Dr. Gawande, Hospice, The New Yorker and the Curious Absence of Some Inconvenient Truths: Here's the Rest of the Story

Media Golden Boy and eponymous web site star Atul Gawande has done it again with a compelling essay about death in the August 2 issue of The New Yorker. Pulling from a grab bag of instructive anecdotes, he describes America's perfect storm of imperfect dying. It's all thanks to the twin ingredients of a culture unprepared to think about mortality combined with a curiously passive health system willing to offer up any treatment, no matter how distant the odds. Steering clear of the "shoals" of blaming dysfunctional economic incentives, Dr. Gawande reminds us about some handy solutions: living wills, which introduce the living to the ars moriendi and hospice, which helps the dying meet a good end.

Unfortunately, expert essayist Dr. Gawande has skipped over some inconvenient truths. The DMCB brings you the rest of the story:

When confronted with a critically ill cancer patient (of the kind compellingly described by Dr. Gawande), popular culture would have you think the physicians can predict the likelihood of not making it out of the ICU alive and can therefore treat accordingly. The problem is that the prediction is far from perfect with an ROC, according to this study, of about 0.8 (where 1 is perfect). In other words, there are enough false positives to give physicians pause before recommending pulling the plug. By the way, for non-cancer patients, the prognostic tools are even worse.

Here's a DMCB anecdote: a patient with wildly metastatic colon cancer showed up in its clinic after a yucky ICU stay with a huge grin and said "Hey doc! Surprised to see me?"

Speaking of yucky ICU stays, common sense tells us that given a choice between a "florescent" ICU death with emotionally distant nurses versus a sunset-lit bedroom death with family, everyone would chose the latter. Suppose, however, if you asked ICU survivors about the wisdom of rolling the dice for that third option of surviving? There is research that says up to 70% would do it all over again and that, among the elderly, a majority are often satisfied with their quality of life afterwards.

Another DMCB anecdote: The DMCB accepted the transfer of an elderly patient out of the ICU onto its inpatient service. When asked about being at the business end of all those plastic tubes for all those weeks, the patient's response was "I don't remember much."

Unfortunately, neither does DMCB and its physician colleagues. Armed with state-of-the-art adult learning theories aimed at the promotion of a patently obvious societal need, the SUPPORT investigators set out to help physicians solicit patient preferences about end-of-life care. They failed. Dr. Gawande's New Yorker article makes for a great read, but it's a recycling of nostrums that's unlikely to change anything.

Which begs the question: why the interest in changing things? Could it be that the 12 months prior to death accounts for a quarter of Medicare costs? As a result, government and commercial insurers have a considerable economic incentive to steer patients with a poor prognosis away from costly health care services. The DMCB recalls another anecdote from when it was a medical director: a physician with special interest in end-of-life care asked the DMCB's managed care plan for financial support to promote living wills and surrogate decision making among our enrol lees. Among the many right reasons for doing this, he also suggested the savings from reduced claims expense would be huge and we'd make a killing. We agreed and took a pass on the creepy opportunity. Years later, this same conflict of interest was the key ingredient in the traction behind the otherwise despicable "death panels" controversy

Readers may also recall that hospitals are generally reimbursed with a fixed payment "DRG." Since the inpatient payment (with many exceptions) per patient is typically capped, patients with prolonged stays in the ICU often turn out to have costs that exceed the payment. Accordingly, steering patients toward palliative care can have a tidy return on investment. Now that is yucky.

Last but not least, it's ironic, given our national manic compulsion for "evidence-based" science to guide treatment decisions, that the research supporting the benefits of hospice is decidedly shaky. Dr. Gawande only quoted some studies that happened to support his point of view. That is the luxury of writing for The New Yorker. Unfortunately, it doesn't inform policy and one can only hope the White House will not repeat its past mistake and not pay attention.

So, what could be done? Writing in Population Health Management, Dr. Kash and colleagues point out that disease management for oncology can facilitate informed decision making about end-of-life options because it's typically external to the risk bearing sponsor and has less of a conflict of interest. The DMCB performed unpublished research that demonstrated that nurses can fill in for docs and are quite capable of doing the heavy lifting on promotion of living wills.

In addition, measurable outcomes in end-of-life cancer care are well within reach, according to Don Fetterolf, also writing in Population Health Management. They include the number of times cancer drugs are used "off label," (particularly as second or third line treatments) as well as the percent of patients that received chemotherapy within 14 days of death. These measures are not supposed to be zero, but Dr. Gawande points out that the number seems to be unreasonably high.

The Well Being Index: The Problem Gets Bigger

The Disease Management Care Blog doesn't necessarily agree with Newt Gingrich's politics, but it has learned to appreciate the insights of former professors armed with the lessons of history. Case in point has been Newt's habit of repeatedly a quoting President Eisenhower's answer to the seemingly unsolvable:

"Whenever see a problem I can't solve, I always make it bigger"

In preparation for a speaking gig at an upcoming international conference, the DMCB has been struggling with its own big problem: boiling the business case of disease management down to an easily grasped elevator pitch. "Mitigating the pooled risk of insured populations defined by the presence of chronic illness" doesn't quite make it. Saying that "health insurers are happy to pay for special services for high risk persons because the expense is lower than the cost of what would otherwise happen" is better, but even that's still too complicated. When brokers, human resources and physicians are around, the wheels really come off because terms like "premiums," "claims expense," "cost," "charges," "revenue," "outcomes," "reconciliation," "return on investment," "engagement," "contact rates" and "value" fly around thicker than hospital administrators on a newly covered Medicare code. Toss in caveats, like "trend," "non-chronics," "confidence intervals" and "program costs" and it's little wonder why skepticism and confusion abounds.

Enter Healthways and their "Well Being Index." Rather than mess with the thorny problem of educating non-mathematician customers about the subtle dimensions of the actuarial sciences and convincing them that there's value somewhere in those numbers, Healthways made the problem larger. Knowing that customers ultimately expect disease management, prevention and wellness programs to make persons, well.... healthier, the measurement solution presented itself. What followed was the decision to partner with Gallup to create a survey that simply asked about health from the consumer/end-users' point of view. All that was left was to settle on the various sub-domains (Life Evaluation, Emotional Health, Physical Health, Healthy Behaviors, Work Environment and Basic Access) and use them to understandably assess outcomes that actually mean something for their customers.

While the business concept is intriguing enough, it remains to be seen how this will serve Healthways over the long run. Kick it up a notch, though, and consider whether the concept of "well being" could turn out to be a key metric in our nation's ongoing search for health reform. Healthways would certainly like that, but that's not the point. The point is that maybe the Obama Administration and Congress should think about the Eisenhower quote when they're thinking about the next meaningful steps in health - not health "insurance" - reform.

We'll see.

The Latest Cavalcade of Risk Is up!

Think of it as a parade or a procession of interesting floats, groups, bands and VIPs waving at you while they regale you with eye-candy. The latest Cavalcade of Risk is pretty much the same way, except this uses brain-food served up from the best of the blogs that deal with business risk. Don't worry though, the eye candy is also there, courtesy of Jay & Louise Norris' photo album. Enjoy!

Outcomes? You Say You Want Outcomes?

The Journal of the American Medical Association (JAMA) can be forgiven for being physician-centric. So when it publishes an article on Medical Leadership in an Increasingly Complex World, the Disease Management Care Blog looks past the politics for the lessons. There's an important one here for not only physicians but, with some additional thought, all health organization leaders.

