Tuesday, August 31, 2010

Disease Management and the Patient Centered Medical Home: Moving the Entire Curve

With all the usual reservations, the Disease Management Care Blog basically buys into the prevailing Dartmouth Atlas belief that the United States has a problem with both over and underutilization of health care services. So do the Feds. For years, Washington has been pursuing areas of underutilization, for example, with programs to reduce disparities and support critical access hospitals. And thanks to the insights of Dartmouth Atlas, overutilization is now being tackled with programs that, for example, bundle payments and deny coverage of unnecessary services.

Both approaches, however, can be criticized because they're all about "chasing the tails." Whenever any performance data are arrayed from high to low, they'll generally follow a Gaussian Distribution. Most hospitals, physicians and other service providers generally cluster around an average, with both high and low outliers at either ends of the curve. In thinking about this, the actions of the Federal government described above are all about attacking the extremes of the curve, i.e., the outliers.

All well and good, says the DMCB, but it prefers care approaches that address the entire curve, since that approach benefits everyone. Low end critical access programs and high end bundled payments aren't really going to do much for persons with satisfactory access to hospitals with middlin' levels of utilization. The patients in the middle deserve better.

Which is one of the reasons why the DMCB likes population-based care and disease management. When credentialled non-physicians start coaching patients, the entire curve can shift in the right direction and the outliers move toward the middle. The DMCB hasn't seen much published on this specific topic, but when it conducted an in-house analysis on the impact of disease management some time ago, that's precisely what it found.

How could this work? In a diabetes population, persons on the "low end" who haven't had an appointment with a provider would be prompted to do so and directed to the nearest clinic with access to care. Persons on the "high end" who are on multiple medications and who are seeing multiple providers could be directed to a primary care provider. In the meantime, patients and providers in the middle would be prompted to foll0w cost-effective and high quality clinical guidelines.

Problem solved.

By the way, the DMCB thinks this is an under recognized benefit of the Patient Centered Medical Home (PCMH).

If any readers are aware of any peer review or in house studies that examine this phenomenon, please share.

The Non-Linearity of Risk and Disease Burden: A Role for Disease Management

The Disease Management Care Blog has always been taken by the non-linear relationship between disease burden and risk. For a telling example of just how curvy this can be, check out this graph from JAMA. It shows the relationship between blood pressure and the risk of a cardiovascular event (such as heart attack). While there are two risk factors at play (24-hour blood pressure and the ratio of nighttime to daytime measurements), note how risk rapidly curves upward at the higher measures. Decreasing a blood pressure from 196 to 165 carries greater risk reduction than decreasing it from 165 to 134.

In day-to-day practice, physicians intuitively understand this when they navigate both the high and low ends of the risk curve. When a patient appears with a blood pressure close to 200, they understand it's a potential emergency. When a patient shows up with a pressure just over the guideline target of 140 systolic, they know the individual risk is quite small. Compared to many other issues typically addressed in an average office visit, the DMCB knows physicians can be forgiven for letting modest high blood pressure wait until later. It's not black (out of control) and white (in control) but decidedly grey.

Of course, that's unacceptable in the linear utopia inhabited by quality assurance weenies. Unable to discern the variable value of blood pressure control, these authorities regard all elevated pressures as "equally," bad and bluntly dichotomize them. Any pressure greater than 140 is "bad" while anything lower than 140 is "good."

Which brings up several issues:

1) The physicians' lament about the short comings of commonly used approaches (scroll two thirds of the way down) to assess quality of care may have an element of truth about it.

2) In the "mainframe" one-size-fits-all world of D.C. dominated healthcare, it's difficult to assess the value of various degrees of blood pressure control at the individual patient level.

There is one solution to the physicians' lament. Those patients with a blood pressure just over 140 may be amenable to care management that uses standing orders carried out by non-physicians. By assigning those patients to disease management, physicians will be better able to care for the patients at greatest risk that really need their attention.

Sunday, August 29, 2010

Taglines for the Patient Centered Medical Home

The Patient Centered Medical Home has achieved another stepping stone in its journey to mainstream respectability: it was featured on National Public Radio's All Things Considered. With that remarkable achievement, it's just a matter of time until this darling of health reform is into primary care thicker than meaningful on use. Knowing that the PCMH will also need to marketed to a grumpy public, the Disease Management Care Blog is pleased to help out by offering these taglines.

Your [insert name of chronic condition] is worse? Call our nurse!

Getting both you and your doctor home by 4 PM.

This ain't your grandfather's gatekeeping.

If your bones be groaning, give us a phone. If your entrails be failing, send us an email!


Turning your costs into our revenue.

Help us help you to help us help you to cut the government's costs.

Health insurers love us.... shouldn't you?

Our scheme is the team. Our cause is the costs.

Don't call it disease management.

Hey, it's primary care. We deserve it.

A cure for the common chronic care conundrum

Thursday, August 26, 2010

Here We Go Again and Again and Again

Is it a rigid orthodoxy? Being stuck in closed information loop? Spending too much time with overweening loyalists? Portraying any opposition as the Devil Incarnate so much that you actually believe it?

These are the questions the Disease Management Care Blog ponders when otherwise smart bureaucrats recycle the same nostrums over and over.

Writing on the Kaiser Health News website, HHS Secretary Sebelius lauded the new momentum behind electronic health records. Thanks to the leadership in Washington D.C. she says, a breakthrough on industry-wide consensus on meaningful use has been achieved. As a result, the Disease Management Care Blog will be able to complete an clinic intake in Topeka and the information will be available in Toledo. If it gets bonked on the head in San Francisco, its old CAT scans will be available in Sanibel. Thanks to fistfuls of HIT dollars for doctors, Medicare, Aetna, United and Wellpoint can assure that the DMCB will get the same high quality care as Pastor Bloedow. Courtesy of Health Affairs, you can vicariously share in all that cheerleading here.

