all good things

Today is a pretty emotional day for my little family.

Tomorrow, my youngest, will start Grade One at a new school. While that's a pretty big deal in and of itself (at least it's the same school his big brother attends), this also marks his last day at the day care housed in his old school.

My family has been involved (except for a few years between kids and when D. was in home care), with the Glebe Parents' Day Care since 1999, when S. was a toddler. It's a great day care but the staff at their First Avenue program are truly exceptional.

When S. was "emergency airlifted" out of First Avenue in Grade One, they re-opened the day care an hour early so that staff could meet him at the bus (his temporary school was further away and the school day ended earlier) for the rest of the term (from February until June).

And, earlier this year, when I needed a space to launch my book, the staff offered their wonderful facility free of charge. They decorated it so beautifully and there was even a message on a chalkboard in the washroom telling me how proud they were of me.

And those are just a couple of examples.

This past week end, D. and I made a poster-sized card with a photo of our family. We all signed it. We also made cookies (I burned the first two batches, my spouse did the baking of the last couple, as I was becoming hysterical). We also gave them a bottle of gourmet chocolate sauce to pour in their coffee.

D. and I made cards for the three teachers who hosted the book launch. I want to make scarves for all three of them but of course, only one was finished. D. had me paste photos of the scarves in the cards for the other two, so that they would know what they are getting (I made a "Lace Ribbon" scarf for J., T. is getting a "Clapotis" and, if I can manage the pattern, I want to make "Juno" for A.)

I had T. and D. deliver it all to the day care, confessing to my spouse that I am "emotional coward." Apparently, the staff and T. have decided that I am not to be let off the hook, though, so S. and I will join T. when he goes to collect D. at the day care this evening.

There might be tears.

These photos were taken first thing this am and are thus not particularly flattering. I just wanted a photographic record.

To distract myself this, I thought I'd do this nifty little book meme that Sassymonkey wrote about at BlogHer:

"Using only books you have read this year (2009), answer these
questions. Try not to repeat a book title. It’s a lot harder than you
think!

Here's the meme with my answers. If you haven't read enough books so far this year to answer all the questions go back as far as you need to get enough books. If you've played it on your blog leave a link so I can go visit."

I was planning to do it even before I noticed that Sassymonkey had used my book to answer one of the questions but that particularly tickled me.

Describe yourself: Dragonslayer (Bone #4, Jeff Smith)

How do you feel: What It Is (Lynda Barry)

Describe where you currently live: Three Day Road (Joseph Boyden)

If you could go anywhere, where would you go? Toronto Noir (Janine Armin and Nathaniel G. Moore, eds.)

Your favorite form of transportation: Walk Through Darkness(David Anthony Durham)

Your best friend is: Tipping The Velvet (Sarah Waters)

You and your friends are: Casting Spells (Barbara Bretton)

What’s the weather like: All the Colours Of Darkness (Peter Robinson)

You fear: The Price Of Darkness (Graham Hurley)

What is the best advice you have to give: Nobody Move (Denis Johnson)

Thought for the day: Don't Look Twice (Andrew Gross)

How I would like to die: A Good Death (Elizabeth Ironside)

My soul’s present condition: Hurry Down Sunshine (Michael Greenberg)

I seem to have read a lot of books with darkness in the title.

Making Health Care Reform "Deficit Neutral" Accomplishes Little--So Why Is That the President's Health Care Reform Budget Objective?

For me, one of the more amazing things about this health care debate is the way the press and many advocates of health care reform have accepted the notion that the fiscal objective should be to pass a health care bill that is "deficit neutral."With health care costs unsustainable, why is that an appropriate goal?Deficit neutral means that any impact of a health care bill on the federal budget

Want to Improve Diabetes Outcomes? Start a Hypertension Disease Management Program

An enduring criticism of disease management (DM) is that it is 'siloed." Contrasting it with the comprehensive care offered by primary care physicians, critics have charged that insurance sponsored DM balkanizes chronic care for patients into separate, inefficient and overlapping programs. As a result, patients with hypertension and diabetes and high cholesterol could spend all day on the phone dealing with separate hypertension, diabetes and cholesterol disease management nurses. The Disease Management Care Blog believed that was a canard, but its opinion fell short of its own evidence-based standard. Up until now, there were no peer-reviewed studies that specifically examined the silo allegation.

Until now. Check out this study from the Durham VA Medical Center and Duke University that was published in the July issue of the American Journal of Medicine, authored by Benjamin Powers, Maren Olsen, Eugen Oddone and Hayden Bosworth. The V-STICH Trial lasted 24 months and compared hypertension disease management consisting of telephonic-based nurse support versus usual care. While there was a modest effect of disease management on blood pressure control, the authors noticed that many of the participants had other chronic conditions, like diabetes and high cholesterol. This was a unique opportunity to assess the impact of the hypertension disease management program on the other conditions.

Of the 588 hypertensive volunteers that participated in the trial, 219 had diabetes and, of these, 216 had had a hemoglobin A1c checked during the course of follow-up. Baseline patient characteristics were not statistically significant among the diabetics in the two arms of the study. However, over the two years, the mean A1c went from 7.54% to 7.26% in the disease management group, while the A1c increased from a baseline of 7.20% to 7.38% in the usual care group. Comparison of the relative changes in the average A1c between the two groups reached statistical significance.

The authors were also curious about the impact on 528 persons who had had a cholesterol checked. The LDL declined in both the intervention and the usual care groups but did not achieve statistical significance.

The authors concluded that their hypertension disease management program had had an 'unintended effect' on blood sugar control among persons with diabetes. The DMCB is unsurprised. Disease management organizations (DMOs) typically instruct their nurses to trigger other engagement modules whenever another chronic condition is detected. At a contractual level that makes sense, because the DMOs often bear some risk for insurance claims expense and it's in their financial interest to help their assigned patients reduce their global risk. However, the DMCB suspect there is something more signficiant afoot: good nurses can't avoid helping patients manage other conditions.

They can't help themselves.

The DMCB witnessed this first hand when it witnessed how disease management nurses do their thing. It sat in on a patient-nurse telephone call for a client-patient and listened how the interchange quickly veered off-course. The nurse helped the patient deal with a new medical problem, offered some emotional support, served up some common sense advice and then closed wth some 'hang-in-there' cheer leading. The DMCB was very impressed but not surprised.

