happy new year

May 2010 bring us all peace, joy and inspiration.

A Review of the Disease Management Blog's Predictions for 2009: How Did It Do?

The Disease Management Care Blog is not above the blogosphere's emerging tradition of marking the end of an annum with bloggy predictions. Unlike many other corners of the blogmos however, the DMCB is also willing to publicly review its earlier predictions and conduct a blogopsy. Just how did the DMCB do, or rather, how much did the DMCB readers benefit from it's blognostications?

Here's the post. In it, the hopefully prescient DMCB said:

The death of the Disease Management Business Model will turn out to be greatly exaggerated.

The DMCB sure got that right. All of the big disease management organizations, save one, are still standing and, for example, looking healthy. The one bankruptcy was not due to any market forces but rather, some strange dysfunction of the Federal government. Who could have predicted that? Lesson learned.

The first reports from the multiple insurer sponsored pilots on the patient centered medical home (PCMH) will be a mix of reality-checking reports that show modest gains in quality and disappointing lack of savings, failures, lack of uptake among many of the non-entrepreneurial primary care sites.

Once again, the DMCB got it right with its doubts over the business case of the current generation of the Ver 1.0 PCMH. There are reports of quality gains, but no proof of savings and no spontaneous uptake outside of money-sweetened pilots or collaboratives, especially among small physician owned practices. In fact, the DMCB wonders if the lack of any peer-reviewed publications showing definitive savings doesn't mean the research is pending, but that the studies are negative and subject to publication bias.

The rise of Disease Management Lite (defined by the DMCB as any remote intervention that doesn’t principally rely on expensive nurses).

Well, while the DMCB predicted a groundswell, this particular trend turned out to be more of a wavelet. However, the future for this still looks bright. For example, iPhone aps.

The Medicare Medical Home Demonstration will lumber along.

The DMCB was too generous. While others expected great things, it lumbered along, alright.... right into a corner where it curled up and died.

Blogs will become even more important in the shaping of health care policy.

What better example than the President having a phone conference involving the big liberal bloggers to whip up support for health reform?

Early reports of health care reform will be tempered by vexing unhappiness over lack of progress for the middle class. Testy impatience will drive a political/policy mandate to include all that looks good, including disease management (and electronic health records).

The DMCB says bingo! Unfortunately, this was powered by the economy unpredictably tanking and allowing too many in the middle class to lose their employer-based insurance. The rest of us have come to realize how close we were to having to personally pay $1500 a month for insufficient health insurance. What the DMCB missed was how subsequent reform would include all that looks good, fair or resembling a kitchen sink in demos and pilots.

Lacking any credible short term fixes, primary care shortages will spike.

Well, it didn't quite spike, but interest in the topic certainly did. Folks have come to realize that health insurance reform won't help access to primary care.

Not 100% accurate, but pretty good. The DMCB takes a lesson from the President and awards itself a B plus.

Next posting: the DMCB's predictions for 2010.

In the meantime, here's wishing you a Happy and Healthy New Year.

The Last Cavalcade of Risk for This Decade.

Welcome, Cavalcade of Risk readers, to the Disease Management Care Blog. It's dedicated to addressing the medical and financial dimensions of health care for populations. That can include care management approaches for groups of persons with chronic illness (like diabetes or high cholesterol), as well as the merits of wellness and prevention. It also likes to write about managing their risks, with a special focus on financing, economics, health insurance and value.

It is the DMCB's pleasure to host the latest Cavalcade. Not only is this 'Cav' the last one of this decade, this week marks two full years that the DMCB has been in existence with posts every work day 52 weeks a year. What better way to celebrate this achievement?

Like other Cavalcades, this is a summary of the better blog postings that focus on risk. Submissions were invited and many other gems were discovered. As usual, they will not disappoint. While the DMCB generally favors health-related postings, it and its readers will get to delight in the related topics of enterprise risk management, banking, checking, life as well as homeowner's insurance, starting a business and asset management

So, onto the Decade's Last Cavalcade of Risk.....

Risk In Health Care

Louise at the Colorado Health Insurance Insider teaches us about the risk of not keeping several months' worth of liquid cash on hand. Pricey emergencies can crop up anytime, and if it's a medical situation, dead presidents can fly out the door faster than Ms. Napolitano can say 'the system worked!' One risk-mitigating way to handle that is with a tax-sheltered health savings account (HSA). Learn all about it thanks to Louise's very smartly written summary here.

Jason Shafrin of the Healthcare Economist provocatively examines this article on European-style health care. While many of my academic colleagues would argue that we'd really all be better off if we all wore berets and drove motor scooters to our doctor appointments, Jason asks if European-style health care really deserves such accolades? In this well written and compact post, we find out that social insurance doesn't necessarily translate to uniform doctor wait times across all socioeconomic classes. Jason offers up some explanations that wouldn't necessarily come to mind. They include spillovers, the impact of political donations, 'tiebout sorting,' personal connections, complaint thresholds and bribes. He asks for others and the DMCB offers up this one: lacking the appropriate incentives, physicians prefer to see persons with fewer healthcare problems earlier in their course, which is more likely in socioeconomically advantaged groups. You may want to add your thoughts to his excellent post.

Brains are very important. In fact, to paraphrase Woody Allen, it's the DMCB's second favorite organ. So minimizing the risk of brain damage is important. In this post, Ed Kent recounts his personal experiences to compare and contrast rugby and football. While he speculates about the merits of any outright ban of trauma-prone sports, the brainy DMCB points out that, when it comes to pro football, the topic may need more research. What's more, there is no evidence of short-term problems from concussions in high school and university sports settings, and the risk of long term problems appears to be significantly influenced by the testing that is used as well as age and gender. One thing however - assuming there is a link to brain damage - becomes clearer: if politics, as former President Clinton remarked, truly is a contact sport, we may finally have an explanation for Congress' approach to health reform.

Have you, do you or will you deal with impulsive, oppositional, secretive, lying, brutish, moody and risk-taking adolescents? The DMCB has, bears the scars to prove it and is proud that three of them made it to adulthood alive. If your standards are higher, however, you may want to adopt more modern approaches like 'responsible worry,' thanks to this online Psychology Today article aptly titled Risk Prevention in Adolescence by Ph.D Carl Pickardt. Note to our political class: this post may help you better deal with the impulsive, oppositional, secretive, lying, brutish and moody nutjobs at the fringes of our Republican and Democratic parties.

Risk Management

Like Top Ten Lists about as much as the folks over at America's Health Insurance Plans like Ms. Pelosi? You may change your mind after reading Nancy Germond's superb Top Ten Risk Management Lessons and Trends from 2009 posted over at AllBusiness. Like social networking run amok at your work site, buying 'cyber' insurance, workforce 'knowledge gap mapping,' OSHA, State government outsourcing, one-person entrepreneurs snapping at your heels, the potential melt-down of worker's comp insurance, the interplay of health insurance frequency and severity, grumpy suit-prone employees and a new form of insurance coverage made necessary by libidinal golfers. Take notes and bring even one topic up at your next leadership meeting: you will sound very smart.

