stranger in a strange land

It's 2:30 in the afternoon and I am sitting in my hotel room, having just eating cold soggy french fries and what I am sure was a hopelessly inauthentic Philly cheese steak from room service (at $14.00 before taxes, surcharge and tip, it was the cheapest thing on the menu and came without the promised fried onions).

The sound of my typing is being drowned out by yelling and the relentless cacophony of sirens on the street below, despite the fact that I am on one of the top floors of what was reportedly Philadelphia's first skyscraper.

I am having a weird day.

My departure for Philadelphia this morning was a bit fraught, the usual clutter and chaos being compounded by last minute additions to the Hallowe'en costumes (D. is going as Wolverine and S. went to school as a hippie and will be dressing up as Sarah Palin - not my idea - this evening. Last night, he was hobbling around the house with one hand on his hip, chirping "You betcha!"). I spent a good twenty minutes looking for the theatrical makeup (for Wolverine's facial hair and a peace symbol for the hippie), only to find it in the very first place I had looked, buried under a pile of rubble.

I managed to get out the door only slightly later than planned and, after 15 minutes of desperate waving, finally snagged a cab.

I sailed through airport check-in (did you know that there is a charge for every piece of luggage now?) and security and got into the line for US Immigration. I always get really nervous when I have to go through Customs or Immigration (doesn't matter which direction), even though I never try to smuggle or hide anything. When the only female worker waved me over for my turn, I was pleased, convinced that she would be more likely to be sympathetic to the purpose of my trip.

I couldn't have been more wrong.

Agent: "What is the purpose of your trip to Philadelphia?"

Me: "I'm going to a conference."

Agent: "What kind of conference?"

Me: "Breast cancer..."

Agent: "What's your job?"

Me: "I am a researcher with a union."

Agent: "Then why are you going to this conference?"

Me: "I'm a survivor."

That's when it started to fall apart. I babbled (I do this when I am nervous) something about it being organized by Living Beyond Breast Cancer and that it was called, "News You Can Use."

And then I told her that I was on disability (I am quite sure that I meant to say something else).

Agent: "How long have you been on disability?"

Me: "Ummm...since I was diagnosed...April 2006." (this is inaccurate but I was really flailing at this point).

Then I pulled myself together and said, clearly and forcefully: "But I have a good job to go back to and my insurance company pays x percent of my wage."

Agent: "OK."

Wow. I don't know if I've managed to convey her hostility but she really was very hostile.

I was shaking a little bit afterwards.

On the flight, I sat beside M., a very nice engineer from Alabama. We talked the whole way about Canadian winters (he had spent a winter in Ontario and enjoyed it), kids, blended families, the book I'm reading (Guantanamo's Child by Michelle Shephard) and life in general. I even took a stab at explaining what it means to live in a Constitutional Monarchy and the Canadian and provinicial electoral systems.

M., an employee of the US military, expressed his frustration that, in his opinion, dissent has come to be equated with a lack of patriotism in his country (he also said that the only part of the constitution with which he didn't agree was the right to bear arms).

He also said that he's hopeful that Obama will be elected and that he will bring about real and positive change ("these things don't happen overnight"), if he can build bridges and start work on some concrete projects (he used "energy independence" as an example).

I don't usually chat on planes but M. was a very cool seat mate and the 90 minute trip passed quickly (despite the fact that we weren't offered so much as a glass of water).

At the Philadelphi airport, I grabbed my bag and made my way to the taxi stand. When I announced my destination, the driver said, "I don't know if I can get you all the way there because of the parade."

The World Series parade! In the middle of the day! On Hallowe'en!

It wasn't long before we came apon the diverse (in every way imaginable), festive and very boisterous crowds.

We drove until we literally could go no further. I relinquished my cab to an incredibly happy young couple.

"Do you have to work today?" I was asked sympathetically.

I replied, "I just got here, I'm from Canada!"

"Wow!!!"

I wish sports could make me that happy.

I watched people dancing and singing, cheering and drinking. I saw strangers hug each other as they passed on the street and I saw a couple of gratuitous acts of vandalism.

Walking agains the flow of human traffic, I bravely made my way to the hotel (there were four large security guys standing outside, each with their eyes as wide as dinner plates) and checked in. I immediately went out again for wine and food. I secured the wine but quickly deduced that the only way I was going to eat was if I ordered room service (every restaurant within miles was packed or closed).

And now I find myself, a few hours later (I interrupted this post for a nap and a shower), typing in my pajamas, with a glass of wine by my side. I am starting to feel hungry again but don't really feel like venturing out again.

I don't feel like facing the last of the revelers. Or the sirens.

And I really don't feel like getting dressed.

Maybe I still have some trail mix in my bag.

You'll be hearing a lot from me this month. NaBloPoMo starts tomorrow (which is why my laptop is with me and the reason I am paying $10.95/day for internet. It's not because I'm addicted. Really).

Outsourcing the Leadership of HHS and CMS?

The Disease Management Care Blog has had a chance to reflect on the October 17 Washington D.C. ‘Patient Centered Medical Home Summit’ that was hosted by the Patient-Centered Primary Care Collaborative (PCPCC). It thinks the highlight of that confab was the twin Working Lunch speakers, the Honorable Brit, Gerald Malone, who served as the ‘Minister of State’ at the UK’s Department of Health and Dr. Bernat Soria, the current Health Minister of Spain.

Both speakers charmed the otherwise suspicious DMCB.

The ever proper and self deprecating Mr. Malone used a classic wry sense of humor to regal the luncheon attendees about how he traveled around the country talking to countless physician groups to get them to buy into the latest government scheme. What was that scheme? The DMCB can’t remember and it bets the physicians he spoke to don’t remember either. What is memorable is the considerable effort taken by a government minister to get buy-in from the docs one buffet-dinner at a time.

Dr. Soria was a heavily accented bespeckled academic technocrat. His smiling demeanor spoke volumes about his belief in Spain’s socialized medical system. While the physician DMCB wanted to be hostile over that apostasy, it was rebuffed by Dr. Soria’s emphasis on his country's belief in primary care. Close to 70% of Spain’s health care encounters begin and end in its primary care system. His country’s goal is to increase that to 80%.

Days later, while the DMCB was contemplating its two pound weight spike thanks in part to the excessively dense PCPCC luncheon dessert of dubious pedigree, it came across the Commonwealth Fund’s Karen Davis’ latest New England Journal of Medicine sermonizing on But For Lessons The USA Should Import From Europe, Lives Would Be Saved. They include the Brit’s ‘National Institute for Health and Clinical Excellence (NICE)’ Denmark’s electronic record system, the Netherland’s use of non-physician providers, Germany’s pricing of pharmaceuticals and bundled payments and all the Europeans’ no nonsense approach to non-partisan solution-seeking.

The DMCB isn’t so sure. It has a belief in the uniqueness of American civilization, a lingering cultural antipathy to central planning and a view that the U.S.’s health care needs can only be partially met with the evidence-based medicine, electronic records, non-physicians and government planning. It thinks reform will take more, that the solution will have to be uniquely American and that Americans will not embrace change until they see it as their own.

