Innovation in Primary Care.... NOT

Much like the earnest gecko hunter of those Geico commercials, a reporter has been dispatched from the New England Journal to observe ‘innovative’ primary care physicians in their natural habitat. According to this intrepid correspondent, there are creative docs out there who are field testing ways to see fewer patients, work-smarter-not-harder and avoid burn-out.

And just what are these precocious practitioners of the Plains, these daunting docs of Dubuque, trying out? According to this safari jacketed writer, the ingredients for physician innovativeness consist of downjobbing routine stuff to the nurses, being savvy schedulers, using group visits, email and telephony. See, this may free up time for precious moments of physician-patient intimacy sprinkled with some real medical stuff, like worrying about potassium levels.

This is insight from the New England Journal? Maybe among Boston's Brahmins. The rest of us know the nurse-physician dyad has been the bedrock of well functioning outpatient clinics for decades. Not only have nurses plowed the road for the physicians in high performing clinics, they know better than anyone else that in primary care, quick one-on-one '12 minute' visits are ultimately more remunerative and that complex time consuming issues can be referred away.

Group visits, e-mail and telephony are not ‘all that’ either. The DMCB suspects these remain pretty much confined to very large physician practices, which seems to be the favored hiking range of the Journal’s academic writers anyway. As for the other 90% of primary care that has been missed by this reporting, these docs have probably calculated that adding to or substituting lots of patient visits with lots of phone calls and emails is a losing hand in a zero sum game. They also know that group visits are not a slam dunk either, especially in smaller practices with limited square feet.

Nonetheless, even this faux field report couldn’t help but spot the recruiting struggles of the large primary care practices. And it begs the question: if large group practices, nurse teaming, scheduling know-how, remote care communications and group visits are all that cool, then why are young physicians not flocking to innovation/large group practices so admired by the New England Journal?

30 posts in 30 days

Well, I made it.

I posted a lot of "filler" this month. I also found that many of the more substantive posts that I have wanted to write (book reviews and news of the conference I attended) remain in draft form. The need to keep cranking out the posts made me less willing to go back to half-written ones and edit them, lest they take up too much time. I will enjoy giving myself the space to write more thoughtfully and to give myself the time to set things aside.

On the other hand, NaBloPoMo made me dig a little deeper, take in the world in a different way (I was constantly wondering, "could I blog about this?") and post some things it never might have otherwise occurred to me to share. The post that probably got the most reaction was the one about toilet sprouts.

The very first year, I did NaBloPoMo, I was diagnosed with mets and never missed a day. In contrast, I faced many fewer challenges this year. On the other hand, November 2006 was filled with stories that were more compelling than the SpeedFit. At least I think so.

meet the 'speedfit'

The brilliance of humanity never fails to astound me.



Why just go for a run when you can take your treadmill on the road?

This is a real company and they are completely serious. S. thinks we should ask Santa to bring me one.

what's in a name

I have lots on my plate today (and I don't mean Thanksgiving leftovers, living in Canada and all) so I thought it would be a good day for a meme. I stole this one from Average Jane.

1. WITNESS PROTECTION NAME: (mother’s & father’s middle names):
Marie Leslie.

2. NASCAR NAME: (first name of your mother’s dad, father’s dad):
Alexandre Christopher.

3. STAR WARS NAME: (the first 2 letters of your last name, first 4 letters of your first name):
Kilaur (I kind of like it!)

4. DETECTIVE NAME: (favorite color, favorite animal):
Blue Dog (or should that read Blue Dawg?).

5. SOAP OPERA NAME: (middle name, city where you live):
Anne Ottawa (that's just plain odd).

6. SUPERHERO NAME: (2nd favorite color, favorite alcoholic drink, optionally add “THE” to the beginning):
The Red Black Velvet (or alternatively Red Wine but I don't like that nearly as much).

7. FLY NAME: (first 2 letters of 1st name, last 2 letters of your last name):
Laon.

8. GANGSTA NAME: (favorite ice cream flavor, favorite cookie):
After Eight Chocolate Chip (now that's just silly).

9. ROCK STAR NAME: (current pet’s name, current street name):
Lucy Fourth.

10. PORN NAME: (1st pet, street you grew up on):
Kelly Smerdon.

Medicare Medical Home Demo Update. What's Coming Next?

CMS has posted an update pdf at its Medicare Medical Home Demonstration web site. It's short, readable and has given the Disease Management Care Blog some additional insights about its plans. For example, CMS has no intention of helping its participating physicians with interm updates on how things are going. There is also going to be reliance on physician professional organizations, academies and societies to aid with recruitment of physician practices. To participate, docs will need to enter at least 150 patients into the Demo.

Recall also that CMS' care management fee will depend on the intensity or depth of the medical home services being provided by the physicians' practices: more depth, more payment. In its post, CMS explains that it decided to use its own two-payment tier methodology instead of the NCQA's three tier approach because its lowest ‘introductory’ tier didn’t represent enough of a practice change. This makes sense to the DMCB, since it is the style of the NCQA to open new recognition programs with low thresholds that grow more vigorous with time. CMS, in the meantime, doesn't have this luxury. This makes the DMCB wonder: if the Demo is sucessful and is expanded, will physicians have to deal with two medical home recognition standards?

The eight regions haven't been selected yet. What will the consultants, electronic record vendors, practice management groups and disease management organizations do?

The DMCB suspects that they will buy several of these......

..........fill them with these

Outfit them with this...........

...................and push them out the door!

being kids together

I want to thank everyone who took the time to leave advice or thoughts on my post about tantrums.

As a direct result of your comments, I kept five year old D. home this morning, just to hang out and have fun together.

We played Dog-Opoly (like Monopoly, except that instead of buying property, you buy dogs. It's a laugh a minute) for almost two hours. We danced to the soundtrack from the SpongeBob Squarepants Movie (D. insisted that we take turns dancing while the other watched. He's a real little showboat). We went out to lunch at Subway.

As we were eating our sandwiches, I said, "I'm feeling happy."

"Me too!" he said.

He ran happily into the school when I dropped him off. Our morning went by in a heartbeat. I realized how quickly he's growing up. He can read and add up two numbers on dice (his future as a gambler looks bright. He even blows on the dice before rolling them). And, as a dancer, he really does have some great moves.

We had fun. And we cuddled. It was good.

the opposite problem

I know several women who discovered they had breast cancer much later than they ought to have, because they were refused access to screening, their doctors dismissed their concerns or their breasts were so dense that tumours were not easily detectable by ultrasound or mammogram.

And then, today I read in the Globe and Mail that a new study coming out of Norway, revealed that some cancers will disappear on their own and that more sophisticated testing, such as the MRI, can lead to "overdiagnosis":

The study, published yesterday in the journal Archives of Internal Medicine, suggested breast-cancer screening may be leading to overdiagnosis, with about 22 per cent of cases likely to resolve themselves without treatment.

