Suggested Disease Management Slogans for the Restore Sanity and/or Fear Rally

While the mainstream news media dissects the successful crossover mockery of Jon Stewart and Stephen Colbert from comedy to news to politics in their Restore Sanity and/or Fear Rally, it occurred to the Disease Management Care Blog that the phenomenon is hardly new. For example, Mark Twain and Will Rogers were the rock star satirist-pundits of their day. Yet, give those wacky Comedy Channel stars credit where credit is due. It takes real talent and judgment to simultaneously mock, be funny and score points. Just ask David "Palin-baitin'" Letterman, Don "nappy headed" Imus and Rick "the Jewish conspiracy" Sanchez.

The DMCB is jealous. If it weren't for some business, it might have been at the rally so it could have carried its own health care placards. To wit:

"We have nothing to fear except running out of my drugs for my chronic anxiety disorder that causes fear."

"Population health management nurses are hot."

"Kathleen Sebelius: not a witch, but one of us. Really."

"Health insurers need love too"

"Be nice. Share risk pools!"

"Man-up: read the DMCB"

"Anecdotes, not actuaries!"

"I want to be meaningfully used by the DMCB spouse!"

"I may be wrong, but you don't have health insurance."

"Everyone sort of likes disease management lots."

"Tea Partying: A chronic condition that can be positively managed with remote telephonic counseling"

"Shared decision making plus cookies: the cure for partisanship"

The Latest Health Wonk Review Is Up!

While you may think the recent spate of zombie movies and partisan extremism are scary, that's nothing compared to not being up-to-date on all the health policy bloggery that's going on. The cure is over at the New America Foundation blog, the All Hallows Eve Edition. Enjoy!

Open the Medicare Claims Data Base to the Wisdom of Crowds.

If you believe that CMS has what it takes to make sure that Medicare claims are paid the right way for the right patients most of the time, you may need to think again. According to this article in the Wall Street Journal, it's too easy for the government to misspend millions of dollars for dubious care involving questionable doctors.

But Medicare's fiduciary ineptness is not why this article is worth reading.

If you believe the Journal, the Medicare claims data base, otherwise known as the "Carrier Standard Analytic File" is a gold mine of information that, but for archaic privacy laws, could be used to spot those questionable doctors. Organized physician groups have generally opposed the public release of those doctors' names, even if it involves public money.

But physicians' right to privacy vs. the public interest is not why this article is worth reading.

Rather, this article is important because it portrays the power of allowing open access to the government's health insurance claims databases. The Journal simply sorted Medicare claims costs by provider and came up with some potentially important insights. Imagine, says the DMCB, what would happen if everyone could access the data from the world's largest insurer and mine it for correlations, regressions and other statistical whattnot. There are a host of amateur statisticians who could not only uncover important practice patterns, but mine other unknown associations involving demographic information, the incidence of disease and likelihood of successful cure. It's called the wisdom of crowds.

While privacy for patients and physicians is important, reasonable protections are possible. As for Medicare itself, the program would not only benefit from the clinical insights that would be uncovered, but other investigations similar to the Journal's might make it more responsive to acting on potential fraud.

Last but not least, those data belong to the American public.

The data are too useful to lock away from its owners. This is an idea whose time has come.

Peer Reviewed Versus Press Released: The Patient Centered Medical Home Needs to Learn from the Mistakes of the Disease Management Industry

In the Stephen King TV movie The Langoliers, passengers in a star-crossed jet airplane end up in a grey featureless world of "past time." There is no energy, people are strangely absent and there is little in the way of sensation like taste and odor. The rest of the movie, featuring big space-chomping bubbles is rather silly, but the Disease Management Care Blog found the notion of a parallel hollow universe strangely... compelling.

That's because the DMCB and the rest of the disease management industry crossed over from that faux reality years ago. It still has nightmares about that colorless place of vacuous press releases, empty branding campaigns, superficial white papers, marketing fluff and insipid trade publications. Once it re-entered present time, substantive and credible publications like this began reanimate the population health universe.

In this instance, Kaiser tapped their databases to conduct a retrospective cohort study, using a matched control group, to evaluate the impact of a "collaborative cardiovascular risk reduction service" on 628 patients. After statistical adjustment, the program was associated with an approximate $22,000 per patient savings. The published study has the modest title of "Reduced Health Care Expenditures After Enrollment in a Collaborative Cardiac Care Service," uses a rigorously contrived control group, got past the scrutiny of objective peer review, states the program was associated with savings (not caused it) and has enough information to allow readers to make an informed judgment. Sure, it's Kaiser, but they're competitors in an insurance industry competing for patients.

Compare that to an ethereal world of press releases like this from another member of the health insurance industry, South Carolina Blue Cross. The release says that 809 PCMH participants showed a 10.4% decrease in admissions and 12.4% fewer ER visits compared "to the same population's previous year." They also "had better control of cholesterol and glucose levels, improved their Body Mass Index and measures of potential kidney damage, as well as had higher rates of recommended eye exams." In addition to the pre-post evaluation, there was also a comparison to a population of "continuously enrolled diabetic patients treated by all other primary care providers" with similar age and gender mix and similar baseline costs. Compared to that group, there were 11% fewer admissions, 36% fewer inpatient days and 32% fewer ER visits.

The Disease Management Care Blog has some unsolicited advice for its colleagues in the PCMH movement: learn from disease management and resist the temptation to release outcomes results into the public domain with stand-alone press releases. The stakes are too high and that universe is too barren. Policymakers, regulators, government, physicians and patients need to understand the merits of comparison control groups, have the input of objective peer review and grasp the details that go into quantitating "improved" outcomes. Without that, the results - even if they the product of a rigorous analysis - may not only fail policy muster, but end up being chomped on by the Langoliers.

Image from Wikipedia

what i would miss

I just did an interesting writing prompt from Old Friend From Far Away by Natalie Goldberg:

"Tell me what you will miss when you die."

The instructions were to write for ten minutes without censoring yourself. Here's what I wrote:

My kids

My spouse

My family

My friends

My dog

Beautiful fall days

Walks along the canal with my dog

Getting lost in a book

Taking a nap on a cold afternoon

Knitting with friends

The feeling of euphoria when I write something good

Music

Good food

Laughing

Wondering at art

A hot bath after exercise

Physical intimacy (all kinds)

The happy feeling when I unexpectedly run into someone I like

Learning new things

Aha! moments

Seeing people do good things

Being proud of my children

Noisy gatherings around my dining room table

Doing fun things for the first time

Doing familiar things that make me happy

Connecting creatively or intellectually

Making new friends

Having old friends and family members who 'get' me

Scrabble

Fresh starts

Clean sheets

Small kindnesses

Spectacular acts of bravery

Feeling proud of myself

The way the pavement smells after a summer rain

The possibility of tomorrow

What about you?