How then, does the DMCB reconcile its admiration of Mr. Malone and Dr. Soria with its Tocqueville-esque belief in American exceptionalism? Maybe it was the dessert’s methylxanthine induced nighttime relux, but the DMCB’s eventual epiphany was that Mr. Malone and Dr. Soria’s successes were the result of their interpersonal skills combined with considerable effort at local outreach.

So here’s the real lesson from Europe: it’s not only a matter of formulating the right policy and legislation, it’s a matter of competent and locally relevant leadership. Ms. Davis misses that from her perch in D.C. Maybe the one 'exception' to the DMCB’s belief in American exceptionalism is the option of outsourcing the leadership of HHS and CMS to Dr. Soria and Mr. Malone, respectively.

Wealth Wonk Review is Up

In this Halloween season, what scares you more? Not being up to date on the latest advances in wonk-based health policy thinking? Not knowing the details about the candidates' insurance reform proposals? Being unaware of just what 'Samhain' means?

You can allay all your fears by heading over to David Harlow's most excellent summary of the best and the wisest of the health care blogs at the HealthBlawg.

Can Health Plans Explain Why They Aren't Re-Empowering Primary Care?

Brian Klepper and David Kibbe offer a post today on the issue of primary care and the role they believe health plans should be taking to encourage greater involvement with PCPs. They ask why health plans are not being more proactive in partnering with PCPs to control costs.Can Health Plans Explain Why They Aren't Re-Empowering Primary Care?By Brian Klepper & David KibbeSometimes a whisper is more

book review: "hell bent"*

I like fast-paced mystery novels that grab my attention from the first page and sustain my interest until the end.

I like books that are well written and that entertain without offending me and that use characters to move a story forward without resorting to stereotype.

And I like suspense novels that surprise me without stretching the bounds of credulity to their absolute limit (there is only so much disbelief I am capable of suspending).

On all of these fronts, Hell Bent, by William G. Taply delivers.

"Boston attorney Brady Coyne finds his own past coming back to haunt his professional life when his ex-girlfriend Alex Sinclair wants him to represent her brother. Augustine Sinclair was a notable photo-journalist, happily married with two small children - until he returned from a stint in Iraq, missing a hand and suffering from Post Traumatic Stress Disorder. Now he's lost his career, his peace of mind and his family. Brady is hired to see him through the divorce but before they get very far, the photographer is found dead in his rented apartment, an apparent suicide.

But something isn't right and Brady starts to think the suicide is staged. With very little to go on and everyone around him wanting to close the books on the case, Brady soon finds himself in the midst of one of the most dangerous situations of his entire life, facing people who will do anything to avoid being exposed."

As a mystery novel, Hell Bent was highly entertaining, a real page turner that kept my interest. It's well written, with interesting characters and unexpected plot twists.

As a central character, though, Brady Coyne is just too perfect. He prefers to represent underdogs, is pining faithfully for the long-term girlfriend who left him four months earlier (despite the fact that she won't let him call her and leaves him messages telling him to move on) and has a stated weakness for strong, smart women:

"I liked feisty, independent, competent, autonomous, self-contained women. I liked women who knew what they wanted and went after it. I liked women who thought they were at least as important and capable and valuable as men."

Women all seem to be vulnerable to his charms (every woman in the book is described in considerable physical detail and they almost all seem to be beautiful) and men want to be his friend.

He is also modest, self-deprecating and fairly self-critical.

And he is very loyal and attached to his dog, Henry.

Brady Coyne is just too good to be true.

I like flawed characters. I like protagonists who screw up but are essentially well-meaning and good hearted.

This is especially true for mysteries which have an inherent element of good versus evil. When good is too good, it can get just a touch, well, boring.

But really, that's just a quibble (and this one that is leagues better than the mystery novels with a hard boiled detective and the inevitable blond, bosomy bimbo who is the secretary/victim/murderess).

I liked Hell Bent. And if you like well-written, fast-paced mysteries, with progressive politics and interesting characters, you will too.

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

Health Wonk Review is UP!

David Harlow hosts this week's edition of Health Wonk Review over at his, "HealthBlawg."It is a very comprehensive sample of some of the best recent posts from the world of health blogs.

The Partnership to Fight Chronic Disease, the Harlem DM CHF Study and When a Medical Home is not House

A Threefer from the Disease Management Care Blog:

Check out this ad from the Partnership to Fight Chronic Disease, featuring famous women using their considerable star power to remind the rest of us to pay close attention to the candidates’ positions on addressing chronic disease.

Well done, but the DMCB wonders if stars who are known to have actually battled some key chronic illnesses would have taken a good commercial and made if better: Mary Tyler Moore (diabetes mellitus), Elizabeth Taylor (chronic heart failure), Lindsay Lohan (asthma), Cloris Leachman (high blood pressure), Patty Duke (coronary artery disease) and Sally Field (osteoporosis), for example. Still, any excuse to include the still remarkable Ms. Bacall in a commercial is fine by the DMCB.

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

You may have heard that the Annals of Internal Medicine published an interesting DM study conducted in New York City’s Harlem. The authors were Paul Hebert, Jane Sisk, Jason Wang, Leah Tuzzio, Jodi Casabianca, Mark R. Chassin, Carol Horowitz, and Mary Ann McLaughlin. Just over 400 patients were randomly assigned to usual care versus ‘nurse management’ that consisted of one face-to-face visit plus ‘periodic’ follow-up phone calls, along with ‘working’ with the physician to optimize medications. The authors were unable to show that they saved money. However, SF-12 scores held more steady and quality of life declined less in the intervention group. Depending on how “quality of life years” were calculated, the nurse intervention was a relative bargain of between $15,000 to approximately $21,500 per 'QALY' gained. In others words, there was a measurable benefit to the patients receiving the intervention and the cost of that intervention compares favorably to other commonly used medical treatments, such as dialysis or the treatment of diabetes. The DMCB has written about this before: maybe disease management for chronic conditions isn’t free, but the cost is worth it.

Some things to think about when you read this paper and decide for yourself if the findings are useful:

The DMCB suspects the money saving potential of disease management is greatest when there is high baseline utilization and considerable variation. It wonders if Harlem is an area with relatively blunted access to health care, lessening the opportunity to reduce claims expense.

The cost of the nursing intervention was $158 per year, which is far less than charged in typical commercial disease management programs. The DMCB wonders if the authors (and the patients) got what they paid for.

There is little detail on just what the nurses ‘did’ in the course of their follow-up. The DMCB is not sure if the coaching was culturally appropriate, made use of state-of-art principles of patient engagement or if the phone call follow-up was intense enough.

Yes, this is the prestigious Annals but other studies on the topic of CHF have indicated that savings are possible.

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

During the course of today’s business planning with two smart colleagues, the topic of the ‘patient centered medical home’ came up. Both responded the same way, mistaking it as some sort of skilled nursing facility ‘where people… go away to, like, get… better?’ The DMCB responded by describing it as an enhanced primary care clinic, like ‘Marcus Welby, only better.’

