The Multi-Payer Advanced Primary Care Practice (MAPCP): Warning! Warning!

Today's Disease Management Care Blog posting can be found over at Vince Kuraitis' excellent e-CareManagement Blog.

Titled The Medicare MAPCP Medical Home Demo: CMS Kicks Sands in the States’ Faces, Vince and the DMCB co-author a critical examination of the much heralded Multi-Payer Advanced Primary Care Practice Demo.

As regular DMCB readers will recall, one of the stumbling blocks to widespread adoption of the Patient Centered Medical Home (PCMH) has been the reluctance of multiple insurers to simultaneously include it in their benefit designs. There is little incentive for a primary care practice to redesign itself for only one insurer. The Sept. '09 announcement that CMS would pilot paying for the medical home and work with other insurers to develop a uniform approach was welcome news to the PCMH community. This was just the ticket. The catalyst. The breakthrough. The tipping point.

Or is it?

Now that the details of the MAPCP Demo are out, the news may not be all that good. In fact, some of it is downright scary. You can find out why here.

A Disease Management Care Blog Link Fest

In addition to prominent mention in the latest edition of the Cavalcade of Risk, the Disease Management Care Blog ....

was recently quoted in the New York Times,

and

featured in the KevinMD blog.

The thousands of regular DMCB readers, Twitter followers, RSS subscribers (and a few additional Kindle customers tossed in for good measure) may recognize the DMCB's skeptical attitude in the former and its high evidence-based standards in the latter.

They also won't be surprised by the DMCB spouse's reaction:

"It's about time."

The Latest Cavalcade of Risk is Up!

.....and this time it's being hosted by the incomparable Wisdom From Wenchypoo's Mental Wastebasket Blog. Once again there's a variety of summaries, commentary and links dealing with risk related issues, from health to business to personal and everything in between. The Disease Management Care Blog is prominently featured, which is quite the treat given Wenchy's exacting standards and critical eye. Check it out and enjoy this Virginia Heat Wave.

Of Actuaries, Consumerism, Care Management and the Patient Centered Medical Home

"But we're saving money!" said the Disease Management Care Blog.

"I don't really care" said the company actuary.

That pretty much summed things up years ago when the DMCB was arguing the merits of expanding the care management programs. The good news is that the DMCB stopped talking, listened and got educated.

It learned that actuaries assess past patterns of health care utilization to project future patterns, much like looking in a rear view mirror to drive a car forward. Knowing that the previous years' rate of hospitalizations is "X%," that physician offices visit rates are "Y%" and that other rates for other forms of utilization are "Z%" etc., actuaries, knowing the cost for each unit of service, can then project the cost of future services. Since care management is an additional cost, that "hard" number is simply added into next year's budget. It's all added up and voila! the cost of providing insurance was known. Our customers never liked it because rates kept going up. Our State Department of Insurance - and their actuaries - required it because they knew rates had to go up.

Even though the DMCB could demonstrate that a $70,000 per year case manager could save (depending on the condition) $100 to $700 PMPM, the actuary only saw spiraling cost inflation with higher rates of utilization. Just because a segment of the overall book of business may have cost less, it was calculated that the costs for all persons with diabetes and heart failure would continue to rise and that the nurses were an additional cost center of $70K per FTE.

Case closed.

That was the logic then and is still believed by naysayers today. So, how has care née disease management survived years of actuarial skepticism?

One answer may lie in this J.D. Power press release. Human Resource directors, managers and owners that have responsibility for buying commercial health insurance are unhappy with the industry's ability to service accounts, design new products, resolve coverage problems and manage costs. However, the most important determining factor in overall satisfaction is "employee plan experience."

In reading the press release, the the DMCB can't tell what makes up "employee plan experience," but it has a pretty good idea that a large part includes wellness, prevention and care management. So, in addition to "patient engagement," and "self care" and "risk reduction" and "behavior change," care management's secret sauce consists of personalized outreach and creating special relationships with patients. It's called talking to your customers.

Which offers two lessons and a warning:

1. Service Recovery: This is one of the reasons why disease management, now called care management, wellness and prevention, has done so well in the self and fully insured commercial insurance settings. If JD Powers' press release is to be believed, insurers are relying on their care management programs to partially make up for their perennial inability to execute well on other parts of the business. That doesn't mean there isn't growing evidence that the actuaries can be wrong and that care management also saves money. This is cake and eating it too.

2. Medical Loss Ratio: Given the actuaries' biases and an in-house perception that disease management was a customer service function, it's no surprise that disease and care management programs were placed in the administrative cost column and not the MLR. The care management industry always thought it was a clinical function, but with the widespread perception that health insurer administrative costs are too high (and that the MLR is too low), the industry is working hard at getting their costs reassigned.

And the warning?

While my colleagues who are promoting the Patient Centered Medical Home (PCMH) are fixated on its ability to increase quality, reduce costs, rescue primary care, minimize variation, reverse the Federal deficit and banish all hunger in America, it may turn out that a key success factor will be none of those things. Rather, the long term staying power of the PCMH may hinge on its ability to enhance the health care experience for patients. GroupHealth understands that (here at the 30 sec mark) and so does Blue Cross Blue Shield of Michigan (here). If the actuaries get skeptical and consumers don't notice a palpable change, the PCMH may go the way of dermatologists who remember which end of the stethoscope goes in the ears, the dodo bird and good taste in a Lady GaGa music video.

Image from Wikipedia

An Intense Program to Reduce Overweight and Obesity Among Children: Minutes From a Disappointed School Board

Corpulencia School District

Business/Work Session Minutes

June 28, 2010

Call of Meeting to Order: Vera Lardy called the meeting to order at 6:03 PM

Roll Call of Board Members: The following members were present: Max Podgy, Seymour Gross and Anita Diet. The following members were absent: Barry Atric (in the hospital getting surgery)

Action Items: The Board considered instituting a school based program aimed at reducing the prevalence of obesity and overweight among the 6th grade school population. In particular, it examined a state-of-the-art program that was reviewed in the New England Journal of Medicine. This was a huge two year study involving 42 Hispanic/Black or highly Federally food subsidized school districts (half of which were assigned to an intervention group, the other served as controls). While Board Members were encouraged to read the protocol for themselves, Ms. Lardy summarized the study. The 21 intervention schools 1) improved the food choices in the cafeteria, vending machines and even fundraisers, 2) promoted exercise targeting specified amounts of time designed to increase the heart rate to 130, 3) used a behavioral intervention to encourage lifestyle choices and 4) reinforced it all with posters and public address message scripts.