The Attorney Generals, Affordable Care Act, Private Economic Activity Versus Interstate Commerce, Lawyering and the Release of the Furies

Along with a small roomful of other docs, the Disease Management Care Blog recently met a sitting State Attorney General (AG) who is running for Governor. He was feeling pretty confident about being ahead in the polls and having a 70% chance of winning. He also happens to be one of the 13 AGs that filed that early suit against the Affordable Care Act (ACA's) mandate. We brought it up and the "General" (that's what we called him) was bluntly unapologetic: "I read it and it was unconstitutional."

According to this article in JAMA, the AGs serve as their States' legal officers with broad powers ultimately aimed at protecting the public interest in areas such as consumer protections, the environment, and the functioning of various State agencies as well as representing the State when lawsuits arise. When they speak, their opponents better listen. Examples of that include the tobacco wars, going after big pharma and defanging managed care.

Anxious to learn more, the DMCB used that handy link to the right to return to the ACA and looked up the mandated "individual responsibility" language starting on page 124. Curiously, a whole page is devoted explaining its legal underpinnings. It describes health insurance as a commercial activity that involves 17.6% of the economy. Much of that 17.6% crosses State borders. It will benefit from "near universal coverage by building upon and strengthening the private employer based health insurance system." Without a "requirement," individuals "would wait to purchase health insurance until they needed care." Accordingly, by broadening the risk pool and capitalizing on "economies of scale," the price of health insurance will become "lower." Using that as a justification, what follows in the ACA is a detailed description of how a "penalty" will be assessed by any U.S. citizen that fails to meet that "requirement."

As the DMCB understands it, the AGs oppose the use of penalties that promote "private" (a word in the ACA) economic activity, even if it is interstate and even if it in the public interest. Ironically, they're arguing that the ACA should have imposed a tax.

The DMCB has no illusions about the Republican undercurrents and the AGs' political self interests versus the non-material distinctions between "penalty" vs. "tax" and the necessary adaptation of Federal law in pursuit of the greater good. While they are all issues that make for great bloggery, that wasn't what impressed the DMCB about its very confident AG interacting with a roomful of docs.

What impressed the DMCB was how the issue had been legally processed by the "General." He read the law, benchmarked it against how he was trained to think and came up with a judgment. Writers write, doctors care and lawyers, well, "law." Principled individuals in these and other professions, including lawyers, can't help it. This sort of backbone is an under recognized ingredient in the battle over the ACA. It's also another reason to believe that the AG suit may prevail.

Who would have thought the DMCB would have a nice thing to say about lawyers. Such is its process of self discovery and professional development.

Which brings the DMCB to the punchline: we can't have one without the other. Our nation's AGs have 1) interpreted the law and 2) have used their considerable powers to skewer tobacco, pharma, managed care (and, by the way, fraudulent food labeling, the obesity epidemic, firearm safety, domestic violence and Medicaid fraud). The DMCB knows admiring what the AG's have done in the past also means having to approve of how they've done it. Like it or not, these principled Furies were enabled and released by all of us years ago.

And now they're coming home.

The Real Reason Why Health Care Is Going Home

Hospital-like care at home. Home health agencies doing disease management. Home visits by technology-equipped physicians. Monitoring devices, telephony and self care all at....you guessed it, home. If it looks like all of these approaches share a theme, you're right. That theme is the topic of a New England Journal "Perspectives" article titled "Why Health Care Is Going Home" by Steven Landers of the Cleveland Clinic.

Regular Disease Management Care Blog readers won't find much new news here. They'll agree however, that more than a decade after the disease management industry began, the denizens of the academosphere are still struggling to recognize a key value proposition of disease management. Hopefully they'll start reading this blog, says the DMCB.

According to Dr. Landers, home-based care has a lot going for it because 1) there won't be enough hospital beds to meet future demand, 2) it turns out being in a hospital bed is dangerous, 3) exiting a home for health care can involve stairs, narrow hallways and other threats to safety, 4) acute illness = hospital care, chronic illness ≠ hospital care, 5) home care is promoted by the Chronic Care Model, 6) modern monitoring and treatment technology is becoming extremely compact and reliable, 7) hospice has an attractive track record, 8) consumerism prefers the convenience of home care and, last but not least, 9) it's a lot cheaper than the alternative.

Dr. Landers is right on all of the above but fails to give credit where credit is due. Consumer goods are increasingly being linked to service contracts to the point where the experience of ownership is more important than the initial purchase. While health care is not necessarily a consumer good, our patients are coming to expect high-end support services. Disease management has known that for over a decade. Examples include home monitoring devices that are tethered to 24/7 nurse support, the willingness of vendors to staff their line for evening home telephone calls and the rise of community-based care management nurses who will not only see the patient at the clinic but in their place of residence.

Disease management's outcomes have shown home care can be cheaper and safer than being in or having to go to the hospital. It capitalized on the emerging need for alternative approaches to chronic illness. It was explicitly adopted by medical device manufacturers. It is also remains the quintessential answer to consumerism.

In short, disease management is a principal reason Why Health Care Is Going Home. Too bad the Journal's editors didn't work with the author to make sure that point was made in the manuscript.

The DMCB will download a copy of this article to its hard drive so that it can use the reference in the opening paragraph of some future manuscript or early on in a PowerPoint presentation. It may be of use to other DMCB readers that are looking for useful marketing "collateral."

The Electronic Health Record and the Realities of Clinical Practice

In response to its last post on the EHR, the Disease Management Care Blog received this sharply written perspective from Kerry Givens, who is a physician in private practice in central Pennsylvania. The DMCB thought it deserved it's own postng.

This is from doc who is really trying to make the much vaunted electronic health record work in that place that seems to be largely unknown to our nation's health information technology intelligentsia - a place called "the real world." This real world is a place where docs want to do the right thing, are not afraid of computers, are skeptical of non-clinicians and have to manage the other moving parts of running a business. It would appear that the real world is promising to be a lot messier when it comes to EHR installs than the current regime would have us believe......

As a physician running a smallish 5-provider practice, I just spent four painful days looking at EHR applications at a national conference---including several programs that have just received formal government approval as having satisfied the meaningful use guidelines.