Critics of DM shouldn't be surprised either.

H1N1: The Obama Administration's Coming Katrina?

In a prior post, the Disease Management Care Blog noted that the Obama Administration’s health care chops would depend on its response to the H1N1 (Swine Flu) virus. So far, it’s been lucky: a serious pandemic has yet to land on U.S. shores. With the coming arrival of fall, however, luck may be running out.

According to this New England Journal of Medicine article, planning is furiously underway. It looks like the patchwork of emergency rooms, public health clinics and primary care providers are being geared up to give the vaccine. Individual clinics are anticipating the coming demand based on the Centers for Disease Control's (CDC's) emerging two shot vaccine recommendations that assign priority to the pregnant, children, young adults and adults up to age 50 years with a chronic illness.

This may look good on paper, but the DMCB worries that this public health campaign is vulnerable to one of two extremes. One is high numbers of persons refusing to be vaccinated because of the fear of side effects. The other is high numbers of persons demanding the two shots and over-running our decaying primary care network. Over the last decade, most primary care sites have reduced overhead to a minimum and have neither the personnel or the resources to take on a new crush of persons demanding the two Swine Flu shots.

For more insight on this, the DMCB turned to one of its primary care colleagues, who, unlike the apparent healthcare experts writing in the New England of Journal, has a real grip on the reality of what could happen this fall:

'I hear rumors that the government is going to pay for the vaccine but the cost of administering the shot (including storing the vaccine and covering the cost of the nurses to administer it) is supposed to be covered by private insurance. We haven’t heard if the insurance payers we deal with will provide first dollar coverage or if they’ll transfer some of that cost through a co-pay or other forms of co-insurance. We also still have no idea about the distribution channels and we don’t know how the vaccine supply will be shared with physicians’ offices, Department of Health clinics or pharmacies. Our small primary care office is terrified of the burden that will be imposed by having giving two more shots to our population with a short lead time. We already have full schedules for the fall season and will have difficulty processing the 1200+ extra contacts and associated paperwork. We are a tiny office that normaly gives 600-700 flu shots a year.'

By the way, the primary care physician had a particularly novel idea. It’s built on the common sense observation that lay people can be trained to give shots.

'My solution: Train census takers to give shots or better yet, put a shot giver on every Fed Ex and UPS truck. Those guys are the best logistical wizards on the planet. You could even get a tracking number and find out where your flu shot is!! They know where everyone lives. My UPS guy knows that if I am not a work to drop by my house. Talk about a neural network.

Readers may think this is naive, but the DMCB points out that the circumstances of the coming H1N1 pandemic may warrant out-of-the-box thinking. This is the Obama Administration's chance to show that it is different - that it is able to come up with non-FEMAoid approaches. Are there plans to involve the public schools? Why can't Visiting Nurse Associations be contracted to set up vaccine stations in our nation's post offices? Or maybe when the Administration isn't pillorying the insurance industry, it is working with it to reduce the out of pocket financial barriers that patients may be facing?

And, in case sizable numbers of persons refuse to be vaccinated for H1N1, check out this thought:

How about a variation of the Cash for Clunkers Program. I call it Shekels for Shots program. At first glance, this may sound silly, but if a voucher not only provides first dollar coverage of the shot for particularly vulnerable persons, but gives them a meaningful cash rewards, the population will be vaccinated and we’ll have another stimulus!!

The DMCB says the traditional response to H1N1 so far does not bode well for the Administration. If the story being told above is typical of many other primary care providers, H1N1 could turn out to be the Obama Presidency’s Katrina.

Bob Bennett Wants to Turn "Control of Our Health Insurance System Over to the Government"–-Say What?

That’s what the Club for Growth is saying about Senator Bob Bennett’s health care proposals.Apparently, the Club for Growth has a reading comprehension problem. Or, are they just trying to twist the truth about the Utah Republican's health care efforts? The Wyden-Bennett Healthy Americans Act has to be the most pro-market health care reform proposal on the table.First, it does not have the

in pictures

These are some illustrations for the post I wrote on August 10, about our trip out east. Thanks to my sister in law, B. for taking the horse photos. There is NO WAY I was letting go of the reigns long enough to point and shoot.

The Health Reform Bills Would Be Great For the Business Of Health Care

Have you noticed how none of the big health care business special interests is running any negative health care reform ads? Why should they when each is poised to gain billions of dollars from it?As President Barack Obama has said many times, any health care bill that costs about $1 trillion would be paid for, roughly half and half, with savings in the health care system and new revenues (taxes).

Synaptic Health Care and the Passing of Senator Kennedy and His Vision for Mainframe-Style Health Reform

The late Senator Kennedy will be laid to rest at Arlington VA on Saturday. His repose is a chance for all of us to reflect on his ceaseless advocacy for a just healthcare system, his appeals to all of us to help the least of us and his tireless efforts to achieve compromise over acrimony. Our nation owes him a great debt of gratitude.

The Disease Management Care Blog also wonders if his vision of government dominated health care will be laid to rest with him.

Mr. Kennedy belonged to a generation that believed in the greatness of government's role in modern society, and why not? Passage of Social Security Act of 1965 , the Civil Rights Act and other important social legislation demonstrated our collective ability to achieve new heights for modern America. Yet, something derailed Washington DC's momentum. What was started by the Great Society was slowed by the Reagan Revolution and reached its limits when Clinton's health reform failed. The DMCB believes Senator's Kennedy's passing may be marked as the beginning of the end.

An alternative world view is growing in our collective consciousness. It prefers networked over hardwired, parallel over serial, organic over static, tailored over pre-fab and synergy over reductionism. Its currency is communication, its actions are individually informed and the outcomes are fractal. It resists established business models and it certainly isn't taxable. It's face is YouTube, Blogging, Twittering, cloud computing and chaos theory while its symptoms are outsourcing, open sourcing, and multi-tasking. It can be easily mistaken for naivete, libertarianism, survivalism and conservatism. It's a wild card in our body politic; how else could Ron Paul become so..... cool? What else explains the misinterpretation of Federal payment for living wills as 'death panels?' It's not the 'web' and our 'Communication Age' only partially explains it. It's ....synaptic.