Board members unanimously voiced support for the program until they found out how the intervention schools fared compared to the controls. BOTH the intervention and the control schools had a decrease in the prevalence of overweight and obese children. There was an absolute decrease of about 4% in both groups that failed to show a statistically significant change favoring the intervention group.

Statistical significance was achieved in reducing the prevalence of just obesity. The intervention schools went from about 30% to 24.6% while the control groups went from about 30% to 26.6%. Because the study was also aimed at reducing the likelihood of future diabetes in these children, the authors also studied changes involving insulin levels and blood glucose levels, most of which also failed to achieve statistical significance.

Mr Podgy shared his impression that much of the news media makes it sound like eating more veggies and getting more exercise will practically cure obesity. 4% is disappointing. Mr. Gross said that Ms. Obama's campaign sure tastes great but is less filling in terms of a satisfying return on investment for taxpayers; would they be satisfied with a 4% rate? Ms. Diet observed that combating obesity will take years, but perhaps the prevalence of obesity has leveled off. Everyone agreed that in the current fiscal environment, the likelihood of funding intense school-based programs like this, given the success rate, is pretty low.

Adjournment: On that depressing note, Mr. Gross made a motion to adjourn and it was seconded by Ms. Diet. The meeting was adjourned over soda and donuts.

(any reference to any persons living or dead or any school boards, except for the part about soda and donuts is completely unintentional)

The Airline Industry and Health Care

In many past speaking gigs, the Disease Management Care Blog used the airline industry as a template in thinking about where health care is going. Increasing automation (releasing the pilots to focus on what was important), shared responsibility (other highly trained professionals share the job of getting the plane in the air), consumerism (destination and safety are assumed, it's how soon that beverage cart gets to my seat that is really important) and transparent price competition (including user-friendly web sites) were all going to mean better travel (quality) at lower fares (cost).

Was the DMCB as prescient as it likes to think?

After reading the Weekend Financial Times article on how dreadful flying has become ("Flying Backwards", the DMCB still thinks so. The airline industry's emphasis on safety (fatalities per passenger-mile have dropped exponentially) and pricing (albeit with a perpetually lousy return on investment) have paid off for fliers. Unfortunately, customer service has clearly lagged.

Patient safety is not where it it needs to be but at least it's being measured: a good first step and it will get better. As for pricing, healthcare is operating under the Medicare fee schedule. This results in relative overpayment for some specialty services and underpayment for others (such as primary care). It's the underpayment in primary care that has led to crowded waiting rooms (like the back of the plane) and lousy customer service (delays? pfft!). Yet, the good news is that the primary care physicians are also looking at automation, shared responsibility and consumerism.

It all adds up to the Medical Home. The only difference is the pricing, which is not being left up to the market. Let's hope the Feds get the pricing right.

Jousting Between the New York Times and the Dartmouth Atlas Over Interpretations of Cost & Quality Variation.

The New York Times - Dartmouth Atlas dueling reminds the Disease Management Care Blog of academic-medical swordplay. Whether it was trapping your peers on hospital rounds with obscure eponyms (“Have you considered Pott’s Disease?!”), battering the Morbidity and Mortality Conference speaker with a displays of expertise (Pseudohypoparathyroidism?! How about your pseudoknowledge?) or quoting contrary statistics at medical meetings (“Are you as confident of your findings knowing the t-test was only one sided?”), the DMCB has seen scholarly blood spill faster than medical school faculty trying to get out of taking emergency room call.

Which is why it’s not alarmed at the tenor of the discourse between the Times’ reporters Reed Abelson and Gardiner Harris and D-Atlasians Drs. Skinner and Fisher. Academicians keep things in perspective. After sharing stale coffee and fat-laden donuts, we generally get back taking care of the patients and publishing good research.

Unfortunately, this kind of jousting can be misinterpreted and used to fuel even partisan rancor. While such pugilism has its place, the DMCB thinks its ultimately OK to have disagreements over interpretations of data. Somewhere between the Times and the Dartmouth Atlas is where the truth lies. We only need to remind ourselves that seeking truth, not political advantage, is why the latest rejoinder to The Grey Lady is worth a close read.

After the DMCB's review, it thinks Drs. Skinner and Fisher are

1) distancing themselves from the intellectual drift a) from there is no apparent reason for the variation in U.S. health care costs, b) to the assumption that lower costs cause better quality. While health care costs are lower and quality is higher in sections of Minnesota and Colorado, we simply don't know if dropping a Mayo in Dade County or an Intermountain in McAllen Texas will accomplish either. Good for them.

2) recognizing that measures of health care quality used to statistically control for the assessment of observed variations are not only imperfect, but may have little correlation with patient outcomes - at least the ones that are important to patients themselves. More work is necessary and who knows, we may find that in some instances for some hospitals, more money is necessary to overcome the impact of factors like local poverty. Good point.

3) protesting too much about the fueling of their rock star status by potential misinterpretations of their data and how it could be leading to flawed public policy. It's not their fault, they say, if politicians are misusing their data. They're innocent bystanders. Really.

The DMCB will continue to ponder this in future posts and invites reader input. Hopefully as Medicare payment policy continues to evolve, the Feds will consider all the angles and exercise the kind of caution warranted when rushed policymaking and imperfect science intersect.

The Latest Health Wonk Review Is Up!

Brad Wright, over at the eponymously named Wright on Health Blog uses his considerable familiarity with research to fashion the latest Health Wonk Review. Retrospective vs. prospective, suspect generalizability, recall bias from self-reporting and some timely tidbits from respected research-based policy makers make for an interesting and timely meta-mega-analysis of sorts. It's read by hundreds of savvy wonky cognoscenti, so it's worth checking out. Enjoy!

The Contamination of Policymaking by Presidential Marketing.

It seems healthcare is no more able to resist the fizzy allure of marketing than any other business enterprise. In a showy glut of tag lines, campaigns, messaging, logos, spin, jargon and positioning, hospitals are re-labeling themselves as "systems," clinics are glomming onto the term "home" and insurers are all about prevention.

