The States' Role in Health Reform

Interested in the States' role in health reform, the Disease Management Care Blog cracked open the latest New England Journal of Medicine on its way to the Disease Management Colloquium. Maybe it's because the DMCB is developing hyperolympicosis and is about to go on a marchmadness bender, but it concluded this article had many parallels to the biased TV announcer favoritism that too often transforms a perfectly fine sports broadcast into a migraine. Too bad the Journal doesn't have a 'mute' button that otherwise helps its readers get past the authors' unwarranted framing to, like, maybe learning about the underlying issues.

The DMCB says check this article out for yourself, but here's a minimalist summary with some other things to think about.

The reason States can't reform health care is because:

Insurance is profoundly expensive: The logic here is that States simply cannot afford to make a 'real investment in the population.' Accordingly, the only entity that come up with the money to pay for expanded Medicaid, preserve Medicare and provide premium subsidies for everyone else is the Federal government.

Think about: States have to make the tough trade-offs between affordability and health care gains. The fact that Massachusetts came up with its own reform suggests it's within reach, but that there are lessons to be learned about combining a relatively rich benefit with optimistic assumptions. That being said, what is the evidence that Washington DC can do that better or cheaper? Where is that remote.....

Practicality: This says the States are unable to stand up to health insurers' ‘price gouging and exclusion(s)’ and, what’s more, insurers will simply exit any State with an 'unappealing 'business climate.

Think about: According to this link, some State Insurance Commissioners have been doing their job with these insurers quite nicely thank you. Many not-for-profit health insurers are State-based or regional and have no where to go. Now, where's that mute button.....

The Law: ERISA shields employer-based and self-funded insurance plans from the States' reach. They are outside the States' purview, which means the Feds need to step in.

Thnk about: The DMCB recalls that ERISA was enacted in the first place because State insurance commissioners were too effective in regulating plans that extended across State borders and a law was needed to restrain the States. Need to aim carefullly.....

Reality: Last but not least, it’s argued that patients and their insurance move across State lines, resulting in adjacent States having insurance programs that “are far less generous” than their neighbors. This creates disparities, which begs the involvement of Washington DC to assure fairness.

The DMCB doesn’t understand why this is necessarily a problem when the elected representatives of a State do what they think is best for their constituents, unless the idea of a national program is to mandate a one size fits all single benefit structure for everyone everywhere.

Click!

The DMCB recognizes that this really comes down to subjective policy preferences, not the faux hard science being portrayed in the Journal. The arguments in favor of greater Federal involvement come down to its ability to control costs once it begins to effectively regulate insurance, that the markets that exist today are neither fish (heavily regulated) nor fowl (free and transparent) and need to be fixed in one direction or another, and that an enlightened legal and regulatory environment courtesy of Wasthington DC could bring the insurers and providers to heel.

Think that makes sense? You be the judge, but don't take this article's word for it.

Post-Summit Health Reform: What a Mess

Everyone agrees our health care system is unsustainable and too often unfair. At the White House health care summit, that was the only common ground between Democrats and Republicans.Many Americans are either left-brain liberals or right-brain conservatives, with the remainder somewhere in the middle. These left- and right-brain types look at the same facts but come to different conclusions—no

Population Health Impact Institute Webinar on Transparency

To the chagrin of the DMCB spouse, looks like her hubby will be housebound today. Trying to be helpful, it pulled some ground meat from the freezer, explaining it's a high value protein platform that offers maximum dinnertime cost-effective savory/flexibility ratios.

Now banished to the office-nerve center of the DMCB World Headquarters, the DMCB has been alerted to another webinar that may be of interest to readers. The Population Health Impact Institute (PHII) is hosting a speaker-rich and complimentary March 11 webinar on achieving methodologic transparency when evaluating population-based outcomes. This looks like a great chance for experts and non-experts alike to bone up on comparative effectiveness, return-on-investment, comparability and communicating results. You can find out about it here, where there is a registration link.

"Reset The Etch-a-Sketch" - Observations from the Feb. 25 White House Health Reform Summit

That line from Rep. Roskam was probably the most memorable quote from today's White House health reform summit. The multi-tasking Disease Management Care Blog kept notes in between the the day-job emails, snacks, calls, caffeine and documents while streaming C-SPAN3 into the bottom right corner of it's second monitor screen while manning the DMCB World Headquarters. In case you missed it, the video is here.

What else do the DMCB notes say?

To no one's surprise, none of the participants appeared to change their minds.

The Democrats stuck to their main point: the bills are big and complex because the provisions are interdependent as well as necessary. For example, if there is no mandate to expand the risk pools, there can be no guaranteed issue, which is why premium supports are necessary which is why taxes.... You get the picture.

The Republicans stuck to their calls for a 'do over,' quoting public opinion polls and pitching their usual counter-proposals. That's what accounted for the etch-a-sketch quote above, likening the current bills before Congress to a messy squiggle resulting from too much fiddling with the knobs.

Yet, the Dems had one big rhetorical advantage: their 'liberal' (pun intended) use of telling anecdotes, including children with menintitis, farmers with sticker-shock insurance bills and middle-class restaurant-owners with chronically ill babies. The Republicans, on the other hand, countered with the unaffordability of a perfect health care system, no matter how deeply we care and no matter how deeply we want it.

Dems vs. Repubs: a tie.

The President's considerable oratorical talent was pushed aside by the preoccupation of policing all of the point/counterpoint discussions. While he occasionally responded to Republican misstatements or showboating, the loyal opposition made their case in a respectful, policy-focused and sometimes surprisingly wonky manner.

Prez vs. Repubs: a tie here means the Repubs won this round by not being led into the trap of being portrayed as the "Party of No."

Other observations:

Media, Editorialists, Bloggers and other Commentariat: even though none of the participants seemed to change their minds and it's unlikely that many health policy adepts gained new insights, the Summit video and transcript is a quotation target-rich environment. The DMCB suspects much of it will be out of context.

Reconciliation? When raised, the Dems implied that there has been no decision regarding the parliamentary path to reconciling the President's proposal and passing the House and Senate bills. Their disingenuousness - acting like they'll be the last to realize what the rest of the country already knows - suggests they're aware that filibuster-busting "reconciliation option" has a LOT of baggage. This is a big big gamble in an election year and this was a key signal that they know it.

