McAllen Texas and Healthcare Utilization: A Function of Statistical Variation, Not Poor Policy

How about McAllen Texas? Readers may recall that locale* was the topic of an essay in The New Yorker magazine by the impressive surgeon-essayist and Democratic advisor Atul Gawande. The McAllen 'hospital referral region' has the dubious distinction of having been identified by the Dartmouth Atlas as being close to the top nationwide (pretty cool graphic) for the amount of total fee-for-service Medicare dollars spent per beneficiary in 2006.

The DMCB’s first reaction was “so what?”

It took a second look when that hapless locale was seized upon by Peter Orszag of the Office of Management and Budget (OMB), Consumer Reports and some notable blogs as the symbol for all that ails American healthcare. Commentators are accusing the ‘McAllens of this country’ of consciously and unconsciously economically ripping off the system with precious little quality to show for it.

Yet, the dubious DMCB remains unexcited about Dr. Gawande’s faux discovery and disappointed that others haven’t considered the most likely cause of McAllen’s outlier status. Is there something really special about McAllen or is something else going on?

To illustrate the point, conduct a thought experiment by imaging many bags of pennies (to pay the primary care providers), quarters (for the rest of the physicians) and dollars (yes, they are available as metal coin) for the hospitals suspended above a huge map of the United States. Mentally open the bags, releasing coins that fall, clatter and roll across the map. Since the distribution of the coins is random, some areas of the U.S map will have no coins, others might have just pennies, others may have dollars and pennies, some will have all three and a few will have lots of all three. Somewhere on that map, however, there will be a pile of coins that is bigger than the rest. Perform the same experiment using Monopoly style plastic clinics and hospitals across a board-map and the same thing will happen. In these thought experiments, the area of the map with the extreme outlier status happens to be McAllen*.

It’s hard for non-statisticians/non-economists to think of human behavior in markets as being ‘randomly’ distributed around an average, but it’s true. The best (painfully so) examples of this are the performance of mutual funds, as well as what happens to losing vs. winning teams and their professional sports coaches . The same is true in healthcare: given the overall upward growth in the number of hospitals, specialists and clinics with an inevitable distribution (both high and low) around that trajectory, it is statistically inevitable that there will be a McAllen somewhere in the United States.

It is the nature of our minds to believe there must be something “causing” outliers. In other words, there must be something about McAllen that attracted all those coins, right? The DMCB, in reading Dr. Gawande’s article, thinks that may be true in Miami (which is number 1 in the U.S), but it doesn’t think that's the case for McAllen as described in the New Yorker magazine article. The gumshoe M.D. reporting clearly shows the McAllen providers are mystified by their status. It’s not as though they planned to take advantage of the system. In fact, they didn’t. That’s because it’s all random.

This is important because most healthcare providers involved in quality improvement learned long ago that ‘identifying’ and then ‘managing’ outliers with targeted interventions is a poor way to promote overall system improvement. Outliers naturally regress to the mean over time and they're not the problem anyway. Rather, the trick is to reduce overall variation around the mean (reducing the standard deviation) and to move all providers toward a better average level of behavior. That’s a lot of complicated work that, frankly, isn’t as enthralling to editors or the readers of The New Yorker. It's too much work.

While popular media can be forgiven for using simplistic descriptions of extreme outlier anedotes to pander to a political agenda, the DMCB isn’t too sure about Dr. Gawande. However, the DMCB is most frightened by potential reaction of the OMB. Short of complete central planning for the entire health care system, random distributions of performance, expense, quality, claims, satisfaction and countless other measures around a mean will be unavoidable. Of all persons, Dr. Orszag should understand that outliers are an ironic certainty, not evidence of malfeasance. Most are anomalies, not proof of anything. They are, in short, interesting, but not lessons and certainly not the stuff of policy making.

*correction: McAllen is not a county in Texas.

Money-Driven Medicine—N.Y. Premiere of Film, June 11

Many of you know Maggie Mahar who comments regularly on this blog and has one of her own.She is also the author of "Money Driven Medicine: The Real Reason Health Care Costs So Much."Now here is something to be impressed by, Maggie's book has been made into a movie! Here is a recent post from her blog, Health Beat, with an open invitation from Maggie to all you health care wonks out there to

Is 'Patient Centered Care' the Jordan River for Health Reform? Thoughts on Dr. Berwick's Piece in Health Affairs & Implications for Disease Management

Ever hear of 'patient centered care?' You might think those are just the standard buzzwords applied to any healthcare initiative that means well. Like.... reducing rehospitalizations, promoting access to primary care, increasing immunization rates and expanding coverage to the uninsured. They’re all ‘patient centered,” right?

Wrong.

The ever insightful and occasionally contrarian Don Berwick of the famous Insitute of Healthcare Improvement takes up the topic in a Health Affairs 'web exclusive.' It's worth a look for anyone interested in treading on the less traveled paths of health reform. While there is a surprising amount of policy history behind the idea, patient centeredness ultimately means that the patient is in charge. Period. That means it's the responsibility of the health care system to meet the patient's needs as defined by the patient - not the professionals, not HIPAA weenies, not pencil headed administrators and certainly not picayune insurers hiding behind reductionist definitions of medical necessity.

Wow.

Before you snort derisively at such a naïve notion and decide to surf on over to the Health Care Blog for more tiresome reruns on the virtues of single payer systems, the wonderfulness of EHRs and the evils of AHIP, pause and think about walking on this wild-side. Then realize Dr. Berwick has already anticipated the three biggest objections from us know-it-alls in the healthcare expert class:

1) Patients may override evidence-based medicine. Dr. Berwick thinks that is a small price pay in exchange for responding to a population of patients that are far better informed than we give them credit for. It is very possible to rely on education coupled with lots of provider dialogue to help patients choose wisely. While some may make unwise decisions, that’s more likely a function of the quality of the education and the dialogue. Last but not least, a few crazy and demanding patients should not hold the rest of the medical world hostage.

2) Patients may use up precious resources. Dr. Berwick asks 'as defined by who,' especially when you consider that demand for health care services doesn't drive supply, rather it's vice versa. Paradoxically, if persons were truly allowed to make their own decisions, the overall demand for health care services could go down.

3) Patients may lose out on the two-way doctor-patient relationship. Dr. Berwick points out that it is far more common for docs’ to tell patients what they can’t have, coupled with emotional distancing. This is a way out of the ‘no, because…’ Desert to the Promised Land of 'yes, if....' Patient Centeredness is our way of getting over the Jordan River.

And he has some simple suggestions. For patients, care needs to be customized, transparent and fully under their control. The training of young physicians needs to be retooled. Older physicians need to be reassured. Finally, providers of health care services can measure performance on patient centeredness using long established and validated surveys created for that very purpose.

The DMCB is intrigued. While Dr. Berwick can be forgiven for restricting his perspective to the patient-physician axis, that doesn’t mean those of us in the population-based care business can’t go further in thinking about this outside the box:

First off, disease management organizations need to approach the topic with cautious optimism. Veterans will recall that the earliest underpinnings of the industry was "patient empowerment." It sounded good at the time, but we were accused of undercutting the physicians' authority. The DMCB appreciates the irony, but doubts a word switch from 'empowerment' to 'centeredness' - even if embraced by Dr. Berwick - will make it any more palatable. That doesn't mean our colleagues in the population-care business shouldn't be prepared to speak to the topic. After all, we are experts.

A small minority of self insured employers and their broker-consultants would be the most likely to embrace a yet-to-be developed 'patient-centered health benefit.' If they can be found (and if the Obamacare blob doesn't impede innovation in commerical employer-based settings), these brave souls could end up being the vanguard of a new chapter in health care reform. An innovative disease management organization could help. Medicare will be struggling on how to sponsor a demo on the topic years from now.

