0-2-9-14

Yesterday was a chemo day, so I don't have much in the way of original thought to offer up to you.

It was more stressful and a longer day than most but made infinitely easier by the presence of my friend T. We had lots to talk about and she ably distracted me when I felt the stress levels rising (the guy beside me was, for much of the time, having a shouted conversation with the man across the "pod."). She even tucked me in very sweetly as I settled in for my post Demerol nap.

Between bloodwork and chemo, T. and I went out to lunch at The Green Door. Over our veggies, we got to talking about food. I've been seeing a nutritionist, who has made some initial adjustments to my diet (minimal sugar, no dairy, more raw food, a high quality protein with every meal or snack). Since I told the nutrionist that I drank no more than five drinks a week, I've also been trying to stick to that. What I need to figure out is what exactly constitutes a drink. Is a pint of beer one drink? Two? One and a half?

T. told me that her doctor has been telling all his patients to stick to the following formula: 0-2-9-14

0 - at least one night every week you have no booze at all.

2- no more than 2 drinks at any given time.

9- women should have no more than 9 drinks per week.

14 - the maximum for men.

That makes sense to me and doesn't seem too onerous. Of course, if one is hoping to lose weight, drinking less (or not at all!) makes sense. Empty calories, decreased willpower, increased appetite...there really are lots of sensible reasons to forego the booze. I do enjoy beer and wine, though and don't do well when I try to cut anything I like out completely.

What do you think?

Value Based Insurance Design and the Synergies with the Medical Home, P4P, HIT and Disease Management. We've Only Just Begun

More than a year ago, the Disease Management Care Blog posted a prediction. It said that the key to achieving improved population-based outcomes at lower cost will lie in the combined five-fold synergies of: 1) Ver 2.0 care/disease management, 2) the patient centered medical home (PCMH), 3) provider pay-for-performance (P4P), 4) the electronic medical record (EMR) and 5) consumer directed health plans. It turns out that the DMCB was slightly wrong in several domains. It's not necessarily just 'pay for performance' but flexible provider compensation that includes enhanced fee-for-service, risk-adjusted capitation, P4P and gain sharing. It's not just the EMR, but EHRs plus decision support and registries. And it's not consumer directed health plans but value based insurance designs (VBID).

What is VBID? It's any commercial insurance product that includes adjustments of patients' out-of-pocket costs and provider reimbursement for specific services based on their clinical benefit. The greater the benefit to the patient, the lower that patient's cost share and the higher the provider payment. It can be tailored to certain services (for example, lipid testing) and/or for certain conditions (diabetes mellitus) and/or condition severity (enrollees with recurrent hospitalizations) and/or level of participation (in care management). It's not necessarily easy to implement, since there are Federal and State regulations to consider, the possibility of employee push-back over perceptions of unfairness, a still evolving business model and questionable scalability across a network.

You can read more about it here and view this helpful YouTube video here.

VBID was an important topic that was discussed by Mark Fendrick at the Patient Centered Primary Care Collaborative Stakeholder's meeting that was held in Washington DC on March 30. His presentation (the PowerPoint is not yet available on line) was timed to match the release of this PCPCC white paper. It's worth downloading and reading. It describes in some detail how the PCMH and VBID can be integrated through reduced patient out-of-pocket expenses for medical home-based visits as well as for referrals coordinated by the medical home, increased health reimbursement/savings accounts to pay for medical home services and co-pay tiering that favors testing and medications ordered by medical home team members.

The March 30 meeting also featured Dr. Blumenthal of ONC, who spoke rather extensively about the synergies of health information technology (HIT) and the medical home. Unlike discussion of VBID, however, there was little else that was particularly new in this discussion, including the assertion that this time, and we really REALLY mean it this time, that "meaningful use" combined with luster of federal funding will cause all those hold-out physicians relent and spend tens of thousands on an outpatient EHR.

What was missing from both Dr. Fendrick's and Blumenthal's presentations, however, was how HIT, VBID and the medical home are probably more than the sum of any of its parts. For example, HIT-based decision support tapping into registries can help prompt value-based interventions coordinated by PCMH team members even if the patient is not physically present.

The DMCB says toss in the right kind of provider reimbursements and the option of distance telephonic support to help coach the patient using principles of shared decision making and....

Well, the DMCB thinks anyone can see the potential here.

Years ago, the DMCB also submitted a paper to Health Affairs on the topic of an overlapping and mutually supportive five-way approach to population-based care. After some tantalizing positive reviewer feedback and requests for revisions, it was ultimately rejected. The thinks it was ahead of its time. The manuscript is in some folder in the DMCB World Headquarters somewhere. Maybe it's getting time to dust it off.

And maybe at a next PCPCC confab, it'll be realized that PCMH-VBID or PCMH-HIT dyads are only the beginning.

First Impression Notes From the March 30 Patient Centered Primary Care Collaborative's Stakeholder's Meeting

It's been a long but rewarding day. The Disease Management Care Blog attended the Patient Centered Primary Care Collaborative's Stakeholders' Working Group meeting at Washington D.C.'s Ronald Reagan Building. You can download most of the presentations here. While the DMCB will be reflecting on some of the Conference's more interesting speakers' over the next few days, here are some immediate insights:

The PCPCC has come a long way with an energetic and impressive leadership that has ably harnessed the talents of a cast of thousands. There was a sense of real momentum in the room.

The "Patient Centered Medical Home" clearly continues to be hot, not only because of its inclusion in health reform, but because conferences on the topic can now attract U.S. Surgeon Generals and National Coordinators for Health Information Technology. Surgeon General Benjamin extolled her many past ties to organized medicine and demonstrated her understanding of clinical practice in small town poverty, making the DMCB wonder why she wasn't more visible during the Administration's recent legislative travails. As for Dr. Blumenthal, the irony of his "I'm from the government and I'm here to help" doctors adopt meaningfully useful electronic records speech at the Reagan Center was almost too much for the DMCB to bear. Lots of coffee helped maintain focus.