Banking

Jason at BankShout knows all about the risks of banking, like letting your checking account be overdrawn and being socked with those $15-$30 overdraft fees. Read it if you want to learn some of the basics that that Mr. Geithner et al may want to also think about, like keeping a register, buying overdraft insurance, linking to a savings account and keeping your debit card usage to a minimum. The DMCB wonders why another option wasn't mentioned: get married to a tightfisted spouse.

Of course, if that fails, just join the folks 'from all walks of life' by closing that bum account and opening up another one at one of the 20% of banks that don't subscribe to 'ChexSystems,' says Nicole over at the appropriately named blog Banks that Do Not Use Chexsystems. This particular blog is festooned with links to said banks, so the DMCB says caveat emptor. However, it's an interesting concept that you may want to read about even more, like here or maybe here. The DMCB wonders if the Chinese know which banks are being used by Uncle Sam for his checks.....

Insights About Other Forms of Insurance

Denise Mancini-Blonda over at GoodFinancial¢ents goes over the risks of dying and walks us through the basics of life insurance. Like insuring for (yikes) ten to twenty times your annual income to make sure you can cover all your debts and expenses for the foreseeable future. The citizen DMCB calculates that if U.S. government keeps it up, its policy would have to be, like, for a gazillion dollars. Good thing our Treasury access to money printing presses.

Speaking of life insurance, Henry Stern over at the InsureBlog discusses how that industry's actuaries may already be calculating the risks associated with the unintended consequences of possible rationing, an increased emphasis on end-of-life-care and a slow-down in medical innovations. Insert a ? in the right place, and could there be a con(?)spiracy afoot? Yo?u be the judge!

And how about home owner's insurance? Check out another Top Ten List of Do's and Don'ts from the 'Silicon Valley' inspired/located Digerati Life, like comparing quotes, maintaining good credit, thinking about coverage levels, toggling the deductible, pondering replacement versus cash values, obtaining discounts, not claiming everything and being aware of a concept called 'insurance standing.' OK, OK, so you're tempted to gloss over this particular entry? Think again, because there are some extraordinary photos of a homeowner's dream being literally smushed by a heavy crane. This makes the DMCB think about the merits of renting, which by the way, despite Federal policy, may not be a bad idea.

Small and Large Business Risk

Then there is the risk of starting your own business. Think that spending big up front will pay dividends with fat contracts and huge cash flows? Think again says The Shark Investor, who offers up some advice about staying small with no office, no employees, no company, no provider fees and no bills by following the adage of borrow when you can, share when can't borrow, rent when you can't share and own only when you absolutely have to. The DMCB agrees with the Shark's logical frugality, which, by the way, also amply demonstrates why blogging is so financially rewarding.

By the way, starting up includes another aspect of entrepreneurial risk that can be managed with a business plan? The Biz-learner has scoured many many sites and found many many resources to help you create one.

Cost control: check. Business plan: check. Business takes off. You'll eventually need to develop policies, along with the people to write those policies, manuals that store those policies, supervisors to enforce those policies and lawyers to review those policies. There is a risk that it could all come to naught, however, for the misstep of not following those policies. The DMCB says good thing there is someone blogging about workplace policies at Lauren Bloom's Blog. Her advice: follow your own rules or change them or expect to be embarrassed and financially beat up in court.

Cost control: check. Business plan: check. Policies in place and followed: check. Business takes off: check. Now you have to deal with all that complicated cash flow, taxes, capital needs, deductions and wot not. It should be obvious that you're going to need an army of accountants who are familiar with the stuff that other accountants are blogging about. Good thing there is a list of all accounting bloggery at Top Fifty Accounting Blogs.

One question you're going to want to eventually ask your accountant (who thanks you for those fees that allow the free time to also blog) about is whether you should park your bundles of cash in Gold ETFs as an additional investment hedge. You can read about that and more at Michael Johnston's The Definitive Guide To Inverse Gold ETF Investing.

Alternatively, you can invest in rental properties in the United Kingdom and fret about the Brits' approach to taxation. Not to worry, TaxFix has this posting titled Tax Return Tips for Landlords. like maxing your deductions, taking advantage of offsets, keeping good records, renting out just a room and managing your capital gains.

An Insider's Take on the Sausage Making of Health Reform

One of the reasons the Disease Management Care Blog is a blog is because that makes it read other blogs. And this particular piece from the Health Affairs blog is worth a look. Written by Stuart Butler of the Heritage Foundation, it gives a veteran insider's perspective on just what's happened in health reform. Whether or not you agree with the conservative politics, Mr. Butler's post offers up some insights you won't see elsewhere:

By the way... U.S. health care is larger than the entire economies of Britain or France. The likelihood that the final bill will even partially match its supporters' coming praises is quite remote.

Did the Obama Administration slyly 'lead from behind' when it came to health reform? While you may want to believe that Ms. DeParle et al were acting behind the scenes to fashion a grand Democratic achievement, think again. All those White House confabs were for show. The Senate and House were for dough.

The single payor zombie lives. Expect its supporters to respond to the demise of the public option by surreptitiously inserting shadowy language in the House-Senate Reconciliation that increases the chance of single payor happening in the coming years. However, expect years of budget deficits to get in the way. Let the games continue.

Ah, you Republicans, tsk tsk. The GOP calculated that there was no political advantage in either cooperating or, more importantly, offering up meaningful compromises. That more or less forced the Democrats - including Mr. Obama - to become partisan. Perhaps the Republicans wanted to avoid a Clintonesque co-opting of their ideas. Ironically speaking of which, if the Republicans had had a legislative majority, they may have been more willing to deal. My liberal friends, be careful what you wish for.....

No wonder the Democrats were in such a rush: While the White House managed to keep the health industry players from poisoning things with attack ads, the slow pace of the legislative process allowed Americans' natural inclination toward skepticism to grow. In the coming years, this may hamper other initiatives outside of health care and diminish their chances of holding onto large majorities in both houses of Congress.

Image from Wikipedia

Mandate a Medical Loss Ratio. Close a Disease Management Care Program or Patient Centered Medical Home Support. How It Could Happen

Develop a wellness program that saves money: close the program. Deliver disease management and reduce costs: close that program too. Develop support for a network of patient centered medical homes and watch your insurance claims drop: close it - gone!

How can that be, you ask?

Read on.

In a prior post, the Disease Management Care Blog reviewed a section of the U.S. Senate's health reform bill (the actual language is on page 9) dealing with the 'medical loss ratio' (MLR). In a fit of populism, the World's Most Deliberative Body has proposed a mandate that required commercial insurers 'rebate' any excess profitability - defined as (depending on the type of insurance) having an MLR that is below 80% to 85%. If that survives the House-Senate Conference, it will become the law of the land.