Leaders are lauded when they increase revenues, build buildings, gain market share and create positive brands. While, for example, academic leaders seek more NIH grants and professional society execs want membership growth, parallel business realities are keeping care management organizations' CEOs up at night.

But are their collective sweat and tears misplaced? Author Robert Brook of Rand wonders if they may be. He notes physician leaders are ultimately using the patient-doc based "medical model" to build their empires. Without mentioning the disease/population health management industry by name, he also recognizes the growth of a second "public health"model ("driven primarily by the quest to eliminate root causes of population behavior that produces poor health"). However, there is also a third "social determinants of health" model that recognizes well being is also a function of income, safety and communities.

His point? Leaders must pursue all three models in balance. He thinks they should be regularly asking what they've done to advance the health of their communities in all three domains. He also thinks medical trainees and members of medical societies should be asking the same question. The DMCB adds the Boards and shareholders of publicly held companies offering care management services should be asking the same question also.

Long ago, while the DMCB was visiting a large health care institution, it asked what would happen to the mortality rate of the surrounding community if its bricks, mortar, equipment, employees, protocols, policies, physicians and nurses all vanished. Would the rate of obesity diminish? Would there be fewer premature births?

There was an uncomfortable silence. It's time to begin answering those simple questions.

Image from Wikipedia

The Affordable Care Act and HHS Oversight of Unreasonable Health Insurance Rates: Is It Good Versus Evil?

Check out this New England Journal July 21 "Truth and Consequences" article that reviews the Affordable Care Act's (ACA) language on the Fed's new oversight of "unreasonable" health insurance premiums. Regrettably, it portrays the folks at Health and Human Services (HHS) as the White Knights come to rescue America from the Black Empire of the Health Insurance Companies. Think of the derring do of a ray-gun toting Princess Leia versus a sociopathic Darth Vader. The good news is that because you read the Disease Management Care Blog, even the Journal's one dimensional storyline can be turned into a short efficient learning opportunity.

If you go online to the ACA and look at Section 1003, you'll see that the HHS Secretary is supposed to establish a "process" to annually review or "monitor" the "justification" for any "unreasonable" health insurance premium increases. This process will not only include the health insurers, but the State Insurance Commissioners. To help them on their way, the Commissioners are invited to dip into a pool of $250 million and, in exchange, give the Secretary their recommendations, including whether an insurer should be listed on their exchanges.

According to the Truth and Consequences article, the ACA is a stand against the insurers' "disproportionate" profits, will buttress the outmatched Commissioners' ability to review rate hikes and provide enlightened and disciplined consistency across the States' regulatory efforts. Yet, the article notes, the ACA ultimately does NOT give the Secretary the power to deny insurance premium increases, which is described as a "lack of regulatory teeth." Another problem is that, now that there's a new HHS sheriff in town, insurers will be tempted to keep premiums down by taking it out on physicians with decreased fees, more administrative hassles, utilization management, a potential return of 1990's style managed care and capitated fees with the inevitable accusations that medical care is being withheld.

The Secretary is now gearing up for this with the announcement that comments are being accepted to help craft the specific regulations that will clarify the "process," "monitoring," "justification" and "reasonableness" language. The DMCB thought it was quite clever when it actually found the web site that is accepting the comments, until it realized that about 230 other groups and individuals have already taken advantage of it.

The DMCB recalls that Ms. Leia could be unpleasant at times. Furthermore, didn't Darth ultimately turn out to be a cuddly saint of a man? Let's look at the world through his black helmet goggles......

The health insurance industry may be making gazillions of dollars but its overall return on investment has been quite anemic. States view the regulation of insurance as one of those powers included in the Tenth Amendment and it still remains how much control they'll cede to the HHS Secretary's potentially intrusive overtures. Critics may charge that health insurers can abandon a State but there are examples of States' wrecking the marketplace with unsustainable demands for low premium levels. The terms "process," "monitor," "justify" and "reasonable" are vague and the final regulations that define them promise to be an overlawyered miasma that will do little to stem our national appetite for more health care. Finally, the insurers were mostly defanged in the 1990's. It'll ultimately be up to the physician community to figure out how to deliver higher healthcare value. If the docs are not up to the task, Plan B won't be the managed care insurers or an evidence-base courtesy of the wise editors of the New England Journal. It'll be the judgment of distant Medicare mandarins holding court in windowless rooms just outside of Baltimore.

Somewhere between all that white and black is a color called grey. To get a sense of that, check out the comments web page mentioned above. The submissions make for interesting reading and run the gamut from pleas to rely on actuarial soundness (the insurers) to demands that they be put out of business (cancer survivors). Hopefully the Obama Administration will put aside its public hostility to the insurers, recognize the Journal's Truth and Consequences article for what it is and steer a middle path.

We'll see.

Decision Tree Scenarios for Health Reform

The Disease Management Care Blog has gone down countless "if-then" decision trees in its intellectual lifetime. For example, it calculated that if it pointed out to the DMCB spouse that the high-end four-way surround sound system will enhance the flat screen viewer experience for cowboy romance flicks, then there would be agreement on buying the high-end cable channels that feature space vixens blowing up planets.

The DMCB's bitter lesson is that it rarely works out that way. Take the same sort of "if-then" assumptions underlying the Affordable Care Act and apply it to how hundreds of millions of people of different backgrounds manage income, taxes, health insurance and consumption under a range of economic conditions and the result is an uncertain spread of possibilities that resemble early hurricane path predictions. The storm may or may not include landfall with or without catastrophic wind or flood damage in or outside metropolitan areas.

That's the downside to this intellectual gaming: it's malleable to any input and every bias. Honest libertarians, conservatives, progressives and liberals can use the myriad if-then decision trees to concoct any scenario that pleases them.

Yet, the DMCB still thinks they're a useful exercise, especially if it helps policymakers better understand where future problems may lay. That's why it paid attention to this July 22 Health Affairs article by Harvard's (John D. MacArthur Professor of Health Policy and Management in the Division of Health Policy Research) Joseph Newhouse. It's worth a review for yourself (read the article just like you should review the bill, view the whole videotape and check with a dictionary when necessary ['refudiate' is at the 2:35 point]).

Here are some of the points that caught the DMCB's attention.

Medicaid: while the Fed's financing of newly eligible beneficiaries certainly helps, administrative rules after 2014 ("if") impose a host of thresholds and income eligibility limits that could lead to State-Federal government appeals and beneficiary audits ("then"). In addition, the newly insureds are likely to end up in Medicaid managed care plans ("if"), which are already struggling with network capacity that could make access problems worse ("then").

Individual and small group insurance: assuming the combination of penalties and financing pushes most uninsured persons into an insurance plan (a big "if"), there are some other issues. One is that subsidies (looks like a pretty definite "if") could increase marginal tax rates ("then"). In addition, the IRS may be ill suited ("if") to adjudicating the income regulations for the various subsidies and penalties (suppose a person gets married halfway through a year.....). That means having use a federal bureaucracy ("then") to reconcile countless income "moving targets" that ultimately determine subsidy levels (including the possibility of clawbacks). In addition, health insurers will still be tempted ("if") and able to develop subtle benefit designs that deter enrollment ("then") of poor underwriting risks. It remains to be seen if risk adjusted payments will overcome this.

Medicare: the Center for Innovation may find that it's easier to find ways to provide better care at the same, not a lower, price. Combined with the historical and remarkably consistent unwillingness of Americans to give more than 18% of GDP to the government, the Feds will "then" have only three choices: continue to borrow, cut the benefit or cut payment rates. The latter is most expedient and could "then" lead to a second class status for Medicare. This may already be presaged by the arrival of concierge practices that are charging high non-Medicare rates in exchange for enhanced access.