There is a telling absence of breaking news about cost savings, a.k.a. claims expense reductions, a.k.a., bending the curve, a.k.a, return on investment from the medical home pilots. The focus on payment reform, blended capitation/fee-for-service/P4P/shared savings models and an interesting discussion on an alternative approach to reimbursement for measurable outcomes that are 'delegated' to medical homes made the DMCB suspect that the pilots have begun to run into the same issues that plagued early versions of the disease management industry. Hang in there says the DMCB. Not only is the science of cost analytics evolving, so is the patient centered medical home itself, including combined approaches that leverage the best of health information technology, value based insurance and modern versions of disease management. More on that in a later post.

The not-for-profit community health plans, represented by ACHP, also have yet to demonstrate hard savings from their PCMH initiatives, but there are some promising "early indicators." The DMCB also does not blame ACHP or its members for being annoyed at being swept up in the anti-insurer bombast of Ms. Sebelius.

Last but not least, the language of "Patient Centered Medical Homes" may have shifted away from jargon about 'the medical home' to rhetoric about "patient centeredness." This sometimes drifted into a parallel universe of perfectly-practiced medicine, special PCP-patient intimacy, appointments whenever wanted, limitless access to caring specialists and virtuous declines in health care costs. It also included, and the DMCB is not making this up, being a role model for "student-centered schools." The DMCB endorses the concept and votes for commuter-centered DC Metro trains, working wireless-centered wirelessness at last night's cheapo hotel and, as always, DMCB-centered spousing.

This means that in workplace meetings, conferences and career laddering sword-play with colleagues, the thousands of regular DMCB readers once again have a critical advantage. You can once again demonstrate your complete mastery of this topic by minimizing use of 'medical home' in favor of the much preferred term 'patient centeredness':

Incorrect: "This initiative is designed to promote quality and consumer value by leveraging the principles of the medical home in our network!"

Correct: "This initiative will capitalize on consumerism, leading to heightened health care value by focusing on patient centeredness in our network!"

Shared Decision Making and Health Reform

Tucked away in health reform's Patient Protection and Affordable Care Act is Section 3506 on the topic of 'shared decision making.' It's on page 1086 and establishes 'collaborative processes' that 'engage' patients and providers 'with trade-offs among treatment options' with the 'incorporation of patient preferences and values into the medical plan." As the Disease Management Care Blog understands it, this directs the Secretary of HHS to establish standards and decision aids that are used in shared decision making and develop a certification process. Grants are to then be made available to assist providers in using certified shared decision making with the help of 'Shared Decisionmaking Resource Centers.'

Google the term 'Shared Decision Making" and guess what turns up: Dartmouth Hitchcock Medical Center's Center for Shared Decision Making which is made possible by a grant from the Foundation for Informed Medical Decision Making and Health Dialog, which was built "in collaboration" with the same Foundation to sell programs that reduce the variation described in the Dartmouth Institute and at the Dartmouth Atlas.

The DMCB discerns a pattern here. While the term "shared decision making" is not owned by any particular entity, many of us in the business of population-based care programs associate it with both Dartmouth and Health Dialog. It appears that the newly passed health reform bill is recognizing Dartmouth's extensive work in this area and, indirectly, has also boosted Health Dialog's market presence. Care to guess which institution(s) will be weighing in on the creation of federal standards on shared decision making, helping to promote their use and helping with the Centers?

The DMCB wishes its Senators had written it into Federal law by establishing standards, certification and promotion of policy and health care blogging based on its topics and style. It comforts itself by figuring the Dartmouth and Health Dialog had a head start. The DMCB reminds the spouse that its time will come and, like shared decision making, will not settle for a pilot or a demo. No sir.

To read more on the topic of shared decision making, check out two articles this one and this one from Health Affairs. Based on the statute, looks like we're all going to become more familiar with the concept.

A Raw Political Analysis of the Nomination of Donald Berwick to Lead CMS

The Institute for Healthcare Improvement's Don Berwick MD has reportedly been tapped by the Obama Administration to be the Administrator for CMS. Like other denizens of the health policy bogmos (here, here and here), the Disease Management Care Blog is a big fan of Dr. Berwick's. Anyone who has done anything about health care quality, patient empowerment, systems of care, access disparities and health care value has certainly read his articles and heard him speak. He has been a tireless advocate on behalf of righting what is wrong with the system and the DMCB wishes him all the luck in the world.

He's really going to need it when it comes to his Senate confirmation.

The DMCB recalls this article suggesting that the White House seems to have two complimentary styles. On one side is the pragmatic Chief of Staff Emanuel Rahm, while on the other is the partisan top aide David Axelrod. While Mr. Rahm was urging caution on health reform following Republican Scott Brown's Senate victory, it was apparently Mr. Axelrod that successfully argued for a full court press. The rest is, as they say, history. Reform passed, leaving the Democrats resurgent and Mr. Axelrod's role intact.

In the meantime, the Republicans are in no mood to cooperate in any way. The DMCB agrees with the pundits who say the Republican game plan is to resist every Obama initiative until the November elections, hoping that's when they can capitalize on voter anger and further reduce the Democratic Senate majority and maybe even take control of the House of the Representatives.

Which leads us back to the iconoclastic and 'extremist' and outspoken Dr. Berwick. This is less about him and more about boxing in the Republican minority.

Which leads the DMCB to a prediction.

While Dr. Berwick is a genius, he may also be part of David Axelrod's purposeful political calculus that is now practically inviting the Senate Republicans to publicly stymie the able and widely admired Dr. Berwick's appointment to CMS. In fact, Harvard's Dr. Berwick has written and spoken so extensively that there should be little problem for some Senate staffers to find some juicy quotes to take out of context. This will prompt the usual D.C atmospherics that will leave both parties bloodied and each believing that the other lost more support. Scott Brown of Massachusetts may also be squeezed with some tough lose-lose decision-making. In the end, and assuming Dr. Berwick hangs in there, there'll be a recess appointment.

Until then, it will be business-as-usual at CMS. Unfortunately, it will also be business-as-usual in Congress.

With The Passage of Health Reform, How Many Dollars Are Being Used To Save A Life?

In the tumult leading up to the passage of health reform, one of the more compelling arguments used by supporters was that the lack of insurance was leading to the death of 'hundreds of thousands' of Americans. In the dust-up followed over just how studies like this, this and this should be interpreted, the rhetoric dipped into research methodology while the Disease Management Care Blog's liberal colleagues scored points with some 'you-have-blood-on-your-hands' political jabs.