Recall the MLR is a fraction made up of the a) the amount of money spent on medical services on top (or the numerator) and the b) the total amount of money collected in the form of payments for the insurance or 'premium' on the bottom (or the denominator). By mandating a MLR of 80% to 85%, the Senate is saying insurers must spend at least 80 to 85 cents of every dollar they collect on medical care. That means they get to 'keep' the other 20 to 15 cents. That leftover is used to pay for administrative expenses and to generate a profit.

At first glance, a large MLR suggests that a large fraction of the total premium is being spent on medical services. If 90 cents of every dollar is being spent on doctors and hospitals, that sounds good, since only 10 cents is being spent elsewhere, right? Alternatively, however, if only 75 cents out of every dollar is being spent for medical care, that suggests that 25 cents not going to the patients. 'Bad,' you say?

To our expert political elite on an anti-health insurer bender, a low MLR may sound like the work of the Devil's spawn, but the sophisticated readers of the DMCB know that health care can be far more complicated. It's not necessarily bad for health insurers to also spend money on other 'stuff' (for some examples here, here and then there's this) and it's not necessarily good for insurers to pay for all the stuff that doctors and hospitals want, do or sell (for some interesting reports and telling examples, look here, here, here, here, here, and here)

But it can get even more twisted. As pointed out previously, the language in the Senate's Manager's Amendment identifies the National Association of Insurance Commissioners (NAIC) as the body that defines exactly how a MLR is calculated. While the DMCB suggested in its prior post that the NAIC is up to the task, the one thing that the NAIC has not done well is to clarify if the costs of wellness, prevention, care management or PCMH support programs are costs that are assigned to the medical costs that make up the MLR or if they are administrative costs.

In addition, if an insurer is lucky enough to have a low MLR, that doesn't necessarily mean that there is unused money sitting in a bank somewhere. As noted previously, the proposed legislation doesn't recognize the role of the surplus in a) acting as a cushion against unforeseen losses or b) enabling an insurance company to grow. As a result, if there is any rebating to be done, insurers are more likely to have to decide if they want to rebate some of their surplus or cut their administrative costs. The DMCB thinks it's easier for insurers to cut administrative costs. If medical costs go down by (for example) 10%, the easiest way to meet a MLR ratio is to also decrease the other costs by a matching amount.

Worst case scenario? If a care management program is successful in reducing health care costs - there are fewer hospitalizations, emergency room visits and encounters with specialist physicians - the MLR will decrease. Insurers have to decide if administration or other 'non-medical' costs can be cut to make the MLR go up. Those cuts could include the very care management programs that contribute to the low MLR in the first place.

The DMCB has been down this road. Not too long ago, a customer realized its administrative costs had grown out of proportion to its medical costs. There were dozens of care management nurses on the payroll, and they were targeted in an effort to trim costs. While the DMCB was able to talk the CFO out of that move, it doubts any logic will stand up to the potentially arbitrary and capricious language currently in the U.S. Senate Manager's Amendment.

That needs to be changed. Hopefully, the Conference process will address it.

Two other points:

1) It bears repeating: as far as the DMCB can tell, the language defining a 'proper' MLR was inserted into the Manager's Amendment at the last minute, without being vetted in the usual fashion in open committee with adequate discussion from all interested stakeholders. Uh, exsqueeze me, have we thought this through?

2) This could lead to what George Will described (and the DMCB is paraphrasing) as the Latin Americanization of U.S law and regulations, where more laws and regulations are needed to make up for the unintended consequences of hopelessly complex and poorly thought out laws and regulations.

A Holiday Reminder

Whatever you may think of Washington DC's road to health reform, the Fat Lady reminds us that we need to put things into perspective. Recall the Fat Lady is the savior in J.D. Salinger's classic Franny and Zooey. Franny is overwrought by the misplaced passions of her time. After considerable struggle and prayer, Franny achieves a newfound insight about what really counts. J.D Salinger wonderfully describes how Franny's anxiety evaporates in the face of knowing What Is Truly Important. She sees the way through and the transcendent Fat Lady is not surprised.

Of course, J.D. Salinger can't take full credit for the metaphor. The Disease Management Care Blog thinks much of the credit goes to an event that occurred 2000 years ago. While Rome was no Washington DC, its citizens were acutely aware of the influence of power, the role of alliances and the struggles that resulted in winners and losers. Little did anyone realize that those temporal ingredients would fade in importance thanks to stunningly new insights on how to deal with the world. All this and much more thanks to a small baby born in a small outpost of the Roman Empire.

The DMCB has been to Washington DC and it's full of statues of dead people. Every one of them did something important and the DMCB thanks every single one of them. It is also thankful to its President and the members of Congress for their efforts on health reform, as well as all the other stuff they're doing. In fact, it wouldn't be surprised if a Senator or two gets recognition with a statue.

However, the Fat Lady doesn't care about that. She is looking deeper at each one of us with a far different measuring stick. This Holiday Season is a good time to pause and be thankful for that gift of insight.

How Will the Senate Bill Impact the Insurance Companies and Their Customers?

How will the Senate bill impact health insurance companies and their customers?Even better, how will it impact a not-for-profit health plan--one with a reputation for being a "good guy" that continually wins the country's top awards for member services and with historic profits of less than 1% of premium? And, one that is operating in Massachusetts--a market that has already been through much of

The Movie Avatar as a Allegory: The Health Reform Debate and Good Versus Evil

The Disease Management Care Blog and the DMCB spouse saw the film 'Avatar' last night. About every decade or so, we can agree on a movie. It likes the cinematic eye candy of explosions, silly techno-fiction and lithe ferocious warrior babes, while she likes romance, romance and romance. While the DMCB almost spoiled things in the theater by pointing out the implausibility of the interspecies coupling that was rather virtual and was accomplished without the presence of any apparent.... er, equipment, both parties were not disappointed and pronounced the evening a dating success.

The plot was an intergalactic remake of Dances With Wolves: nice guy (Jake Sully) from an evil race (humans, a.k.a Sky People) that is attacking nature (the Planet Pandora) discovers the truth (an abiding reverence for all living things), attains innocence (thanks to communion with Eywa) and, (with the benefit of an uplink to a genetically engineered avatar), wins a woman, in this case a very blue ten foot woman (Neytiri).

Such is a classic theme of redemption that the DMCB thinks it can be extended to the health reform debate. All that remains is to take sides:

Jake Sully is a...

a) naive progressivist activist, or

b) soon to be former health insurance executive, who...

takes on the task of...

a) bringing a predatory corporate insurer to heel, or

b) is assigned the job of recissions for pregnant women who have just lost their job, because....

of 'unobtainium,' a substance...

a) that renders unparalled social justicium from the governmentium, or

b) can be turned into free marketium.