Democracy in Action: persons living outside of the U.S. (and maybe Great Britain) will undoubtedly marvel at the willingness of our members of Congress to repeatedly interrupt and attempt to correct the Leader of the Free World. The first generation DMCB thinks the quote is apropos: "Only In America."

Wellness/Care Coordination: Maybe it's because the proceedings were televised, but participants on both sides of the aisle pointed to several things they can agree on. A prominent one was wellness and care coordination as a means to control costs. The DMCB found that to be not only very gratifying but very insightful of our elected officials.

And some surreal moments:

After the President made his opening remarks, the Republicans turned to the folksy Lamar Alexander of Tennessee to be the first out of the gate. As the cameras panned around, it really appeared as if the House Speaker and the Senate Majority Leader were pointedly looking away. Maybe the DMCB is being over-sensitive to the depths of the partisan rancor.

Representative Louise Slaughter (D-NY) had her own anecdote involving dentures and seemed to imply that they should be included in the Medicare benefit.

Sen. Rockefeller (D-WV) described all health insurers as "rapacious" "sharks," and later seemed to agree that all Americans should be obliged to buy health insurance.

Senator Harkin (D-Iowa) said segregating groups into various risk pools with the premium differentials they entail is the kind of "segregation" that is unjustly discriminatory. Now that's a new one.

Last but not least, one Representative observed that never before had he seen so many from Congress act so well for so many television cameras. That prompted some chuckles, but it also speaks to what must be going on behind the scenes. If true, our country deserves better.

('’)


Etch-a-sketch image from Wikipedia

The White House Health Care Summit--Democrats: 0 Republicans: 0 -- The Republicans Win

There is politics and there is policy.On the policy front what we saw today was the same exchange of the old talking points we have watched for a longtime. No progress was made toward any kind of health care bill. That is no surprise--this was never going to be the place to fashion any kind of compromise.At the end the President asked the Republicans if it was worth it to spend another month or

Live Blogging During the Health Care Summit

I am blogging live with a number of others at the NewsHour site.

The Latest Cavalcade of Risk Is Up!

Managing, transferring, categorizing and fearing risk: you can find out how to do all that and even more by checking out David Williams and his Health Business Blog's latest Cavalcade of Risk. It's safe to go in the water and it's even smarter to check it out.

Obama to Uneasy Democrats: Please Walk the Plank for Me But If It Doesn't Work Out Here's Plan B

The President and the Democratic leadership have been pushing hard on the idea that the Democrats should ram their unpopular health care bill through by using reconciliation--no matter how many Democrats in swing districts lose their jobs over it this November.But Laura Meckler had an important story in the Wall Street Journal yesterday that is bound to give many of the nervous moderate Democrats

J.D. Salinger, Franny and Zooey's Fat Lady, Lent and the White House Health Reform Meeting

Since the Disease Management Care Blog has repeatedly belabored J.D. Salinger's Fat Lady, familiar readers may ask why it didn't mark the author's passing on January 27.

It was waiting for the right time. This posting is dedicated to him.

Recall the 'Fat Lady' is that piercing insight achieved by the crisis-addled Franny. Thanks to the counseling of her precocious brother Zooey, her breakthrough helps her deal with a favorite theme of J.D: the modern world's self-absorbed fakery. Franny realizes that her deepest human potential will be met so long as that poor distant woman 'sitting on a porch, listening to the radio' is served - because that Fat Lady really represents something far more wonderful.

Which leads us to the confluence of two other events, one being major and the other relatively minor. One is Lent, the other is Mr. Obama's Feb. 25 go-for-broke Blair House health reform meeting. Lent is that 40-day season before Easter when believers practice self-denial, penitence and seek insight, including thinking about all the other '40's' that are embedded in the Christian calendar. That includes the Jews' 40 years of wandering about in Sinai, as well as Jesus' fasting for 40 days in the desert while being tempted by the devil.

And what temptations they were. The DMCB's amateur interpretation is that Satan's three offers appealed to our most basic human needs: turning stones to bread means freedom from hunger, the 'on-call' availability of angels after leaping off a pinnacle means being immunized against death, and having dominion over all the world's kingdoms means absolute power.

The DMCB isn't suggesting that ashes be passed around or that scripture be read at the Feb. 25 health reform confab, but the Temptation of Christ does have something to teach about the fundamental hard wiring of the human condition. Being "human" means to live by more than bread alone, by being content with some hard facts about our mortality and to being acutely aware of the hazards of concentrated political power. Otherwise, we risk falling far short of meeting our deepest human potential. In order to achieve that, something far greater is necessary.

The DMCB has little doubt that there are honorable people on both sides of the health care debate, that there are critical policy issues at stake and that social justice is in our lifeblood. While some may wonder if the DMCB has turned into some wingnut case full of the Devil Made Me Do It, it thinks the lessons of Lent and the Fat Lady should give pause about the tempting notion of being able to practically cure any threat to our mortality if only we were willing to apply the right kind of enlightened political power.

Franny was a radio entertainer, so she knew something about audiences. When she recognized the Fat Lady was out there, she got her life in order. For the Feb 25 Health Reform meeting, our elected representatives would be well advised to remember the Lenten season and that the Fat Lady is in the audience. It can only help.

The DMCB thinks J.D. would probably approve.

*Since J.D. probably wouldn't permit an unauthorized image of him to be shown, the DMCB decided to portray the prayer (this one's in original Romanian) repeatedly uttered by Franny until Zooey's rescue

About A Third Of the President's Reform Proposal is Devoted to Attacking Medicare Fraud: Will It Work?

Looking back at its career, the Disease Management Care Blog suspects at some point or another, it could have been accused of having technically committed Medicare fraud. Not intentionally of course, but the intensity of service, the documentation, the modifiers, the "incidental to's" CPTs, DRG's, ICD-9's and whatever else was used by the billing office was a thicket of coding logic that seemed to get more complex with each passing year.

