inspired by Life

I rarely read the Life section of The Globe and Mail. In the mornings, I tend to skim the front section over breakfast and then get the rest of my news from the radio and online. However, today, as I was waiting for something on the stove, I grabbed the Life section and found several articles to be of interest.

I didn't know about modern Superheroes, who don costumes to patrol the streets or do good works. These guys are proud of who they are and they think they're pretty cool, too. "I'm not a fat kid in someone's basement or some geek living out a fantasy," says a caped crusader based in Vancouver, who calls himself 'Thanatos'. Dunno. Seems a little odd to me.

I am now worried about the fact Bhisphenol A can be absorbed through cash register receipts and water pipes as well as through food.

I have seen evidence of knitted graffiti in my own city but had no idea it had become a world wide phenomenon until my Danish friend M. sent me a link to an article about "craftivists" in Copenhagen. Now I can't help wondering, if it's in the Life Section of the Globe, is it still subversive?

I learned that men undergoing vasectomies can sometimes see a puff of smoke coming from their groin area during the procedure. What would make that happen?

I was reminded that yoga will enhance my cardio performance and that exercise can help stave off diabetes and heart disease. What I didn't know that short, intense burst can be especially beneficial. Now that got my wheels turning.

And I was moved to tears as I read how one woman lost her precious son to suicide at the age of 17. My spouse and I have both struggled with depression at various points in our lives, as have family members. I do worry about my boys. I want to protect them from everything. Hopefully, love, patience and all the right kinds of support (along with a generous dose of luck) will lead them to live happy and healthy lives.

What did you learn in the news today?

To Break the Bank or Not to Break the Bank With Health Care Reform?--The Wrong Question

The new debate in Washington these days seems to be over whether we can or cannot afford to do health care reform given the financial crisis and the huge budget deficits.Some argue that with the rising unemployment rate, certain increases in the number of those uninsured to follow, and the need to inject money into the system, this is the right time.Others say that in the face of daunting

Rhode Island's Health Insurance Commissioner and the Patient Centered Medical Home

The Disease Management Care Blog virtually attended a very interesting January 28 webinar sponsored by the Patient Centered Primary Care Collaborative. Access to this kind of learning experience is one of the advantages of PCPCC membership. (Hint -by the way, it’s free).

The topic was a fav of the DMCB, the Patient Centered Medical Home, titled ‘What is it? Why is this important to employers?’ There were two speakers, and it was the second, Christopher Koller, who really caught the DMCB’s ear.

First, some background. Chris Koller is the Health Insurance Commissioner for Rhode Island. Every State has an Insurance Commissioner, but the DMCB thinks Rhode Island is a distinct outlier because of two unique features:

First, this State has a Commissioner for just health insurance. As far as the DMCB is aware, other States don’t carve that function out, let alone put a former health insurance executive in the post.

Secondly, while State Departments of Insurance are charged with 1) protecting consumers (from unscrupulous insurers who refuse to pay up) and 2) assuring insurers’ solvency (preventing an insurer from declaring bankruptcy and walking away from its debts in the event of a bad year), this Commissioner is additionally charged with protecting providers and ‘encourag(ing) policies that improve quality and efficiency…’ and ‘encourag(ing) and direct(ing) insurers toward policies that advance the welfare of the public….’ This goes well beyond the usual role of being a simple regulator.

One of the centerpiece policies of the Rhode Island Health Insurance Commissioner? You guessed it, The Patient Centered Medical Home.

So what’s the big deal? The vast majority of other PCMH pilots underway are typically being sponsored by a single insurer or are happening on a limited regional basis. Rhode Island has one that is called the Chronic Care Sustainability Initiative, and the difference is that it’s state-wide. More importantly, all of the major commercial insurers (the Blues Plan, United and Neighborhood Health) plus the State Medicaid program plus the State Employees Benefit Plan, the Business Group on Health and other self-insured entities are participating, using a single:

a) set of criteria to accredit a physician practice as a PCMH,

b) contract (with $3 PMPM),

c) fee schedule and

d) set of quality measures.

This is not regulation, it’s intervening and jawboning. This is what many consumers want.

The DMCB wonders if the activism of a State level officer at the level of a Insurance Commissioner may emerge as a key ingredient for the success of the PCMH. Without it, insurers will not only be reluctant to cooperate with their competition but fearful of appearing to anti-competitively collude. What’s more, this gets government Medicaid and the private commercial plans on the same page. This can also act as a safe harbor for further cooperation on other future initiatives. By the way, the same approach is being used in Pennsylvania, though it isn’t the Department of Insurance. Rather, it’s the Governor’s Office of Health Care Reform that is leading (and maybe browbeating?) the multi-stakeholder parade.

Last but not least, the DMCB is very impressed with the ability of the States to execute on novel health care initiatives. By the time ObamaCare passes Congress and the first data arrive from the Medical Home Pilot years from now, Rhode Island and Pennsylvania may long have the answers we need. These State residents won’t need Washington’s Czars telling them what to do and how to do it.

Any problems here? The DMCB is aware of several. There seem to be a relatively low number of involved physicians (N=28), which may make the results hard to assess at that unit of measurement. It may also make the results less generalizable and there is no guarantee that all physicians will want to participate, even if the pilot is successful.

Secondly, the evaluation will be performed by the Harvard School of Public Health. The DMCB has high regard for HSPH, but it thinks that decisions about insurance design and affordability are fundamentally more of an actuarial than a health services exercise. Ideally, it's both.

Finally, this is a test of the PCMH only, without any later generation features such as additional remote telephonic coaching, synergistic benefit and pharmacy designs, consumerism and yes, intelligently designed information and technology registry and decision support.

The DMCB wants to keep an eye on Rhode Island. The State's Motto? Hope. The DMCB’s view? Hopeful over what one State is up to and hopeful that if the PCMH is successful, it works in a multi-payer, State-wide environment.

salty

Whenever I have bloodwork done before chemo, the nurse will flush out my port with saline. I always get a salty taste in my mouth and in the back of my throat.

Lately, I have been getting that taste when I am out walking my dogs in the city. I have a lot of winters under my belt but this is the first time I have noticed this. I don't know whether there is more salt on the streets this year or if more of it is being churned up by the extra traffic (there certainly more, along with more pollution from exhaust since the bus trike started five weeks ago). It freaks me out a little.

A couple of week ends ago, I woke up to find out that the power was out in half the house. The living room had no power, the dining room was fine. Our bedroom had no power. The other upstairs rooms were OK. The furnace worked (thank goodness) but the hot water heater did not. The fridge was working fine but the microwave was not. The strangest part was that half the stove was working (three of the elements and the oven were working. The display panel and a fourth element were not) The breadmaker, which was plugged into the stove, was chugging away.

We dithered a bit about what to do until I insisted that we call an electrician (it was a Saturday morning). Three hundred dollars later, he told us that the problem was around a little box outside the house (I believe it's called a "crimp"). If the issue was on one side of the box, Hydro (the electric company) would have to fix it, if it was on the either side than it would be "very, very expensive."