I have a big problem with meaningful-use guidelines. It seems that they were concocted by federal attorneys and think-tank consultants---the same kindly folks who enriched everyone's lives with HIPAA. As it looks to me, few physicians were asked to contribute during the crafting of the current EHR "recommendations." Am I alone in that concern? Any time attorneys and policy wonks are allowed to administrate other professions with impunity, mandating their vision of how the rest of us should do our jobs better (and on a deadline, no less), there is a fundamental disconnect with reality, if not outright system failure. Last I checked, attorneys don't take care of patients or disease.

Now, about current small-practice EHR offerings. My disclaimer: I am not a computer neophyte. I have owned and built countless PCs since the mid-1980s, have reviewed software professionally, learned how to code database languages back in the day, and am comfortable working within with multiple operating systems. EHR software to me looks like someone took the worst parts of freeform databases, contact managers, and spreadsheets, put them all in a blender, and then let a toddler smear this slurry on the monitor. All of the programs I saw had migraine-inducing, shotgun-blast screens caked beyond belief with pull-down menus, radio buttons, flashing alerts and a general sense of chaos. Linear data entry is nonexistent as you leap from screen to menu to different screen to menu etc. At no time did the word "ergonomic" enter my mind during countless frantic demos I witnessed. The standard company reassurance was "you get used to it after a few months." The same can be said of many chronic diseases. Not encouraging.

The other grim EHR decision that countless small practices face: taking on electronic medical record-keeping may require them to scrap their practice management/appointment/billing software. The EHR absolutely should feed off the same database, since one of its alleged benefits is to assist in correct billing/coding, recalls, etc. Generally that only works (or works well) if the two programs are written by the same company. So if your current practice management software doesn't include a worthwhile, snap-on EHR option, the upgrade ride suddenly gets a lot bumpier. Anyone who has lived through migrating from one appointment/billing system to another has knows what I mean. Small practices don't have, and cannot afford, dedicated IT teams to work out the kinks in such a transition. Layer those costs (and psychic trauma) onto the big hardware/software upgrade expense of EHR, and that $44,000 carrot-on-a-stick from Medicare looks a little scrawny to me.

The EHR is just another in a growing list of "look what we did!" fait accompli policy from misguided, politically-appointed brainiacs who are dangerously out of touch with real life. We need to scrap the current EHR mandate, re-evaluate the entire process with physicians and hospitals at the table, and get rid of the current ticking-clock timeline altogether. In the meantime, the attorneys should, for a refreshing change, scent-mark the only arena they really understand---the legal system. Hey guys---where's that tort reform everyone keeps talking about?

Until then...God help us all. AGHHHHHHHHHHHH.

Image from Wikipedia

serendipitous cycle

I feel like a little kid again.

On August 15, I won a bike.

I was at the Ottawa Folk Festival and I bought three raffle tickets for five dollars. I told several people that I planned to win the third prize - a Kona Africabike 3, donated by McCrank's Cycles.

And then I did!

And here's the interesting part. I really, really wanted a new bike. I've been riding the same diamond frame (commonly called a men's bike) hybrid for almost twenty years. It's probably the wrong size for me and had started causing me neck and shoulder pain when I rode for more than a few minutes.

Over the summer, I test rode at least a dozen bicycles from four different bike shops. I came close to buying three times but each time, something held me back.

Our finances are really tight right now and I would have to commit to any bike I bought for a long time. And although several bikes I tried seemed fine, I didn't really love any of them. I had begun to think that I was just being too picky. I had pretty much resigned myself to spending a bit of money to fix up my old bike when the week end of the Folk Festival came around.

And then I won a bike that was nothing like any of the bikes I'd test ridden. And I love it.

With it's heavy frame (42lbs!) and big tires, it feels solid and safe to ride. I love how the coaster brakes (the kind where you stop by pedalling backwards) allow me to slow down gradually (there's a hand brake that helps me to stop quickly when I need to). I really only ever used seven speeds on my old bike, so I haven't really minded that my new bike has only three. The step-through frame means I can wear whatever I want to go cycling (and means that I have fewer excuses not to ride). And the "sit up and beg" style of riding means no pain and whole new way of taking in the world.

It's so much fun to ride! As I did all those test rides this summer, I kept waiting to fall in love and it just didn't happen. It turns out that the bike I needed was one I had been refusing to even consider (and that some of the features I had rejected are the ones I love the best).

For the first few days after I brought my bike home I'd sneak out to the garage just to admire it. I've even named it Steel Horse (because it's such a beast and after the song "I Am An Excellent Steel Horse" by Rock Plaza Central, a band I heard for the first time at this year's folk festival).

I've noticed that people smile at me when I ride my bike. I think it's because I'm grinning like an idiot.



When I was seven years old, I had a red bike with a yellow banana seat. That was my first bike and I've never loved another bike as much. Until now.

For every two Africabikes that are purchased, Kona donates one to it's Basic Needs program in Africa (these bikes were designed to be virtually maintenance free and to be easily ridden on the most rugged of roads). These bikes have been used to help health care workers to deliver HIV/AIDS drugs and to enable girls to travel longer distances to get to school.

If you live near Ottawa and are thinking of getting an Africabike (or any Kona bicycle) for yourself, please go to McCrank's Cycles. Peter Conway is a really good guy (and very generous!), who provides great bike service. He deserves your support.

The "Water Water Everywhere, Nor Any Drop To Drink" Problem of Electronic Health Records (EHRs)

As further evidence of the growing mojo of the population health (née disease) management industry, go no further than the ability of the Care Continuum Alliance's Forum10 to attract speakers of national stature. Case in point was the October 13 appearance of National Health IT Coordinator David Blumenthal. This was the second time the Disease Management Care Blog saw him speak. He was just as measured, serene, confident and mistaken as he was the first time.

Listen to the rhetoric of Dr. Blumenthal and others like him, and it's easy to get the impression that the U.S. on the cusp of joining the rest of the civilized world in a new computer age of medical efficiency, englightenment and safety. If you believe them, it seems a major hurdle toward this era of electronic enchantment is being overcome by the enlightened application of meaningful use criteria coupled with provider financial incentives.

Yet, when the DMCB talks to physicians from smaller practices, it hears a recurrent and contrarian theme that matches news reports: they are actively shopping electronic health record (EHR) vendors but, so far, the offerings disappointingly fall short in ease of use, have marginal point-of-care decision support and don't generate significant patient value. While they stand to get some serious money, their calculus also includes the bitter past lessons of promises broken while struggling to keep their patients healthy and satisfied. As for the large medical groups, one read of Health Care Renewal's collection of depressing stories of endless HIT hubris, waste, mismanagement and patient harm should be enough to give any reasonable person pause.