That's because with each passing year, the regulations grew more complex in response to increasing levels of Medicare fraud. The DMCB recalls when the teaching hospitals got slammed, the Tenet imbroglio and HCA's expensive troubles. And it hasn't stopped there, including issues, for example, with 'professional courtesy,' enrollment rules, and lately the dreaded Recovery Audit Contractors. In fact, the DMCB stumbled across a Google function that collects web pages on the topic of Medicare fraud and they number in the hundreds. Like an arms race, the government ratchets up its anti-fraud efforts and still, the miscreants find new ways to steal.

Which is why the DMCB is turning once again to the President's Health Reform Proposal. Out of the 11 pages, there are three on attacking 'waste fraud and abuse,' and most of it is directed against the fraud part. There are items that pertain to following bad actors with a history of malfeasance (sort of like a Medicare 'no-fly list), background checks, real time as well as wider data sharing among various enforcement agencies, profiling increased penalties and greater enforcement lattitude.

We've heard this before (here and here, for example) and we're supposed to believe this time it's really really going to work. Trust me.....




Right.

And if the posture of the President's Proposal, when it comes to fraud, strikes you as borrowing concepts from the war on terrorism, then you may understand why some docs may fear being ensnared somewhere in that increasingly complicated grey zone that separates 'simple mistakes' and 'trying to take advantage of the Medicare system.'

sunday was a good day (by lucy, as told to laurie)

On Sunday, two of my humans and I went to a very special birthday party.

There was cake.


The birthday girl turned 17.


She looked very pretty.


A good time was had by young and old (I thought S. was a little too cuddly with that puppy).


It was fun to be at a party.

It was nice to have a nap, too.

Did Wellpoint's Rate Increase Lead the Obama Administration to Propose the Health Insurance Rate Authority ("HIRA")?

Wow. 'The President's Feb 22 Proposal' will cut health premiums, increase competition, promote accountability, eliminate pre-existing condition denials and reduce the deficit. The Disease Management Care Blog knows it is so, because that's what it says on the 1st page.

The DMCB is still chewing on this, but here are some of the more important features in store for commercial insurance reform: the individual insurance mandate is still there with financial assistance consisting of a mix of 'carrot' tax credits and direct payments to insurers. These are combined with the "stick" of "assessments" (a.k.a fees) for those who go without insurance. In addition, employers still need to provide insurance coverage (helped with tax credits for small businesses) or also face "assessments." Once those new fangled insurance exchanges kick-in in 2014, there can be no denials of coverage based on pre-existing conditions and there can be no annual or lifetime limits. As for those so called 'Cadillac' plans, the plan is to delay the excise tax and raise the premium threshold. Many of the comparative number details can be found in the Wonk Room.

There's one other key feature of commercial health insurance reform, which is quoted below:

"...creating a new Health Insurance Rate Authority to provide Federal assistance and oversight to States in conducting reviews of unreasonable rate increases and other unfair practices of insurance plans..... health insurers must submit their proposed premium increases to the State authority or Secretary for review... if a rate increase is unreasonable and unjustified, health insurers must lower premiums, provide rebates, or take other actions to make premiums affordable....(the Government will) provide needed oversight at the Federal level and help States determine how rate review will be enforced and monitor insurance market behavior" (bolding from the DMCB).

The alleged origin of all this, of course, is Wellpoint's political tone deafness when it raised its insurance rates right in the middle of a national debate over health care reform. It would appear that when Anthem's February letters went out announcing the rate increase, the White House announced that enough was enough, went on offense and came to the rescue with its proposal for increased Federal "HIRA" oversight.

The DMCB doesn't think so.

According to this article, the California Department of Insurance knew of Wellpoint's plans in mid-November. The DMCB can't believe that the White House only recently learned of the planned rate increase and was just spurred to action by shocked moral outrage. More likely, it decided weeks ago that it needed cover for its tweaked evolving health reform proposals, looked around for an insurer it could mug and naturally landed on that perennial recissioning, coverage-denying, for-profit and outrageously paid executive-led Wellpoint. Talk about a political windfall of perfect timing.

But the political DMCB doesn't mind, even if it hasn't been invited to the February 25 Health Care Summit confab. Here's why.

In the end, it really doesn't make any difference if the States are presiding over health insurance premium increases or the Feds are. In the end, each line of business within an insurance portfolio needs to stand on it's own two feet: the DMCB and Ms. Sebelius know that health insurers a) have a fiduciary duty to charge actuarially sound rates that will pay the medical bills, and b) are not allowed to cross subsidize between insurance lines, no matter how profitable one or more may be. While the Washington DC's "assistance," and "oversight" are technically an intrusion on the States' Departments of Insurance, the DMCB is betting that most of the Commissioners won't mind giving up that political and regulatory headache.

Which is why the DMCB will close this posting with this piece of advice to the Republicans: even though you may discern that this is another repugnant expansion of Washington's bureaucracy, it's OK to yield on this particular issue in front of the C-SPAN cameras because it won't ultimately make that much of difference. You'll look less like the 'Party of No' if you agree and, who knows, maybe you can leverage this in exchange for a compromise over what's really important.....oh, like physician liability insurance reform, further rolling back all gun control laws or, better yet, getting an agreement from Jon Stewart to book at least five softball interviews to make up for this blunder on The Daily Show with y'all.

The President’s Health Care Plan—Not a Game Changer

It is hard to see how the health care plan the President released this morning changes anything.There is nothing new in it save a health insurance rate regulatory board that is an awkward political proposal at best. What powers would it really have and how would it operate in conjunction with the states already charged with insurance company oversight are just two of the first questions it does

A Quick Summary of Arguments Against the Dartmouth Atlas and Why They May Come Up at the White House Reform Meeting

Like two large ancient armies, the Democrats and Republicans are grimly getting ready for their Feb. 25 White House Health Reform 'dialog.' Around the distant camp fires, rhetorical pikes, speaking point axes and argument maces are being distributed up and down the line, while plans and counter-plans are being prepared in the pursuit of total victory.