The DMCB thinks the industry-wide focus on ‘evidence-based’ discreet HEDIS measures is a barrier to patient centered care. One way to dispatch this is for insurers to think about a) waiving any and all utilization review and b) pay full P4P to any provider group that convincingly demonstrates they adhere to patient centeredness. Why not? If a patient doesn’t get a mammogram, it’s because the educated patient chose not to. If a high dollar MRI is ordered, it’s because the educated patient wanted it. To go even further, insurers could offer up their own X-Prize to any physician group that develops the criteria and delivers on the promises of the patient centered care approach. Disease management organizations could provide the necessary support for a patient centeredness initiative and help sponsor the Prize.

Why not?

When We Really Do Health Care Reform They'll Know It In McAllen Texas

In recent posts I have expressed my concern that the Congress has all but given up on real health care reform and seems more interested in entitlement expansion.I worry that the Democrats have found the path to paying for a health care bill (note that I did not say health care reform).I will suggest that path includes a little cost containment window dressing so they can spin that they have a way

the Latest Health Wonk Review Is Up!

Tinker Ready is a Bruce fan, which has 'juiced' her summary of the best and brightest of the latest health policy blogs over at the Boston Health News blog. Let's face it, the Disease Management Care Blog's magic may give you one step up but if you really want glory days, stop dancing in the dark, get in your pink cadillac and (e street) shuffle on over to the paradise of wonky insight here.

UnitedHealth Knows How to Save $500 billion In the Medicare Program--So Why Do They Need the Extra Private Medicare Payments?

This from Erica Werner's AP story today:A major health insurer [United Health Group] says the government can save more than $500 billion in Medicare spending by sending patients to less expensive, more efficient doctors, reducing hospital visits by the elderly and cutting down on unnecessary care.So UnitedHealth knows how to save $500 billion in Medicare spending.Aside from the fact that all of

The Healthcare Reform Circus

The Disease Management Care Blog spouse doesn’t understand why her husband likes to go to the circus. Well, it’s the Technicolor noisy 3-D spectacle of it all: the elephants, trapeze artists, the ringmaster’s bombast, the army of silly clowns, grimacing tigers, brazen horse-riding Cossacks plus the children of all ages whooping it up while they wave their overpriced battery-powered blinking plastic batons.

Plus, as an added bonus, who else but the DMCB would use this year’s version of The Greatest Show On Earth as a link-laden metaphor for the Big Top of healthcare reform?

In General: compared to previous years, this show was skinnied down: the arena seemed cavernous compared what was happening on the floor: fewer acts with fewer actors. It seemed the economy was sucking some of the air out of the theatrics. It reminded the DMCB of $1.5 trillion worth of air.

The Clowns: the DMCB may have been touchy thanks to the sugar-based caloric density in the surrounding miasma, but it thinks the jesters sported a rather snooty European French-accented persona. This is what we aspire to? What's more, the clowns were clearly responsible for filling the ‘empty’ parts of the show with distracting feel-good silliness while the real work went on outside of the spotlight.

The Elephants: good grief, they are huge. There may have only been ten of them but when they appeared, there was no looking away. Like the uninsured. And one of them, well, did what elephants are known to do while they’re stomping about. A warning perhaps?

The Trapeze Artists: success of Le Cirque du Soleil has clearly prompted a disruptively innovative change from the old fashioned airborne aerial acrobatics to a more flowing crowd-pleasing style of eye candy. Behold the new style of policy making.

The Guy Being Shot Out of the Canon: Absent. Just like the Republicans. ‘Nuff said.

Dogs Chasing Frisbees: quick, nimble, never giving up and often unwilling to let it go. Reminds the DMCB of the healthcare blogs.

Motorcycles: that’s right, a metal caged sphere of death filled with up to seven (seven!) noisy high-speed choppers that miraculously failed to crash into each other. The DMCB doesn’t know how they did it, but it has come to appreciate the how the physics of centripetal force can be altered to make things go up when they common sense says they should go down.

The Tigers: what magnificent beasts. It was quite the sight to see them slinking meekly into position, either sitting, laying down, rolling over or leaning back with claws up on command from the trainer. The DMCB, however, remembers the days when a rifle toting guard was discreetly posted just outside the ring. That may not be such a bad idea even today.

The Horses: and at full gallop too. When they and their riders were stampeding across the floor, it seemed there was no stopping them. But, as persons in the front rows quickly discerned, the horses’ trajectory was not inevitable.

The Ringmaster: The appearance and style were eerily similar.

The $16 Dollar Seats: Considerably cheaper than the seats down below and probably far less than the ‘celebrity’ guests who got to ride around in festooned carts right in the middle of the show. While the righteous DMCB is thinks it’s a crime to deny equal access to first-dollar coverage of the best circus view available for everyone, the DMCB is sad to report that the likelihood of getting the spouse into clown wagon next year is remote. In the coming year, the DMCB will seek movement across the stages of change and aggressively attempt to modify her noncompliance.

Care Management Can Help As Medicaid Enrollment Increases Nationwide

The Disease Management Care Blog got this submission from one of its colleagues who helps coordinate McKesson's ubiquitous disease management programs. As noted in prior DMCB posts, the value of these kinds of population-based initiatives is not being questioned by commercial insurers or in State sponsored managed care or Medicaid fee-for-service settings. Jim presents a convincing argument about why the taxpayers and their elected representatives cannot afford to not have disease management programs as part of the solution to increasing enrollment, escalating costs and serious concerns about quality.

By Jim Hardy

One percent doesn’t seem like a lot.

But every time the U.S. unemployment rate increases by 1%, about 1 million more Americans join state Medicaid programs, our country’s health insurance program for children and adults in low-income families, the elderly and people with disabilities.

This is always a cause for concern, but is potentially catastrophic in today’s economy.

As more people become eligible for Medicaid, the revenue to fund a state’s share of Medicaid and other services shrinks by 3%-4%, according to the Kaiser Commission on Medicaid and the Uninsured. Even so, in fiscal 2007 Medicaid accounted for a whopping 21% of all state expenditures, tying for first place with elementary/secondary education as the largest portion of state spending, according to the National Association of State Budget Officers.

In Colorado, for example, the Department of Health Care Policy and Financing reports that its overall Medicaid caseload increased 13% since January 2008. In February 2009, the caseload increased by more than 3,900 bringing the total number of cases to 440,274.

Because Medicaid programs are funded by tax dollars, states now face significant challenges as revenues plummet because of rising unemployment. A recent Rockefeller Institute of Government report shows that during the end of 2008, tax revenues declined 3.6% nationwide.

States aren’t about to cut Medicaid completely. But with the country’s economy in bad shape, what can we do?

Tough Choices Next?

As the Deputy Secretary for Medical Assistance Programs at the Pennsylvania Department of Public Welfare, I faced similar dilemmas. There’s no single answer, and the decisions aren’t easy to make.

To control Medicaid costs, we could:

· Toughen eligibility standards allowing fewer people to enroll;
· Eliminate certain healthcare services;
· Shift more costs to hospitals; and/or
· Reduce reimbursement rates for providers who already face significant economic challenges to maintaining their practices.

These are options of last resort, but options nonetheless.

But we have another way to trim costs, and improve health and wellness at the same time: care management programs for the chronically ill. While this may sound like another entitlement program and a way to drain nearly empty state coffers, it’s neither.

Medicaid care management programs are proven and have generated one year savings for the states of Illinois and Pennsylvania of $34 million and $35.9 million, respectively.