After all, it was hard to argue with the research. The studies showed a very strong association between the lack of health insurance and mortality that could not be explained by any other sources of known bias. Proponents of the Democrats' plan correctly argued that prospective clinical trials on health insurance would be unethical and take too long. Instead, anecdotes, experience, common sense and a judgment about the reasonableness of the association was good enough to argue that lives were at stake.

The DMCB supports the use of that type of reasoning. It should be similarly applied to assessing the strong association between population-based disease/care management and insurance cost savings.

But that's not the purpose of this post. Now that health reform is the law of the land and we have a credible cost analysis, your intrepid DMCB is willing to tread where few will go. It asks if the price tag of $940,000,000,000 is worth spending to save 'hundreds of thousands' of persons' lives. A quick calcuation says that's $94 billion a year to save 22,000 persons a year who, but for lack of insurance, die every year. That works out to $4,272,727 per person. If the DMCB highballs the lives saved without including other costs alledgly not included in the health reform bill, it's $2,088,888.

The DMCB will be the first to point out that that figure doesn't tell the whole story. In addition to lives saved per single year, there are the additional years of life expectancy minus the additional cost of caring for survivors plus tax revenues from their gainful employement. There are also many lives improved, including fewer complications from treatable disease and increased quality of life, minus lives lost with better (albeit questionable) access to health care. In addition, expansions in health care seem to lead to additional demand, which indirectly but significantly increases cost. Finally, there is the time value of money. Reconciling all of that would require some high octane health services research using dollars per quality adjusted life year. That's currently out of the DMCB's reach.

But it does raise an important point about health reform. While it has considerable benefit, it also comes at a significant cost. That has little meaning to individuals and their families who are confronting life threatening disease, but Americans and their elected representatives (i.e., the ones who, effective March 23, 2010, are now apparently responsible for running the health care system) will need to continually ask if we are getting our money's worth. Prior to the advent of health reform, $100,000 per year life saved was considered reasonable. The DMCB thinks that with the hundreds of billions of dollars going into health reform, we just decided, as a society, that $100,000 is not enough. We're willing to spend more - a lot more.

Last thought: there is no right or wrong answer to the number of dollars that should be spent to save one year of life, to save failing schools, increase employment, reverse failed nation-states, shore up our financial system, keep the sea lanes open, enable home ownership, preserve our infrastructure and resurrect our manufacturing base. The DMCB has personally presided over the consumption of hundreds of thousands of dollars in the care of its patients. Unfortunately, however, no matter how well intentioned we are about the many needs out there, other considerations that are outside of our direct control are looming.

That may force us to reconsider things in the not too distant future.

inside laurie's head

saying "no" to:

beating myself up

people who make me feel bad about myself

feeling ashamed

hiding from people who love me

giving into my fears

jealousy

Saying "yes" to:

spending time with the people who fill me up

reading for pleasure

tapping my own creative resources

trying new things

fun

talking to my Mom more often

giddy about:

all the great books that are available to read

the way my kids and spouse make me laugh until I cry

dog bellies and snouts

the potential of things I could knit

the thought that I am a Writer

scared of:

dying

not being able to read, or write, walk my dogs or play with my kids

writing fiction and discovering that I don't have the talent for it

anything bad happening to someone I love

deeply inspired by: 

beautiful prose

my sister

my friends

my kids

Lene

being in love

obsessed with:

the clutter in my house (not that I do anything about it)

wondering where the day goes

finding peanut and nut alternatives

thinking about things I could knit (as opposed to actual knitting)

tracking what books i read and planning what books i'm going to read next

Scrabble

in love with:

Tim

my boys

the dogs

feeling the sun on my face on a warm spring day

saved by:

blogging and my journal

world class health care

Tim

the people who love me

good chocolate

finding a reason every day to be happy.

and you?

Thanks to Mocha Momma and Dancing Mermaid for inspiring me to do this.

What Congress Got Right on Prevention and Three Things To Consider in the Future

Based on what’s been written in its prior posts this week, readers may think the Disease Management Care Blog has, when it comes to prevention, dismissed the entire health reform package as woefully inadequate. Actually, outside of not doing enough to prevent diabetes and continuing to rely on one-on-one provider visits for prevention 'planning,' the DMCB thinks there is lots to be happy about in the legislation.

Medicare and Medicaid will now eliminate cost sharing and other forms of out of pocket expenses for many preventive services. In addition, States will be eligible to receive extra Federal funding to make this possible. In the area of tobacco, cessation drugs will now be included in State Medicaid formularies and cessation services will be available to women who are pregnant. Commercial insurers will also be largely prohibited from imposing any out of pocket costs related to immunizations as well as for preventive care for children and women and aspparently have to cover the "A" or "B" recommendations set by the U.S Preventive Services Task Force.*

Regular readers may also recall that Congress was being pressured to reset the cap on the percent of premium financial incentives that could be used by employers to promote wellness. The DMCB is happy to report that the original language has been preserved and that it is now set at 30%.

Last but not least, there are many grants, councils, task forces, demos and pilots that will include various initiatives to test approaches to and generally promote wellness and prevention. While it remains to be seen how much of an impact all of this will have, successes may breed additional successes and lead to additional changes in how government and commercial insurers pay for prevention.

Yet, is this enough? The DMCB isn't all too sure because much of the legislative language directs the Secretary of HHS to make all this happen using the "shall' verb. Between here and there is a lot of regulatory language and a large number of moving pieces that could mean delays and poor execution. That, to paraphrase our Vice President, is also a big deal. DMCB is rooting for the HHS Secretary and giving the taxpayers their money's worth.

In the meantime, here are some ideas for Congress to continue to consider in the inevitable fixes that will follow:

1. The next time Medicare beneficiaries are sent a rebate, why not send vouchers instead that can be used for a year's worth fitness training and/or nutritional counseling?

2. If randomized control trials show that case manager directed life-style interventions reduce the incidence of diabetes for persons at risk, why not cover this in Medicare and Medicaid?