Yet, before you think the DMCB is being an neo-Luddite weenie, let it be the first to agree that the fact that docs are now actively looking EHRs tells us something. It would appear that conversion away from paper records may be reaching a national tipping point. The DMCB thinks there are two reasons: 1) the drumbeat of Medicare money can't be ignored, and 2) the shift of some docs in some regions into larger physician practices is enabling those groups to accumulate sufficient capital for an investment in HIT.

Of course, as that happens, non-readers of the DMCB will make some painful discoveries. EHRs with or without "meaningful use" have little hope of controlling costs, don't necessarily increase quality, have little impact physician or patient behavior and trade new problems for the old ones.

But, says the DMCB, none of these are the Achilles heel of the metastasizing medicalinfotechnology complex. Rather, the biggest EHR vulnerability is its glut of data with little in the way of any real information.

The growing body of raw data contained in all those EHR servers, if it remains unorganized, will rapidly outstrip the ability of providers and patients to keep up. Drug lists are being cluttered with unimportant or discontinued medications. Past patient histories are becoming a logarithmically expanding mash of rule outs, billing codes and pay for performance buttons. Pop-up prompts, lists, tables and sidebars are diverting attention. Terrabytes of other pharmacy, insurance claims and personal data are being imported like spaghetti being thrown against a wall. Other than some flatfooted nods to organizing some of information into "lists," the emerging "meaningful use" criteria are failing to distinguish between being comprehensive and attaining comprehension. It's like the Rime of the Ancient Mariner: "Water water everywhere, nor any drop to drink" (which explains the graphic above).

Which brings the DMCB to an ironic punchline: this is a problem that will be solved. The change from a "capture all data" to a "assemble all insight" user-interface will enable providers to quickly drill through a patient's information set to find the right (not all) information at the right (not all the) time. When that happens, someone will deserve a Nobel. In addition, an up and coming electronic device that really has the greatest health information technology potential for market disruption will make current paradigm of a health-system dominated EHR obsolete.

That would be the cell-smart phone. More on that in a future post.

Primary Care - Hospital Negotiation Over the Formation of An Accountable Care Organization (ACO)

The Disease Management Care Blog recorded this exchange between a hospital administrator and a primary care physician over the terms of participating in an Accountable Care Organization. Chances of success seem high.....



This same physician is expert in the Patient Centered Medical Home.

The Latest Cavalcade of Risk Is Up

Once again, the folks at the Cavalcade of Risk have provided a brain fest of links about the vagaries of insurance (what happens if you don't pay the premium on time?), auto safety, social networking, identity theft, cancer from CAT scans, accountable care organizations and worksite wellness. You're taking a big risk if you don't keep up with all this stuff, says the DMCB.

Check it out here. It's ably hosted and smartly written by Julie Ferguson at the Workers' Comp Insider Blog. A bonus is that there are some humerous videos that show the connect between risk and insurance.

News About An Upcoming Webinar

The Disease Management Care Blog has been alerted about a Care Continuum Alliance sponsored webinar on Wed. Oct 26 from 1-2 PM EST that may be of interest to DMCB readers. It's on "The Beacon Community Program."

Here's some of the blurb:

"Many agree that the federal government, although well-intentioned, challenged the prospects for success in its chronic care management pilots and demonstrations with stringent design and methodology requirements. The Office of the National Coordinator for Health Information Technology (ONC) has learned much from these past projects and created The Beacon Community Program, which goes beyond building infrastructure to actually encouraging innovation to improve and transform health care delivery.

As part of the program, the ONC has allocated $235 million for cooperative agreements with communities. These community cooperatives will build and strengthen their health IT infrastructure and health information exchange capabilities to achieve measurable improvements in health care quality, safety, efficiency and population health. Additionally, the ONC will provide technical assistance to the cooperatives and evaluate the success of the program

This 60-minute Webinar will feature Aaron McKethan, PhD, Beacon Community director, Department of Health and Human Services, Office of the National Coordinator for HIT; Patrick Gordon, Colorado Beacon Consortium director; and Randall Williams, MD, FACC, CEO, Pharos Innovations. By joining us for this webinar, you will learn:

* The fundamental nature and vision of the Beacon Community Program.
* How the program will influence nationwide delivery system reform and be a guide-path toward developing community infrastructures.
* Tips and ideas for implementing such innovations in your community or organization.
* Implications for the future of health care delivery.

The Care Continuum Alliance is making this valuable Webinar, "The ONC-funded Beacon Program - A Beacon of Light in Transforming Health Care Delivery," available to members for $49 and to non-members for $99. "

You can register here.

ottawa october

All photos: K. Bruin

In October, I live in the most beautiful place in the world.

On, Thanksgiving week end (two weeks ago for those of you reading outside of Canada), my family was so fortunate to have a wonderful guest. My friend K. and I have been friends since we were 17 years old. We met as new room-mates in Room 1 of McLaughlin House at Lester B. Pearson College of the Pacific. She was there representing the Netherlands and I hailed from Hawkesbury, Ontario.

We became friends pretty much instantly, through struggles with friendships, school and heartbreak and whole lot of fun. We travelled to Vancouver together and she once took me out on a sail boat into the bay so I could engage in a little primal screaming.

In my second year, after she'd graduated, I missed her terribly. We've been lucky though. Work has brought her to Canada three times in the last five years and we've been able to spend time together. My family has fallen in love with her. And I can't wait until next year, when she comes back.

When we were at school together, we lived in a very beautiful place and I know that K. loves this country almost as much as I do. But until this year, she'd never seen Eastern Ontario on a beautiful fall day.

This year, we had a chance to rectify that and we took advantage of the long week end and the glorious fall weather to go for a walk in Gatineau Park. K. was the only one of us who took photos on our outing and she's given me permission to share them with you. My only regret? There are no photos of the two of us together. We'll have to rectify that next year.

Three Novel Suggestions for the Regulations That Will Govern Accountable Care Organizations (ACOs)

When Robert Berenson speaks, the Disease Management Care Blog listens. In the past, Dr. Berenson had some important cautions about the Patient Centered Medical Home and now he's tackled Accountable Care Organizations (ACOs). It worth clicking here and reading it at some point, but until you have the time, your helpful DMCB is pleased to offer this quick summary.