‘Who is Marcus Welby?’ I was asked by both. Disappointed by this reminder of the DMCB’s age and that neither were regularly reading this blog, it reached into its bag of vulgar popular culture and asked if they were familiar with the TV character ‘House.’ Both immediately recognized the misanthropic doctor, so I explained the medical home as ‘anti-House on niceness steroids.’ I think they got it.

The DMCB believes the term 'medical home' is something that only its fellow 'internists' could have agreed to.

heartbreaking

Beautiful Jen, from the Comfy Place, wrote a post that really got to me today.

"Last night came thoughts about how dying of cancer is in some ways a kinder way to leave those you love behind. It gives those we love time to come to terms with our demise well before it happens. I have even had my Mum remark that she feels she has been grieving whilst I am still alive. One of my close friends has said the same thing, in a sense. She says she has grieved already, she knows it will continue in fits and starts and she is sure that when I do finally pass she will grieve again but I have noticed how people seem to come to terms with their loss whilst the person with the illness is still alive and with them. I believe this is because they can think about it, as horrid as it is to think about the world without that particular person in it, they can think about it while safely knowing that the person is within touching distance or a phone call away. Then it came to me how children may not get this option of slowly grieving whilst the person they love is still alive. I think because we tend to protect them and want to shelter them from anything painful but I believe in cases like this, we are making it harder on them when the person does actually pass."

Jen needs to have a talk with her sons, one that I have often thought about. She is brave and strong and thoughtful and loves her boys passionately.

There was a time, not that long ago that I thought a similar conversation with my own boys was imminent. Jen's honesty is inspiring and I will think of her when my time comes.

But I grieve for her tonight.

Cross-posted to Mothers With Cancer.

A Tale of Two Diabetics

Meet Homer. His appetite for doughnuts and aluminum wrapped carbonated carbohydrate-rich beverages has finally caught up with him. His doctor has told him that he's overweight and has diabetes mellitus. An oaf he may be, but he’s a lovable well-meaning oaf who does his best to follow his doctor’s advice most of the time. He’s been told by his doctor about the role of diet, exercise, medications and regular follow-up. He remembers little of it.

Homer’s neighbor Ned hasn’t been immune from exposure to Fatland either. A victim of one too many yummylicious Church suppers, his waist line has also reached critical mass. He is very attentaroonie to the need for blood glucose control, has bought a meter and is already thinking of giving that eye professional he saw just last month a call to see if there was any sign of a new word he learned on line i.e., ‘retinopathy.’ He’s been told by his doctor about the role of diet, exercise, medications and regular follow-up. He’s tried to remember what he’s been told. He remembers little of it.

Who is going to have the better outcome – Ned or Homer?

While Ned is the obvious choice, don’t dismiss Homer, especially if he gets the kind of health care coaching that is tailored to his life-style preferences. While it’s always hard to predict just how Homer will process things, given his preferences, he’d probably be reluctant be hassled by the polypharmacy combination of medicines of dubious value and heightened risk of side effects that only marginally lower his A1c to that one-size-fits-all guideline value of 7.0% or lower. While he’ll probably neglect getting his yearly eye examination, chances are likely that his vision will do just fine. Because he works at a nuclear power plant, Mr. Burns – not out of any soft hearted notions of niceness but out of a hard assessment of a likely return on investment - has probably invested in an aggressive on-site wellness program that has made donuts far less available. Last but not least, Homer is high risk and has been tagged by a disease management organization as someone that warrants regular phone calls. Homer’s nurse has determined that Marge can be a resource in modifying Homer’s dietary habits.

By-the-book Ned, in the meantime, is probably going to go along with the ADA recommendation that he get his A1c below 7%, even if he has to take a combination of three different medicines to do it. While he’s worrying about all those side effects, the increase in his visits to the doctor is going to prompt additional testing and referrals for other long dormant conditions, including that vague pain he’s had in his low back and his concern that that long standing mole could be something serious. And by the way, Ned’s business pays for a bare bones health insurance program with a high deductable and no disease management support. There are no on site wellness programs and Ned doesn’t have access to any disease management.

The DMCB will put it's money on Homer.

my big little man

D. in 2003

D. in 2008

The McCain Health Plan's Good Idea for Health Care Reform--Likely Going Down With the Candidate

John McCain would reform the American health care system by providing big tax incentives for it to transition from being employer-based to one built on a system of individual responsibility. He would do this by eliminating the longtime personal tax exemption on employer-provided health insurance and replacing it with a $2,500 individual, and $5,000 family, tax credit for those who have health

Say Discharge Planning and Disease Management in the Same Sentence

Whether you ask patients what happens to them after they leave the hospital or review the discharge summaries to determine whether recommended follow-up occurred, the message is the same: a substantial proportion has problems that could have been managed much better in the time around the exit from the hospital (5% in this study), and that needed testing and follow-up never happens (up to a third of the time in this study).

Readers of the Disease Management Care Blog are probably aware that many acute inpatient stays are paid under a ‘Diagnosis Related Group’ or DRG basis. This is a global payment that covers the cost of the entire hospitalization based on the diagnosis and not on the number of days spent by the patient hospital. Accordingly, hospitals have an economic incentive to admit patients (which triggers the DRG payment) and then discharge them as quickly as possible (emptying the bed so another patient attached to a DRG can fill it). The resulting churn can lead to haphazard discharge planning where still sickly patients and their confused families are given complex instructions, lists and brochures while being wheeled toward the front door.

How can anyone tell if patients are being discharged too soon? While measuring the number of subsequent problems in follow-up surveys or comparing the discharge summaries to intended follow-up are useful, a readily available metric is the re-admission rate. If patients are being ‘pushed out’ of the hospital before they’re ready, a proportion is going to come back. The DMCB found this study that indicates a baseline rehospitalization rate within 30 days for persons greater than age 65 is is about 12%. Readmission for the same diagnosis (which is probably a better gauge of how DRGs are being managed) is about 5%. Therefore, it a rehospitalization rate for a hospital is significantly greater than 12% or 5%, respectively (by say, by 2 or more standard deviations), one could infer there might be a problem.

Why is this important? Two reasons:

1. From the point of view of the disease management industry, coordinating care among freshly discharged patients is an important opportunity. The health professionals staffing DMOs are intuitively aware of the breakdowns that can occur in the transition from inpatient to outpatient care. In addition to better discharge planning, a few phone calls to make sure that these patients know who to call if there is a problem and are taking their medications without any side effects could make a big difference in the readmission rate and get it lower than 12 or 5%. For health insurers that want to avoid unnecessary hospitalizations for key enrollees, this looks like a no-brainer. That is, until number 2 happens......