3. And while this is a little different, while the Centers for Disease Control is charged with significant leadership responsibilities in the various working groups, why not ask it to lead the creation of a multi-faceted and state-of-the-art social media campaign in support of a national wellness agenda?

*though these are the folks who precipitated the mammography controversy

not unrelated to my last post

Last night I dreamed that I had a lump in the lymph nodes above my collar bone.

I woke up terrified.

The comments on my last post were among the most thoughtful, moving and provocative that I've ever read. I have much to think about. Go read the stories that and responses that women shared with me. I feel grateful to each one of them.

Today, I am going to take the dogs for a walk and then ride my bike (unless I decide it's too cold) to Sassymonkey's house, where we will eat, drink, knit, watch a movie that has nothing at all to do with cancer.

Viagra and Sex-Offenders? Medical Directors to Congress: Welcome To Our World

In a prior post, the Disease Management Care Blog predicted that the recently passed health reform legislation would unleash an unending torrent of additional legislation, regulation and litigation for years to come. It knew that inevitable benefit holes, shortcomings, fixes, clarifications, lawsuits and lobbying would lead to a logarithmically expanding legal logic tree that would make the mathematics of fractals simple by comparison and banana republics look like models of good governance.

But even the DMCB failed to anticipate how quickly that would occur. Granted, the Senate Republican minority's latest gambit is a cynical ploy, but the uncovering of a pharmacy benefit involving a certain class of erectile dysfunction drug involving certain classes of beneficiaries is a perfect example of the law of unintended consequences.

As a former Medical Director, it was the DMCB's job to deal with this all the time. As part of the much maligned insurance company 'administrative overhead,' we had a small army of benefit nurses who defended the premium against this and multiple coverage determinations. We basically used a standard of medical necessity laced with good judgment. It worked well then and it still does today.

Well, now we have 435 Congressional Medical Directors whose job it will be to make similarly detailed determinations of medical necessity. The viagra-sex offender issue is only the start. The furies have been unleashed. Welcome to our world.

Coda: Sildenafil (Viagra) has been shown to be useful in the treatment of a fatal medical condition called pulmonary artery hypertension. As of posting time, the DMCB isn't sure of the status of the amendment. While it isn't happy about the prospect of giving proven sex offenders any consideration, this kind of live saving therapy shouldn't necessarily be conditional on past sins. Good luck trying to hammer out the D.C-speak that makes that medically, legally and ethically possible.

Why Health Reform's Medicare Prevention Provisions For Diabetes Are As Inadequate As Octogenarian Moon Walking

The Disease Management Care Blog often invites feedback from the DMCB spouse. With her usual discerning eye, she critically appraised yesterday's Part 2 post and characterized it as "bleh bleh disease management blah prevention blah blah blah Medicare personalized prevention plan bleh Pam Anderson bleh blah prevention."

Guilty as charged, but the DMCB forges on with this Part 3 post on the topic of prevention and health reform, while drawing more inspiration from another Dancing With The Stars contestant, Buzz Aldrin. The octogenarian, former jet pilot and moon-walking astronaut did a remarkable job of competing against a much younger field, but his future appearances on that show are numbered. The DMCB agrees with judge Bruno Tonioli: he moved like he still had his moon boots on.

And so does Medicare when it comes to prevention. The DMCB explains.

In the (allegedly off-topic) prior post, it was pointed out that the published science takes a dim view of 1) physician-led and 2) non-selective exercise and obesity prevention programs. That doesn't mean that ALL programs are a waste of time, as amply demonstrated in employer based programs and by Silver Sneakers.

What makes them different than the plodding non-evidence-based approach now included in Federal health reform? They a) don't rely on the patient-physician dyad and b) target their interventions.

Consider the need for preventing diabetes mellitus, where is good news. This randomized prospective New England Journal of Medicine study published back in 2001 showed nutritionist-led "detailed" dietary advice with food record review, along with regular, supervised and tailored exercise sessions reduced the incidence of diabetes in persons at risk to 11%, versus a 23% in the control group, over 4 years.

And check out this Diabetes Prevention Program study that was published the following year, also in the New England Journal. Persons at risk for diabetes were randomly allocated to either a) "life style recommendations," b) receipt of the same recommendations plus taking a drug called metformin (which was thought to possess some preventive potential) or c) a far more rigorous "intensive program of lifestyle modification." The latter arm of the study was designed....

"....to achieve and maintain weight reduction of at least 7 percent of initial body weight through a healthy low-calorie, low-fat diet and to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week. A 16-lesson curriculum covering diet, exercise, and behavior modification was designed to help the participants achieve these goals. The curriculum, taught by case managers on a one-to-one basis during the first 24 weeks after enrollment, was flexible, culturally sensitive, and individualized. Subsequent individual sessions (usually monthly) and group sessions with the case managers were designed to reinforce the behavioral changes" (bolding from the DMCB).

After just less than 3 years, the incidence of diabetes was 4.8% in the intensive group versus 7.8% in the metformin group and 11% in the life style recommendations group. A follow-up study showed that the beneficial effect continued after ten years. That's pretty impressive with a number needed to treat of about 20 to prevent one case of diabetes.

So what can be concluded from the success of employer based wellness programs, Silver Sneakers and these New England Journal diabetes prevention studies?

1) Employer based programs succeed because they typically focus their interventions on segments of the population that stand to gain the greatest benefit. They use health risk assessment surveys to identify those persons at risk and to ascertain willingness to participate. The DMCB thinks it may be possible for physicians to also do this during a 1-on-1 personalized prevention plan encounter, but - based on physicians' lack of confidence and perceptions about their patients described in the prior post - that'll be the exception and not the rule.

2) Silver Sneakers succeeds without requiring a physician office visit as a condition of participation. Patients show up at the gym and there are fitness coordinators that tailor programs, much like the interventions described in the New England Journal.

3) The diabetes prevention studies described above, Silver Sneakers and employer-based wellness programs succeed by relying on non-physicians such as nutritionists, fitness trainers and case managers to do the "heavy lifting" of patient engagement and supervision.

And finally, it should be pointed out that fee-for-service Medicare still doesn't cover the actual preventive care by nuritionists, fitness experts or case managers. As of yesterday's health reform signing ceremony, the only that's covered is the physician-based "planning."