So, after torturing ourselves with some worse-case scenarios, we called Hydro.

Then the power came back on.

Hydro came a couple of hours later and narrowed down the likely problem to some wires that had been corroded by salt (I should point out that we live on the corner of a very busy thoroughfare). They fixed the wires closest to the house but were called away before they could fix the ones by the box on the street (don't you all love my technical expertise in these matters?) they were called to a fire.

The power went off again a couple of hours later.

I called Hydro again but since we still had heat, we weren't at the top of their emergency list.

Hydro came back the next morning, by which time the power was on again.

The guys (the same ones as the day before) fixed the street end of the wires and we have not had a problem since.

And yes, T., we should have called Hydro in the first place.

It's made me wonder, though, about all the salt we must be breathing in (along with all the other pollutants from cars and other things). It can't be good for you.

I'd ask Mr. Internet but I'm too scared.

And it occurs to me that I didn't even think about pollution (let alone salt) when we bought the house more than 10 years ago.

City State Health Care Systems and their EHRs

Dr. Lesitsky is a community-based primary care physician who practices in rural northeastern Pennsylvania. He's not only a buddy of the Disease Management Care Blog, but someone with a working knowledge of life in the trenches of primary care. When docs like him talk, the rest of us should listen.

By Neil Lesitsky, MD

I am a busy solo family physician located 25 miles from the nearest hospital but within 50 miles of at least 9 separate healthcare institutions. My patients may frequent any one of these or their ancillary branches. In addition, there are literally hundreds of providers within the same radius who are not aligned with any system.

As I see it, each one of these institutions is run as its own City-State, each of which has their own unique monarchs, deities, moats, armies and, most importantly, its own electronic health record (EHR). Each institution treats their EHR as their coin of the realm. This coinage functions well within its own borders but lacks infrastructure to be recognized or connect outside its sponsors’ sphere of influence. The information is locked away in the City-States’ treasuries and inter-treasury transfers continue to require a byzantine process.

One City-State in my area, Geisinger has published a paper demonstrating how its coin has become the gold standard in its region. It makes a compelling case from the viewpoint of that King's Court. From my vantage point, however, the other institutions in my area haven’t necessarily agreed.

Our Government has addressed this issue by suggesting that there be a common language for EHRs, so these City-State realms can communicate with a common diplomatic tongue. However this is not the same as a central treasury. This perspective has also been noted by Rick Peters of the HealthCareBlog in an excellent article noting the difference between standards and interoperability.

In my view, a major barrier to the adoption of an EHR by my primary care colleagues is the lack of a common treasury that aligns the City States in a global infrastructure. In primary care, the attraction of an EHR has more to do with data transfer and preventive care prompts than documentation of care (although my back office may disagree).

There is much more data flow into a primary care office than out of it. In my situation, until such a central treasury exists, and the city states easily transfer their deposits, it is not prudent for me to align myself with any of the monarchs.

some days are blue, some days are indulgent

I have been feeling kind of blue these last few days.

I'm always relieved after I get good scan results but a feeling of let-down seems to follow almost every time and I find myself, once again, channelling Peggy Lee and asking "Is that all there is?"

I just finished the latest round of edits on my book (coming out this spring with Women's Press!) and I have been left wondering, 'so, what's next?'

I haven't looked at the outline for my novel since I submitted it for my writing course on December 31st. The course is over and I am feeling kind of daunted. I've been asking myself, "Can I do this?" and "What purpose would it serve?"

This morning, I had an appointment with my wonderful oncologist who confirmed my CT results. He also referred to my "normal" life.

I told him that I have been feeling kind of "ground down" by the emotional wear and tear of treatment, as much as the buildup of toxins.

He gently reminded me that I need to think of myself as having a chronic illness, "like diabetes", that needs to be managed but that doesn't stop me from living my life.

I told him that I know how lucky I am and that I am very grateful not to be dead (at which point he rolled his eyes) and that I've been doing other things to keep my life full and interesting (like writing) but that I miss the more fast-paced, structured work environment.

My oncologist was sympathetic but said that we are working at keeping treatment "as innocuous as possible." I only go for treatment every four weeks and I phone in for every other appointment with him. And he's right.

The truth is that I couldn't go back to the kind of long hours that I worked before cancer. Even if I could miss three or four days on treatment weeks, my body couldn't tolerate the stress or long hours. And I am not sure that I really want that back or if I am just missing the sense of identity that I got from my job.

My oncologist suggested that I skip a cycle over the summer and I'll do that. I'll also keep working at doing the things that make me happy.

I have the chance to work at making art (and writing is art). I have to embrace this rare privilege, not feel guilty about it or self-censuring and just see what happens.

Some days are easier than others.

I asked my oncologist whether there were any restrictions on my activities. He said, "No." He added that there were also "No restrictions on lifestyle" - this is the same oncologist who suggested that dope would help me to cope with the side effects of chemo (it did!) and who routinely suggests I go out for a drink to celebrate any kind of news (wine for good news, scotch for bad) - "The liver is healthy. So you can party."

To which my spouse replied, "As if she needs any encouragement."

However, given the fact that I have gained 30 pounds since I was first diagnosed (10 of those in the last two months), I think I'll be living a more ascetic existence for a while.

Cross-posted to Mothers With Cancer.

"Consumer-Driven Health Care: Promise and Performance"

I am always struck by the difference between the salesmanship of health plans offering consumer-driven health products and the reality of the data.James Robinson and Paul Ginsburg have an article in the January 27th edition of Health Affairs with an objective review of the consumer-driven movement of recent years.Here is the central point of the article:The performance of consumer-driven health

Do Computers in Hospitals Save Lives? Reduce Costs? Make the Food Better?

Well, a hot-off-the-press article in the Archives of Internal Medicine says maybe two out of three. Is this a landmark study? Some media reports suggest that's the case.

Given how starved adherents of healthcare technology are for any news that can justify Congressional largesse to the tune of $20 billion, this little gem of a manuscript may garner additional attention in the coming days. If you’re interested in knowing whether computers in hospitals really save lives, the Disease Management Care Blog is at your service with a summary. Another bonus is that you won’t have to rely on the mainstream media to get it wrong.

Dr. Amarasingham (Parkland in Texas), Ms. Plantinga (Bloomberg Public Health), Dr. Diener-West (Bloomberg Public Health), Dr. Gaskin (Hopkins) and Dr. Powe (Bloomberg Public Health) surveyed a variety of Texas hospitals’ physicians about their hospitals’ level of ‘automation.’ The survey they used was the validated Clinical Information Technology Assessment Tool (‘CITAT), which assesses four domains of ‘record keeping, test results, order entry and decision support.’ If 5 or more surveys were completed, each hospital was assigned an average score based on the physicians’ answers. The Texas Hospital Association then provided the hospitals’ data on mortality, costs, complications and length of stay for all patients as well as those with heart attack, chronic heart failure, open heart surgery and pneumonia. A total of 41 of 72 targeted hospitals had 5 or more surveys completed and could therefore be scored and included in this study.

