong' to the practice and address the patients' needs with care plans, self management support and continuous improvement. It provides links to multiple other sites with additional information.

While the AHRQ deserves credit for working with the MacColl Insitutute to put this resource out there, it doesn't provide the details necessary to successful switch to a Patient Centered Medical Home (PCMH) or to what Medicare will use in its upcoming Medical Home Demo. Coming out with a similar document that supports either would be a timely public service.

Don't hold your breath.

Given the government's hidebound speed in getting these kinds of things done, the DMCB predicts that by the time THAT happens, NCQA PCC-PCMH Ver 2.0 will be long established or - more likely - the CCM and/or PCMH will be supplanted by even newer versions of care that combine disease management, consumerism, health information technology and new reimbursement models. At least it hopes so.

The Big Bailout, Obamaite David Cutler vs. McCainiac Gail Wilensky and the New England Journal of Medicine Roundtable on Health Care Reform

Take a diazepam, don your dark sunglasses, apply those ear plugs, don’t look at your 401K and disregard the Feds’ looming commitment of $2300 dollars per person to The Big Bailout. Imagine the US Congress will not be distracted by the wars in Afghanistan and Iraq, the growing militancy of Iran or the volatility of energy prices. You’re now ready to view the remarkably civil and educational 56 minute on-line video that pits the earnest optimist Obamaite David Cutler against the experienced technocrat McCainiac Gail Wilensky in an “Election 2008” roundtable on health care reform. Q&A were from Karen Davis of the Commonwealth Fund, Jon Kingsdale of the Massachusett's Health Insurance Connector Authority and Thomas Lee of Partners HealthCare.

No time? No problem. The Disease Management Care Blog had a glass of Sauvignon Blanc (the best is still Cloudy Bay 2005), donned the high mag spectacles, turned the volume up, accepted its financial advisor’s advice to not cash out (now is the buying opportunity!) and wrote up this summary for your reading pleasure.

David Cutler of Harvard says Obama has 3 goals:

1) Access to quality and affordable care. This should “not very hard” if waste and redundancy are reduced and if we have the will to spend money in the short term. Spending can be partially funded by rolling back the Bush tax breaks and using that to fund tax credits. Lower prices plus insurance reforms that encourage more participation in risk pools will lead to even lower costs.

2) Modernizing the costly wasteful and doctor-unfriendly system. This will happen thanks to “investment” in state-of-the-art prevention, comparative effective analyses, quality measurement and reporting, electronic records, paying for quality and achieving tort reform by preventing errors with health information technology HIT and settling disputes outside of courts.

3) mainstreaming non-politicized public health principles to address tobacco, obesity global epidemics and other issues. Emphasis on non-politicized.

The DMCB take away: even with the fiscal room to maneuver, it was unlikely that Congress would go along with “short term” spending increases. In the Q&A, Dr. Wilensky correctly pointed out that true “waste” is rare. What is far more common is health care that is high cost, low value and high demand. There is little proof that the modernization items listed above will reduce cost individually or in combination. And while the present administration elevated this to an art form, when hasn’t public health been vulnerable to political interference?

Gail Wilensky of Project Hope reports McCains’s emphasis is on controlling costs. To do that, he proposes harnessing the purchasing power of an increasingly mobile job-changing workforce. Giving these individuals tax credits for insurance purchases and letting insurers openly and transparently compete across State lines will not only reduce the number of uninsured in the short term but force the market to control costs over the long term.

Yes, there are predictably high spenders who will be unable to buy insurance at any price. For those who can’t access employer-based coverage under COBRA, the Feds can kick in new dollars for “high risk” insurance pools.

There was little disagreement over the need for the modernization ideas listed above.

Dr. Wilensky reminded the audience that the admittedly imperfect Medicare Modernization Act taught us that passage of a health care bill is possible when Congress’ preeminent role is respected and Presidential leadership is deployed to achieve the best compromise. Contrast that with the Clinton reform debacle. Ms. Wilensky asked which candidate has the best track record of working with a Senate in which 60 votes are never a sure thing.

The DMCB take away: Dr. Wilensky believes individuals spending their own cash can deputize health insurers to do something about runaway cost inflation. Health insurers are already doing their darndest to do that within State lines, so it’s hard to see how that will happen in a cross state market unless they’re willing to risk another backlash. The more likely result is that persons will buy inadequate coverage. McCain is also counting on a precarious pre-bail-out pot of money. Finally the MMA was an example of what happens when a single political party uncompromisingly dominates the national discourse.

Is the DMCB being a morose, cynical nattering nabob of negativity? While both sets of proposals have their problems, they offer a real contrast between government involvement in a failing market versus using government to rehabilitate that market. In the end, however, their reliance on new spending, other national security distractions, recent news that the number of unsinsured dropped and the willingness of States to promote their own reforms makes the DMCB believe that the likelihood that either candidate’s proposals will succeed in the next year or two is very unlikely. Anything meaningful happening after the Big Bailout will require a miracle.

The Chances for Health Care Reform?

5 minute fantasy

A couple of Sundays ago, I participated in a writing workshop with my breast cancer survivor/former co-worker support/writing group. It was a fantastic, inspiring energizing experience.

I wanted to share one of my more light-hearted pieces from that day.

The exercise: Choose an object that is important to you (I brought in a necklace, designed by my friend Jacqueline (who also designs clothing for women who have had mastectomies). The necklace has a pendant that says “Rebel” (it’s a beer cap) and eight beads. Four are red and one is white, representing the one woman in eight who will get breast cancer.

We were asked to write a description, a memory, a fantasy and a monologue in the object’s voice. Each exercise lasted five minutes.

This is my fantasy:

I am not a rebel by nature. Perhaps it’s my birth order but I have always been a good girl, even through my teenage rebellion and even when breaking the law.