In the course of its career, the DMCB has stumbled upon the phenomenon many times. For example, one of its programs was prohibited from naming itself using the word "Center." It seems the term was reserved for special use by our marketing mavens (we joked we ran afoul of the "Center for Center Nomenclature"). Another time, an allergist telephoned and announced that he had developed a "comprehensive disease management program" for refractory seasonal rhinitis.

Not a problem says the DMCB. Branding is inevitable. Who can blame hospitals, clinics, disease management programs and allergists for wanting the best possible position in their marketplaces. A few less billboards on the road to downtown Philadelphia would be nice, but heck, it could be worse, eh?

Where the DMCB draws the line, however, is when marketing or branding masquerade as either science or public policy.

For a science example, it's beginning to look as if robotic prostate surgery may offer some distinct advantages, but that's not how its being portrayed by its hawkers. The DMCB recalls a past business meeting involving a gutsy urologist-colleague who dismissed a marketing executive's efforts to portray the robotic surgery program as a special advance in the field. That doc knew the difference between science and marketing. It's too bad others haven't taken that lead.

Unfortunately, it now appears that formulating public healthcare policy isn't immune either. Check out President Obama's apparent effort, in the face of stubborn voter skepticism, to revitalize health reform with the tag line "Patient's Bill of Rights." The term was first invented in 2001, but its namesake failed to pass muster in Congress. While the policy failed, the term has lived on, not only as a lingering symbol of evil health insurer lobbying, but how medical care should be universally guaranteed - just like access to U.S. built econobox cars, low interest, income-doesn't-matter mortgages and regular rounds of golf.

The DMCB can't recall that the insurance regulating, bureaucracy expanding and demo/pilot-laden Affordable Care Act was passed by Congress under a banner of a "Bill of Rights." As far as it can tell, the term was resurrected long after the fact by HHS Secretary Sebelius on May 27.

And the campaign doesn't stop there. Presidential Advisor and health care expert/spokesperson David Axelrod is quoted using the word "message" in this New York Times article. While the purported audience is the insurance industry, let's face it: this is a former news reporter whose "sell" motivations are as transparent as many a hospital billboard.

There are a lot of Health care issues requiring a lot of policy leadership (solving the SGR, calming restless States and clarifying the intent of the MLR restrictions). Instead, the public square is being littered with worn out canards about pre-existing conditions, lifetime benefit caps and not coming-between-you-and-your-doctor, iced with unusual and heartbreaking anecdotes.

Scroll down to the bottom of this White House blog posting and check out the pic. Keeping a politely attentive, impassive and expressionless face is fast becominjg part of the insurance executive skill set. While the President is doing all the talking, the DMCB is confident that the insurers are hearing but aren't listening. They know it's not hammering out policy details. It's all about the photo op.

Collecting Data on Race and Ethnicity in Patient Surveys

The Disease Management Care Blog has been looking into inquiring about race in patient surveys. While it may be a charged topic, it's important data and has important implications even outside of face-to-face care. Traditional Federal standards include asking about race (American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander) as well as ethnicity (Hispanic or Latino). And by the way, relying on administrative or chart data doesn't appear to be enough.

Here's a good discussion on why its important and how how to do it right.

The biggest insights gleaned by the DMCB are 1) questions about race/ethnicity should allow for multiple answers, since patients can identify with more than group, and, 2) after extensive investigative research in the world's scientific literature, the DMCB has determined Estonians and Lutherans are generally NOT included in patient surveys as either a race or ethnic group. Despite that disappointing setback, however, the DMCB continues to search for a rationale for identifying Norwegians as a population segment worthy of special racial/ethnic consideration. After all, they possess some unique traits such as use of the term "uff da," preferring morbidly depressing cinema and having a special talent/appreciation for some weird if compelling art.

('Alt for Norge' translates literally to 'All for Norway,' a statement that doubles as both a mighty oath and a toast that is best uttered while wearing one of those silly battle hats with the horns on the 17th of May)

A Potporri of News About Marketing & Social Media, Savings from Telephonic Disease Management and Methodologic Problems in the PCMH Pilot Evaluations

Today brings a grab bag of worthy news to the Disease Management Care Blog readers. Topics include social media, old fashioned telephonic disease management and the Patient Centered Medical Home.

First off, did you know the population health/disease management company Healthways has a Facebook page devoted to its elder wellness program SilverSneakers? The Disease Management Care Blog did also, but what it didn't know is that, according to this press release, uptake lagged until a professional marketing firm began to promote it.

The DMCB insight: while social media is supposed to be a "viral," bottom-up democratic phenomenon, the professionals have moved in.

Secondly, there are two research findings on the topic of old fashioned "telephonic" disease management. Does it or doesn't improve quality? Does it save money?

In this early release publication in the prestigious Journal of General Internal Medicine (known to publish papers with high methodologic rigor), Daren Anderson et al were unable to demonstrate in a prospective randomized clinical trial that a telephonic disease management program versus usual care resulted in better blood glucose control. However, this was a single site study involving a community health center serving disadvantaged patients. Patients were enrolled in the study without regard to baseline diabetes control, the intervention group had a lower A1c at the start of the study and there was a significant prevalence of depression in both groups. In addition, it's possible the intervention may have changed provider behavior for the control patients.

The second study JL Rosenzweig and MS Taitel was only released in abstract form (its P3-715) from this year's Endocrine Society's meeting. This research involved enrollees from a Medicare Advantage plan that focused its telephone diabetes disease management program on high risk patients. This was also a randomized prospective study that showed the intervention patients....

"....decreased ... all-cause total medical costs by $984,870 per thousand members per year (PTMPY), compared to a $4,547,065 PTMPY increase in the Control Group (p≤.05). All clinical quality measures significantly improved from baseline (p≤.05) including A1C, LDL ,and microalbumin testing, retinal exams, foot exams ACE or ARB use,and aspirin use.

The DMCB insight: as publications expand in number, the science matures and other settings/patients are explored, both positive and negative studies are not unusual. However, if that Medicare Advantage study is correct, that's some serious money being saved. Looks like the the taxpayers were getting their money's worth after all in this particular Medicare Advantage plan. The DMCB is looking forward to seeing more details in a peer review publication soon.

Thirdly, in this study, the authors surveyed the larger PCMH pilots and provide a useful national-level summary overview. For example, per member per month (PMPM) payments for eligible patients range from $0.50 to $9 plus pay for performance (P4P) bonuses along with other payments to fund practice transformation or other care strategies, such as embedded nurse care managers or quality improvement programs.