The Disease Management Care Blog will leave it to the far more connected commentariat to provide minute-to-minute analysis of the unfolding order of battle. However, the DMCB figures that one issue that may figure prominently in the televised verbal jousting is the issue of 'unnecessary' or 'wasteful' healthcare variation, a.k.a., the Dartmouth Atlas. This says, but for the export of the efficient care of places like the Mayo Clinic to the rest of the country, we could be saving a LOT of money. According to years of research (much of it based on Medicare beneficiaries in the last two years of life), there are considerable geographic variations in the national healthcare cost landscape that cannot be explained by quality or any other outcome variable. In fact, the Atlas data suggest the opposite: that the more money is spent, the worse the outcomes.

Regular DMCB readers, however, know that the Dartmouth Atlas has not been without controversy. The DMCB is pleased to review its prior posts and offer this efficient and linked executive summary of the reasons why the Atlas folks may not be entirely correct. In the coming televised verbal combat, look for one or more of these five arguments to be used by the reform opponents:

1. It's Local Patient Poverty: critics charge that the variation in the observed cost of care correlates with the degree of local poverty, which leads to a higher burden of (especially chronic) illness, more readmissions and longer lengths of stay with greater intensity of care. This interesting post contends that when chronic illness is backed out, white the Colorado suburbs end up looking a lot like the infamous McAllen, Texas.

2. And Hospital 'Poverty' Too: it's also been pointed out that areas of high poverty tend to have poorer hospitals that can't afford the quantity and caliber of nurses or state-of-the-art technology. They're probably getting more than their fair share of Medicaid patients, which is a notoriously poor payer. The degradation in efficiency and inability to provide additional programs also results in more readmissions with complications.

3. 'Bring Out Your Dead!': this article shows that when you look backwards at the patterns of care for Medicare patients that have died, you're excluding the patients that are still alive thanks to pricey health care resources. In contrast, looking forward reveals that higher costs and longer hospital lengths of stay can be associated with survival. This opinion piece in the New England Journal concurs, pointing out that it's important to not only examine the costs for patients that have died, but the severity of illness as well as the outcomes for all patients receiving care.

4. The Underlying Assumptions: this same opinion piece in the New England Journal points out that hospitals don't necessarity control all health care costs in the two years leading up to death.

5. It's Medicare: it's also been pointed in the Journal that the Dartmouth Atlas looks only at fee-for-service Mecdicare. A better gauge of hospital costs would be to examine all charges on all patients. What's more, the charges for FFS Medicare has poor correlation with overall hospital efficiency.

Why care about this? One cost-saving proposal in the pending legislation is to examine the possibility of using economic sticks and carrots to reward hospitals on the basis of Atlas-style efficiency. So, while there is debate about its underlying scientific merits as well as the leveraging of any argument that could upend Obamacare, there is something far more political here. Since hospitals are large employers in many Congressional districts nationwide, the DMCB predicts the Republicans will attempt to use this as a classic "wedge issue' to peel away the Dems that are from districts with allegedly high cost hospitals. Look for it on the 25th.

this happened today

Important Webinar Alert

Are you flummoxed by the methodology utilized to evaluate disease management outcomes? Do you wonder why the experts utilize the word "methodology" instead of "method?" Do you wish they'd stop with the "utilize" stuff and just use the word "use?"

You're in luck because the DMAA is hosting a pair of Webinars that will help you better understand its important (and free, by the way) guide, the 'Outcomes Guidelines Report, Volume 4.' The March 4 kick-off includes faculty who really know what they are talking about: Soeren Matke of Rand and David Veroff of Health Dialog. Compared to other webinars, the pricing is quite modest, especially if you're a DMAA member.

HealthReform.Gov: Insurance Companies "Prosper," Families Suffer and CMS Gets Even Slicker With the Facts

The Disease Management Care Blog doesn't know just how it happened, but its email address has ended up on the HHS press release list. It likes to think that it's because of the DMCB's sprawling internet Wikio Top 5 readership, but more likely it's because it signed up to receive automatic alerts from CMS about its ongoing demos.

The DMCB spouse points out that it certainly isn't because anyone in charge at HHS is actually paying attention to what the DMCB has been posting (here and here). As usual, she's right: if that were the case, they wouldn't have released today's HHS FOR IMMEDIATE RELEASE 'Press Release' about this fiasco of a report.

Titled "Insurance Companies Prosper, Families Suffer: Our Broken Health Insurance System," the report is all of 1286 words. While the DMCB salutes the folks at HHS for their break with a habit of issuing text that routinely exceeds 1286 pages, this bullying demagoguery reflects poorly on the former State Insurance Commissioner with a reputation for moderation.

According to this manifesto, the White House's plans for 'reform' (i.e. what the President and the Congressional Chair-Mandarins seem so far unwilling to compromise on) will:

'Increase government oversight, enforce medical loss ratios, increase public scrutiny and leverage exchange participation.'

It could also increase red tape, lead to regulatory uncertainty and, no matter how much they bully, do little to slow down the relentless medical cost inflation or change the fact that 'billions' in insurer profit is the result of single digit returns spread over very large reserves and regulated surpluses.

'End arbitrary limits placed on coverage by insurance companies.'

Benefit packages are regulated by the states, many of which have run amok by being unable to say no to any constituency and blowing past limits on medical services that strain the definition of 'medically necessity.' Federal meddling could only make it more complicated. And here's some apostasy: caps on benefits, like it or not, are also one way to cap the cost of health insurance: why not contemplate their reasonable use, especially if costs are truly out of control and if (and that's a big if) consumers are aware of they entail?

'End denials of coverage based on health status.'

We've been through this. Without an accompanying universal insurance mandate with teeth, the only persons who will want coverage are those with poor health status. Right now, despite shifting polls, the chances of Congressional approval of a mandate looks about as good as Ms. Sebelius posting a comment on this blog that thanks the DMCB for its erudition.

Create competition among insurers with a health insurance exchange.

While the DMCB likes 'competition,' it's the big insurers with big reserves and big surpluses that are able to survive the inevitable underwriting cycle.

Ensure value in our health care system by rewarding quality, efficiency and coordination.

The DMCB asks if that's the case, then why are the majority of these initiatives being assigned to pilots (whatever they are) and 'demos,' a political morass where good ideas go to die?