Care Management, the Chronically Ill and Medicaid

The National Association of State Medicaid Directors says that Medicaid beneficiaries with one or more chronic conditions, such as asthma, diabetes or heart failure, account for 80% of Medicaid spending even though they make up only 40% of the non-institutionalized Medicaid population.

Helping these beneficiaries get a primary care provider and learn new ways to better self-manage chronic illnesses – everything from ensuring prescriptions are filled and medications taken as prescribed to learning what to do when a condition gets worse – is the foundation of care management.

Care management programs support providers through consistent engagement and partnership. This close integration gets results by reducing the unnecessary use of some healthcare services through a whole-person approach to managing chronic illnesses and co-morbid behavioral health conditions.

But this is just one piece of the puzzle.

It’s difficult if not impossible to concentrate on improving health, if you don’t have a way to get to a doctor’s appointment, a roof over your head or not enough food. If beneficiaries don’t have transportation to a doctor’s appointment, food or shelter, these programs can guide them to helpful services.

Care Management Programs Decrease Medicaid Costs

When Medicaid beneficiaries get help managing asthma, for example, and work with a primary care provider, the disease is better controlled and unnecessary visits to the emergency department (ED) – where costs are much greater and the care episodic – can be reduced significantly. The same can be said for other debilitating chronic diseases. Improved health and wellness is an added benefit. Better controlled diseases can lead to more activity, getting back to work and simply feeling better.

Even so, depending on whom you ask and which report you read, care management programs may not work as well as I’ve described.

Nevertheless, it’s been my experience that a focused program – one that targets high-cost, high-risk beneficiaries with a face-to-face intervention and ensures that each participant has his or her own primary care provider and makes allowances for transitions to different levels of care – does work.

For people with asthma it’s possible to decrease annual ED visits and in-patient admissions by 11% and 29%, respectively. For those with coronary artery disease, ED visits and in-patient admissions can be cut by 2% and 4%, respectively.
A few percentage points may not seem like a lot, but applied to groups with significant costs it’s easy to see how Illinois, Pennsylvania and other states have saved millions of dollars by reducing the use of expensive and unneeded services through better Medicaid beneficiary self-management.

I’m not suggesting that this is a panacea for the economic and healthcare challenges the nation faces today; however a comprehensive Medicaid care management program is part of the solution. Now more than ever states need to explore every option, especially those that ensure the most vulnerable among us continue to get the help that they need.

About the author: Jim Hardy is Senior Vice President and General Manager at McKesson Health Solutions in Broomfield, Colo., and is the former Deputy Secretary for Medical Assistance Programs at the Pennsylvania Department of Public Welfare.

maybe it's the demerol

Or post-chemo brain rot.

But I loved this:

Death From a Thousand Cuts Outside of the Patient Centered Medical Home

The Disease Management Care Blog continues to invite and receive submissions from readers. This is one from a family physician buddy who is concerned that the patient centered medical home (PCMH) will not necessarily fix all that ails primary care. The examples below are the dysfunctions of a thousand cuts, best described as deprofessionalizing, demoralizing time consuming annoyances that are outside the PCMH. While each one may make individual sense based on the limited point of view of the specialist/insurer/administrative sponsor, they are collectively bleeding this corner of the profession dry. While money is mentioned, keep in mind that the PCPs gave up getting rich a long time ago. Rather, to quote one sage, the cash is simply a method of keeping score. Decide for yourself who is losing.

With the economy swirling down the commode and primary care at the bottom of the proverbial medical hill, the physicians that actually see patients full time are finding that clinical practice is becoming ever more difficult. The patient centered medical home (PCMH) is in danger of being overrun by hassles before the foundation even gets poured.

Some examples:

According to a local gastroenterologist, Medicare is now requiring that a complete history and physical (H&P) is completed and documented before a screening colonoscopy with anesthesia will be scheduled. Since doing an H&P is apparently outside the skill set of busy 'scopologists' or 'gas passers', completed that task is defaulting to being the responsibility of the primary care doc. Reimbursement? $0.

A large rural integrated delivery system that is currently all the rage in DC requires multiple pages of medical records with the ‘appropriate’ documentation (that demonstrates the need) to be faxed before specialist referrals will be covered. Reimbursement? $0.

Patients seeing diabetes specialists result in a payment of $200- $300 to that physician for their visits. Yet, these patients are typically seeing non-physician providers such as nurse specialists. Knowing that they are not seeing a 'real' doctor, many of the patients have come to the conclusion that the family doctor is closer, cheaper and just as good. Reimbursement for that just-as-good service? It’s not $200-$300. It’s $50. What’s more, the diabetes specialists have done little to help me improve my clinic’s HEDIS measures, torpedoing my chance of getting some pay for performance (P4P).

Centralized scheduling in large physician-hospital systems are making urgent appointments to specialists complicated, cumbersome and all but impossible. In several instances, my patients were unable to wait and had to urgently seek out care in the local emergency room. Since emergency room use is another HEDIS measure, this in turn has led to withholds of P4P, leading to negative reimbursement.

I tried to schedule an magnetic resonance imaging (MRI) scan for a possible extension of an old CVA. Personnel in the MRI facility argued that their 'protocol' for a 'CVA' was MRI plus an magnetic resonance angiogram of the head plus an MRI of the neck. I had to argue to get less!!

If this primary care home has any chance of being habitable, some basics need to change. The drainage pattern of the offending septic 'systems' of care is hurting community-based practice. We’re running out of boots at the bottom of the hill.

Coda: For additional examples of how the system is becoming hopelessly complicated, cumbersome and unfriendly for primary care, check out how the Feds are offering training on how to avoid being threatened by accusations of overbilling, how appointment times may be subject to regulation, and how patient billing warrants attention from the Federal Trade Commission. Egads!

An Open Letter to the New National Coordinator for Health IT: Part 4 -- Bringing Patients into the Conversation About "Meaningful Use" of Health IT

by DAVID C. KIBBE and BRIAN KLEPPERThe Obama health team at HHS and ONC are gradually establishing the rules that will determine how approximately $34 billion in ARRA/HITECH funds are spent on health IT over the next several years. But there is a "missing link" in these deliberations that, so far, has not been addressed by Congress or the Administration: how the patient's voice can be "

poignant and powerful

This past week end, I attended my niece's 13th birthday party. It was a really big deal (over 100 guests in attendance), with great food and a DJ. We all had a great time.

I spend a little time on the dance floor (when the era was right. Music from the 60s to the 80s tends to call my name). At one point I noticed my spouse looking over at us rather intently. When I asked him later he told me that he was having a "poignant moment."

We were three strong women, all mothers, all activists in our own way and all at different stages of cancer survivorship. And we were tearing up the dance floor. We were smoking (if I do say so myself) and not just as cancer patients, not just as women over 40. We were three women who loved to dance and who were having a great time.

I remember thinking, I really love dancing with these women. And when I was on the dance floor, I didn't think of cancer at all.

The Biggest Secret About the New Disease Management: Externally Supported & Shared Nurses for the Medical Home

At the Chronic Care & Prevention Congress, the Disease Management Care Blog heard about Pennsylvania’s chronic care initiative, North Carolina’s Community Care, the 1115 Waiver in Los Angeles County and Health Dialog’s involvement and support for care management programs. All involved a ‘medical home’ approach to chronic illness and all shared a key ingredient: the nurse coaches were not hired, underwritten, salaried, supported or owned by the primary care sites. Instead, all were bankrolled, controlled, managed or employed by an external third party. That third party was often a public or commercial insurer, a not-for-profit agency, grantee or disease management organization. By the way, the same is functionally true in integrated delivery systems' medical homes, where a cost center other than the primary care network typically bears the cost of the training and staffing the care management nurses.