Jake's soul discovers the price of unobtanium is too high, thanks to mind-melding with Eywa,

a) a diety that uses the Tree of Blogs to help us discern the wonderful limitless goodness of all living things, or

b) a diety that uses the Tree of Blogs to help us discern the miserly selfishness of humans and, by the way, who cares about other living things?

Jake's evil people....

a) post provocative health reform videos on YouTube or

b) hold secret meetings in sumptuous hotels that are closed to the public, which causes great vexation and consternation of the...

Na'vi, an underdog group of ....

a) Republican leaning health insurance workers with families who go to Church, take out their neighbor lady's garbage and work hard to keep premiums down and pay providers fairly but as little as possible, or

b) politically agnostic and uninsured persons who never voted until President Obama came along.

Tens of thousands of Na'vi die, hundreds of thousands declare bankruptcy. Jake's guilt helps him to see The Truth because of a woman, because

a) according to the DMCB spouse, when they are heeded, great insights occur, or

b) according to the DMCB spouse, when they are heeded, great insights occur.

As a result, Jake leads a David vs. Goliath counterattack of the Na'vi by

a) appearing on Fox News with rabid denunciations of infringements on our liberty, or

b) appearing on MSNBC with breathless insider exposés.

As a result the Evil Ones

a) face loss of Federal funding support or

b) are brought before Congress for some uncomfortable questioning

leading to righteousness for all. Play inspirational music. Fade to credits. Leave theater knowing that there will be health reform sequel after sequel after sequel.

Rebating When the Medical Loss Ratio Gets Too Low: What Are Some of the Possible Outcomes?

The Disease Management Care Blog has been thinking about the 'Manager's' Amendment that turned it around for the Senate Democrats.

There's an interesting provision that requires health insurers to ‘rebate’ their customers the difference if the medical loss ratio (MLR) is less than 85% in the large group market or 80% in the small group or individual market. It's supposed to go on a year-to-year basis effective January 1, 2011. Then, on January 1, 2014, the rebate will be based on a three year rolling average of the MLR. So, if an insurer collects, say $100 million in revenue from their policy holders and spends $75 million, that's (depending) $5 or $10 million in checks going out the door.

For the small and individual market, it’s up to the Secretary to ‘adjust’ the percentage if the 80% requirement ‘may destablize’ the insurance market; whats’ more, States can ‘seek to ensure' adequate participation, competition and consumer value. Just how the MLR is calculated will be up to the Ms. Sebelius' old stomping ground, the National Association of Insurance Commissioners (NAIC).

Thoughts from the non-expert DMCB:

Pseudo-mutuals: This fiat seems to transform commerical health insurers into lite version 'upside only' mutual insurance funds. These are insurance entities that are invested in and owned by the persons or entities that pool risk. They get to share in any profits, but are also responsible for their losses. In the Democrats' version, the insureds don't need to invest and get to benefit from the upside risk.

Tax? Rather than a 'rebate,' the U.S. government has other levers at its disposal. The DMCB is pleasantly surprised that the Feds didn't try to grab the money.

Capital shortage: Could this drive capital away from the insurance companies? Since their already anemic profitability would be effectively capped, it may make more sense for investors to put their money elsewhere.

Just what is an MLR? Take it from the DMCB: there are all kinds of tricks used by CFOs to squirrel away unused premium and protect it from the MLR. The Senate did a wise thing by a getting the NAIC involved, which knows how the MLR for any year should be calculated.

For example, what is a year? It can take time to adjudicate all claims; sometimes insurers don't get a claim for 'services rendered' for a whole year. Actuaries use a concept called 'incurred but not reported' or IBNR: will this be used to set a rebate amount?

What about the surplus? While the Senate has declared war on the MLR, another key factor in the 'health' of health insurers is the 'surplus,' or the cushion that's used in case claims reserves are inadequate. Having a good year enables some of that MLR to be added to the surplus which also enables business growth. If the MLR rebates 'starve' their surpluses, these companies may be unable to take on new customers.

Overreaction: When insurers start seeing their MLR headed south, they’ll respond by cutting their administrative costs first. Will customer service, claims payment timeliness and accuracy and detection of fraud be the babies thrown out with the bathwater?

Advantage to the large insurers: Small insurance companies, i.e. the regional insurers with 100 to 500K members, may have trouble thriving in a capped MLR environment. The DMCB wonders if they'll be swallowed up by the big boys.

Wither the employees? While the rebate goes back to the buyer of the insurance, what happens if that the buyer is a company that has transferred some of that premium expense to their employees through payroll deductions? Is the company obligated to give a fair portion back to their employees? Will they? If they do, is it taxable?

Wither the docs? The physicians have always maintained that low MLRs are off their backs because they're not being adequately reimbursed. Could this drive a political wedge between the health consumers and the physicians? The docs will now not only have to contend with another party, but it's also first in line. Think patients that are getting their rebates will feel sorry for the providers that are trying to increase their fees?

and....

This is democracy in action? Remember all the interminable Congressional Committee hearings on all the permutations of every form of Federal involvement in the commerical health insurance market? Everything seemed to have a full hearing with input from all sides. The DMCB wasn't playing close attention, but it doesn't think the 'rebate' option was fully aired during that time. While there is a lot that is good and bad about the rebate idea, there is also lots that is simply not known. So much for debate and transparency.

The Senate Bill--Wall Street Likes It and the House Will Have To

In morning trading HMO stocks are once again hitting 52-week highs with each of the major publicly traded plans up 3% to 6% from their Friday gains.Hospitals and pharmaceutical companies are also doing pretty well.Liberals have been talking all weekend long about having to make the Senate bill better—and more like the House bill. That just won’t happen. Reid’s 60-vote majority is held together

A Tale of Two Holiday Parties for the U.S. Senate's Health Reform Amendment

As the Disease Management Care Blog predicted, it looks like a health reform bill is going to win Senate passage. There is a good, if opinionated, summary here if you don't want to read the compromise amendment that has 60 Senators' support. The prospects for this 'legislative breakthrough' reaching the President's desk for signature looks bright and, aside from some nattering nabobs, congratulations are being passed all around.

The DMCB isn't fooled by the Democrats' celebration. Their public face may be about breaking open the bubbly, donning the party hats, collecting around the piano and lustily singing to this 'genuine reform that offers security,' or 'the culmination of a struggle ...to make health care reform a reality. They claim to be in a 'very, very good mood' and 'jubilant' with a huge victory over the outraged and blundering Republican opposition.

Don't believe it. Behind closed doors, the DMCB suspects their glad-handing and back-slapping are muted. A few key Senators stymied the public option, voter support waned and Mr. Obama's considered eloquence was barely enough to pass a reform bill outside of the narrowest of legislative margins. Think sighs around the punch bowls, glum guests arriving late and leaving early while muted conversations conduct political autopsies, all while gazing into the distance at.....