In the meantime, Ashish Jha, Catherine DesRoches, Peter Kralovec and Maulik Joshi have this Health Affairs web-first article on the recent uptake of electronic records in U.S. hospitals. Using survey data from the American Hospital Association, they investigated the progress made since passage of the American Recovery and Reinvestment Act. They found that less than 3% of hospitals are using fully functional electronic records and that the proportion using a more limited or "basic" record was less than 10%. Smaller and rural hospitals were the most likely to not have any system in place. What's more, a large majority of the hospitals that had made investments in electronic records do not meet the Fed's newly developed "meaningful use" criteria.

And then there is this New England Journal of Medicine article by Howard Koh and HHS Secretary Sebelius on "Promoting Prevention through the Affordable Care Act." They argue that the legislation will remove cost as a barrier to evidence-based preventive care, promote wellness in the workplace, boost community involvement, promote vaccine use, reinvigorate health promotion throughout the health system and attack the twin scourges of tobacco abuse and obesity.

If that sounds too good to be true, then maybe you've been reading too much DMCB. But don't take its word for it, here is an independent reality check appearing in this week's JAMA. If you can't access the full article by Neda Laiteerapong and Elbert Huang that's OK. While it has some positive features, the bottom line is that the ACA not only doesn't address the inability of primary care providers to manage the coming surge in demand and ignores the looming sustainable growth rate formula-driven cut in Medicare Part B physician payments. It also skips over the inconvenient truth that the prevention (and, by the way, treatment) of many conditions, "most notably, obesity" isn't really all that effective, especially over the short term.

The DMCB doesn't believe the Administration is intentionally spinning the ACA in sympathetic forums like KHN and the Journal that cater to entities most likely to benefit from the Federal healthcare ATM. Instead, it figures the folks at HHS are being unwittingly caught up by a perfect storm of cognitive dissonance, political sociopathy and overconfidence. It's looking forward to the time when the political class moves on and talks seriously about the next steps. More on these in a future post.

Coda: The California Department of Insurance has finally put the final approval on Anthem's scaled back but still double-digit rate increases. Since Federal-style health reform does little to handle costs, look for more of these types of premium increases being dumbed down to "reasonable."

And speaking of the Fed's ability to handle costs... a centerpiece of reform, the federally supported high risk insurance pools, have kicked off. Interestingly, one started in New Jersey on August 2 and so far, a total of two people have signed up. NPR says the premium levels have led to enrollment nationwide being lower than expected. Hat tip to the InsureBlog.

Wednesday, August 25, 2010

The Rise of Social Media: Implications for Disease Management, Patient Centered Medical Homes, Health Insurers and Accountable Care Organizations

The ever perspicacious and self-promoting Disease Management Care Blog has penned an editorial appearing in the latest just-released issue of the peer-reviewed journal, Population Health Management. Blog reading DMCB readers may appreciate the topic: the emerging nexus between social media (like Facebook, blogging and Twitter) and care management.

Calculating that social media aficionados may find printed paper unsatisfying, the DMCB is pleased to offer this 160 character (why 160, you ask?) tweet-like summary:

Social media promises 2B important addition to voice/print-based outreach 4 pop.-based outreach. Key concepts: pt. loyalty, synergy, privacy

Tweeters can stop here and return to more important pursuits, say, seeing what's new with Fergie. The rest of you can read on.....

Here's a more complete yet compact summary about social media's implications for the disease/care management industry. The DMCB suggests it also applies to patient centered medical homes, accountable care organizations and health insurers:

The various forms of social media (SM) have already begun to disruptively intrude into how consumers interact with health care. Many of your current and future patient-client-customers prefer to use SM because of its convenience and personalization. While little is known about its impact on patient self-care behaviors, early studies indicate the potential is significant. Therefore, you cannot afford to ignore it. As you embark in SM, keep in mind that a) the ultimate return on investment will be a function patient loyalty (though it will help with recruitment stats), b) SM communication is additive/synergistic - not substitutive, c) its participatory nature means the role of credentialed trained experts will change, d) short n' frequent will replace detailed and quarterly, e) the area is ripe for research and f) the downsides include unclear HIPAA rules and dysfunctional as well as predatory user behaviors.

The Latest Cavalcade of Risk is Up!

The first year medical student at the notwithstandingblog has created a curricular mash of standard freshman course work in pathology, physiology, anatomy etc., mixed in with a decidedly unique look at the best recent postings of the "risk" related blogs - including this Disease Management Care Blog. The DMCB was assigned an histology theme, because of its close scrutiny of the recent medical-loss-ratio NAIC decision. There's much more schooling waiting for you there - enjoy!

Tuesday, August 24, 2010

Star Wars' Master Yoda Advises President Obama on Health Care Reform: Communicating, The Role of Experts & Top 100 Lists

The virtual Disease Management Care Blog has learned to navigate the duality that bridges particles and waves, channel dark matter and access the cosmic video game that governs humankind's Sim-like existence. It is in that polymension that the DMCB discovered that President Obama and Yoda have communicated.

This exchange was plucked from a bosonic mimetic string and is shared as a DMCB exclusive for your reading pleasure.....

Mr. Obama: Master, my poll numbers on health care reform are in the crapper. I've blamed the insurers and the conservatives again to try to generate better support, but it's not working. What is your advice?

Master Yoda: As wily Cato described has, using the Force is the product but the pitch not. To recognize the flaws in the Affordable Care Act and seek to correct them, you need, young knight!

Mr. Obama: But, Master, I don't have time for that. Midterm elections are a less than a parsec away. What do you think about giving some more speeches in a tour of the heartland, like the Great Communicator?

Master Yoda: The difference learn between communicating and oratory, you must. Yes, hmmm.

Mr. Obama: But President Reagan....

Master Yoda: Silence young one! Speak the name of the greatest Jedi Knight that ever lived, do not. A rare Gladwell Academy Outlier he became.... spent decades writing and giving speeches training his superb communication talent. Many thousand hours at Earth poultry dinner gatherings helped him his skills hone. Just a rookie novice you are. Yeesssssss.

Mr. Obama: Hey, let me remind you that you're just a mix of green latex and computer animation, while I'm President of the United States and Number 1 on this list of the 100 most powerful people in health care.

Master Yoda: Silly, are you. Other insider insurance execs, ivory tower policymakers, politicians and bureaucrats in a closed information loop on that list, see you, hmmm? A way to retread old news and generate web traffic, "Top 100" lists are. Little green droppings on them, I leave. Blah!