Did high CITAT scores correlate with death rates, cost, complications or length of stay? Well, as the CITAT score increased in each of the four domains, adjusted odds ratios of death and complications for some conditions decreased. Costs and length of stay also decreased for some conditions. Many did not change.

The curmudgeonly DMCB says 'not bad.'

The insight here is that useful inpatient information technology – as defined by physicians, not technobabbly consultantspeak pseudoscience – is associated with impacts on death rates and costs. Importantly, there was a ‘dose response relationship’; as the CITAT increased, the impacts grew. Even better, the insight has greater credibility because it’s gained from real world hospitals, not disconnected academic medical centers authoring studies that are only read in other academic medical centers.

But the DMCB offers up some cautions:

Association is not the same as causality. It is possible that hospitals with the ability to invest in automation also have the ability to invest in nurses, maintain quality programs, attract the high caliber clinical/administrative leadership or leverage other unmeasured features that really account for the observed changes. The authors attempted to statistically control (neutralize) for hospital status, but this is never perfect (the same techniques were used to control for limitations in the same kinds of studies of estrogen in women, which were shown to be mistaken once a prospective randomized trial was done). The bottom line is that there is no guarantee that an install of this kind of IT in year 1 will lead to fewer deaths, decreased complications, lower cost and shorter length of stay in year 2. It might.

This is hardly a slam dunk panacea. The authors noted the swing in mortality rates was in the range of 0.5%. If you’re among those 5 in a thousand, that’s a lot. For the other 995, survivorship doesn’t change. However, those 995 are facing some other issues including never events, being adequately vaccinated, being disconnected from real doctors or being discharged safely. Swings in the amount of dollars numbered mostly in the low hundreds - when an inpatient stay costs thousands and the ambient national healthcare inflation trend rate eats hundred dollar bills for lunch. We don’t know how the savings profited the hospitals or the insurers and, what's more, we don’t know if any profit was greater than the cost of all this IT.

Sorry ye worshippers of the physician office-based electronic health record. This study tested elements of the EHR outside the physician office setting. It does not apply to your vision of a paperless physician office. You’ve still got work to do in terms of providing reasonable assurance that you really save money and reduce costs in that arena.

Multiple comparisons were performed, making the likelihood of statistical mischief greater. Many of the changes were statistically significant (seemed to be of a magnitude that were mathematically unlikely due to random chance) but barely so. To the authors’ credit, they attempted to statistically control for this also and recognized it as a limitation of their study.

The DMCB doubts a single study can answer the question, but this is an important addition to our knowledge base. Good work, authors. Finally, kudos to the Archives for making the manuscript readily available on-line.

42

Older, yes.

And definitely wiser.

But better, too.

With every passing year.

And every gray hair.

I love you.

Health Affairs Broadcast: Prevention Doesn't Save Money. Is Anyone Listening?

Now that the Obama Health Reform Dirigible is about to be launched, recall much of its ballast is predicated on the twin notions that electronic health records (EHRs) and prevention will ‘save money.’ Both fictions have been past topics of the Disease Management Care Blog, which is confident that both initiatives will add to health care costs. The DMCB doesn’t think additional cost is not necessarily a problem, so long as the end-user patients get reasonable value for their dollar. It’s just that the DMCB distrusts the ability of a huge sprawling ‘mainframe’ Federal bureaucracy to get anything right.

You don't have to take the DMCB's word for it. To learn more about the important topic of prevention, the DMCB recommends Rutgers University’s Louise Russell’s Health Affairs perspective piece. Freshly published, short, to the point, highly readable (few references to ‘QALYs’) and packed with references pointing to the original research, it points out what many health services researchers have been saying for decades: most interventions designed to prevent heart attack via blood pressure or blood lipid control or aspirin cost. Well run programs that promote lifestyle changes to prevent diabetes cost. In fact, of the hundreds of published studies on the topic of prevention, about 80% have been shown that they cost.

Too bad disease management’s legacy is so entangled in the cost ‘savings’ business proposition, especially because many vendors also offer prevention programs. In its travels, the DMCB is still running into this simplistic black and white either-there-is-or-there-isn’t-an-ROI archetype. The truth is, depending on the population, the condition and the insurance benefit, some later generation disease management programs may reduce costs and, if not, are still a great deal for the healthcare dollar. If healthcare consumers want tailored programs to achieve blood sugar control, weight reduction, lower blood pressure or better fitness, it may well cost them via higher premiums from their health insurer. Is that necessarily bad?

The DMCB has read that the HHS Secretary Designate likes to relax by thumbing through issues of Health Affairs. Hopefully he’s read Dr. Russell’s manuscript. Hopefully the new class of Health Czars is aware of the budgetary implications of promoting healthcare prevention programs. Hopefully they’ll get around to telling the American public the truth. By the way, Governor Ed Rendell (D) of Pennsylvania has amply demonstrated that taxpayers are willing to take on new costs if it’s in their interest. I’m sure he’d be willing to share some pages out of his playbook.

For more peer-reviewed truth than you’ll ever want to know about the topic, check out this link at the Tufts CEA registry. It was used by Dr. Russell in her paper. The registry reminds the DMCB of the commercial in which the hapless traveler checks into a dusty motel and is told he can access every movie ever made in every language anytime day or night. When it comes to a huge organized data base of intervention studies that reconcile the benefit versus the cost of care, the same is true here: every paper ever published in every journal anytime day or night.

What Do Professional Wrestling and Political Wrangling Over Health Insurance Have in Common?

Check out this January 21 editorial from The Hill. Apparently, while the Obama administration is playing nicey nice with all the stakeholders in his various initiatives, one group that has been left out in the cold are the health insurers. According to the editors, President Obama et al are getting ready to spill some blood. Woo hoo!

Don’t be fooled. The Disease Management Care Blog knows that health insurers are inured to being the bad guy when it comes to blame games. While the public face of health insurance is a curious mix of ‘We Care!’ platitudes and ‘You Don’t Love Me?’ dismay at public hearings and in press releases, they have a) been getting pseudo-beat up for decades and b) are continuing to use back communication channels to have very meaningful and constructive dialogues with the politicians, policymakers and regulators. While things may certainly 'change,' the likelihood of a wholesale disembowelment of the insurers is remote. They know their job is to reconcile what doctors and patients want with what the premium will cover while maintaining reserves and a surplus that are tightly - and I mean tightly - controlled by State regulators. They'll continue to do that while contributing to the shape of coming health reform...quietly.

This is more akin to the faux professional wrestling than bloody cage fighting. Every time a politician rails against those loathsome insurers, think Hulk Hogan throwing a fake forearm at the Undertaker while stomping on the mat to make a big noise. Once they’re on the bus heading to the next show, they’re sharing drinks.

Cheers!

another irresistible list of books

I have lifted this from Sassymonkey who stole got it from Kailana, who got it from Booklogged's blog.

It's Entertainment Weekly's "New Classics" List. It's an interesting list, sure. I have read 20 of the books on the list (crossed out below) and loved them all except The Da Vinci Code (meh) and The Corrections, which I couldn't finish.