Which is why the admiring DMCB regretfully thinks dancing Buzz Aldrin is symbolic of an aging and plodding Medicare. In their prime, Buzz and Medicare were truly remarkable. As the years have gone on, both still deserve utmost respect but let's face it: neither are up to their assigned tasks. This latest bill's prevention provisions is much like Buzz's shuffling moon walk last night: decades late and unable to adapt to the rhythms of a modern age.

In the last installment of this series tomorrow, the DMCB will speculate about what could be done in health reform to take full advantage of what science tells us about prevention. As for Buzz, there is little the DMCB can do, but it wishes his coaching dance partner much luck.

With Health Reform, Medicare Now Covers a Prevention Visit With A Doctor: A Look At the Scientific Evidence, Part 2

In yesterday's post, the pernickety Disease Management Care Blog contrasted Speaker Pelosi's victory speech description of the newly passed health bill's prevention provisions with the actual legislative language. While her characterization bordered on bombastic, it's clear that there's a lot of grant money and new government being devoted to prevention. What really caught the DMCB's attention, however, was the decision for Medicare to now pay for an annual visit devoted to the creation of a "personalized prevention plan."

Sounds good right? Imagine being ushered in from the waiting room and huddling with your personal physician, Dr. Nowpaidenuf. Dream about reviewing, sharing and discussing how little you exercise, how much you eat and how unwilling you are to get a colonscopy. Then visualize exiting the clinic with a plan, being thankful that your version of Medicare is under the stewardship of an enlightened political leadership and resolving to eat more vegetables. And fruit.

Sound too good to be true? There's plenty of research to say that it probably is.

While there are plenty of studies (for example) that show that physicians could do better when it comes to counseling their patients about prevention, it turns out that lack of payment has been only a small part of the story, compared to other issues, such as their own lack of confidence or patient barriers that include socioeconomic issues, competing medical conditions, and the lack of motivation. If physicians wade in anyway, their advice can be wrong and, even if they're right, the benefit that patients may get typically decays over time. No wonder the U.S. Preventive Services Task Force has concluded there is no evidence that primary care counseling works to meaningfully increase physical activity and that a very thorough review of the medical scientific literature found no evidence to support the notion that counseling alone has any sustained impact on obesity.

While the DMCB is thankful, that's because a certain Ms. Anderson has thrown her hat, plus ample amounts of fruit, into the ring of Dancing With The Stars. Armed with that inspiration, the DMCB thinks it's ironic that, just when Medicare is emphasizing value based purchasing, Congress has created an additional entitlement that, by itself, has little apparent value.

But all is not lost. The DMCB ultimately thinks that there is plenty of value to be had in prevention counseling. More on that in a Part 3 post tomorrow.

perspective in grey

On June 30th it will be three years since my first clean scan, after the cancer had spread to my liver.

For almost three years, I have had no evidence of disease (been NED, in cancer lingo).

And yet I remain in treatment.

I am asked frequently why I continue to receive chemotherapy and Herceptin, if there is no sign of cancer in my body. And the truth is that I often ask myself the same question. Certainly, I don't feel like I have cancer. And I do feel that the cumulative effects - both physical and emotional of ongoing treatment are wearing me down.

I am stuck in cancer's grey area.

My oncologist said to me last summer, "For all we know, you could be cured."

We just don't know enough.

Another oncologist I spoke to, hinted that some would take me out of treatment at this point. A third suggested that some doctors might take me off the chemotherapy and leave me on the Herceptin.

But they all agree that we just don't know enough to make any decision based on certainty. There are just too few women in my situation, younger women who have been diagnosed with metastatic breast and responded so well to treatment, to know what to do with us in the long term.

There are more of us every year, though.

In ten years' time, there will almost certainly be more answers.

And when I get too frustrated, I remind myself that if I had been diagnosed ten years earlier, I would almost certainly be dead.

So, for now, I'll take the grey.

stepping in the right direction

On the Saturday evening of the 10th Annual Conference For Young Women Affected By Breast Cancer, a group of participants went out for dinner.

Many of us had not met before that evening. We came from Texas, California, Massachussetts and Georgia. I was the lone Canadian. It was a truly lovely evening. The food was great and the conversation flowed - from the trivial to subjects of greater import, from the general to the intensely personal.

About half-way through dinner, the subject of health care reform was raised. I said that, as a Canadian, I couldn't understand why anyone would oppose universal health care, especially anyone who has had a life-threatening illness.

Most around the table agreed with me, while one woman stated that she was resistant to any more government interference in people's lives. I soon found myself addressing the pervading myths about our health care system and was asked whether it was true that Canadians were cut off from health care when we turn 75.

I said, "No, that's not true and we don't have death panels, either."

The conversation was very respectful and never tense (unlike many, many other debates on this issue) and soon we moved on to other subjects.

And today, I want to congratulate my American friends for ignoring the fear-mongering and taking a significant step towards greater access to health care.

The House Passes Health Reform: What Does It REALLY Say about Prevention?

The Disease Management Care Blog watched last night's speechifying that accompanied the House's health reform and was struck by Speaker Pelosi's repeating the 'prevention' refrain:

"...the list goes on and on about the health care reforms that are in this legislation: insure 32 million more people... end insurance company discrimination .....creating a healthier America through prevention, through wellness and innovation, create 4 million jobs in the life of the bill and doing all of that by saving the taxpayer $1.3 trillion dollars" (bolding from the DMCB).

Which begs the question: now that reform is at hand, will our new and improved health insurance system now pay for preventive care?

To find out, the trusting but verifying DMCB blew tanks, dove through the House's legislative language posted here and uncovered this quote:

The CMS Administrator would conduct an assessment of the diseases and conditions that are the most cost-intensive for the Medicare program. The assessment would inform research priorities within HHS in order to improve the prevention, or treatment or cure, of such diseases and conditions. Not later than January 1, 2011, the Administrator would submit the report to the Secretary of Health and Human Services and the Secretary would transmit the report to the Congress.

So, a more more accurate interpretation of the legislation that was passed by the House may be that it would create prevention research for a healthier America.

