Has the Florida Judge Stopped the New Health Care Law in Its Tracks?

Reading page 75 of today's Florida opinion it sounds like that is his intent:(5) InjunctionThe last issue to be resolved is the plaintiffs’ request for injunctive relief enjoining implementation of the Act, which can be disposed of very quickly.Injunctive relief is an “extraordinary” [Weinberger v. Romero-Barcelo, 456U.S. 305, 312, 102 S. Ct. 1798, 72 L. Ed. 2d 91 (1982)], and “drastic” remedy [

Moderating Risk for Health Insurers: They're Very Much In Charge and Will Stay That Way

When you listen to the health reform advocates, it's easy to conclude that the health insurance industry's days are numbered. Thanks to health reform, goes the logic, those malevolent insurers will no longer be able arbitrarily rescind policies of patients and refuse to pay doctors what they deserve. They're going to be defanged by empowered, organized and regulated provider organizations that, thanks to their enlightenment, accept insurance risk and reduce costs. As a result, they say, direct buyer-provider contracting will turn those evil insurers into hollowed-out utilities that are destined for the scrapheap.

The Disease Management Care Blog respectfully disagrees. There is considerable market demand for the intellectual and financial capital it takes to manage risk transfer. Insurers know that, and they're not about to let a hostile President armed with bad anecdotes from the broken individual market get in the way of their fiduciary duty to find the best quality at the lowest cost for their tens of millions of enrollees. For many insurers, then, notions like wellness, disease management, the medical home and ACOs are subject to the same tough greenshade scrutiny: show me the money.

Which is why the DMCB thinks this Hawaii Medical Service Association (i.e., Hawaii's Blue Cross Blue Shield or BCBS) press release is telling. By way of background, recall that Healthways has been working with HMSA for years. Based on positive outcomes such as this, HMSA has basically decided to completely outsource health, wellness, prevention and disease management - along with over a hundred employees - to Healthways. The contract can't be a small one and may be one reason why the company continues to hold its own.

Which leads the DMCB to two lessons for the Healthways-style wannabe ACOs, medical homes and care management companies vying for a piece of the "risk" action:

Show you can really and meaningfully reduce risk and increase quality and only then will you succeed. For example, the Patient Centered Medical Home (PCMH) has begun to show some mojo in this regard, and if the initial success continues, it will be rewarded in more and more settings.

What is given can be taken away. Healthways learned that lesson bitterly years ago thanks to another BCBS plan. While the DMCB is not privvy to the details, it expects HMSA will aggressively monitor how its partner is performing on an ongoing basis. As a result, the company will need to prove itself on an onoing basis .... or else.

Doesn't sound like the health insurers are on the run at all.

The Finely Crafted Watch With One Defective Part

From Florida Federal Judge Roger Vinson's decision today on the suit against the Affordable Care Act brought by the governors and attorneys general from 26 states as well as the National Federation of Independent Businesses (bolding by the DMCB):

In the final analysis, this Act has been analogized to a finely crafted watch, and that seems to fit. It has approximately 450 separate pieces, but one essential piece (the individual mandate) is defective and must be removed. It cannot function as originally designed. There are simply too many moving parts in the Act and too many provisions dependent (directly and indirectly) on the individual mandate and other health insurance provisions --- which, as noted, were the chief engines that drove the entire legislative effort --- for me to try and dissect out the proper from the improper, and the able-to-stand-alone from the unable-to-stand-alone.... The Act, like a defectively designed watch, needs to be redesigned and reconstructed by the watchmaker.

If Congress intends to implement health care reform --- and there would appear to be widespread agreement across the political spectrum that reform is needed --- it should do a comprehensive examination of the Act and make a legislative determination as to which of its hundreds of provisions and sections will work as intended without the individual mandate, and which will not. It is Congress that should consider and decide these quintessentially legislative questions, and not the courts.

.... it is reasonably “evident,” as I have discussed above, that the individual mandate was an essential and indispensable part of the health reform efforts, and that Congress did not believe other parts of the Act could (or it would want them to) survive independently. I must conclude that the individual mandate and the remaining provisions are all inextricably bound together in purpose and must stand or fall as a single unit.....

....The existing problems in our national health care system are recognized by everyone in this case. There is widespread sentiment for positive improvements that will reduce costs, improve the quality of care, and expand availability in a way that the nation can afford. This is obviously a very difficult task. Regardless of how laudable its attempts may have been to accomplish these goals in passing the Act, Congress must operate within the bounds established by the Constitution. Again, this case is not about whether the Act is wise or unwise legislation. It is about the Constitutional role of the federal government. For the reasons stated, I must reluctantly conclude that Congress exceeded the bounds of its authority in passing the Act with the individual mandate. That is not to say, of course, that Congress is without power to address the problems and inequities in our health care system. The health care market is more than one sixth of the national economy, and without doubt Congress has the power to reform and regulate this market. That has not been disputed in this case. The principal dispute has been about how Congress chose to exercise that power here.

Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void. This has been a difficult decision to reach, and I am aware that it will have indeterminable implications....

What's next?

Now We Have Real Uncertaintly--The Entire Health Law Ruled Unconstitutional!

We all knew the question of the constitutionality over the new health care law was going to be taken up by the Supreme Court.We knew that because the law inexplicably lacked a severability clause a judge could throw the whole thing out if the individual mandate were to be found unconstitutional and critical to the legislation.And, we expected this Florida judge would likely rule against the law

It Will Be Democratic Senators Leading The Charge To Fix Or Improve The New Health Law

I wrote this Kaiser Op-Ed before today's federal court ruling, that held the entire health care law unconstitutional because of the individual mandate. Now that two federal judges have held the individual mandate unconstitutional, this one overturning the entire law because of it, I have to wonder just how long the Democrats are going to wait before they try to amend the Affordability Act in

Atul Gawande's The Hot Spotters: Targeted Care Management Is Something New?

During World War II, Luftwaffe General Alfred Gerstenberg had a radical idea. Instead of spreading Germany's finite military resources in an attempt to protect every potential Allied bombing target, he argued that the Ploieşti oil fields in Romania warranted the flexible concentration of air defenses. Based on the experience of a prior Allied raid and knowing that oil was vital to the German war machine, the High Command agreed. Herr General got his flak gunnery and fighters. When the Allies finally launched "Operation Tidal Wave" against the enemy on August 1, 1943, the losses were horrific. 53 aircraft and 660 aircrewmen were lost, while the Romanian oil production actually increased in the weeks that followed.