Dr. Berenson points out that the Affordable Care Act (ACA) specifically addresses ACOs as a "program" that will promoted nationwide through regulations. This is a big departure from the usual pilot or demo approach that that hinges on "requests for proposals" (RFPs). The ACO was included in the ACA because of its promise to generate savings by incenting physicians to reduce waste and inefficiency in a non-threatening manner. Another reason was its potential to promote better coordination of care for costly and chronic conditions "under one virtual roof."

In order to make this happen, the regulations may ultimately make ACO funding look a lot like the "delegated capitation" that's been used for years in risk-bearing "provider service organization" (PSO) arrangements. Unlike PSOs, however, ACO's will only have "upside" risk. In other words, if claims expense is lower than anticipated, the savings will be shared with the ACO. However, if claims expense is higher than anticipated, the ACO will be held financially harmless. It's a no brainer and ACOs wannabes will flock to this faster than IT consultants glomming onto "meaningful use."

Which, according to Dr. Berenson, is the rub.

If the risk is only upside, the physicians and hospitals pondering forming an ACO will be far more likely to participate, even if they have little interest in true coordination and cost savings. Since there are no penalties for higher than expected spending and they don't have to deal with the unpleasantness of patients being "locked" into their networks HMO-style, they'll figure they have little to lose. Years later, it'll look much like a lottery. Many nascent ACOs will fail while some will randomly succeed. The resulting disappointment may lead to an otherwise promising idea being abandoned.

To combat this, Dr. Berenson has three suggestions:

1. Avoid invisible assignment. While the regulations have yet to be unveiled, it's widely anticipated that ACOs won't really know which patients have been "assigned" to them. Knowing that up front would better enable the physicians to avoid unnecessary costs, patients should know that their physicians may have an economic incentive to withhold care and physicians and patients may ultimately benefit from a mutual social compact. The chance of success will increase.

2. Introduce shared risk. In other words, there should be a downside, albeit "limited and manageable" chance of a loss, using "risk corridors." This will separate the wheat from the chaff. To guard against any significant losses, ACOs that are serious players could purchase "reinsurance."

3. Use a different baseline: Instead of using local costs as the comparison baseline for shared savings, use a) the national projection of Medicare spending growth in dollar terms, or b) adjust the baseline against an national historical risk-adjusted average. That way, baseline wasteful spending patterns would not be rewarded in the reconciliation of the pre vs. post shared savings calculations.

For additional reading on ACOs, there's more DMCB discussion and links to the peer-reviewed literature here.

omg

Measuring Outcomes in Disease Management: An Emerging Standard for the Rest of the Health Care Industry

If you're interested in the evaluation of case management, disease management, care management, health promotion, wellness or other programs that are designed to improve quality, reduce costs or increase satisfaction, take it from the Disease Management Care Blog: you need to download this. It's the recently released and FREE 5th Volume of a series of Outcomes Guidelines Reports that collectively describe the various approaches to the evaluation of outcomes in population health management.

Since different programs may have a mix of preventive and care management services, the 5th Volume offers up a checklist and algorithm that helps you decide on an appropriate evaluation methodology. That's followed by some important insights on minimum standards, qualification for inclusions, attribution, statistical adjustments, assessing various evaluation approaches, meeting client expectations, accuracy, validity, selecting a comparator, time spans, outliers and determining denominators and numerators. There's also an important chapter on assessing the impact of wellness programs. And that's all just for starters.

Case in point? Check out this important graphic that describes the Population Health Management "framework":

The image doesn't come close to capturing the detail in the Volume 5 report, but it's notable for two things: 1) in contrast to the Chronic Care Model, it places the person-health care consumer in the middle of system, and 2) it's quite dominated by measurement. In fact, to the DMCB, it almost looks like population health management is being transformed to "applied" real world health services research that breaks down the barriers that have traditionally separated the investigation and the delivery of medical care.

Which brings the DMCB to an insight about the managed care health insurance industry: it thinks one of the reasons it's been so vulnerable to attack is because hasn't been able to build on the initial measurement promise of HEDIS®. It certainly remains an important yardstick for quality among competing plans and it's had its successes. Yet, it's been diluted by a) a slowly expanding process based on hidebound conservatism and quality improvement, b) an aggregation of participating health plans around an uncompelling average and c) declining visibility among buyers, politicians and skeptics - especially during the "government option" debate. While managed care's been sticking to its HEDIS® measures, critics have used other metrics to undercut the insurers' claims that they're all about quality. Fairly or not, they've been accused of cherry picking, rescissions, withholding care, shortchanging doctors and driving up costs. Without objective data and an accepted methodology to assess the extent of those allegations, anecdotes ruled and drove policy. It's still going on. It could be argued that HEDIS® let the health insurers down.

The population health management industry, in the meantime, is fostering a rapidly expanding set of expert measures that not only evaluate the classic clinical domains of care, it's also established processes to measure key economic and quality of life outcomes. With each Report (now up to 5), the industry is leapfrogging its way to a degree of credibility that was absent a few years ago. It may be one of the reasons - despite its proximity to managed care - that it came through health reform largely unscathed.

Ten Reasons Why Fully Insured Commercial Health Insurers Don't Offer Worksite Wellness Programs For Their Customers

During the Care Continuum Alliance's annual Forum10 meeting, the Disease Management Care Blog ran into yet another session presentation by another consultant on the culture changin', outcomes enhancin', money savin' and transformationalin' merits of an employer-based wellness, prevention, health promotin', and exercisin' program. If you understand employee incentives, benefit design, absenteeism, presenteeism, intranets, surveys, getting the CEOs' spouses to also participate and hiring enthusiastic worksite fitness counselors, you too can preside over a tidy positive return on an up-front PMPM employer cost that, according to Health Affairs, averages about $12 PMPM. Not a bad way to make a living.

So if the consultant says so, worksite wellness is a no brainer, right?

Yes, says the DMCB, except in the fully insured commercial market. So far, every time the DMCB runs into another glowing report about worksite wellness, it seems to involve a self-insured business setting. It seems the traditional health insurers - where an enrollee pays a premium in exchange for a commercial health insurance plan covering the cost of any illness - have either 1) decided not pay for worksite wellness programs for their customers, or 2) are not reporting on their experience. The DMCB suspects it's mostly the former: they're not paying.

The DMCB thinks that may no accident. While it was at Forum10, it asked various colleagues about this phenomenon over some beverages and solicited this list of possible explanations for your reading pleasure:

1) When an employer decides to self-insure, it's usually because its leadership believes the company has a healthier population with a lower burden of disease. This means a lower risk, which means reserving less money against any losses. That makes comparatively more money available to pay for health promotion.