Lower premiums, based on a Congressional Budget Office report that estimates streamlining and the entry of more people in the market will lower individual costs by 14 to 20 percent.

Oh? The DMCB went to the CBO Director's Blog and found this November 30 quote about Senator Reid's proposed Patient Protection and Affordable Care Act:

"Average premiums in this (the non-group market) would be higher than under current law primarily because the typical insurance policy in this market would cover both a substantially larger share of the average enrollee’s costs for health care and a slightly wider range of benefits."

Crossing swords over what the CBO said or meant and when that happened aside, however, the fact is that projections about future health insurance are like looking at a blurry chest x-ray from an moving and uncooperative emergency room patient at 2 AM: guesses built on assumptions made up of shadows.

Last but not least, in watching the accompanying video, it really appeared to the DMCB that Ms. Sebelius spent less time addressing the points above and more time trying to portray how 1) CMS can be the watchdog agency that will bring the insurers to heel if only wearegiventhepowertodoso, and 2) righteous the President's agenda for health care reform is. Watch it and draw your own conclusions here.

+++++

Coda: Carl Mecurio has a pair of worthwhile posts on the topic with a different spin over at the Corporate Research Group (CRG) Blog. He agrees that insurers make an easy target, that the rhetoric is, well, rhetoric and that the individual market is in need of some serious work. He also provides some important insights about Pennsylvania's adultBasic. In the meantime, the DMCB isn't sure if the Administration's health reform proposals will a) just spread the underlying cost inflation over a larger pool and hide it with unsustainable deficit funding or b) jump off a political cliff by imposing an unsustainable mandate. Well worth a look.

eye witnessed

Yesterday, the Globe and Mail ran this article about Joe Webber, a man from Aylmer, Ontario, who was falsely accused of forcible confinement and robbery. He was convicted and served nineteen months in jail, based solely on eye witness testimony Although, the perpetrators of the crime were masked, one of the victims of the home invasion identified Webber, claiming to recognize his "bright blue eyes."

Webber's eyes are actually gray. 

Webber was sentenced to 7 1/2 years in jail but was later cleared when two other men confessed to the crime.

Duane Hicks, who identified Webber, remains adamant that it was Webber and his blue (really gray) eyes that he saw behind the mask.

It's a fascinating and tragic story but it's not the first time, in recent weeks, that I've had cause to think about the unreliability of eye witnesses.

A couple of weeks ago, I was walking the dogs home from the park when I saw a woman and her Bernese Mountain Dog coming towards me. I knew them both from the park and called out a greeting as she grew closer.

J-Dog, my older, bigger dog (55 lbs, the Bernese was much bigger than he was) has been getting a little crochety in his old age. He's taken a dislike to younger male dogs, especially when he's on leash. There's never been any serious fighting but, as a precautionary measure, I've been crossing the street or making J-Dog sit when other dogs are approaching on leash. This time, though, since the dogs had met many times, I didn't think to do it.

When the Bernese got close, Jasper lunged at him and growled. The other dog reacted the same way, his owner went to pull him back and slipped on some ice. She fell into a snow bank and the force of her fall brought her giant dog down on top of her. His paw hit her in the face and cut her lip.

We were both uspet (the humans were. The dogs, having recovered from their tussle, were just standing calmly beside us). I felt terrible not to have foreseen the interaction. We were both apologizing to each other, when two women who had been walking behind us felt the need to jump in, one yelling at me and the other fussing the other dog owner.

They kept asking her over and over again if she was OK. She kept saying "yes!" We both tried explaining that it was fine, that we knew each other and so did the dogs ("That doesn't matter!" one woman exclaimed) but they were zealous in their condemnation of me (and my dog) and vociferous in expressing their anger and outrage.

I realized later, based on a few things they said, that both women believed that they had seen Jasper attack the other dog owner and the Bernese leaping in to protect her. 

And I'm sure they would have made sworn statements to that effect.

The dogs and I ran into the Bernese and his human (off-leash) in the dog park and the dogs played together happily. I apologized again for not anticipating J-Dog's bad behaviouor and she once again stated that she feels both dogs (and both owners) were at fault. She also commented on how the intervention of those "witnesses" had just made things so much worse.

I've learned my lesson. I'm now completely consistent in making J-Dog sit when another dog approaches, even when I know it's a dog he likes. And it goes without saying that the only comparison to what happened to J-Dog and Joe Webber was the absolute conviction on the part of witnesses that they saw something that did not happen.

The Latest Health Wonk Review Is Up!

There's the politics, the economics and then there's the medical dimensions of health care reform, but what about its psychology? Even so-called 'pop' psychology can give important insights into what is going on. Dr. Phil is coming to the rescue in a superbly hosted Health Wonk Review over at Brady Augustine's medicaidfirstaid. Bravo!

The Reality of Health Insurance in the Individual Market: Even State Programs Are Increasing Rates

The Disease Management Care Blog doesn't much care for drama that pits white hats against black hats. Novels, plays or movies that portray triumph and tragedy despite our very human flaws are the ones that have staying power because they give us insights about ourselves. Franny's borderline mawkishness, Hamlet's dithering and even Hans Solo's mercenary swagger are the ingredients that can distinguish the serious from the superficial plots. These are the stories that tell us about the human condition and how we deal with our grey world.

Contrast that with other vacuous fictions, like each of us has a marketable talent awaiting discovery by Idol, adolescent vampires routinely sport 6-pack abs and that stand-alone health insurers exist only make huge profits at the expense of the little guy. These simple plot-lines provide a nice fix in a culture addicted to superficial explanations, but little else. What's next, that all that's needed to be President is common sense and conservative values?

Anthem and other health insurers were pilloried ('screw its customers,' or 'defiant and unapologetic') for passing its increases in overall health care costs in a changing book of business to their individual market customers. Yet, for a grey-world reality check, take a look at this report about Pennsylvania's adultBasic program. Run by Pennsylvania's Insurance Department using funds received from the National Tobacco Settlement and through 'voluntary' contributions from the State's 'Blues' plan, it serves as the health insurance program 'of last resort' for indigent individuals unable to obtain insurance elsewhere. Currently, there are just over 40,000 enrollees who pay a subsidized premium of $35 a month, but, due to lack of funding, there is a waiting list of approximately 3500 qualified individuals who pay the full premium of about $330 a month.