But particularly worrisome was this finding:

"...the evaluation plan for nearly 60% of demonstrations had not yet been devised in detail at the time of the interviews. Even among those with more developed plans, the specification of which variables would be measured, along with surveys to be used, was uncommon."

What's more....

The heterogeneity in program design suggests an urgent need to incorporate evaluation in all programs’ designs. Less than half of the programs had well specified evaluation plans that were designed in conjunction with the pilot. In most cases, although evaluation is considered important, the evaluation designs had not been pre-specified, thus necessitating a reliance on existing data, and funding had not been secured to support a robust evaluation. Furthermore, many of the pilots do not identify adequate control groups against which to compare the intervention practices.

The DMCB insight here is that if the PCMH pilots are not careful, they could end up being condemned in a CBO report saying there's no good evidence that their intervention works. Based on the two disease management studies described above, it's safe to say that the disease management industry has learned its lesson: valid comparator groups are being used to accurately assess their impact. The industry has even developed a state-of-the-art evaluation guide that addresses many of the methodologic issues (that's for free, by the way) in program evaluation. PCMH pilot managers should take note.

"family personalities illustrated"

There's the Health Reform Law and Then There Are the Regulations

The nonviolent Disease Management Care Blog knows that there is more to a punch than just a punch. The distinction also helps it understand that there is more to health reform laws than just the laws themselves.

The DMCB explains.

It'd be easy to think that curling up the fingers and then making forceful contact meets the definition a punch. Popular media makes it look easy, but not so. Two techniques that can make a big difference in its execution include twisting (pronating) the forearm in the course of extension (if you watch closely, you'll see it happen just prior to the board breaking at the 37 sec mark) and pulling the punch back as fast as possible after contact (for example). These and other modifications can, when there's no other choice, make the difference between angering and disabling your opponent.

It's just as easy to think that passing a law meets the full definition of health reform. Regular DMCB readers know otherwise. For example, the Genetic Information Nondiscrimination Act (GINA) sure looked like a good idea until the supporting regulations that came out. All of a sudden, it looked like insurer sponsored health risk assessments could end up violating federal law. In other words, the fine tuning of the simple 'punch' of GINA with regulatory 'technique' made a huge difference.

And so it goes now with the Affordable Care Act (ACA). According to this article in the New York Times, the law's seemingly reasonable provisions on 'grandfathering' existing health insurance plans will be clarified through additional regulatory language to mean that even minor changes to the benefit will result in its loss of protected status. Paradoxically and despite Presidential assurances to the contrary, this could accelerate a flight from employer sponsored insurance. Looks like ACA packed a bigger punch than anticipated. The DMCB expects more of the same as more ACA regulatory language issues forth from the legions of federal lawyers, bureaucrats and policymakers that are now hard a work fine tuning the other disabling features of health reform.

Don't think the parallel with martial arts is too strained either. While the DMCB prefers martial arts hyungs (here's a classic for example), every insurer, physician group, device manufacturer, trade association, consumer group, employer-purchaser coalition, State and countless other lobbying groups will close in for hand-to-hand combat in the ditches and weeds of every exclusion/inclusion, every "and" vs. "or, " every comma, and every overlawyered extension of Federal power that goes along with them.

The only important difference between the fine tuning of a marshal arts technique and creating the health reform regulations is that the former is designed to bring an end to the confrontation, while the latter will be a fight that keeps on giving for years to come.

Image from Wikipeida

Jasper "Friendly Bear" Kingston-Wayne (aka J-Dog): August 2000-June 18, 2010

Rehashed Arguments From the White House - Again

With the Disease Management Care Blog's advancing age, it's come to appreciate the ready access to convenience. If it's too far, it can take a taxi. If it's too warm, a dial thingy on the wall can make it cooler. If it's not completely sated, it can order basil flavored ice cream with its cappuccino. Problem solved.

Too bad the same isn't true for the problems facing U.S. Presidents. Stopping the Gulf oil leak remains stubbornly out of reach, while twin toxic "plumes" of red ink and voter discontent are lurking below the waves of health reform. Since expedient solutions remain out of reach, the White House solution seems to be to repeatedly tell anyone who will listen that its not too far, it's not too warm, there's enough food, they're in charge of BP and that the Affordable Care Act (ACA) will lead to savings.

Case in point is a recent Perspectives piece on the merits of health reform authored by none other than the Office of Management and Budget's Peter Orszag and Ezekiel Emanuel.

This is a litany of the usual Administration arguments of how the ACA is the legislative breakthrough that will a) reduce fraud and abuse (with a return on investment of 1:17), b) lead to administrative simplification, forcing commercial insurers to adhere to a common set of standards for claims submissions c) promote faster generic biologic drug approvals (so that they are merely very expensive, not shockingly expensive), d) reduce imaging costs by unilaterally cutting the fee schedule for radiology studies, e) reduce Medicare Advantage payments f) impose an excise tax on "Cadillac" plans and g) promote the three "I's" of information (a.k.a., electronic health records and effectiveness research), infrastructure (medical homes, accountable care organizations and post-discharge care to avoid readmissions) and incentives" (payment rates that act as both carrots and sticks to reduce avoidable complications and along with various pilots programs).

In addition to this, Drs. Orzag and Emanuel point out that an Innovation Center will develop, test and evaluate new policies and programs and that an "Independent Payment Advisory Board" will develop and propose policies for reducing health care cost inflation.

Readers may find that this article is a handy reference, suitable for building a PowerPoint slide or quoting over shared morning lattes. However, if the White House feels that publishing this in the New England Journal is going to reduce citizen-physician skepticism, they need to know a) there is nothing new here; these are the same recycled arguments and b) much of the Journal's readership is probably already predisposed to accepting the White House's nostrums. Just saying it over and over in a friendly venue isn't likely to advance the political discourse.

The DMCB is looking for better arguments that genuine health reform isn't too far away, that the cost trend can be cooled and that it can have it's ice cream and eat it too.

ok

I want to let you all know (those of you who have been asking, wondering or worrying) that the reason I've not blogged since Friday is that I've been incredibly busy and that I haven't fallen completely apart.

I'm still feeling incredibly sad but there have also been some unbelievably beautiful moments in the last few days and those have kept me going.