But in my fantasies I am superhero in a beer cap necklace. A one-breasted warrior, wearing big boots and a really cool scarf (you can’t be a superhero without the right accessories. That’s where the confidence comes from when it lacks more internal origins).

I am a superhero who can command a room with my presence and make CEOs tremble with a furious glance from my piercing blue eyes.

I know how to right wrongs and rid the world of injustice and I pull it off – with time left over to finish the queen-sized blanket that’s been languishing in its basket for more than a year.

The Chance for Major Health Care Reform in Either 2009 or 2010 Is Now Zero

A couple of weeks ago I did a post, The Pretend Presidential Debate on Health Care--The Health Care Press Needs to Force the Presidential Candidates to Get Real on Health Care "Change".In it I made the point that facing a $500 billion budget deficit next year, the sunset of the Bush tax cuts in 2010, fixing the alternative minimum tax problem once again, and the cost of the Freddie and Fannie

JAMA to Retail Pharmacies: Get Out of the Tobacco Biz. The DMCB Agrees & Has Additional Recommendations for Managed Care & Disease Mangement

Let's see.... time to pick up that 30 day supply of my prescription drugs for my diabetes and heart disease and while I'm here grab some razor blades, some shampoo and some.... smokes?

Not if Mitchell Katz of the Department of Public Health in San Francisco has his way. Writing in the Sept 24 issue of JAMA (issue is not up at the time of this writing), Dr. Katz says it's time to force pharmacies to get out of the tobacco product business. Not ask. Not encourage. Force.

Why you ask?

Pharmacies are Special: Pharmacies hold themselves out, unlike other retailers, as agents that promote well being. The passage of laws and regulations that hold them to that standard are reasonable, especially if the sale of tobacco products in health-oriented pharmacies undermine the message that tobacco is harmful. Customers with illness who need pills for their coronary artery disease or an inhaler for their emphysema are also relatively more vulnerable to tobacco. Last but not least, the sale of tobacco is a huge conflict of interest.

Pharmacies Will Not Be Hurt Economically: There are no data demonstrating that patients will not continue to patronize pharmacies. Similar bans in Canada did not drive any pharmacies out of business. Small private owned pharmacies will continue to be able to compete against the big boys. In fact, help in some States is available.

Government Intrusion is Warranted: Other attempts by the pharmacy industry to self-regulate themselves on this matter have not been very successful. In the meantime, the government has had a successful track record in similarly important areas such as the banning of vending machines and requiring motorcycle helmets. Dr. Katz recommends that local governments are probably in the best position to do this.

Why Stop at Tobacco? Maybe pharmacies should get out of the business of selling alcohol or calorie dense foods to combat the evils of alcoholism and obesity. However, unlike that pint of vodka or that candy bar, tobacco is a product for which there is no such thing as a safe level of consumption. Dr. Katz says it's OK to stop at tobacco.

Should stores with a pharmacy also be included? Maybe not, says Dr. Katz. Stores with a 'side' pharmacy aren't perceived to be in the business of health promotion.

The Disease Management Care Blog thinks this is an important issue with other implications for the managed care and disease management industry.

Suppose a retail pharmacy (example) or a store with a pharmacy offers additional care services in the form of health screening, advice, flu shots or a retail clinic? Should that be an added reason for local government to ban the simultaneous sale of tobacco products in the same setting? The DMCB thinks that may be a good idea.

Maybe managed care organizations that are willing to include retail clinics in their network should make credentialing locally or nationally contingent on not simultaneously selling tobacco products. Audit/site visit a small number of pharmacies to show you mean business and offer your enrollees a gift certificate if any of them 'catch' a retail pharmacy selling smokes. By the way, the docs will support you on this. Maybe it is self-serving of the physicians, but attacking tobacco at this level may buy some good will.

Maybe managed care organizations that offer a pharmacy benefit should declare that its participating pharmacies have one year to get out of the tobacco business. Pharmacies failing to meet that standard are out. Good bye. If some patients are unable to access their retail pharmacy as a result, offer terms on a mail order benefit and dare the Department of Insurance to tell you that's unfair.

Where is the leadership of the disease management industry here? They have access to millions of persons with chronic illness and undoubtedly can recommend against patronizing pharmacy settings that sell tobacco. They could even develop an on-line data base for use by their enrollees and their physicians. If there are emerging data-based/co-promotion/business venture partnerships with retail pharmacy chains that sell tobacco products, maybe they need to be re-examined.

Thanks Dr. Katz.

well, that's a relief

My ten year old son, to my spouse:

"You guys did a good job of bringing me up."

Pursuing Weight Loss Among Obese Asthma Sufferers: Time for Disease Management Organizations to Step Up

Most physicians are well aware of the association between obesity and asthma. While persons with obesity may complain of shortness of breath or have altered lung function because of their anatomy, it's been clear for a long time that there's more to the story. Genes promoting both may occur together, leading to a disposition to develop both diseases. Obesity provokes a systemic "inflammatory" state which may involve the airways leading to bronchospasm. Increased levels of leptin may also lower the threshold for airways to become reactive. Dietary factors may be responsible for both the increase in asthma incidence as well as the development of obesity. Persons with obesity tend to be more prone to gastroesophageal reflux, which can also provoke airway irritation and asthma.

Just because there is an association, however, doesn't necessarily mean one causes the other. Yet, that just may be the case here. Obesity tends to predate the development of asthma and there have been reports that reductions in body weight tend to lead to a reduction in asthma severity. Obesity may be guilty as charged.