It is being underestimated by and hasn't helped those in favor of health reform. It has aided but hasn't been harnessed by reform opponents. Its cultural sexiness has greater appeal than the efficiencies from central command and control and its ascendancy is eclipsing classic liberal notions of social justice and progressivism. Government may be able to preside but it cannot own this. It is too complex, nimble and amorphous.

Which is why Senator's Kennedy's demise may be symbolic of the passing of an era. Whether it's big bang or incrementalism, and whatever its merits, the sun is setting on the likelihood of buy-in over the notion of a uniform benefit package being overseen by single authority. The DMCB doesn't think it's reached a majority yet, but the tipping point is fast approaching. When it arrives, the likelihood that Kennedy's vision will be fulfilled will be gone forever. This is another reason why supporters of health reform intuit that this last chance is not only hostage to the short term election cycle but to a profound long term trend. Taking Ver 1.0 reform's place is a Ver 2.0 vision of healthcare that is more local, responsive, personal, information-based, tailored, consumerist, rich and all those other terms that have been incorrectly dismissed as jargon. A telling example* can be found here.

That doesn't mean that experts won't continue to embrace a mainframe-style single payer, top down, highly proscribed system with regulated salaried physicians and policy being set by a Health Fed - for example, such as this article appearing in the New England Journal.

Waiting in the wings are folks like those who prefer a Guaranteed Healthcare Access Plan, consisting of vouchers that support a flexible minimum benefit. There are other approaches that meet the spirit of synaptic reform. Their proponents are waiting and watching to see what happens.

*Hat tip InsureBlog

Chronic Illness Survivor?

The DMAA web site has an 'online bank' of individual patient testimonials about the virtues of care management. Including patient quotes and sometimes mentioning disease management companies by name, the stories take sterile statistics like reductions in inpatient admissions and blood glucose control and put real faces on them. The Disease Management Care Blog finds the anecdotes credible: get a good system of patient support in place, and it's amazing how well persons can do.

This made the Disease Management Care Blog want to open a separate page for reader testimonials. Something along the lines of.....

'After years of low awareness of disease management and forgoing daily updates offered through the internet, Mabel finally decided to subscribe to the DMCB, a great source of free info about population-based care management. Through regularly logging on, Mabel has become really smart, amazes her co-workers with her fund of knowledge, has helped her U.S. Senator better understand health reform, prompted a local hospital to close one wing from lack of business and has reduced the PMPM in her State by $0.03. 'This is so great,' said Mabel, 'I've forwarded the link to the rest of the folks in my Department!'

But seriously, if we're going to show how persons can get their quality of life back to normal, how about a variation of CBS' successful Survivor show? To qualify, persons would have to have a major chronic condition that is a) under control, thanks to b) having to take two or more medications on a daily basis and c) having to self-monitor/treat. The show would not only feature feats of stamina and guile, but how contestants manage the disease on a daily basis through of combination of as needed treatments, rest, nutritional adjustments and contact with a support team. The DMCB is thinking a 45 year old man with diabetes mellitus versus a 35 year old house wife on IV meds for rheumatoid arthritis versus a 55 year old office worker with paroxysmal atrial fibrillation......

Cavalcade of Risk #86 is Up!

The Political Calculations blog has used a variation of the Moody's Bond Rating system to assemble this week's postings in the Cavalcade of Risk #86. Great stuff on all things having to do with business and finance risk. It's worth a look.

The Disease Management Care Blog wondered why it didn't deserve Aa1, but then it realized that's the credit worthiness of U.S. Bonds. It likes not being in that company......

ottawa folk fest 2009

It's a highlight of every summer for my family, and this year's Ottawa Folk Festival was no exception (although we did miss S. a lot. He's staying with his Grandma and going to comedy camp. He says they spend their days doing improv routines and watching highlights from Saturday Night Live. The kid is in heaven). And this year, despite forecasts to the contrary (and some really nasty looking storm clouds) the weather was perfect.

I think I kept the rain away through sheer force of will.


This is Vishtèn, a group we really liked from PEI and the Magdalen Islands. Other highlights for me included James Keelaghan, the Good Lovelies and a workshop called Outstanding In Their Field that featured Digging Roots (excellent musicians, great voices, hard rocking native musicians), the Arrogant Worms, Charlotte Cornfield, Tall Trees (the teenage winners of this year's "rising stars" award. I was really charmed by them) and Stewed Roots. I also think I might have fallen in love with Victoria Vox and her ukelele.

My spouse and I both loved James Hill and Anne Davidson.

Every folk festival has moments of magic. T. (whose personal highlights were a lot like mine), D. and I all agree that those moments this year came courtesy of the Common Ground Cross-Cultural Collaboration (couldn't find a link to explain this amazing process of bringing together artists from all over North America and throwing them together to make music):

"When the artists are having fun it is infectious. Our final daytime show ended with the whole group getting off the stage and leading the audience dancing around the room. One of those special festival moments."

On Saturday afternoon, my sister and brother-in-law collected D. so that T. and I could enjoy some child free time and take in some music without being subject to the (sometimes tyrannical) whims of our youngest child. That night, we stayed to the very end (although, I did take in Bruce Cockburn while lying down with my eyes closed. It was nice).

Attending the Folk Festival with a six year old is a different experience. You don't always get to choose what concerts you attend and you can never be sure if you will hear a full set.

But I got to sit in the shade with my son between my legs. I listened to music and watched his face as he read to himself (hooray for reading!).

I balanced him on my knees and we listened to music together.

And we all danced our hearts out.

While it was frustrating to miss out on some workshops I wanted to hear (like Songs From The Road, featuring Bruce Cockburn, Steven Page and Joel Plaskett), I got to do and see some things I might have missed entirely.





We spent more than an hour building a model of a cob house.

We watched some folks learning to dance the Charleston.

D. painted his name in Japanese characters and made an origami flower.

And we did all this without setting foot in the kids' tent.

Going to the Folk Festival with a six year old is exhausting but I don't resent it for a moment (although I would probably feel differently if we hadn't had the break on Saturday).

And the thing is, I think that these are the memories that will stay with me.


And it wouldn't be the FolkFest if I didn't spend some time knitting in public.

I didn't even mind when, at around 5:00 on Sunday, D. announced that he wanted to leave. It would have been great to stay and hear the evening concert but going to St-Hubert for dinner was special in its own way.