What's more, the nurses described at the Congress were not the typical remote telephonic coaches that characterized past 'Ver. 1.0' disease management programs. Instead, these nurses were ‘boots on the ground,’ hands-on nurse coaches that were ‘embedded’ in the primary care sites.

To the DMCB, this represents the biggest secret about modern versions of disease management. 'Head-set' enabled nurses occupying a floor in some generic building across State lines still have a role to play in population-base care management, but that is so... 'been there, done that.' We're now witnessing the integration of the same highly trained non-physician professionals in the primary care sites. They're giving the local community physicians a leg-up in attaining status as a team-based medical home.

This turn of events has been conspicuously absent in the healthcare media and medical literature and has been largely ignored by policy makers - at least in public. For smaller primary care sites struggling on shoe-string budgets, the gratis provision of a ‘plug and play’ nurse is a no brainer. What’s more, the nurse support can be ‘flexed’ on a day-to-day basis, depending not only on the daily number of patients with chronic illness but the needs of other clinics – which can share the nurse. In other words, circuit-riding disease management/medical home ‘blended’ nurses can support multiple PCPs, resulting in far greater efficiency.

The DMCB realizes that purists may tut-tut over the notion of a generic nurse being diluted among multiple sites. While this runs counter to the notion that each site is a 'home' unto itself, the DMCB suspects shared nurses are more likely to support a single standard of care, leading to reduced variation. While there is no research (yet) that has shown that the shared nurses are really better, relying on them in the settings described above is early compelling evidence that this approach can work.

The DMCB asked an expert panel at the Congress to comment on the prospect of disease management organizations or other types of 3rd parties supplying the nurses. They agreed with the idea: so long as the primary care physician is closely integrated and ultimately responsible, it shouldn't make any difference.

What does this mean? The DMCB suspects adoption of the medical home by primary care sites in any given network will be spotty. In sites that have the resources and are able to build a medical home from the ground up, that'll be fine. However, other sites may be unable to commit to a fully functional home. In that instance, the nurse circuit riders will come to their - and their patients' - rescue.

back and back

I am home after a lovely, packed extended week end away.

I also pulled something in my back getting my suitcase off the train as I arrived in Ottawa. It hurts.

I have a bunch of things I want to write about here (my week end, some thoughts on this whole book promoting business, two book reviews and a couple of other things) but today, I am too sore to sit still for long.

Maybe a gentle walk will help.

The Latest Cavalcade of Risk is Up!

Risk. You can quantify it. You can transfer it. It will build financial empires. It will destroy market caps overnight. It may also generate a lot of spam. Learn about all of that and more over at Richard Eskow's 'The Sentinel Effect' and its Spamalot Version!

Nyuk, nyuk, nyuk.

One reason the Disease Management Care Blog likes to go to national meetings like the World Health Care Congress is because of the lunches. Yes, the chicken may taste like decolorized rubberized by-product and the dessert's fat content will induce an unending afternoon torpor, but that's the price of doing business if you want to make or renew old acquaintances.

Case in point? The 'we're not worthy' DMCB got to chat (again) with a very well-known academic physician from an even more well-known teaching hospital. She's not only published reams of peer review studies on the quality of healthcare, but she still sees patients as a primary care doctor. Like most of the DMCB's agreeable physician colleagues, she is extremely bright, has the scars that give her every right to be deeply cynical and has a scintillating sense of humor. Think nyuk-nyuk-nyuk laughter over anecdotes about despotic insurers, clueless administrators and mercenary specialist physicians between bites of big bowl Cesar salad and sips of watery iced tea.

And she doubts that her home institution primary care site's recent NCQA recognition as a patient centered medical home (PCMH) will ever lead to any measurable increase in her personal compensation or the availability of additional care resources for her clinic's patients. The DMCB believes her.

While primary care clinics within large multi-specialty care systems typically have revenues from insurers and expenses for salaries and other direct costs, the budgetary fact is that all they money they make typically goes to the institution. There are many reasons for that kind of arrangement: the institution provides the overhead, the physicians are salaried with a small amount of variable compensation and the centralized allocation of resources by a Chief Financial Officer can be more efficient. What's more, many primary care sites in large multispecialty practices are functionally 'loss leaders' that are kept around not only because they are a 'feeder' source of remunerative referrals, but because they also contribute to the larger mission - despite what Senator Grassley says - of their not-for-profit organizations.

Ironic, isn't it? The DMCB has doubts that smaller physician owned practices will want or even be able to achieve recognition as NCQA medical home. Yet, they are the ones that supposedly stand to gain the most from additional revenue if healthcare payment reform includes a care management fee that supplements collapsing primary care income. They eat what they kill. In the meantime, physician practices that are in the large not-for-profit multispecialty clinic-hospital systems will see their PCMH revenue continue to disappear upstairs while they make due with the same number of office assistants and a cost-of-living adjusted salary. If this plays out nationwide, there are big implications for the ability of the PCMH to turn primary care around.

She and her colleagues deserve a lot of credit for succeeding as an NCQA medical home. My mug-faced congratulations were interrupted by her Blackberry buzzing. It was an email from her boss that inviting her to the Open House and Grand Opening of a new tertiary care cardiac electrophysiology center. Nyuk, nyuk nyuk.

Coda: Another speaker at the Chronic Care and Prevention Congress pointed out that that there was a simultaneous meeting going on in an equally windowless room somewhere in the basement of the White House. That's where decisions were being made about billions of dollars for health care by individuals who have no experience in real patient care by real physicians. If that windowless basement room exists, the DMCB hopes - but doubts - they are talking to some of the its physician colleagues.

The First "Harry and Louise" Ads!

To me a "Harry and Louise" ad is negative health care reform advertising meant to defend a special interest's self-interest in what we all pay for health care. Whether it actually has "Harry" or "Louise" in it is for me beside the point. To qualify it just has to be trying to scare people to protect a special interest.Yesterday, CQ's Drew Armstrong had a story with the headline, "Labor Unions'

We Are On Our Way To Confusing Entitlement Expansion With Health Care Reform

I generally find Washington Post business columnist Steven Pearlstein levelheaded. But his column today has me shaking my head.Effectively, he is saying forget what it costs--health care reform needs to be done.His biggest problem is that he doesn't know the difference between entitlement expansion and health care reform.But the way things are looking neither does the U.S. Congress.From

A Report from the Chronic Care & Prevention Congress

What a day. The Disease Management Care Blog got to moderate an afternoon session at the World Health Care Congress' 3rd Annual Chronic Care & Prevention Congress. The speakers were David Nash, MD, MBA and Dean of the Jefferson School of Popualtion Health, Chris Selecky, the President and CEO of LifeMasters and Charles Wilhelm, MD, the Chief Medical Officer of Health System One. The theme of the session was "modern approaches to to chronic care design."

Dave led things off by describing the founding of the school and the creation of the first ever Masters program in 'Chronic Care Management.' That's right, population-based chronic care has evolved to the point where the science warrants its own higher degree track. Disease management is growing up.

Chris described several care programs being run by LifeMasters that clearly demonstrate how much disease management has grown up. No longer relying on a simple 'call center' model, this disease management organization is using a variety of interlocking approaches, outreach and incentives that are designed to help the patient and the doctor do the right thing. Given numbers like an 85% physician action rate in response to 'health alerts,' LifeMasters may be closing in on the secret sauce.

Yet, Charles described a population-based initiative that was remarkably minimalist when it came to any external support. Rather, assigned patients in a full-risk population were stratified, their needs and gaps in care were communicated to the physicians, a risk adjusted fee was provided and then Health System One got out of the way. And the docs responded.