Mr. Obama: Hey, now you're sounding like the party of no that got us in this mess in the first place!

Master Yoda: Work on me, your tired rhetoric will not [whack with weenie cane here]. Advise to jettison your mistaken notions into deep space, you I do. Best find advisors who on that Top 100 list are not.

Mr. Obama: But my administration's policy making is being formulated by the brightest folks this country has to offer!

Master Yoda: Of great danger, over-reliance on experts is. Commune exclusively on Planet C-SPAN do they, pretending that Federal healthcare Jabba the Hut is not. Lack day-to-day understanding of patient care, they do! Publish in journals that are read by few. Instead, hologram message view you must from New York Times about the future of publishing, using the wisdom of crowds this is.

Mr. Obama: You are truly wise, Master Yoda. My last question is how I can get the First Lady to don Princess Leia garb.

Master Yoda: Ahhh, brazen young pilgrim. Eternally wise DMCB also frequently that asks. Thinks its spouse looks better than a new star drive when sport she twin buns of hair, says it. When the answer to that find, a true Force become, shall you!

Monday, August 23, 2010

Retail Pharmacists Doing Care Management Coaching? Doubtful.

Can retail pharmacists take the lead in care management-style patient coaching? To answer that, check out this New York Times article and this description of Asheville Project (more details here). Pharmacists receive extensive instruction in patient education and consumer surveys consistently show high levels of trust in community pharmacists. Pharmacists also have the advantage of "teachable moments" when consumers return to renew their prescriptions, especially if value-based insurance designs are incenting patients to pay attention. There are oodles of studies that show that, compared to usual care, pharmacists can increase health care quality and/or reduce costs (for example, here, here and here).

Full steam ahead, right?

Maybe not. The methodologically nudninky DMCB notes the Asheville data (here, here and here again) seem to be based on more than a fair share of suspect pre-post study designs and use approaches that aren't necessarily generalizable to all community/retail settings. The DMCB also worries that:
  • Next to physicians, pharmacists are among the most expensive health care professionals. Education can be done more cheaply by other highly trained, credentialed non physicians.

  • Despite the logic of using retail setting, setting up a separate window or a cubicle between the foot insole displays and the reading glasses tower isn't really conducive to patient engagement

  • While some retail pharmacists embrace patient education, most got into retail pharmacy because they, well.... like fill the pills n' bill retail pharmacy. Pharmacists in other settings with a greater emphasis on patient education/coaching -- such as hospital-based consulting services (which work quite well in the area of anticoagulation), disease management programs, the medical home or within pharmacy benefit management companies -- are there because their professional goals may be different.

It may be that the DMCB is wrong. It may be that retail pharmacies are retooling for a new wave of disruptive innovation, that there are generalizable and prospective randomized trials that have been overlooked and that, when the DMCB went to its community pharmacy window, joked about getting some educatin' and the pharmacists chuckled along, it misread things.

If so, it'd like to hear from some readers.

Sunday, August 22, 2010

Fix the ACA

Perplexed by the lingering voter skepticism over the Affordable Care Act (ACA), the White House apparently commissioned a series of "focus group" surveys on the health reform. While this is probably only one of many voter sentiment studies being undertaken by our hyper-wired political class, this time seems different because it was placed in the public domain by Politico and, to the delight of a conservative/libertarian opposition, it purports to show an Administration in mid-term disarray.

The Disease Management Care Blog has a slightly different spin. When it reads the survey summary, it sees an underlying fundamental assumption by the authors and their audience that the key constituencies from the 2008 Obama landslide haven't been adequately educated about the merits of ACA. What's needed, therefore, is a messaging/outreach/marketing/awareness-building campaign for Medicare beneficiaries, moms, Latinos and persons under age 40 years that....

1. credibly showcases the parts of the ACA with greatest appeal (more healthcare providers, tax credits as well as fixes of pre-existing conditions and lifetime caps)....

2. subtly leverages populism (tax the rich)....

3. appeals to a patriotic sense of shared responsibility (i.e., the mandate)

4. uses real world anecdotes and "transition or bridge language"....

5. in a calm and rational tone, recognizes that no law, including the ACA, is perfect.

Educated?

The DMCB has seen that hollow canard fall flat on its face countless times among its professional colleagues who, when confronted by the so-called solutions concocted by an all-knowing administrator-policymaker-political elite (such as RVUs, capitation, pay for performance, electronic records and the sustainable growth rate, to name a few) didn't suffer from a knowledge deficit. They were perfectly aware of the details. The "problem" was that they didn't believe in them.

And what do you know: this phenomenon is not limited to doctors.

Such are the optics of any expert elite who are unable to discern the thin line between being educated and being convinced. While the sheer complexity of health reform makes it hard to grasp, much of the opposition to the ACA is not the result of ignorant assumptions but fiscal, philosophical, economic and political rationales. Therefore, a marketing campaign is unequal to the voter discontent, the coming challenge of slimmer (or absent) Congressional majorities, fighting a constant rear-guard action over additional enabling legislation/regulatory language and "repeal the law" grandstanding. To even consider this kind of political gimmickry calls to mind a passage from the Fat Lady's favorite bedside reading:

"You will be ever hearing but never understanding; you will be ever seeing but never perceiving. For this people's heart has become calloused; they hardly hear with their ears, and they have closed their eyes."

The DMCB is not political consultant that runs focus groups, but it has some advice for the Administration. Open your eyes, your ears and your brains by looking inward and asking:

1. have you faced up to those parts of the ACA with greatest problems (the complexity, expansion of government, inability to control underlying cost inflation and deficit spending,)....

2. should you tack toward the political middle (a good start would be some aggressive cost cutting....)

3. if its time to accommodate your opponents

4. reduce the overlawyered and hyperanalytical approach to problem solving and

5. recognize that the ACA is far from perfect, that there is a commitment to fixing it and that no option is off the table.

In other words, co-opt 'em. "They" say repeal the ACA. The DMCB says the response should be to "fix it."

Fix the ACA.