Focusing resources for greatest effect is also the theme of Atul Gawande's article "The Hot Spotters" that appeared in the January 24 issue of The New Yorker. While the military parallels may be a bit of a stretch for the peace-loving peoples of the Disease Management Care Blog, the question remains: should everyone get the same protection, or should we concentrate our special resources on those who are especially vulnerable?

Dr. Gawande, using a common sense narrative laced with some rich anecdotes, correctly argues on behalf of the vulnerable. While they may be few in number, the non-compliant, disabled and socially isolated persons with multiple illnesses are the most likely to be victimized by a dysfunctional and inflexible care system. Instead of oil and war, it's millions of dollars in claims expenses and a fraying primary care safety net. Dr. Gawande describes how the vulnerable can be protected with a high concentration of community-minded docs, nurses and social workers who can simultaneously reach out to these patients and save taxpayers millions of dollars.

And yet, maybe the DMCB's wartime analogy is appropriate. Drawing battle lines at the end of his article, Dr. Gawande points out that "the new health-reform law's" targeted approach, could be "scuttled" by a sinister and unnamed "well organized opposition."

Really? "Where?" asks the DMCB. The "protect the vulnerable" approach has been the standard of care for commercial insurers for years. Population health management (PHM) vendors have been using health insurance claims in very sophisticated statistical algorithms (for example) to spot who is most likely to end up in an emergency room or be hospitalized. Once identified, just as The New Yorker article describes, professional care managers can coordinate with the docs and telephone or visit these patients in an attempt to reduce their risk. Since a single avoided hospitalization can save thousands of dollars, it's not long until the nurses can more than make up for their salaries - and then some - using the same common sense approaches described in Gawande's article.

Until the Affordable Care Act (ACA) was passed, there was no coverage by standard Medicare or Medicaid for care described in Gawande's article. Even with passage of the ACA, it will still not be explicitly covered, pending years of further study of various pilots by CMS. What's more, until the regulations were clarified, there was a good chance that the onerous Medical Loss Ratio (MLR) requirements of the Act would scuttle the commercial insurers' "protect the vulnerable" programs.

Sorry Dr. Gawande. "The Hot Spotters" didn't look in the right place and your discovery of targeted care management is more than a decade late. In fact, the focused and flexible application of resources to achieve the greatest impact has been around for some time for both good and bad. The one good thing about your article is that it may help CMS to catch up with both history and our patients' needs.

welcome to my life

Earlier this week, my friend K. sent me an article from the New York Times that was the best piece of journalistic writing on metastatic breast cancer I've ever read. And I've read a lot on this subject.

I cried when I read it (but as I told K., in a good way) because it resonated so deeply with me, juxtaposing the facts and the experiences of women living with cancer that can never be considered cured. I started to highlight the best bits to share with you here but ended up cutting and pasting more than two thirds of the article.

I've decided that it's best not violate copyright or my own ethics and just post the link and ask you to please go read this article:

A Pink Ribbon Race, Years Long.

One Actuary Beats 250 Experts, Or The Failure To Fight Fire With Fire

If there's one thing that the Disease Management Care Blog has learned over the years, it's never ever second-guess an actuary. When those brainiacs measure and monetize future risk using today's dollars, it's their job to be prudent, morose and unsympathetic. While their forecasts may not be perfect, their methodologies have enabled modern society to financially withstand small mishaps and huge disasters. We mess with that process at our peril.

So when Medicare's Chief Actuary Richard Foster says the ACA wont bend the cost curve, the DMCB listens. The White House, on the other hand, has decided to blog, pointing to a letter signed by nearly 250 Nobel laureates, former Council of Economic Advisors members, one former Congressional Budget Office chief, high ranking economists and budget experts who "disagree."

Aside from the truism that one actuary always beats 250 experts, the DMCB is surprised that the White House hasn't learned from what the State Commissioners do when they are vexed by bad news about premium adequacy: they double down by hiring their own highly qualified actuaries to render nominally independent opinions. The Administration's failure to fight fire with fire makes the DMCB wonder if enough people in the White House really understand just how insurance works.

Speaking of government incompetence, you know it's getting pretty bad when the pro-reform Kaiser Health News allows this critical Michael L. Millenson opinion piece to see the light of day. Michael is shocked, shocked that the Medicare Physician Compare web site is failing to exceed consumer expectations! Alas, the DMCB predicts this won't be the first disappointment for its pro-government enthusiast friends who need to really ponder whether any government bureaucracy is capable of handling what is on this chart. If they still naively think it's all just going to come about because a law says so, the DMCB has a Medicare Health Support pilot that it would like to sell them.

least horrified by the worms

"Alabama governor touches off controversy with Christian comments."

Newly elected Alabama Republican Gov. Robert Bentley, speaking on Martin Luther King Day:

"Now I will have to say that, if we don't have the same daddy, we're not brothers and sisters," he told parishioners at a Baptist church in Montgomery Monday shortly after being sworn in. "So anybody here today who has not accepted Jesus Christ as their savior, I'm telling you, you're not my brother and you're not my sister, and I want to be your brother."

"CNN's Erick Erickson suggests "mass bloodshed" may be necessary if Roe isn't overturned."

From the conservative blog Red State, of which Erickson is editor in chief:

"...once before, our nation was forced to repudiate the Supreme Court with mass bloodshed. We remain steadfast in our belief that this will not be necessary again, but only if those committed to justice do not waiver or compromise, and send a clear and unmistakable signal to their elected officials of what must be necessary to earn our support."

"How much would you pay to eat this man's worms?"

Zoom wrote a post about a guy named Jasper Lawrence "who sells hookworms which he harvests from his own poop." It's really gross but also extremely fascinating.

And I think I'd be more comfortable with Jasper Lawrence than either Robert Bentley or Erick Erickson.

The Latest Cavalcade of Risk Is Up!

This time the Cavalcade is hosted by the medical student author of The Notwithstanding Blog. It is a collection of some very interesting and neatly summarized linked posts from other smart bloggers dealing with the topics of business risk and finance (including moral hazards, statistics, the time value of money and, yes, health reform). It's worth a read by heading over here.