2) Once the decision-making about paying for worksite health promotion is taken from conservative insurance actuaries in settings that are heavily regulated by a State Department of Insurance to independent thinking Human Resource Directors and company CEOs, there is little argument: of course health promotion reduces costs and absenteeism, health shouldn't be medicalized and investment in the well-being of a workforce is simply the right thing to do.

3) Many commercial insurers' lines of business are dominated by smaller businesses with smaller workforces. It's mathematically more difficult to demonstrate savings for a company across a smaller number of insured individuals, which makes it harder for commercial insurers to justify the expense in the first place.

4) Commercial health insurers are, well... commercial health insurers. That means disciplined underwriting, adequate premium pricing, accurate claims payment and setting appropriate reserves. Worksite wellness has little to do with insurance and is not only outside their comfort zone, they have no idea on how to do it..

5) The actuaries are in control. They rule.

6) Employers have a stable work force with little turnover, especially in today's economy. While they still manage their health insurance costs on a yearly budget basis, they can afford to take a long-term view and be more confident that they'll eventually recoup their up-front costs in reduced claims expense. Not so in the commercial insurance market, where customers flee to the competition over a few cents difference in the monthly premium. That's called churn.

7) Employers can use a variety of financial and cultural sticks and carrots on their captive employee population to encourage participation in wellness. Commercial health insurers are generally distrusted by their individual subscribers and have fewer options to encourage participation.

8) Thanks attacks by the political class, the uncertainty over the definition of the medical loss ratio and the travails of having to catch up with numerous other regulations that are part of health reform, commercial insurers are rather preoccupied. Now is not the time to worry about worksite wellness.

9) Self insured companies are willing to make time and commit other non-financial resources to making their worksite programs pay off. In contrast, buyers of commercial insurance simply expect their insurer to provide worksite wellness with little to no effort on their part. They won't make room for company wide emails, use of their corporate intranet, time off for employees to do wellness during a workshift or accomodate any other intrusions into the company's workflow. Commercial insurers know that, so why bother?

10) Commercial insurers do offer some value-added gimmicky options that are designed to look like work site wellness, like health club membership discounts or health risk assessments. Every day that these faux programs are accepted as "wellness" by their unsuspecting fully insured customers is another day gone by without a credible onsite health promotion initiative.

This makes for a significant policy challenge, despite the provisions of the recently passed Affordable Care Act. The DMCB sees little in the current law that actively translates the success of health promotion in self-insured settings into the commercial fully insured market.

The DMCB may be wrong. If so, please feel free to comment.

making the best of it

I think I've coped with chemo week much better this time around (thanks in part to some good advice from a friend).

Insights from the Care Continuum Alliance Meeting: Federal Planning, Small Low-Overhead Practices, Full Risk Contracting and Social Networking

A number of insights from attending today's Forum10 in Washington DC:

It seems that once D.C. policymakers get armed with Federal health legislation, they like nothing better than to talk-circuit with bubbled, arrowed, jargon-filled and notion-addled PowerPoints. The Disease Management Care Blog witnessed this first hand today, when it learned from a plenary session speaker that our government is developing a national health agenda that will drive measurement and change quality for the better. All well and good, says the DMCB, but the fact is that it's locally developed programs that have always been the source of real innovation, and that they only use the Feds' resources only when they add real value. The conceit was astonishing.

If physician income is no object, it's possible to set up a small, low-overhead, limited panel clinical practice and still take good care of patients. It may mean that the docs escort the patients back to the single examining room themselves, draw up and administer their own immunizations, carry a cell-phone 24-7 and create their own primitive records on desktop PC's. That was not surprising to the DMCB - what was interesting was the physician-speaker's assertion that doing all that gives that clinic a head start on getting NCQA recognition as a medical home. Will "concierge practices" add claims of also being a medical home to their other supposed virtues?

Conduct one big study of a disease management/telephonic care management program that shows a big return on investment. Check. Get it past peer review to make sure that what you think you've found is correct. Check. Conduct a bunch of similar in-house studies involving other clients that show the same thing. Check. Then, and only then, can you be confident enough to go to market with that program with a guaranteed, full-risk contract option. To do otherwise would be foolish.

Did you know there are 105 million Twitter users? 400 million on Facebook? That there have been 6.5 billion views on YouTube? Yet, while the telecommunications, computer, specialty retailers and the food industry have all tapped into this "social networking" phenomenon to great effect, the health care industry is still looking at it as an answer that's in search of a question. While there are some health care examples of social networking like hospitals (that use it to market and get patient feedback), patient communities (an example is PatientsLikeMe) and the Centers for Disease Control and Prevention (podcasts and videos are out there extolling the virtues of influenza immunization), this has yet to truly fill it's potential. Consumers are worrying about privacy and they'll only use social networking if it yields better information than a simple Google search. As you ponder this for your company, think about issues involving 1) identity (how much personal information must users share?), 2) authenticity (is this really good from the users' points of view?), 3) accessibility (you cannot afford to have your site go down), 4) reputation (users may not trust managed care-run networking, no matter how well-meaning) and 5) reciprocity (this is two way). These and other insights are courtesy of Deloitte. You can read more here.

The Latest Health Wonk Review Is Up!

Economists can be a brainy, insightful and efficient bunch. Put lots of emphasis on efficiency when you take the time to check out the latest health wonk review that's being hosted by Jason Shafrin of the Healthcare Economist. Read it, get rescued and decide for yourself if the DMCB is the victim of wishful thinking.

Quick Impressions From the Forum10 Care Continuum Alliance Meeting

The Disease Management Care Blog's web traffic is noticeably down and it knows why: many readers are preoccupied with the goings-on at the Forum10 annual meeting of the Care Continuum Alliance (formerly known as the DMAA). So, by the way, is the DMCB, which arrived today and has been catching up with old colleagues and making new acquaintances.

Three quick impressions:

Compared to previous years, the disease management vendor exhibit booths seem larger and more garish. This suggests that the industry is feeling more confident about their future. What's more, there seems to be a wider array of exhibitors with wares in informatics, wellness, prevention and pharmacy, with a special emphasis on interacting with consumers through their cell phones. More on this in a future post.

The DMCB also got the impression that the core disease management companies are being sought out by other entities that are seeking a variety of relationships, partnerships and alliances. Two examples were in the area of Accountable Care Organizations (ACOs) and telecommunications (see above).