While much of the Congress focused on that Chosen Favorite Darling of the beltway policy makers, the patient centered medical home (more on that in a later post), the DMCB's session was instructive on the growing maturity and diversity of population-based programs in general. The 'take-aways' for the DMCB were a) this care management science is really growing in sophistication and 2) there is a 'suite' of options out there when it comes to chronic illness care; the best fit may be less a matter of dogma and more a function of what best meets the needs of the population and the perspective of the sponsoring organization.

Some good quotes:

"We are moving away from Dr. Marcus Welby to Dr. Marcia Wellbyte."

"Some would have you think transparency means placing that black box inside a lucite container."

"The plural of data is not information."

A Simple 101 Intro to Taxing Healthcare Insurance

The Disease Management Care Blog really wishes it was more interested in healthcare tax policy. It tried to pay attention during a recent C-Span rebroadcast of the 3rd Senate Finance Committee hearing that focused on where the money for Obamacare was going to be found. The DMCB tuned in while on one of those Hilton Hotel's exercise machine thingies with a built-in TV. Alas, the topic was a yawner and, well, the spandex on the treadmill to the right was just too distracting.

Uwe E. Reinhardt and the readable New York Times' Economix Blog to the rescue. It turns out that the tax code's treatment of employer-based health insurance is giving Congress a target rich environment. Since the full deductability of health insurance functionally represents a huge Federal subsidy, it's highly likely things are going to change.

Professor Reinhardt points out there are two basic approaches that could be used:

1) Tax any expenditure that for health insurance that exceeds a certain total value. For example, anything beyond a yearly expense of $10,000 in premium would be subject to a levy. One problem with this approach is that low wage earners would also be subject to the same tax as higher wage earners. That's unfair.

2) Only tax expenditures for health insurance when it pushes a total salary plus other compensation beyond a certain level. For example, any premium that pushes beyond a salary level of $75,000 would be subject to the levy. Since lower wage earners would be relatively protected, this would be more fair.

Of course, one big problem is the regional U.S. variation in healthcare costs. How the Congress will deal with this remains to be seen. It would be very complex to vary the tax code county by county. On the other hand, complexity doesn't seem to have stopped Congress before.

There. Now you can amaze your friends and colleagues with your familiarity with basic health care tax policy and continue to focus on the reform stuff that's really interesting. Like whether care plans are a key ingredient in the 'meaningful' use of a federally subsized EHR, the pros and cons of restricting the Medical Home Demo to practices at the 3rd tier of NCQA recognition, how bundled payments mechanisms may benefit disease management organizations and whether health insurers should cover bone marrow transplants for terrorist souped-up prion infestations - or whether the treatment should be denied because it's considered experimental.

As an aside, the DMCB is happy to report that it will be moderating a session tomorrow at the Chronic Care and Prevention Congress. If you're reading this from the meeting hotel, look for the DMCB and say hi. Better yet, give it your insights on any one of the sessions. Who knows, you may not only be quoted, but the other many co-workers or competitors that read this blog will be even more impressed with your expertise.

Progress on Finding the $2 Trillion--Insurer Association Says Physician and Hospital Payment Changes "Won't All Be Voluntary"

Just how will the health care stakeholders who promised President Obama $2 trillion in savings last week achieve the reduction?This from a May 18th Bloomberg story:Standardized billing and forms would cut administrative expenses, said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, a Washington-based trade group, in an interview today. Some likely measures, such as changing

Want to Win a Healthcare X Prize? Start Here

Back on April 14, while at the World Health Care Congress, the Disease Management Care Blog heard about the 'X Prize' for healthcare. Recall that it was these folks who first offered up a $10 million purse to the team that could fly a 3 passenger vehicle into space twice in two weeks. A private firm pulled it off on October 4, 2004. The X Prize Foundation is also offering similar prizes in human genomics, robotic space exploration and extreme automobile efficiency.

Not satisfied with easy stuff like ultra-rapid genomic sequencing and 100 miles per gallon cars, the X Prize Foundation, along with health insurer WellPoint, has turned its attention to the Final Frontier of improving well-being and lowering the the cost of healthcare. The challenge is to go where no one has gone before: to 'create a paradigm...that will dramatically improve health value.' The actual goal - should you and your team wish to compete - is to 1) achieve at least a 50% improvement in a details-not-yet-determined measured ratio of community health to cost (the threshold) and 2) beat the competition. As the DMCB understands it, contestants need to submit an idea along with a $10,000 fee, develop a plan and pilot it. Five finalists will then be chosen, who will then each launch their interventions in a community of about 10,000 people. There will be comparisons to actuarially similar communities to determine if the 50% threshold was met and which team won.

If the DMCB were involved in the planning (and it's not), it would focus on two things:

1) while one option would be to improve health by 50% while holding costs neutral, the path to victory may also be achieved by reducing costs by 33%. Rather than getting everyone to exercise and eat veggies, the DMCB would focus first on keeping persons away from emergency rooms and specialists. It would probably hope that the communities have high baseline costs, preferably with a limited number of employer-sponsored insurance plans with a rich benefit structure.

2) $10 million spread over a community of 10,000 people is a thousand dollars a person. The DMCB would offer to share the prize with the community individuals via cash or supporting a worthy community resource (a community center for example), educational scholarships or free internet access so persons could read the DMCB and be even smarter about healthcare.

As an aside, an article in the May 8 Wall Street Journal by Robert Lee Hotz notes we may have gone science prize crazy. In addition to the X Prizes, there are a total of $1 billion out there for solving dilemmas that range from HIV to greenhouse gases to plastic piping. It's an attractive business model for any sponsor, since the awareness-building can be significant, the budget is capped and only the winner gets paid. In the meantime, it's up to the competitors to make all the necessary investments which are not capped and which, in toto, can add up to far more than the Prize itself. No wonder New Gringrich likes them.

This 'Prize' approach is an interesting contrast with Medicare's Medical Home Demonstration. Care to guess which effort is more likely to yield up useful and timely information?

we had so much fun the first time...

"Health Care Leaders Say Obama Overstated Their Promise to Control Costs"

That was the headline in yesterday's New York Times regarding Monday's promise by health care stakeholders to reduce spending by $2 trillion.A couple of snipets from the Times article:Hospitals and insurance companies said Thursday that President Obama had substantially overstated their promise earlier this week to reduce the growth of health spending.“There’s been a lot of misunderstanding that

An Update on the Medicare Medical Home Demonstration

The Disease Management Care Blog listened in on today’s ‘CMS Employer Forum,’ conference call, where James Coan, a Project Officer, gave listeners an update on the status of the Medicare Medical Home Demonstration. As DMCB readers may recall, the next step is the selection of the 8 States where the demo will be carried out.

According to Mr. Coan, that selection has been made. All that's needed is the green light from the President’s Office of Management and Budget (OMB). ‘Assuming’ it’s given a ‘go,’ physician-based practices in the 8 States will be notified that the application process is open. Following approval of that first application, practices will then need to apply (with all the necessary documentation) to the NCQA for Medical Home status. Six to nine months (or even a year) later, sites will be notified of their ‘Tier One’ or ‘Tier Two’ status and be given the go-ahead to enroll beneficiaries using a ‘beneficiary agreement’ form. The payment from CMS to Medical Home clinics will be ‘like capitation.’

There was more information from the Q&A:

There is no update on the timeline and in particular, there is no idea when the 8 states are going to be announced. Mr. Coan cautioned this was a lengthy clearance process, involving many moving parts, many stops, many questions, many recommendations and many negotiations.

CMS will reserve the right to conduct periodic audits of medical homes using samples of claims, but it is really counting on the application process to keep fraud to a minimum.

There are no plans at this time to switch from a two tier to a one tier system.

There are no plans for any vendors.