Well, thanks to 'sharply rising costs,' persons on the waiting list will see their preimum double to $600 a month. For those already in the adultBasic program, their monthly premium will go up by $1 to $36, but office visit as well as emergency room co-pays are doubling and other services will now have a 10% co-insurance. The reason for these increases in a group least able to afford it isn't because this health insurance program is putting profits before patients, but because:

'...general “medical” inflation: medical appointments and procedures simply cost more than they used to. Another major reason for ... cost increases is that everyone who accesses the benefit package tends to use medical services at a level much higher than in the commercial market. Because of these factors (general medical inflation plus significantly higher usage), the rates needed to be increased substantially to allow the program to continue covering as many people as possible.'

Of course, upon further quiet reflection, smarter folks recognize that it's not the insurers' 'fault,' but a business model that even Republicans agree is broken. Yet like any good storyline, flawed fixes abound: individual mandates to increase the risk pools seem politically unpalatable and do little about the underlying rising frequency and severity of claims expense, while tax breaks and cross border sales could result in a race to the bottom for even fewer people who choose to buy insurance.

This is not easy stuff. Superficial storytelling may make for heros and villains from either end of the political spectrum, but our flaws and the greyness of reality is far different.

olympic figure skating ate my brain

I've a post I want to write about the unreliability of eye-witnesses, inspired by this article in the Globe and Mail and something that happened a couple of weeks ago.

I am, however, just too tired.

I've watched four nights in a row of Olympic figure skating and I am bleary-eyed. I love the drama, the spectacle, the artistry and the strength of the skaters along with the feeling that anything could happen at any moment. I also love the personalities and the costumes. It's too much fun.

I have, however, found myself thinking more than once that I would be able to take it all much more seriously if I hadn't seen Blades of Glory.

Unemployed Sons and Fathers: Implications for Disease Management and the Patient Centered Medical Home

Writing in the New York Times, David Brooks points out that we're entering the lean years with 8% unemployment extending out to the horizon. It's men that are turning out to be the victims of our Great Recession, with a close to 20% umployment rate for those between the ages of 25 and 54 years. For the first time, a majority of the U.S. workforce will be made up by women.

For the chronically unemployed, there are issues that go beyond the impact on health status. On a long term economic basis, there could be less upward mobility and stunted wage growth. At a more significant level, the cultural American ideal of masculinity itself may have to be redefined.

While this megatrend continues to unfold, the Disease Management Care Blog thinks there are some more immediate implications for the disease and care management industries:

While pregnancy care appropriately focuses on the mothers (for example), how will the pre and perinatal 'dyad' care be impacted (think HEDIS first trimester care) by mothers who also happen to the sole family breadwinner? What's the role of fathers in assuring timely follow-up for their newborns? When disease management and medical home care managers call the child's residence to see how things are going, will they be prepared to deal with a male voice?

At the other end of the age spectrum, until now it's been up to the daughters to deal with most of the work involved with being in the sandwich generation. The DMCB has seen them at clinic appointments and in hospital hallways. As more men assume greater responsibility for their struggling parents, how will gender issues that surround coping skills play any role in the support systems for our nation's elders? How will the disease management industry respond? Will care managers in patient centered medical homes adjust appropriately?

And finally, in the absence of a one-size-fits-all insurance mandate, there are implications for the families that primarily depend on an employed female breadwinner. The DMCB thinks women employees are not only more vulnerable to being underpaid, but being in pay-grades with more minimalist insurance or being forced to chose skinnier insurance options with a smaller pay check deduction. Navigating a family though high deductables, co-pays, co-insurance and benefit limits will be more important than ever in care management.

('’)

update on 10 for february

Last week, I joined a BlogHer Group committed to getting ten things done in February. In the spirit of accountability, here is my progress thus far:

 

1. Finish sewing the eyes and mouth on D.'s sock monkey hat.

Still to do, but D. has really stepped up the nagging, so I promised him that I would get it done by Friday.

2. Graft the toes on my sister's socks (both these projects have been very, very close to finished for months. It's embarassing). 

No progress yet.

3. Make soup twice twice.

I made sweet potato soup with roasted garlic. It was extremely labour intensive (and I made it worse by not paying attention to the directions and, instead of slicing 12 sweet potatoes in half, I sliced them all thinly. It was ridiculous and made every other step ridiculously complicated) but delicious. And I froze some to eat during chemo week. Very pleased with myself.

4. Read 6 books, including Generation X: Tales for an Accelerated Culture, Good to a Fault and The Jade Peony

So far, I've read four books, inclduing Good To A Fault (loved it!) and Generation X (meh). One of the books (Dragonfly in Amber, the second book in Diana Gabaldon's Outlander series) was almost 750 pages long.

5. Average 6 hours of walking every week (I was doing this easily for a long time but have slacked off and I'm feeling it, as are the dogs).

I've decided to change that to 6 hours of cardio (of any kind) per week but I've still only been averaging 4.5 hours.

6. Re-read the first draft of my novel (haven't touched the thing since completing NaNoWriMo).

I've read the first forty pages. It doesn't suck as much as I was worried that it would. In fact, there are some bits I actually liked.  I find it exhausting to read, though - not because it's heavy or difficult but because I wrote it. Can any of you relate to that feeling?

7. Write something 3x every week (I have been anxious and procrastinating. I thought that setting the bar low might help).

I wrote, for at least a few minutes, four times last week.

8. Organize my clothes.

Haven't started. Unless you count putting one pair of pants that don't fit anymore (wore them a few weeks ago but couldn't do them up on the week end) where they won't make me feel so pissed off at myself.

9. Go skating (I live steps from the Rideau Canal yet I didn't even make it out once last year).

I went once with my family and twice on my own!

10. Send a card to my Aunt, with the photo we took in the summer.

I really do need to get to this one. It's something I've been wanting to do for some time. I don't know why it keeps getting pushed down the to-do list.

Anyone else have any progress to report?