But then the DMCB paddled back to the Senate's language and looked for more. It found that that creates an Independent Medicare Advisory Board that is charged with making cost-saving recommendations that promote prevention, a National Prevention Health Promotion and Public Health Council to coordinate prevention, a Preventive Services Task Force to make recommendations about prevention, a national private-public partnership to raise awareness about prevention and a web site on prevention. In addition, there are provisions for research grants and contracts that fund health teams so that they can counsel patients about prevention, grants to States to test prevention programs in Medicaid as well as fund community programs, offers of technical assistance to employers for wellness programs and establishment of a "Prevention and Public Health Fund" that would invest in prevention and public health programs. Last but not least, Medicare would cover an annual visit that creates a "personalized prevention plan."

So, a really really more accurate description of this legislative bundle is that it would fund research, contracts, assistance and grants on prevention, create various bureaucracies devoted to prevention and include coverage for provider visits devoted to counseling about prevention.

As its prior posts may indicate, the DMCB has been skeptical about Feds' ability to deliver on their health reform promises. However, 1) it's now the law of the land, 2) all still remains right with the universe because the Orange are hanging in there and 3) some solace was within reach yesterday thanks to this mixed with a version of this. Who knows, maybe some good will come of reform, especially if some of the folks running things in DC read this blog once in a while.

In the meantime, it appears to the DMCB that the short answer to the question at the beginning of this post is that, outside of lots of Federal largesse and bureaucracies, the health insurance system will now cover provider counseling on prevention for consumers. In tomorrow's post, we'll examine in greater detail whether that is really as wonderful as Ms. Pelosi's speech implied.

Grammy-Like Health Care Reform

The Disease Management Care Blog doesn’t pay much attention to the annual Grammy Awards. It can’t remember who won what and when. After all, who really cares? Many of those tunes by Kelly GaGa Spears are better suited for that dimwitted corner of the DMCB world made up of long elevator rides or being reminded again on how the SGR formula will mean the end of Civilization. Unable to participate in the vicarious joy that comes from viewing vulgar dance sets, shallow coolness, sappy acceptance speeches and ephemeral talent, the DMCB's situation is, by any modern measure, sad when it comes to this corner of the music industry.

And such is the uncanny and likewise sad resemblance with the Grammy Awards of the U.S. House of Representatives' passage of health reform with 219 ayes. No wonder that so much of modern politics involve pop-star concerts and vice versa. While admittedly historic, House passage Sunday night was really made possible by a White House and Congress that trumped glitter over governance, personalities over policy and rhetoric over reality. The public behavior of our elected officials has been no less characterized by dancing around the real issues, shallow glibness, silly speeches and ephemeral facts. They have composed partisan legislation that deserves a 2010 Grammy for Best Vacuous Easy Listenin’ Tune. Tap you foot and hum along with this basic chord progression of evil insurers, funny-money deficit reduction and cowardice in the face of our insatiable appetite for health care.

While the coming tsunami of bureaucrats, lobbyists, supplicants, regulators and litigators is bad enough, what really alarms the DMCB is the prospect of even more Grammy Award-like competitions in the coming health care wars. The result will be an unending series short-lived, muzak pieces that play on anecdotes that best serve the interests of whichever party in power can bend the system to get its way.

The DMCB isn’t quite sure how to score all the societal-political-cultural-economic ingredients that got us to this point. While the smarter news outlets and the sister blogs will undoubtedly have lots of insights, the DMCB doubts few will recognize how pop music mentality has been woven into the fabric of our national decision-making.

Others may tut-tut about the DMCB being a nattering curmudgeonly sourpuss weenie. After all, the political process is what it is and you win some and you lose some. In addition, who’s to say what makes for good legislation or music, other than the test of time? Granted, but the DMCB is betting that this health care bill will ultimately be more akin to a one-hit wonder than any enduring piece of music. This superficial piece of legislation will likewise fall far short of any meaningful legacy that adequately tackles costs, reduces the dysfunctions of government or harnesses market-based ingenuity. Expect to come back year after year to new slates of tunes followed by more tunes.

*Picture from Wikipedia

Geo Mapping and Other Analytics for Open-Sourced Health Data: The Uptapped Potential

Take a five minute break from thinking about the process of health bill deeming, posting, reconciliation, passing, voting, slaughtering, CBO scoring, not reading and up or down voting and watch this fascinating video on open data by Tim Berners-Lee. While it deals with geo-mapping 'mash-ups,' the level of world-wide participation that correlated access to city services by race and updated the street-mapping following the Haiti earthquake was truly astonishing.

While you are watching the video, think about the potential of similar open sourcing of population-based health care data. This could lead to the mapping of the prevalence of disease that tracks the allocation of health care resources at a population-based level.

Or, forget about the mapping and just ponder the ability of amateur mathematicians to correlate (for example) demographic information (say, age) with disease (say, diabetes), out of pocket health expenses (by the type of health insurance), medication use and the use of cell phones AND display their results on-line for free for anyone to use. We could quickly discover that a certain drug may be causing diabetes among persons over age 60 and that an appreciable percent are subject to a high co-pay for testing and are accessible via text messaging. The DMCB doubts the Food and Drug Administration could ever match that.

While the DMCB is being rather naive, it thinks a) there is an untapped potential to making health care data freely accessible on-line and b) there are sufficient numbers of people that would be willing to make their personal health information readily available with c) reasonable (and not necessarily ironclad) safeguards.

On an uncompletely unrelated note, the DMCB's March Madness Policy Brackets had a prescient first seed position for another cancellation of an overseas trip for Mr. Obama. Too bad the DMCB's NCAA Men's Basketball bracket bets are already cratering.

The Health Wonk Review Is Up!

It certainly is a mad time of year and no one does a better job of telling us why than the bloggers from the Robert Wood Johnson Foundation. It's their turn to host the Health Wonk Review and they've done an outstanding job of providing some insightful commentary about the players, the coaches, the match-ups and the favorites. If you're interested in health reform, this post is for you!

Reducing Social Isolation Among Elders Enrolled in Medicare Advantage Plans: One Secret Sauce Behind the Cost Savings of Silver Sneakers?