The DMCB reads that this decision tree could be leading, under most scenarios, to a difficult administrative and fiscal outcome. Dr. Newhouse ends his article with a telling quote:

"In fairness to those who devoted many of their waking hours in 2009 and early 2010 to passing this legislation, doing more than was done about cost was not politically feasible. Nonetheless, the nation remains in a fiscal hole, and the digging continues."

seriously targeted marketing

living large

Chemo typically turns me into a horned, fanged, clawed she-devil for at least one day following treatment. Today is that day.

My head knows the mood will pass but boy am I pissy.

But I'm trying to re-commit to having something vaguely resembling content on this blog, so I thought I'd share a couple of shots taken in a parking lot outside a Sonny's restaurant in South Florida (we'd had lunch that day at my first ever Waffle House. We were on a greasy streak).



We had just come back from a day at Corkscrew Swamp and filled up on ribs and other good fried things and I think I was a little giddy.

Anyway, this car just called to me and I made the boys take photos.

Pay for Performance (P4P), Large Physician Groups and Accountable Care Organizations. Insights from Behavioral Economics

MEMORANDUM

To: Sr. VP and Chief Financial Officer, Health Insurance Operations

From: VP, Network Provider Relations, Health Insurance Operations

Re: Provider Pay for Performance "P4P"

Thank you for so repeatedly sharing your insights about our provider pay-for-performance programs ("P4P"). My staff truly appreciate the energy and passion that's been reflected in your many emails and voice mails in which you've vigorously contrasted our modest quality outcomes with the millions of dollars in additional expense that has gone to out to our contracted providers. Like you, we continue to seek better understanding about the role of this important initiative in mitigating our company's continued unfavorable cost trends, especially since this is on the Agenda of an upcoming Board of Directors meeting.

Since we've agreed that there may be one more opportunity to continue P4P, please allow me to share some important insights I've gained thanks to the Disease Management Care Blog. I highly recommend that healthcare leaders such as yourself receive regular doses of DMCB, since scientific studes have shown it can reduce the size of throbbing forehead veins, which has been a concern for you.

Thanks to the DMCB, we now know about this hot off the presses American Journal of Managed Care article titled "Using the Lessons of Behavioral Economics to Design More Effective Pay-for-Performance Programs" by Ateev Mehrotra, Melony Sorbero and Cheryl Damberg. This is an important manuscript, not only because it can help us better incent physicians, but because it also gives some insights about how physician groups and Accountable Care Organizations (ACOs) can screw this up.

First: the lessons:

1. Divide the incentives rather than a single lump payment: repeated payments have more appeal than single ones.

2. Tier the performance thresholds: everyone should have a goal and a reward that's within reach.

3. Reward the providers right away: a lag-time can undermine the priority of today's performance measures versus other concerns.

4. Witholds are bad: it can annoy docs, who are already grouchy. It you must do this, try a "deposit contract."

5. Keep it simple: otherwise, complex decisions will make persons risk averse. Contrast shared savings or quartile scoring with say, simply paying a bonus for every A1c that's ordered.

6. Make it stand alone: it shouldn't be mixed up with other forms of reimbursement, which could dilute its impact

7. "In kind" rewards can work: a "splurge" is more enjoyable than a check.

This is why our Provider Relations personnel have been concerned about the terms of our P4P programs with our larger physician groups. As you are aware, these groups tend to demand that any P4P from our insurance company go to the group and not their individual physicians.

They claim that it is difficult for us to accurately credit their individual physicians, that the group is ultimately responsible for performance improvements and that we can "trust" them. Yet, we believe we have a stake in assuring the physicians are fully and personally rewarded and suspect the group is diverting money toward other capital projects. What's more, every single of the lessons described above are routinely ignored by the large groups.

Which has important implications for ACOs. As we've noted before, there is a long history of physician-hospital distrust. That alone should give pause to the notion of funneling P4P to a hospital dominated organization without careful assurances that the P4P is flowing to where it is intended.

Once again, I want to thank you for your interest in shaping our P4P programs so that our enrollees can achieve the greatest benefit possible. It is clear the science of P4P is still in evolution and your support will be greatly appreciated going forward.

watch me wave my hands around a lot

As promised, here is a direct link to the Connected segment on cancer blogging:

http://www.cbc.ca/video/#/News/TV_Shows/Connect_with_Mark_Kelley/ID=1549366307

The Latest Health Wonk Review Is Up!

Things are hot - really hot. No, the Disease Management Care Blog isn't thinking about the east coast heat wave, the rising temperature of the body politic or the sizzle of all those alluring summer dresses. Rather it's all about the Health Wonk Review over at Lynch Ryan's Workers' Comp Insider Blog. Get yourself a cold beverage and bask in the collective warmth of the latest and bestest health policy wonkiness from around the blogosphere.

Getting All Americans Covered Falls By The Wayside

The Disease Management Care Blog gained one major insight during its recent Washington DC health care conference.

In all the talk about "health reform," there was very little discussion about one of the past leading justifications of the Affordable Care Act (ACA): that by giving tens of millions of Americans insurance, there'd be more preventive and screening services, earlier care for chronic illnesses and better access to hospitals after unexpected illness. It was argued that disease detection would be increased, and disease progression would be decreased and avoidable high-cost complications would be... well... avoided. The expensive and shameful "hidden tax" of unnecessary and inefficient cost-shifting would be replaced by enlightened and cost-effective public financing.

There may be merit of the argument, but it's conspicuous absence at a D.C. conference and, by the way, in many of the health journals, policy media and blogs makes the DMCB think that many of the cognoscenti silently doubt it. Ask policymakers and academics about bending the cost curve today and what you'll get is a refrain consisting of bundled payments (that intelligently capitate physician services), primary care medical homes (that shift health services to a cheaper level of care) and accountable care organizations (that align all the economic incentives).

The DMCB sees the merits of each of those concepts. Congress obviously did also when it mandated them in a variety of demos and pilot programs. What's more, the ACA is remarkable for the power it gives to the HHS Secretary to rapidly expand them, and to do so without Congressional approval.

Which is the rub. While the Secretary's flexibility is a good thing, the one thing that is standing in her (or his) way is that the pilots/demos really have to show cost savings. While many of my colleagues believe that is a mere formality, the DMCB recalls many in the disease management industry felt the same way about Medicare Health Support Demo. It didn't quite work out as planned.

Which brings the DMCB to the ultimate question: if the pilots and demos don't work, just what is "Plan B?" The answer at the Conference, for Medicare at least, was across the board delays in any scheduled fee schedule increases and/or reductions. Yikes.

Which is the insight. The discussions about the possibility of across-the-board cuts may have greater visibility today than merits of extending insurance to the uninsured. It's not out there in the media. so you read it here first.

The DMCB will continue to monitor this.

watch me on tee vee!

Or catch it online.

I'm being featured in a story on cancer blogging on CBC News Network (formerly Newsworld). Tune in this evening, between 8:00 - 9:00 p.m. ET

You can also watch online at cbc.ca/connect (I'll post a direct link to the video once the show has aired).

I promise to blog more about the whole experience (I was interviewed at home with my family and in the chemo room) but I wanted to give all a chance to check it out..

If you watch the show, let me know what you think.