The likely causal link and the benefit from weight loss should be of great interest to disease management organizations. They're probably on the phone right now asking thousands of enrollees if they are using their peak flow meters, if they have access to a rescue plan and if they are being compliant with their inhalers. The association of obesity and asthma, however, probably hasn't been enough for the DMOs to start asking about their asthma enrollees' BMI and, if obesity is present, readiness to enter a weight loss program.

Well, maybe after reading this article by Eneli and colleagues, it may be time to pursue obesity as a modifiable risk factor in asthma care management and start asking patients about weight. Eneli et al performed a literature review and found there are 15 studies on the topic and all have shown an improvement in at least one asthma outcome measure when there was obesity-reducing weight loss.

The Disease Management Care Blog recognizes that purists would argue that a prospective randomized clinical trial comparing weight loss to no weight loss among asthma sufferers is necessary first, preferably using an outcome of interest (for example, emergency room utilization) to the DMOs. Others may wish to wait until organizations such as the NQF or the NCQA get around to establishing weight loss among persons with asthma one of their measures. Or maybe they're hoping that the managed care organizations they contract with don't bring it up.

The DMCB disagrees. The causal link between obesity and asthma makes too much sense to wait. Asking height and weight among persons with asthma is a start (if medical records are not readily available). If the BMI is elevated, an assessment of readiness to change lifestyle may be warranted. If the patient is ready, DMOs have programs available that can help, or the physician can be alerted, or the patient can be referred.

A Top 100 Member

The Disease Management Care Blog is pleased to note that it has been named among the 100 Best Health Care Policy Blogs at RNCentral.com.

Woo hoo!

nothing new going on here

Just got my CT results from a very up-beat sounding nurse.

No change.

I have not begun to appreciate how relieved I am.

Updated: I have a new post, The Metastatic Cancer Patient's Guide to the CT Scan in 16 Easy Steps up at MyBreastCancerNetwork.Com.

The New England Journal Writes Lots About the Patient Centered Medical Home

Like the latest issue Health Affairs, today’s New England Journal of Medicine (NEJM) has been glommed onto by irresitible Patient Centered Medical Home topic. Despite the newsworthy heart pounding excitement of (gasp!) Heathways’ URAC accreditation and (zounds!) McKesson’s New Hampshire Medicaid contract renewal, the siren call of the PCMH is just so irresistible, isn’t it?

After all, CMS is getting ready to launch its three-year eight-state dirigible, the USS Medical Home Demo, while dozens of commercial insurers are in the midst of their own PCMH pilots, trials, studies, collaboratives, programs, research, tests and assessments. This issue of NEJM has not one, not two but three articles looking past all the smoke for the fire, beyond the froth for the caffeine.

Don’t get the NEJM, don't want to take advantage of the free access (thanks NEJM!) or don’t have the time? No problem, you’re a short read away from getting what you need to know.

Before we briefly look at what John Iglehart, Meredith Rosenthal and Elliott Fisher and have to say, the DMCB discovered that CMS updated its Medicare Medical Home Demonstration web site on Sept 11 with a new fact sheet.

• There is much involvement of the organized primary care medicine groups. While transparency is an issue, kudos for getting the docs involved.


• Subspecialty practices (endocrinologists, for example) will be allowed to participate.


• The NCQA PCC-PCMH Recognition Program template will be used to define what constitutes a “medical home”, but two, not three tiers will be used. That tiering (and the payment that goes with it) will be based on a specially modified version of PCC-PCMH. One key feature that distinguishes the two tiers is the presence or absence of an electronic record.


• One chronic condition is all that’s needed for a patient become ‘high need’ and be eligible for recruitment into the demo. That’s a very low threshold.


• Primary care site recruitment begins in the Spring of 2009. The DMCB suspects the organized physician groups will play an important role here.

Enter John Iglehart in the NEJM with more information. He writes the RVU-based monthly payments to physicians will probably range from $30-$50 per patient per month, which contrasts nicely with the $3-$10 fee prevalent in the private sector. He also notes there will be an upside gain share. The good news is that it will be up to 80% of any savings above a 2% savings. The bad news is that the case management monthly payment fees will be subtracted first.

P4P Guru Meredith Rosenthal’s interpretation? This sure looks like going back to the future with capitation, albeit a ‘soft’ version. Instead of incenting physicians to withhold referrals, physicians are being incented for ‘quality and efficiency.’ Do not despair, however, because we are making progress toward 1) paying for value, 2) distinguishing random variation from case mix from avoidable complications and 3) getting to the point where payment ‘form’ equals ‘function.’

The dour Elliott Fisher agrees the medical home has considerable face validity but counsels against unrealistic expectations like saving lots of money or getting medical students to abandon careers in botox administration. He argues two key success factors will be 1) full access by medical homes to all patient information across all hospitals and care providers and 2) physicians’ buy-in over collaborative decision making. He also wonders if consumer support is guaranteed and if funding in a zero sum environment is realistic. Finally, there is a disturbing lack of information over the impact of the medical home on health care spending versus the cost of implementing it versus the well known ability of the system to neutralize savings with increases in volume and service intensity. His common sense suggestions include creating supporting practice networks that share data for the medical homes, increasing medical home ‘connectivity,’ using fully transparent evaluation methodologies and relying on credible payment updates, P4P and gainsharing.

telling it like it is

My youngest son had an appointment with the allergist yesterday. It had been two years since his last visit and it was time to check whether he had outgrown any of his allergies (as we hoped) or whether he had acquired any new ones (two years ago we learned that he had developed an allergy to nuts).

The results were pretty much the same as last time. He is allergic to peanuts, nuts, sesame and poorly cooked eggs (this one doesn't matter much, since he won't eat eggs at all, even well-cooked ones). His environmental allergies include cats and feathers. Elm trees have been added to the list (we suspected a tree allergy since he does seem to react in the spring).