I have also bolded the ones I have in my house (via my spouse, gift, long term loan or my own purchase) that I haven't read yet. There are quite a few of those too. I'm happy to see several graphic novels on the list.

What do you think?

1. The Road , Cormac McCarthy (2006)
2. Harry Potter and the Goblet of Fire, J.K. Rowling (2000)
3. Beloved, Toni Morrison (1987)
4. The Liars’ Club, Mary Karr (1995)
5. American Pastoral, Philip Roth (1997)
6. Mystic River, Dennis Lehane (2001)
7. Maus, Art Spiegelman (1986/1991)
8. Selected Stories, Alice Munro (1996)
9. Cold Mountain, Charles Frazier (1997)
10. The Wind-Up Bird Chronicle, Haruki Murakami (1997)
11. Into Thin Air, Jon Krakauer (1997)
12. Blindness, José Saramago (1998)
13. Watchmen, Alan Moore and Dave Gibbons (1986-87)
14. Black Water, Joyce Carol Oates (1992)
15. A Heartbreaking Work of Staggering Genius, Dave Eggers (2000)
16. The Handmaid’s Tale, Margaret Atwood (1986)
17. Love in the Time of Cholera, Gabriel García Márquez (1988)
18. Rabbit at Rest, John Updike (1990)
19. On Beauty, Zadie Smith (2005)
20. Bridget Jones’s Diary, Helen Fielding (1996)
21. On Writing, Stephen King (2000)
22. The Brief Wondrous Life of Oscar Wao, Junot Díaz (2007)
23. The Ghost Road, Pat Barker (1996)
24. Lonesome Dove, Larry McMurtry (1985)
25. The Joy Luck Club, Amy Tan (1989)
26. Neuromancer, William Gibson (1984)
27. Possession, A.S. Byatt (1990)
28. Naked, David Sedaris (1997)
29. Bel Canto, Anne Patchett (2001)
30. Case Histories, Kate Atkinson (2004)
31. The Things They Carried, Tim O’Brien (1990)
32. Parting the Waters, Taylor Branch (1988)
33. The Year of Magical Thinking, Joan Didion (2005)
34. The Lovely Bones, Alice Sebold (2002)
35. The Line of Beauty, Alan Hollinghurst (2004)
36. Angela’s Ashes, Frank McCourt (1996)
37. Persepolis, Marjane Satrapi (2003)
38. Birds of America, Lorrie Moore (1999)
39. Interpreter of Maladies, Jhumpa Lahiri (2000)
40. His Dark Materials, Philip Pullman (1995-2000)
41. The House on Mango Street, Sandra Cisneros (1984)
42. LaBrava, Elmore Leonard (1983)
43. Borrowed Time, Paul Monette (1988)
44. Praying for Sheetrock, Melissa Fay Greene (1991)
45. Eva Luna, Isabel Allende (1988)
46. Sandman, Neil Gaiman (1988-1996) (The first one..)
47. World’s Fair, E.L. Doctorow (1985)
48. The Poisonwood Bible, Barbara Kingsolver (1998)
49. Clockers, Richard Price (1992)
50. The Corrections, Jonathan Franzen (2001)
51. The Journalist and the Murderer, Janet Malcom (1990)
52. Waiting to Exhale, Terry McMillan (1992)
53. The Amazing Adventures of Kavalier & Clay, Michael Chabon (2000)
54. Jimmy Corrigan, Chris Ware (2000)
55. The Glass Castle, Jeannette Walls (2006)
56. The Night Manager, John le Carré (1993)
57. The Bonfire of the Vanities, Tom Wolfe (1987)
58. Drop City, TC Boyle (2003)
59. Krik? Krak! Edwidge Danticat (1995)
60. Nickel & Dimed, Barbara Ehrenreich (2001)
61. Money, Martin Amis (1985)
62. Last Train To Memphis, Peter Guralnick (1994)
63. Pastoralia, George Saunders (2000)
64. Underworld, Don DeLillo (1997)
65. The Giver, Lois Lowry (1993)
66. A Supposedly Fun Thing I’ll Never Do Again, David Foster Wallace (1997)
67. The Kite Runner, Khaled Hosseini (2003)
68. Fun Home, Alison Bechdel (2006)
69. Secret History, Donna Tartt (1992)
70. Cloud Atlas, David Mitchell (2004)
71. The Spirit Catches You and You Fall Down, Ann Fadiman (1997)
72. The Curious Incident of the Dog in the Night-Time, Mark Haddon (2003)
73. A Prayer for Owen Meany, John Irving (1989)
74. Friday Night Lights, H.G. Bissinger (1990)
75. Cathedral, Raymond Carver (1983)
76. A Sight for Sore Eyes, Ruth Rendell (199
77. The Remains of the Day, Kazuo Ishiguro (1989)
78. Eat, Pray, Love, Elizabeth Gilbert (2006)
79. The Tipping Point, Malcolm Gladwell (2000)
80. Bright Lights, Big City, Jay McInerney (1984)
81. Backlash, Susan Faludi (1991)
82. Atonement, Ian McEwan (2002)
83. The Stone Diaries, Carol Shields (1994)
84. Holes, Louis Sachar (1998)
85. Gilead, Marilynne Robinson (2004)
86. And the Band Played On, Randy Shilts (1987)
87. The Ruins, Scott Smith (2006)
88. High Fidelity, Nick Hornby (1995)
89. Close Range, Annie Proulx (1999)
90. Comfort Me With Apples, Ruth Reichl (2001)
91. Random Family, Adrian Nicole LeBlanc (2003)
92. Presumed Innocent, Scott Turow (1987)
93. A Thousand Acres, Jane Smiley (1991)
94. Fast Food Nation, Eric Schlosser (2001)
95. Kaaterskill Falls, Allegra Goodman (1999)
96. The Da Vinci Code, Dan Brown (2003)
97. Jesus’ Son, Denis Johnson (1992)
98. The Predators’ Ball, Connie Bruck (1989)
99. Practical Magic, Alice Hoffman (1995)
100. America (the Book), Jon Stewart/Daily Show (2004)

Insurance Risk & Performance Risk: An Alternative Payment Mechanism, Compliments of the Robert Wood Johnson Foundation

While readers and the Obama Adminstration search for better ways to pay for health care, the Disease Management Care Blog remains skeptical of basic fee-for-service, capitation (or 'global fees') and pay for performance. Like the Three Little Bears, the first is too hot (it promotes overuse), the second is too cold (it’s a disincentive for care) and the third is just… unproven.

That’s why it continues to like the ‘episode of care’ (EOC) reimbursement approach of having a single fee for a medical event that covers all subsequent services over a set period of time. An example would be paying for the hip surgery, the hospitalization(s), the physical therapy and all the follow-up physician visits with a single check. Think of EOC as capitation (which is supposed to cover all unrelated medical services over a period of time, typically a month) for a single condition, not a single patient.