Image from Wikipedia

Friday, August 20, 2010

Details details...... the Latest Health Wonk Review Is Up

The Disease Management Care Blog fancies itself as a "big picture" kinda guy that unwillingly gets pulled down into the weeds. Yet, that's where the countless details are - the details that make or break the success of any venture. Joe Paduda of Managed Care Matters offers up plenty of weeds for your reading pleasure in this review of the best posts from the health policy blogs titled "Implementing Health Reform." Read it and get your own sense of where health reform is succeeding or failing - and how to make it better.

Thursday, August 19, 2010

The NAIC "Blank" Proposal, the Medical Loss Ratio and Disease Management: An Explanation

The Disease Management Care Blog has driven by those unfortunate people. The car stopped by the side of the road. Hood open. The man? Staring at the engine maze of boxes, belts, wires, bolts and metal, looking for that disconnected or unset something to reconnect or reset. The woman, of course, is on the cell phone. She is intelligently calling AAA, which she joined months ago against her partner's advice. She is arranging for roadside assistance.

Such was was the initial reaction of the male DMCB when it opened the hood and stared at the just-released National Association of Insurance Commissioners' (NAIC) "Blanks Proposal." Readers may recall that this is the NAIC's long awaited response to the Affordable Care Act's requirement that health insurers use 80% to 85% of their premium dollars toward patient care. Defining just what comprised "patient care" was left up to the NAIC.

In typical actuarial fashion, the released "Blank" is a maze of obscure boxes terms and calculations that defies easy understanding. Looking down at it, it made the DMCB want a reset by hitting an "Easy" button. However, since the DMCB has changed oil, swapped air filters, replaced brake shoes, repaired mufflers, topped brake fluids, drained radiators and rotated tires, it figured it would dive right in anyway. That didn't work. So, it took an important cue from the spouse. It got on the cell phone and called some folks for some much appreciated help.

Here's what it found.

As the DMCB understands it, the "Blank" is the proposed form that would need to be completed by health insurers when they submit information about their expenses to their respective State Departments of Insurance. Close examination reveals that on line "7" on page 2, the preliminary MLR includes "total incurred claims" plus "total of defined expenses incurred for improving health care quality." The DMCB then headed over to page 16 of the document and found that the NAIC would like to define "improving health care quality" as....

"... plan activities that are designed to improve health care quality and increase the likelihood of desired health outcomes in ways that are capable of being objectively measured and of producing verifiable results and achievements.... [They] should be grounded in evidence-based medicine, widely accepted best clinical practice, or criteria issued by recognized professional medical societies, accreditation bodies, government agencies or other nationally recognized health care quality organizations. They should not be designed primarily to control or contain cost, although they may have cost reducing or cost neutral benefits as long as the primary focus is to improve quality..... [They] can include case management, care coordination and chronic disease management .... such as providing coaching or other support to encourage compliance with evidence-based medicine" (italics DMCB).

This is very good news for the disease/care management industry. This will clearly preserve the ability of insurers to buy their services. No wonder why the DMAA is pleased with the outcome. If care management activities had been excluded from the MLR (and therefore counted as an administrative expense), the most likely outcome would have been reductions in these programs.

And check out the uncharacteristically measured response of HHS Secretary Sebelius in her HealthCare.gov blog post. No longer able to cling to her Democratic allies' canards about MLR gaming with faux-quality expenses, she thanks the NAIC and then changes the subject by recycling the anti-insurer grousing about "marketing, medical underwriting, executive salaries, and bonuses that don’t improve health outcomes and drive up costs." Right.

The DMCB isn't impressed with the health insurers' trade association "AHIP" response to the Blank either. The DMCB agrees with one observer that AHIP has little political reason to broadcast any agreement with NAIC; to do so would only prompt additional scrutiny over the 90% that AHIP successfully got out of this process.

This is not the end, since this seems to be a proposal and additional language will need to be written. The DMCB will continue to stare under the hood. And if anyone wants to call (or email) with additional roadside assistance and insights about this, please do not hesitate to do so.

more soup


Starring (in order of appearance): olive oil, onions, garlic, garam masala, chipotle powder, water, vegetable stock, brown lentils, tomatoes, yu choy sum (Chinese greens), lemon juice, ground coriander. Served with a dollop of yogurt.

Loosely based on a Lebanese lentil soup recipe from the Toronto Star. I was out of cumin so substituted the garam masala. Ditto on the chipotle powder instead of cayenne. Soup is spicy but very, very good (if I do say so myself).

Wednesday, August 18, 2010

More On Those "Right" Patients for Disease Management In the "Middle"

Thanks to everyone who requested a copy of the Disease Management Care Blog PowerPoint slide describing those "right" patients "in the middle." As regular readers may recall, the DMCB argued that care management may be best reserved for the relatively lower number of health insurance enrollees that fall within a more moderate risk profile.

The DMCB also got some great feedback. The most insightful was from an email by Bob Stone of Healthways, which is (mostly) copied below:

I would be comfortable with that conclusion if it was caveated to reflect the growing understanding that they’re the group to target for short-term improvement and return. The evidence is also abundantly clear, however, that next year’s middle and high risk patients are most likely to come from the lower risk profile groups. Most studies – including the ones you cite – don’t run long enough to capture that dynamic.

Exactly, says the DMCB. The "logic of the middle" only works in economic environments where care/disease management contracts with their performance guarantees extend from one fiscal year to another. As one seasoned nurse executive taught the DMCB, the irony of that approach is that after three years or so, it's typical for the "return on investment" from these programs to trail off. Risk can be managed within a year, but it seems insurance beneficiaries have a habit of living year after year after year....

Bob Stone takes the irony one step further. He points out that the disease management programs that use this "middle" business model are ultimately the product of a myopic "sickness" care system that fails to deliver what patients really want and what society really needs: better wellness and prevention programs that function many years further upstream. Until America achieves that, we're going to spend precious treasure figuring out how to spend less of it.

Good point.