"This is such a great feast!", D. announced. It was a great end to a wonderful week end.

(You can see the full list of FolkFest artists here).

Health Care Reforms Deeper Problems

by BRIAN KLEPPER and DAVID C. KIBBENote: We were asked by Northeast Florida's regional newspaper, the Florida Times-Union, to write a piece for lay audiences distilling our thoughts on what's behind the reform curtain. This piece published this week and, while we doubt much of it will be news to this blog’s readers, we wanted to offer it up as a summary statement.Congress' health care reform

he's only six years old

Today's scheduled post is being pre-empted by a story I want to share with all of you.

My younger son, D., had an appointment at the dentist's today. I decided to turn the day into a special outing and go out for lunch and then to the movies (G-Force. I still do not like rodents).

When the movie was over, he announced that he had to go to the bathroom. As I wrapped up a phone call with my spouse and went to open the bathroom door, a man stepped towards me and said, "I think he's way too old to go in there with you. He looks like he's at least four years old."

I thought he was kidding. I smiled and said, "He's six."

"Six! You really shouldn't be going in there."

He was serious. And outraged (I'll bust some stereotypes and tell you that he was young - no older than early 30s). As I stepped around him and gently pushed my son through the door, I heard him say, "I'm going to talk to the manager."

I was flabbergasted.

D. was quite upset as he has been really reluctant to go into the women's washroom for the last year or so (although lately he's gone in with me when we are out alone without complaining).
He was mortified.

I am not an overly protective parent nor am I prone to paranoia. I also know all that so many more children are harmed by adults they know than ones they meet in the bathroom at the movie theatre.

However:

He can barely reach the taps in public washrooms, let alone the soap dispenser.

He often can't get the stall door to close.

Sometimes, he can't get it open.

Despite his protestations, he's afraid to be by himself in an unfamiliar place.

He's six years old. And it is still several years before I am going to let him out of my sight in any public place.

When I was six years old, a stranger exposed himself to me.

I let my 11 year old go into the men's room by himself. Once, when D. had a friend with him at the movies, I let both boys go in together and stood outside with my heart in my mouth until they re-appeared (I asked if they had washed their hands. My son said, "Yes!" His friend said, "No, you didn't!").

I think the answer to "When is your child old enough to [fill in the blank]?" depends very much on the individual child and on the parents' comfort level (I often say that it's really good that my boys have two parents, otherwise they would never be allowed to do anything). I am, however, very comfortable asserting that my six year old will be coming into the women's washroom with me for a while yet.

And what's the big deal, anyway? Women's washrooms have stalls. It's not as though D. is peeking under the doors. When I went to university, at least one of the residences had only co-ed bathrooms. Now that was weird - brushing my teeth in the morning and having some guy walk by in a little towel.

How do you handle the bathroom situation when out with your kids? How do you feel when you see a child of the opposite sex in a public washroom?

Clinical Practice? Evidence Based. Health Care Policy? Just Argument

Pity Victor Fuchs. He's a Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy at Stanford. He has all those articles in the New England Journal, JAMA and Health Affairs and his sensible suggestions are not seeing the light of day in the health reform debate. According to Kaiser Health News (KHN), he's disappointed with the President. He's just so plain wrong on:

Prevention: 'there's hundreds of studies showing you don't save money on that stuff.' The DMCB agrees, but don't take its word for it.

Electronic Health Records: "you are just throwing money away." Hear hear says the DMCB.

The Public Plan:' 'cost shifting' doesn't do anything about the real cost of health care.' The DMCB wonders if it read some of Dr. Fuch's articles in an unremembered past, leading to its current point of view.

Keeping What You Have: 'Most of these stories [Mr. Obama] tells about the way he’s going to save money don’t ring convincing to me when they are accompanied by the repeated insistence, 'If you like what you have, you can stay with what you have.' A big part of the problem of the high cost of medicine is precisely because of the system we have. If you don't contemplate changing that system, everything else is kind of a pretense.'

According to Dr. Fuchs, the system is riddled with bloated overhead (brokers, administration, marketing, bureaucracies, specialists), excess capacity and open ended financing. How he proposes to fix this was left unsaid in the KHN interview, but he likes the idea of handing out risk adjusted vouchers that cover a pre-defined benefit.

The Disease Management Care Blog is sympathetic. It's ironic that clinical practice is supposed to be evidence-based, while it's OK to simply argue past one another on healthcare policy.




There may be some good news for our democracy, however. Check out this article from the New York Times that suggests, while some raucous Town Halls have been spotlighted by the media, the a majority of them were civil and informative. Maybe some of Dr. Fuch's points have gotten through.

When Patents Become Patients (At Least When It Comes to Payment)

The Wall Street Journal (WSJ) has an interesting front page article on how lawyers' 'Billable Hour' style of reimbursement is 'under attack.' Instead of being paid an hourly rate for their lawyering, many firms are yielding to 'alternative billing arrangements.' Stressed by the economic downturn, customers are balking over the hourly 'incentive to rack up bigger bills,' with 'flat fee contracts' and, faced by declining revenues, the lawyers are acquiescing. While activities like 'anti-trust fights,'or 'tricky corporate mergers' or having the 'absolute best team of trial lawyers' will likely continue to be billed hourly, more routine work like 'patent applications' will be paid with.... capitation.

Capitation you say? That's how the Disease Management Care Blog thinks of it. Donning an insurance hat for the moment, the legal customers are transferring the risk of high work effort cost of patent management to its lawyers. If some detail in a patent plan gets thorny and requires more time, that cost is borne by the lawyer, not the payer. Without the remuneration from of fee-for-service (measured in time units), work effort that used to represent revenue now becomes a loss.

The Disease Management Care Blog feels their pain, though it points out that what is described in the WSJ may not represent a full capitation arrangement. That would involve transferring the risk of all the costs of a patent application, such as all the other fees, additional unforeseen litigation (patent infringements?), having to call in additional lawyers (referrals) or loss of income (from delays?). Rather, it's likely to be 'partial capitation' that is limited to a narrower range of services, such as just the legal legwork owned by the firm.