There’s a very understandable discussion of the topic in a Robert Wood Johnson Foundation supported report from the Network for Regional Healthcare Improvement. The DMCB likes their notion of distinguishing between ‘insurance risk” (based on the numbers and types of diseases that occur in a population) and ‘performance risk’ (based on what is done to mitigate those diseases, which is a function of the numbers and types of treatments that are applied). The folks at the Network argue that while there is overlap of performance risk with insurance risk, the performance risk still can be measured, monetized and transferred to the providers.

Think of it in terms of automobile insurance. Insurers can sell policies that are designed to make you 'whole' if you have an accident (that’s the risk). They assess your age, gender, past driving record and zip code, which helps define much of the risk being priced. They collect your check (the premium) along with checks from thousands of others. However, they also have to pay attention to how much it would cost to fix the various cars in their book of business, such as parts and labor. In the Network world, the car insurers would collect your premium but then could cut a deal with the car repairmen and their body shops by negotiating a standard fee (which is functionally now an insurance premium that they ironically have to pay) to manage all the repairs that occur over the course of a year. Since the repairs occupy the lion’s share of the costs most of the money goes to the repairmen in the ‘network.’

Ahhh, but you correctly point out that diabetes and high blood pressure don’t work that way, because there is no end - like there is with hip surgery or a car that comes out of the repair shop. No problem, says the Network folks: there are cars out there that don’t necessarily need new fenders but burn oil, have threadbare tires, worn seats and cracked windshields. Since the drivers can’t give them up (they don’t like the alternative), their car needs lots of extra maintenance. For those cars, the insurers can still cut a global performance risk transfer deal with monthly payments that don’t end. That’s called ‘condition-specific capitation.’

The DMCB likes the concept because its ultimately rewards the services that are being provided for the condition at an EOC level. The payment is better targeted. That being said, it has several caveats to keep in mind while we think about paying providers a set monthly fee for a specific condition:

1) if the payment is to be done at a provider level, it requires a significant amount of physician/hospital/provider coordination, with good information transfer and ironclad hand offs. That is more likely to be present in smaller integrated healthcare systems but is tough to achieve in usual community settings with independent providers. Electronic health records are necessary but are not sufficient to pull this off.

2) while many physicians ‘get it’ and would do all the things necessary to mange their risk with higher levels of efficiency, using technology appropriately and keeping their costs to a minimum, many fine physicians would struggle in trying to adapt to this kind of arrangement. Between ‘here’ and ‘there,’ much work would need to be done. This is not a turnkey payment solution. A new fee schedule is necessary but not sufficient.

3) which is why performance risk transfer may be better thought of in terms of disease management. The DMCB thinks DM organizations understand risk (that's their pedigree) and can partner with providers in the absence of formally integrated networks to maximize coordination. Disease management, however, is also necessary but not sufficient to pull this off.

4) this would be a bear to administer, which makes it unsuited for large “mainframe” insurers like Medicare. Accordingly, the DMCB doesn’t expect this to see the light of day in national healthcare one-size-fits-all reform efforts. However, among the smaller innovative, nimble employer-based self-insured entities out there, the DMCB hopes to see this given a shot. Who knows, if a competing government sponsored insurance entity is created, the private insurers may be able to compete by offering novel payment systems like this.

5) finally, while the payment process described above transfers risk, it’s not ‘insurance’ from the point of the State or Federal regulators. Ultimately, only one party can be responsible for managing the total risk of health insurance for an individual policy holder who pays a single premium. In other words, if a hospital fails to meet its contractual obligation to provide timely and medically necessary care which, in turn, results in additional cost to the policy holder, the party ultimately responsible for fixing it is still the health insurer, not the provider.

Five "Shovel-Ready" Health Care Reforms

Five "Shovel-Ready" Health Care ReformsBy Brian Klepper & David C. KibbeMicrosoft Health Vault's leader Peter Neupert has a wonderful blog post that makes two important points really well. One message is that health care reform is about the outcomes, not the technology. We should think expansively about which technologies to invest in, based on the results we want to get.The other message is the

The Post Inaugural Health Wonk Review Celebration Event

There is something very unique about the United States’ mix of unabashed patriotism and Hollywood showmanship during times of national celebration. Sure, other countries can assemble their own organized spectacles, but there is something exceptional about all those flags, speeches, music, salutes, color guards, banners, close ups on children’s faces, tributes to heroes past and present as well as the earnest rhetoric that makes the hardest cynic proud to be an American.

What better example of this phenomenon than the star studded We Are One pre-inaugural concert, complete with its own Washington D.C memorial building with an A-list cast of cinematic liberal luminaries and mega-rock stars? Sure, the entertainers may not know all that much about the ins and outs of our new President’s policies and yes, the music’s lyrics had nothing to with foreign affairs, health care or the federal budget, but their hearts were in the right place. It was a heluva show, even if you had to watch it on a jumbotron.

Since this is a grand participatory democracy and the Disease Management Care Blog believes no part of our nation’s body politic should be immune from having a chance to celebrate, it decided that we wonks and readers could have our own concert. ‘What?!’ you say? No stage, no sound system, no Hollywood types, no rock stars? ‘No problem’ says the DMCB. This is a virtual world, the web is our stage and the music is only a click away. And we have speeches aplenty. The DMCB knows because it has screened them all.

Ladies and gentlemen, welcome to the Post Inaugural Wonk Celebration Event, brought to you by the best and the brightest thinking of some very smart health policy blog writers. Read, learn, listen to some tunes (assuming you have speakers) and enjoy while we wish President Obama the best in his coming administration.

Taking the stage first is New Health Dialogue Blog’s Joanne Kenen, who examines a recent MedPAC recommendation that hospice care be ‘front loaded’ with higher payments at the start of the care and then “back filled” with higher payments when the end comes. MedPAC knows that when you cover a service that offers better care for a higher payment that is welcomed by hospitals, physicians, families and patients, gaming is as inevitable as death and taxes. And look, the band taking the stage is Aerosmith, singing take me to The Other Side.

Oh double look, here comes Brady Augustine of the MedicaidFrontPage blog, who has a three-fer. He looks at the status of SCHIP renewal and extension and the implications of failing to secure Republican support for the inclusion of immigrants as well as the lack of available funding at the State level. Then he reviews the recent report in the New England Journal of Medicine that operating room check-lists save lives. Most of all, DMCB likes his explanation of the curious logic behind Florida’s nursing homes’ willingness to support a tax increase to secure more Federal matching funds. Complex? Yes. Creative? Yes. Is this the kind of dysfunctional funding that distracts us from creating high performing care systems? Yes. The very opaqueness of public funding is not unlike the lyrics from Brimful of Asha by Cornershop. The DMCB doesn’t understand these words to this song either, but doesn’t care because it thinks a camera is focusing on him and the spouse while they are grooving.