Once a breast cancer is found, however, it would currently be considered unethical not to treat it. So - if the theory is correct - large numbers of women may be having surgery, radiation, chemotherapy and other treatments that would never have been needed if their cancers had not been detected.

[]Radiation can damage the heart and coronary arteries. A previous randomized controlled trial showed that about one in 10 women who receive radiation for breast cancer will die from heart damage attributable to the treatment, he said.

In a telephone interview from Oslo, Dr. Zahl said that if he and his co-authors are correct, two women die from complications of breast-cancer treatment for every woman saved by screening.

"And that's a very bad tradeoff."

The study's authors argue that, since it is considered unethical to treat cancer once it has been detected, more aggressive detection can lead to unnecessary treatment that may cause more harm than good.

I was feeling a little uneasy when I read this article and trying to articulate why, when I read a response from Dr. Amy Tuteur (thanks to Jenny for the link). Her last paragraph was the clincher for me:

Finally, and most importantly, there is no way to tell the difference on mammography, or by any other technique, between the cancers that will disappear and the ones that will go on and kill the woman. Without a practical way to separate those who need to be treated from those who do not, the finding is intriguing and worthy of further investigation, but cannot guide us in determining the best way to screen for breast cancer and the best way to treat it.

It's hard, when reading this stuff, not to consider my own situation. My breast cancer was diagnosed after I found the big, hard lump in my right breast. The kind of cancer I have is aggressive, and by the time we found it, fairly advanced. If I had had an MRI and my tumour had been discovered before the cancer had spread to my lymph nodes, the chance of metastasis could have been much lower.

How would doctors know which cancers to ignore and which to treat?

Until we have the answers to those questions, this study seems to me to be meaningless.

And I hope it doesn't used as a reason to deny tests to women who are high risk or who suspect they might have breast cancer.

Cross-posted to Mothers With Cancer.

Bounties for Patients or Divvying the Market: the Next Frontier of Collaboration for the Medical Home and Disease Management?

After decamping the Hollywood Florida DMAA Forum 08 Meeting, the Disease Management Care Blog considered several presentations that described referrals to disease management programs by either physicians or medical home programs.

Be still the DMCB beating heart, talk about a “win-win” arrangement.

Wyoming Medicaid calls it 'Pay for Participation.' While Wyoming doesn’t have any managed care (it’s all fee-for-service or FFS) they do have vendor supplied programs in wellness, disease management (DM) and case management. After a lot of physician office outreach and education (focused not on the docs but on the office nurses), Wyoming Medicaid launched a series of billing codes that prompted referral of patients to the DM vendor. The interesting thing is that theses codes were accompanied by an extra payment. Essentially, physicians were being paid using a system already in place to refer patients into these programs. Wyoming reasoned that the work of referral warranted compensation. The vendor? APS.

In the meantime, Pennsylvania Medicaid’s ACCESS Plus Program serves FFS patients outside of Philadelphia and Pittsburg with disease management programs. Physicians are paid anywhere from $30 to $60 for patient referrals, working with the disease management vendor or signing off on a care plan. The vendor? McKesson.

And up in Boston, Massachusetts Blue Cross Blue Shield (MA BCBS) had one large medical group in its network with its own exquisitely designed diabetes care program. It was apparent to MA BCBS that this program was a ‘high intensity’ intervention that seemed better suited for complex patients - versus patients that would benefit from a softer and gentler version of telephonic disease management ‘lite’ coaching (the DMCB’s characterization). The fix? Predictive modeling was used to identify patients that would benefit from the physicians’ program and those that would benefit from the lite program. The large medical group agreed to this arrangement and even agreed to vet the referrals and endorse/sign the patient recruitment letters. Referrals to disease management increased and referrals to the medical group’s diabetes care program increased. The vendor? Healthways.

What did the DMCB learn from this?

By having physicians review and sign off on the referrals, insurers and DM programs can feel much more confident that the patients actually have the condition (a claims analysis, even buttressed with predictive modeling remains disappointingly inaccurate) and are more likely to agree to being entered in the program. That’s called ‘less effort on wasted letters and phone calls’ attempting to recruit patients. That’s spelled ‘C-O-S-T S-A-V-I-N-G-S.’

Paying primary care physicians for the work of referring patients into disease management programs makes sense. They need to assess the suitability of the patients’ fit as well as review and sign the letters. That’s called effort and is how things are done in an unbundled FFS world. The only caveat is the appearance of opt-in programs providing kickbacks to providers. That’s spelled S-T-A-R-K and the DMCB advises C-A-U-T-I-O-N.

Meaningful amounts of cold hard cash (this is not time for cheapness; the amounts above rival what docs get from their core FFS business) signals disease management vendors and their managed care partners are demonstrating a credible willingness to bridge the physician-disease management divide. The only problem is that it looks like Medicaid or BCBS is paying. The DMCB advises the disease management organizations to associate their name with the payments - like ACCESS Plus. That’s called G-E-N-E-R-A-T-I-N-G G-O-O-D W-I-L-L .

As is their wont, the Bostonians have kicked things up a notch by going beyond the Ver. 1.0 referral arrangements described above. Instead of cold hard cash for each patient referral, MA BCBS and the unnamed physician group have segmented the population and aimed the right resources at the right people: Healthways gets the ‘low intensity’ patients while the docs get the ‘high intensity.’ Both benefit from increase referrals. S-M-A-R-T

The DMCB suggests this may serve as the initial terms of endearment between the Medical Home and Disease Management. Let the DM vendors/insurers a) PAY the physicians for referrals to their programs as part of the care coordination suite of services and/or b) WORK WITH the Medical Homes to divvy up the market for mutual benefit.

canada reads

The CBC just announced the five books and panelists for this year's Canada Reads competition:

"Canada Reads announced the contenders Tuesday for its annual contest to choose a single book all Canadians would enjoy reading.

The field has five Canadian books, including two debut novels and works by Quebec's Michael Tremblay and New Brunswick's David Adams Richards.

CBC Radio One, host of the Canada Reads series, also announced members of the panel who will defend the five books in an effort to get theirs chosen.

They are:

• TV personality Avi Lewis defending The Book of Negroes by Lawrence Hill.
• Singer Sarah Slean defending Mercy Among the Children by David Adams Richards.
• Actor Nicholas Campbell defending The Outlander by Gil Adamson.
• TV host Anne-Marie Withenshaw defending The Fat Woman Next Door is Pregnant (La grosse femme d'à côté est enceinte ) by Michel Tremblay, translated by Sheila Fischman.
• Author Jen Sookfong Lee defending Fruit by Brian Francis."