The Jefferson Colloquium on Population Health and Disease Management

The Disease Management Care Blog is getting prepared for travel. PowerPoint files are being updated, literature searches are being finalized, graphics are being prettied up, hotel rooms are getting reserved and planes, trains and automobiles are being arranged. It has two speaking gigs coming up and one of them is Jefferson's once-a-year Population Health and Disease Management Colloquium.

In a three-for-one bargain, the Colloquium will be collocated with the National Retail Clinic Summit and the Second National Medical Home Summit at the downtown Marriott in Philadelphia. It promises to be a premier event, what with speakers from Health Affairs, AHRQ, government, academia, physician organizations and industry. The DMCB is especially looking forward to hearing what the disease management organizations are up to and what advanced versions of care management are being assembled in conjunction with patient centered medical homes. There's also the happy prospect of seeing old friends and making new ones.

And the loquacious DMCB is looking forward to serving double duty at the conference. On the first day, the Colloquium organizers were foolish enough to cede the DMCB the last 45 minutes of the day so it can discuss 'health communication and social networking.' When THAT's over, it'll be time for celebratory beverages. On the second day, the DMCB will be part of the closing panel discussion on Innovation, Strategy and Practice.

If you can't go because your boss is a short-sighted cheapskate who doesn't want to pay for travel even though the DMCB will be there, point out that you also have the option of watching the conference via live streaming video. It'll be available on-line afterwards, making it even easier for you to liberally quote from it.

Finally, as a bonus for the thousands of regular DMCB readers, here's one preview on the topic of communication and networking: the competition for 'eyeballs' (attention) in social media is won by a) content and b) nimbleness. The former is only partially defined by accuracy and the latter is only partially defined by timeliness. What is important, however, is that neither depend all that much on formal credentials. In it's travels around the blogmos and the twitterverse, the DMCB is running into 'netizens' who, with study, hard work, passion and some luck can turn out to be just as much of a player as many of us so-called university-trained experts. This has huge implications for the transmission of health information gleaned from advances in health care, especially for research journals, health educators and the disease management industry.

See you there!

Some Common Sense Suggestions on Health Reform

In a prior post, the Disease Management Care Blog reviewed Business Week's dour report on disease management. As readers may recall, BW relied on the single anecdotal experience of a dubious General Electric medical director to portray the entire care management industry as a waste of money.

Well, that same General Electric medical director has penned a common sense editorial about health reform in the most recent on-line version of American Journal of Managed Care. It gives good insight on how a commercial non-governmental employer-insurer thinks about insurance reform.

His DMCB-abbreviated short and sweet recommendations follow:

First, everyone has to agree on four assumptions:

1) Reform is a work in progress and rapid cycle assessment of pilot programs is necessary,

2) Provider payment systems need to evolve quickly to being performance based,

3) Not only is all politics local, so is health care

4) Continued flexibility on pursuing quality and cost is important.

Assuming everyone can agree on these, then.....

CMS and the private sector will need to coordinate performance-based payment approaches. Neither alone are likely to get the docs' attention.

Beware the unintended consequence of increased provider coordination that could lead to the formation of local physician-hospital monopolies. Pricing transparency is a minimum requirement and if that fails, CMS and private insurers will need to enforce price ceilings.

That being said, the collective experience of the experimentation described above could act as a national information resource and act as a safe harbor that allows the physicians to focus on clinical quality improvement rather than payment rates.

The DMCB hopes someone points these out at the Feb. 25 White House health reform meeting.

A Report on the Electronic Record and a Report on the Patient Centered Medical Home: Good Reading

The bookish Disease Management Care Blog found two recent and interesting pieces from the medical literature for your consideration. One deals with the electronic record and the second deals with medical homes. Both are written with the physician incentives in mind and deserve to be considered by policy-makers and anyone with 'line' responsiblity for dealing with either of these two initiatives in a provider network.

The first is from David Kibbe MD, a senior advisor to the American Academy of Family Physicians. Writing in an online 'ahead of print' version of Family Practice Management, Dr. Kibbe offers up some words of caution over the latest plan (proposed rule making) by the Feds to promote the 'meaningful use' of the electronic health record (EHR). This should give pause to policy makers that think the EHR is a wonderful idea that only needs a nudge to make it become reality in every corner of every physician practice.

Basically, he says, the Feds' latest actions have raised even more uncertainty. As a result, physicians without an EHR may elect to sit tight and use paper for at least one more year or longer. According to Dr. K, here's why:

1. emerging 'meaningful use' requirements by the Feds will force EHR vendors to reconfigure their wares, which is leading to future price uncertainty. (Ditto for the docs that were brave enough to invest in EHRs, by the way).

2. health reform has been slowed, leading to additional uncertainty about future physician fee schedules, revenue and their ability to afford investment in an EHR in the first place.

3. 'modular' EHR-like components are around the corner, which will allow docs to assemble 'clinical groupware' into a functioning EHR, which raises additional uncertainties.

4. the Physician Reporting Quality Reporting Initiative (PQRI), another CMS program that promised to reimburse physicians outside of the normal fee schedule 'P4P style,' has not gone all that smoothly. Docs may doubt that the government can really deliver the goods, er, make that checks.

5. money aside, it's just a big hassle to deal with Uncle Sam

6. the meaningful use process will eventually require the on-line submission of quality outcomes data. Right now, it's not clear how CMS will handle what promises to be a huge data load, introducing even more doubt about the promise to pay physicians in a timely manner.

7. the Feds are threatening penalities down the road for physicians that don't comply with meaningful use EHRs. Many physicians may respond by planning on using paper until that date and then simply retire from practice altogether (when the economy eventually turns around and the 401k's get back)

The second article is available (subscription required beyond the abstract) at the Annals of Internal Medicine. Recall that advocates of the Patient Centered Medical Home (PCMH) suggest that physicians who offer it should be reimbursed with a monthly and risk-adjusted fee per PCMH enrollee in addition to the usual fee-for-service payments. If that sounds like 1990's style capitation, you're right. Written by Ann Mirabito and Leonard Perry of Baylor, the article presents three HMO mistakes that need to be avoided by capitated PCMHs:

1. resist the temptation to go along with any mandated patient enrollment in medical homes. If PCMH's work so well, they should have no problem attracting patients by acting as a 'trusted' guide to navigating referrals in a patient-centered and evidence-based manner.