Health Reform and the State of the Union Address

While it is true that the Affordable Care Act is the law of the land, lingering political resentment, second thoughts and inconvenient truths promise to distract President Obama from his new "jobs" agenda over the next two years. Last night's State of the Union (SOU) not only gave the Disease Management Care Blog a preview of the strategy that will be used by the Administration to counter this, but was a lesson on the use of the kind of self-serving rhetoric that the DMCB can use to get its way.

The relatively brief 209 words specifically devoted to health care reform were tucked away in the latter half of the speech. It acknowledged that there were concerns, made use of humor, offered vague concessions, pointed to some favorable anecdotes, concocted a villain, portrayed Mr. Obama's positions as principled and held out the possibility of compromise. In other words, change the subject while trying not to burn a lot of political capital, confound the opposition with time-consuming as well as unsubstantive negotiations outside of the public spotlight and always, but always, take the high road.

The DMCB likes the approach so much, it's adapted the speech to a recent favorite topic:

Now, I have heard rumors that you still have concerns about the DMCB purchase of a multi-media surround sound system with a 3D HDTV. (Laughter.) So let me be the first to say that anything can be improved. If you have ideas about how to improve this situation by making our cable TV viewing better or more affordable, I am eager to work with you. We can start right now by correcting a flaw in the set-up that has an unnecessary wire dangling out the back of the screen. (Applause.) What I’m not willing to do -- what I’m not willing to do is go back to the days when room acoustics could deny us of adequate audio because of cheapo speakers..... (Applause.)

The DMCB also looked into the "skutnik" SOU anecdotes.

One involved a Texan brain cancer patient. According to this link, the DMCB believes the patient didn't buy insurance (or, rather took a big chance) until he developed headaches. The other apparently involved an Oregon businessman who used tax breaks (which generally has bipartisan support) to purchase commercial insurance (that is becoming arguably unaffordable due the lack of any spending restraints as well as mandates). Hardly fair, says the DMCB.

How will the Republicans counter this? The DMCB predicts by forcing the White House speak a lot more words about health reform. By holding noisy hearings and passing unacceptable legislation. By demanding big concessions, finding other anecdotes, portraying big government as the villain while also appearing pleasant, humorous, principled and reasonable. The Republicans have the additional advantage of arguing that a moribund job outlook and scary government deficits are linked to the ACA.

Let the games continue.

Helen Hunt and the Patient Centered Medical Home (PCMH): Making Accountable Care Organizations Want To Be A Better Provider

In the anti-managed care cinematic screed "As Good As It Gets," Jack Nicholson proclaims a famous movie love-line to Helen Hunt: "You make me want to be a better man!" It's an ironic Disease Management Care Blog favorite, and not just because it occasionally shows the DMCB spouse that that statement is not always true. It simply likes the idea that good people can sometimes change dysfunctional behaviors for the better.

Which brings the DMCB to the "Helen Hunt" player in the ACO drama: Patient Centered Medical Homes. Given all the hub-bub over the Republican efforts to appeal the ACA and speculation over the pending ACO regulations, the Disease Management Care Blog began to lose track of the PCMH movement. There are still a lot of state and commercial health plan sponsored pilots out there. What is going on?

Based on the numerous confabs it's attended, the many manuscripts it's read, the many conversations it's had and the many blogs it's scanned, the fate of PCMH appears be increasingly linked to that of ACOs. Not content to wait until there's proof that the PCMH actually "works," policymakers have doubled down by mashing the two concepts together. Unless the majority of stand-alone pilots unexpectedly begin to show some solid results, they'll be completely overshadowed by the ACO feeding frenzy.

Which is why the DMCB suggests that if ACO architects can only read one article about PCMHs that they turn to this past issue of Managed Care Magazine. They will be reminded that the bottom line about the PCMH is that most of the pilots are only two to three years old, which is not enough time to make an informed judgment about whether the PCMH not only merely but sincerely and really reduces health care costs. While there are some success stories (Blue Cross Blue Shield of Michigan, Pennsylvania's Southeast Collaborative and Group Health), there are years to go and lots of hard work ahead before anyone knows for sure.

That being said, the article points out that there are some important features that ACOs will need to keep in mind when they build a healthy primary care medical home capacity, namely:

It's not just the desire to do the right thing as much as paying the primary care docs a lot of money. Repeat: a lot of money.

It's not the electronic health record as much as having a patient data registry to track outcomes. In fact, forcing a full-fledged EHR on primary care clinics can be a distraction.

It's not only a matter of the docs in medical homes working smarter, it's also working harder with extended hours on evenings and weekends.

It's not just the physicians, it's getting the patients involved with written provider-patient agreements.

It's not just the big bang change management in large integrated practices, but finding those practices with six or fewer physicians who can achieve consensus and "just do it."

Why should ACOs go to all this trouble? The DMCB argues that the real reason why ACOs need healthy PCMHs is because of the impact that these primary care practices can have.

There is evidence that greater emphasis on primary care - with or without the wrapper of medical homes - is associated with health care efficiency, quality and effectiveness as well as equitable access and leads to fewer unnecessary ER visits and better coordination. Over and beyond that, however, the DMCB thinks when primary care docs have a credible role, i.e. a "seat at the table." in these emerging mega-organizations, it increases the odds that the ACOs will be better able to reconcile their social mission with profitability.

In other words, even if there is no evidence yet that the PCMH reduces costs, having a strong primary care presence will make ACOs want to be better providers. While that may not do much for the an ACO's bottom line, building a robust primary care network may lead all those angry Helen Hunts out there to buy into the "love line."

A Short Efficient Update On More Than You'll Ever Want To Know About Accountable Care Organization (ACO) Patient Attribution (Courtesy of Milliman)

Learning obscure concepts and baffling terms is one reason why thousands of readers continue to return to the Disease Management Care Blog. They know they can count on the DMCB to help them bedazzle their competition with enigmatic yet precise insights that amaze and appall. Case in point is the DMCB discovery of this gem of Milliman actuarial summary paper written by Susan Pantely on the attribution of patients to Accountable Care Organizations. The link is here.

Knowing you're busy, the DMCB offers the concise summary below:

"Attribution" is necessary because ACOs will ultimately be held "accountable" for a population's health care cost and quality. Since ACO's will not have a gatekeeper function, patients will be able to seek care from any provider they choose. Data on the performance of any ACO will therefore only be meaningful if patients can be "attributed" to a provider in an ACO.