Tuesday, August 17, 2010

Community Health Workers and the Promotion of New Social Norms

Years ago, when a patient showed up in its clinic the morning after a bad ankle injury, the Disease Management Care Blog asked him why he didn't just go to the emergency room. The patient recalled that, about a year before, he had discussed his rising insurance premiums with the DMCB. High ER usage rates were mentioned as one cause. So, one year later, he decided to wait by staying at home with some ice, elevation and aspirin.

Which is why the DMCB agrees with the title of this Health Affairs article titled "Community Health Workers: Part Of The Solution." While authors Lee Rosenthal, Nell Brownstein, Carl Rush, Gail Hirsch, Anne Willaert, Jacqueline Scott, Lisa Holderby and Durrell Fox only hint at the reason why community health workers (CHWs) have much to offer, the DMCB draws on the lessons of behavioral economics to speculate on why.

CHWs can be defined as lay members of a community who provide basic health and medical care to their community. They've been discussed in the medical literature for more than 30 years. Outcomes may be varied but there is impressive evidence from randomized clinical trials (for example, here and here) that CHWs can improve quality and reduce the need for expensive health care services. In the Health Affairs article, Dr. Rosenthal et al argue that both Massachusetts and Minnesota have had a good experience with CHWs, who have helped sign patients up for insurance and increased access to primary care-based education. In fact, Minnesota has established training programs and enabled insurance coverage for CHW services.

However, is that all there is? The DMCB isn't too sure that increasing access to insurance necessarily leads to better and cheaper health care. What's more, the links between patient education, primary care and better and health care savings can be indirect. Ultimately, however, the DMCB buys the notion that CHWs can increase quality and reduce costs, but suspects there's another ingredient at play.

Which brings us back to the ankle patient described above, who adopted a new social norm about avoiding the emergency room, laced with the added convenience of staying home. While the DMCB is no behavioral economist, the ankle patient is a lesson on how people can quickly "tune in" on trying to do the right thing, especially if it's easy. If that sounds like a stretch, then so is the Obama Administration bet that a weakly enforced health insurance mandate will succeed, thanks to it also becoming a social norm.

While the literature shows that CHWs can sign patients up for insurance and behaviorally engage patients in self care, the DMCB also wonders if they also promote new social role models. The DMCB suspects that they are also very effective in developing new attitudes about accessing the health care system in different and ultimately more effective ways. That may also be true for professional and credentialed nurse care managers, but since CHWs have the added advantage of being able to leverage culturally appropriate and trustful relationships, it's possible that they're far more effective in promoting new social norms.

As health reform continues to unfold, CHWs are likely to assume greater roles in the delivery of care services. Hopefully, future research will unravel and help us better understand the interplay between increasing access to insurance, broadening to primary care services, increasing self care and changing attitudes about how and when to access health care services.

Monday, August 16, 2010

"Repeal Obamacare" is Irresponsible. There are Better Ways to Address the Shortcomings of the Affordable Care Act

The Disease Management Care Blog has decided on two things for the 78 days between now and the midterm elections:

1. It's not going to drink bottled water. The claim of better taste is questionable and the waste of energy and plastic is atrocious. If the DMCB was worried about the safety of its public water supply (and it's not - water is safer than ever), it would petition local government to do something. It figures that if it's going to be environmentally responsible, the DMCB would be better off recycling these kinds of containers.

2. It's not going to vote for any candidate spouting silly rhetoric over the "repeal of Obamacare." The odds of prevailing against a Presidential veto are likewise questionable and the waste of political energy would also be atrocious. The only merit to a repeal debate is that every minute spent on that would be a minute less spent on crafting more ill-considered legislation - from both sides of the aisle. Our Republic deserves better.

What could responsible candidates offer as serious remedies to flaws in the Affordable Care Act that are within political reach? If they must, the politically naive DMCB sees two categories:

1. Blocking: In its role of keeper of the purse strings, Congress can withhold or alter the funding of the more questionable parts of the bill. One option is to underfund that part of the budget of the Internal Revenue Service (IRS) that will need to be expanded to support the controversial mandate. Another is to squeeze the funding of the Center for Medicare and Medicaid Innovation.

2. Tackling: During and after the health debate, the DMCB recalls hearing a lot of good ideas on how to keep the ACA but make it better. Examples include allowing for a more rational interpretation of the medical loss ratio, rethinking the not-so-obvious merits of electronic records, coming up with meaningful tort reform and preserving what's good about Medicare Advantage with smarter funding.

The DMCB looks forward to hearing more about the "blocking" and "tackling" options from the conservative candidates. Both issues have downsides. Both will test the mettle of the Republican opposition. Both will tempt the Republicans to take either a) the easy, visually appealing and scientifically bankrupt "bottled water" approach to health care reform or b) the sound common-sense approach of relying on what works.

We'll see.

just another conversation


I've started to record bits of conversation that occur at our house. This one took place yesterday morning betweem my spouse and me.

T.: "Can you send a Facebook message to someone who's not your Friend on Facebook?"

Me: "You can. I get emails all the time from strange men saying they can't live without me."

T.: "You do?"

Me: "Yes, sometimes they say they saw my photo and that they can't stop thinking about me."

T.: "Wow."

Me: "I especially wonder about those because my profile photo is of the dog."

(Conversation interrupted by laughter)

Me: "I think they might be spam."

T.: "In those cases, I hope they are, because the alternative is disturbing."



Sunday, August 15, 2010

down-time at the ottawa folk festival


My spouse and youngest son and I went to the Ottawa Folk Festival this past week end. I love these shots T. took of D. and I chilling out between the afternoon and evening programming.






I didn't have any pockets, so I resorted to an old habit of sticking my cable needle in my cleavage. Except, I don't really have cleavage any more. The pointy cable needle kept falling over and I had to keep reaching into my bra to fish it out.

This amused me.

The scarf I'm making has one asymmetrical cable.

This amuses me, too.


The Definition of Patient Centered Health Care, Courtesy of Health Affairs

When Disease Management Care Blog readers were wondering just what the literature had to say about the catchphrase "care management," they were in luck. When readers wanted to know more about the policy underlying Accountable Care Organizations, the DMCB responded. Health insurance exchanges? No problem. The same is now true for the term "patient centered (medical) healthcare," courtesy of Ronald Epstein, Kevin Friscella, Cara Lesser and Kurt Strange writing in the August issue of Health Affairs.