The DMCB asks what's next for our legal colleagues. Other unrecognized but important services may or may not need to be carved out. Customers may want phone counseling over the merits of their patents, the anxiety of dealing with them or now to market them once they are awarded. This would involve specially trained non-lawyer professionals who can work within their scope of practice. Patents probably range from simple to complex, so payment may have to be risk adjusted. Persons who are elderly or socioeconomically deprived may warrant government support: PatentCare or PatentAid. Visiting a patent office and pleading the case with the necessary follow-up correspondence (for, say... 60 days) may have to be managed with a global payment and there is no, repeat NO payment for 'mistakes.' Since there are so many patents, an electronic record of some sort could become necessary to adequately follow progess and populate a registry that can assess patent outcomes. While trial lawyers only get paid if they win (the ultimate pay for performance), some sort of reward for a patent process measure or two (time to application, time to notification) may have to be considered. They may have to be publicly reported on a vetted web site. Of course, the firms offer a spectrum of services, so coordinating them may prompt some to offer client centered legal homes.

Despite that, costs for patents may rise uncontrollably, leading to high costs that hamper our nation's ability to compete globally. We'll debate if equal access to patenting is a right or a commodity. Cherry picked and heart breaking anecdotes of loss of patents will abound. Presidents will wonder why blue ink is preferred versus red ink. Lack of iron-clad evidence that any of this works, of course, may prompt comparative effectiveness research. The government may need to step in with a single patent payer system.

You read it here first.

There Will Not Be Health Care Reform in 2009 Without Republican Leadership

I will suggest that there is an opportunity for the Republicans to score a huge political and policy win. It can be done in a bipartisan way and it can be done in a way that does not sell out the core principles that either Republicans or Democrats believe in.It would require a new effort—a clean sheet—this time initiated by the Republicans.The Republicans have won August. No doubt about it. But

not done yet reviewed for the cmaj

I have recovered from chemo but a week end at the Folk Festival and a night of insomnia have left me completely brain dead.

In lieu of any original content on my part, I wanted a share a wonderful review of Not Done Yet, published in this month's Canadian Medical Association Journal.

A physician who treats breast cancer patients might wonder what this blog-cum-book could offer a busy professional whose daily practice likely holds its own heartbreaking quota of Lauries...

However, Kingston’s book provides the detail and emotional shadings that give meaning to these stark, exterior facts. The honest telling of a singular story weaves the experience of cancer into the whole cloth of a life, reworked after a devastating rupture. She vividly integrates events and see-sawing emotions...

Comfortable in her lay-expert role and an inveterate listmaker, she draws from the negative encounters to compile pointers for health care professionals: "Don’t look horrified when I tell you I have metastatic breast cancer; … Don’t ask me questions about my treatment[s] that are irrelevant to the procedure being performed and/or outside your sphere of knowledge [p 190]"

The author of the review, Sharon Batt, is a Doctoral Candidate in the Department of Bioethics at Dalhousie University. She is also the author of the book, Patient No More: The Politics of Breast Cancer about her own experience.

Many thanks to my friend N. (herself the editor of Women Who Care - an upcoming book about "Canadian Women’s Personal and Professional Experiences of Health Care and Caring") for submitting my book to the CMAJ for review.

You can download the full pdf of the review here.

The National Public Radio (NPR) Interview on Health Reform: Dr. Howard Dean, You Need to Regularly Read This Blog

When interviewed last Friday on National Public Radio's All Things Considered, Howard Dean explained the polls showing declining support for health reform by saying:

'And we do know from polling - because I've seen some polling about messaging - is that when you talk about health care reform, a lot of people disapprove of it. When you explain the president's health care reform views and his bill, then people support it overwhelmingly.' [bolding from the DMCB]

Aha! So the concerns out there are the result of an information gap.

Readers may recall that Howard Dean is not only a former Vermont Governor and former Chair of the Democratic National Committee but is an academically trained general internist. And in the quote above, he demonstrated a classic sign of the syndrome of Chronic Unremitting Insufferable Physician-Centric Generalinternistitis (CUIPCGI). This is an abiding belief that education is the single ingredient that transforms patient non-compliance into compliance. Its dysfunction becomes extreme when this delusion intrudes in other aspects of living, such as national politics or changing a spouse's mind about the merits of letting the porch go uncleaned. The Disease Management Care Blog is also similarly trained internist physician and has observed that CUIPCGI frequently among members of its specialty, in much of the academic peer reviewed literature and among many of the Brahmins advising the Obama Administration.

For the longest time, patient care was built on the notion that the transmittal of facts from Those-In-Possession-of-Knowledge to Those-Not-In-Possession-of-Knowledge was suffuciently transformative. We believed it made the dumb smart, the lazy energetic and the disinterested inspired. Accordingly, the uncontrolled diabetics would become controlled, hypertensives would become normotensive and the obese would become thin.

Unfortunately, victims of this disorder soon suffer severe consequences: 1) the subjects of their belief system often discern they are incorrectly being labelled dumb, lasy and disinterested, 2) persons with chronic conditions don't make much progress in disease control and 3) stymied by a lack of buy-in, these unfortunates paradoxically inflate their confidence in the merits of education and compensate by framing the same facts with accelerating degrees of bias.

Fortunately, for the many otherwise excellent professionals who are afflicted, there is a cure. It involves humility and paradoxically applying the same educational standard to oneself, starting by reading some of the vast amount of peer reviewed scientific literature from the last ten years that has revolutionized the science of patient behavior change. It has amply demonstrated that recounting of 'facts' are only the beginning. 'Expalining' the facts is necessary but not close to being sufficient when it comes to getting patient buy-in and behavior change. The literature on this is not hard to find and examples include this, this, this and this. There is a good review of the topic at AHRQ and the Population Health Journal has this thoroughly researched description of various approaches to behavior change. Last but not least, regularly surfing, RSSing and Twittering the modest DMCB is also a good way to keep up on care management. Regular readers know the bottom line is that when state-of-the-art patient engagement is applied, variations of shared decision making centered on the patients' knowledge and values results in a mutually acceptable care-plan.

Viewed through the prism of population-based health care, therefore, the August recess Town Halls are one stop in the process of a sort of shared decision making that could lead to a national 'care-plan' consensus on healing our broken health care system. While rancorous and sometimes loopy disagreement has slowed reform's momentum, responding by smugly 'explaining' the President's views to the opponents is insufficient, implies they are lacking in knowledge, is disparaging and damaging to our national dialog.