The Limits of a "Successionist" Mind Set in the Search for Payment Innovation in Medicare

The Disease Management Care Blog survived today's panel discussion at the 6th Annual Leadership Summit on Medicare. We discussed CMS' search for payment innovation that leads to increased quality with lower costs.

The DMCB started out by noting that not all quality means lower claims expense. What's more, even if there are savings, the cost of delivering the quality can negate any savings. There are ways around that, but that's for another post. Something far more interesting came up.

The DMCB focused on the more fundamental issue of measurement methodology. If you think about it, this typically uses a "successionist" mind set. In other words, scientists and policymakers expect that if an intervention is made in a system and everything else is held neutral, that anything that follows must have been "caused" by the intervention. Succession means "the act or process of following in order or sequence." The study of interventions and how they lead to outcomes forms the basis of health services research, evidence-based medicine, clinical research trials and the like.

There are two problems with using the successionist mind set to assess the quality and costs that follow medical interventions:

1) The measurement environment is statistically "noisy," including a general upward trend in overall health care costs. Picking out the impact of a single intervention is like trying to hear the East River's tug boats from atop of New York City's Empire State Building.

2) Health care is a messy, complex social system with many moving parts. It's hard to control the other factors that play a role in quality and cost, especially from a patient's point of view. That makes it hard to know just what caused the movement of those tug boats.

There are solutions though. The DMCB paraphrases from an excellent article that appeared in JAMA back in 2008:

A successionist tool kit that holds all sources of bias neutral while [what] it measures ... may be unequal to the task of evaluating complex, nonlinear, interpersonal social programs, with findings that ... [are] ... typically non-cumulative, low-impact [and] prone-to-equivocation. The emphasis on knowing whether something works leads to little insight on how/why it works. There are four ways to overcome this:

1. Use a wider range of research methodologies that draw on ethnography, anthropology and other qualitative methods.

2. Reconsider the threshold for action on evidence, especially if the status quo is unacceptable.

3. Measure bias, don’t seek to eliminate it. The knowledge of trusted insiders may be more powerful than the conclusions of distant third party evaluators.

4. Don’t get in the way with insistence on weighing evidence with impoverished tools but asking what is everyone learning.

The DMCB agrees that CMS needs to think about incorporating these approaches in its search for value.

Who wrote this, you ask? Don Berwick, the new Administrator at CMS. The link is here.

Medicare and Payment Innovation

The Disease Management Care Blog is very much looking forward to participating in a closing afternoon panel discussion in Washington DC this July 20. It'll be at the 6th Annual Leadership Summit on Medicare. The DMCB will be fortunate to be sharing the dais with Stuart Guterman of the Commonwealth Fund's Program on Payment System Reform and Len Nichols of George Mason University's Center for Health Policy Research and Ethics. By the way, the DMCB is also pleased to recognize both institutions' blogs (here and here) presence among the blogmos.

Is the DMCB anxious about being on a podium with such obviously smart speakers? Absolutely. Especially when the topic is "payment innovation in Medicare," including the coming pilots and demos, the mechanics of state and federal partnering, what's working and what's not and, last but not least, what the future holds.

To prepare itself, the DMCB has developed a kinder and gentler version of the sometimes obnoxious "talking points memo." It'll probably print out a copy of this blog and refer to it during the proceedings.

1. Does Quality Always Mean Lower Costs? Underlying much of D.C.'s interest in "innovation" is the assumption that clinical and organizational quality and efficiency inevitably lead to reduced claims expense. Unfortunately, while the notions certainly make intuitive sense, proof in many corners of the healthcare system has remained remarkably elusive. That's because a) measuring savings is a difficult exercise in measuring what doesn't happen in a "statistically noisy" environment of rising costs and b) any savings that are achieved may be exceeded by the direct, indirect and uncategorized costs of delivering the intervention in the first place. Reconciling this may be out of reach of even the Center for Medicare and Medicaid Innovation.

2. Can You Count on the Feds? Medicare has had more than its fair share of fickle behavior when it comes to partnering. Not only have the physicians been whipsawed, but witness what happened to the insurance community with Medicare+Choice in '93 and Medicare Advantage in 2010 That makes two constituencies that have been burned by the Feds. While these may be exceptions, consider the details Medicare's participation in the multi-payor medical home pilot. This may have implications for the prognosis of federal, state and commercial payor partnerships.

3. Is the Road to Being Covered by Medicare Lined with Demos? Many of the high visibility innovations out there, like the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) remain largely unproven outside of government sponsored insurance settings or integrated delivery systems. That's why the Affordable Care Act relegated them to pilots and demonstrations in the first place. While the past performance is no guarantee of future disappointment, Medicare's ability to execute on demos in general have not fared well. In fact, the experience of the disease management industry's star-crossed Medicare Health Support should give pause to the PCMH's and ACO's fans. That may be doubly true since, as pointed out here by one of the DMCB's fellow speakers, there is widespread bipartisan consensus that CMS is generally underfunded, which could hamper CMS' ability to manage the countless details of actually running a multi-site demo.

4. What Do Physicians in the Trenches Think? It is hard to underestimate mainstream physicians' disappointment over the Sustainable Growth Rate's (SGR's) impact on the Medicare fee schedule and the inaction on meaningful tort reform. The DMCB isn't fooled by organized medicine's political support for health reform, which has only obscured the distrust and cynicism in many grassroots doctor's offices. By the way, physicians have always been suspicious of their local hospitals also, so it remains to be seen how much they'll cooperate with the creation of ACOs. Accordingly, the DMCB rates physician discontent as the biggest threat to the future of Medicare's efforts at innovation.

There are two big suggestions that help address all of these challenges. The DMCB didn't think of them first, but that's not to stop it from bringing them up at the July 20 Summit. Those suggestions, my co-speakers' reactions and what the audience has to say will be discussed in greater detail in the next posting.

The Latest Issue of the Population Health Management Journal

It's that time again! The Disease Management Care Blog spent 6 of its last 24 hours on the Pennsylvania Turnpike. That's nothing, however, compared to the many hours of hard work and ongoing commitments facing many DMCB readers. They can't just stop what they're doing and read those all those journals piling up on their desk corners. Good thing for them that the DMCB has a spouse and was able to ask her to take the wheel while it curled up with the latest issue of the Population Health Management Journal. After about a hundred miles, the DMCB emerged with this useful, efficient summary for your efficient perusing pleasure.

Michael Hopmeier, Jean Pape, David Paulison, Richard Carmona, Tim Davis, Kobi Peleg, Gili Shenhar, Coleen Conway-Welch, Sten Vermund, Janet Nicotera and Arthur Kellermann: Reflections on the Initial Multinational Response to the Earthquake in Haiti.

Put a bunch of disaster relief experts in a room and ask them how it went in Haiti in the days and weeks following the horrific quake and you'll learn about what went well and not so well. There could have been better anticipation of needs, better coordination, better use of bilingual expatriates, better security and a better transition plan toward sustainability. This is must reading for anyone interested in disaster preparedness, but has little use for workers in chronic illness, wellness and prevention. The DMCB wonders, however, if this article is ushering in the concept of a traditional part of public health laced with "population-based" approaches to disaster care?

Paul Terry, Jinnet Fowles, Lisa Harvey: Employee Engagement Factors that Affect Enrollment Compared with Retention in Two Coaching Programs - The ACTIVATE Study.