I haven't really paid attention to Canada Reads since the first year. This year's list however, contains two of the best books that I have read in 2008 - The Outlander and The Book of Negroes (which I loved so much that I might actually get emotional if someone says anything bad about it. It was published in the US and elsewhere as Someone Knows My Name, something the author had mixed feelings about). This makes me intrigued enough to want to read the others (Mercy Among the Children is the only one I had heard of. It's about a part of the world I know very well and I fear it will depress the hell out of me).

The panelists will make it interesting, too. I like Avi Lewis, and Nicholas Campbell is always entertaining.

I think I need to log onto my library' s web site and place some requests.

Care to join me? Have you read any of these books? What did you think of them?

Consensus on Health Care Reform Means More Than 70 Senate Votes

The Clintons have been criticized for agreeing to allow their 1993 health care reform plan to be subject to the Senate’s 60-vote rule. With the Democrats controlling what will end up to be 59 or 60 votes in the new Congress, some are arguing that the Democrats should move quickly and get their plan passed under the budget rules that would require only a simple majority.Trying to get legislation

Stimulus Spending and Health Care

Last week I was saying we were facing a $1 trillion budget deficit in the current fiscal year and that made health care reform problematic.This week, the operative number is $2 trillion.It was $1 trillion before reports that the President-Elect would be looking at a stimulus bill in the $700 billion range as well as reports his planned income tax cuts are on track and his planned income tax

"Two Girls Two Countries One Cancer"

David Whelan has an interesting article at Forbes.com following two girls through the same serious cancer diagnosis here and in Britain.As David put it, "When stories get specific, as in the cases of Zoe and Ellen, two kids from similar backgrounds with the same disease, the generalities [about the differences in our health care systems] start to break down."

Insights on the Prospects for Healthcare Reform from the DMAA

Today the Disease Management Care Blog heard former U.S. Senator Breaux of Louisiana and former HCFA Administrator Gail Wilensky talk about the prognosis for health care reform.

Senator Breaux belongs to the ‘too much other stuff to do this year and fundamental health care reform is too complicated camp.’ He predicted Congress will go for the low hanging fruit with funding for SCHIP, information technology, comparative effectiveness and physician payment reform. He thinks Obama-esque reform will take two years - at least.

Dr. Wilensky belongs to the ‘I was unable to sleep and had an 'aha!' moment 2 weeks ago’ camp. Her insight was that the public is concerned about one thing and one thing only: health care affordability. In the meantime, policy makers, politicians and wonks are worried about quality, safety, economic sustainability and entitlements. While they correctly note these issues ultimately drive affordability, Dr. Wilensky predicts the public will have little patience for these high falutin concepts and look for understandable solutions that directly lead to lower costs for insurance and/or health care. This mind-set may be the secret weapon for those opposed to health care reform: Harry and Louise aren’t going to fret over loss of choice, but over rising of cost.

While Dr. Wlensky also agreed that quick reform was unlikely, she pointed out that care coordination and disease management were areas that are benefitting from strong bipartisan support. She felt the future was bright for DM industry.

And before the DMCB had a chance to ask her about it during th Q&A, the topic of bundled payments came up. She likes the idea, because 'ala carte,' fragmented fee-for-service Medicare is one of the biggest drivers of increased utilization. Bundling, in her economist point of view, is a good fix.

Last but not least, the topic of an independent national health board came up. As noted in prior DMCB posts, this may be the most controversial feature of the Democratic reform package. Senator Breaux said the idea has legs not because the U.S. Congress enjoys giving up power, but because there is an emerging consensus among his former colleagues that the Congress can no long micromanage the increasingly complicated details of Medicare and Medicaid.

Tomorrow: a plenary session in which leaders from the health insurance industry, disease management and an integrated delivery system will talk about the prospect of closer coordination between the medical home and disease management. Your intrepid DMCB reporter will be there.

Small Business Health Insurance Coverage: A Sobering Report From the Trenches

One of the things I enjoy the most about my travels across the country is meeting benefits brokers and health plan sales reps--they have the best feel for the real market and what their customers and their employees are up against.This very sobering and, from what I independently hear, accurate report about the small group health insurance market comes courtesy of Brian Klepper. Please note the

"are you a writer?"

The guy at the UPS Store asked me this question (I was using UPS to send some photos to my publisher because PSAC members at Canada Post are on strike).

I looked around to see to whom he was speaking.

Then it dawned on me.

"Yes, I am."

Or at least I'm working on believing it.

I've mentioned before that I have been meeting with a coach since last January. Joyce has a Masters in Education and is part therapist and part life coach. She works with lots of struggling artists and writers, many people currently working in the labour movement and several cancer survivors.

I have always made my living with words but this year I pledged to begin to think of myself as a writer. This need for this had become acute as I relinquished the sense of identity I had derived from full-time work and as the struggle to stay alive had (thankfully) moved the back burner.

With Joyce's input and guidance, I established three goals for this year:

I wanted to finish my book. I am proud to say that I accomplished this (although it never seems to be quite done and I am currently reviewing the copy-editing). I could not have done this without Joyce.

I wanted to build links to other younger people with cancer and spread the word that many of us are living long and well with metastatic breast cancer. I feel really good about my contributions to this blog, Mothers With Cancer, BlogHer and MyBreastCancerNetwork.Com. I also attended a wonderful conference, organized by Living Beyond Breast Cancer.

This networking has gone so well that I burned myself out a little. I have taken a step back of late.

My third goal was to write fiction. I started by playing around a little with my "morning pages" (which I don't always write in the morning). I read and did exercises from several great books (Writing Down the Bones, The Artist's Way, Bird by Bird and The Writer's Path).

Joyce suggested that I needed a writing group and it dawned on me that I could start one. I've done that.

Joyce suggested that I should sign up for an online writing course that would give me some progressive assignments to work on. I did some research and registered for one called "I've Always Wanted To Write Fiction." We are in week four and I am up to date on my assignments.

I am not thrilled with what I have produced so far but I am proud that I have done it. My prose still seems stilted and pedestrian but I am putting my toes in the water. Everything I have read tells me that art takes hard work. I may not be Virginia Woolf (or even Sue Grafton) but I can make art for its own sake. And mine.

And as I re-read this blog post, I realize that I have come a long way this year.

Cross-posted to Mothers With Cancer.

my brain is a sieve

I was really looking forward to my book club tonight. I even tweeted about my excitement.

We read Run, by Ann Patchett. I really liked the book but I was especially looking forward to getting out and seeing my friends.

I really wanted a beer with dinner (we were having pizza) but I passed because there is always wine at book club. I even got my spouse to pick up a bottle this afternoon, so that I could contribute.

I gathered up my purse and my knitting. I hadn't organized a ride, so I got ready to call a cab. I looked up the host's email to confirm her address and because I wanted to make sure that I was planning on going to the right house. My memory is not what it once was.