Quoting the IOM's Quality Chasm report, the authors define it as any care that is "respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions."

This means the system has to promote doctor-patient relationships that are:

1) a two way relationship, where the patient's responsibility is to learn about the disease and share his/her preferences, while the providers have to embrace the patient's values, beliefs, hopes and ways of dealing with adversity. Ultimately, consensus is achieved.

2) enriched by teaming, since no single provider can manage it all.

3) reliant on "framing," in which the health care providers "tailor" the information they provide in response to patient literacy, concerns, beliefs and expectations

4) deliberative, because expectations and circumstances change over time.

Why is this necessarily a good thing? The authors argue it's not only the "right thing to do," but quote studies suggesting that it is associated with improved care (quality), improved well-being (quality of life), reductions in disparities, lower costs, fewer allegations of malpractice and increases in patient safety.

To make it happen, the authors have suggestions for measurement (using a combination of tools that go beyond mere patient surveys) health information technology (better access to patient-centric information), "informed flexibility" in the organization of health care (more than just policy, procedures and protocols) and the support of collaborative "loosely affiliated communities of care."

Very helpful, says the DMCB, because:

1. When it and any other member of the disease management industry writes, quotes, brands, markets, extols, points to or describes "PCHC," it can point to a reference from a credible scientific resource*,

2. While the article relies on 57 references to describe patient-centered healthcare, a close examination of that literature fails to show that there have been any prospective randomized trials on the topic. It's correct - yet ironic - that the authors have not issued a call for comparative effectiveness research. It's better to think about how, not if, PCHC should be adopted in the mainstream of medical care. One answer to that lies in the disease management industry, because of number 3.....

3) The authors correctly salute the "community" of health care that can surround a patient in PCHC, which is precisely analogous to the medical "neighborhood," "village" and "ecosystem" that has been described as a key virtue of a population-based care management system working to support the patient centered medical home. Why not? There's evidence that patient-centeredness is has been an ingredient of disease management all along.

*Epstein RM, Friscella K, Lesser CS, Stange KC: Why the nation needs a policy push on patient centered health care. Health Affairs 2010;29(8):1489-1495

Friday, August 13, 2010

43 things (part four)


32. I can organize ideas, a campaign or a project but I can't organize my house or even a room to save my life.


33. If I become interested in something, it can easily turn into an obsession. At least for a little while.

34. I'm trying to ride my bike as much as possible. I think I'm becoming addicted (see above).

35. I'm always a little surprised to discover that someone likes me.

36. I didn't think Facebook birthday wishes were a big deal until it was my birthday. I loved getting messages from all over the world and from people from all parts of my life.

37. I have already passed my minimum goal of raising $150 for the Run for the Cure. I dream of wildly exceeding that.

38. Two of my favourite childhood memories are of a family cross-country ski trip and going sailing on my uncle's boat. I don't particularly want to do these things now but I felt happy doing them then.

39. I like the idea of creating fun memories for my kids. I wonder if they will hold close the memories of our trips to Florida and our week end at Blue Skies when they are adults.

40. When I was six years old, a man in a raincoat flashed me. I was passing through the parking lot of the Catholic Church, on my way to school.

41. When I'm depressed, I feel invisible.

42. I'm making good progress in my quest to lose 44lbs before I turn 44 (on August 4th, 2011). I lost three pounds in the first week. I know it's going to slow down from here on in but I'm feeling encouraged. And determined. And you're going to be reading a lot about it here and on Twitter/Facebook because I want to stay accountable.

43. I think it's really cool that I'm planning for a year from now.

44 (bonus thing). I really do think that the red Smarties taste best.

Thursday, August 12, 2010

Why the Disease Management Industry Thinks It Makes Sense for Patient Centered Medical Homes

The Disease Management Care Blog listened in on the August 12 DMAA seminar that was given by Darren Schulte of Alere and Greg Sharp of Ideal Family Care in Colorado. It was titled "Towards a Collaborative Care Delivery Model: The Role of Population Health Management in the Patient Centered Medical Home."

This was well worth the DMCB's time because it provided important insights on how the population health improvement providers, formerly known as the privately held disease management organizations (DMOs), are positioning themselves in response to the Patient Centered Medical Home (PCMH). As Arte Johnson would say with his classic catchphrase, "very interesting....." If you missed the webinar, you could also say "very convenient....." of the DMCB to take notes and share them here.

First off, it's clear that the health insurance reform contained in the Affordable Care Act will fall short of assuring satisfactory access to health care, especially primary care. Following the passage of Massachusetts' health insurance reform, there were credible data that indicated that one in five patients had difficulty in obtaining primary care and that only about 40% of internists were accepting new patients. This may be a coming preview for the rest of the United States.

The PCMH is one solution. Yet, despite widespread support for it among physicians, many independent practices, especially the smaller ones, may find that implementing it will be a tall order. Enter the DMOs. They share in the commitment to "patient-centric care models" and believe that this can be the basis for "win-win" alliances between industry and the physicians' PCMHs. The DMOs believe they can provide synergistic and complementary partnerships with physicians struggling to create PCMHs and can help disseminate the early successes of the PCMH into these and other health care settings.

If that sounds like a stretch, check out this article that was published in Health Affairs. When the authors looked at successful PCMH pilots, they found four key features: 1) meaningful financial incentives, 2) access to data that allowed performance management, 3) expanded patient access and 4) dedicated non physician coordinators. The last one is bolded by the DMCB because it's a key point. The authors found that the coordinators could be embedded in the practices or located in community health teams. That latter option - providing nurses in the community - is what the DMOs are offering.

The DMOs are betting that a critical mass of physicians will like the idea. They're also confident that health insurers and employers will also like the evolution the DMOs away from working independently of patients to being better aligned with the physicians.

Which naturally brings up a new set of catchphrases. The DMOs are offering MEDICAL NEIGHBORHOODS, because IT TAKES A VILLAGE within a healthcare ECOSYSTEM that has a virtuous cycle of provider alignment, patient convenience and universal connectedness. In that context, community-based coaches can engage patients for those primary care practices that chose not to build a fully functional PCMH.