For further insight about SCHIP, listen to Anthony Wright of the Health Access Blog. He points out that the Democrats not only have the Republicans to deal with, but also their more leftward leaning colleagues who are demanding a lower threshold for access of immigrant children to SCHIP. Drawing on the lessons from California’s star-crossed run at expanding access to health insurance, he notes the pursuit of bipartisanship in the defense of health care is no virtue – it’s a delay. Which is why Dierks Bently bemoans his inability to keep the Republicans and Democrats from splintering by singin’ Trying to Stop Your Leaving.

And here comes Maggie Mahar of the Health Beat Blog on the same topic of SCHIP. Yes, she says, partisanship is a messy time consuming feature of the formulation of policy, but that’s because partisanship is another word for a willingness to debate and act on social values. Ditto the role of ideology in evidence-based medicine, which she argues should be implemented using a set of beliefs. Is this a necessary evil or a vital part of our democracy? Check out Maggie’s twin posts here and here on the matter and decide for yourself. Katy Pery can’t decide, so she’s decided to croon Hot N Cold for the crowd.

The DMCB and the crowd are big fans of nurses. Overworked, underpaid, these healthcare foot soldiers probably know more than anyone about what’s good and what’s bad about the system. Which is why Annie of the Virtuous Skeptic’s recounting of the American Nurse’s Association’s Social Policy Statement would be welcome in any venue. Read and learn more than you’d otherwise hope to learn about his noble profession. Yes, they’re Unglamorous sings Lori McKenna, but they rock!

Think our neighbors to the north are convinced that their healthcare system is all that it should be? Sam Solomon is now up and points out in Canadian Medicine that that may not be the case. The physicians are debating the merits of a public vs. more private approach and it’s being played out in a contentious Canadian Medical Association election between family practitioner Dr. Tracey, who leans toward greater privatization of the system, and Dr. Turnbull who supports a publicly funded system. Read their ‘vote for me’ statements and find out that even with the dominance of public funding, there are eerily similar debates over administrative work, access, payment levels, evidence based medicine, the role of market forces and electronic records. Along with us, our Canadian friends are struggling to find a Better Way. Ben Harper is now up singing about it.

While we’re on the topic of Canada (hey, if an Irish band can rock the pre-inaugural concert, international stuff is fair game) check out The Lucidicus Project’s Jared Rhoads’ assertion that Canada is really all about pseudoscientific global budgeting that really relies on patient queues and the questionable substitution of cheaper services to make up the difference when the yearly allotment runs short. The DMCB has heard this argument over and over but some Canadians apparently believe it. Why else would they Drive South asks John Hiatt?

It’s David Williams of the Health Business Blog’s turn and he’s here to discuss the Ingenix settlement. As the DMCB understands it, Ingenix was a business hatched by the managed care industry that in turn sold information about prevailing fee schedules to the managed care industry. The allegation from the New York Attorney General is that it artificially lowered the published fee schedules so that insurers could pay less when their patients went out of network. While many reports would have you believe that the AG helped the little guy here, this contrarian post by David points out that many fee schedules are inflated, opaque and highly variable. He doesn’t think the terms of the settlement is all that. This reminds the DMCB of just another chapter in the financial arms race between insurers and providers. Figuring out how to understand just how insurers pay providers? Donovan from this black and white vintage link tells the jumbotron viewers that we might as well try to Catch the Wind .

Not satisfied and want to hear even more about claims payments? Then pay attention to this other post from the Health Access Blog. In a fit of unusual clarity, the California Supreme Court has ruled that individual patients should not be put into the middle of a payment dispute between a big institutional hospital emergency room and a big institutional insurer HMO over the adequacy of payment for treatment. If the ER feels they are not being paid enough, the California Supremes say there are plenty of mechanisms that allow them to appeal. Emergency rooms balance billing patients? Outrageous sings Paul Simon. The crowd loves it.

But wait, there’s more on the Ingenix matter. Richard Eskow of The Sentinel Effect is telling the revelers about the Ingenix settlement from the perspective of someone who personally got stiffed to the tune of an extra thousand bucks – and he’s an industry insider. While he thinks the terms of the settlement are good, he has his doubts about its overall impact because consumers still won’t understand the pricing, won’t be able to negotiate the charges or avoid being billed for extraneous services. Beware, he says, the settlement is only a piece of the puzzle: it won’t have a big effect. Del Amitri agrees and is now singing that patients are always the Last to Know.

Henry Stern of InsureBlog helps the concert-goers be among the first to know about a study on Consumer Driven Health Plans released by UnitedHealthCare. They found there were considerable savings and that the bulk of them come from changes in health care utilization, not cost shifting. The DMCB wants to learn more but, along with the rest of the crowd, needs to move onto the next act. You can find the post and the link to this report by clicking here. You can hear Joe Walsh sing about this Happy Way of insuring folks by clicking here.

Joe Paduda of Managed Care Matters entertains by donning the swami hat and helps our virtual concert-goers prepare for What Is Coming for Health Plans. The ‘shun’ keywords are consolidation (and he names names), their response to coming legislation (a mix), regulation, physician collaboration (‘Why can’t we be friends?’), expansion of Medicaid, contraction (thanks to loss of jobs and fewer member months) and stagnation. Find out the details while Patty Griffin commiserates with the health plan audience members out there by singing We Don’t Need No Bad News.

Nancy Miller of ultrasound technician schools blog frets that open computer terminals laying about hospitals are making it too easy for n’er do wells and evil doers to blow past the nominal HIPAA safeguards and steal your identity. It must change, she is telling the crowd – hospitals are obliged to take appropriate action. And here comes Green Day, emphasizing her worries by singing Warning.

Tom Wilson and Vince Kuraitis of the e-CareManagementblog give the throng eight takeaways from the Medicare Health Support on how to build better bridges toward better population health care. This is a must read if you want to know where the disease management industry is going. While you’re at it, you can enjoy his updated picture. And now up, appropriately enough, are the Pretenders telling the disease management vendors to Stop Your Sobbing.

Few people on the Mall would agree that’s there’s nothing necessarily wrong with making some money, unless of course, you are a for-profit health insurer and have a reputation for sticking it consumers. Not so fast, says forenamed Louise of the Colorado Health Insurance Insider, who went insurance shopping and found the premium amounts for a comparable policy from for-profit and not-for-profit insurers were pretty much the same out in her section of the country. Since the health insurance market is driven by price, price and price, concert goers would think that the non-profits would be able to use their favorable tax status and lack of any need to pay shareholders to reward consumers with lower costs. Not so, and that’s why the Mavericks are on stage singing Crying Shame.

Speaking of making money at a company level, how about making money at an individual level? Roy Poses of the Health Care Renewal Blog discusses one allegedly underhanded way of doing it in this post about a $1 Million CEO. Is this greed? Is this failure of Board governance? Conflicts of interest? Just another sad example of how disjointed things have become when it comes to performance vs. compensation? Roy has his opinion and this is your chance to develop one on your own. Whatever we do, however, the most important thing is that we don’t Shut Your Eyes to the matter. That’s what Snow Patrol is singing.