I was right about the house but wrong about the date.

My book club is November 30th.

My kids felt bad for me because I took a shower and put on clean clothes for nothing.

I am sulking telling myself that, next week, I will enjoy myself twice as much for having had to wait.

The Disease Management Care Blog Pauses While on the Way to the DMAA Meeting

In a compelling anecdote from the New England Journal of Medicine, a primary care doctor demonstrates the value of a personal physician by describing how she protected a fiercely independent elderly woman from the best intentions of a family and a health care system that would have otherwise gone amok. Talk to any doc and you’ll hear many stories like this. It’s an honor to be valued guests in other people’s lives at such times.

Here’s a story from the Disease Management Care Blog. Details are changed but the fundamentals are true:

It was the first day of my turn as attending on inpatient general medicine rounds. As usual, my team of residents, interns and medical students started rounds in the intensive care unit. One patient was a truly unfortunate young person who had been permanently injured as a result of a motor vehicle accident. Our duty was to preside over the countless details of care, anticipating that transfer to another hospital would happen in the not too distant future.

And that moment couldn’t come soon enough. Starting each day of rounds in that ICU was awful because the patient was smart, manipulative, angry and, most of all, depressed. The usual professional counseling and medication trials really didn’t have much of an impact on attitude and mood: the morose lack of eye contact some days, blubbering other days, refusals of care at times. Countless questions about details that only led to more circular questions took its toll on everyone. In the middle of it all, I repeatedly turned to my usual stock phrases that encouraged the patient to get through this, that persons learn to live with disability and, with time, this ICU would be a distant memory in a renewed life filled with new possibilities etc. etc. Deep down inside, however, I believed from years of experience that this person had been screwed and that life would suck.

The transfer eventually happened. We filled our days with other disasters until, after three weeks, I exited inpatient rounding and returned to my outpatient clinic.

Years later, after many other inpatient rotations, I was plotting my escape from rounds. Fewer of my physician colleagues were willing to do it, call was more frequent, and the ever increasing numbers of patient admissions was turning into a game of emergency room throughput and decreasing the length of stay filled with more and more patients with incurable chronic illnesses. Should I trump my growing administrative responsibilities? Seek other sources of clinical or research income to prop up my salary? Follow my spouse’s advice and draw a line in the sand? I steeled myself for a showdown with the Chair.

The mail pile of pharmacy reports, updates, memos and meeting notices on my desk beckoned as usual. In the middle of it was a card with a generic cover and a simple cursive hand written note that said: “You were right. I’m feeling much better.” I had to retrieve the medical record to recall the person who had signed it. It was the hopeless patient from the ICU.

I hung in there in inpatient rounds for several more years. I still have that card.

An Adult Conversation About Health Care Reform

Zeke Emanuel and Shannon Brownlee have an op-ed in Sunday’s Washington Post that should be required reading for anyone interested in health care reform.The title is, “5 Myths About Our Ailing Health Care System.”They suggest the “5 Myths” are:America has the best health care in the world.Somebody else is paying for your health insurance.We would save a lot if we could cut the administrative waste

crushing on jamie oliver

I love him for his potatoes.

Last night, I made this.

I am, at best, an indifferent cook. I am working on changing this, as I don't think it's fair for my spouse to do all the cooking. Also, if I want more control over what we eat, I need to contribute.

This week, I made (or helped to make) an unprecedented four meals. Macaroni and cheese (with onions and garlic). Chicken cacciatore in the slow cooker (with bottled tomatoes, onions and garlic). Updated hamburger helper (my friend L. instructed and did all the chopping. I browned the meat and stirred a lot).

So, as you can see, a recipe that requires fresh herbs and boiling the potatoes before they go into the roasting pan is a bit of a departure for me (I roasted my first chicken two years ago. At least three times since then, I have roasted the chicken upside down.)

Last night, I painstakingly followed all instructions. It wasn't that hard. And it worked. The potatoes did not look as golden in as in the photo but they were delicious.

I don't even like potatoes and I had seconds.

And more for breakfast, swooning and moaning all the while.

I kept saying, "I made this!"

I'm still a little stunned. I have never, ever been able to say about anything that I have cooked, "That was the best I ever had." It felt good.

the worst idea ever. or am i just too uptight?

Please help us settle an argument.

My spouse, who grows sprouts in our kitchen, thinks this is a good idea. So does S., my oldest son.

I think it's disgusting. My sprout growing friends (yes, I have sprouting friends) agree with me.

Take a good long look and let me know what you think.

It's a theoretical discussion because, as long as I live in this house, we are not growing sprouts in my toilet.



- More cool how to projects

The Healthy Americans Act--Wyden-Bennett Bill--Still in Play

A recent letter from 15 Senators to President-Elect Obama caught my eye.The letter was from Senators Ron Wyden (D-OR), Bob Bennett (R-UT), and the other 13 Senators on their health care reform bill--7 Democrats 7 Republicans, and one independent--to President-Elect Obama reminding him of the progress this bipartisan group has already made toward health care reform.As readers of this blog know, I

Mr. Daschle and Medicare Health Support

From the savvy Merrill Goozner of the GoozNews blog about Mr. Daschle's likely ascent to head of the U.S. Dept. of Health and Human Services (HHS) (italics mine):

'.... he has the knowledge that will allow him to make his mark in the short run by instituting bold administrative changes at the agencies under his new command, especially the Center for Medicare and Medicaid Services. Changes in the government's two big health care programs, which account for half of all health care spending, can pave the way for changes throughout the system.

For instance, look for him to reinstitute programs like Medicare Health Support, which offered individualized chronic care management to beneficiaries with heart disease and diabetes, but was abruptly canceled by the Bush administration earlier this year. He may experiment with broader pay-for-performance rules for physicians, or tinker with the relative compensation system that pays radiologists and surgeons three times the salary of primary care physicians. Look for an exponential increase in pilot programs at HHS that could set the stage for broad-based reform.'

Eight Reasons Why the Health Insurers Are Agreeing to Community Rating & What It Means to Disease Management

Why would the nation’s health insurers - represented by AHIP and Blue Cross Blue Shield - trade an agreement to submit to community rating (i.e. law that would require them to accept all customers) in exchange for a universal mandate (i.e., law requiring everyone to play in the insurance pool or pay a fine or tax)?

As the Disease Management Care Blog understands it, community rating is an actuarial insurance concept. Recall that the purpose of insurance is to ‘transfer risk.” Party A has the risk (of illness, a crushed car fender or a house fire) and pays Party B to assume that risk during a set period of time (a year) in exchange for some money (a premium). In a regulated insurance market, it’s possible to require that the pricing of the risk for any individual be based on the average risk within a large population within a ‘community’ i.e., region or state. Because the risk (and cost) is spread over a larger pool of individuals, the risk/cost is not only smaller per person but more predictable. In health insurance, the few persons with high risk are balanced by a high number of healthy persons. It’s all smoothed out.