The DMCB is unaware of Dr. Dean's readiness to change, but if the DMCB was using motivational interviewing to help him, it would reflectively listen and offer up the option of reading this blog as one way to be a more constructive force in getting to meaningful health reform.

A less clinical way of saying the same thing is to bluntly point out that our national discourse and the listeners to NPR deserve better.

The Latest Health Wonk Review is Up!

David Williams of the Health Business Blog wastes no time in an efficient series of almost Twitter-like descriptions of the latest and greatest wonky bloggery. Alas, while many are shouting at Town Halls, the health wonk reviewers are thoughtfully writing about everything they like and don't like about health reform. David has a masterful summary of quite a large number of posts - there's something here for everyone!

The DMCB was also remiss in alerting readers that the Cavalcade of Risk Downunder was posted days back. Chatswood Consulting has a series of links to posts that deal with the management of risk, be it be it life, health, disability or business risks. Also well worth your time.

Accountable Care Organizations: The Good, the Bad and the Better Thanks to Health Affairs

In a prior post, the Disease Management Care Blog not only explained, but got all mushy over the notion of ‘Accountable Care Organizations” (ACOs). The DMCB felt that ACOs could provide the endoskeleton over which a mix of carve-in and carve-out population-based systems of care - including commercial disease management - could be assembled.

ACOs may be a healthcare policy golden-boy, but the Health Affairs Blog has a posting authored by Jeff Goldsmith that argues the concept is simply not ready for prime time.

The Bad: Jeff Goldsmith notes the ACO concept was born when policy makers realized that many community physicians are loosely organized around hospitals anyway. So, the thinking went, it shouldn’t be too hard to devise risk-based incentive payment mechanisms to nudge these nascent ACOs into coordinating care. Dr. Goldsmith disagrees. He says we saw this bad movie before back in the 1990s when hospitals snapped up physician practices like brides grabbing gowns at Filene’s. Payers didn’t like their closed networks, their internal controls were atrocious, they couldn’t manage risk contracting and the administrators knew about as much about running ambulatory-based clinics as Barney Frank’s dining room table. What’s more, Dr. Goldsmith charges, once they failed, single-specialty physician groups had learned to integrate, leading to local monopolies that are still present in many U.S. cities. Even though things are different ten years later, physicians are still unlikely to play nice across specialties, the proceduralists have cherry-picked the remunerative patients for their own surgi-centers and the Generation X physicians are more likely to trump kayaking over the after-hours call it would take to make ACOs a success.

Aaron McKethan and the famous Mark McClellan have a different take in separate post.

The Good: They like ACOs and think they have a decent shot at success thanks to a wider range of more sophisticated payment options such as upside risk or quality-based payments. What’s more, since ACOs are just starting out, it should be possible to experiment and to see what works best. As for Dr. Goldsmith’s criticisms, ACOs may be just the ticket to bridge the physician-physician and physician-hospital divides, there are physician leaders that can make this work and today's information technology is much better compared to the 1990s. Indeed, they point out that there are some anecdotal reports of success emerging from the ‘ACO Learning Network,’ (hm... the DMCB Googled that one but found very little), various State-level reform efforts and, last but not least, the Medicare Demos. Last but not least, if the ACOs can also figure out how to motivate their patients toward better self-care, it won’t be a rerun, it could be a hit movie.

The Better: The DMCB points out that the consolidation of specialty physician groups could actually work in favor of ACOs; rather than deal with multiple small physician groups, getting buy-in from the big cardiology group would not only be administratively simpler, they’d be less likely to feel victimized by take-it-or-leave-it contracting. What’s more, if organized correctly, ACOs are more, not less likely, to help Gen X physicians stick to their precious 35 hour work week. The DMCB likes the point about role of physician leadership and thinks there are a whole new generation of MD-MBA-MHSAs that are up to the task.

Last but not least, when it comes to patient support services, savvy ACOs will be far less likely to insist on a 100% ‘own’ strategy if they can buy a better product at lower cost. That and the experimentation mentioned above will lead to exciting new models of care that incorporate the best of HIT, decision support, registries, disease management and the medical home.

The only downside? ACOs control of the local hospital(s) and physicians could tempt them to act like a regional monopoly. While the DMCB can be suspicious about government regulation, much work remains on crafting the kind of checks and balances that assure that ACOs translate their efficiencies into competitive and not predatory pricing.

(There's lots more on Accountable Care Organizations here)

Splitting the Bills? The Democratic Leadership and the White House Staff Really Need a Vacation

The latest word is that the Democratic leadership and the White House see a “60% chance” they will split their health care bill into two parts—one a budget bill that would be eligible for the 51-vote Senate rule and the other the operational non-budget portions that will need 60 votes. This is all intended to get around the Byrd Rule—which allows the use of reconciliation

Medicare: A Mainframe Using Levers. Why Health Reform Is So Complicated

Drive through Hartford Connecticut on Route I-84 and you cannot miss Aetna's huge corporate headquarters. Or how about visiting Indianapolis and running into Wellpoint’s headquarters? That’s a big impressive building too. The Disease Management Care Blog had seen both of these insurance behemoths, but it can assure you that they’re pipsqueaks compared to what’s at 7500 Security Boulevard in Baltimore.

The DMCB recently visited our Centers for Medicare and Medicaid Services and was blown away by the size of the place. The buildings are not only colossal, the parking lot is probably visible from space. Two words occurred to the DMCB on its way out of the complex: mainframe and leverage.

The word mainframe, coined by former HHS Secretary Leavitt, probably doesn’t do it justice, because CMS is obviously far more, well.... organic like the DNA controlled machines in the movie District 9. Armed with a unique combination of information technology and human resources, this nation-state has a budget that exceeds most countries’ GDP. It somehow manages to move hundreds of billions of dollars around in an opaquely complex system of policies, regulations, claims processing and provider billing. It probably uses more processing power and full time equivalents than what was used to put men into space and describe Britney Spears' behavior combined.

It’s the money that also prompted the DMCB to think about one of the earliest and simplest tools known to mankind: the lever. Since CMS is a payer, its administrators understand that economic incentives can be used to incent or disincent the provision of health care services. While CMS’ influence is far more complicated, a bottom line is that its machinery is increasingly being used to manipulate provider and patient behavior.