Last but not least, this is a crowd with a high level of enthusiasm. Thanks to a combination of cash from the Federal health reform legislation and a reemergence of disease management, a.k.a care management a.k.a population health management as a key ingredient in increasing quality and lowering costs, everyone seems enthused.

The Forum10 continues for another two days and the DMCB will be keeping notes for future postings. If you recognize the DMCB, please say hello. The first person to do so will be rewarded with an increasingly rare "DMAA" lapel pin.

What Can Baseball Teach Us About the Return on Investment (ROI) of Disease Management? Nothing, Actually.

Growing up in New York City and then living outside of Philadelphia, you’d think that the Disease Management Care Blog would have a better appreciation for major league baseball. It likes the stadium spectacle (and food), but league standings, box scores, individual player statistics and television game play is as soporific to the DMCB as looking at the aortic valve “Mercedes Benz” sign on an echocardiogram. Try as it might DMCB cannot understand what gets baseball fans and cardiologists so atwitter.

Maybe it's because the DMCB thinks because baseball is so linear. The entire game consists of a series of singular events involving individual players surrounding one ball occurring over the time dimension of nine innings. Sure, there are other moving parts, enormous talent and high drama and but the game has a compelling degree of compact simplicity.

To each their own, says the DMCB, which is one reason why it tried to compact the moving parts, talent and financial drama of disease management (DM) into a (curvi)linear display. This is an admittedly very simplistic and not-drawn-to-scale graph of what financially happens to the return on investment in an ideally executed one-year DM contract:

The black line represents the typical accumulated savings of a well run disease management program over time. Thanks to the use of health risk assessments and predictive modeling, the patients that initially get recruited in the program are those that are a) most vulnerable and b) most amenable to care management coaching and outreach. They’re “rescued” from unnecessarily visiting emergency rooms and being unnecessarily admitted to the hospital. Note that savings grow rapidly. With time, additional patients at lower risk are recruited, but since they’re at less risk, the savings curve begins to flatten out. As more patients get recruited, it’s possible that savings can erode, because the low risk/low utilizing patients can ironically be prompted to seek out additional care services.

The red line represents the cost of the disease management program over time. Initially, there are steep and fixed start-up costs which then slow down over time but never flatten. As additional patients get recruited, more personnel and infrastructure are required for coaching and follow-up. If the program pursues each and every additional patient with multiple attempts at outreach, costs can accelerate.

The small yellow area displays when the savings exceed the cost. That means the "return on investment" (ROI) is positive. That doesn’t happen early in the program and it doesn’t happen late: it's in the middle. Early and late in the program, there are losses. Also note that the ROI is a moving target that changes that as more patients get recruited. This also explains why a positive ROI can be achieved when far less than 100% of patients are engaged in DM.

Of course, this is very rudimentary and doesn't take into account the moving parts of the baseline utilization patterns, the enormous talent of the nurse-coaches and the high drama of how costs and savings are actually calculated.

Every baseball game is arguably unique, but DM is far more complicated. It's sort of like baseball, but all the players have bats, there are 100 balls, pucks and Frisbees in play and the bases move as the game goes on. That's one of the reasons it's so much fun.

The Playbook Used by the Food & Beverage Industry to Avoid All Blame for the Obesity Epidemic, and What Disease Management Can Do

The Disease Management Care Blog thinks that the disease, care and population health management providers deserve a lot of credit for leading the way in our national battle against obesity. This industry "gets it." It's more than just "consumer education" and go-see-your-PCP about starting a diet. While those elements are certainly necessary, disease management also knows about consumerism, engagement, overcoming barriers, behavioral theory, relationships, life-style management, being realistic and follow-through. These vendors are getting far more savvy about studying outcomes and using those data to continuously improve. They are participating in coalitions, joining public health initiatives, off-loading overburdened physicians, establishing partnerships, leveraging community resources, and formulating a compelling business case. They can do all that and still end the day with a tidy profit.

The DMCB also figures the disease management (DM) industry is also well aware of the cynical speciousness of the food and beverage industry's public posture about obesity. At the same time it's intentionally packing calories and salt into servings are both unhealthy and excessive, the food and beverage manufacturers have somehow escaped being lumped with tobacco and pharma. Something is terribly wrong with this picture.

That's the topic of an October 6 JAMA paper by Jeffrey Koplan and Kelly Brownell aptly titled "Response of the Food and Beverage Industry to the Obesity Threat." It's worthwhile reading for those combating the obesity epidemic. It gives special insight on how that industry combats greater scrutiny and regulation as well as why overweight patients desiring to lose weight can be so misinformed. This is important to know about so that patients can be better educated, know what they're up against, overcome barriers and better manage life-style choices.

Drs. Koplan and Brownell's report on the food industry's strategy is summarized below for DMCB readers that may not have full access or lots of time:

Associate with a widely respected health organizations: this gives the casual observer that the industry's wares are good for you.

As the DM industry's role in the crusade against obesity grows, it should probably resist any affiliation with the businesses that profit from making people fat.

Associate with a widely respected connotation: this generates the impression of wholesomeness. The authors mention featuring svelte exercisers on the packaging and in TV commercials, but the DMCB thinks claims of being "green" are also part of the mix.

Ironically, a disease management care plan with overemphasis on exercise as a cure for obesity is playing right into the food and beverage industry's hands. That has a role to play, but the key thing remains smart food choices and long term calorie restriction.

Reframe the issues: instead of addressing the merits of caloric excess, the idea here is to move the focus onto caloric neutrality (a serving of broccoli can be equal to a side order of fries), "in versus out" caloric balance (hence the intrusion of exercise as a fix for being fat; think about that the next time you watch Biggest Loser), keeping collateral societal costs out of the discussion ("even though half of all obesity related costs are paid for with public funds") and trumping free markets (we have a constitutional right to be fooled into making bad decisions).

At the individual patient level, part of the strategy of coaching is to help patients keep their eye on the caloric ball. Thanks to its growing visibility at various policy-making levels, the DM industry should continue to step up and shine a light on those collateral costs and take a greater leadership role in figuring out ways to help people make right decisions. Kudos, by the way, to the Care Continuum Alliance for doing its part.

Deceptive advocacy: this is setting up faux grass roots groups that are allegedly against regulation and taxation.

Hey, it's free speech. The DM industry needs to fight fire with fire.

Deceptive science: consisting of sponsoring biased studies and creating hollow self-regulating standards based on those biased studies.

The DM's industry's long tradition of tapping into vetted guidelines has been an important counterweight in its care for millions of Americans. It needs to stick to that tradition and educate policymakers and politicians about what works - and what doesn't.