Why would insurers be opposed to such a fair minded system? The problem is that while the average price of a health insurance policy in community rated systems is fairly priced at the ‘macro’ community/regional/state level, that’s not how the policies are bought and sold. Instead, the community is broken up into employer-groups and individuals. Some groups/individuals have high risk and some have low risk. This is spread unevenly over counties or an industry. As a result, insurers have a stake in assessing and pricing risk transfer at the level that it is being bought or sold. This is known as ‘experience rating.’ This is what makes selling insurance to persons pre-existing conditions a money loser – even if it is heart breaking and a public relations nightmare.

Why are insurers willing to abandon the certainty and control of experience rating in favor of community rating? The DMCB has several theories:

1. Insurers are betting (remember, these guys know risk) that the income from all persons being forced by play (buy insurance) - rather than pay an onerous tax - will be greater than any losses from community rating. Margins will be lower but millions more will be buying their product.

2. If health care reform passes, community rating is likely to be included anyway. Might as well try to trade rather than have it imposed.

3. Opposing community rating during heightened national scrutiny over health care only worsens the insurers’ already bad image.

4. Community rating only applies to traditional ‘fully insured’ insurance policies. More and more employers are fleeing to self-insured ERISA-protected plans, which, absent their reform also, are immunized against community rating. In that situation, the employer owns the risk, not the insurance company. However, many health insurance companies still provide ‘back office’ functions such as claims processing, network development etc. for a fee. The point is that traditional experience-rated insurance is shrinking anyway and ERISA plan administrative fees will be unaffected.

5. The economy is taking its toll on health insurers too. Growth in the gross domestic product is likely to remain languid for many years. As a result, there will be more unemployed and part-time uninsured, leading to a decreased head count for the insurers. In addition, income from the insurers’ investments of their reserves and surplus will be down. This will add to the stress on their bottom lines, making alternative business plans even more attractive.

6. And, absent any government intervention, who will be forced to continue to buy experience rated insurance policies in the face of an economic downturn? Persons who really need it. On the other hand, persons who are healthy will drop their insurance. Since only persons with high risk will be continue to buy insurance with a decreasing risk pool, the result will be the classic death sprail.

7. Remember administrative costs? Insurers don’t want lay offs any more than any other company. As head count declines, fixed administrative costs will occupy an even bigger part of the total premium. An insurance mandate could reverse that.

8. Last but not least, community rating and the increased regulation that accompanies it will paradoxically assure their short and long term existence in the face of otherwise stressful market forces. Toss in tax credits and other sources of public financing and they’ll be getting the same kind of taxpayer support – though not as obvious – as the banks.

The DMCB has two long term predictions:

1. Smaller insurers will go out of business or be absorbed into larger insurance companies. Community rating is a game of large risk pools numbered in the millions. Community rating in a 20 county area involving a few hundred thousand people is generally not feasible.

2. Innovative approaches to reducing the impact of risk in community rated plans will appear more attractive. Since insurers will no long be able to 'duck' risk with experience rating, they’ll find approaches like disease management to be an important option in managing their book of business. As an aside, if a competing government program doesn’t have disease management, this may be one way for private insurers to reduce their risk 'burden,' ultimately charge a lower premium and stay in business.

coping with cloudy skies

We have been struggling with temper tantrums around here lately.

When my spouse and I turned to the Internets for advice, we came up with some wildly different, even contradictory advice:

1. We need to institute a "systematic behavior management plan" that includes time-outs. The time out should not start until he is seated and quiet.

If I could get him to be seated and quiet, I wouldn't need a time out.

2. We need to investigate his diet and exposure to allergens. Also, hugs are more effective than time outs:

"Until you find one that works, however, hold your son gently when he falls apart and talk to him softly in a singsong."

When my son is having a tantrum, I can't really get my arms around him and the screaming tends to drown out my gentle crooning.

3. Call the cops and have the kid arrested.

This is what one Florida school did:

"To subdue the unruly kindergartner, school officials phoned Avon Park's police department ("committed to enhancing the 'Quality of Life' of the community"). When the cops arrived, young Desre'e attempted to resist arrest by crawling under a table. But Avon Park's finest pulled her out, cuffed her, put her in a police cruiser, drove her to the county jail, and charged this 50-pound menace with a felony and two misdemeanors."

I think I'll call the doctor, make sure he never gets too hungry, talk to his teachers (they assure me that the tantrums are not occurring at school or day care), reinforce good behaviour and keep hoping that it's just a phase...

Thoughts?

Insurance Industry Reform Proposal––Little Ado About Nothing

This week the health insurance industry trade association announced that its board had approved a new policy position. The industry has agreed to guarantee the insurability of everyone if the nation passes a health insurance plan that requires everyone is covered.That’s a no-brainer for the industry to offer and not much of a deal.If everyone is in the insurance pool—sick and healthy alike—there

If They Build a Medical Home, Will the Docs Come?

Among its many admittedly good qualities, the patient centered medical home (PCMH) has been lauded as the means to resuscitate, re-engineer or revive primary care. The Disease Management Blog asks: assuming the PMCH has plenty of merit by itself, what does it have to do with rescuing primary care?

Simple question, but the answer is more complex. Most reasonable observers agree that primary care is hard work and undervalued. The demoralized physicians leaving primary care are not being replaced in sufficient numbers by medical school graduates, leading to shortages in many areas of the country. While the causes for this are myriad, supporters of the PCMH suggest it can reverse medical student disinterest and help the current cohort of primary care physicians to hang in there.

Will it? In this day of slavish devotion to evidence-based health care, just where is the evidence for this contention? There are no surveys of what rank and file community-based primary care physicians actually think about the medical home. We don't know how well it will address the physicians' lifestyle concerns or their income expectations.

There are plenty of studies on what they believe ails their profession. For example, this study indicates physicians are unhappy about the loss of clinical autonomy, the number of hours they work and their inability to obtain services for their patients. Being responsible for any gatekeeping services is also a dissatisfier, as well as being under pressure to see a minimum number of patients per day. For younger physicians, income is a more distant consideration, compared to personal satisfaction and fulfillment outside of work.

And just what is it about the medical home that will fix these problems? Just because there is a medical home doesn’t mean high cost radiology services will not continue to come under preauthorization, that drug formularies will not put continue to put certain medications out of reach, that restrictive physician networks won't be used or that managed care organizations won’t continue to bluntly prod physicians to achieve HEDIS benchmarks. Keeping patients away from the emergency room or the hospital requires a zealous amount of hustle that goes well beyond the 8-5 business day.