Why is this important? Aside from the observation that big bureaucracies with imperfect levers seek to become even bigger bureaucracies with more levers:

1. The ability of so vast an enterprise to fine tune its leverage across an even more complicated U.S. health care landscape can be questioned. For example, DRG-based prospective payment reform was successful in decreasing hospital lengths of stay, leading to earlier discharges. The line that separates early from premature discharges is thin, however, especially when good discharge planning is lacking and patients get readmitted. CMS is now piloting paying for the former and increasingly not paying for the latter. Think hospitals won't respond by doing everything they can to not re-admit patients, even if that would be in their best medical interest? Can the mainframe develop a new lever to address this, or will there be even more unintended consequences? How will this work in downtown LA, in Peoria and in Boise?

2. Man lives by more than bread alone. The rich web of relationships that exist between doctors and patients are driven by far more than money, but when all you have is a lever, all the world looks like a moveable object. Leaving aside the conflict of interest in a health insurer trying to promote living wills, the DMCB doubts CMS’ paying for living will counseling will meaningfully increase their use. It’s already easy for physician to ‘bill’ CMS for patient encounters that include such discussions, but it’s not happening. The reasons for this lapse are multiple (and maybe the topic of a future posting) and most are not a function of an undersupply of shekels from CMS.

3. Which leads to the combination of mainframe reforms and new levers appearing in the health reform bills before Congress. Critics complain they are too complicated. The DMCB says visit CMS outside of Baltimore and you'll understand why.

The Obama Admistration Would Do Well to Read the Senate Rules and the Polls

The latest reports are that the White House is getting ready to ditch any thoughts about a bipartisan health care bill and just ram the Democratic bills through the Senate with bare majorities. Readers of this blog know that I don’t think it is ever possible to ram anything so big as health care through with slim Congressional majorities and even less public support. I

Heart Failure: JAMA Helps Us Understand Counting Measures and Measuring What Counts. Implications for CMS and Disease Management

Most population-based care afficionados will recognize these: measuring left sided heart function if there is a diagnosis of heart failure, using angiotensin converting enzyme inhibitors (ACEi) drugs among patients with low left-sided heart function, providing complete diagnosis-specific patient discharge instructions and giving tobacco cessation counseling when needed. That's right, these are the four state-of-the-art performance measures used by Medicare and the Joint Commission (thanks to recommendations from the National Quality Forum or NQF) to assess the quality of care for recently discharged patients with chronic heart failure.

JAMA has published (Aug 19, 2007;302(7):792) an important article on lingering quality-improvement disconnect between what is measured and what matters. Titled 'Heart failure performance measures and outcomes. Real or illusory gains' Drs. Gregg Fonarow and Eric Peterson of UCLA and Duke, respectively, point to the persistent gap between the gains in all four of the areas mentioned above versus the stubborn and persistently flat U.S. heart failure 30-day rehospitalization (about 20%) and one year mortality rates (close to 40%) over the last five years.

What is going on? The authors point out that the patients themselves may have changed: better care may have led to a relatively higher percent of sicker patients being left among those who make up the statistics in the latter part of the measure periods. Alternatively, the hospitals that are reporting these statistics may simply be doing a better job of documenting care that was really being given all along. Finally, the processes themselves may have limited impact. After all, only ACEi's have been definitively shown to slow the progression of heart failure.

It turns out that CMS is already looking at measures that matter, like readmission and mortality rates. Drs. Fonarow and Peterson point out that's a step in the right direction, but also suggest that future quality metrics should be linked to 'outcomes of interest' like tobacco cessation rates (not counseling), better statistical risk adjustment, developing registries that go beyond simple administrative claims and working with independent physicians and hospitals to create better buy-in.

This has implications for CMS' recent self-congratulations over the updated results from the MCMP and PGP demonstrations. The DMCB notes the demos included additional measures that could have accounted for the improvements, such as flu shots and use of beta blockers. On the other hand, much of what CMS is up to is still heavily laden with process instead of outcome measures. What's more, how well CMS can translate their promising successes among voluntary organized systems into the mainstream of its FFS payment environment remains to be seen.

Finally, there are important implications for other stakeholders in population-based management. The physicians from UCLA and Duke should know better and think about the track record of disease management in managing heart failure, including its endorsement by the American College of Cardiology/American Heart Association (check out p. e448) and its wide use by the participants in the very demos named above. Furthermore, they need to consider the emerging role of the medical home in better coordinating care once patients get discharged. These two (and soon to be one says the DMCB) systems of care may be just the ticket that pulls together all the resources it takes to reduce re-hospitalizations and decrease mortality rates. They can credibly apply their information technology, EHRs, registries and richer data bases to measure the progress really matters.

The DMCB thinks the population-based care approaches have a much better chance of success than a bureaucracy like CMS, no matter how much they read JAMA or try to follow the author's well-intentioned recommendations.

5 Ways to Improve Health Reform, Beating Germs, Health Co-Ops and the DMCB is on Twitter

So many things going on, so little blog. So, in the perfunctory style of KevinMD:

Can the Health Reform Legislation Currently Before Congress Do An Even Better Job With Chronic Illness?

The answer is yes, but by the time the Disease Management Care Blog began to think this through, the Partnership to Fight Chronic Disease was already on the case with this highly readable report. It's only seven pages, but important reading for anyone interested in advancing population-based care. Even if health reform gets scaled back to more modest levels, these five recommendations from the PFCD are worthy of urgent consideration at both the Federal and State levels:

1. Phase in evidence-based next generation care coordination models over the next three years. Emphasis on next generation. In other words, reducing re-admissions, piloting medical homes and experimenting with medication management programs are insufficient; no wonder that the CBO is unimpressed. More fruitful areas include increasing patient adherence and reducing barriers to chronic illness treatment options.

2. Expand on pay for value. Patient adherence to treatment recommendations needs to become a key outcome measure in any assessment of quality. And while we're at it, let's move the cost of care management and disease management programs out of the numerator of the health insurers' administrative cost ratios and recognize them for what the are. There are medical costs.

3. How about preventing chronic disease? That includes the work-place and the community with the right incentives, partnerships, community-based teaming, expansion of the public health infrastructure and getting the schools involved.

4. Reduce patients' out of pocket expenses for the prevention and treatment of chronic disease. It doesn't make any sense to charge a co-pay for the many services needed to manage chronic illness. The insurance benefit can be tweeked to reduce barriers and incent patients to do the right thing. Use co-pays when you want to reduce utilization, like in the case of multiple MRIs.