When the Disease Management Care Blog isn't looking for its meclizine to help it deal with the vertigo-inducing travails of health reform, it's been looking at the seniors at its local health club. That's because, like many fitness centers, the DMCB's gym offers Silver Sneakers (SS). If SS is in session, forget about finding a convenient parking spot, an open treadmill or any room in front of the free weights: these elders mean business. There's one buddy of the DMCB who is working on her lats. You go gurl!

Readers may recall SS offers specially tailored exercise and wellness programs for the elderly. The outfit is owned by Healthways and it's services are typically sponsored (a.k.a., paid for) by health insurers, many of which are Medicare Advantage or Retiree plans. SS and similar wellness programs are not part of the fee-for-service Medicare benefit. While the insurers seem to market SS as a value-added insurance benefit that helps retain business (and may have some underwriting advantages), there's credible research that shows SS also reduces claims expense. You can get a sense of what this is all about by looking at this short video.

In its travels to the gym, what has struck the DMCB isn't the prevalence of Grateful Dead T-shirts or the disappearance of blue rinse as a fashion statement, but the amount of socializing going on. Not only is there lots of chit chat around the work-out machines (and, by the way, they're not very happy with the President), but the once-a-month pizza night is a big favorite. For that, folks start arriving 1/2 an hour early.

Which makes the DMCB think that that may part of the secret sauce behind SS's track record in reducing claims expense in this elderly population. It's been long recognized that social isolation has significant neuroendocrine effects, has a significant association with disease outcomes, correlates with the sense of overall well being and may influence seniors' level of cognition. While the exercise itself certainly has benefits (it reduces falls for example), the comraderie typified by Tuesday night pizza may be an important ingredient in achieving the insurers' cost savings.

Lacking any evidence, however, that's only a DMCB suspicion. Short of some sort of randomized clinical trial (comparing exercise without socialization to the same exercise with socialization), the 'degree' of social interaction (asessed, perhaps with a standardized survey of the participants) of a random sample of SS clubs could be mathematically correlated with insurers' claims expense. R squared anyone?

In the meantime, the DMCB says keep it up. While Medicare Advantage plans seem destined to have their premium payments reduced (and who knows when the mandarins in Congress will see fit to offer it in FFS Medicare), it seems that continued investment in Silver Sneakers is a smart thing to do. It increases fitness, decreases the key problem of social isolation and gives the DMCB some serious inspiration, even if has to wait to complete its preferred exercises.

Now where's the meclizine......

happy news

I'm in Toronto for March Break and having a lovely time and have been online only intermittently. Yesterday afternoon, though, I got some surprising news that I wanted to share.

I found out yesterday that Not Done Yet is a finalist in the ForeWord Reviews 2009 Book of the Year Awards in the "autobiography/memoir" category.

"The finalists, representing 360 publishers, were selected from 1,400 entries in 60 categories. These books are examples of independent publishing at its best...

...ForeWord's Book of the Year Awards program was designed to discover distinctive books from independent publishers across a number of genres."

I feel very, very proud.

The Insurance Mandate, State Legislatures, Regional Opposition and the Specter of Inviting Civil Disobedience

Adding to the the drama of health reform, the Virginia General Assembly has passed its own legislation that seeks to nullify the proposed Federal health insurance mandate. That makes this New England Journal of Medicine article on the States' prospects timely reading.

Readers won't be surprised that author Timothy Jost dismisses this as right wing-funded and politically motivated posturing. He also points out that it is also not without precedent. Past attempts to emasculate Federal law include outlawing school desegregation and decreasing access to Medicaid funding for abortion after rape and incest. Mr. Jost says this manuvering didn’t work then, and he doubts it will work now. As an aside, however, he cautions his doubt is not ironclad, because he describes an insurance mandate as “constitutionally vulnerable.” Supreme Court, here we come.

But it’s his summary of the mandate's two other downsides that make for the really interesting reading:

1. Resistance in 34 State legislatures is a telling symptom of the depth of popular opposition to health reform. While a widely followed metric is whether a national majority of Americans support or oppose the plan, the national patchwork of simultaneous disdain and support bodes poorly for the ultimate success for this piece of social legislation and the ascendant governmental activism behind it.

2. Even though the insurance mandate has enforcement provisions, they’re ultimately based on the behavioral economics of voluntary proactive compliance, jazzed up with some "or else" tax penalties - which aren't that large anyway. This good intention may run head first into what could become an open invitation to civil disobedience akin to the spectacle of the Federal enforcement of its marijuana laws. What will be the effect of passing a law that, whatever its merits, leads to an significant proportion of the U.S. population being in technical violation of that law?

The DMCB traveled on Route 81 today. On one of the overpasses, there was a group of 5 people waving to the traffic below and waving an American and the telltale Do Not Tread On Me flag.

Accountable Care Organizations & Criteria For Piloting Them in the House Reconciliation Bill: Include Disease Management & the PCMH

In another step in the high political theater of arm twisting, outright threats, secret deals, back-stabbing, towel snaps, shifting voting blocs and It Takes Courage high rhetoric, the U.S. House of Representatives' Budget Commitee has passed the 2000 plus page reconciliation legislation, which is aptly named.....(surprise) "The Reconciliation Act of 2010." It may or may not be the real thing, but hey... it's something.

That legislation was only just posted in the last 24 hours and, unlike many of the House members, the DMCB is still reading through it. A first step was to make sure "Accountable Care Organizations" (ACOs) are still included. Your diligent Disease Management Care Blog performed a scan and is happy to confirm that the concept is still there, namely in Section 1301 on page 453. ACOs will be "piloted" with two purposes: 1) reduce expenditures and (not or) 2) improve health outcomes, by a) promoting provider accountability, b) encouraging infrastructure and c) rewarding quality/efficiency. The pilots are supposed to start January 1, 2012 and last 3-5 years.

The DMCB is still confused by the notion of a "pilot." A superficial review of the bill fails to precisely define it, but the language mentions what may be a key determinant for the ACO pilot: the HHS Secretary may issue regulations that permanently implement ACOs, apparently without checking with Congress first, assuming CMS' Chief Actuary can "certify" that they save money*.