The main purpose of the Medical Home demo is to determine if this approach to care is cost neutral, with particular attention to hospitalization rates, ER claims, medication complications and 'testing' redundancy using the Medicare claims data sets. Practices may (or may not) be asked to submit quality data.

The DMCB’s impressions?

If all CMS wants to do is reduce claims expense, all it needs to do is junk this medical home stuff and open the playbook of the 1990s style HMOs. Saving money is easy, especially if a payment system resembling capitation is used. Saving money and a) maintaining or b) improving quality and satisfaction is what’s difficult. Not having an explicit plan in place (with or without the statutory authority) to assess the quality of care is remarkable.

Given the degree of OMB processing, the DCMB still wonders if the unveiling of the 8 states may be delayed thanks to the Administration’s conundrum of reconciling overall healthcare reform with the Medical Home statute.

While CMS prides itself on being a leader in innovation and promoting transparency, even the perception of delays (thanks to the OMB) and opaqueness (is one tier a possibility or isn’t it?) in the demo has implications for the ‘optics’ of health reform in general. The primary care community will point to the non-physician, over-lawyered technocrats and start quoting Reagan's 'there you go again.'

The Latest Health Wonk Review Is Up!

That's right. If the Disease Management Care Blog isn't enough to meet your growing dependence to policy wonkishness, get a massive dose of the best of all the known and not-so-known policy blogs over at the Workers' Comp Insider. You'll feel very good and your brain will thank you.

Paying For a Big Part of Health Care Reform With New Taxes Would Be a Terrible Mistake!

How would you like a chunk of your income taxes tied to the top line in this graph?The top line represents the health insurance cost trend rate over the past 20-years.The two bottom lines represent the increase in worker earnings and overall inflation during the same period.This chart comes from the Kaiser Family Foundation.I have repeatedly reported here that the Congress is having trouble

Red Flags on the Patient Centered Medical Home

The grateful Disease Management Care Blog was alerted to this must-reading paper from the latest Annals of Family Medicine for anyone interested in the patient centered medical home (PCMH). The physician-authors (Paul Nutting, William Miller, Benjamin Crabtree, Carlos Roberto Jaen, Elizabeth Steward and Kurt Strange) are from a spectrum of institutions and were asked by the American Academy of Family Physicians (AAFP) to evaluate their National Demonstration Project (NDP). The NDP was kicked off by AAFP to pilot the PCMH over two years. It took place in 36 family practices and closed in June of 2008.

The news is not good. Some of the literature and much of the policy on the PCMH would have you believe that physician interest is high and, if it weren’t for mean-spirited insurers, change would be easy. That ain’t necessarily so. While the data are still being analyzed, the authors have gathered enough information to ‘identify some potentially red flags’ for the other demonstrations that are underway.

Each of the red flags are summarized below.

The PCMH requires epic levels of transformation – The redesign of a primary care practice site involves complex and interdependent practice functionalities that range from scheduling to patient access to decision support to other domains. This is a 180 degree turn from supporting ‘physician workflow’ to ‘patient experience.’

The necessary supporting technology is not plug-and-play – The addition of registries, e-prescribing, patient portals and other technology to the core PCMH-friendly electronic record are far more difficult and time consuming than generally appreciated. Work-arounds were common.

This involves the personal transformation of physicians – Changing docs away from authoritarian, scienced-based, one-patient-at a time physician-centered style care to patient- goal focused, collective and team-based style care runs counter to years of training and years of socialization. It doesn't sound like a fee schedule update is going to do it.

Change fatigue is a serious concern. It’s not uncommon for the process to be plagued by fits and starts with unanticipated ripples that buffet every corner of the practice. While there are gratifying breakthroughs, they are not enough to preserve the very fragile momentum.

The developmental process requires 'adaptive reserve' – Just because a practice is well run and enthusiastic about the PCMH doesn’t mean they have sufficient ‘adaptive reserve.’ Physician-led ‘just do it’ tactics don’t work over the long run. What’s more, if there’s any dysfunction in the practice, you can count on the transition to a PCMH to bring it out.

Change is local – Transformation depends on the uniqueness of the practice, the system and the community. Multiple paths lead to the PCMH and no one size fits all.

Based on these red flags, the DMCB:

....wonders if the PCMH, as currently envisioned, is out of the reach of most community based physician owned practices. The financial and change management support may likewise be out of reach for government and health insurers no matter how much they want to see it happen,

....has doubts, based on the tone of the paper, that the NDP PCMH pilots achieved any reductions in claims expense. Hopefully, healthcare reform that includes the PCMH will pass before the economic analyses from all the pilots become available,

....suspects the disease management community will probably be the least surprised over the description of physicians as authoritarian, science-based (vs. patient-goal based), and fixated on one-patient-at a time style care. Indeed, this is the first recognition in the care management literature that doctors may not be completely innocent when it comes to the gulf between disease management and the physician community.

Halfway to Paying for Health Care Reform? A Growing Consensus for Taxing Health Insurance Benefits Produces Lots of Money

But do we want to pay for most of it with tax increases?This is a reprint of an April 22nd post.Yesterday in Senate Finance it was clear that changes to the tax treatment of employer-provided health insurance are on the table.I thought it important to revisit my earlier summary of just what such a tax change does toward raising the needed money for reform. Since I posted this, the most commonly

cash would be nice

The last time I checked in for chemo, I accidentally handed the receptionist my Subway card, instead of my green hospital card.

She thought this was so funny, that she showed everyone in the room. I pretended to be angry, trying to grab the card back. It felt good to laugh in that, sometimes sad, place.

I told her though, that my subconscious had been at play. I gave her the Subway card because I feel that after so many rounds of chemo, I should get some sort of bonus prize.

The $2 Trillion Offer to Reduce Health Care Costs—Now They've Done It!

First it was great to see the press coverage of the $2 trillion offer come back down to reality as the day wore on yesterday. From gushing over the “unprecedented” commitment to reform by these key stakeholder groups the news reports and editorials finally, by days end, reflected the fact that nothing is really promised or enforceable yet.Now we hear that these groups have to deliver specifics on

When Actuaries Talk, the DMCB Listens.

The Disease Management Care Blog reviewed the latest Milliman Research Report titled 'Imagining 16% to 12%.' As actuaries are wont to do, they have looked at the healthcare cost trend numbers and do not like what they see. However, they also know where us providers 'bury the bodies' literally and figuratively. Armed with this knowledge, Bruce Pyensen, Kate Fitch and Sara Goldberg know where to squeeze out the cost savings. That can enable us to simultaneously cover the uninsured and reduce the total amount the nation spends on healthcare from 16% to 12% of GDP.

Their proposals have a lot of merit and the report is worth a read for anyone interested in getting serious about controlling The Trend That Will Eat Us All. When actuaries talk, we should humbly listen - or else!

While the devil is always in the details, the (bolded) suggestions from Milliman below make a lot of sense (to the DMCB, which follows up in parentheses).

Hospitals work on a seven day a week schedule with the full compliment of services.

(Comment: The DMCB recalls imaging studies and procedures were simply not available when it was on call on Saturdays and Sundays. If it could wait until Monday, we waited. That's SOP everywhere).

Hospitalists manage the inpatient episode of care. No part timers, no amateurs.

(There are good data that indicate hospitalists result in shorter lengths of stay for inpatients. The DMCB thinks they also do a better job of chasing down all the loose ends typical among patients with other chronic illnesses).

Computerized order entry, standard order sets, pathways and decision support on every hospitalization. Healthcare is NOT local.

(Unlike other parts of the electronic health record, inpatient CPOE and a menu of routinized orders has been shown to promote higher safety thanks to a credible reduction in medication errors).