If you gave a wellness program and no one showed up, could you still call it a success? In this study, the authors describe the patent characteristics with their success. Stay Well Health Management offered two types of programs (“traditional health” and “activated health”) for two companies (one in health care and the other an airline) with a total target population of 1628 persons. In order to be counted as enrolled, persons had to complete a health risk assessment and go through clinical screening. 39% were enrolled, and of those enrolled, 64% were determined to be “high risk.” 61% of those enrolled stayed in the program for one year. Persons employed in health care, tobacco users and with statistically significantly higher levels of “health activation” were less likely to enroll, while those working in health care, older and white were less likely to stay enrolled. There is a flow chart that shows how over 1600 persons at the start percolated down to groups of 20 to 92 persons being retained in each arm of the study. The search for ways to boost enrollment continues. This is a good reference to show grumpy bosses and customers who insist you could have done better.

David Smith, Eric Johnson, Micah Thorp, Kathy Crispell, Xiuhai Yang, Amanda Petrik: Integrating Clinical Trial Findings into Practice Through Risk Stratification: The Case of Heart Failure Management.

After reading many publications on the topic, the Disease Management Care Blog suspects chronic heart failure is the condition most amenable to disease management. However, does that mean that all patients with heart failure should be targeted for disease management? This article tapped into that literature to develop a credible, soup-to-nuts review of what purchasers and payers could expect if they launched a disease management program in a community setting – like Kaiser’s in the northwest United States. In contrast to the 45% one-year admission rate reported in academic settings, Kaiser’s overall rate was lower at only 18%. Those at highest risk, based on a low ejection fraction (that they were able to use in their data thanks to the electronic record, had an admission rate of 33%. Assuming care management nurses cost around $25 per hour with 16 hours of nurse-time per patient, they determined the cost per patient was around $700. Based on the various cut-offs used in their predictive modeling with other reasonable assumptions on cost, utilization and effectiveness, the authors found that targeting disease management at the patients in the top 20% of risk of hospitalization had savings in excess of cost. Broadening care management to include persons at lower risk resulted in loss of a return on investment. The DMCB has run into this before and the logic has implications for insurance programs. It may be that access to special services should be based not only on the presence of a qualifying condition, but on the severity of the condition.

Jeff Beich, Dennis Scanlon ad Patti Boyce: A Community-Level Effort to Motivate Physician Participation in the National Committee for Quality Assurance Diabetes Physician Recognition Program.

This reports describes what happened when a several northern New York managed care plans (one of which was Medicaid) created a registry, used a tiered pay-for-participation program and supplied supportive consultation services to increase physician participation in the NCQA Diabetes Physician Recognition Program (DPRP). Of 79 physicians in 8 practices, 37 (47%) achieved recognition, with “considerable variation” among the DPRP measures. Physicians liked it when the Plans pooled their results. The docs were also genuinely interested in improving quality, relying on recognized metrics and, of course, the getting the additional payments. DPRP turned out to be more time consuming than anticipated and common reasons for not doing well in DPRP measures were getting the documentation done, getting the ophthalmologists to perform/code the all-important eye exam and having less control over the patient-dependent/controlled measures. Practice size and the presence of an electronic record did not appear to be associated with success, while greater physician autonomy was associated with less success. Problems with the registry included incorrect physician-patient attributions, delayed data entry and gaps in data by insurance type.

Albert Crawford, Christine Cote, Joseph Couto, Mehmet Daskiran, Candace Gunnarsson, Kara Haas, Sara Haas, Somesh Nigam, Rob Schuette and Joseph Yaskin: Comparison of the CE Centricity Electronic Medical Record Database and National Ambulatory Medical Care Survey Findings on the prevalence of Major Conditions in the United States

followed by another article with the same authors except JY

Prevalence of Obesity, Type II Diabetes Mellitus, Hyperlipidemia and Hypertension in the United States: Finding from the GE Centricity Electronic Medical Record Database

This issue of PHM was closed out with two back-to-back articles about a large commercial EMR. While the first article compared the population-based health status data of a large commercial electronic health record (in used by 20,000 providers taking care of 30 million persons) to the mother of all population-based measurement programs, the National Ambulatory Medical Care Survey (NAMCS), (younger persons of female gender with a higher burden of chronic illness seem to be accessing care than would be indicated by NAMCS), it raises a more important point: will the spread of electronic health records ultimately be the window that we utilize to assess our nation’s health status and use of health care services?

The companion article follows demonstrates the use of the electronic record data to describe the associations between BMI, age, gender, race, diabetes mellitus, hypertension and hyperlipidemia. None of the associations seemed particularly novel. Beware, though, says the DMCB: in order to extract these data, the researchers used methodologies that seemed quite specific to this particular electronic record. The DMCB looks forward to the day when health care providers can simply double click on a desktop icon and be able to access these kinds of summary statistics.

Diabetes Disease Management Saves Money in a Medicare Advantage Plan

In a prior post, the Disease Management Care Blog was set astir by a scientific meeting abstract showing that disease management saved money. Meeting abstracts typically make their way to print, and the DMCB is pleased to report that's what happened here. Authored by James Rosenzweig, Michael Taitel, Gordon Norman, Tim Moore, Wendy Turenne and Pei Tang, the manuscript is assertively titled "Diabetes Disease Management in Medicare Advantage Reduces Hospitalizations and Cost." It's available on-line at The American Journal of Managed Care.

The DMCB donned it scrutiny spectacles to see if its initial zeal was warranted. It was.

The setting for the study was Medicare Advantage (MA) "in one region of a large national health plan." To be eligible for disease management, the MA enrollees had to meet four criteria between May of 2005 and April 2006: 1) have insurance claims for diabetes and 2) have insurance claims for coronary artery disease, and 3) have an urgent care or emergency department or hospital visit for a diabetes related condition and 4) not have another highly significant condition like HIV, be in hospice or be on kidney dialysis.

526 persons met criteria and "were selected by the plan to be considered for the study." They were then "unequally randomized" (so that a majority could be placed in disease management). 462 were offered and 356 consented to be in disease management (106 didn't), while 64 persons were assigned to the control group. The average age in both groups was around 74 years, about 43% were female and the groups didn't significantly differ in baseline measures of health care costs.

The disease management was a standard mix of a baseline telephonic clinical assessments, nurse phone calls every 2-4 weeks, reminders, mailed educational materials/newsletters, home biometric monitoring and routine/as-needed-urgent physician reports. Based on some of the authors' affiliations, it looks like the company responsible for delivery of the disease management intervention was Alere, which, in turn, used patient education materials from the Joslin Diabetes Center.

In addition to being prospective and randomized, this was also an intention to treat study with an analysis that included utilization data from the 106 patients assigned to disease management but didn't give consent to participate. Compared to the baseline year (May '05 to April '06), the costs of the group assigned to disease management declined by $984 per member per year (PMPY), while in the control group's costs increased by $4547 PMPY. The difference was statistically significant. The savings were accompanied by reductions in diabetes as well as all-cause admissions and emergency room visits. While comparison to controls was not possible for the clinical measures, there was an across-the-board and statistically significant pre-post improvement for the disease management group in foot exams, A1c testing, LDL testing, microalbumin tests, retinal exams, use of ACE/ARBs and use of aspirin.

The DMCB thinks this is a compelling study. The methodology is solid, involving randomization in a prospective study of two parallel groups that were otherwise similar using an intention to treat analysis. It's hard to argue with it's conclusion that traditional disease management saved money. Given the extent of the reduction in costs, it's likely that the savings exceeded the costs of the program and/or the fees that were charged to the insurer. Kudos to Joslin, Alere and the unnamed MA plan for going the extra step and moving these data into the public domain.