...the bright lights, the sounds of great merriment and windy toasts with clinking glasses across in another part of town. That's right, the folks who favored market-based insurance and opposed the 'public option' every step of the way are partying far outside the media spotlight. For now, they don't have to fear that they will be put out of business. Instead, they improbably stopped a populist President and his hostile majority of Democratic allies in their single payor tracks and, what's more, snagged a mandate that requires everyone to buy their products. Huzzah, skal, salut, mazel tov and cheers!

And don't expect anyone from the health insurance industry to give anything other than the blandest of non-comments to the media. If they're smart, they'll keep their public heads down Tiger Woods style and take satisfaction in knowing that the President knows that they know they won this round. Handily.

beginning to feel a glimmer...

Coal in Your Christmas Stocking?

Is there anyone left, on either side of the political spectrum, who wants the Senate health care bill to pass?Republican Mississippi Governor Haley Barbour had this to say about the Senate bill last week, “This health care plan is like mackerel in the moonlight. Longer that it's out there, the more that it stinks.”And yesterday, MoveOn said this about the Senate Democratic health care bill in an

An Interview About the Health Insurance Mandates, the Public Option and Health Care Costs

The Disease Management Care Blog typically doesn't do 'interviews,' but it often speaks to itself. It's therapeutic and it beats staring at the television's fatuous offerings. This interview is with a typical medical director from a regional and free standing not-for-profit health insurance plan.

DMCB: What do you think about the current status of health reform?

Not-for-profit Medical Director (NFPMD): Enabling the uninsured to obtain commercial health insurance through a mandate plus premium assistance for persons less well off will be a bonanza for us. Let the good times roll.

DMCB: What about those new requirements that you can't refuse to cover anyone or charge a higher premium for someone with pre-exisiting conditions?

NFPMD: Not a problem if the mandate forces everyone to buy insurance, because that spreads the risk around. We always knew the individuals' ability to afford insurance was a problem and this seems like a good fix.

DMCB: Were you out to screw these individuals with your evil insurance ways?

NFPMD: I can't speak for the large for-profit insurers, but us small not-for-profit insurers had our share of problems with individuals seeking insurance: 1) too many persons who needed it applied for it, usually because paying for their health care out of pocket was going to be more expensive than their monthly insurance bill. For us, that was a guaranteed loss, 2) just like other businesses, things are cheaper if you buy in bulk. Large employers can buy insurance and command a discount. Individuals can't do that, and 3) the ' law of large numbers ' says large insurance pools are more stable than small insurance pools. The threat of a loss is mathematically higher among individuals, so we have to charge more. It's not evil, it's business. By forcing people who don't technically 'need' insurance to buy it, the playing field becomes level.

DMCB: Your reference to 'it's just business' sounds like someone out of a Godfather movie.

NFPMD: Michael Corleone didn't get to where he was by accepting a 3% margin. That is our reality.

DMCB: And what about the public option?

NFPMD: Once again, I can't speak for the large for-profit insurers, but the talk about keeping us not-for-profits 'honest' was insulting. We don't have profits, we have surpluses that can't go anywere and that help provide financial stability. They're a rainy day fund. We have no stockholders, so the money we 'make' is kept in trust.

DMCB: Critics say you don't like the public option because you can't 'compete' against its higher quality, lower prices and lower overhead.

NFPMD: The National Committee for Quality Assurance has a widely and long recognized approach that measures quality and those numbers say we are doing pretty good. Medicare - which is held up as the poster child for the public option - does not participate in the NCQA and has only just begun to measure quality in ways that makes it hard for me to compare their apples to our oranges. As for lower prices, duh.....isn't Medicare isn't going bankrupt? And finally, Medicare's lower overhead is possible because it uses regulations instead of employees. Other companies that are off Medicare's books have to carry the cost of the employees to carry out those Medicare regulations, which are growing more complex every year. Even then, they don't work very well.

DMCB: You seem to feel pretty strongly about this.

NFPMD: I can't blame our trade association for really digging their heels in on this. If the public option came about, all of us small regional not-for-profits would be the first to go out of business. Ironically, it'd be the bigger insurers that would have the best chance to survive and they're the ones with the worst reputation.

DMCB: Well if there is no public option, critics charge you should be more heavily regulated.

NFPMD: I personally think the State's health insurance commissioners have done a pretty good job of that. They don't get appointed or voted into office unless they can show that they're prepared to beat up on a health insurer. That being said, I know you read the Libertanian CATO blog from time to time, so you probably saw the report from the Congressional Budget Office that pointed out that more stringent regulation of the insurance industry - specifically over their medical loss ratios - may well effectively turn it into a government function. According to the CBO, that means all its costs would need to be put into the government budget.

DMCB: Ha ha! Little chance of that happening!

NFPMD: Ha ha! We'll see. I may yet become a government employee.

DMCB: How about health care costs?

NFPMD: They're going to continue to go up up up, but the average person won't see it because those costs will be spread around in taxes, premium assistance and larger risk pools that force previously uninsured people to pay in. In fact, it's going to be worse because the non-insured have pent-up demand and the additional dollars will enable hospitals to build more wings and doctors to buy more devices, which create their own demand. My colleagues in the insurance industry doubt the 'reforms' in the current legislation will really reduce costs because that is what our actuaries are telling us - and the CBO would seem to agree. Instead, if legislation passes, it may be a replay of Massachusetts, which did insurance reform first and decided to tackle costs later. Regardless, there will be a day of reckoning, hopefully after the economy has recovered. I bet it'll be the second half of the Obama Administration or, who knows, during a McCain Administration.

DMCB: Anything else you'd like to say?

NPFMD: Dr. Howard Dean's pain couldn't happen to a nicer guy.

DMCB: Good night.

better than yoga

Lucy could give lessons in how to relax.

Spandex, Pounds, QALYs Rationing and Health Reform.

Years ago, the young and impressionable Disease Management Care Blog was struck by the appearance of a decidedly overweight person clad in tight spandex. An insightful friend remarked the appearance reminded him of 50 lbs. of potatoes in a 40 lb. bag. That summed things up pretty well.

And so it also is for Washington DC's attempt to offer a generous public insurance health benefit inside of a limited budget. Writing in this week's New England Journal of Medicine, Drs. Baiker and Chandra review the numbers and the politics of Uncomfortable Arithmetic - Whom to Cover versus What to Cover. While it could be argued that we have a) a moral obligation and/or b) a long term return on investment to be gained from covering 'everyone,' the authors point out that a) there is only so much Federal budget and b) covering everyone for everything is a poor use of money.

Given this uncomfortable reality, the authors argue that a more rational approach may be to ration low 'value' care by promoting the coverage of services that lead to a) higher numbers or b) higher quality years life gained at an attractive cost (a figure in Table 2 quotes $100,000 per year of additional high quality life expectancy).