The test involves a scratch test on the arm. Lots of little scratches at the same time. My spouse says that D. cried when the test was being done but recovered quickly when he was offered a little prize. After the test, D. and his dad went out to the waiting room to await results (or while D.'s arm "lit up like a Christmas tree" according to my spouse).

While they sat there, a mother was trying to comfort her daughter, who was obviously very nervous. "It doesn't hurt," the mom said. This prompted D. to get out of his chair, walk up to the girl and look her in the eye. "Oh, no," he said. "It hurts."

Welcome to the Health Wonk Review, Political Convention Style

Ahhh, the ranting. The soaring rhetoric. The partisanship. What’s there not to like about the political season's spectacle of spin, framing and bombast? Thank goodness for the wonkers who can help us separate the inconvenient half-truths from the easy misstatements. Think of this issue of the Health Wonk Review as our own virtual ‘open mike’ free-for-all Convention, sans Roman columns, faux patriotism, naïve rock stars and country-music boogying elders. Wherever you are on the political spectrum, there is something here for you. Don your straw hat, the silly glasses and lapel pins and read on. Your Convention Chair, the Disease Management Care Blog is bringing the gavel down and announcing this compendium forum is now open......

David Williams of the Health Business Blog argues that Obama’s health care proposals, contrary to popular perceptions, would increase competition in the individual insurance market. That competition may be called ‘the government,’ but why not? He points out the private insurance industry has had something of a free ride with their high executive salaries, lofty share prices and inattention to their poor track record on quality and costs. He also notes how absent Medicare is from all the teleprompters, which may not be such a bad thing. David’s post is Part 3. After you read that, you’ll want to read Parts 1, 2 and 4.

John Joseph Leppard IV of the Healthcare Manumission Blog rises in opposition to that motion. He argues Obama is recycling worn out liberal nostrums while McCain is meritoriously attempting to get at the underlying problem by making consumers spend their own hard earned cash for competitive policies across State lines. Hang in there to the bottom of this well-rounded posting and you’ll be asstutely aware of the history and arguments that buttress his thinking.

Not so fast, says Joe Paduda of Managed Care Matters. After recalling the well-known phenomenon of CAT scanners having patients go in one end while dollars come out the other, he contends that an underlying flaw in free-market thinking is the nasty track record of health care increasing demand and with it, costs. Go ahead and buy cheap cross State border insurance you Bush supporters you: you’ll still get irradiated, your physicians’ judgment will be negated and your outcomes will be … variated.

Senior wonkician statesman Matthew Holt of the Health Care Blog once again field dresses his favorite health policy expert spokesperson and his favorite health policy advocacy group by showing how they are muddling the distinctions between revenue, mission, premium income, expenses, profit, shareholder value and surplus. He asks if maybe, given huge amounts of money at stake, that’s the point?

And speaking of money, think all economists would vote for unfettered healthcare markets? Think again. Jason Shafrin at Healthcare Economist points out that another word for ‘decentralized’ is ‘fragmented.’ Other words for fragmented include turnover, cherry picking, inefficient payment systems, competing incentives, excessive variation and monopolistic consolidation. There are links at the bottom that lead to more speechifying about the models that have overcome these problems as well as some policy options that are worth your consideration.

As is her style, Maggie Mahar of the HealthBeat Blog brings the house to its feet with a ‘Part I’ examination of the important difference between having access to care and having access to insurance. Case in point? Go to Boston and toss an 'Obama for President' button in any direction and chances are you’ll hit a specialist physician. Good luck in finding a primary care physician, however. They’re out there, but hiding from new patients because they’re overworked, underpaid, stymied by a hostile training environment, unlikely to hire enough nurses and fed-up by their unattractive life style. The result includes hospital readmissions, emergency room overuse, excessive variation, shortages and queues. And that’s just Part 1. The DMCB is looking forward to Part 2 when the Health Beat Blog shines the light on the notion of a Medical Home (will anyone be at home in this home?). The DMCB is also looking forward to an explanation about why primary care shortages and patient queues aren’t the natural outgrowth of de facto price controls.

Can't wait to hear Maggie's view on the Medical Home? No problem, our next speaker is Arnold Milstein, who uses the Health Affairs bully blogpit to distinguish between medical homes and medical home runs. The DMCB thinks this makes for interesting not only because it has had its own doubts, but because it views homes as 'process,' while runs are the 'outcomes.' As we've learned in other clinical domains, one doesn't necessarily lead to the other. Is the same true here?

Neil Versel of the Healthcare IT Blog takes the dais and shows us just how impolitic it is it is when politicians laughingly speak the honest truth. Rep. Pete Stark (D-CA) introduced legislation with some commonsense reforms, including an open source EHR, the promotion of de-identified data use, and clarification of HIPAA. Likelihood of passage? Zero. And those of us who have watched Congress deal with other parts of healthcare reform? We say welcome to the club.

But it’s a sad day when doctors fail to speak the truth. Say it’s not so, but Henry Stern of InsureBlog alerts us to a report that some British physicians may not be letting their patients know about the option of getting potentially life-saving treatment abroad. Egads. Maybe they should put their mis-speaking skills to use by coming across the pond, getting U.S. citizenship and running for Congress.

When it comes to politics, timing is everything. Well, the same is true when it comes to generic drug pricing in the Medicare program. Dr. Fein of Drug Channels shows us how quarter-to-quarter delays in pricing and reimbursement can simultaneously harness the for-profit motive and increase the use of generic drugs. Too good to be true? Not if the Department of Health and Human Services Office of the Inspector General gets its way.