While "greedy insurers" and their allegedly overpaid MA plans are a favorite piñata for the Obama Administration, it appears that doing the right thing is possible. As discussed in this CBO report, many MA plans offer disease management programs, but their impact was not known. Thanks to this report, we know more.

As the DMCB has noted before, "disease management" has evolved since it's earliest days. Modern "remote" or telephonic interventions are making more effective use of behavior change theory and the industry is far more sophisticated in targeting patients with the greatest likelihood of benefit. While that's not explicitly spelled out by the authors, the DMCB thinks both factors played a big role in this study's success.

The DMCB will close with this link to Don Berwick's first public appearance as CMS Administrator (it starts at the 9 minute mark and ends about 6 minutes later). The DMCB has seen this dismal phenomenon before: energetic, edgy, bright and sometimes confrontational physicians being elevated to positions of organizational authority, such as Chief Resident, Section Chief, Chairman or Vice President and then sadly becoming a mouthpiece for The Man. The DMCB forgives Don this time for parroting his bosses' unquestioning faith in electronic health records as a panacea for all that ails healthcare. With time, however, it hopes we see the familiar, skeptical and pushy Don that believes in outcomes, not vacuous political nostrums. He can start by looking at this AMJC paper by Rosenzweig et al and re-examine the role of the newer, smarter and more sophisticated versions of disease management as one option to increase quality and lower costs among the Medicare's enrollees.

Catheter Related Central Line Infections: The Numbers (and the Truth) Behind the Story

A "preventable" "plague" that needlessly results in "30,000" deaths because the health system refuses to implement a "stunningly basic" set of preventive measures. According to impressive research, implementing them could reduce their occurrence by "two thirds."

The Disease Management Care Blog was also alarmed when it read this Washington Post article. so it decided to look into things.

The topic is "catheter related bloodstream infections." While most intravenous fluids are delivered via an arm vein, sometimes the volume or the make-up of the fluid requires a larger diameter tube (or "catheter") to be tunneled or placed in a larger diameter vein. The good news is that many times, these veins are relatively close to the surface of the neck and shoulders, a fact that hasn't been lost on the producer's of HBO's True Blood. The bad news is that large plastic catheters are also large deep foreign bodies that can enable skin bacteria to track/grow along them and easily spill into the blood stream.

The unit of measurement for these infections is based on the counterintuitive concept of "catheter days." This combines the number of large vein catheters in use with the number of days they are being used. So, if the DMCB needed a large vein catheter for ten days, that would represent "ten catheter days." If the 4th floor of Our Mother of Holy Deficit Hospital had three patients that each needed a large vein catheter, say .... one for four days, another for five days and another for six days, that would add up to 15 (4 plus 5 plus 6) "catheter days." If one of those patients develops a blood stream infection involving bacteria found on the skin, that works out to "one infection" per "15 catheter days." For ease of discussion, this can be normalized (like percents) to "100 catheter days" - so the infection rate is "6.6 per 100 catheter days." If it were "per thousand" catheter days, it'd be 66. More on this below.

Congratulations, because you can now read this free access article in the New England Journal that showed how well these infections could be reduced. If you don't want to, that's OK because your DMCB blog can expedite things by getting right to the bottom line:

When, in October of 2003, providers in 108 Michigan intensive care units agreed to: 1) hand washing prior to sticking in the catheter, 2) using "barrier precautions" (gloves, gowns and drapes) when placing it, 3) using chlorhexidine to clean the puncture skin site ahead of time, 4) avoiding use of the large veins in the groin and 5) removing the catheter as soon as it's not needed, infection rates, compared to baseline, dropped:

The overall median* rate of catheter-related bloodstream infection decreased from 2.7 (mean,7.7) infections per 1000 catheter-days at baseline to 0 (mean, 2.3) at 0 to 3 months after implementation of the study intervention and was sustained at 0 (mean, 1.4) during 18 months of follow-up. A significant decrease was observed in both teaching and nonteaching hospitals and in small hospitals (less than 200) (Bolding DMCB)

Note that the unit of measurement used was infections per thousand catheter days. That's necessary because the total number of infections at the start was relatively small: at baseline, the mean* (or "average") number of infections was 7.7 per thousand catheter days. In other words, if a hundred patients were treated with these catheters for ten days, only about 8 would get an infection. The other 92 would do fine.

An Unwieldy Unruly Hospital System?

Check out that many of the participating study hospitals had less than 200 beds. Go to this American Hospital Association web site, and you'll see that the average number of beds in U.S. community hospitals is 161. Assuming that, at any time, 20% of the patients filling these beds have large venous catheters (a huge overestimation but for illustration purposes) 32 persons over the course of the year (365 days...) would comprise 11,774 catheter days. The physicians and administrators would have to deal, based on these data, with about 90 infections. That's between one to two a week. It's probably far less.

While any infection is one too many, the DMCB thinks that rate, compared to other hospital safety concerns (they can be seen here) is easy for the average hospital administrator or physician to miss. After all, most patients coming and going from the average hospital with these catheters do just fine. The DMCB doesn't think it's money, laziness or a failure: this is a problem that defies easy detection at the individual hospital and patient level.

And that's why its possible for so many hospitals with far less catheter days to report "no" infections. They're rare to begin with.

Perfect Patient Safety Is In Reach?

Check out that the rate of infections declined from 7.7 to 2.8 (at 3 months) to 1.4 (18 months) per thousand catheter days. That's not zero: infections still happened. Using the 100 patients for 10 days analogy above, there'd still be 1-2 patients developing an infection and, instead of 92 doing fine, 98 would do so. That's better, but not perfect.

It also portrays the pernicious use of "relative" risk reduction statistics. If a drug reduced death rates from 50 per 100 cases to 25 per hundred cases, that would be a "50%" reduction. However, decreasing a death rate from 2 in 10,000 persons to 1 in 10,000 persons would also represent a 50% reduction. The "two thirds"reported in the article above is technically correct but inflates the appearance of the benefit.

Role for Government

Finally, in case readers perceive that the eternally skeptical DMCB believes that Washington DC can't do anything right, it says the government did it right this time. The Federally funded Michigan ICU study pooled the data of over a hundred hospitals because that's what it took to see if the five preventive measures described above could reduce the rate of something that happens relatively rarely at an individual patient/hospital basis. This is an instance where the taxpayers got their money's worth. The DMCB uses the term "impressive" in the opening paragraph. That's the only part that is completely and transparently true.

*This article reported "median" infection rates because the distribution of infection rates was probably skewed and medians are better measures of central tendency. Mean or average is a more familiar concept, however, so the authors are to be commended for reporting both. You can read more about the distinction here.

Image from Wikipedia

A 109th Cavalcade of Risk Picnic and You're Invited!

Welcome to this 109th edition of the Cavalcade of Risk, proudly hosted by the Disease Management Care Blog. For the last three years, the DMCB has been writing about the intersection between clinical medicine, health insurance, health policy, research, public health and politics. It all about the emerging science on the care of populations, with advances in insurance designs, disease management, health technology, wellness, prevention, the medical home and accountable care organizations. Thanks for stopping by and feel free to visit the DMCB again.

Given the summer season, the DMCB thinks hosting this Cavalcade is much like a big noisy backyard barbecue. Anyone can cook up a pair of steaks medium rare, but having the Risk Blogging Community visit the DMCB is like having the whole neighborhood over for huge combined multi-grill menu pot-luck dinner picnic. Think of it as a party where we can each learn from smart friends about the other aspects of the backyard culin-bloggery risk-arts. Everybody is bringing something, each of which is described in delicious detail below.