2. Think CMS is not going to continue to build on the success of their non-payment for “never events” occurring in hospital settings? It’s too easy for Medicare and its intermediary payers to detect - through a simple claims analysis – potentially avoidable DRG-based readmissions for beneficiaries within a defined period with the same or similar diagnosis code. The DMCB suspects the Medicare program will eventually wake up to the option of simply denying payment for readmits of some index conditions (for example, exacerbations of chronic heart failure) by rolling both hospital stays into the “same” single DRG payment. What's more, CMS is unlikely to recognize a baseline rate: all will be denied just like the approach to 'never-events.' In response, hospitals will probably work to improve discharge planning by anticipating and managing problems in the discharge period and making sure their patients have adequate follow-up.

That's all well and good. But the DMCB thinks the smarter hospital administrators will also consider the option of contracting with a DMO rather than hiring additional personnel responsible for outpatient care. And while commerical insurers would probably follow suit in denying payment for readmissions, they'll still have an interest in reducing hospital readmission churn and will support hospitals' interest in minimizing readmissions. The DMCB recommends health insurers see if they can contractually deduct a proportion of their DRG payment if there isn't referral to a DMO. Radical thinking, but given the stakes, maybe it's time....

What Does Baseball Teach Us About Healthcare - Not

Unusual things do happen. If the Oracle Alan Greenspan admits to making econometric mistakes and the elderly Cloris Leachman exceeds a dancing land-speed of two miles per hour, the Disease Management Care Blog will pay attention. That's why the improbable co-authorship of Newt Gingrich and John Kerry (with baseball expert Billy Beane) in this New York Times piece lauding the use of data-driven health care piqued its interest. If these opponents from either end of the political spectrum can actually agree on something, whatever it is must be good, right?

And agree they do on the notion that 'a health care system driven by robust comparative clinical evidence' will save lives and money. According to these well meaning politicos, physicians and hospitals need to learn from baseball's modern approach to outcomes data in day-to-day healthcare. Lives would be saved, walks and hits per healthcare encounter (WHHC) would increase, the on-base rate per insurance dollar claim (OBRpIDC) would go up and Frequency of Lowly Unwarranted Functionless Funnybusiness (FLUFF) would go down.

The DMCB likes the idea, but finds the baseball analogy a stretch. Here's why:

C0-morbitities: imagine at-bat statistics that involved different sized baseballs, multiple pitchers, shifting bat lengths and weights, changing distances and directions to first base and new rules about the numbers of balls and strikes allowed with each patient. Then multiply that times the number and types of docs and hospitals per region. Much of that variation is admittedly unexplained, but just because it's unexplained doesn't mean it's manageable by a Steinbrenneroid health czar. The statistical methodology necessary to account for the underlying variation is within reach (necessary) but hardly enough (not sufficient) to manage a health care system into a quality and cost World Series.

Incentives: in the rarified atmosphere of professional baseball, the pyramid single elimination winner-gets-all reward system is short-term (within a season) and extreme (huge pay out). When Newt and John suggest Intermoutain deserves to stand at the top of a heap, they lose sight of the fundamental intent of healthcare reform: to make all healthcare providers better and translate that improvement into a palpable difference for all patients - from Tampa Bay to Philadelphia to Los Angeles to Chicago to Boston.

Causality: Players clearly 'cause' runs, hits and errors. While this directionality is simple and appealing to denizens of the 'Beltway,' its not so simple in the clinical trenches of day-to-day medicine. For example, do physicians 'cause' better glucose control among persons with diabetes, or do persons with better glucose control see physicians more often? And while the brutal business of pursuing a Pennant affords owners the luxury of banishing players to the minors over the sin of being merely associated with a low ERA, it's not so simple with independently licensed physicians or local community hospitals.

Margins: The DMCB's spouse wishes it were a minority investor in one of the MLB professional franchises. If it were, she would invest in a robust information-technology based medical version of 'Sabermetrics,' because, let's face it, money would be no object and the ROI would be palpable. In contrast, money is an object in a 1-3% margin healthcare system dominated by a dysfunctional Medicare and Medicaid fee schedule in which the ticket prices have no relationship to their cost and the players are micro-managed on an unbundled system of payment (for each swing) and pre-determined cost-plus methodologies (pinstripe cost X .0028 RVUs, all subject to down coding).

Let's face it. The reason why healthcare has been resistant to change is because it truly is different with different rules and different statistical approaches, incentives, management styles and financing. Based on the overly simplistic nostrums demonstrated by the authors (and editors) in this New York Times piece, the DMCB wonders if we need different experts weighing in on how to fix things.

Sorry guys, you've struck out. And that, unfortunately, is not unusual.

and the gold star goes to...

Mother to 10 year old son: How did you get to be such a good kid?

Son: Good parenting?

random fall friday

1. It was lovely enough to sit outside for a while today. The air was crisp and the birds were very, very loud. I had to come in for a phone appointment and meant to go out again but got swept up in other things.

2. We have a couple of good friends staying with us for a few days. We sat around at the dining room table this morning and I realized that the last time we had done that was when I had my head shaved in March 2006. Doesn't feel that long ago.

3. I am listening to an audio book and really enjoying it. It's The Ethical Assassin by David Liss. I am thinking of becoming his groupie.

4. The puppy (I need to take more photos of her, she is much bigger and hairier now) was spayed yesterday. She is feeling a little low, poor thing but I admit that I have enjoyed the quiet.

5. A few friends and I have formed a writing group. We are meeting one evening every month and I am very excited about it.

6. I have not had a major project on the go since finishing the book and I need one.

Disease Management Does Save Money.... but Its Fees are Too High.

Remember Medicare Health Support?

Jerry Cromwell, Nancy McCall and Joe Burton have had an article titled 'Evaluation of Medicare Health Support Chronic Disease Pilot Program' posted in the Fall 2008 on-line issue of Health Care Financing Review. It casts additional light on just what the trial has shown to date. Some highlights:

Fees paid to the participating disease management organizations (DMOs) ranged from $74 to $159 per month. Recall that in order to avoid having to give this money back, the DMOs had to reduce health care costs by 5% (compared to a control group of Medicare beneficiaries) plus an amount equal to the fee.

6 out of 8 of the participating DMOs reduced utilization by amounts ranging from $17 to $80 per month. There were several wrinkles however: 1) These savings were achieved in a background of considerable cost inflation. Cost didn't really go down, they increased less thanks to disease management; 2) the observed savings don't appear to have been due to a reduction in hospitalization rates compared to the control group; 3) for most of the DMOs, the observed savings were not 'statistically significant.'

And then there were the contract terms. In order to keep the fees of $74 to $159 per month, the DMOs had to reduce spending by 5% plus whatever the fee was. Only two DMOs achieved 5% or greater savings and none recouped their total fees. It appears that inorder to have gotten to the 5%-plus-fee threshold, the DMOs would have had to reduce utilization in their Medicare fee for service populations from about 10% to 16%.

Take-aways from the Disease Management Care Blog:

Disease management does save money. 6 out of 8 of the participating DMOs reduced utilization in a background of considerable cost inflation and 2 achieved statistical significance. The DMCB did not see a 'pooled' comparison of overall savings (a meta-analysis) in MHS, but it suspects the program all in all, even if it didn't get to the threshold of statistical significance, showed considerable promise of financial significance. This is still real money, which is why both candidates still prominently feature disease management in their reform proposals.