The DMCB suspects there are some partiers on the mall. Alas, allowing alcohol and drug abuse to wreck your personal and professional life is a terrible waste and a huge toll for our nation’s health care system. A standard approach is to refer such persons for counseling and treatment. But does it really work? That is the question raised to the crowd by Glenn Laffel of Pizaazz. This is not an insignificant issue. In these days of evidence-based healthcare, Glenn asks about that evidence and furthermore, points out that without it, it’s difficult to credential drug and alcohol rehab programs. MGMT asks if this means it’s Time to Pretend that we really know what we’re doing.

Think those wall sized jumbotrons are technology writ large? Well, healthcare is also moving so fast that its disruptive technology is being disrupted by the disruptiveness of even newer technology. Case in point brought to the audience thanks to David Harlow of the HealthBlawg: American Well, which consists of a virtual online and telephone consultation service with access to a wide range of physicians that are available for 10 minute appointments that cost about $10 (a co-pay with insurance) to $45 (no insurance). Madonna agrees about the pace of change while she sings Ray of Light.

Michael Cannon of CatoAtLibertyBlog takes on the prospect of the Obama administration pulling the rug out from under the ENTIRE 9 million member strong Medicare Advantage Program. Michael reminds listeners that this contrasts conspicuously with candidate Obama’s promise to maintain choice when it comes to insurance options. He thought that Plan A of those darn liberals was to starve Medicare Advantage by slowly reducing payments but this frontal assault via outright cancellation could mean the end of a huge batch of innovation, cost savings, quality improvements, provider incentives and care coordination in a successful part of the Federal insurance program. Has the Obama Administration already Missed the Boat? Modest Mouse sings about it.

Robert Aurbach of Workers’ Comp Insider is next up and looks at how workman’s compensation payments that have already been arranged for injured workers can be held hostage by Chapter 11 bankruptcies. Patients are ill prepared when their payments suddenly stop, are unequipped to deal with the cross-state legal issues and are being shortchanged by underfunded so-called guaranty funds he warns. Even Joe the Plumber, for all his bombast, could be left holding the bag as a ‘least worthy creditor,’ not a human being who was counting on that monthly check to make ends meet. And even though Ted Nugent would probably rather sing for Michael Cannon, he rocks on over this by calling it an unnecessary Stranglehold.

And here’s a new term to reward you for attending this concert all the way to the end! Neil Versel of the Healthcare IT Blog finds that the definition of ‘academic bulimia’ has reached enough of a critical mass to be applicable to the error-dense environment of the teaching hospitals that don’t have adequate information technology (IT) decision support. Wake up hospital administrators, he says: When it comes to IT support, the choice should be Easy. The Barenaked Ladies are on stage saying so.

too good to be called filler

I think I am taking the day off from writing today. I have another video for you that is well worth watching. It's from ill Doctrine and it is the best video blog/rant that I have ever seen.

Call for Abstracts!! Do You Have a Good Story to Tell About the Care of Populations?

If so, you should strongly consider submitting an abstract for the DMAA Forum '09 Meeting. You or your colleagues may be put off by the prospect of assembling a presentation and having to present it in a mini-lecture format, but keep in mind that its a heluva lot easier than you may suspect. The abstract reviewers from DMAA are not only interested in a sufficient degree of methodologic rigor but they are more interested in new and meaningful approaches to employee, insured, uninsured or community-level populations. Folks in the audience are supportive and enthusiastic. They'll be counting on the same level of support from you when they make their presentation.

How does the Disease Management Care Blog know this? Because it has served as an abstract reviewer. It likes new program descriptions from newcomers. That's where all the innovation is.

Ask yourself:

Thanks to your novel program, did people lose weight or exercise more often? Stop using tobacco? Have better control of their chronic illness?

After your unique intervention, did enrollees see their primary care physicians more frequently? Stay away from emergency rooms? Have lower claims expense?

Once you were done, did persons express greater confidence in dealing with their chronic illness? Did they like their relationship with your health coaches?

While your excellent initiative was being launched, did the physicians change their approach? Were they willing to participate? What feedback did you get?

And let's not forget the Patient Centered Medical Homes. This is a perfect setting to share preliminary results about the many pilots underway and share notes with others at the Forum who are undoubtedly going to be talking about the same topic.

There are many reasons to submit. It's not only a reason to go to sunny San Diego, it's a chance to gauge the reactions of other experts in the field and solicit their input. It may help you spot changes that could be made to further improve your program going forward. You may be approached by the media for a quote. Various peer review journals representatives may ask you to submit a manuscript for possible publication. You may get an award for best presentation. You'll be labeled an expert. You can put this on your CV. Once you break the ice, you'll be even better at submitting for Forum '10. DMAA is a good place to trial run your abstract prior to submitting it to another meeting. This is a good way to not have to think about the prospect of how badly healthcare reform will be messed up in D.C. The DMAA 'Faculty' name badge makes a great fashion accessory and memento to show your relatives. Finally, you'll also get to meet the most excellent DMAA staff and their indefatigable leader, Tracey Moorhead.

Face it: when you and your colleagues launch a population-based care program, you probably have a pretty good idea of what the baseline is like and you probably have at least a good idea of what you'd like to see happen. By performing at least partially complete measurements and having an adequate comparison group, you have the ingredients necessary to submit your abstract along with all the big boys.

Go ahead.... the Disease Management Care Blog dares ya. You have until 8 PM EST Feb. 20 to pull it together. Mark your calendar, close down your web browser and hammer out a preliminary Word document. You thought about it last year, this year is your chance to actually do it.

moments

Typing this with the TV on...

What a day! I'm watching Michelle Obama wave at the crowd as I type this. And I have shivers.



This video gave me shivers, too. Pete Seeger is an old man now. I wonder if he thought he would ever see this day. I loved this so much.

And I loved the inclusion of the lyrics that are so often excised in this song (I certainly didn't learn them in school):

As I was walkin'  -  I saw a sign there
And that sign said - no tress passin'
But on the other side  .... it didn't say nothin!
Now that side was made for you and me!

Chorus

In the squares of the city - In the shadow of the steeple
Near the relief office - I see my people
And some are grumblin' and some are wonderin'
If this land's still made for you and me.

Obama is onscreen now, heading down the stairs to join the crowd. What must he be thinking right now?

Did you know that there is a Canadian version of this song?

"from Bona Vista, to Vancouver Island, from the Arctic Circle to the Great Lake Waters - this land was made for you and me!"

The video also includes my two boyfriends, Bruce Springsteen and Tao Rodriguez. Yum! And everyone in the crowd is so happy. Check out George Lucas. And a bunch of other people who I'm sure I should recognize.

Here he is!!!!! He's looking very Presidential. And confident.

My older son called me from school this morning. He and his friends had been combing the school for an available (and functioning) TV. His teacher suggested that a parent could tape it, so I am doing that now and they will watch tomorrow. I think it is so cool that they want to. Remember that we are in Canada and they are in Grade 5.

Rick Warren is speaking now. I imagine he will stay away from gay marriage. He's invoking Dr. King as I type this.