5. Better health information technology that includes telehealth, expecially in physician shortage areas. This includes remote monitoring, telephony and self-management support.

It's spelled 'a-m-e-n-d-m-e-n-t-s.'

Singing Happy Birthday Beats Germs?

So said HHS Secretary Sebelius on the Sunday news show This Week when she was not only ratcheting down the Administration's cleaving to the public plan option, but helping the public steel itself against the coming H1N1 epidemic:

'Because this virus spreads quickly child to child. Schools are taking preparation to get ready with hand sanitizers and frequent hand-washing, teaching your children to wash their hands, singing "Happy Birthday" to themselves as they wash their hands is good strategy.'

Oh?

The DMCB tried to look that one up and ironically could find no comparative effectiveness research in the peer-review literature to back that assertion. It appears that the CDC's Clean Hands Save Lives! 'Happy Birthday' approach was developed as a timer. Singing the song twice through while soaping up makes the wash last at least 15-20 seconds. Fifteen seconds is at the limits of what health care workers will tolerate when it comes to hand-washing, even though going for 30 seconds reduces bacterial skin counts even further. If you decide to include this tactic in the battle against H1N1, this video is quite instructional.

Unfortunately, disease management organizations may decide that this doesn't quite meet evidence-based muster.

A Member of the U.S. House of Representatives That Doesn't Know What a Health Care Cooperative Is?

Representative Phil Gingrey (R-GA) appeared on today's MSNBC 'Hardball' to be interviewed about health reform and, now that the public option is on ropes, was asked about health insurance cooperatives. His disingenuous reply was that he didn't know what a cooperative exactly is. The DMCB hopes he just being cagey, but if he really doesn't know, he or his staff can simply 'Google' health insurance cooperative and look for the number one listing that has been used by thousands: that's right, the DMCB is at your service with an unbaised literature-based discussion of the topic.

and finally.....

The Disease Management Care Blog Is On Twitter?

Good news! Yes, even if the DMCB doesn't really understand Twitter either. Gosh darn it all, it decided it was going to find out. If you Twitter and are into Tweets, you can look for the DisMgtCareBlog and follow or whatever is done to twitterers. More to follow in this interesting journey.

Co-Ops Are the Single Dumbest Idea I Have Heard in the Health Care Debate in Twenty Years

This is a repost from June 23--sort of like regifting...I am sure you have heard the story about the committee that was charged with designing a horse but, because of the bureaucratic ways of the committee process, instead ended up creating a camel.We will not see a Medicare-like public health plan as part of any health care reform bill in 2009. I know proponents don’t want to hear that but it is

The Other National Universal Systems of Care Are Not Our Problem

You can't have an American health care debate without plenty of trashing of single payer systems elsewhere.I am not a single-payer advocate. I believe it is simplistic to think that if we just had one and eliminated the duplicate expenses multiple payers bring with them everything would be OK.I think a single-payer solution is simplistic because it misses the different histories that have gone on

Health Reform Needs Villains: Here Are Three

Egads, promoting health reform is really hard work, especially for a U.S. President. Not only do you have to become expert in health economics, contend with others’ imperfect decision-making and settle for less than what you'd prefer, your family vacations have to be cut short. Since letting others do the heavy lifting isn't working out so well, Mr. Obama has turned to old-fashioned political rhetoric and generalities to garner support. Unfortunately, even that tried and true method is wearing thin.

But there is another approach that oten works: pin the blame on a villain. Yet, unbelievably, Mr. Obama gave up using that approach when, reproached by an insurance broker at a Town Hall, he answered:

'First of all, you are absolutely right that the insurance companies, in some cases, have been constructive. So I'll give you a particular example. Aetna has been trying to work with us in dealing with some of this preexisting conditions stuff. And that's absolutely true. And there are other companies who have done the same. Now... in some cases what we've seen is also funding in opposition by some other insurance companies to any kind of reform proposals. So my intent is not to vilify insurance companies. If I was vilifying them, what we would be doing would be to say that private insurance has no place in the health care market, and some people believe that.' (bolding from the DMCB).

Talk about a political blunder. Thanks to a deal with big pharma, a separate deal with the hospitals and breaking bread with the AMA, the only villain left standing was the health insurance industry. Now that’s gone.

The Disease Management Care Blog understands that finding someone to blame is a long-standing tradition in today’s ends-justify-the-means politics of partisan elbow throwing. What's more, half of the August recess is gone and big-bang health reform is in trouble. Knowing that it’s do or die time for the Administration, the DMCB is pleased to come to its rescue with three ready-made villains that are available to kick-start the health reform debate on the President's terms:

Global Warming: Can anyone doubt that the simultaneous warming of the planet and skyrocketing health care costs are more than just a coincidence? Their co-occurrence is not only clear proof than one is causing the other but fixing one will fix the other. The DMCB is thinking both ways: not only will cooling the planet preserve precious farmland (nutritious veggies) and halt the spread of bugs (like malaria and spiders), but vice versa: controlling health care costs will reduce our carbon footprint. Think smaller hospitals using less power, less use of internal combustion engines to access physicians thanks to the greater use of blue pills in lieu of red pills, fewer pacemakers and better preservation of both legs so that folks can bicycle to the organic Farmers' Market and the next Town Hall.

The Taliban: These enigmatic bad boys are behind a host of things that are wrong with our world, so why not toss in health care. Sure, they’re half a world away and their threat to the homeland is questionable, but that hasn’t stopped a prior President from successfully rallying the country to defeat these evil-doers. Time to dust off this template and say it out loud: unless health care reform passes, the terrorists will win.

Aliens: Why not leverage our country’s fascination with nefarious space beings. Case in point? How about the eerie resemblance between the wacky Sarah Palin and the space beings of Area 51? Is her bouffant hiding an unacceptably large head cavity? Are her spectacles making her eye sockets appear smaller than they really are? Can her behavior only be explained by orders beamed by some orbiting craft? While the DMCB wonders about this, it also thinks that implying that only a not-of-this-world entity could equate death panels with advance directives will resonate with a huge swath of gullible Democrats and Republicans. This will rally naysayers faster than managed care CEOs to an insurance mandate.