So, let's eat!

A list

What's a picnic, especially if the DMCB spouse is involved, without a detailed list to help organize the countless details like - getting the plates (with beer), the ice (plus some beer), mosquito repellent and, adds the DMCB, additional beer. If you agree with her, then check out this list of the top ten mistakes persons make when they thoughtlessly park your money in a bank, courtesy of the blog at the depositsaccount web site.

The Seasoning!

The Scope Crêpe Blog serves up a basic lesson in how humans process risk. Take the test and find out for yourself how the loss of $20 can be too salty for some. There's more on the implications for medical care here (Hat Tip to TinkerReady).

Slow basted ribs.....

Greg Mankiw's Blog ponders how insurance companies could deal with the advent of genetic testing that can identify persons with an unfavorable profile. Perhaps his dish of ribs is better moved to the back burner and put on very low heat for a long time. As this article from the New England Journal makes clear, we have a way to go before the sensitivity, specificity and reliability of these tests are ready for prime time. There's also the issue of the Genetic Information Non-Discrimination Act (or GINA), at least when it comes to health insurers.

Burgers? And now for something completely different....

Meat patties, check. Buns, check. Oh, but wait! With some creativity, this classic staple can take on some novel features. And so it is among students of risk, who can reshape ho-hum life insurance into "return of premium" term life insurance. The cashmoneylife blog explains.

Just not complete without dogs

The DMCB never quite understood the attraction of these cylinders of pressed meat byproducts, but it does know there's a spectrum of quality out there. The DMCB personally prefers Kosher hot dogs because the contents don't include filler and scraps. That same discerning taste can be applied to car insurance, which has been ranked by JD Power. You can go to the christianPF site and see if your car insurer is also a dog.

Yes, I said an entire turkey.

Did you know it's possible to put an entire bird on a grill? It's a complicated and involved affair that involves a lot of attention and lots of time with rotating, basting, collecting all that grease and keeping things from being burnt on the outside and raw in the middle. So it is with life insurance and estate planning, eh? Freemoneyfinance provides a lengthy option-filled recipe on the big bulky topic, with an emphasis on a surprising variety of trusts.

Everyone has a favorite....

...and so does the DMCB. It's happy to see that the topic of health insurance high risk pools are on the table. Louise of the Colorado Health Insurance Insider unveils how Colorado is using Federal money to cover persons that were previously uninsurable. The premium levels seem quite tasty.

More on that favorite...

Insuranceproviders has prepared a discussion on the topic of assigned risk auto insurance, which seems similar to high risk health insurance pools. This seems rather cut and dry, which makes the DMCB wonder a) why couldn't the States have done the same thing for health insurance years ago, and b) if it'll be so non-controversial years from now?

How about something tasty from overseas?

The ever vigilant DMCB spouse has kept it from bringing pickled herring when it's a guest at picnics. She understands hosting is different though, so the Brits from TaxReturnBlog neighbors could have brought blood sausage and we'd say thank you. Fortunately, they have something far more yummy: an adjustment in tax policy that has led to an increase in Her Majesty's citizens' "tax free allowance." That's so delicious sounding, the DMCB would like more of that.

Health foods?

Well if the entire neighborhood is coming over, there's bound to be someone insisting on something additive free, organic and vegetarian. If so, direct them to the naturalezine site, where persons can find out more about health insurance coverage of 'natural' remedies. Beware, though: the DMCB thinks health insurers are willing to cover this stuff not because the remedies included in the benefit actually do any good, but because these kinds of beneficiaries are low risk.

Let's Be Creative

There's no shortage of recipes for other crazy dishes involving all kinds unexpected ingredients like dandelions, marshmallows or turnips. If that's what you're hankering for, try a spoonful of I Could Make A Fortune over at the New York Personal Injury Blog. The DMCB sampled the haircuts/cut ears, yet somehow, the taste is very familiar.......

The Beverages

It's sure hot isn't it? Those cold sudsy beverages that were on the DMCB spouse's list sure are good. But they're enough to make one forgetful and cloud rational thought. A number of things could be going on, but it you're really worried, read about another stop on the endless road to find a reasonably accurate test for that dreaded dementing disease called "Alzheimer's", courtesy of Hank Stern over at the InsureBlog.

Salad anyone?

The variations of leafy greens, tomatoes, carrots, cukes, peppers and the like seem good for you, which mathematically cancels any bad calories in the other foods, right? Well, surfersam has a description of why annuities may be a worthwhile investment option that can neutralize the bad effects of negative interest from chasing returns in a moribund economy.

Getting the Fire Going

The Digerati Life Blog wanders over to a corner of investment diversification that involves buying FDIC insured certificates of deposits based in other single or basket combinations of currencies, like the South African rand or the Australian dollar or the Brazilian real. Good thing thing this particular currency isn't an option, since it'd be better used as paper kindling to light the charcoal.

The Gas Grill

The DMCB's spouse is eternally leery about the risks associated with her spouse's handling of propane cylinders. The threat of things going horribly wrong is likewise a factor in obstetrical physicians' overcautious and "cascading" use of tests and interventions that have led to, according to the healthcare economist blog, an epidemic of C-sections. Author Jason Shafrin, being the economist that he is, points out that physicians are also vulnerable to its financial incentives. The solution says he? "Midwives." Finally, the DMCB knows the answer to the question posed here. Any midwives at a DMCB BBQ are welcome to take over the grilling, so the physician DMCB can pursue other less risky and more remunerative activities, like having $100 per pop Botox party over by the keg.......

Propane Fired Deep Fryers?

The DMCB tried to get the spouse to agree to this last Thanksgiving. Given her noisy veto, it's highly unlikely that she'll let a bunch of men, whatever their safety record, deploy this within a hundred yards of a summer picnic. Julie Ferguson of the WorkersCompInsider Blog would probably agree, and you will too when you go beyond the story of the DeepWater Horizon and see what a fire disaster does to people's lives.

What About the Guests?

Sure, you can have the best food offerings, but what good is it if everyone leaves early? Nancy Germond of the All Business web site has an article minimizing the risk of not being able to retain talent. She has some excellent suggestions, but if it doesn't seem to be working, the DMCB suggests employers turn to a long honored BBQ methodology: free beer.

Politics Intrude

Let's face it: it's just unavoidable that some guests will want to talk politics. That could get heated if any of them are allowed to check out EarthPM's video link that contrasts what should have been learned about managing the past risk of offshore oil drilling to better deal with the current risk. Egads.

Picnic faux pas

The DMCB has its moments when, to the chagrin of the spouse, it says something impolitic ("Oh, are you pregnant?"), oafish ("Be careful sitting in that chair, you might break it!") or just plain dumb ("The dessert is ready! I can tell how much you were looking forward to that...."). Guests would be well served to be similarly en guard, especially when it comes to giving your social security number to anybody for any reason at any time. Getrichslowly shows why.

Ugh, who invited that person?!

The DMCB will close with this link to a post it co-authored with Vince Kuraitis, which examines the risks of inviting Medicare to a party. There's one in every neighborhood.

Thanks for stopping by everyone. See you at the next Cav!

Smart People Adding Too Much Value

The Disease Management Care Blog is happy to host Kit Gorton, MD. Kit is currently a healthcare consultant who is a former VP of Medical Management at HP Enterprise Services, served as President and Chief Medical Officer of APS Health Care and was Chief Medical Officer of Pennsylvania Medicaid. As someone who has developed and presided over a host of good ideas, this is a professional who knows of what he speaks.