"Why not?" say the DMOs. They have have the experience, the tools and the resources. They offer a bundle of services that can be individually adapted to individual primary care sites. They can provide tailored levels of management assistance, decision support, patient coaching and monitoring.

Last but not least, DMOs are not being naive about the challenges involved in pulling this off. They know that there will be physician skepticism, imperfect insurer/hospital/provider integration, that payment reform may fall short, that sponsorship cannot be taken for granted, that there will be a tension between the unknown of "virtual" vs. onsite care management and that the DMOs have an uphill battle to face over past history and lingering perceptions.

July 17: You can view a recording of the DMAA webinar online and a download of the slides is available here.

Wednesday, August 11, 2010

Finding the Right Patients for Disease Management: They're in the Middle!

The Disease Management Care Blog was a speaker at a recent health care conference where it discussed the "targeting" of care management programs. It doesn't believe that every patient with a chronic condition will benefit from disease management. The audience agreed, so the DMCB will try it out here.

Apostasy you say? Read on.

This Kaiser study showed that patients with low risk heart failure didn't benefit from "telephone mediated nurse management." In the meantime, this Medicaid study said that patients with high risk heart failure didn't benefit from disease management. What gives?

From a pure economic perspective, if a typical health insurance plan arrays its membership by cost from low to high on the X axis and examines the numbers of persons in each cost category (the Y axis), the curve will be low on the left (persons who are never never seen have low cost and are relatively few in number), high in the left-of-middle (low to modest charges are typical of most persons with health insurance), and then have a low tail going off the right (persons with very high claims are few in number).

Stare at the graph for awhile and it will make sense:


While the absolute costs will vary, the same graph applies to most subpopulations in a health insurance plan, such as children, persons living in rural areas or even elderly duck hunters. It also applies to subpopulations defined by the presence of diabetes mellitus, chronic heart failure, or asthma, which will have the same pattern of low cost-low numbers (left), moderate cost-high numbers (toward the middle-left) and some will be very high (way off to the right)

So, if the idea is to save money, which patients should you aim your care management programs at?

Check out the next graph:


Patients who are in left side of the population have low baseline costs, so it's unlikely that care management will lower their costs any more than they already are. On the other hand, patients who are way on the right are unlikely to have illness that is meaningfully amenable to education, engagement, behavior modification, self-care, counseling, more frequent primary care visits or care plans. They're going to need specialists, they're likely to have to go to the emergency room frequently and they're going to have to be hospitalized a lot.

Rather, the DMCB thinks that there is a population toward the middle that are sick enough to warrant care management and have baseline costs than can be reduced. They're the sweet middle and that's where disease management programs should be directed. The Kaiser study focused on patients too far to the left, while the Medicaid study focused on patients off to the right.

Three additional points:

1) While the graphs above portray a health plan's current population, the purpose of predictive modeling is to array the future risk of a population using the same logic.

2) This also demonstrates how an insurance benefit - like access to disease management programs - shouldn't necessary be uniformly applied to everyone that would nominally qualify. It also shows why many of the quality measures in use today are imperfect because their binary "black/white" methodologies don't distinguish between populations that are likely to benefit the most.

3) This is another Achilles heel for the Patient Centered Medical Home (PCMH). While physicians may be able to intuit which patients are most like to benefit from primary care based, team-delivered and patient centered care, the same logic described above applies to a population assigned to a primary care site. Not all patients will detectably benefit from the PCMH, and it's important to know who will and who won't.

P.S. The powerpoint slide is available to anyone who asks. Just email (the address is off to the right somewheres).

soup


DSCN8217


Starring (in order of appearance): onions, garlic, tumeric, ginger, coriander, cumin, chipotle powder, cabbage, carrots, sweet potatoes, salt.

Tuesday, August 10, 2010

at the aquarium










All photos taken last month at the Mote Marine Laboratory in Sarasota, Florida.



43 things (part three)



22. One day, when I was small, my aunt bought me a Buster Bar. Before I could eat it, it fell off the stick. She didn't buy me another one.

23 I had Dilly Bars instead of cake on my birthday this year. I ate two.

24. I also had a beer during the day on my birthday, something I consider very decadent. I usually only do this with my friends L. and K. (otherwise known as Sassymonkey).

25. The day after a social gathering, I spend a lot of time second guessing my behaviour, even when especially when I had a good time.

26. I feel guilty about something several times a day. Only recently did I discover that this is not a universal experience. I'm curious what it's like not to feel guilty.

27. My life in treatment is a constant tension between search for structure and then rebellion against self-imposed structures.

28. I have voted NDP in every provincial and federal election since I was old enough to vote (although I have sometimes done so while holding my nose).

29. This was the first year since 2007 that I didn't go to BlogHer. I'm OK with missing it (I had three great years there. The first was an amazing birthday present, the second I was a speaker and last year, I got to bring my book) but I'm a bit sad, especially since I finally feel like I figured out how to really enjoy the experience. There are lots of folks I would have liked to see (Average Jane and Nonlinear Girl were on a panel together. Whymommy was on a panel about blogs as an agent for change) and there are so many folks with whom I would like to spend more time.

30. When I was a teenager, I had a huge crush on the Cassidy brothers. I especially loved Shaun.

31. I was a hideously self-absorbed and narcissistic thirteen year old. It's amazing that my mother let me live.


The "I'm Weak" Lamentations of Physicians Over Quality Measures in the New England Journal of Medicine

"I'm weak!" says the Disease Management Care Blog.

Over the years, that short sentence has served as the perfect neutralizer to unwanted responsibility, conveying a perfect combination of victimhood, martyrdom and passivity. When used at the right time, it works so well, the DMCB wonders why it's not used more often, like when corporate titans succumb to temptation, or when politicians get caught making stuff up or when the AMA has to grovel for an SGR fix.

Unfortunately, the argument has generally failed to make the DMCB spouse show any mercy. She suspects the DMCB's claims of feebleness are merely a cover for its unwillingness to hang up its clothes or stop channel surfing until it finds the most tasteless show on TV.