Help the emergency rooms to NOT admit every sick patient by making alternative care options readily available. Right now, ER physicians are overworked and find it much easier to simply arrange an admission for patients.

(It's 1 AM. She had chest pain hours ago. She's stable, EKG is normal, labs indicate no heart damage and the history suggests the likelihood of a heart problem is very low. Does she really need to be admitted? The answer is often yes because it's 1 AM).

Effective discharge planning with comprehensive follow-up on every discharge.

(Depending on the numbers, 5-10% of inpatients need to be readmitted and many of those readmissions are avoidable. While it will never be zero percent, we can do better).

Bring the family into the care plan at the time of admission, during the hospital stay and when the patient is discharged.

(The DMCB and its team have shown countless spouses and children how to help get grandpa out of bed, how to give shots and what symptoms to look for. It works).

Help skilled nursing facilities (i.e., nursing homes) to reasonably keep patients if there is an acute decline in health status.

(Patients can get ill while in the County Home, and the strain on nurses in giving those patients a higher level of attention is considerable. The DMCB doens't blame them for routinely calling the physician and getting authorization to have the patient transported to the local emergency room).

Commoditize the process that gets drugs from the manufacturer to the consumer.

(Mark-up anyone? Wal-Mart has shown us that it's possible to manage this better).

Align payment mechanisms for drugs with one purpose in mind: medication compliance.

(The DMCB does not clinically understand why persons with chronic illness are rewarded by signficant high out of pocket costs and co-pays when they take medications that control their disease. It understands the pooled risk insurance and policy principle that everyone should have access to the same benefit. If the Feds want to pass a law or two about healthcare, this area might be a good place to start).

Evidence-based prescribing of drugs.

(This can be thorny, but there is a lot of merit behind the notion of simple generics being a first line treatment option for persons with chronic illness in lieu of all those heavily promoted brand name drugs that really are no better. While Comparative Effectiveness Research can help, we already have a lot of information that can help us increase the use of effective generics).

Allow non-physicians to prescribe medications.

(Well, the DMCB didn't say any of this would be politically easy. That being said, there are medications that aren't that hard to prescribe, decision support can add another layer of safety and physicians can be in the loop. With compromise, the DMCB thinks something should be do-able here).

As an aside, this report doesn't support the notion that disease management reduces health care costs. The DMCB thinks the answer is far more complicated (hence, this blog), but let's also recognize that more modern disease management programs haven't really been tested as well as reported in the public domain and that the literature does show that they deliver great quality for the healthcare dollar. The DMCB forgives Milliman for being so orthodox. Afterall, they are actuaries.

The Rumor Mill About the Medical Home Demo (and good news about today's meeting at the White House on health reform)

The Rumor Mill:

The Disease Management Care Blog has heard a completely unconfirmed report that CMS will delay until 2010 the announcement about which States will be chosen to participate in the Medicare Medical Home Demonstration.

It would make sense. The Medical Home may well be a component of major healthcare reform and it wouldn't make sense to have a concurrently running demo. What's more, my primary care colleagues are concerned that participation by smaller primary care sites may be put out of reach by imposing a Tier 3 requirement. Perhaps the whole thing is so star crossed, it should be scuttled.

Let The Horse Trading Begin

Nothing like being invited to the White House for a friendly chat. The DMCB would have liked to been in on some of the background conversations leading up to today's meeting on healthcare reform. If the details about simplification, efficiency, coordination and improvement seem vague, it's because they are. Think of this as a warm up to the painful details that will be discussed at the May 12 U.S. Senate Finance Committee.

Unlike the Bank CEOs, however, everyone hopes they have a chance getting something in return. DMCB readers are already aware of AHIP's posture toward the public insurance option. Kaiser's excellent Health Policy Daily Report points out pharma is holding out to keep cost-benefit analyses out of comparative effectiveness research while providers want to avoid onerous take it or leave it fee schedules. Care to guess what the physicians would like?

However, the disease management community doesn't need to necessarily 'trade' anything. Today's White House meeting affirmed that billions in healthcare costs can be achieved via

'Encouraging coordinated care, both in the public and private sectors, and adherence to evidence-based best practices and therapies that reduce hospitalization, manage chronic disease more efficiently and effectively, and implement proven clinical prevention strategies.'

The DMAA has it right. If there is any hope of intelligently reducing healthcare costs in the coming years, we have to address the burden of chronic illness. Let the details begin.

"Trust But Verify"--Health Care Stakeholders to Pledge $2 Trillion in Reductions

This from the Wall Street Journal on Sunday:Major health-care providers are planning to pledge Monday to President Barack Obama that they will work to reduce cost increases in the nation's health-care system by $2 trillion over the next decade, officials said…Groups representing hospitals, health-insurance companies, doctors, drug makers, medical-device makers and labor are joining in Monday's

Snatching Humiliation From the Jaws of Compromise

Much is being made of the apparent ‘concession’ from America’s Health Insurance Plans (AHIP) to drop gender as part of underwriting.

You can read Karen Ignagni’s statement here. On first read, the Disease Management Care Blog wouldn’t have caught the its significance, but on page 4, it says ‘We envision a rating system based on the following demographic factors: geography, age and [insurance] product type.’

That’s right, the word ‘gender’ as an underwriting factor is absent.

Massachusetts’ Senator John Kerry’s staff certainly picked up on it, which enabled some public puffery over the issue of gender discrimination in the follow-up Q&A. This in turn flushed Ms. Ignagni ‘s page 4 insurance industry ‘setback’ out into the open.

What has been absent from the press reports about this is how the commercial insurers are hanging tough over the linkage of an individual mandate to guaranteed issue and community rating as well as the non-necessity of the public plan option. It may be paying off. Senator Charles Schumer of New York is working hard to find a compromise that will allay the concerns of enough conservative democrats who are apparently willing to break ranks and vote ‘no’ against what could be shaping up to be a public-option poison pill. The optimistic and naïve DMCB believes compromise is in reach and will ultimately depend on how a ‘public’ plan is defined. A very regulated plan administered by a private insurer of last resort could fit the bill.

But how about that gender issue? As a physician, the DMCB is well aware that women are, well, built differently. That translates into different healthcare needs. To further research the issue, the DMCB went to many interesting web sites but ultimately headed on over the USPSF’s Guide to Clinical Preventive Services and searched on the word ‘women.’ It found things have not changed much since Senator Kerry’s wisdom was given such public display: women have considerable healthcare needs. What’s more, they deserve to access to the full range of services that will address them. It could be argued that insurers agree and charge women more in their premiums so that they can be assured that those services will be available to them.

Readers need to decide for themselves if the insurers are guilty of clandestine conscious and unconscious sexism or enlightened business practices aimed at doing the right thing for an important market segment. As for Senator Kerry’s comment about ‘the disparity between women and men in the individual marketplace is just plain wrong and it has to change,’ the DMCB is having trouble between the choosing between a) grandstanding for political advantage and b) showboating by beating up on a favorite whipping boy, er sorry, person. Compromise is one thing. Making it appear as if it's humilation is another.

Post script: By allowing rating based on age and geography, is the US Congress going to permit ageism and geographism? Don’t the elderly deserve the same consideration? Shouldn’t persons living in New York have the same low insurance costs available in Minnesota? Tsk tsk.

thank you

The book launch last night was lovely.


And at least one person had a very good time.

I am feeling more than a little overwhelmed. Thanks to all who came, helped get the word out and put up posters.

Thanks especially to the staff at the First Avenue Day Care and Octopus Books. I don't have words to what a fantastic, beautiful and loving job these women did.

The only hard thing was that I didn't get to spend as much time with every single person who came as I would have liked. I love you all.