2. early HMOs were regarded as patient friendly, but things quickly turned sour when there were too many patients and things turned impersonal. Physician practices without the capacity to truly be medical homes will need to resist the allure of signing up too many patients and grabbing all that capitation revenue.

3. simple risk-adjusted payment systems will simply reward physicians for signing patients up. Better to include meaningful dollar incentives that reward measurable quality.

on the canal

I like to say that "I moved to Ottawa kicking and screaming." I loved living in Toronto and only moved because my spouse's short term contracts had led to longer term work and I had quit my job.

But then I fell in love with the place. And yesterday's adventure skating sums up why.

It was a beautiful sunny day, unseasonably warm for February. On impulse, I grabbed my skates and headed over to the canal.

When I hit the ice, I found myself giggling like a little kid. My calves were burning (and when they loosened up my thighs took over. My butt still hurts today) but it was fun.

There were folks out skating in office clothes (including at least one guy in a full suit and tie) and a teenager turning cartwheels on the ice. There were little kids that looked too young to walk, gliding past me. And there were other adults wobbling along or holding the hands of more stable skaters. There were people of all races, ages, shapes and sizes - all out enjoying the sunshine and the joy of movement.

A little more than an hour after I left the house, I returned to drop off my skates and ran to catch the bus that would take me to an appointment. I was hot and sweaty. And happy, too.

The Feb. 25 Healthcare Summit: Time to Transition from 'Yes We Can' to 'Yes We Will'

It starts at 10 AM here

President Obama has invited the Congressional leadership from both political parties to a televised Feb. 25 White House 'summit' on health reform. The Republicans are leery yet confident, the Democrats are grim and determined, and the bloggers promise to be on this thicker than cardiologists on a proposed fee reduction. Like other denizens of the blogmos, the Disease Management Care Blog looks forward to viewing the video, combing through the transcript and reading the participants' body language.

This could turn out to be grand political theater at its dysfunctional finest. Yet, while the DMCB is fed up with all the Machiavellism, it thinks the Feb. 25 meeting is a necessary evil. It could turn out to be the dark before the dawn - the cloud behind the silver lining.

Here's why. In order for bipartisan health care reform to succeed, the naive DMCB thinks it will need to devolve into the boring complicated policy-over-politics process that it really is. That means having many more competent, serious and responsible meetings dealing with stuff like entitlement reform and changing how providers are paid.

There are three ingredients that will help that happen:

1) the Republicans need to be 'win-win' kept at the table over the long term with the goal of giving everyone credit. They've demonstrated an ability to derail things and their cooperation has moved from optional to necessary.

2) with the usual exceptions, ongoing C-SPAN video style transparency is needed to keep posturing to a minimum. While the common wisdom is that public scrutiny could derail delicate negotiations, the DMCB is confident that the mainstream media will move on in its search for the salacious, leaving behind a committed viewership. Sure, it won't be pretty, but it'll be better than the big government reformists being trapped in a closed information loop.

3) our elected representatives are given free reign to behave badly at this kick-off meeting. To quote the Godfather's Clemenza, some opening-bell rancor will 'help to get rid of the bad blood.' The DMCB says it's OK if the Feb. 25 meeting serves as an opportunity to photo-op for each party's base. After that, it's time to roll up the sleeves and get to work.



So, watch the Feb. 25 meeting. If there are no plans to a) continue meetings b) in a televised manner, the DMCB will fear that health reform will truly remain in disarray. If there are plans for additional meetings and they fall off the news-cycle radar screen, we may have a chance at actually accomplishing something. This is how we'll know if the Obama Administration is stuck in campaign mode or is really interested in serious policy accomplishments.


It's time. Less Yes We Can and more Yes We Will.

The Latest Cavalcade of Risk is Up!

John Leppard describes it as the best risk-based writing on the web. The DMCB says it cannot disagree and that this is stuff you won't see anywhere else. Check out HealthCare Manumission and all the provocative posts that range from weed to workers comp to health care to investing!

it scares me

Every since I could read (and probably even before), I have wanted to be a writer of fiction.

And now that I have the opportunity, I am terrified.

My professional life helped me overcome a great deal of writing anxiety. When you have a writing deadline and you know that fifteen other people are going to comment and edit what you write, you learn to just put fingers to the keyboard and get the job done. This is a lesson it took me a long time to learn but I got there (more or less).

I enjoyed doing the kind of writing that I was able to do for advocacy organizations and labour unions but I seldom got to pick the subject of the pieces I wrote. I learned to write in the voice of the organization I represented or the person for whom I was writing a statement or speech. It was fun and I got to be reasonably good at it but keeping the writing at some distance helped me to overcome most of my anxiety. 

And the sheer volume of work meant that I frequently had little time for angst between cranking out one piece and then beginning the next.

This blog was the next step in my writing evolution. Beginning when I was first diagnosed with breast cancer and at my most vulnerable, there was little that I did not reveal here. Before long, I realized that my writing had changed, that the voice use is now my own.

Then I began to long to create something new, to make up stories in the way that I had as a child. I set this as my next goal.

And then I froze.

Participating in National Novel Writing Month was a breakthrough for me, as I took the short scenes I had written for a fiction course and the notes in my journal and cranked out 50,000 words in less than a month. I celebrated with champagne when I finished. The completion of this project marked a huge personal triumph.

But I have not looked at a single word of the manuscript since November 29th. Moving continuously forward was the key to getting through NaNoWriMo and I did not let myself re-read as I wrote. Then I permitted myself to take a break in December. Then January came and went. And now, we are well into February.

When I set my ten goals for this month, I included the task of reviewing my draft novel. Two days ago, I finally printed it. The pages fell out of the printer and onto the floor. I scooped them up and dropped them on the dining room table, where they remain, out of order and unread.

I'm off to Toronto tomorrow evening. I'm going to bring the document with me and on Sunday's train ride home, I'm going to start to read.

I'll let you know how it goes.

Is there anything that you really want to do that scares you?