Product formulation: it may still be the same air-filled puffs of fructose and fat, but add some vitamins or fiber and "voila!" the overwhelming impression is that it's now good for you.

In its day to day interactions, this and other attempts at caloric camouflage need to be countered one patient at a time. It may be that no patient coaching is complete without addressing that particular falsehood.

Go on the attack: it's not enough to deny any harm. Rather, get a stable of loyal talking-head scientists, lobby heavily, fight every unfriendly public health measure and label opponents as enemies.

The DMCB is looking forward to the day when a member of the DM industry is attacked by the food and beverage industry or one of its lackeys. They we'll know we're getting somewhere.

Health Care Rationing and the Role of Physicians In Its Design

Writing in the October 6 issue of JAMA, RAND physician-scientist Robert Brook ponders how physicians will react to the certainty that current efforts at bending the cost curve will fail and "sooner or later, health care will need to be explicitly rationed." Examples of more local explicit rationing include Oregon Medicaid’s experiment with selective coverage and the use of tiered economic incentives by pharmacy benefit plans.

According to Dr. Brooke, all that remains is a decision on whether the national plan to ration will be led or not be led by physicians. After all, they’re not only generally knowledgeable about health care, but they're trusted by a majority of the U.S. public. Unfortunately, he notes, there is little research on just how U.S. physicians would install "explicit" rationing. Rather, docs seem to prefer using “implicit” and "microsystem" approaches, such as queues (“we can give you an appointment next Tuesday”), subjective priority setting (“that rash sounds worse than the headache”) and networked relationships (“Fred’s referring another patient and I gotta keep him happy").

Dr. Brooke also cautions that the current mix of single specialty organizations, practicing physicians' distrust of ivory tower policy making, physician vs. physician jockeying over the SGR and the one-at-a-time Hippocratic devotion to the "here and now" of each patient make it unlikely that the docs will be collectively able to drive change. The only thing that is buying them time – for now - is that the chances of Washington doing anything about this in the near future is about as likely as witnessing a dermatologist successfully figure out which end of a stethoscope goes on the patient.

While this isn't a pretty picture, the DMCB points out that Dr. Brooks' original premise - that there aren't "systemic" changes that could bend the curve - isn't necessarily correct. As a society, we’ve only just begun to appreciate the interlocking synergies of ACOs plus medical homes plus disease management plus shared decision making plus bundled payment plus value-based insurance designs plus wellness/prevention plus smartly regulated market-based competition. If the premise is that it’ll be up to the vast Washington DC blob-collective to show how it can’t execute on these policy-options, the DMCB agrees that diktat-style rationing will be inevitable.

Plus, there’s another premise of Dr. Brooke’s that isn’t quite correct. Check out this 2006 JAMA article by Dr. Gruen and colleagues that shows that physicians are paying lots of attention, but their focus is on the local community and public health issues such as obesity, poor nutrition, immunizations, substance abuse, and seat belts. What’s more, recall that physicians not only helped lead the way in defanging health maintenance organizations (HMOs) but the AMA’s umbrella organizations were a positive force in the successful passage of the Affordable Care Act.

Last but not least, physicians’ participation in Medicare is not mandatory. Call that BATNA, leverage or a "nuclear option," the fact is that once physicians become actively engaged, they are quite capable of wielding considerable leadership and influence. They may not have a single public service union president, a trade association president or a sympathetic cable news channel that Dr. Brook can point to, but the DMCB suspects that rationing, at this point, is only a possibility. What's more, thanks to their track record, the DMCB is confident that any Central Committee-style planning will be dead in the water unless the docs have a major hand in its configuration.

"body, mind, spirit" a national conference for younger women affected by breast cancer

From the Canadian Breast Cancer Network:

Please circulate this to your network members, friends and family, we would love to see them there!

OTTAWA, Oct 1 /CNW/ - Today, October 1, is the start of Breast Cancer Awareness Month and the Canadian Breast Cancer Network and co-presenter Canadian Breast Cancer Foundation will recognize the month with a unique networking event for 400 young women with breast cancer.

The National Conference, called "Body, Mind, Spirit", will offer young women with breast cancer the opportunity to network with others who understand their situation, find out about the latest research directly from some of Canada's bright young researchers, and follow theme sessions on issues everyone with breast cancer is confronted with.

Young women will have the chance to be supported in all aspects of their cancer journey. Theme sessions for the body include healthy living and prevention; for the mind, sessions on chemo brain, self-advocacy, medical research and the latest about breast cancer; for the spirit will touch on everything from Yoga sessions to a chance for a guided walk in a specially constructed Labyrinth for spiritual centering.

Participants can look forward to frank discussion and to be able to question experts about babies after breast cancer, breast reconstruction, what to tell your children about breast cancer and when, and intimacy and sexuality after breast cancer.

A writing workshop and a creative art session will aid self-expression, and book signings and a breast-cancer related art show will give participants a chance to create art, meet authors and to view theme art by people from all over Canada affected by breast cancer. Poster presentations will cover all that is new from breast cancer resources to community support groups. Author and breast cancer husband Mark Silver will interest many with his experiences and encouragement. .

The conference will feature two gala evenings; a "Dinner and a Movie" night presented by Rethink Breast Cancer, a special glimpse of their upcoming BreastFest with Jonna's Body, Please Hold and an appearance by filmmaker and comedian, Jonna who will present her Girl Manifesto - an uproarious look at our kooky notions of body image, defying the Image Police and freeing your inner renegade. Movie night food at a picnic in the park will feature everyone's favorite treats.

The second Gala will feature an Arabian Night with belly dancing, hand kohl painting, a blaze of color, special décor and treats for everyone present, a banquet as only the Hilton Hotel can produce, and special guest Rock Star Bif Naked who will share her breast cancer journey with her story "Rock Your Cancer".

Canada's own beacon of hope Carole Ann Cole, originator of the Comfort Heart symbol worn by hundreds of thousands, will be one of the speakers at an upbeat closing ceremony.

"Body, Mind, Spirit" takes place in Toronto, October 29-31. No registrations will be available on site for this conference, which is expected to sell out to 400 participants. A special hotel conference rate of $129 per night at the downtown Toronto Hilton will only apply to a block of rooms being held until October 8.

Registration is now open through www.cbcn.ca

I attended the first conference organized by the CBCN in 2007. It was an amazing experience. I'll be attending again this November (I am the fortunate recipient of a scholarship). Will you join me?