While it's real money, it's also relatively modest money. Gone is the heady hubris of the early days when the DMOs promised the sun and the moon and the stars. That being said, disease management has a role to play, but

Disease management fees are too high and exceed the money saved. Welcome to the club. While the DMCB doubts there were will sweeping reform, it expects the next President will tackle healthcare's administrative costs. The most visible target is the 'medical loss ratio,' which is simply an expression of how much of every insurance dollar is actually spent on medical care. If the disease management industry wants to be a viable option in the short term, it will have to demonstrate that it is part of the solution to the MLR and that it can do the task in chronic illness with far less expense. Better start planning now.

Compare what happened in MHS to what will happen in the Medical Home Demo. Participating practices will be paid (depending on the tier) blended per beneficiary fees ranging from $40 to $52 (contrast that with the DMO fees of $74 to 159) and have to achieve a savings threshold of 2% (not 5%). According to my prior analysis, smaller Tier 1 practices will have to reduce utilization in the range of 5-8% to achieve profitability, depending on the number of patients that get signed up and assuming they have the personnel to do the job right. Can practices achieve this? The reductions in the MHS Demo would suggest that changes in utilization are within reach. Once again, it comes down to the expense necessary to achieve it.

book review: "belly of the whale"

I try to only review things on my blog that I would recommend to others. When I don't enjoy a book that I have been asked to review, I usually keep the review over at Library Thing or don't review it at all.

I don't go out of my way to trash someone else's hard work.

Most of the time, if I write about it, I like it.

However, Belly of the Whale by Linda Merlino is an exception.

This novel, a thriller, is about Hudson Catalina, a 38 year old mother to three kids with breast cancer, is badly written, heavy handed and manipulative from beginning to end.

Hudson Catalina has given up. Having lost both breasts to cancer, she is emotionally and physically exhausted, no longer willing to endure the nausea and crushing weakness that chemotherapy causes. Until the wrecked-by-life young Buddy Baker arrives, bent on murder. Linda Merlino’s harrowing, touching story of despair, abuse, murder and survival takes you on a journey through the darkest places of the human mind and spirit, and in the end leads you back out of “the belly of the whale” enriched by the experience.

The cover art is garish and features a bald woman, cringing, as a tear rolls down her cheek. ( Also she has stubble. Honestly, if they couldn't find a woman who had really lost her hair to cancer, instead of a model with her head shaved, then they really shouldn't have bothered). I know that you aren't supposed to judge a book by its cover but in this case, the cover told me almost everything about the book that I needed to know.



As a novel, this book is not just bad but jaw-droppingly bad. I had a list of examples of terrible writing and factual inaccuracies (I have post-its with exclamation marks on every other page) but I will spare you the lengthy list. The narrative is overwrought and repetitive. The dialogue is terrible and the characters speak in stereotypes.

Several of the women who write for Mothers With Cancer were asked to read and review this book as part breast cancer awareness month. I don't think very many of us liked it. And I don't think this book does anything to raise awareness about the real experience of breast cancer.

I agreed to review it because I was told that the author is a breast cancer survivor (although it doesn't say this anywhere on her web site, in the book or on its jacket) and because I do like to do book reviews. And there have been many, many books with breast cancer as a central theme that I have liked (The Middle Place is a good example).

I was worried that I was being to hard on the book because I live with breast cancer and I could not identify with this character (despite the similarity in our ages).

But bad writing is bad writing.

And exploitation is exploitation.

Do not read this book if you, or someone you love, is going through treatment.

Do not read this book if you like good writing.

And I for one, plan to think twice before I crack the spine of another book from Kunati Press.

Of Motorcycle Laws and Consumer Directed Health Plans

The Disease Management Care Blog spent the last few days in sunny Texas, where motorcycle drivers seem to have a remarkable affinity for offering themselves up as potential organ donors by forgoing protective headgear. This display of two-wheeled freedom during the car ride to DFW reminded the DMCB of consumer directed health plans.

How so you ask?

When patients have to choose between using their own money for medical care versus not spending it and forgoing potentially important care, is this exercise in choice-making awful? According to the Blue Cross Blue Shield Association, the answer is 'not necessarily.' This press release states consumers enrolled in consumer directed health plans (CDHPs) are ‘more likely to be cost conscious and shop around.’ CDHPs have a lower monthly premium, which makes them a policy option in the search for stemming healthcare cost inflation.

As an aside, the DMCB hasn’t seen the BCBS data, but it wonders if this may be a classic example of ‘self selection bias.’ While the non-critical reader would be tempted to go along with the notion that CDHPs cause healthcare frugality, it’s just as possible that the opposite is going on. Persons inclined to cost consciousness may choose (i.e., ‘cause’) CDHPs. But that’s not the point.

If one accepts the notion that CDHPs put 'skin in the game,' the larger question is whether persons enrolled in CDHPs who actively minimize their out of pocket medical expenses are a) knowingly or unknowingly being b) thrifty or cheated over a c) responsibility or a right to d) commoditized health services or necessarily illness treatment for e) preference sensitive or preference insensitive care? Back in the days of DMCB’s clinical practice, it wasn’t unusual for its patients to decline to follow its recommendations for a variety of reasons including inconvenience, lack of time, fear of side effects, independent judgment of the potential benefit (especially among healthcare workers) and the out of pocket cost. The DMCB didn’t sweat it just so long as its patients were making a truly informed choice. Just like the Lone Star State’s attitude about its bareheaded iron-horse cowboys, the DMCB figured that persons had a right to choose to be unwise. If motorcyclists are being allowed the risk of having Mr. Brain get up close and personal with Mr. Concrete, maybe society should be willing to accommodate the exercise of cost-based patient autonomy.

Has the DMCB been seduced by the Wild West? While it did admire them cowboy hats, it would like to point out that there is a considerable body of data that suggests much of health care recommended by doctors is a) fraudulent or b) unsupported by any credible evidence or c) of only marginal benefit and high cost. Contrast that truism with the results from this article in Health Affairs that determined that persons enrolled in high out-of-pocket cost CDHPs experienced an absolute increase of about only 2-4% of going without ‘recommended care.’ While that percent probably included care that was not fraudulent, was evidence-based and was high value, the DMCB asks this: if patients use economics to make informed choices about paying for health care services, is that small increase bad judgment or bad policy? Can it be improved upon to be one of many approaches to controlling healthcare costs among the insured? Or is it the medical equivalent of a silly helmet-optional law that deserves to be repealed?

Last but not least, if we are going to rely on some version of CDHPs as an approach to tackling rising healthcare costs, the DMCB believes disease management (DM) has a proven track record in helping patients participate in wise decision-making and that it can be deployed here. Incorporating economic considerations in its patient coaching strategies is well within the industry's expertise.

Coventry Health Care Stock Down 48%--"Sort of" No Surprise

Readers of this blog will not be surprised to see Coventry Health Care's stock down 48% this afternoon after its earnings call this morning.That is a 77% drop from their 52-week high.Last July I commented on their earnings call where senior management used the precise financial term "sort of" 63 times to explain their then earnings and operations situation: Required Reading for Health Care

What Impact Do Medical Costs Have on Home Mortgage Foreclosures?