If you're saying 'uh oh, QALYs again?' you're right. While these are simply mathematical expressions of the trade-offs we intuitively make when we're thinking about gains in life expectancy ('how much time, doc?') and the quality of those years (will I be able to get out of bed and walk?), the authors in this essay argue their use will become unavoidable. It may be rationing, but 'we will have to engage in the difficult discussions required to choose whom and what our public insurance programs should offer.'

The DMCB gets the argument but doubts this will gain much ballast outside the medical academosphere. There are two issues at play:

1) There doesn't appear to be much disagreement over the ultimate need to 'ration.' Rather, the authors' premise is that everyone agrees rationing should ultimately be a function of some enlightened and dispassionate public entity. Disagreeing with that assumption, a significant number of our citizens and policy experts would argue that rationing is better handled by an unfettered market. That perspective can be summed up by the proposals to regulate a stripped down minimum benefit designed to prevent bankruptcy and leave it up to insurers and providers to compete (across State lines) for the consumers' to 'buy up.' Vouchers could be used to help persons afford a plan that exceeds the minimum.

2) The current bevy of Congressional Committee Chair Barons are unlikely to countenance No. 1, above, so the DMCB offers up another reason to doubt that Drs. Baicker and Chandras' perspectives will ever see the light of day: voters don't understand the numeracy of researchy trade-offs in years, quality and dollars. What's more, Tea Party-like activists will quickly seize on their obtuseness to fashion even more rhetorical poison. The Committee Chairs may be insulated from this, but the rank and file members of Congress are looking at the 2010 elections with an increasinly grumpy electorate.

Most regular persons understand that more spandex is no substitute for losing weight or having too many potatoes for too little bag. While it may be a minority of voters who believe that it's up to individuals to figure out how to lose weight (arugment number 1), a majority are unlikely to have patience with the ratios of how much spandex is necessary to adequately contain a certain amount of girth and pounds.

*Image from Wikipedia

time passes

A Requiem for Joe and the Public Option....

Senator Lieberman has apparently succeeded in driving the final nail into the public option's coffin, earning him an eternal damnation from the Church of Universal Coverage. The Disease Management Care Blog agrees: oh, ease up on Joe already.

But the empathic DMCB feels your pain. And what better way to feel better than to break into some song? This one may be morose, but after a few verses, the DMCB guarantees that the suffering will ease and the work of influencing policy can begin anew....

With apologies to 0ne Eskim0 and their lovely and haunting version of Kandi

Joe’s made a scene for longer than you know
Reform thanks to you
Has been a big headache
Every day we stop
It’s make or break…..

And if we get things wrong
Don't want us to think we're running away
But we’ve heard from Joe about this plan
And we want to know

What did he say?
He said no way, no way no way all along
What did he do?
He said no way, no way all along…….

Why? Why? Why, do we need him?
Filibuster
Just how close are we to sixty?
Every smile he gave
Every pledge he made
Every word he said…..

And it hurts beyond hurt
A plan that Reid insists
And our base is pissed
When we heard from Joe about his “no”
And we want to know

(OK, everybody sing!)

What did he say?
He said no way, no way no way all along
What did he do?
He said no way, no way all along……

Do insurers ever touch you…..
Can Move-On ever reach you….
It’s never enough….

What did he say?
He said no way, no way no way all along
What did he do?
He said no way, no way all along…….

Putting the CAT Scanner Cancer Risk Into Perspective: Risk Compared to What?

After listening to and reading the news media's alarmist interpretations of an Archives of Internal Medicine report on the risk of 'yikes cancer!' from computerized (axial) tomography (CT or CAT) scans, the ever curious Disease Management Care Blog decided to take a look at the basis for all the fuss. Amy Berrington de Gonzales and colleagues used radiation and cancer data to project the future national incidence of additional cancers that can be expected from today's CAT scanners. The bottom line can be found in this table from the paper. Basically, the highest calculated risk of 'yikes cancer!' runs from a high of 7 per thousand CAT scans (or 0.7%) to 1 per ten thousand CAT scans (or 0.01%). There is a companion article that indicates that the dose of radiation may be even higher, suggesting there will be even more cancer down the road.

That all may sound awful, but the DMCB likes to keep the following factors in mind:

1) The lifetime risk of cancer from exposure to the radiation from a CAT scan is highest among children, but that pales compared to the more immediate risks that come from sedating children to keep them from moving. In the real world of clinical practice, this risk threshold is already considered so high that the added 0.7% risk from the radiation is not much of an additional consideration. Informed guardians already have a powerful incentive to keep CAT scan use to an absolute minimum - and they generally do.

2) As for the grown-ups, stumbling over the assessment of the real magnitude of risk may be a function of innumeracy, but the DMCB believes it can be managed by asking 'compared to what?' So while a CAT scan can present a lifetime risk of hundreths to tenths of one percent:

- having high blood pressure gives 40 year old men an additional 4-5% (one in twenty) chance developing heart failure over a lifetime. The DMCB says know your blood pressure, get it treated if it's high and then smile when they take your picture with the CAT scan.

- the risk of a brain hemorrhage from taking daily aspirin is 2 per 10,000 per year which is on the same order of magnitude every year as the lifetime cancer risk from a CAT scan. The DMCB doesn't recall any alarmist media reports on this risk. Hmmm. Once again, take two aspirins and smile for the scanner in the morning.

- the risk of a dying in a car accident during an average life time, according to this report, is 1 in 83, which works out to be more than 1% for every man, woman and child in the U.S. today. The DMCB recommends wearing a seat belt when you drive to your CAT scan appointment.

3) One way of gauging the risk of any health threat that is reported in the media is to examine the number of reports: the greater their number, stridency and alarm, the lower the real risk. The hubub over CAT scans suggests this inverse relationship is holding up.

4) Yet, Radiology Benefit Managers (or 'RBMs') have long regarded the cancer risk associated with CAT scans (example here) as one factor in controlling their utilization. If unecessary CAT scans are 'denied' for coverage by managed care oganizations, is that now no longer evidence of 'evil' managed care putting profits before patients? Were they right all along?

The DMCB has always been less worried about the radiation dose from CAT scanners than their far more dangerous tendency to find abnormalities in the absence of disease. Asymptomatic spots, densities, signals and other lesions of dubious significance have always bedeviled physicians and their patients, leading to ever more sophisticated imaging studies. If patient fear over CAT scan radiation exposure leads to fewer scans with fewer of their inevitable false positives, that may ultimately be a good thing.

Oh, Ease Up on Joe Already

The Democratic rhetoric coming from Capitol Hill today beating on Joe Lieberman is, in the least, disingenuous.The public option has not been tenable for months. It was not just Lieberman that has been against it in all forms--robust Medicare-like or the neutered variety in the House and Senate bills.All of the liberals claiming they weren't going to vote for a health bill without a public option

oh oh...