Here's a quotable definition. ACO atrribution is....

...assigning a provider or providers who will be held accountable for a member based on an analysis of that member's insurance claims data. The attributed provider is deemed to be responsible for the patient's cost and quality of care, regardless of which providers actually deliver the services.

This attribution can be based on costs, visit number or claim type.

You also need to decide on:

"Patient-based" vs. "episode based" attribution: The former assigns all study duration days (typically one year) of data for each patient to an ACO provider. The latter assigns "episodes" of care for each condition from the first to last provider visit. For example, if a patient sees a nurse practitioner for a sinus infection, gets an x-ray and then sees an ENT physician who orders the MRI, all that gets "bundled" in to an episode. Other unrelated health care costs are excluded from the attribution.

"Single" vs. "multiple" attribution: Patients' costs can be attributed completely to a single provider in one ACO or to multiple providers in one or, theoretically, several ACOs.

"Majority" or "plurality" attribution: The former happens if 50% or more can be assigned to an ACO provider; if 50% isn't achieved, there is no assignment. The latter happens to whichever provider gets the majority.

"Prospective" vs. "retrospective" attribution: Based on past utilization patterns, patients can be assigned to a provider today, who then is responsible going forward for the study duration. Retrospective assigns patients based on past utilization. The former has the advantage of being able to yield timely data. The latter has the advantage of being more accurate.

Note that it's possible to simultaneously use different approaches for different specialties within a single ACO.

Other issues to think about are 1) duration (typically one year), 2) continuous enrollment issues, (if a patient leaves a health plan after 10 months, should he or she be attributed?), 3) no claims (these patients are low cost and their attribution could make an ACO look good), 4) family attribution (members of a family tend to cluster) and 5) risk adjustment.

The author points out that the best mix of attribution methods may depend on the organization and its goals. For example, an ACO that values the involvement of multiple providers may favor combined "episodic" and "plurality" approaches in their attribution algorithms.

The DMCB thinks the bad news is that the CMS ACO regulations may be unable to accommodate the multiple methodologies described above. As a result, organizations thinking about becoming ACOs will need to determine if the narrow range of attribution methodologies proposed by CMS in their coming regulations are good organizational fits.

The good news is that there are now readers who can confidently ask business meeting or policy conference show-stopper questions like .... "That was a great talk, Mike. Do you believe prospective, risk adjusted, majority and patient-based approaches based on one year of continuous enrollment is an important option in the emerging science of ACO attribution?"

Enjoy.

coldest January 24th in recorded history

It was -30C (-22F) or -38C (-37F) with the wind chill when I got up this morning. It was that cold yesterday too. I did go out yesterday but I didn't take a picture.

Zoom did, though.

It had warmed up to a balmy -21C (-6F) by the time I went for my run this afternoon. See the frost on my coat?

This is a very boring post. I wish I had something more interesting to say.

90% in 2020, Health Reform and the State of the Union

When the Disease Management Care Blog views the State of the Union (SOU) this week, it will be keeping the following in mind, courtesy of Mike Chernew et al writing in the New England Journal here:

The accumulated U.S. debt at the end of 2009 was $14 trillion*. While that's a big number, economists use the debt to gross domestic product (GDP) ratio to put things in perspective. The European Union would like to see its members keep it less than 60%. Troubled Greece and Japan - who stepped in to save their banks - have exceeded 100%. Bond markets and economists seem to agree that a sovereign debt ratio up to 90% may be manageable, but not for long. The U.S. was at 53% in 2009 and is on pace, even with the growth of our economy, to exceed 90% by 2020.

Government debt is financed by borrowing, which is accompanied by having to pay interest. About 1.3% of today's U.S. GDP goes to pay that interest, which is likewise manageable. As debt levels increase, the risk to lenders (who fear inflation more than default) also increases, which leads to higher interest rates. So far, the all-important 10 year US Treasury Bond rates haven't notched up, which is good news at two levels. The U.S. government hasn't been forced to pay higher interest rates, which means there is more money for important public programs. In addition, the cost for consumer borrowing hasn't gone up, since consumers are "competing" with our government for loans. That cannot continue forever.

Want to avoid 90% in 2020? Assuming the economy's growth will not appreciably change, you'll have to raise taxes and/or reduce spending.

While increasing taxes seems to be a political bridge too far, the other problem is the tax code equilibrium of "Hauser's Law." Real world tax receipts are remarkably pegged at 20% percent of GDP and always fall short of projected revenues no matter how much they're raised. Economists and politicians are also worried that increasing taxes will harm a fragile economy, which could ironically hamper tax receipts. So that's not a good option right now.

That leaves government spending cuts. In health care, that means the painful prospect of cost sharing, skinnied benefits and higher eligibility thresholds along with reductions in provider payments. While politicians may be tempted to assuage their constituents by pairing cuts with new programs, that will do little to avoid the looming 90% debt to GDP ratio.

The amateur economist DMCB's opinion?

The U.S. is not on the brink of financial crisis, but a day of reckoning is taking shape and there are huge implications for health reform. While the Congressional Budget Office is on record as saying that the Affordable Care Act's tax increases, benefit changes, risk pooling and innovations will reduce the deficit, the inconvenient truths above add up to a good reason to be skeptical.

The lack of any pre-SOU signals about credible spending cuts is lowering the DMCB's expectations. If there is more economic bad news in the coming months, renewed urgency over deficits will mean either a) more posturing with budget gimmicks or b) spending reductions... finally.

The former will increase the risk of rising interest rates, which would hurt consumers and undercut the economy. The latter will mean immediate trouble for two constituencies: 1) the politically marginalized medically indigent and 2) physicians, who have the bad luck of dealing with Medicare (see SGR) and Medicaid payment rates in the middle of a increasingly perfect fiscal storm.

*Not "1.4 trillion." The DMCB appreciates the correction

"Quit the RUC"

Brian Klepper and David Kibbe have a notable column at Kaiser Health News arguing that the American Medical Association's Relative Value Scale Update Committee (RUC) is specialist dominated and steers health care resources away from primary care:Not surprisingly, the Committee’s payment recommendations have consistently favored specialists at the expense of primary care physicians. More

someone pour me a drink

A couple of months ago, I bought a sports watch at Zellers.* The clerk at the store convinced me to get an in store credit card, so that I could get a twenty-five per cent discount.

Against my better judgment, I agreed.