In case you’re wondering why your excellent idea isn’t going anywhere, the good news is that you’re smart. Read on and find out about the bad news……

Why do so many good ideas get so little traction? As a guy whose job has often been to support innovative programs, I find myself thinking about this a great deal. The reasons why ideas languish are of course complex: too few resources, too many competing priorities, too little consensus, too much information out there. All are solid explanations for why smart people I’ve worked with accomplish less than everyone would expect.

I was reading Marshall Goldsmith’s book What Got You Here Won’t Get You There (Hyperion, New York, 2007) as I got geared up for my current career transition and I came across another possible explanation that I hadn’t entertained before. Goldsmith posits that smart people impede their organizations and their own careers through what he characterizes as the bad habit of adding too much value. He observes, “It is extremely difficult for successful people to listen to other people tell them something that they already know without communicating somehow that (a) ‘we already knew that’ and (b)’we know a better way.’” He points out that whatever incremental improvement that the smart person provides to an idea is often overshadowed by the loss of enthusiasm and commitment of the other people in the process.

Perhaps smart people’s ideas don’t get more traction because of the smart people’s behavior? In a knowledge economy, adding our two cents is how the idea guys make a contribution, right? Perhaps not. Goldsmith argues that the more powerful or influential we people become (or wish to become…), the more behavior factors into their success. His premise makes a lot of sense: that it is counter-productive to always try to improve on the ideas of others. After all, the obverse of “I’m smarter than you are” is obviously “You are dumber than me.” No one likes to be on the losing side of that conversation.

The typical approach of smart people to care management solution development and academic research is to design incremental improvements or disruptive changes and then demonstrate proof of concept in either a pilot program or through a research protocol. Adoption is then supposed to be driven by the innovators promoting their ideas through publications, seminars and, to a lesser extent, commercial marketing approaches. Their underlying assumption has been is that good ideas sell themselves. They think their job is to simply to build a better mouse-trap and then explain it to the rest of us.

Goldsmith’s perspective suggests to me that innovation processes that focus largely on coming up with and presenting the next best idea are likely to be ineffective in driving improvements in chronic care management, medical homes or wellness and lifestyle programs. Innovators may not have the interpersonal skills and communication behaviors necessary to promote adoption. By “over” delivering on value and underestimating the response of their colleagues around them, innovation can dissipate.

Clearly there is work to be done in translational research and in identifying control points in the diffusion of healthcare innovation. Still Goldsmith’s observations about human behavior raise the question of how much interpersonal relationships and individual communication may impact the success of transformational change. That is a topic I think is worthy of a great deal of silent reflection.

More On the Risk of Growing Physician Non-Participation in Medicare

Wow. The two Disease Management Care Blog posts on the 1) non-death of small physician owned practices and 2) the risk of a physician boycott of Medicare caused a flurry web traffic, comments and emails. Thanks to all for their feedback.

The most interesting of all is a reply from the author of the HealthBeat blog, Ms. Mahar. It's in the Comment reply section of the original post. Since it makes so many interesting points, the DMCB decided to give it the visibility it deserves by reposting it here. (The DMCB answers are italicized.)

++++++++++

Thank you for linking to HealthBeat, but I didn't write the post suggesting that fears of doctors boycotting Medicare are overblowm.

The post was written by my associate, Naomi Freundlich (She came up with the idea, wrote it without any help from me.)

I doubt Naomi would characterize herself as a "liberal pundit." Formerly the Science Editor at Business Week, she's an excellent journalist and her posts tend to be fact-based. (I also wouldn't call myself a pundit--to me this suggests someone on TV who comes up with clever one-liners. But I am happy to be labeled liberal/progressive.)

(The DMCB regrets the error and not giving Ms. Freundlich her due. The good news is that the word "pundit," is from the Hindu word "pandit," meaning "learned" and "scholar." In addition, thanks for the reminder that all of us in the public square have a responsibility to minimize using single word labels to characterize complicated opposing points of view.)

Finally, I do agree with Naomi. The facts suggests that docs aren't moving away from Medicare in large numbers.

For what it's worth, I have a relative in NYC on Medicare who has no trouble specialists, and not too much trouble finding a new primary care doc--though everyone is having a hard time finding primary care docs. This is not unique to Medicare patients.

And the numbers support Naomi's argument.

Of course, it could be "different this time" but those three words usually turn out to be wrong. And docs have been threatening to stop taking Medicare patients for years.

(Use of the word "could" means that we agree that there is a likelihood that there could be a physician exodus. Since it could happen, the point of the DMCB post is that Congress has a duty to the taxpayers and to Medicare's beneficiaries to define the risk, understand its potential magnitude, minimize it and measure the progress in minimizing it. That duty transcends the size of the risk since, even if it is quite small, the implications are huge. It's simply good fiduciary business practice to carefully assess it.

The DMCB will leave it to readers to ponder the track record of similar "no problem" anecdotes combined with expert opinion when it came to our government's ability to assess other low risk situations, like say, deep water oil drilling, government-backed mortgage guarantees or invading countries in the Middle East.)

More importantly, only quite young, very successful docs would actually be able to keep a practice going without Medicare patients. (Younger patients tend to prefer younger docs).

More than 43 million Americans are on Medicare. Medicare patients account for over 22 percent of U.S. health expenditures .

And of course older people go to more specialists. The average age for a cancer diagnosis is 67, which means it would be particularly hard for oncologists, as well as cardiologist, orthopedic surgeon (who do all of those knee and hip implants) urologists or many other specialists to make it with Medicare customers.

Middle-aged people will come in for testing and check-ups, but seniors are much more likely to need the big-ticket invasive procedures that keep a practice afloat.

(The DMCB agrees that Medicare's monopsony will make physicians of all ages think twice before thumbing their nose at Uncle Sam. Yet, some replies to Ms. Freundlich's post as well as the ACP Advocate Blog suggest there are other forces at work including margin (if it's not there, economics 101 says shortages are inevitable) and a lesson from the Three Temptations: health care professionals live by more than government fees alone.)

Could docs begin turning down new Medicare patients? Sure--as long as the Medicare patients they have never die . .

Finally, it would be odd if, after all of these years, primary care docs dropped Medicare, just when they are about to get significantly better payment (up 10%) plus many opportunities for bonuses.

And by and large physicians are very enthusiastic about Berwick heading up Medicare.

All in all, a strange time for a cascade of physicians leaving Medicare.

(The DMCB agrees these are truly interesting times in health care policy which makes for great bloggery. It thinks we both agree on the need to assess the risk and to not let the risk upend the the Medicare program just when other parts of health reform beginning to kick in.

While the DMCB shares your admiration for Dr. Berwick, it's less sanguine about the cards he's been dealt: a recess appointment with the need to renew in 2011, a resurgent Republican Congress this fall and the remote possibility that anybody can tame Medicare's unwieldy bureaucracy. Will he make a tangible difference in the real world of patient care? We'll see.

As for the 10% increase, the DMCB recalls that only happened when long-made predictions of the collapse of primary care began to come true. Whether the better payment is enough to save primary care remains to be seen, which is the point. If Congress had credibly assessed the risk years ago and managed provider income expectations, it wouldn't have come up arguably a dollar late and a day short. They messed it up then and, by relying on MedPAC's shoddy methodology (focus groups? gimme a break), they run the risk of repeating the mistake with a potential for far greater problems for the beneficiaries and the President's still vulnerable agenda.)