New America’s California branch members Leif Wellington Haase and Micah Weinberg take to the lecturn and dissect California’s messy budget impasse and its impact on MediCal and the individual insurance market. If you believe the Golden State is still a window into the future and support State sponsored reforms, however, be of good cheer. According to this report, a budget will eventually be passed in the short term and Californians are more than ever supportive of meaningful reform and seem to be willing to pay for it over the long term.

And speaking of California (and the rest of states), Anthony Wright of the Health Access Weblog examines the pros and cons of State reforms aimed at the individual insurance market. He points out the ‘lipstick’ of guaranteed issue, risk pooling, consumer protections, basic benefit structures and tight regulation may not be enough, but he wonders if it isn’t worth a try. Take a read and see if you agree.

Never mind kissing babies, Roy Poses over at Health Care Renewal calls both the American College of Cardiology and Johnson and Johnson awardees quoted in the Wall Street Journal to task for wanting to keep the bathwater and the babies AND the CME/research funding. Let's face facts, says he. Lingering K-street style conflicts of interest, both known and unknown, are influence-peddling physicians in obvious and subtle ways. He makes a good argument over the groupthink notion that transparency is enough. A case in point is when apologists for the status quo themselves aren’t being fully transparent. The DMCB suggests readers Google their own names before going public with a high profile opinion in the area of pharma support for CME.

Louise of the Colorado Insurance Insider is angry at Pharma. Biased research. Underhanded marketing. Ghost writing. Predatory pricing. And now this: our receptors are possibly being nudged in unforeseen ways by microscopic but potentially significant amounts of myriad drugs coming out of our faucets. She asks if the improper disposal of pharmaceuticals is the result of laziness and an unhealthy profit motive. Blister packs may help, but more importantly, Louise asks where the leadership of the health insurance industry is on this issue? When the DMCB takes his drugs, he’s going to wash them down with bottled water. And then recycle the plastic, naturally. And try not to feel guilty the next time he goes to the bathroom.

Are you a practicing physician and a blogger? Do you like that spotlight of a cheering audience’s attention? Sam Solomon at the Canadian Medicine Blog reminds you that it may pay for you to be scrupulously circumspect when it comes to writing about your patients, especially if there are allegations of negligence. You may think you can mask your identity or protect your patients’ privacy. Think again, because if this determined trial lawyer can find out who you are, chances are others can also. Right after they check out that regrettably unprofessional profile on a social networking site.

Maybe instead of blogging, physicians (and other health policy experts) may want to make better use of their time by not only getting familiar with P4P, DM, PCMH, CDHPs and EHRs but with MPs that are being championed by IHI. Click here to find out if this particular initiative will warrant its own set of initials, thanks to Joanne Kenen of the New Health Dialogue Blog, also of the New America Foundation.

There are the new initiatives of course, but then there are the old ones that work. David Harlow of the HealthBlawg reminds us that the CEO Leah Binder of the Leapfrog Group is still reminding us that we have to start somewhere. That somewhere may be outcomes-based, like hospital acquired infections and multiple other remediable complications that can be addressed with a turnkey NQF-based methodology, maximum transparency and purchaser activism. Now that will warm any crowd.

And then there’s always a speaker that cuts through all the chatter with inconvenient truths. Merrill Goozner of Gooznews reports on the countervailing perspectives of a debate sponsored by the New America Foundation. In the end, we Americans will never yield on our death-is-optional pursuit of happiness, even if means taking a pill of dubious benefit or being tethered to a ventilator with cost effectiveness ratios well north of $100K per QALY.

the waiting game

I am waiting for results from yesterday's CT scan. My oncologist said that I should call him for results after five days, so I am going to start calling on Friday (it's only four days post-test but what have I got to lose by calling?).

I did have bloodwork done yesterday and was very relieved to see that all my liver functions are well within the range of normal. I actually startled the nurse who was hooking me up for chemo by giving a little yelp of pleasure.

It is still possible to have tumours on the liver (or nearby) and have normal liver functions. However, abnormally high liver functions can be a sign of a problem.

And I will embrace every indication that all is well.

I have a new post up (I wrote it on Monday) at MyBreastCancerNetwork.Com. It's about how hard it is to play the waiting game:

"I have no real reason to expect anything but good results this time, yet I can’t escape the feeling that something is wrong. My digestion feels a little off and I can’t decide if the pain in my side is a phantom one.

The truth is, I am scared. I am trying to reassure myself with the fact that I have been feeling pretty good, that I have been biking and running But I was diagnosed with breast cancer when I was feeling the healthiest and most fit that I had in years. And I was diagnosed with liver mets three weeks after I returned to work, at a time when I was feeling strong, energetic and (so I thought) on the road to reclaiming my life from cancer.

I have been fairly racked with anxiety these last few days and yet today I feel calmer. Perhaps I have had the time to come to terms with the fact that I have no choice but to meet whatever challenge lies ahead. Perhaps it has helped to keep myself really busy. Or maybe I am in denial."

I also wrote in the same post about how I how I cope with the anxiety. I was a little crazy on the week end but there are definitely things that help, when I can remind myself to do them:

"My advice to women awaiting test results or doctor’s appointments remains the same.

Try not to torture yourself with worst case scenarios.

Go out and play (I went to the National Art Gallery with my family yesterday).

Get together with friends (I had a great time at last night’s book club meeting).

Get some exercise (I am going running with my son after school today).

Write it all down (I procrastinated over doing this but I can’t tell you how much it helped."

Cross-posted to Mothers With Cancer.

AIG and Regulation Versus Deregulation

As I posted earlier today, I believe the feds did the right thing in making sure AIG did not fall.But as the dust settles, that takes us to another big question--the question of more or less regulation generally and, more specifically for readers here, more or less regulation for the health insurance industry.The first thing to note is that the existing state regulation of the insurance industry

AIG--The Feds Did the Right Thing and Only They Could Have Done It!