Fast forward to a couple of weeks later, when the bill arrives. Knowing that store credit cards have usurious interest rates, I pay off the balance in full immediately.

Fast forward to a few weeks after that, when I get another credit card bill, showing that I still owe the full amount plus interest.

Annoyed, I call the credit card company to complain. The woman on the other end of the phone was polite and helpful. She quickly identified the error, fixed it and told me to have a nice day.

Fast forward to a couple of weeks later when I start getting calls phone calls from “credit services.”

Now I'm downright irate. I call the credit card company again. The person with whom I speak this time has no record of my previous phone conversation. When I ask to have my card credited with the amount that I have already paid. He informs that's “not how things work.”

This is how Zellers proposes to resolve the problem:

They will send me a cheque covering the amount that I have paid them. And I will send them a cheque to cover my bill.

Allow me to restate this – Zellers is sending me a cheque for sixty dollars. And I'm expected to mail them a cheque for sixty dollars.

They can't just credit me with the money I've paid. I can't pay them online or over the phone.

Zellers and I have to send each other cheques for the exact same amount, so that they can cross in the mail.

At this point, I inform the agent on the other end of the phone that I want to cancel my card. He says that I have to call another number to do that and that he can't transfer me.

I place that call, cancel my card (“No, I say firmly, I do not want to give the company another chance”) and am then told that I have to call a third number to cancel the insurance on the card.

Nearing hysterics, I call the insurance people and am bluntly told (after being on hold for a while) that the insurance is cancelled automatically when you cancel the card.

My spouse will tell you that I am extremely tolerant (to the point of ridiculousness) of bad service, generally speaking. But this experience left me feeling that someone at Zellers needs to give some thought to getting it's act together.

*For readers out side Canada: Zellers is a large chain (like Walmart or Kmart). The Hudson's Bay Company just sold it to Target.

Closing Thoughts on Accountable Care Organizations: A 60% Chance of Making Money and the Concentration of Risk and Power

The Disease Management Care Blog closes its Accountable Care Organization Orgy Week (4 out of 6 of the last posts have to do with ACOs) with two reader alerts.

The first is this very readable New England Journal piece by veteran policy watcher John Iglehart on the latest Medicare Physician Group Practice (PGP) Demonstration results. Ten group practices (two freestanding, two academic faculty, five integrated delivery systems and one hospital sponsored provider network) continued to care for Medicare beneficiaries under fee-for-service, but agreed to invest in organizational change, clinical programs and care management. Doing that meant that they could compete for an upside gainshare based on increased quality and reduced expenditures versus targeted expenditures and "comparison group" measures. Here's the CMS press release, but readers will find the combined clinical and financial results in a neatly summarized table here.

The data are interesting because all of the participants met at least 29 of 32 clinical quality goals but only 6 received any gainshare money over the four years. According to Mr. Iglehart, PGP is a key template being used by CMS to tee up the ACO regulations. It makes the DMCB doubt the nostrum that increased quality means lower cost. More significantly, it wonders about the wisdom of investing millions to participate in a CMS ACO pilot when there is a 60% chance of getting anything back.

The second alert is a repeat of a point made in a prior post: gain sharing is merely a policy stepping stone toward the eventual assumption of insurance risk by these newly formed mega health care organizations. While that experiment in the 1990s was a time of great tribulation, things may be different this time thanks to better information technology and care coordination. Maybe. The prospect of another wave of physician bankruptcies worries the DMCB less than the concentration of power along with the concentration of risk. Not only will these big organizations achieve "too big to fail" status, but they'll be just as tempted as health insurance companies to withhold coverage if it means reducing their losses. If the playing field can be made level, it may not be such a bad idea to have the holders of risk on one side versus the patient advocates on the other. It's like divided government: it's a terrible system until you ponder the alternatives.

Extormity EHR Hilarity

Extormity link here.

More Accountable Care Organization Conference Notes: No Faux ACOs Here!

After a second and equally rewarding day at the Opal Summit, the Disease Management Care Blog has decamped from Austin Hyatt Hotel venue armed with additional Accountable Care Organization insights.

In yesterday’s post, the DMCB mentioned that it discovered there already are a host of ACO-like legal organizations providing patient-centered care to thousands of commercial insurance beneficiaries using evidence-based guidelines and data reporting with feedback under full or almost full capitation. More of them strutted their stuff today. The DMCB was impressed with their physician-friendly culture and repetitive use of the phrase “do the right thing.” While CMS Administrator Berwick has warned the industry that he won’t tolerate applications from faux ACOs, it looks like there are some genuine provider organizations that are primed and ready to go. The only things they’re missing are 1) an upside gainshare contract with Medicare and 2) invites to the conferences, symposia, meetings and forums being held inside the D.C. beltway.

One thing even more striking than the spandex on the Hyatt’s treadmills was that ALL of these organizations had made a huge investment in non-physician coaching programs that, depending on patient need, used both face-to-face and telephonic counseling to change patient behavior.

Additional food for thought:

Organizations that are ready to go for the ACO demos took at least 3-4 years to get where they are today. Unless the building blocks are already present, the DMCB thinks it will be very daunting for a regular hospital or a vanilla physician group to get up to speed by January 2012.

Want to be a truly “accountable” organization? Then you should, in this order, build: 1) an HIT infrastructure that includes an electronic record with an information exchange, 2) a primary care medical home network, 3) nurse-based patent counseling/coaching capability that is either embedded in the medical homes or shared among several medical homes, 4) an ability to assess the needs of your population and your organization’s performance in meeting those needs and then 5) be prepared to negotiate insurance risk-based contracts with the insurers.

Yes, evidence-base patient care protocols are important, but there are exceptions to every rule. Those exceptions are more common that you might think, especially in the elderly. Be prepared to support your providers when they break those rules.

Since it is unlikely that the Federal Trade Commission and the Department of Justice will allow ACOs to zip up an entire local provider market, will ACOs allow those non-participating providers access to their information systems? The DMCB thinks they should because patients “attributed” to ACOs will inevitably wander outside the network and benefit from the information sharing. The economics of upside gainsharing says they shouldn’t allow access, but that wouldn’t be the right thing to do, now would it?