I'll try and find some time to blog tomorrow afternoon but I wanted to take a moment tonight to say thanks to each one of you who have offered your love, support and understanding.

We're keeping J-Dog as comfortable as we can for as long as we can and I am spoiling him rotten (lots of treats, feeding him from the table, wet food and lots of cuddles).

Goodnight blogosphere. Thank you for reminding me why I love you so much.

More on the Success of Blue Cross Blue Shield of Michigan's Success With the Patient Centered Medical Home (PCMH)

The Disease Management Care Blog heard back from the folks at Blue Cross Blue Shield of Michigan (BCBSM) about their positive experience with Patient Centered Medical Homes (PCMHs). As outlined in this prior DMCB post, it may be that this Blues plan has finally found the PCMH Holy Grail: genuine savings in a commercial real world, i.e., non-academic, non-integrated delivery and non-government insurance setting.

Questions that the DMCB asked and the gently edited BCBSM responses are below. The DMCB, because it cannot help itself, has some additional comments in italics.

Question: It isn’t clear how the medical homes were certified by BCBSM: did you do onsite visits, use NCQA criteria, or simply rely on attestation?

"BCBSM works with more than 100 physician organizations across the state on the PCMH program. Physician organizations nominate practices from within their organizations for designation. Physician organizations work with their practices to self-report data on PCMH capabilities into BCBSM. BCBSM also reviews quality data on key metrics, such as generic dispensing rate, ED visits for non-emergent conditions, evidence based care, and imaging use. BCBSM then conducts a site visit at a sampling of nominated practices to validate the data and to see the PCMH capabilities in place.

Designation decisions are made according to how much progress the practice has made in implementing the PCMH capabilities, and on quality and use data. Practices are analyzed and scored using a weighted measurement model."

This tells the DMCB that cooperation between a regional insurer and physician groups can be an important asset in promoting the PCMH. Imagine that: real partnerships between and insurer and physicians. What's more, the PCMH is not operating in a vacuum: there's a link with pay for performance and managing the pharmacy benefit.

Question: The PCMH certification you use itself seems pretty generic. What was the secret sauce(s)?

"Designations are conducted annually, and each designation lasts for one year. Designation is based on 50% progress on adopting PCMH capabilities (124 capabilities organized around 12 domains of function) and 50% quality and utilization performance.

Our “secret sauce” is the voluntary engagement of the physicians themselves. We developed the PCMH model together with the physicians. We are not dictating that primary care physicians become PCMH-designated. There are 5,800 physicians in Michigan who are eagerly and voluntarily choosing to transform their practices to earn designation."

This tells the DMCB that BCBSM didn't assume that all of the State's primary care sites would automatically want to become PCMHs. Rather, the model was jointly developed and remains voluntary. Some physicians are apparently not turning their clinics into PCMHs and BCBSM is not only fine with that, it has enough of a critical mass to work around it.

Question: Do the savings in your press release match your administrative costs as well as any P4P/gainshare or other economic incentives to the PCP? In other words, did you bend the total cost curve?

"The data that we shared on savings should be considered “early findings.” A complete cost analysis will be completed in the fall. However, our early findings indicate that the PCMH model is helping to avoid costs, such as ER visits, hospital admissions and radiology usage. BCBSM’s “spend” on the extra 10% payment to PCMH doctors in 2009 was approximately $8 million. These are dollars that were reallocated from other areas of the annual fee schedule. In other words, no extra or additional dollars were expended. PCMH doctors earned a higher fee, while some specialists earned slightly less.

BCBSM worked in partnership with its physician organizations to help provide administrative support to physician practices. As part of our Physician Group Incentive Program, BCBSM allocated approximately $30 million in 2009 from that reward pool to go toward PCMH capabilities and performance. Those reward dollars go to the physician organizations. The physician organizations determine how they wish to use those dollars. Many have used the funds to help pay for care management nurses, disease registries, electronic medical records, and physician training."

Let's be realists: unlike the Feds, regional insurers like BCBSM cannot print money and it has to come out of somewhere. It appears to the DMCB that money that would have been used to pay for year-to-year trend was used to support the PCMH. They apparently did not assume that "savings" this year would pay for next year.

Question: The numbers in your press release are percents. Any preliminary dollar numbers you can share?

We do plan to share dollar numbers later in the year, after the cost analysis is complete. BCBSM actually began developing the PCMH program with our partner physician organizations in 2004, and in 2009 we left the “pilot” phase and launched the full program. One of the first initiatives we launched with our physician organization partners was the generic dispensing effort – we estimate that since this program began in 2001, generic use has saved more than $700 million.

We are working with researchers from the University of Michigan School of Public Health on a comprehensive evaluation of the PGIP program, which includes the PCMH program. Funding for the evaluation has been received from Robert Wood Johnson Foundation, Commonwealth Fund and Agency for Healthcare Research and Quality (AHRQ). We have some articles in development for submission to health care publications and industry journals.

The DMCB agrees that if you are in the health care industry, you have an obligation to advance the science by sharing your knowledge in a transparent fashion that allows peers to review your results. That may involve traditional publications but can also involve other venues. However it is done, other workers in the PCMH field need to learn what works and why.

The DMCB hopes we learn more soon.

The Latest Cavalcade of Risk Is Up!

There are the provider-related risk issues and then there are the customer-related issues, but they're all learner-reader issues, especially when you want to learn about all the dimensions of measuring, monetizing and minimizing risk. And learn you will if you check out the latest Cavalcade of Risk - a one stop posting of the best and brightest of the blogs - over at My Wealth Builder. Enjoy!

Disproportionate Share Clinics Are More Likely to Have Features of the Medical Home

The Disease Management Care Blog would have guessed that primary care sites serving socioeconomically disadvantaged populations would be more likely to be shut out of coming medical home payment bonanza. Given the assumption that their practice income is lower than average, it follows that they'd probably be unable to afford the added costs of a practice redesign to qualify for the additional payments.

Not so, says this paper* just published in the Archives of Internal Medicine. Titled "Medical Home Capabilities of Primary Care Practices That Serve Sociodemographically Vulnerable Neighborhoods," Bostonian authors Mark Friedberg, Kathryn Coltin, Dana Gelb Safran, Marguerite Dresser and Eric C. Schneider used their own survey to determine how much 'medical homedness' was already present in sample of Massachusetts primary care sites. They then used geomapping to assess the sociodemographic case mix of the sites' surrounding neighborhoods.