And, as the DMCB understands it, much of the supplemental payment for the extra services of a medical home are calculated to cover the expense of those extra services such as health information technology, staff that manage care management services and the additional physician time necessary to oversee the primary care site team. It's only after these costs are met that physicians are expected to be rewarded. We don't know what their price point is.

The DMCB suspects the support of the rank and file physicians for the medical home is being overestimated. True, there are reports that the PCPCC and TransforMED pilots underway have been enthusiastically received, but this represents a small fraction of the docs out there who may not be representative of the usual mainstream doc. The point is we don’t know how they will react and, without more data, we cannot be sure that if we build the support for the medical home that they will come.

We also need to vigorously look for other solutions to what ails primary care outside of the unproven assumptions surrounding the PCMH.

Daschle for HHS?

Word around town is that Tom Daschle, the former Democratic Senate Majority Leader, is going to be named HHS Secretary.That would mean that President-Elect Obama is going with a political and health care policy heavyweight.With word yesterday that Senator Kennedy has appointed Hillary Clinton (presuming she stays in the Senate) to take the lead on the health insurance reform portion of his health

it's come to this

This is now a 'cute kids and animals' blog.

I have a very good friend in town for a couple of days. We are hanging out.

Regular programming will no doubt resume post-visit.

Here Comes Ted Kennedy! Implications for Disease Management

Here comes Ted Kennedy (D – Massachusetts) and he's looking remarkably trim and energetic. Details on his health care reform legislation are not being reported in the media, but it's clear that he’s getting ready to unveil something that will be ultimately aimed at universal coverage.

You may recall that Mr. Kennedy was one of four Senators who wrote to CMS Administrator Kerry Weems about continuing the Medicare Health Support initiative. Will he continue this support when his legislation is introduced? The ever optimistic and naive Disease Management Care Blog hopes the answer will be yes, because.....

1. There are few patient friendly interventions out there that have any hope of blunting health care cost inflation. Disease management is one of them. (Looking at this contrarian post and scrolling down to November 13 may make you think that the EHR is not necessarily a cost savings slam dunk either)

2. Disease management - either as a carve-in or a carve-out - is embedded in most commercial insurance plans. Why not build on their optimism about the value of this approach?

3. Widespread support for the unproven medical home is not incompatible with support for disease management. In fact, this is a chance to craft language that recognizes their complementary nature and supports innovative insurance benefit designs that capitalizes on the value of both. This is a theme in the Baucus Plan.

4. Legislation aimed at major health overhaul could use all the help it can get, which means inclusivity rather than exclusivity. A big multi-dimensional problem requires a big multi-dimensional approach with the support of a host of stakeholders.

5. President Elect Barack Obama has voiced support for disease management. His HHS Transition includes the anti-tobacco and primary care center-experienced William V. Corr and former SGIMite (they are smart people) Nicole Lurie, who, by the way, has written about disease management and is familiar with the good:

'While numerous studies described such interventions, we found only 45 studies that formally evaluated their effect and only six that contained any information on the cost of the intervention or the savings it achieved relative to the no-intervention baseline. All six of these studies, all
on disease management for asthma, found the interventions to be cost effective. One intervention that provided 60- to 90-minute, one-on-one educational sessions was even found to have produced annual net savings of almost $2,000 per patient.'

and the not so good:

'However, a recent RAND review of the effectiveness of disease management interventions found no conclusive evidence that disease management for asthma can reduce direct medical costs. To summarize, we found insufficient evidence to try to answer our questions on the cost of reducing the gap in quality and the return on investment for programs that attempt to close the gap.'

6. A major highly regarded disease management organization is headquartered in Massachusetts.

The DMCB looks forward to learning about the Kennedy approach in the not to distant future. By the way, considering the news coming out of Tennessee, it suspects Healthways hopes inclusive reform is put on a fast track: time may be running out.

Health Care Reform a "Longer Term Goal" For the Obama Administration?

Under the headline in today's Washington Post, "Kennedy Announces Plan to Submit Bill For Universal Care" was this:"Some Democrats, including members of President-elect Barack Obama's circle, have begun to view expanded [health care] coverage as a longer-term goal."Is the new administration trying to send a message to its health care eager constituencies that given the economy and all of the

feeling nostalgic already

This was taken just a few weeks ago. The leaves are mostly gone now and winter is in the air.

"The Changes We Need"

The Changes We Needby Brian KlepperThese are, as the Chinese curse reputedly called them, interesting times.If the burst of new Democratic health care reform proposals is any indication, the fresh breeze of the Obama campaign's "Yes We Can" optimism is blowing across the nation. Mr. Obama’s team is expected to make health care one of its priorities. First out, though, was Senate Finance Committee

Reasons to go the DMAA Forum 08

The Annual DMAA confab is less than a week away. In addition to hearing the latest in population management, seeing old friends and making new ones and enhancing your professional development, here's another reason to go, straight from the DMAA eNews:

'There will be a keynote panel Nov. 25 at featuring four thought leaders for an informative discussion of approaches to integrating population health improvement into the patient-centered medical home. This special presentation will feature representatives of organizations delivering solutions in collaboration with primary care practices. Panelists will explore the successful fit of population-based strategies in the medical home from the perspectives of health plans, Medicaid programs, disease management organizations and integrated delivery systems.

Panelists for the morning presentation include:

* Ricardo Guggenheim, MD, McKesson Health Solutions
* Lisa M. Latts, MD, MSPH, MBA, FACP, WellPoint Inc.
* Paul J. Wallace, MD, Kaiser Permanente

Former DMAA Board member and population health expert Jaan Sidorov, MD, will moderate the discussion. Dr. Sidorov writes the popular Disease Management Care Blog and speaks nationally and internationally on health services research, disease management and managed care insurance.

"This is without question a must-attend presentation," DMAA President and CEO Tracey Moorhead said. "These are exceptional speakers who will provide Forum attendees invaluable insights into the synergy between the medical home and population health."'

The self promoting DMCB does not disagree with Ms. Moorhead. The overlap between the medical home and disease management is a critically important topic and Dr. Sidorov intends to squeeze each of the panelists for every insight they can muster.

By the way, there are plenty of other reasons to go, according to the latest issue of the Population Health Management Journal, including:

Hearing about transparency from the very famous Elizabeth McGlynn PhD and David Wennberg MD. Reminder: Dr. McGlynn wrote that article in the New England Journal of Medicine on how the health care system fails to deliver basic quality. The DMCB thinks that if she talks, it should listen.

Learning from Elain Mischler MD about the DMAA's market survey on what the real wold thinks about disease management and wellness.

The role of pay for performance in Medicaid disease management, thanks to James Bush MD of Wyoming and David Kelley MD of Pennsylvania.