That is the subject of a recent paper by Christopher T. Robertson, Richard Egelhof, & Michael Hoke.The authors studied homeowners going through foreclosure in four states and found a big impact on their being able to stay in their house because of the health care cost issues these families had to deal with.Here is an excerpt from their work:"This preliminary study reveals that the standard

Why You Should Read the Disease Management Care Blog

If you are among the hundreds of regular readers of the Disease Management Care Blog, you're already aware that:

...persons can use Second Life avatars to access information on health care. It seems to have started in Spain, but it's only now being reported here.

...it's not news that the U.S. Chamber of Commerce hasn't really endorsed a candidate for President. After all, who cares. What is news is that they apparently endorse 'open-sourcing' the entire Medicare claims data base. Regular readers are familiar with this concept thanks to a total of ten posts from the DMCB that examine the advantages of harnessing the independent judgment of collaborative crowds.

...the head of the Congressional Budget Office keeps a blog. You're right - so what, but in it, he endorses the incorporation of behavioral approaches to health care. This involves setting up systems of care that in turn take advantage of helping persons do the right thing. He doesn’t mention that’s at the core of Disease Management, but give him time. He posts regularly and will get around to it once he catches up and reads this.

...because you believe in 'systems' of care, you should apply on-line to be on the committee that judges candidates for the X-Prize in Health Care. The DMCB filled out the online application because it believes - along with many of its readers - that the award should be based on how well the proposal integrates and implements the multiple solutions already at hand, including disease management, the medical home, the electronic health record, other information technology solutions, novel insurance benefit designs, consumerism and patient as well as physician incentives.

And speaking of synergies, that the DMCB has been writing lots about the potential advantages of combining the best of the medical home and disease management. Well, the DMAA has published this White Paper on the topic. The DMCB suggests that even if you are a regular reader, this particular piece may be worth a look (even if it is the author). It examines the overlap between NCQA Disease Management accreditation on one hand and the NCQA PCC-PCMH recognition program on the other. If a physician practice takes full advantage of all the services offered by a disease management vendor, are they not also fulfilling many of the standards that define a medical home? Read it and decide for yourself.

deconstruction not required

I have been dreaming about houses again (you can read previous posts on this subject here and here).

In this latest dream, I am in the middle of moving. It's not my choice to move and I didn't choose the new house. I like my old house and my old neighbourhood and I feel quite sad to leave them behind.

The new house is not filthy or scary or rundown, just unfamiliar and not what I have chosen for myself.

In the dream, I am trying to make the best of it, figure out how to set up this new home so that I feel safe, comfortable and happy.

I think I'm feeling a bit at loose ends this days.

Additional Follow-up on the Patient Centered Primary Care Collaborative: Will Physician Support Be Universal?

The Disease Management Care Blog has had another chance to review its notes from last Friday's PCPCC meeting. It recalls much of the data presented at the meeting lacked control groups and tests for statistical significance. Maybe the DMCB shouldn't necessarily expect the rigor of a scientific health services research meeting, but it is also reminded of the adage that initiatives like the Patient Centered Medical Home (PCMH) aren't cost saving until the Congressional Budget Office (CBO) says it's cost saving. CBO is going to need better data.

The non-critical fervor in the room over the Patient Centered Medical Home reminded the DMCB of the early pre 'hard science' days of disease management (DM). The underlying elements making up both approaches to chronic care – such as enabling autonomous patient self management, increasing reliance on computerized information systems, strengthening primary care and leveraging the expertise of non-physicians – was just as sexy back then as it is today. Who would have anticipated anything would get in the way of DM?

Unfortunately, what got in the way were a) a disconnect from physicians, that not only undercut its clinical effectiveness but hampered its adoption outside of commercial insurance settings, and b) the appearance of results from more rigorously conducted studies that undercut confidence that DM could reduce costs all the time for all populations.

Pending an answer to the data question, the DMCB asks if we can assume that all primary care physicians will rush to embrace the PCMH? Don't be be too sure. A literature search by the DMCB failed to uncover a survey of rank and file community based physicians concerning their opinions the concept. Lacking good survey data, a very savvy colleague pointed out that modern primary care physicians are increasingly seeking out positions with predictable hours and salaries. In contrast, the PCMH is predicated largely on an old fashioned ongoing “on call” style of practice. He wondered aloud if many of the time-clock punching docs envisioned as staffing today’s “Homes” would be more interested in getting home by 5:30 than staying late to keep a patent out of the emergency room.

Will efforts to implement the PCMH in its current form turn out to be a reprisal of disease management? Time will tell.

way too cool

Want a Medical Home? Just Pay Enough to Get Primary Care Physicians to Smile

The Disease Management Care Blog attended the October 17 Washington DC meeting of the Patient Centered Primary Care Collaborative. One highlight of the conference was Perdue’s Chief Medical Office Roger Merrill's description of his company’s approach to chronic illness care. It doesn’t 'pay' for the Medical Home. Instead, it pays primary care providers in its network a 20% mark-up over the next highest fee schedule. Dr. Merrill showed some interesting data indicating their trend line with this simple approach is considerably lower compared to similar companies. While the 20% fee schedule increase seems like a lot, it’s only a paltry 1% of the total spend for health care. They feel they get more than their money’s worth.

What is this secret sauce you ask? In short, Perdue wants physicians to ‘smile’ when a Perdue employee darkens their clinic doors. Perdue has decided that those smiles make physicians bear a remarkable likeness to Marcus Welby – and soon enough they’ll start acting like him too. Think of it as Medical Home the way it was meant to be and portrayed years ago on TV without all process, reengineering, engagement, policy, verbiage, regulation, incentives, requirements, legislation, benefit redesign, work and hassle.

book review: "the whiskey rebels"*

The Whiskey Rebels by David Liss is a big book and yet I practically read it in one sitting, allowing only the responsibilities of parenting to intervene.

Set in the late 1700s, the book is a piece of meticulously researched historical fiction (at times perhaps a little too meticulously, in terms of detail, but that is my only criticism and it's nit-picking, really). I learned a lot about American history leading up to the Whiskey Rebellion (and the presidency of Thomas Jefferson). I also found myself devouring the details of the early US banking system (truly!).

But it was the plot and characters of the book (along with beautiful writing) that hooked me from the very first page.

The story moves back and forth between two principal (and fictional) characters, Ethan Saunders (a disgraced soldier) and Joan Maycott (a woman who sets out with her husband to settle on the Pennsylvania frontier and becomes a whiskey maker). Both characters are flawed yet intensely compelling. And I fell in love with each of them, as the story moves them towards conflict with each other.

The narrative moves smoothly between perspectives and the author speaks convincingly in the voice of each character It's not easy to write in the voice of someone who is very different from ourselves, yet even Joan Maycott is a believable character whose behaviour and dialogue rings true.