So now that we have a better handle on just what a "pilot" may be, what defines an "ACO?" According to the legislation, it still is a hospital-physician group entity that 1) has a legal structure so it can receive and disburse money, 2) has "sufficient numbers of primary care physicians," 3) is able to report on its outcomes, 4) "provides notice" to beneficiaries about the "pilot," 5) participates in a CMS hosted "best practices web site" 6) uses "patient centered processes of care" and 7) meets other criteria determined to be appropriate by the HHS Secretary (italics DMCB).

Readers can check out the good and the bad about ACOs for themselves, but to the DMCB, an awful lot of the ACO pilots' success will be riding on their ability to cement mutually beneficial physician-hospital relationships. The legislation apparently strives to achieve this by requiring 1) the right kind of financial arrangements (dollars that go to the docs) and 2) robust information technology (networked electronic records).

Which is why the DMCB, assuming The Reconciliation Act of 2010 survives, humbly offers up two suggestions about option of other criteria mentioned above. If it is the intent of Congress to pilot ACOs that have a good chance of success, the Secretary of HHS should give explicit preference to ACO pilots with either 1) a majority of their primary care physicians with meaningful (say, more than one year, 10% of their patients) experience in a DMAA defined disease management program, or 2) a majority of the primary care physicians with experience in a patient centered medical home demo that has been cited on the Patient Centered Primary Care Collaborative web site, or that possess NCQA PCMH recognition.

These two criteria are warranted because a track record of exposure to the 'systemness' of disease management (DM) or the PCMH can serve as a important sign that the ACO participants 'get it' when it comes to patient engagement and care management. While there may not be much in the way of research that has examined the links between DM/PCMH and ACO success, it stands to reason that having population-based care "seasoned" docs on board will increase the likelihood of achieving the outcomes and savings targets. These criteria will also increase the right kind of infrastructure, encourage experimentation with models of care that combine DM and the PCMH in usual care settings and explore that synergies between health information technology, physician incentives and state of the art population-based care management. As mentioned before, if done right, it will start where the MCCD left off.**

ACOs are the best part of this health reform package because they're one approach - if done right - that may actually "bend the curve" Even though it's tied up in Medicare's slow motion and often bumbling evaluation process as a pilot, so far, so good. The DMCB is hoping that this part of the bill remains intact in the sausage making yet to come.

* in legislative-ese, the quote is "would result in estimated spending that would be less than what spending would otherwise be estimate to be in the absence of such expansion"

** thankfully, the Senate bill's MCCD mandate appears to not be included in the Reconciliation Act

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

March Madness and Health Reform: The Policy Brackets are Announced

March Madness is officially upon us and the Disease Management Care Blog is very excited - and not because it gets to simultaneously wear bright organge and root for a certain group of Wildcats from just north of Philadephia. It's also because the end of the beginning for health reform has an uncanny resemblance to the NCAA tourney. Sure, health reform may look like an unending and slow-motion care wreck, but there are also favorites, underdogs, hunches, winners, losers, rivalries, cheerleaders, media hoopla and bombast. The only thing that's really different is that it's not single elimination: U.S. health reform is more like double elimination to the fifth power involving a cast of thousands.

The un-information techie DMCB was stymied in its attempt to upload a landscape-style portrait displaying a 65 participant health reform tournament. So, the DMCB is making due by typing out two brackets of 32 key players/concepts. Note that the soothsaying DMCB has given "Health Reform Passes" a 1st seed position. Intrade now rates passage at greater than 50%. Apparently, bettors are thinking that it'd be unusual for Ms. Pelosi and Mr. Rahm to press toward a vote if they didn't think they could succeed. Who knows, they just may pull this off.

The East Bracket

(1) Health Reform Passes!

~vs.~

(16) Just What IS the Meaning of Meaningful Use?

(8) Integrated Delivery Systems Are Swell, Even If They Can't be Replicated

~vs.~

(9) Health Insurers Promote Living Wills to, er, Show A Commitment to Quality

(5) Reconciliation: Democracy in Action

~vs.~

(12) Health Cost Inflation Outlawed by Congress

(4) Caesarian Rates: Get What You Pay For

~vs.~

(13) Electronic Records: Stuck Eternally in the Future

(6) Insures: Love That Mandate

~vs.~

(11) D.C. Accounting Logic: Spend More, Reduce the Deficit

(3) Four ‘Ideas’ = Compromise!

~vs.~

(14) FDA Outlaws All Medication Side Effects

(7) Malpractice Reform Stillborn

~vs.~

(10) Primary Care: A General Motors Approach

(2) Accountable Care Organizations: PHO Redux

~vs.~

(15) CMS' Budget To Exceed Europe’s GDP

The More of the East Bracket

(1) Obama Cancels Another Trip

~vs.~

(16) Never Mind the Law: Here Come the Regulations!

(8) Cross POTUS Chief of Staff & Say Hello to Underside of Mr. Bus

~vs.~

(9) Academic Med Centers & CER's Outcome: Gravy Train

(5) HHS Secretary Appears in Dancing With The Stars

~vs.~

(12) Pay for wellness and disease management, please

(4) Pilots Fly, Demos Die, & Politicians Never Lie

~vs.~

(13) The United States of Greece

(6) Health Reform Polls Consistent with Any Preconceived Interpretation

~vs.~

(11) Sheryl Crow Gets Invite to Signing Ceremony

(3) Prez Gets Cadillac Check Up

~vs.~

(14) New Engl Journal of Medicine Wishes They Were Invited to Signing Ceremony

(7) CMS Administrator: AWOL

~vs.~

(10) Dems’ Health Care Information Loop Causes Death March

(2) Republicans: Scorched Rarth

~vs.~

(15) Blogs Glom onto Reform Like Blobs

The Disease Management Care Blog Gets Quoted

.....but that's not the only reason to read this article in the Texas Tribune by Emily Ramshaw. This is well written as well as interesting and is a good example of the difficulty in evaluating the economic outcomes associated with disease management. In this instance, it deals with the McKesson contract with Texas Medicaid.

So which is it? DM is a waste of money? It's too difficult to measure savings in an insured population? We need different metrics? We need a single industry standard? This year's DM is different than last years' and comparisons are unfair? It's not savings, but value? Read this and decide for yourself......