Obama's Playlist has been posted. One of the song's I nominated (it means "the complaint of the seal in Alaska") made the cut. It's a terrific list - diverse and interesting. And truly representative. Apparently, there were more than 130,000 votes cast.

If you are stuck inside today and want some diversion, check out The Seated View. Lene has lots of great links to interesting things posted there. There's one link though that struck me as typically American. What do you think about the Back-Up?

Oh, Aretha is singing! Shivers again! And goosebumps the size of golf balls!

I am going to try and tear myself away from the TV soon (but not just yet) so I can make dinner and go and meet Sassymonkey for decadent afternoon pint (or two) and some knitting. Going to celebrate a clean scan, the completion of my latest round of edits - and this incredible moment in history.

Biden is being sworn in! Obama is next!

Let's all hold some joy in our hearts so that we can work together to bring some real, lasting and positive change to this world of ours.

He's being sworn in now! He's screwing it up a bit, it's so cute. First sign of nerves. That's it! Congrats my American friends!

Another Top 100 List for the Disease Management Care Blog

While the Disease Managment Care Blog reels from all the excellent submissions for the upcoming Health Wonk Review, it takes comfort (and some pride) from knowing that it's been named in another top 100 list. If you're reading this and learning something, you're not alone.

HWR deadline tomorrow!

Healthways Crawls Back

As regular readers know, the Disease Management Care Blog likes to keep an eye on Healthways' financials. Because it's a publically traded disease management organization, the DMCB thinks its rising and falling fortunes are a bellwether for the rest of industry, particularly the privately held companies (an example might be LifeMasters) and the entities that are subsidiaries in in larger companies (an example might be McKesson).

It took a while for the DMCB to catch up with the latest report that was released on January 8. Briefly, it looks like 'top line' revenue for the three months ending November 30 is up compared to a year earlier by almost $10 million. By the time all this money trickled though the organization, there was a net of $12.6 million, which was also up compared to last year by over a million. The number of covered lives in the U.S. and internationally is up, internal costs are being pared, there has been 'continued improvement in result from the Hedicare Health Support pilot (comment: does that mean losses and/or foregone fees are not as steep as anticipated?) and Silver Sneakers is expanding. Debt is down but so is their cash on hand (from about $35 million to just over $4 million).

Not bad. Healthways may be crawling back. And it would appear the street agrees. The image below may be blurry but check out the slight upward trend in the stock price waayyyy over on the right. There's also an analysis from that crazy guy Cramer here. That's pretty good for a company in today's markets.

As discussed many times, the DCMB is generally bullish on the disease management industry. More companies are seeking self-insured arrangements (that include disease management), disease management organizations can scale telephonic coaching with maximum efficiency better than anyone else, the DMCB doesn't think most health insurers ultimately want to own clinical care programs and last but not least, health care reform is tilting in the direction of care management for chronic illness.

The disease management industry is also tied to the health insurance business cycle. Such are the fortunes of a maturing industry with good years and bad. In the short term, the DMCB expects growth to be blunted as a) unemployment continues to climb and persons lose the insurance that's paying for their disease management and b) insurers push back on price. Healthways is also dealing with a potentially expensive lawsuit that could theoretically result in ' treble damages plus up to $11,000 per false claim .' Yikes

In the long term, however, prospects for the core business of helping healthcare consumers manage their chronic illness remain good. P/E ratio still around 8 and the stock may be on a rebound. Draw your own conclusions.

The DMCB does not knowingly invest in the disease management industry and, like many amateurs trying to build a retirement fund, relies on a professional financial manager to help it lose its money.

right to the point

This blog is having an existential crisis. I don't seem to write that much about cancer these days. A more appropriate title might be in order ("Occasionally About Cancer?" "Not Just About Life, Kids, Dogs, Books, Weather Extremes and Cancer"?) but then how would people find me?

I was interrupted by the phone ringing. This is the subsequent telephone conversation, transcribed pretty much verbatim:

A (nurse who works with my oncologist, returning my call about my most recent CT scan results*): "May I speak to Laurie, please?"

Me: "This is Laurie."

A: "Hi, it's A. from the cancer centre."

Me: "Hi A."

A: "Everything's fine. No change."

Me: "Yay! Yay! Yay! Thank you, A!"

A: "You're welcome! Bye!"

The cancer centre's stated policy is that they do not give out results over the phone but my oncologist has been making an exception for me for a while now. If they ever do ask me to come in, I will be very suspicious.

So, I am happy to say that I have nothing new to report on the cancer front.

On another note, go read the comments from my last post. There's some good stuff in there.

*I just tried to link to the post about my most recent scan (it was last Wednesday) and found that I didn't write one. Instead, I wrote about the weather and losing my dog. It appears that, while they still make me anxious, CT scans are less newsworthy than the cold and my pets. Lucky me.

JAMA Commentary on Consumer Driven Health Care: It's Time to Give Healthcare Consumers a Chance

In the latest (January 21 and not on line yet) issue of JAMA, physicians Robert Berensen (of the Urban Institute) and Christine Cassel (of the American Board of Internal Medicine) argue that consumer driven health care may not be what patients need. Briefly, they argue that this kind of approach – in which consumers have full access to information on price, quality and services and get to choose accordingly – places patients at a huge disadvantage. It also discounts the proven and long standing value of physician professionalism. According to Drs. Berensen and Cassel, the knowledge needed by the consumer is too complicated, the relationship with the health care system too asymmetric and patients are too vulnerable to making bad choices. Compared to your physician healthcare system tour-guide where your doctor can act as an advisor, fiduciary and advocate, the medical marketplace is a lousy option.

The Disease Management Care Blog doesn’t entirely buy this at several levels.

While physician professionalism is an ideal, physicians are also:

Humans who carry their own bias and agenda into their patient encounters.

Vulnerable to economic factors when framing patient options.

Even when salaried and even when in premier academic settings, may belong in organizations that are monopolistic, predatory and not acting in their patients’ interests.

Drs. Berensen and Cassel also fail to distinguish between preference sensitive and insensitive care. The former involves healthcare services that are subject to patient choice (for example, a total knee replacement for progressive osteoarthritis), while the latter involves services are not readily optional (for example, a total hip replacement following a fracture). The DMCB accepts the notion that women in labor, men with heart attacks and grandmothers with hip fractures generally cannot exercise the usual laws of economics in a medical marketplace.

However, persons with chronic illness – such as osteoarthritis, prostatism, diabetes, high blood pressure and coronary artery disease – generally do have the ability and the time to get involved in determining much of the content of their care. This includes the outcomes they want from treatment and the amount of money and effort they are willing to expend to get there. There is plenty of great commentary and reviews that show that consumerism is an untapped force in healthcare.

The DMCB has lived through decades of physician professionalism and isn’t all that impressed. While it’s a great notion, relying on its routine applicability to day-to-day medical practice, while attractive, is at best naïve and at worst the last refuge of the status quo. It's what the doctor ordered, not what patients need.

We can work on expanding and improving the profesionalism but it’s time to give the consumers a chance when it comes to health care choices for chronic illness.