There is that old saying: "There are the bears, the bulls, and the pigs--and the pigs get slaughtered."This past weekend I witnessed the most incredible thing I had ever seen in the insurance industry with the demise of the world's largest insurer--AIG. AIG was not just a company--it was a legend in the industry.Now, a couple of days later, that has been trumped--in spades--by the United States

Wall Street, Stress and Diabetes.

Good grief. Major financial houses are vaporizing. Stock prices are tanking. Dire headlines are extending across not three but all six columns of the Wall Street Journal. And if Mad Money Cramer's reaction is emblematic of the resulting emotional turmoil among the financial traders, it’s likely that there’s some major stress out there. Since there is no reason to believe that workers in the major exchanges are any more immune to chronic illnesses like diabetes, the Disease Management Care Blog wonders if level of stress can really lead to poor chronic disease control. In these times of high anxiety, are there more polydipsic and polyuric traders out there? If so, what is the role of population-base approaches to care?

The answer to that question is more complicated than readers may imagine. It is well known that depression and anxiety are more prevalent among persons with diabetes mellitus. Whether having diabetes causes stress, or if the stress causes the diabetes, or if other factors cause both is unknown. Either way, persons prone to anxiety will experience more of it when they are stressed. But what is the impact on blood glucose control among persons with diabetes?

One way to answer the question is a clinical trial in which patients are intentionally exposed to stress. This was a study involving persons with Type 1 diabetes mellitus. Interestingly, if they were fasting at the time of the exposure, their blood glucoses did not increase. However, stress applied following a meal showed a delayed but significant increase in the blood glucose.

Such a clinical trial has not been done among persons with the more common (including on Wall Street) Type 2 form of diabetes. However, check out this natural experiment from Japan. The DMCB leaves it to readers to decide if earthquakes compare to the temblors roiling the U.S. stock markets, but this study showed a life threatening 7.2 Richter stress caused a widespread bump in the A1c among persons with diabetes compared to persons experiencing a milder 4.2 earthquake in another part of the country. The authors suggest the cause was a combination of disruptions in the neuroendocrine system as well as an impaired psychological ability to adhere to diet, lifestyle and medications.

Given these data, it may be tempting to equip a battalion of disease management coaches with bromo-seltzers, Xanax and insulin and parachute them into Manhattan. A better approach may be to alert anxiety-ridden patient-enrollees and their disease management nurses to the important role of emotional stress in blood glucose control. Awareness may be half the battle. Formal stress management interventions may also help. So would opening the Fed Window, lowering interest rates and reducing the federal deficit. Cramer may prefer the latter interventions, but for his colleagues with diabetes, it may be more realistic and worthwhile to stick with the former.

P4P, Disease Management, the Medical Home, Electronic Records and Consumer Directed Plans: The Unified Field Theory of Population Health

The Disease Management Care Blog checked out a publication from the Journal of Medical Practice Management authored by Charles Peck MD, the Chief Medical Officer of LifeMasters. He argues that usual pay-for-performance programs (P4P) are more trouble than they are worth to busy physicians because of burdensome data collection. Enter disease management organizations (DMOs). Dr Peck argues they’re ready to be “partners” and help busy physicians get ahead of the curve. DMOs can not only achieve outcomes, they can help get them documented. Unfortunately this particular article is light on specifics. It doesn’t describe how LifeMasters does/would do it and offers no examples.

Interested in more detail on how this might work? One example is what McKesson is doing in the DMCB's home state. It is contracted to provide disease management services for fee-for-service Medicaid enrollees in Pennsylvania. According to this press release, a Mercer audit confirmed there was a net savings of $35.9 million over the course of one year. While this press release doesn’t mention it, the McKesson program not only deploys the usual distance telephonic patient coaching, but also compensates physicians with a version of P4P for the work of referrals, recruitment and follow-up.

The DMCB wishes, however, that the methods and results from this program be detailed in a peer-reviewed forum. No disrespect to the folks from Mercer, but let's face it: it’s hard to know what’s going on here. Without kicking the scientific rigor and transparency up a notch, the DM industry will continue to be disdained as black-box voodoo by policy makers. While we're thinking about that, here's another option to think about.

Never mind that, though. Think disease management combined with the medical home.... Medical home sycophants have suggested it can be supported with P4P..... Both disease management and the medical home rely on information technology, registries, decision support and electronic record keeping..... Now we see disease management and P4P.

See a pattern?

The Disease Management Care Blog does also. It continues to be interested in a unified field theory of population management. This view suggests disease management, the medical home, pay for performance, the electronic medical record and even variations of consumer directed health plans can be not only integrated into mutually supportive programs, but combined in a single approach to care. Doing so will make up for the weaknesses of the other. Is this another opportunity for the DMO community to show some leadership?

Sounds good conceptually, but writing it up, keeping it less to 5000 works and getting it published somewhere has turned out to be a daunting challenge. The DMCB continues to work on the manuscript. We’ll see.

delusions of grandeur

I have a new post up at MyBreastCancerNetwork.Com.

It's called, "If I Were Queen of the World."

The Atmospherics Just Keep Getting Worse for Healthways

With all the bad news that the company has had to endure, now this:

Shares of Healthways, a Franklin-based health management company, edged almost 5 percent lower on Thursday, two days after a Goldman Sachs analyst said the firm could be a takeover target now that its stock is so low-priced.

And who would be doing the targeting you ask?

But Thomas Carroll, an analyst at Stifel Nicolaus in Baltimore, said he believes that Ben R. Leedle Jr., the company's relatively young chief executive officer, doesn't want to sell out. Carroll said that if Healthways were to sell, a pharmacy benefits manager would be the most likely buyer. "Then, maybe a company like Walgreens," he said. "Probably not a managed care organization. I'd be surprised to see that."