The authors' survey included asking if interpreters and multi-lingual physicians are available (features not specifically spelled out in this and this description of the optimum features of a medical home, but heck, it's their survey). It turned out those two features and - depending on the definition used of being a disadvantaged primary care clinic - electronic records, having staff for patient education and being aware of patient experience ratings were all more likely to be present in clinics located in socioeconomically vulnerable neighborhoods. None of the other medical home features that were assessed were less likely to be in these sites either.

While the study may be limited by the lack of generalizability (the sites surveyed were physician owned practices that were not public health clinics, plus this was Massachusetts) and by the vagaries of the survey that was used (as opposed to the more widely accepted NCQA assessment tool), the DMCB thinks this counterintuitive study may have important policy implications. Clinics that serve populations with care disparities may be helped by a payment stream promoting medical homes.

In retrospect, it makes sense to the DMCB that 'disproportionate share' clinics might have access to funding or other resources that enable them to have electronic records and rely on non-physicians for patient contact. If that is the case outside of Massachusetts, the DMCB suspects that NCQA accreditation would be within reach for these clinics if they decided to go through that process.

Hopefully this study will be replicated in other areas of the country to see if it holds up. If it does, it may make sense for disease management organizations to anticipate possibly not having to support disproportionate share clinics in their medical home activities and being able to count on them as resources in their ongoing care management.

As an added bonus, the DMCB notes that if you can get past the manuscript and into the online article itself (requires a subscription), the Archives has an on-line copy of the survey that was used to assess the clinics' medical home characteristics. This could be theoretically be used by a payer or purchaser in their own network.

*Hat tip to HealthHombre

The Broader Implications of Letting the Sustainable Growth Rate (SGR) Formula Happen

According to the Washington Post, it is highly unlikely that Congress will undo the planned "sustainable growth rate formula" (SGR) mandated Medicare fee schedule cuts. While there's an outside chance of a fix, the American Medical Association, as well as other organized physician groups, can't be happy about the near-certain arrival of the 20% payment reductions that are slated to begin within a week.

Recall that the SGR was signed into law back in 1998. It was designed to be "cumulative and prospective," setting spending health care targets that, if exceeded any given year, were supposed to be proportionately applied to the following year's target. Until now, each yearly reduction has been temporarily cancelled by Congress. With the passage of the years, the excess has accumulated to approximately $20 billion. Without passage of a "fix" by Congress that can be signed by President Obama, this is the fiscal year when the SGR will force CMS to recoup its pounds of flesh.

Despite Mr. Obama's now classic ploy of blaming "some Senate Republicans" for the impasse, the Disease Management Care Blog suspects the AMA and its membership will rue its Faustian Deal of supporting the Democrats' health reform in exchange for assurances that the SGR would be permanently repealed. Without it, the DMCB wonders if this kind of political malpractice could lead to a spread of Texan-style refusals to accept new patients with Medicare, making even MedPAC to take note. To make things worse, commercial insurers use Medicare as a base when they calculate their payment rates. Whether they'll also reduce the fees or knuckle under to this attempt by the Feds to use them to cross-subsidize Medicare remains to be seen.

The DMCB doesn't think this is going to end well:

1. This is only partly about the money. It's about commitments. Will the primary care physicians dealing with Medicare need to think twice about embarking on a CMS medical home demo when payments can be unilaterally reduced like this?

2. On a larger scale, this is demonstrating that a mainframe government healthcare system seems incapable of intelligently targeting cost reductions. If Mr. Obama's health reform Ver 1.0 fails to tame overall health care cost inflation, the same blunt Medicare decision-making could to happen to hospitals, nursing homes, medical device manufacturers and to the insurers/patients counting on Federal subsidies. Hello Mr. Mudd.

3. And on an even larger scale, this may also be symptomatic of a more profound underlying problem of governance. Modern and enlightened government activism is so far turning out be no different than old fashioned if well-meaning government activism when it comes to dealing with blown-out oil wells, Keynesian deficit spending, war-making and compromising with an obstructionist if loyal opposition. Mr. Obama's rhetorical skills and distant intellectualism may not be the secret sauce that many of us hoped would make the difference. We'll see.

Image from Wikipedia

TRICARE Saves Taxpayers Millions on Chronic Illness Disease Management

Suppose you were on the leadership team of a 9.2 million member, $45 billion health insurance plan that had enrolled 80,000 persons with asthma, 11,000 with chronic heart failure and 225,000 with diabetes? Well, if you were leading TRICARE (the health insurance program for members of the military and their dependents), you would have had those persons enrolled in disease management. Fortunately for Disease Management Care Blog readers, the leadership didn't stop there: they also used standard research methodologies to assess whether the taxpayers were getting their money's worth AND submitted their results for peer review in the American Journal of Managed Care.

TRICARE has three regional “managed care support contractors” (MCSCs) that each provide disease management services (MCSCs). TRICARE forwards the names of patients with high rates of medical service utilization to the MCSCs who, in turn, contact the patients for participation in disease management. Patients can agree to receive “personalized telephonic counseling and educational mailings” or just mailings or choose to opt out entirely. If patients agree, their intervention includes a 40-50 minute baseline telephonic assessment, monthly follow-up calls to set/review care goals, additional educational mailings, newsletters and emails. Depending on the MCSC, patients can be graduated either after 12 months or after they've met their educational goals.

73,156 patients were contacted over the two years leading up to September 2008. Approximately 9000 opted out, 4700 were only in the program for 6 months and others lost TRICARE eligibility or were excluded because of end stage renal disease or HIV. That left 57,490 (about 23,000 with asthma, 4000 with heart failure and 29,000 with diabetes) for the outcomes analysis.

A control cohort using claims data from October ’04 to Sept ’05 of “comparable” patients with asthma, heart failure and diabetes populations was then fashioned to help the researchers better isolate the impact of the disease management programs. There were slight differences – the DM populations had slightly worse Charlson Comorbidity Index scores, higher rates of ambulatory visits as well as lower rates of ER and inpatient days.

As you might expect, all 6 groups of patients (the three intervention groups and the three control cohorts) experienced a pre-post decrease in claims expense. However, the patients in disease management experienced a bigger drop, which was calculated on an adjusted basis to from $152 for heart failure (which was not statistically significant) to $783 for diabetes (p < .05) to $832 for asthma (p < .05).