Want to reduce readmissions? Then: 1) have a care management nurse conduct a in hospital visit with the patient, 2) conduct one or more home visits 3) carpet-bomb the patient with phone calls, 4) refer the patient to every community-based organization you can think of 5) over-communicate with the primary care provider 6) expect every discharged patient to be seen by that provider within seven days of discharge and 7) make sure the home health agencies understand you are not out to steal their business.

Heard of “hospitalists?” How about “post-hospitalists,” who are outpatient physicians responsible for seeing a patient within seven days of discharge? Two of the ACO-ready organizations mentioned above are doing this. Really.

While ACOs are taking on gainshares and capitation, they might also want to announce that they have a “center of excellence” that is open for the rapidly accelerating medical tourism business. Since they’re organizing providers to drive better clinical outcomes at lower cost, they could also argue that their hand, plastic or heart surgeons are among "the best" and steal some overseas business from places like the Cleveland Clinic.

That's a picture of the Congress Bridge in Austin, TX. The DMCB walked across it last night to a great barbecue place. The "sampler" plate serving was as big as its head. The DMCB spouse says that's huge.

almost wordless wednesday: playing hookie

He said, "That was perfect."

ACO Conference Notes

The Disease Management Care Blog is broadcasting tonight from Austin, Texas, where it is attending the Opal Events Summit on ACOs.

Some important takeaways:

Power Reform: While you may have been astonished at the degree of power granted to the Secretary of HHS under the Affordable Care Act, it’s worse than that. It was really a conscious decision by Congress to move power on health care from the Legislative to the Executive branch.

ACO Wannabes: There is no shortage of varying provider, hospital, commercial insurer and Medicaid arrangements, partnerships, collaborations and contacting relationships that already involve an array of risk transfer arrangements. This means there are a large host of entities that believe they can step up and be ACOs tomorrow. Once the regulations come out, the DMCB suspects many will be tempted to participate.

Shared Services Model: As the DMCB has suspected, many of the ACO wannabes have invested quite heavily in non-physician led care management that is external to the primary care sites.

Accountable Care Organizations Are Only the Beginning. They’re a “transitional” model of care because, if they work out as planned, many of the easy to implement system changes will result in one-time and short-term savings. In the meantime, the performance baseline will be reset every one to three years. Developing a long-term business model will take “creativity” will be ultimately based on providers assuming real insurance risk.

ACO Marketing: Since patients couldn’t care less about health care policy, how about “We’re accountable, we’re current and we measure.” The DMCB’s suggested brand tag line: “We care, we’re the best and we have results.” You get the idea.

Actuaries! If you’re hoping that ACOs make money, you’ll probably prefer that the projected cost performance baseline is based on a “concurrent” methodology (using this year’s cost modeling) versus a “prospective” methodology (using a projection of last year’s cost modeling).

Whither “concierge practices?" The DMCB thinks that they’ll act as an alternative to the ACO’s patient centered medical homes. If many take root in an ACO service area, that will be an indication that the ACO is failing to adequately meet patient expectations.

A Profession of Faith: If you believe in ACOs, you also believe 1) health care costs are too high, 2) in collaboration between physicians and non-physicians is good, 3) collaboration between physicians and health plans has potential, 4) in data and 5) the eventual assumption of risk by providers.

Should Health Plans Whiter On the Vine? No, because they bring 1) care management experience, 2) a financial back stop and 3) access to other people’s money i.e., capital.

Leveraging: Physicians may be able to hold out for the best deal from competing ACOs with overlapping service areas.

End of Life Care: How does a risk bearing health insurer institute a potentially creepy program that promotes hospice and saves money by reducing hospital stays? By not telling anyone about it.

cluck, cluck.

The following things have occurred in my recent past. My spouse has moved his office to our house and I have acquired a smart phone and the knowledge/ability to send text messages.

 Now that we are in the same house all day, it's possible that we actually speak less. He works in the attic and when I want to talk to him, instead of picking up the phone to call him, as I used to, I'm more apt to send a text (I'm late to the texting party, I know but I'm making up for lost time with a vengeance).

The following conversation took place this morning, via text message (the blog post in question is the one directly below about last night's dream):

Me: "Can you proof my blog?"

T.: "Sure."

Me: "Thanks!"

T. (a few minutes later): "No typos, that I could see. Just weirdness."

Me: "Do you want to have me committed?"

T.: "Hardly. We need the eggs."

Me: "I don't understand."

T.: "Old joke about a man who thought he was a chicken."

Me: "SNORT."

riddle me this

I had a very vivid dream last night.

Perhaps you can help me understand it.

I was a participant in a "So You Think You Can Dance" type show and it was time for three "girls" (I know I am long past girlhood but that's how it was worded in my dream) to be voted off by the other contestants.

When it came time for the results to be read, I felt absolutely relaxed. I was very confident that I would not be cut - and yet my name was the second one read out. I was voted off the show.

While I was surprised at this, my disappointment was fleeting and almost immediately replaced by relief. Euphoria even. I wondered to myself if I'd been voted off because I was viewed as a threat but mostly I was just happy to get the hell out of there.

All of this had taken place in a doctor's office waiting room and the three of us who had been ousted were expected to leave right away. 

But it was winter and I had lots of gear to put on and then I couldn't find my mittens (this kind of thing happens to me in dreams a lot). I checked in the closet, under chairs and then finally in the bathroom. As I left, after giving up, I noticed that the show's producer (a bland, balding man with a pocket protector) was looking worried.

I quietly asked if I could help with anything and he said, "Not unless you can defuse a bomb."

To which I replied, "Well, actually I can."

When he looked skeptical, I handed him an invisible business card, which he took from me without hesitating. I told him to call the number on it to confirm that I was indeed an undercover agent.

I went to the guest room (yes, there was a guest room. It had a single bed and and a faded bed spread, carpeting and a big closet) to lie down and await the go ahead. I was visualizing defusing the bomb and mentally preparing himself.

A few minutes later, the producer came in a with a younger, heavily made up woman (as though dressed for success in a high end law firm). She was holding a set of rental car keys and said, with disgust, "The number you gave us was for a car dealership."

I was perplexed but determined to sort things out. I gestured towards the cell phone that the man was carrying and dialled the number on the car keys. The phone rang a couple of times and then an automated female voice said, "You are being connected to Leila."

The call was forwarded to Leila's voice mail and I said, "Leila it's Juno. I'm at the studio and there's a bomb here that needs defusing. I need you to get in touch and give the OK."