"CT scan radiation may cause cancers"

but on the other hand

"Study: Coffee and tea may lower diabetes risk"

'Change Request 6540' and the Dem's Proposed Medicare Expansion: Bad News for Insurers and Providers

Senator Lieberman (I-CT) has come out against the Medicare expansion, earning the vitriolic spittle of the left leaning commentariat. Undeterred, this new healthcare 'Sen. No' seems to be hanging tough in opposition to alleged busting-busting government insurance creep.

While thinking through the implications of this, the Disease Management Care Blog ran across this CMS document that deals with updates to the hospice benefit.

[pause]

Unless you're a technical writer, compliance officer or bureaucratic weenie, your reaction to opening this 'CMS Pub 100-04 Medicare Claims Processing Transmittal 1870 Change Request 6540' was probably similar to the Disease Management Care Blog's: egads, how on earth is a health care entity supposed to put up with all this detailed and soporific minutiae?

The DMCB discerns three lessons:

1. Behold the Medicare approach to the 'Hospice Benefit.' By the way, this is also the approach to pay-for-performance, inpatient reimbursement, physician fee schedules, medical devices, all forms of rehabilitation, demonstrations and the myriad other touch points between the health care delivery system and government-run health care. The Dems may call it Medicare, providers call it a hassle. And folks wonder why the AMA isn't supporting this?

2. There is no better example that explains why Medicare's administrative costs are so low. It probably takes an afternoon for a CMS full time equivalent (FTE) to develop a 'Change Request 6540.' It takes a full time position on the delivery side to deal with it.

3. Finally, armed with forms like this, who can argue that Medicare won't crush any commercial insurer? Think the regional not-for-profit Blue will also be able to 'require' providers in their network to deal with Change Request Form 6540? No way.

Maybe the Connecticut Senator has a point.

melancholy meme

These are questions from the Proust quiz in a recent issue of Vanity Fair magazine. I stole the idea from a friend (she did it on Facebook, so I won't identify her here) and I've been thinking of it ever since.

It was interesting to do. My answers reflect the fact that I have been in a somewhat melancholy mood of late. I tried to answer without censoring myself.

Feel free to answer the questions in the comments or to link to your on blog if you do it there.

What is your idea of perfect happiness?
Being somewhere beautiful, being with someone I love. Happiness can come out of nowhere. I am better trained to notice it now.

What is your greatest fear?
That I will die and my kids will forget me.

What is the trait you most deplore in yourself?
Lack of discipline and the fear that causes it.

What is the trait you most deplore in others?
Intolerance of difference.

On what occasion do you lie?
Sometimes to protect others' feelings. Occasionally to protect myself.

What is your greatest extravagance?
It used to be shoes. I do like nice glasses but that's only every couple of years. I'd have to say that now, it's eating out and yarn.

What is your current state of mind?
A little fragile, anxious and blue. Figuring out how to get past it.

What is the quality you most like in a man?
Intelligence. The ability to laugh at himself. And if he's in love with me, that's pretty attractive, too. OK, so that's three. I did say that I lack discipline.

What is the quality you most like in a woman?
Intelligence, strength and a sense of humour.

Which words or phrases do you most overuse?
Lately, it's "Oh, for pity's sake!" Trying to excise the potty mouth.

When and where were you happiest?
No particular moment in time. In PEI with T., in London with S., at the family cottage, in the arboretum with the dogs...

Who are your favorite writers?
Depends on my mood. John Steinbeck, Jane Austen, Joseph Boyden, Sarah Waters...and lots of mystery novelists too.

Which talent would you most like to have?
I wish I could sing.

If you could change one thing about your family, what would it be?
I'd make us all appreciate what we have.

If you died and came back as a person or thing, what do you think it would be?
A well-loved dog with a stay at home alpha human and a family that loves me, walks me and feeds me well. In other words, I would come back as one of my dogs.

What do you dislike most about your appearance?
Where to begin? Trying to be healthier in my attitude about this. But my weight (exacerbated by lymphedema) is getting me down lately. And it would be nice to have my breast back.

Where would you like to live?
Somewhere where there is no winter.

What is your most treasured possession?
If you agree with me that the dogs are family members and not possessions, then I guess that would be my raven ring.

What do you regard as the lowest depth of misery?
Being 38 years old and learning that your liver is riddled with tumours and you don't have long to live. Needing morphine to control the pain for months. Having your heart ache on behalf of those who love you, especially your kids.
And life really is pretty good when you climb out of those depths.

What do you most value in your friends?
Loyalty, love and and humour.

What are your favorite names?
Sacha
Daniel
Katya

What is it that you most dislike?
People who think they have already learned all there is to know. And cancer. I don't like cancer either.

What is your greatest regret?
Not maintaining friendships with some people who were very important to me.

How would you like to die?
Painlessly and after having lived a long life.

What is your motto?
Be good.

Health Care Demonstrations, Pilots and Extension Programs. Are They All That When It Comes to Health Reform?

If you're not careful when you read the fawning commentary (for example) about Dr. Atul Gawande's Testing Testing article in The New Yorker, you may end up accepting two canards about the conspicuous absence of any hard solutions to the United States' health care cost inflation in any of the health reform legislation before Gongress:

1) Legislating pilots, demos and other tests of interventions that have the potential to yield up savings is a great idea. There is no single fix for health care cost inflation, so let a thousand flowers bloom

2) Dusting off a cost-savings 'Extension Service,' similar to what the Feds used back in the early 1900s to promote science-based farming, is Washington DC at its best.

Really? The Disease Management Care Blog doesn't share in all the exuberance:

Check out this article from the Heritage Foundation as well as this article from Kaiser Health News that show that Medicare demonstrations are a political graveyard where good ideas go to die. Thanks to Congress' inability to shield its decision-making from all the special interests, the odds of a demo'ed cost-saving intervention actually making it into the Medicare benefit is often zero to none.

In fact, the DMCB is even more cynical. It thinks Congress has historically pressed the 'Demonstration' button when there is nowhere else to hide. Unable to say 'no' to any constituent, our legislators use 'demos' and 'pilots' as a hollow-man substitute for real change.

As for the farmer-like 'extension program,' the DMCB points out that this is not a new idea. But Dr. G is right: it turns out that the latest version of the health reform legislation before the Senate does create State-based competitive grants for primary-care hub-based extension programs to 'educate providers about prevention, health promtion, disease management, and evidence based... therapies and techniques.' While the hub must include a State entity (like a Department of Health) and 'one or more health professions schools in the State,' it's interesting to note that 'other appropriate entities" are allowed to participate.

The only problem? In our evidence-based world of health care, there is really no hard proof that the extension-teacher approach would work. Is health care quality like bushels per acre? Can costs be managed like pounds of fertilizer? Do docs listen when this kind of help is being offered? We don't know, but apparently we may get to find out.