The spouse would probably feel the same way about Danielle Ofri's New England Journal article (here's the link) titled "Quality Measures and the Individual Physician." Anyone who has read about the travails of individual physician performance measurement and feedback will probably recognize all of Dr. Ofri's lamentations about being simply unable to live up to its expectations. They include:

Over time, the numbers typically don't budge.

Over time, physician behaviors don't budge

Over time, the only thing that does budge is physician morale, and that's downward.

In the end, physicians are already trying hard and the numbers add little to their motivation.

After awhile, physicians stop paying attention.

The numbers may be unequal to the task of measuring true quality, not to mention the "art" of medicine

The numbers fail to discern between being just missing a quality measure threshold and having disease that is dangerously out of control.

It's difficult to worry about simple quality measures when patient's real world needs are far greater.

It's too easy for patients to misinterpret the numbers

What could be done to improve the numbers is out of reach in most physician's offices

The DMCB feels Dr. Ofri's pain. Unfortunately, something has to be done and vacuum of physician inaction has predictably led to the intrusion of multiple outside organizations horning into day-to-day clinical practice. There are other solutions at hand, including partnering with disease management or starting a patient centered medical home. Both can liberate physicians from personally handling the details of office-based quality improvement.

The good news is that there are plenty of docs that get it. As for the ones who don't, the "I'm weak" style lamentations of Dr. Ofri will get those docs about as far as the DMCB has gotten with the spouse: no where.

Two FREE Webinars on the Medical Home and Workplace Wellness

The Disease Management Care Blog wants to point out that there are two webinars that warrant your attention. The topics are timely, the speakers are expert and best of all, it's free. The DMCB will be listening in:

DMAA: The Care Continuum Alliance will host two complimentary Webinars to preview programming planned for its annual meeting, The Forum 10, and an employer-focused event, the Integrated Care Summit, which it co-hosts with the National Association of Manufacturers and Center for Health Value Innovation.

The first of the Webinars is this Thursday, Aug. 12, from 2 to 3 p.m. Eastern Time: "Toward a Collaborative Care Delivery Model: The Role of Population Health Improvement Organizations in the Patient-Centered Medical Home." Tune in to learn about new opportunities for collaboration between primary care practices and population health management organizations to fully realize the medical home. Presenters are Greg Sharp, MD, co-founder of Ideal Family Healthcare, an NCQA-recognized, level 3 patient-centered medical home; and Darren M. Schulte, MD, MPP, executive vice president of collaborative care solutions at Alere.

The second is on Aug. 18, from 11 a.m. to noon Eastern Time. "Demonstrating ROI: Insight into Eastman Chemical Success" will provide a sneak peek of Integrated Care Summit programming. This session will demonstrate how Eastman Chemical Company successfully generates cost savings through a comprehensive health and wellness program that includes onsite fitness centers, health coaching and other strategies and incentives to drive participation. Presenters are David Sensibaugh, MBA, director of integrated health at Eastman Chemical Co., and Gregg Lehman, MS, PhD, CEO of HealthFitness.

The Forum, Oct. 13 to 15, in Washington, D.C., and the co-located Integrated Care Summit, Oct. 13 and 14, are among the best opportunities to learn what innovative program purchasers and program providers are doing to improve health and productivity - and lower health care costs - through wellness, prevention and disease management. With a significant federal investment in wellness and prevention in health care reform and mandates for public and private insurers to provide preventive services, these events are must-attend to understand how to leverage these new opportunities. You can save on registration for both with early bird rates through Sept. 17 and even greater discounts for partner organizations, employee benefits administrators, academics and students and other select groups. Visit TheForum10.org and IntegratedCareSummit.org to learn more and register.

Monday, August 9, 2010

The U.S. Surgeon General Tackles Obesity.... NOT

Remember when we had, for example here and here, U.S. Surgeon Generals that really shook things up? That's not the situation today. Vice Admiral Regina M. Benjamin, M.D., M.B.A has issued forth with a milquetoast style public appearance to promote a "Healthy and Fit Nation" report that's stuffed with more bland nostrums than the creme in a supermarket donut.

Despite its admiration for for Dr. Benjamin, the Disease Management Care Blog is disappointed over her recitation of the usual anti-obesity bromides: eat fewer calories, improve food choices, promote physical activity, bring physical education/playtime back to schools, create worksite wellness programs, engage the physicians and establish healthy communities. Public health experts have been reciting the same thing for years without effect.

Here's some unasked-for advice DMCB to our Surgeon General:

While you serve at the political pleasure of the President, you also have the benefit of Senate confirmation, the stature of your office and the confidence of the American people. Why not use it?

To wit, you could point out:

....there are many reasons to not listen to Mike Hukabee, but there's
one reason why he has some credibility on the topic. You need to announce that your leadership on the topic will start at the top. 'Nuff said.

....since the
U.S. government happens to also be a large employer, it could be doing much more to lead the way in combating workplace obesity. The silence in this area is deafening.

....that the risk of obesity should be
into perspective. Shouldn't we be less irrational about our bodies and more realistic about what can be achieved?

.... that there is merit to the idea of harnessing private-public entrepreneurship with
competitions aimed at sustainable but challenging weight loss goals in schools and communities.

.... there may be something to an enlightened
soup nazi approach to worksite wellness.

.... that the rationale of
aggressively taxing sugared beverages makes sense and that you stand against the food industry's actions in this area.

.... that
banning internal combustion engines within a mile of our schools is an intriguing idea.

.... that there may be merit to conducting expeditiously conducted pilot programs to
determine the role of medications to combat obesity, especially in children. The DMCB doesn't like the idea either, but since good comparative effectiveness research indicates just diet and exercise has little impact, what other options are there? Bariatric surgery?

....that
remotely positioned disease management that engages persons using the latest advances in behavior change is an important part of the solution.

The DMCB admits to bringing up some controversial topics. The point is that it came up with these in an afternoon while working on other stuff. Our Surgeon General can report on these and other options in the battle against obesity. All she needs to do is to take a cue from her more famous predecessors, step outside the political safe zone, invest more effort in thinking about breakthrough/high impact approaches and challenge Americans to actually do something fer cryin' out loud.

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