The Disease Management Care Blog has had an ongoing interest in Healthways because it's a bellwether for the for-profit DM industry. The DMCB has predicted in prior posts that 'combined' or 'integrated' approaches to population health are likely. Who would have thought that combined or integrated could be synonymous with merger or acquisition.

have you ever? (a stolen meme)

I stole this meme from Average Jane. It's originally from Sunday Stealing.

It felt like the perfect distraction for a lazy, rainy Sunday morning.

Have you ever....

1. gone on a blind date?

Once. More than twenty years ago. His entire family came along (including grandparents) and he didn't make eye contact with me once. Very strange experience.

2. skipped school?

There are two answers to this question.

For my mom and my kids: "Never."

For everyone else: Fairly regularly, in high school.

3. watched someone die?

No

4. been on a plane?

Many times.

5. been on the opposite side of your country?

I have been to west and east coasts (born in New Brunswick!) and to two of the three northern territories.

6. swam in the ocean?

Yup.

7. had your booze taken away by the cops?

I have never been caught.

8. lettered in high school sport?

Do we letter in sports in Canada? No sports teams for me, anyway. I did theatre and band...

9. cried yourself to sleep?

Yes. But not lately.

10. played cops and robbers?

My friend B., my sister and I used to pretend we were Charlie's Angels. Were they cops?

11. sung karaoke?

Once. Under duress.

12. paid for a meal with coins only?

Of course.

13. done something you told yourself you wouldn’t?

Almost every day.

14. cheated on an exam?

Never.

15. made prank phone calls?

"Is your refrigerator running?"

16. laughed until some sort of beverage came out of your nose?

Yes.

17. caught a snowflake on your tongue?

I live in Ottawa, in Canada! What do you think?

18. written a letter to Santa Claus?

I think I did.

19. watched the sunrise with someone you care about?

I've been up all night...can't remember watching the sun come up.

20. been kissed under the mistletoe?

My parents had the plastic kind.

21. ever been arrested?

Yes. Occupying my MPs office, as part of a demonstration against the first Gulf War.

22. gone ice skating?

See above re Canada.

23. been skinny dipping outdoors?

Lots of times as a kid. As an adult, in the dark only. One time, a couple of years ago, my spouse and I were about to dive into the lake at his dad's cottage when a little boat we hadn't noticed flashed a bright light on us (most likely one of the neighbours out fishing). I hid behind T. The light went off and the boat went away.

24. had a nickname?

Not really. A grade school friend tried to nick name me "Wombat" but it never really stuck.

25. been on TV?

I have acted as a spokesperson for several advocacy organizations. It used to be my job.

....and I've just found the medical home!

We've come to the nation's capital and you'll never guess what we found: the medical home! It seems we won't let it hide here either. Simply insert organized medicine's criteria and we'll all be connected at cost reducing speed. Email patients. Access registries. All on the go.

I'm a policy maker, and I've just found the medical home.

circular

Am I freaked out because I can feel a stitch or am I feeling a stitch because I am freaked out anxious about my CT next week and what it might reveal?

Inside my head is not a fun place to be, today.

These are the facts:

• Scarring causes tightness which can make me feel a bit of a stitch.

• I have been exercising hard and felt nothing.

• But as I type this, I feel a dull ache.

• I cannot tell if my liver is swollen because I a have too much belly fat (and lymphedema) and an inadequate sense of my own anatomy.

• If I press really hard, the area where I think my liver is, hurts. But if you press hard enough on any part of the body, it hurts.

CT scan and blood tests on September 16, right before chemo. I will have the blood tests back on the same day but must wait a few days for the CT results.

Until then, deep breaths, lots of positive distractions and more exercise (if the rain ever lets up).

The Five Ugies of Disease Management

Almost everyone has heard the term ‘the good, the bad and the ugly,” based on a movie by the same name starring Clint Eastwood. In fact, the Disease Management Care Blog has personally used the GBU theme in a ‘canned Grand Rounds’ lecture on the topic of chronic heart failure (there is Good treatment, it’s still a Bad disease and what Medicare will need to do is Ugly). Well, Brenda Motheral has authored a contentious article on disease management in the Journal of Managed Care Pharmacy that is short on good and bad and long on, not one, but five uglies that are ailing the disease management organizations (DMOs):

Vendor and Client Misalignment – ‘opt-out’ programs generate income in the absence of engagement, which tempts DMOs to cut costs to maximize profits. Solutions include minimal staffing guarantees, performance guarantees and using opt-in approaches.

Insufficient Transparency – engagement definitions, intervention methods and reporting methodologies are not only black box, they differ from vendor to vendor. The solution is, you guessed it, ‘transparency.’

Wanting Plausibility – examples include 1) mismatches between the timing of interventions (for example, engagement levels) and the oversized ROI’s as well as 2) suspect correlations between the changes in process/clinical measures (for example,A1c and LDL) and reductions in ER use and admissions. Rigorous scientific assessments of plausibility are needed.

Substandard Evaluation Methodologies – This has been an historical Achilles Heel that has hampered the establishment of a causal link between what DMOs do and what DMOs claim. The argument that there is a trade-off between rigor and practicality is dismissed as not holding water. Even worse, establishing links between wellness/prevention and outcomes like absenteeism is even more daunting.

Where’s the Convincing Evidence – you’d think it would have shown up by now, thanks to ten years and tens of millions of enrolled members. What we do have is a publication bias combined with a stubborn lack of conclusive proof. Maybe an industry-wide commitment to find the proof once and for all is necessary or maybe it should be a matter of assessing the impact on quality of life for the dollar spent.