In the meantime, the DMCB is partial to collaborative learning, involving mutliple payors such as in Pennsylvania or Vermont. Given the success of these and other initiatives, the DMCB wonders if the extension approach is really necessary.

The Medicare Buy-In Is Dead--The Liberals Are Now the Swing Votes in Health Care

The Medicare buy-in idea is dead. After Democratic Congressman Weiner's candid comment, “Never mind the camel’s nose, we’ve got his head and neck in the tent," no senator from the likes of Arkansas or Indiana is going to vote for this.Add to that yesterday's critical Washington Post editorial and the sharp response from the various doc and hospital lobbies and this was dead before Reid's request

How Can the AMA Wield Such Power in Health Reform? The DMCB Explains

There they go again. Tossing a monkey into the wrench of Senator Reid's fragile health reform compromise, the American Medical Association has come out against the Medicare buy-in plan for persons age 55 to 64 years. While physicians, hospitals and insurers dislike the economics, the AMA has stressed that it's Medicare budgetary woes that are the real problem. Things are on hold until the Congressional Budget Office 'scores' this latest scheme.

Let the games continue.

But who IS this AMA and how can an organization with a membership that is only a fraction of all U.S physicians wield such clout? There are other physician groups out there, there is no shortage of docs that vociferously oppose the AMA's positions and some of them have the President's ear. Yet, when the AMA rises in oppotion to the motion, Presidents, Legislators and the media still pause and listen.

The Disease Management Care Blog explains.

1) Despite having a membership that comprises only minority of physicians, it is still the nation's largest physician organization.

2) While there are sufficient numbers of docs to fill a Rose Garden for the cameras or create impressive web sites, the AMA argues that it also represents the silent majority of politically inactive and non-dues paying physicians who don't belong to any advocacy group. They may have a point.

3) While many physicians are members of 'other' professional specialty-based organizations, a huge number of those organizations participate in the AMA. The AMA has been referred to as the House of Medicine for a good reason.

4) Despite attempts of some hostile media to convince folks otherwise, the 'AMA' has a recognizable advocacy 'brand.' It makes no difference if, as many allege, that the association is slowly losing it's grip on the physicians' conscience, the public believes it still has it. The President's political calculus recognizes that. By the way, so does the AMA - and they just might.

5) You may call it lobbying, but the AMA has an impressive policy infrastructure that has been long relied on Inside The Beltway for its expertise. Their insider access is not a function of money or lobbyists but history, relationships and insights.

6) JAMA, a premier peer review journal that is must reading for any physician. 'Nuff said.

The DMCB is a proud member of the AMA. While it may not agree with all of the House of Medicine's positions, it thinks it has a greater voice by being a dues paying participant. It immodestly believes the AMA is better off for it.

writing your way through breast cancer

It's been two days since chemo, so I feel lousy and have the attention span of a gnat.

It works out well for me, therefore, that I have something I've been meaning to share with you all for a while now.

I really like the Philadelphia based organization Living Beyond Breast Cancer. I've been fortunate enough to attend two of their own conferences (one called "News You Can Use" and one specifically for women living with metastasis) and the Annual Conference For Young Women Affected By Breast Cancer, which they co-sponsor (last year's was in Dallas and I'm applying for a grant, in the hopes of being able to attend in Atlanta this year. It will be the 10 year anniversary of the conference).

A little while ago, LBBC contacted me to see if I would be willing to be interviewed for their Winter 2009/2010 newsletter about "writing your way through breast cancer." I didn't hesitate, as this is a subject about which I am passionate.

You can read the interview on their web site. I am also please to not that they have listed "Not Done Yet" under the heading "Creative Coping: 10 Publications To Motivate You."

The Health Wonk Review is Up!

Can you BELIEVE it's December already? That means this year's last Health Wonk Review's been posted, this time hosted by the very able Lynch Ryan at the Worker's Comp Insider Blog.

It's here: Ho ho HO!

More On the Parallels Between the Airline Industry and Population-Based Care Management

In its various speaking gigs, the peripatetic Disease Management Care Blog has alluded numerous times to the parallels between flying jets and plying care management. Sure, the delays, nuisance fees and cramped seating can make for misery, but you have to admit that the safety record is superb. It's no longer up to just the pilot. It takes a team. Passenger safety depends on systems. Travel quality divided by price times consumerism equals value. While these and some other insights have generally stood the test of time in numerous presentations, some recent media reports have made the DMCB pause.....

First off, WHYY's Radio Times with Marty Moss-Coane had an interesting interview with an experienced pilot. If you're a road warrior, it makes for good insightful listening. But there were two major points of significance to the population-based care management industry:

1) While today's aircraft are backed up with state of the art digital avionics, computerized decision support and automatic safety systems that practically fly themselves, the truth is that the pilot's job has become far more complicated. While there are flight envelope protections, the complexity of today's planes commands ever higher skill sets that are no longer restricted to old fashioned flying.

And so it is for the physicians. They not only need to know to singlehandedly deal with the manifestations of disease, but they also need to navigate wards or clinics full of people through the myriad other issues of a complex health system. Both pilots and docs are now also network operators.

2) Despite their unique talents and the lives that are stake, pilots' compensation has not been immune from the travel industry's economics. Starting annual salaries for the regional jet pilots are now in the unbelievably low range of $35,000. While there are 8 hour rest rules, it's not unusual for pilots to put in 16 hour days with multiple take-offs and landings capped off with an hour to get to their hotel room for 6 hours of sleep so that they can get back to the airport the next day after day after day. It's hard work, sleep deprivation and low pay over many years before they get to fly those coveted international routes with a six figure income.

And so it may be for the physicians. The cost structure of the airlines back in the 1990's became unsustainable. Costs had to be cut everywhere and the industry did what it had to do. Unfortunately, despite assertions that we can preserve much of the status quo with payment reform, information technology, better use of research and rooting out fraud and abuse, our highly paid physicians may end up like our nation's commercial pilots. $35,000? Yikes.

And finally, check out this 'Bring Back the Off Switch' Wall Street Journal editorial. In it, Holman Jenkins argues that we need an analog option to deal with the rare but still possible human-digital interface system malfunctions. It's called an 'off' switch. Lexus cars can accelerate out of control with no way to turn the 'key' and Airbuses' speed sensors were vulnerable to ice build-up, leading to a cascade of errors which may overwelm pilots. Ditto on the healthcare future of our digital home monitoring devices, computerized clinical decision support, drug delivery systems and robotic surgeries (to name a few). The DMCB thinks that one of the roles of a pilot or a physician is to know when to recognize systems failure, turn it off and take control.

For maintaining that skill and knowing when and how to use it, both classes of professionals deserve to be richly compensated by passengers and patients. Whether that happens remains to be seen.