I had never read anything by David Liss before the Whiskey Rebels, but I have since ordered every other book he has written from the library.

Absolutely one of my favourites this year.

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

seven more things

I've been tagged.

By Mom2Amara, who I tagged for this same meme last year.

Here are the rules:

1. Post the rules on your blog.


2. Write 7 random things about yourself.


3. Tag 7 people at the end of your post.
   


4. Pass on the tag.

I am not sure if there are actually seven things I have not already shared on this blog but, as this seems like a good subject for a post-chemo Friday, I will give it a shot.

1. I love the way my dogs smell. I stick my face in their fur sometimes and inhale.

2. I am afraid of heights.

3. My greatest insecurity is that the people I love will stop loving me.

4. Laughter is very important to me. I credit my mom for my goofy sense of humour.

5. I have been to every Canadian province and territory except Saskatchewan and Nunavut.

6. My first two bikes were red. I loved them very much. Both were surprises from my parents, although I got to choose the second one. The first one had a banana seat. The second was my first bike with gears and hand brakes.

7. In December, it will be three years since I found the lump that turned out to be cancer. Some days, this fact still surprises me.

I tag Lene, the Maven, Rebecca, Dee, Babz, nonlineargirl and deb (who I am not linking to because I am not sure how public she wants her blog to be but I want her to do the seven things anyway).

Bloggin' for Pennies

An Oct 17 link for the Disease Management Care Blog spouse!

A Hippocratic Oath for Disease Management Organizations Involved in Healthcare (or is it Health Care?!?)

The Disease Management Care Blog was alerted to this link by colleague Tom Wilson of the Population Health Impact Institute. It describes an article in the Harvard Business Review that examines the merits of a ‘Hippocratic Oath’ for business people. It seems some persons in the banking sector of our economy haven’t exactly been angels.

Regular readers of the DMCB are already familiar with the concept of the Oath, which was reviewed in some detail here. In the meantime, new visitors and readers of HBR are welcome to access the post gratis, print it out on glossy paper and place it on those coffee tables and lamp stands in your corporate waiting areas alongside all those other copies of the business journals.

The DMCB was right then, and it’s right now. Healthcare trumps “first do no harm,” while commerce stresses “buyer beware.” While some would argue tough luck when it comes to the mortgage mess, it can also be argued that the current market turmoil had its roots in a widespread unawareness, due to opaquely leveraged financial instruments, predatory lending and clueless mortgage holders. The DMCB isn’t sure that the fix is a do-no-harm ethos or that it is even possible in most business settings. Rather, it expects lawmakers and regulators to turn up the heat on trying to make things even more transparent. If buyers can be more aware, that’s not a bad thing.

That’s the banking sector. In the commerce of healthcare, however, there will always be the added tension between those who would require a high standard of proof before exposing patients to potential harm (including wasting time or money pursuing questionable outcomes) on one side and those who would operate our clinics, hospitals and disease management organizations in classic business-like fashion. The two points of view are not irreconcilable, and when they're not, some tension between the ‘white coats’ and the ‘suits’ is a good thing.

That’s why the white coat DMCB continues to argue that disease management organizations need to continue to show why they are not doing harm, and why usual business-standard transparency (especially in the current environment) is not enough.

But, think the business posture of the disease management industry isn’t that important? Well, ponder this critical issue: is ‘healthcare’ a word or should it be spelled ‘health care?’ Hillary apparently prefers that it be spelled health care. The wordsmith sleuthing DMCB has found that Barrons says yes to health care, while the Free Dictionary and Merriam-Webster say both are OK. The New England Journal of Medicine can't make up its mind and says yes and no. The AMA also seems confused here versus here. Is this a compounding faux pas, the coarsening of proper English or the natural evolution of a living language? What's next? Diseasemanagement? Patientcenteredmedicalhome?

Pending expert commentary on this controversy in written communication, this tempest in medical typing, this lapse in medical language - it looks as if it's up to the writer.

In the meantime, the DMCB has set Word to accept 'healthcare.'

fall is the prettiest season

The weather here has been absolutely gorgeous and unseasonably warm for the last couple of weeks.

And I am convinced that, in the fall, I live in the most beautiful place in the world. This past week end at the cottage, the fall colours were an unbelievable riot of reds and oranges and yellows. There was a carpet on the ground and yet the trees were still brilliant.

The nights were cool (great for sleeping) but it was warm enough in the day that some of us wore shorts and none of us wore jackets.

And the food...Oh my, did we feast.

As we drove away, I looked at the spectacular view and thought, "It's so gorgeous, it looks like a badly done oil painting."

And it occurred to me that we had not taken a single photo all week end.

Sigh.

At least we have the memories.

It took us seven hours to get home. But it was worth it.

The suitcase still sits unpacked by the back door. I had chemo the day after we got home (and Tim has had his hands full with the boys).

I'll deal with it on Saturday.

Latest Health Wonk Review is Up!

The latest pre-election policy Health Wonk Review is up over at Joe Paduda's Managed Care Matters. Head on over and read Joe's excellently written summary of the best of the blogs and find out why this is such a Big Deal.

One Way to Obtain Less Wasteful Test Ordering Behavior: Recognize that Physicians Also Need to Manage Uncertainty

The Disease Management Care Blog delighted in reading Dr. Lisa Rosenbaum’s personal essay that appeared in the October 16 New England Journal of Medicine. It was the high point of the weekly “Perspective” section of the Journal that was otherwise abysmally hijacked by a pair competing partisan pseudo-evaluations of the McCain and Obama health care plans. The DMCB has decided that it’s going to stop paying attention to the two candidates’ health care proposals until after the election, especially when they're reported in the Journal. It's not until after January 2009 when the real swordsmanship begins.

Dr. Rosenbaum is a 2nd year internal medicine resident in training in Boston. She wryly describes in wonderful narrative the struggles of a young physician in dealing with patient symptoms for which there is no explanation. Caring for such individuals is a struggle, she writes because 1) the culture of modern medicine has little patience for the unknown, 2) patient-consumers want answers and 3) it’s practically impossible to submit a bill without a diagnosis code. An EHResque ‘Rise of Machines’ is only adding fuel to this fire, since electronic formatting of patient encounters makes it impossible complete them without a diagnosis. As a result, physicians are being cornered into diagnoses of pseudo-certainty like “Lupus” or “prostatitis” that take on a zombie electronic life of their own. These faux diseases work their way into patient problem lists, past medical history records and care plans not only long as these patients live, but well beyond.

In the DMCB’s former life as a primary care physician, symptoms of lingering numbness, unsteadiness, fatigue, aching, poor memory, vision changes and the like were quite common. Docs deal with it, usually with some combination of intuitive understanding of what could be serious versus what isn’t, providing comfort with assurances of what isn’t wrong and using the most important test of all: time backed by a confident caring demeanor, ready availability if things change and firm plans for a follow-up appointment.

Note that the DMCB did not indicate that it routinely ordered many blood or imaging tests or referred patients to many specialists to help sort out the known from the unknown. That’s because it quickly discovered that tests commonly ‘lie’ thanks to ‘sensitivities’ and ‘specificities’ that are commonly south of 100%.