The juicy details behind LifeMasters' program for dual eligibles in Florida, straight from Linda Mango of CMS and Christobel Selecky, former DMAA Prez.

Health promotion and disease prevention guru Vic Stretcher MD will be talking about the return on investment of an interesting program in Hawaii. Vic's methodology is worth learning about because it has widespread credibility.

The ever actuarial Ian Duncan will discuss the more sublime aspects of wellness program evalution using risk factor change. Have things gotten to the point where there is no room for amateurs? This is your chance to find out.

Sue Jennings PhD will update us about the latest update in the DMAA outcomes methodology. This is worth the price of admission because that's the process that you can use to tell your CFO whether your program saved any money. Ignore this at your own peril.

Jefferson's Neil Goldfarb MD will update us on what the medical literature tells us, and doesn't tell us, about obesity management. When you return home, you'll be able to quote from this session and amaze your friends and silence your naysayers.

David Brumley MD and partner in crime Sarah Sampsel will tell us what a major New England insurer is doing to improve obesity assessment and treatment. Dr. Brumley has a two-fer, because he'll also be talking about the real world support of the Medical Home.

The very strategic Vince Kuraitis will challenge us about being leaders or laggards in the march toward data interoperability. This is the IT glue that will bind disease management to the rest of the world.

There will be plenty of other excellent sessions that are too numerous to mention here.

writing

This was actually taken on chemo day but it kind of sums up what I feel like doing. Note the bed, the book and the laptop. The only thing missing is a great big chocolate bar.

And yes, that is the world's meanest cat, all cuddled up with me. Don't be fooled by appearances. One false move and he'd slit my throat.

I've actually been doing some non-blog writing today, so not much left over for this space. Please bear with me. There will be a more substantial post one these days, I promise.

Medicare Advantage Payments to Insurers--Baucus Zeroing In!

Senate Finance Chair Max Baucus (D-MT) released his health plan white paper last week.Buried in it was this regarding how private Medicare payments to HMOs should be changed:“Congress must act to level the playing field between traditional Medicare and Medicare Advantage payments and the Baucus plan would do so. Enacted in July 2008, MIPPA [the July physician fee fix that will end PFFS] took

A Round Up of Baucus Plan Commentary - Part 3

The Disease Management Care Blog compared the Baucus Blueprint to its own Principles for Reform. Maybe Senator Baucus didn't read them when they were first posted, but the DMCB suspects the Senator and/or his staff used much of the same underlying logic. There's the overlapping approach chronic illness care, ramping up primary care payments outside the RUC, bundled payments and recognition of the worksite, schools and community as the best locus for wellness, prevention and obesity care.

The DMCB believes the Baucus plan at this time is just a functional stalking horse. That being said, it yields up some interesting insights into the thinking of a leading US Senator, which is probably shared by many of his colleagues; think of this as some important market intelligence.

The two biggest issues for the DMCB?

1) While forcing more persons into the risk pools will lower the average health insurance premium (the same amount of insurance risk is being spread over more persons), as it stands now, it has little hope of controlling health care costs, and

2) The proposed Independent Health Coverage Council is a huge grab of power away from the States and the market.

The DMCB hasn't seen any reaction from the Republicans, but if this proposal gets any legs, it expects the wily Mitch McConnell to raise questions about the affordability and the Council. Let the games begin.

In the meantime, in addition to thinking about it's own blog, the DMCB likes to scan the other postings out there to see what they say. This is another version of market intelligence and it found some interesting stuff:

The 'insiders' line up over at the National Journal Expert Health Care Blog, including conservative John Goodman of the National Center for Policy Analysis (“a rehash… a start”), Len Nichols of the New America Foundation (it takes many paragraphs for him to say he likes this, and lots), Nancy Nielsen of the AMA (they look forward to ‘working with’ Mr. Baucus, like, er, they have any choice), Karen Davis of the Commonwealth Fund (she endorses the ‘building block’ approach and thankfully spares the reader from mentioning how swell healthcare is in Denmark), Ed Howard of the Alliance for Health Reform (is saying the Baucus plan is 'thoughtful, comprehensive and coherent' code for supportive or non-supportive inside the beltway?) Rich Umbdenstock of the American Hospital Association (‘good ideas,’ he says, but the DMCB thinks they'' ultimately like the notion of getting out of the business of charity care), Ted Kennedy (lauds the 'bipartisan' potential - uh huh, sure) and Henry Aaron of the Brookings Institution (he likes the Connector). The DMCB likes quoting all of this and giving the reader that he’s familiar with all these brainy think tanks.

The asute Robert Laszewski notes the proposal lacks detail on a) the size or source of the premium subsidies, b) controlling health care cost inflation, c) getting buy in from the specialist physicians who would be affected by a re-tooling of the Sustainable Growth Formula or d) finding the money to pay for this beast.

For an example of the intricacies of twiddling the knobs on the impossibly complex tax code to change human behavior, see this over at the Wonk Room. Tools of this trade include excluding premiums, income sliding scales, deductions, marginal rates, subsidies and exemptions.

As mentioned in a prior post, the health insurers AHIP and Blue Cross and Blue Shield issued short terse statements. They're still thinking this over.

How about the DMAA? Well, funny you should ask. No statement from them. Ditto the Patient Centered Primary Care Collaborative.

The American College of Physicians Blog (internists are primary care docs that treat adults) asks about the politics of taking money from other specialists and mentions the luster of a sustainable growth rate fix. The KevinMD blog (also from an internist) likes what he reads ("almost sounds like something I could have written") and curiously echos the question about the cooperation of the specialists. The DMCB asks if the internists are spoiling for a public fight inside the House of Medicine as a means to engage their otherwise busy membership?

There's also no underestimating the physicians' distrust of the RUC committee. Medrants likes the Baucus plan proposal to move decisions about primary care reimbursement out from the under the RVS process.

The Liberals you ask......?

Nobel Prize winning liberal Paul Krugman hopes that Obama will agree that the means justify the end in “do[ing] the right thing” and break the campaign promises he made about not supporting mandates. Keeping your word is apparently optional for the conscience of a liberal.

Maggie Mahar savors each morsel in the Baucus plan in delicious detail for the sweet and the bitter and finds it an ultimately tasty but vague dish. Her biggest fear is that this will lead to legislation that resembles the U.S. version of Chinese food: tasty but unfilling.

Folks over at the California-esque Health Access Weblog imply the Executive branch's President Elect Obama should welcome help from the Legislative branch's Senator Baucus. They also distrust the inclusion of any individual mandate in a health care plan, thinking it's better to make one big risk pool. Curiously, they include the failed California Schwarzenegger – Nunez template as some sort of example of how things can go well.

The Physicians for a National Health Program are also uncomfortable with anything less than one big risk pool. Otherwise, if Senator Baucus' position takes us closer to a single payor system, they're for it.