Patients with asthma also appeared to be more likely to get spirometry (but NOT controller medications), patients with heart failure were more likely to be on life-saving beta blocker and ACE inhibitor medications and patients with diabetes were more likely to get A1c, retinal and urine testing) – all of which were also statistically significant. Finally, patient surveys were littered with “agree” and “strongly agree” answers to surveys asking about the disease management programs’ effectiveness.

Bottom line? The total cost of disease management from September 2006 to September 2008 was $22.7 million. Cumulative gross savings was $28.5 million, with a return on investment (ROI) of 1.26. The DMCB believes that is not only statistically significant, it's quite financially significant.

While the canard that disease management “doesn’t save money” continues to stalk the hallways of academics, policy makers and regulators like a zombie that refuses to die, there is an emerging body of literature showing that disease management has evolved considerably from its early days. This study, conducted in a commercial setting involving millions of members, showed how other leaders of insurance plans can save some serious money.

Last but not least, this is a way for taxpayers to save some serious health care money. Hopefully the leadership in the Obama Administration will take note of this good news.

10 in june part two: writing through heartbreak

June is a very busy month. The end of the academic year means that there are meetings, plays and endless school-related events (most are fun but they do keep me busy). Also, I've been very distracted because J-Dog (known to us as Jasper Friendly Bear) is very sick.

We are waiting on the biopsy results of tissue taken from several large tumours in his mouth. Honestly, it doesn't look good. Even if the tumours are benign, which is highly unlikely, the surgery to remove the growths would be dangerous and painful (not the mention the fact that having half his upper jaw removed would leave him with a dubious quality of life). Leaving them where they are is out of the question because they are making him very uncomfortable and affecting both his breathing and his ability to swallow.

We love this dog a lot. He's a very sweet old soul, who was born with tremendous dignity, intelligence and loyalty. I can't bear the thought of losing him but I can't stop thinking about it.

And you can imagine that this family would find all of this especially traumatic. As a wise and dear friend said to me, "You have to make sure the kids understand that he's not you." And even as we all understand that, this is all rubbing salt into some wounds that may never fully heal.

This was meant to be a post about writing, though - something I am reminded means more to me than an obligation or an item on a 'to do' list - so let me get back to that now.

Here are my goals for the month (taking up the numbering from where I left off in my last post):

5. Write for ninety minutes, four times a week (or 300 minutes per week). Given how busy I knew I'd be, I thought I'd set a more realistic goal (I'm already behind but not iredeemably so).

6. Write the speech for the Weekend to End Women's Cancers fundraiser (I don't have much of a choice about this one because I'm delivering it on Monday. I've got some detailed notes but a fair bit more work to do. Did I mention that I'm delivering it - at least in part - in French?).

7. Write a first draft of a short story (I've had this idea about Elvis and my home town for a while now).

I'm also going to continue to re-read and edit my draft novel but I'm not going to write that one down as a goal, since it's an ongoing process and I'm on track, thanks to my writing buddy and our regular exchanges and phone meetings.

It felt good to write all of that - about the fear and the grief but also about the goals I have set for myself. Writing gives me hope and a sense of purpose. When I do it well, it gives me confidence.

It's also very therapeutic.

Update: The vet called this evening. It's cancer. We have some choices to make but none will be easy. 

CMS Steps Up With the Multi-Payer Advanced Primary Care Practice Demonstration on the Patient Centered Medical Home (PCMH) at $10 PMPM

Readers have questioned the Disease Management Care Blog about its Facebook and the other glow-pink eyed portraits in the right side of the page. It's been told that it conveys a buffoonishness that is inconsistent with the DMCB reputation of sober erudition and morose skepticism. What's more, it's been asked: just what are those lights?

Well, the pic is not long for this blog, but that doesn't mean it doesn't hold a special place in the DMCB Galaxy. Those are, by the way, pink flamingo tree lights, surreptitiously added to the cart by DMCB after being invited by the spouse to accompany her on a holiday shopping errand months ago. Despite the DMCB's merry participation, it was pointedly warned during check-out that this was the "last time" it would "ever" etc. etc. It seems it turned left in the aisles when it was supposed to go right, touched things it shouldn't have and said things that weren't helpful. While the lights were disappointingly never tasked to their original celebratory purpose, the DMCB has discovered - despite occasional attempts at spousal sabotage - that they are suitable for year-round display in the Executive Suite of DMCB World Headquarters.

And the States with Patient Centered Medical Home (PCMH) pilots may gain a special appreciation for the DMCB spouse's travails after they're done checking out just how CMS intends to merrily participate in their programs. The Feds have just released their "solicitation" for their "Multi-payer Advance Primary Care Practice Demonstration." This is **THE** three year demo designed to test the PCMH across multiple insurers, including Medicare fee-for-service (FFS).

Recall that one big problem encountered by the current bevy of pilots is that they're typically sponsored by just one or a few insurers. As a result, it's been difficult to ask primary care practices to reengineer their daily workflows to offer the "Cadillac" PCMH to patients with one type of insurance and "Chevy" usual care to patients with another type of insurance. Up until now, Medicare has relegated its patients to the Chevy.

Can the Cadillac PCMH pay off in Medicare FFS? To find out, CMS is inviting up to six States with ongoing multi-payer pilots to submit applications by August 3, 2010.

CMS' requirements are considerable. It wants (in "40 pages or less"):

1) a State agency to lead it,

2) enlistment of multiple group/individual private payers (that together enroll ">50% of State residents") as well as its Medicaid program,

3) the State to"demonstrate [the] commitment" of majority of its PCPs,

4) identification of and a way to certify PCMHs that also have links to State/community, public health, wellness and prevention resources,

5) to have the provider payment mechanisms in place,

6) CMS's uniform payments for the clinics/coordination/CMS' share of the administrative expenses (plus not to exceed $10 PMPM) all set up,

7) a way to figure out how to "attribute" a beneficiary to a PCMH (for example, by "designation"),

8) the State to line up any necessary waivers,

9) the creation of an adequate monitoring system,

10) State agreement to participate in an independent evaluation by an entity of CMS's choosing,

11) a reasonable assurance that the demo will be "revenue neutral" ("describe the anticipated effect of the State initiative on aggregate or global expenditures under the Medicare program for all covered services combined"), and

12) be ready to go by the end of 2010.