And then my alarm went off (in real life) and I woke up, very disappointed that I didn't get to defuse the bomb.

I told T. about the dream. He agreed that it was pretty weird. I instructed him to call me Juno all day today.

Armchair psychologists: I leave it to you. What the heck did this dream mean? What am I trying to tell myself?

more yoga for those of us who live with cancer

Do you live in Ottawa? Have you been treated for cancer or are you in treatment now? Can you get to Old Ottawa South on Wednesdays at noon? Maureen Fallis, Director of Surround Circle Yoga, Certified yogaTHRIVE© Teacher has put together what promises to be a great program. I'm excited and planning on participating. Care to join me?

YOGA THRIVE

A course specifically designed for people who have an experience with cancer.

“Peace, ease, strength and a renewed sense of being human – this was my experience. It must have been the power of yoga at work!” S.B.

yogaThrive© is a therapeutic yoga program that will help improve body mechanics, breathing, ease, flexibility and strength. This 8-week program is designed to work at a physical level providing for immense shifts physically, mentally, emotionally, spiritually … which could open the door to even more profound changes throughout the psyche. What begins on one level tends to continue at multiple levels – an absolute necessity for full healing to occur. The change can be fast, even when the stimulus or the input appears slow and steady.

Discover the beauty of yoga ~ feel better-stronger, more relaxed and in more control!

Surround Circle Yoga

15 Aylmer Avenue, Old Ottawa South

Wednesdays 12:00 – 1:15pm

January 19 – March 9, 2011

March 23 – May 11, 2011

$88.00 (HST is included)

www.surroundcircleyoga.com

613-730-6649

Accountable Care, Version 2.0 - The Business Line Approach to ACOs

Is the Disease Management Care Blog a picayune naysayer when it comes to Accountable Care Organizations (ACOs)? Is it a petulant personality disorder that accounts for its unwillingness to recycle the progressives' praises, the academics' accolades and the Obama Administration's nostrums?

Fortunately for the DMCB's self-esteem, it found it isn’t the only nattering nabob out there. The latest issue of Health Affairs has an article by another skeptic who reminds us that ACOs are a fragile species. The DMCB also gives author Jeff Goldsmith extra credit for not going completely negative in his article titled Accountable Care Organizations: The Case For Flexible Partnerships Between Health Plans And Providers. After reviewing all the things that could go wrong, he has some ideas on what could be done to make things right.

In other words, while the regulations haven’t even been written yet, but it’s not too early to start thinking about ACO Ver. 2.0.

A lot could go wrong. According to Dr. Goldsmith, early-mover hospitals that already have acquired physician practices are experiencing financial losses. Their initial mistakes were assuming that docs do what their told and guaranteeing their salaries in excess of billings. Once ACOs launch, those blunders could easily compound thanks to allowing the work units to function independently while underinvesting in utilization management, administrative support and clinical discipline. There is a good chance that, once they are confronted with declining revenues and disappointing gainsharing, ACOs will have to turn to the only option they have left: using their market dominance to squeeze higher payments from the commercial insurance sector. At the end of the day, it’ll be managed care that once again cross subsidizes Medicare.

In the unlikely event that gainsharing that's been grafted onto a still dominant fee-for-service system does change physician behavior, high revenue specialists will need to not only need to forgo some of their practice income but agree to a redistribution of what’s left over. That will be a tall order. Physician lines could end up exiting the ACO relationship, becoming large single specialty regional providers with considerable market clout.

Dr. Goldsmith proposes that the commercial insurers rethink ACOs and consider economically dividing payment for medical services into three physician-based service lines. This “modular approach” preserves the better elements of “ACOness” but avoids many of the dysfunctions mentioned above:

Primary medical care: reimburse primary care providers with risk-adjusted monthly payments for medical home services. Unlike full capitation, primary care physicians would be shielded from the downsides of any overutilization, especially for services that they can’t control. Evidence-based medicine at the point of care will hopefully lead to smarter patients, greater coordination and less downstream health care expenses (The DMCB thinks of this an enlightened form of capitation but thinks some fee-for-service is necessary to incent physicians to also provide timely and convenient care).

Unscheduled care: use traditional fee-for service to pay for episodic care, diagnostic services and unscheduled emergency services with the right degree of patient cost-sharing and the right amount of insurer-based preauthorization (The DMCB agrees that using fee-for-service will likewise incent providers to see these patients. The problem is that there is no one-size-fits-all cost sharing, meaning some patients will inevitably forgo care for the wrong reasons).

Specialty care – reimburse hospitalizations or organized outpatient services that involve multiple specialists by using a global payment that pays for a service from the start (the initial evaluation) through the middle (the operation) to the end (all the aftercare services). Hospitals, health systems or physician groups could develop or sponsor “specialty care marts” that organize the care and disburse the payment for each episode (The DMCB thinks this borrows heavily from Porter and Teisberg's book on Redefining Health Care. It liked it then and it still likes it today)

The DMCB is intrigued by this because

1) Payment seems to better “targeted” to the unique circumstances of the three lines. Primary care physicians get a global payment to reimburse them for the tangled suite of services encompassed in a medical home, episodic care is supported by episodic payment and the specialists share in a payment that spans a coordinated period of time that also rewards them for efficiency.

2) Hospital mischief is minimized and restricted to the third line specialty stuff they’re good at. Having a single payment to pay for a span of care is not unlike familiar inpatient DRGs.

3) Instead of ending up with large ACOs that will probably end up being regulated like electric utilities, small clusters of providers can really compete for patients. On the other hand, there is nothing to keep ACOs from using the three payment models above when it comes to their own internal transfer pricing.

The DMCB hopes the coming ACO regulations permit the varied payment methodologies described above.

The House Health Care Repeal Vote, the National Debt, and the Imperative for Democrats and Republicans to Compromise

This week's House health care repeal vote is little more than a political stunt--everyone knows the effort will die in the Senate.But, when the day is done the only way for the Republicans to do anything with the new health law will be to work out a compromise—repeal before the 2012 elections is impossible and it isn’t very likely after the 2012 elections. Even if the Republicans sweep the

Will Dropping Partisan Extremism Extend To Health Insurers?

As expected, the Sunday morning talk shows discussed the prospects for less political vitriol and how to improve care for persons with mental illness. The Disease Management Care Blog won't hold its breath for either.