And if you're from Massachusetts and involved with their Health Connector, you gotta like it when the Feds believe in your idea.

Finally, what's liberalism and blogging without Ezra Klein? He points out that it looks like Mr. Baucus is throwing some elbows to establish court dominance under the health care reform basket. He also provides a solid outline of the Senator's proposal and summarizes the principles, including the mantra of if you (are crazy enough to) like your (overpriced for profit) plan you won’t have to change (yet). In addition, the proposed Health Coverage Council would make most of the hard decisions (for you). Interestingly he predicts the Wyden plan is “dead in the water”

How about the Conservatives.....?

The DMCB has just learned Clay Aiken is gay? John Edwards is trying to make a political come-back? Diane Sawyer believes Elliott Spitzer's prostitute is a newsworthy interview? On top of all that shocking ... SHOCKING news, the über right Health Care BS blog (which is curiously never mentioned by the New York Times or Kaiser’s weekly blog round up) decries the Baucus bureaucrats and their dysfunctional price ceilings. He suggests docs oughta be allowed to charge what they damn well please.

The home of the father of health savings accounts isn't THAT far behind and predictably decries narrowing choice, unaffordability and growing government interference.

And to continue this conservative theme, CATO points to far darker implications of the Bauchus proposal for the Republican right. Man the barricades! This is not health care, this is a plot that will win over portions of the South and the West into the Democratic camp with a new public program that promises and improvement of the social safety net.

lest we forget (part two)

My spouse and my ten year old son are reading Maus together right now. So, so hard.

I am glad S. wants to learn this but so sad he has to learn how cruel people can be.

S.: "So they were just allowed to shoot Jews for fun?"

T.: "Jews were not considered human."

S.: "They were treated like vermin."

S. and T. together: "Like mice."

T.: "Not all the Germans felt this way but when your government and all the news and your neighbours are all telling you one thing...People get swept up."

So hard.

not missing a day

Market Capitalism and Health Care--It Will Never Be the Same

Washington Post business page columnist Steven Pearlstein's Friday column, "Toward a New International Capitalism," caught my eye.Here's a snippet:"From the Latin American debt crisis of the 1980s to the Asian financial crisis of the 1990s to the Internet craze at the turn of the century to today's economic conflagration, the past 20 years have provided ample evidence that uncontrolled flows of

what he said

"I think we are asking the questions that will get us funded, not the questions that that will solve the problem."

- Lovell A. Jones, PhD, MD Anderson Cancer Center

(This was part of the closing key note to News You Can Use, organized by Living Beyond Breast Cancer. The conference was excellent but this last session, entitled "Helping Promote A More Equal Approach to Health Care", just blew me away.)

To the Congressional Budget Office: Please Keep Playing it Straight!

I guess this is an open letter to CBO Director Peter Orszag and his colleagues at the Congressional Budget Office (CBO).I have great respect for the CBO and that has been the case under different majorities--Democratic and Republican. Never more than now.The CBO is intended to be non-partisan and objective. They provide the information and estimates the Congress needs to complete the budget

The Baucus Blueprint for a Call to Action for Healthcare Reform, Part 2

How about chronic illness? Even if the Senator Baucus' Call to Action never sees the light of day, this document gives some useful insight on a prevailing attitude in Congress. In this post, the Disease Management Care Blog pays special attention to the Baucus Blueprint (BB) chronic illness recommendations. No reproduced quotes here about the growing prevalence of disease, stubbornly poor quality and unsustainable costs. DMCB readers already know that stuff and want the bottom lines:

Hanging by a thread but there’s hope: This is rather important, so the DMCB pulled this quote verbatim (italics added): ‘Vendor-based disease management programs, which typically involve phone-based care planning and follow-up by nurses, have found some success in the private market but have not fared as well in recent Medicare demonstrations. While these approaches should not be jettisoned without consideration of new evidence from state and private payer programs, it remains an open question whether Medicare should make direct payments to vendors outside of a comprehensive care management model, such as the medical home.'

To the DMCB this means that under the BB, 1) all insurers except Medicare are free to include disease management (DM) in the benefit if that's what they prefer, 2) there is still time to pursue new evidence about what works and what doesn't, and 3) there is less support for traditional 'stand-alone DM' versus an integrated approach that uses DM as part of a broader care management care system.

Medical Homes remain the darling, but ‘require ongoing evaluation: The BB describes the medical home is described as a 'work in progress' and expansion will require 'ongoing evaluation.' An interesting twist is that the measures have to be meaningful to consumers, not academics, editors, the NCQA, economists, policy makers, partisans, advocacy groups, physicians or politicians. Can the Medical Home consistently bend the trend and reduce claims expense? Until it succeeds where DM has not, the BB urges that coverage not be automatic.

Bundled payments! That's right, the BB mentions 'episode groupers.' In fact, it states Medicare should develop its own 'open-source technology platform' that includes information on both episodes of care and per-capita resource use. This will presumably help ensure that episodes of care are both necessary and efficient. What isn’t mentioned is how this is a first step on the inevitable road to bundled payment. By the way, the DMCB adds, this will also pave the way for no-pay for inpatient readmissions, because they’ll be rolled into the global payment.

And bundle the providers too: The BB praises the assembly of providers into 'Accountable Care Organizations' such as hospitals that employ their own physician staff, academic medical centers and their affiliated faculty practices, multispecialty group practices, physician hospital networks or independent practice associations, and primary care physician groups able to identify the other providers from whom their beneficiaries receive their care. It suggests there should be an ACO pilot in communities and regions where meaningful integration does not yet exist — such as in rural areas and small group practices.

If you don’t measure it, it doesn’t happen: The Blueprint would give the Independent Health Coverage Council described in the prior Part 1 post the ability to set standards for chronic care management and quality reporting. Insurers would be responsible for collecting and reporting the performance of providers in their networks. Presumably, patients would make better decisions about their own care.

Value-based insurance benefit: Out of pocket expenses for recommended preventive services will be dropped.

‘Studies’ and ‘Demos’ remain a fav: The BB asks for a ‘study’ to identify the various federal programs that can help prevent the development of chronic disease and suggests options to more effectively coordinate efforts going forward. There are lots of the standard goodies such as “demonstrations’ for obesity, and grants to nudge local governments, employers, schools, health care systems, communities and individuals to work together and support healthy lifestyles.

And the DMCB offers closing thought about the physicians. As Governor Rendell is discovering in Pennsylvania, if you're going to change the system, it sure helps to have the physicians on your side. The BB has two features going for it: 1) the support of primary care physicians who believe anything is better than the status quo, especially if they get paid for the medical home, and 2) a promise of permanently repairing the Sustainable Growth Rate formula used to threaten all physicians with deep fee schedule cuts.