So just how does one reconcile this piece and the article written by Gordon Norman? The DMCB isn’t sure you necessarily have to. While DMOs may understandably view non-supportive articles as a business threat, the DMCB believes the scientific literature is supposed to be a contentious bumpy search for the truth. There are no free passes in health services research. Here are your five credibility gaps, says Dr. Motheral, it’s time to do something about it.

In fact, there are many unsung heros in the industry that are doing something about it. The DMCB has witnessed rigorously defined guarantees in contracting. Reductions in ER use and admissions, in the DMCB’s estimation, seem to be a function of difficult-to-measure case management (recall in the prior post, it’s nurses that are the ‘secret sauce,’ not NCQA'oid' A1c measures). The DMAA meeting abstracts and the renamed Population Health Management Journal’s manuscripts have had significant jumps in rigor; we're getting there. The DMCB wonders if the industry should lead the way and start open-sourcing the data behind its conclusions. Finally, the DMCB is detecting a growing appreciation that the industry is moving away from simplistic notions of saving money based on a 1st generation business model to better demonstrations of value, asking ‘what works,’ and changing the care management approach accordingly.

As the industry continues to evolve, let’s hope we better deal with the ugies so ably described by Dr. Motheral.

more randomness

1. I forgot to mention that my new-found commitment to riding my bike (spent a couple of hours on it again, today, although some of that was getting lost) was inspired in part by Rebecca. She trained on her bike (and kick-boxed!) right through breast cancer treatment.

2. It was also inspired by the fact that I dropped a whack of money (in violation of our current austerity measures) on a fancy lap-top bag that attaches to my bike rack. I have to ride instead of taking the bus or a taxi, in order to justify it. The first time I used the bag, it flew off while I was riding on a busy street (now lap top in it, thank goodness). I have since figured out how to secure it properly (don't you love instructions that read like they have been put through a universal translator?). I spent almost two hours on my bike today. Some of that was getting lost. I have absolutely no sense of direction. I had to pull out my bike map many, many times and I still took a few wrong turns.

3. I had a routine echocardiogram today. The woman who did the test explained what we saw on the screen in response to my questions (she compared the mitral valve to a fish). We also chatted about a bunch of stuff. I have never felt so relaxed while being tested or had an echo go by so quickly. She also told me that all is well. This experience was in such stark contrast to others I have had that I found her before I left to thank her for treating me "like a person." I told her that it meant a lot.

4. My father in law pointed out to me the other day that the Amazon.ca link to my book had it classified under "astrology." That has been fixed.

5. Yesterday, I had to chase the puppy around to cut out something that was matted in her fur (don't ask). My 10 year old stopped me, patiently turned the scissors around and said, firmly but calmly, "Could you please hold the scissors properly, if you are going to run with them?" I know that sometimes children and their parents reverse roles. I just didn't expect it to happen so soon.

6. As I was riding to the hospital today, a car pulled up beside me at an intersection. The car's window was open and the guy inside was snapping his fingers and bopping along with a big smile on his face (it was "Dancing Cheek to Cheek." I think it was Ella singing but I'm not sure). He must have felt my glance , because he turned to me and asked, "Are we going to have a good day?"

"I am now," I replied, with a big smile on my face.

The Pretend Presidential Debate on Health Care--The Health Care Press Needs to Force the Presidential Candidates to Get Real on Health Care "Change"

Let's pretend that either Senator Obama or Senator McCain will be able to implement their respective health care reform plans if elected. Should be easy--we've been doing it for months now.Or, we can get real and expect them to do the same.For all the arguments both are making that they are change agents, including over the candidates' competing health care reform proposals, is this dirty little

Impressions from the Health Affairs Briefing on Overhauling Health Care Delivery

Impressions and quotes from the Washington DC Health Affairs ‘release party’ min-lecture series over the September/October issue on ‘Overhauling Health Care Delivery’:

Large, high ceilinged room at the InterContinental stuffed with academics, policy makers and note-taking congressional staffers. It ended at 11 AM with the hotel staff noisily wheeling in the next function's lunch tables at 11:01 AM. The DMCB regrets not having the chance to meet the hard working editors.

Paraphrased quote from Mark Smith of the California HealthCare Foundation: ‘The solution to health care access and cost will not be mathematical linear rearrangement. The solution will be structural.’ The DMCB wonders if it will involve dynamite.

Challenges to the Patient Centered Medical Home identified by Bob Berenson: 1) lack of an operational definition, 2) it won’t cure the ‘tyranny of the urgent,’ 3) it will be a struggle for small practices, 4) it won’t cure the PCP shortage, 5) it’s unclear if this is for all patients or patients with chronic illness, 6) there are many local management challenges, 7) non-PCP specialists (endocrinologists) may warrant inclusion, 8) it’s unclear if patients should be locked-in to their primary care site and 9) becoming all things to all people may mean that this becomes another failed silver bullet. The DMCB adds that it has yet to leverage remote and efficient industrial strength telephony and monitoring as one ingredient in its suite of services.

A large integrated delivery system CEO saluted its EHR, large mass and adaptable primary care practices as the key ingredients in its version of the medical home. The DMCB disagrees and thinks it was parachuting in nurses into its primary care sites that are paid for by the managed care organization (or disease management function). They are the secret sauce.

The jargon used most stridenty to describe what health care consumers want: ‘personalized medicine.’ The DMCB recommends that DMOs alert their DC lobbyists to resurrect this term.

An unnecessarily complicated health care engineering term from Richard Bohmer: It will be impossible for primary care to diversify enough to meet all that is being asked of it. The answer is a new ‘care platform’ designed from the bottom up. All retail clinics are one type of care platform. Not all care platforms are retail clinics. And the DMCB’s running shoes are a type of aerobic exertion platform.