The DMCB's first reaction is that these requirements to the States and their physicians will be, er.... daunting. It is going through the other documents on the CMS web site and will be pondering them over the appropriate beverages this weekend. Look for lots more on the topic here.

The Latest Health Wonk Review Is Up!

A murderously delightful Health Wonk Review awaits you at Tinker Ready's Boston Health News. Titled "A killer edition of Health Wonk Review." Join other countless other policy cutthroats, academic butchers and health insurance slayers in this cleverly written review of insights, perspectives, opinions and, yea, hatchetjobs by the best of the bloggers. You won't see ANY of this in the mainstream media.

For Profit Healthways and Harvard's David Cutler Agree: It's Bending the Curve Stupid

In yesterday's posting, the Disease Management Care Blog briefly touched on David Cutler's recent Health Affairs article on the Obama Administration's cost-reducing logic in the recently passed Patient Protection and Affordable Care Act. In it, Dr. Cutler writes that over the short term, lowering costs is all about reducing Medicare Advantage payments, reducing hospital payment rates and squeezing big pharma (and, the DMCB adds, the taxpayers). Ultimately, however, they represent "one time" gains. Instead, he argues, the real success of health reform, over the long term, will need to come from bundling, provider-hospital collaboration, pay-for-performance and coordinated care.

It's the opportunities in coordinated care that led Dr. Cutler to opine:

"Private-sector providers and large private payers must actively participate in the change to new models of care delivery. For example, we already have much evidence that medical homes, bundled payments, and other reforms can save enormous amounts of money while simultaneously improving the quality of care. Providers need to move into these areas rapidly, and a fair amount of industry integration and consolidation may occur as a result. Payers, including insurers and businesses, need to consider piggybacking other changes onto payment reforms to help speed the creation of new care models and delivery systems."

The DMCB salutes Dr. Cutler's timely reminder to our friends in academia and policy making that non-governmental entities have much to offer in "bending the curve."

To see just how much money could be had from the coordination of chronic illness care, prevention and ultimately wellness, check out this report from Healthways' Center for Health Research titled "Savings Potential From Prevention & Risk Reduction for the Commercially Insured." Mr. Obama and his Democratic colleagues need to read this. It's good news.

Using actuarial methods and U.S. vital statistics, the authors project the health care costs of the approximately 4,257,000 persons born in 2007 by dividing them up into low, medium and high risk categories. As persons move through the known different levels of risk over time, the average lifetime cost for each person from that year until they reach Medicare age is projected to be a whopping $243,804. If movement into the various risk categories can be reduced by 10 to 25%, or, delayed a few years, the savings range from the tens of billions to more than a trillion dollars.

The DMCB figures that may be enough to pay for all the promises of health reform plus years of Gulf spill clean up - and leave some left over for the considerable unemployment benefit needs for Kate thanks to looming Kate Plus Eight viewer fatigue, the cost of Ms. Lohan's future multiple D&A detox admissions and - most importantly to the DMCB spouse - funding for a federal Health Policy Blogger Protection and Guaranteed Income Act.

The folks from Healthways, a company that is rapidly creating a business model so favored by Dr. Cutler in Health Affairs (and the Obama Administration) may have a point. Sooner or later as a nation, we'll need to figure out how to reduce our unsustainable spending in sickness care and invest in wellness. There's too much money at stake and our children's lives depend on it.

10 in june part one: health

The last month has been challenging, as far as my health is concerned. There is nothing seriously wrong with me and as far as the cancer is concerned, I'm in fine shape. Instead, I've been dealing with some unpleasant and uncomfortable digestive issues. Whether this is due to my age or the toll of long term systemic cancer treatment, I don't know. I just know that, by the time I went to see my doctor, I was feeling prettty miserable.

I suspected my gall bladder was the source of the problem but we had the benefit of a recent abdominal CT scan that showed that organ to be fine. My doctor diagnosed me with Gastroesophageal Reflux Disease (or GERD) and instructed me to stop consuming coffee, tea, chocolate or coffee (my immediate response was the somewhat ironic, "I'll die!" She also gave me some medicine. 

After a couple of weeks, I do feel very much better. I've only been eating tiny amounts of chocolate and I have had a couple of pints of beer (which didn't seem to bother me). What does turn my innards inside out is coffee, something I find to be fairly tragic. I'm now drinking a mug of Matcha green tea every morning and then, only occasionally having a single mug of half-decaf (and I am coming to accept that this needs to be a pretty occasional thing). 

I was feeling pretty bummed out about all of this (haven't I already been through enough?) until one day I was out walking the dogs and I got to thinking. What if I chose to look on this as an opportunity to clean up my diet?

I've also come to realize that fatty foods or eating anything too quickly can give me pain and heatburn. But I should be avoid junk food and mindless eating anyway, so that shouldn't seem like a bad thing.

When life gives you lemons, make lemon water (which also really helps with digestion and I like how it tastes).

Next visit to my doc, I'm going to risk being labelled a hypochondriac and ask to be tested for Celiac's disease (my sister has it, and although I've had the blood test, I know that it can result in false negatives) and also asked to be tested for a stomach bacteria called H. pylori (because a friend just tested positive and really I am a bit of a hypochondriac.

Keeping all those things under consideration, here is the part of my "Ten Things" to do list that addresses health:

1. Make soup twice. I've been having fun on this soup adventure. I've already made chicken soup this month. What surprised me though was that I took a recipe from my nutrionist and altered it significantly to make it more flavourful. On the heels of my made-up cabbage soup from last month, I am displaying a willingness to depart from recipes that I have never been brave enough to do. It pleases me enormously.

2. Do an average of sixty minutes of cardio five times a week (a total of 300 minutes a week). 

3. Start the Running Room beginner program and run/walk three times a week. I'm on track and on week two, which means I'm alternating one minute of walking with one minute of running for twenty minutes.

4. Follow the diet prescribed by my nutritionist, while cutting mysellf some slack (ie letting myself have a cookie or a piece of chocolate every day, eating exactly what I want once a week, cutting down on carbs and increasing fruit and especially low sugar veggies). If my approach isn't moderate, it's not sustainable.

I'm putting the strength training on hold in the hopes that July will be a little less busy and my gut will be healed enought that the thought of sit-ups doesn't make me puke (although I'm not sure if this is a real problem or just a dislike of sit-ups).

I'll save the rest of this month's goals for another post. What's on your to-do list for June?