A Grumpy View of Comparative Effectiveness Research: What You Won't Read in the New England Journal of Medicine

The Disease Management Care Blog found three predictable articles on comparative effectiveness research (CER) in the latest [May 17 Volume 360 (19)] New England Journal of Medicine. You’ll need a subscription to read them. Don’t have one? Don't have the time? Well, thanks to the DMCB you don't have a problem, because there is a brief one paragraph summary on each:

The first is written by Alan Garber, from the Center for Health Policy at Stanford University and Sean Tunis of the Center for Medical Technology Policy. They address the criticism ‘of some’ that CER will be unable to account for individual patient differences. This will stymie the kind of personalized medicine (PM) that uses (for example) age, co-existing conditions, individual preferences and other variables to that can be used to tailor therapy. Using genomic testing as one arena where CER and PM might clash, they reassure readers that trials on the use of genetic testing have helped patients and physicians better understand when they do and do not help guide therapy with a high level of granularity. More trials built on this kind of success should help better inform these kinds of issues, especially if they are paired from the insights possible from large observational databases.

The second is by Jerry Avorn of Harvard. Funding CER at a level of 1/20th of 1% of our annual healthcare spend doesn’t seem unreasonable to him. What is unreasonable are opponents to CER who are cloaking themselves in moral and policy ‘nonfacts,’ falsely warning in Orwellian tones about government intrusions into the doctor-patient relationship, cookbook medicine and rationing. Thanks goodness Congress resisted those nutcases. He asks our just citizenry of righteous persuasion to remain focused on the task and not be distracted by continued disinformation.

Aanand Naik and Laura Petersen of Baylor ask if CER will lead to better care. They are optimistic it will, because there are some examples of the rapid translation of clinical research into mainstream practice. One is the time for heart attack victims to go from the emergency room door to percutaneous coronary intervention (PCI). They note this success was based on an emerging ‘implementation science’ that included the dissemination of tool kits. They advocate that CER include the creation of ‘connections’ between researchers and practitioners that go from the science of recommendation to the science of implementation.

The curmudgeonly DMCB agrees with all of these guys. It is not a Grumpy nutcase and it is not being defensive. Nonetheless, some reasonable skepticism about CER may be warranted:

No one has done CER on CER: While the door-to-PCI anecdote is a good example of how well things can work, the DMCB recalls the tool kits were ultimately disseminated by the American College of Cardiology without the help of the Feds. Given the ‘unknown unknowns’ about the execution of CER as currently envisioned and its impact on day-to-day practice, the DMCB wonders if the oppositionally-minded Trogdolyte opponents of CER really need to worry all that much.

Minimizes other research by industry: While 1/20th of 1% of comparatively small, it is comparatively huge versus the budget previously devoted to clinical research by other entities, including employers and disease management organizations. As a result, other worthwhile science may wither on the vine in the rush to get a piece of this new Federal largess or be pushed aside, even if the concepts or findings are useful. As was pointed out in The Age of the Unthinkable, real breakthroughs are thanks to mavericks working outside the funding mainstream. CER could crush them and it certainly won't help them.

There are the means and then there are the tails: Critics of research that ultimately compares an outcome based on a better average value in an intervention group compared to an average value in the comparison group have a point. Clinical research is based on the clustering of detectable patient outcomes around the mean, while smaller numbers of patients in both groups may get a lot better or worse. While the authors in the New England Journal assure us that subgroup analyses will help spot the outliers, the DMCB isn’t so sure. For example, what is the optimum level of blood glucose control in a Type 1 diabetic night-time truck driver with post-traumatic stress disorder who won’t take his blood pressure pills?

Will never assume a high level of confidence, only high probability: Comparative effectiveness research implies a degree of confident scientific certainty that has served medicine’s branding for decades. The fact is, however, that CER is only as good as the last published study. It represents the most recent estimate of a likelihood that a treatment is better and, like the promise to fix the SGR, is subject to change at anytime.

Rapid, efficient or relevant? Hardly. It takes months to even plan large multi-site clinical trials, years to recruit patients and collect the data and even more time to analyze it. By the time we begin to see any good results, there will not only be new untested treatment options but the Republicans will be in charge.

Information monopoly: Care to guess who will be the greatest beneficiaries of CER? Academics in our largest and bestest medical institutions will build on their pattern of getting the lion’s share of the funding, designing the research and releasing the data in the same old hidebound ways. That style will continue to inform policy at the Federal level, which will lead to more programs that continue to feed the tertiary academic medical-industrial complex. And as an aside, it will perpetuate the New England Journal’s business model. No wonder they neglected to have that 4th article that presented a contrary point of view.

An Open Letter to the Men and Women Over at the CBO--Hang In There!

Last November I did a post: To the Congressional Budget Office: Please Keep Playing it Straight!In it I said:I hope the CBO doesn't cave to political pressure and keeps doing its non-partisan down-the-middle job.If I hear the politicians whining and the special interests squealing about CBO's conclusions about how these cost containment "lite" proposals...don't save much money I know the CBO pros

the apple and the tree

At about 8:30 last night, D. came downstairs.

D.: "Papa, can I sleep in your bed?"

My spouse: "Why can't you sleep in your own bed?"

D.: "There are too many books in my bed."


Tonight is my Ottawa book launch. My right eye has been twitching furiously all morning. Going to step away from the computer and take some deep breaths.

Latest Cavalcade of Risk is Up!

The latest Cavalcade of Risk is up over at the Roth & Company Tax Update Blog. Summarizing the best of the recent blog-based writings on the topic of risk, it's well worth a visit. Lots of links to some great posts.

The Age of Unthinkable Health Care

The Disease Management Care Blog read ‘The Age of the Unthinkable’ by geostrategist-economist Joshua Cooper Ramo. While written for foreign policy types, the DMCB thinks there may be lessons for healthcare.

Highly readable, this book draws on the deceptively simple intellectual model of a sand pile. When the cone of sand first develops, it’s very easy to predict its dimensions. However, as it becomes a progressively larger pile, it will eventually reach a critical mass at which a ‘sandslide’ will occur somewhere on the surface. It turns out that as the experiment is repeated, the sandslide varies in size and stage. What’s more, it is impossible to mathematically model just when and how each slide will develop. As it grows in size, a simple sand-castle phenomenon witnessed many times by the DMCB and its spawn is just too much for our largest supercomputers.

The point? We live in a sandpile world, where complex financial instruments, shifting military alliances, risk contracts, transnational movements, transborder pandemics, 24-7 media, currency exchange rates, global warming and countless other interactions involving billions of individuals can lead to tipping points of any size, any time and anywhere. Joshua Ramo points out that the linear calculations (input: ‘sanctions,’ output: ‘a compliant Iran’) is simply unable to manage, let alone predict any outcome with sufficient certainty. While it’s possible to retrospectively go back and calculate why or how something happened (! The shadow banking system and government sanctioned easy credit!), we have nothing to forewarn us about the next crisis.

So what are the lessons for healthcare? While translocations in the health and cost status of populations may not receive front page news, it still happens. For example, despite the best planning, health plans can experience big drops in their State and national NCQA rankings, incurred but not reported (IBNR) can gyrate up or down, COX II’s can kill, State Attorney Generals can sue, cost trends can spike and primary care appointments can vanish. New laws and new regulations may or may not help, but they will certainly make the sand pile even more complex. Inputs like: ‘electronic records,’ output: ‘health care savings’ or input: ‘cover all Americans,’ output ‘access to care’ in a world of genetic testing, possible insurance mandates, an insatiable appetite for technology, growing pharmacologic options, an aging population and H1N1 viruses (to name a few) are not only simplistic, they’re naïve and by no means assured.

Joshua Ramo has some ideas on how to manage this. How it might work in healthcare is for a future post.