That’s right. Stress tests, CAT scans and blood tests can be remarkably imperfect, with falsely positive (positive tests in persons without any disease) and falsely negative (normal tests in persons with disease) test rates that can approach 30%. It’s the job of smart docs to weigh the probability that ‘positive’ test result is a lie and if the likelihood of a lie is greater than the possibility of real disease.

The DMCB also got used to many of his specialist colleagues’ inability to grasp that fundamental truth. The DMCB is not surprised that electronic records (and their evil twin, our latest generation billing systems) are also unable to accommodate this.

To Dr. Rosenbaum, the DMCB says hang in there. The system needs good docs like you to rescue us from ourselves.

Demystifying U.S. Health Care Spending--Some Surprising Information

Paul Ginsburg, of the Center for Studying Health System Change, has just authored a new report, "High and Rising Health Care Costs: Demystifying U.S. Health Care Spending." The report is part of the Robert Wood Johnson Foundation's Synthesis Project.This paper reviews existing literature in search of a more clear understanding of U.S. health care costs, the drivers, and the trends.It is an

Obesity: The Emerging Role of Disease Management and An Important Opinion Piece in JAMA

Good news. The DMAA has established an Obesity Resource Center. There are links to useful consumer information, links to a literature search engine preloaded with the term obesity, links to information that employers would find useful and other goodies.

There is also a link to the newly released DMAA Obesity Toolkit. The Disease Management Care Blog would like to immodestly point out that it was involved in its formulation. In it's humble opinion, the .xls spreadsheet that allows insurers to load assumptions into an actuarially sound calculator is a neat tool. Depending on what is covered, how it's paid for and what utilization patterns are likely, users can price the insurance cost of covering obesity-related services in a benefit rider. Very cool.

And while we're on the weighty topic of obesity, the Oct 15 issue of JAMA has come out with a provocative article on the food industry's inability to curb its insatiable appetite for profits. The authors, Drs. David Ludwig and Marion Nestle, describe a glutinous pattern of underhanded public relations that is designed to deflect criticism over the avarcious marketing aimed at getting consumers to eat more high profit-margin, calorie-dense, processed and waist expanding food.

The authors note that cars are responsible for a certain frequency of injury and premature death, yet we don't expect car manufacturers to regulate their own industry. Instead, the government uses a blend of regulations, taxes, mandates, incentives and the threat of being hauled up before a Committee of Congress to shape the industry. The FTC, U.S. Department of Agriculture, and the FDA have the means to deliver many of these readily available tools. Given the conflict of interest between maximizing shareholder value versus the public health burden of obesity, the authors call for these government organs plus academia and public health advocates to rigorously apply the appropriate checks and balances.

While the DMCB wishes the authors had mentioned the role of disease management organizations along with academia and public health, it will forgive them. It is also generally suspicious of government's ability to intelligently regulate, but it recognizes that the authors make a good point.

The DMCB thinks it would be neat if this article were posted on the DMAA Obesity Resource Center. It's.... good food for thought.

Cogitations and Calculations Over the Medicare Medical Home Demo

Unable to stay away from the reimbursement numbers in the Medical Home Demo slide set, the Disease Management Care Blog broke out the protractor and asked just how much in the way of savings (from reduced utilization) would be necessary to make participation in the Demo worth the effort of smaller physician owned practice. In 'demo-speak,' this would be a ‘Tier 1’ practice that assumes the duties of a medical home, establishes policy for ready patient access, tracks patients, uses care plans, provides patient education and support and tracks tests and referrals. It also doesn’t have an electronic health record. As a result, it would qualify for a fee of $40.40 per member (a.k.a., Medicare beneficiary enrolled in the Medical Home) per month.


The DMCB started with the Milliman report on FFS Medicare and found that the average 2006 Medicare beneficiary with chronic disease can expect to have a ‘per member per month’ (PMPM) cost of $1473. That’s how much the Medicare program spends on average for every chronically ill Medicare beneficiary per month.

Let’s assume (and underestimate) that the small primary care practice gets 100 of its Medicare fee-for-service patients to sign up for this Demo. The expected monthly cost of this group of patients to the Medicare program is $1473 times 100 or $147,300. The Demo is willing to pay the physician practice a blended monthly fee of $40.40 for the Medical Home services for each patient. That works out to $48,483 per year. Let’s also assume for the sake of argument that the cost in the following year is not increasing thanks to cost inflation, etc. Many observers also believe a practice might have to hire a nurse to act as a care manager, health coach or telephonic advisor. A last assumption is that the DMCB's back of the envelope calculations have not been compromised by a major case of late night arithmetic brain block.

The DMCB mapped out three scenarios: a savings of 2% versus 5% versus 8% off that monthly baseline cost of $1473. The Table below shows the monthly savings, what happens when the Medicare Program takes 2% off the top and shares 80% of the remainder after subtracting the Medical Home fees. This scenario also assumes a nurse was hired to provide care management services (at $60,000 per year).

Savings have to approach about an 8% reduction in base line cost before the practice makes any money:

The DMCB did the same thing for a Tier 1 practice that signs up 250 patients. Savings still have to exceed 5%:

Based on this admittedly limited analysis, the DMCB would offer up a few observations:

1. This is clearly a game of:

a) Aggressive cost reduction. An 8% reduction in claims expense for FFS Medicare is possible, but daunting. Assuming an average Medicare hospitalization costs around $11,000, a practice with 100 signed up participants would need to avoid 1 or 2 hospitalizations to make it happen. On the other hand, not all hospitalizations are controllable and it's very easy to get burned by a random increase in hospitalizations.

b) Economies of scale. The more beneficiaries get signed up, the more likely a practice is to turn a profit.

c) Cost control. Practices may be tempted to rely on personnel that are already in place and not hire a new nurse FTE. Given how financially tight things are in primary care practice, however, the DMCB suspects the numbers and qualifications of persons available to primary care practices is already minimal. If a nurse is tasked to care management, who is going to take over all the other duties of an office nurse?

2. Practices will be tempted to 'cherry pick' participants. While the Demo has a risk adjusted payment, physicians intuitively understand which patients will "get it" and work with them to reduce hospitalization and ER rates and which patients won't. This is a key difference from the star-crossed MHS demo and may turn out to be their 'ace in the hole.'

3. In the experience of the DMCB, nurse case loads in case or care management and/or disease management can range from 30 patients to more than 200. If a practice intends to sign up even more patients than the scenario above, then it may be obliged to hire a second FTE, which will erode margins.

4. Note that a few percentage points, cost assumptions, local cost factors and utilization stats make all the difference in a program that makes a profit versus lost money. Toss in other known assumptions as well as the myriad unknowns and the win-loss ratio could shift significantly.

5. Last but not least, random utilization spread around a mean virtually guarantees there will be a number of physician practices that "win." The challenge will be to sort out those practices from the ones that have the secret sauce of optimal care management.

The DMCB could sure use the insights of others here. Can anyone see any holes in this logic?