Even if partisan extremists tone it down, the DMCB thinks Washington DC's culture, a 24-7 news cycle and the start of 2012 campaign guarantees that opponents on the right and left will continue to be demonized, reasonable comments will continue to be taken out of context and the news media will continue to be manipulated. The pessimistic DMCB fears a faux-reformed Obama Administration will return to a familiar pattern of portraying all health insurers as evil. If those attacks stop, maybe change has really taken hold.

While we know that being paranoid and socially withdrawn is associated with murderous behavior, it's not that simple. While it's easy to look back and reconstruct how the terrorists succeeded or how an ice cube melted, it is decidedly difficult to look forward and predict a crash or the pattern of a water puddle. While there are identifiable risk factors for violence, using them to construct a "positive predictive value" is unsuitable for day-to-day use. The DMCB doubts even Congress will contemplate screening everyone with something like the Mental Safety Administration.

The Electronic Health Record: Better Process, Still Need Outcomes

If you are like the non-techie Disease Management Care Blog and only distantly aware of electronic health record (EHR) market trends, you are not alone. It too is unable to distinguish between "XML" and "ONC," and thinks "meaningful use" describes how the DMCB spouse gauges her husband's assigned chore output. That's why it was worthwhile checking out David Kibbe's and Brian Klepper's readable Health Affairs Blog posting "Unfreezing The Health IT Market." While it's unnecessarily fawning over the Obama Administration's enlightened HIT wisdom, it also renders a handy summary of some 2011 trends that us EHR newbies may only be vaguely aware of:

Cheaper and Better: Increased processing power, lower unit costs, more vendors and greater competition have pushed that oft-quoted $50,000 per physician price tag down to a "$150 to $400 per physician per month" price range - free if the doc and nurses are willing to put up with ads. This year may be the EHR adoption turning point.

Modular Plug n' Play: In lieu of Extormity monster-like EHR systems, buyers can tiptoe into limited solutions that handle a single function, like electronic prescribing or quality reporting. This not only "breaks the ice" for skeptical docs, but helps fulfill those remunerative meaningful use criteria. Another reason why this may be the turning point.

Universal Language: While there are many reasons why different EHRs from different clinics and hospitals won't speak to each other, different data formats won't be one of them. It's called "XML." This will be an important issue for Accountable Care Organizations.

Mobile Devices: Unhip desk tops and cables are being replaced by app-festooned iPads with wireless connectivity. This coolness factor may also help spur greater EHR adoption

Clouds: Personal health information is moving from local mainframe storage to remote networks made up of remote servers. While not specifically mentioned in the blog posting, it makes the DMCB wonder about the implications for registries (make it make it easier to assemble the information?) and the personal health record (who is responsible for aggregating and organizing all those CAT scan results, labs and op reports?).

Enlightened Government: While many may doubt the Obama Administration's dedication to free markets, it appears a more level and transparent EHR playing field has led to genuine competition.

All well and good, says the DMCB, but it's still waiting for conclusive, lasting, generalizable evidence that the processes described above lead to meaningfully better and statistically significant improvements in clinical outcomes at lower cost with a better patient experience.

Maybe that'll be something the DMCB can report on in 2012. We'll see.

How To Get Independent Physicians Into An Accountable Care Organization? Here Some Lessons Courtesy of One Large System

The folks at Advocate Physician Partners (APP) argue that they're a national model for Accountable Care Organization (ACO) wannabes. They're saying that because they assert that they've figured how to out how to "Integrate Independent Physicians." The intrigued Disease Management Care Blog first got a close look at them at the recent Health Affairs "Across The Nation In Health Care Delivery Conference" (second video down) and, when it got snowed in today, decided to take a closer look at their hot-off-the-presses published report.

As the DMCB understands it, Advocate Physician Partners is a 15 year joint venture between a consortium made up of over 2700 independent community-based physicians and the ten-hospital/800 salaried physician Advocate Health System (AHS) located in northern and central Illinois. It appears the independent docs are aggregated into the local physician-hospital organizations that make up AHS. Each PHO sends a delegate to the overall APP Board, which has oversight of an entity that can commit with a “single signature” to HMO and commercial fee-for-service insurance contracts.

All their physicians are required to meet individual clinical and work performance measures. Examples of the latter include their number of active patients in a registry, use of computerized order entry and efficiency measures such as length of stay. APP favors goals that also advantage their hospitals and are common across payers. They cite data collection with reporting feedback, strong governance and enforcement of mandatory protocols as the key to their success. As evidence of their discipline, they noted that the "partnership removed more than fifty physicians for noncompliance with their policies on the availability of information technology."

The published "Integrate Independent Physicians Into ACOs" report linked above is modest about its outcomes (eICU, top ten rankings, HEDIS-based measures, asthma care, generic drugs and electronic data exchange). In contrast, their 2010 Value Report, which seems to be based on extrapolated data, says (on page 7) that they've saved millions of dollars.

What does the DMCB think? While this isn't quite generalizable everywhere, there are some interesting lessons when it comes to wrestling the independent docs into ACOs:

When you’ve seen one ACO, you’ve seen one ACO: The Affordable Care Act may make you think ACOs can be neatly categorized. The mix of players in this physician-led APP suggests that the reality will be a complicated mix of integration approaches. This may complicate CMS' ability to draw any generalizable conclusions about physician-led ACOs that can be effectively used in health reform.

Can’t accomplish this overnight: As noted above, APP had a 15 year head start. The current ACO models don't contemplate taking years to develop a governance structure involving the buy-in of thousands of physicians. Pulling something like this off by January 1, 2012 may prove to be daunting.

The need for speed: While APP is herding cats, they've already demonstrated their ACO chops with a signed ACO-style commercial contract. If you think that's complicated, imagine what the Medicare regulator-lawyers are going to do to this. And they are already - and unsurprisingly - behind schedule.

Only works in a city: While not mentioned above, the Health Affairs manuscript points out that APP has not drawn FTC ire because it occupies only 15% of their local market. Being able to simultaneously fire physicians and maintain a base of thousands of providers is impossible in rural America.

Whither disease management? On page 13 of the 2010 Value Report, there is a mention of "personalized one-on-one professional coaching by health and wellness professionals" but in reading further, the DMCB suspects APP has been largely focused on improving the physicians' day-to-day performance. The DMCB suspects most doctor-dominated ACOs will initially stick to that formula, wasting precious physician time on stuff that non-physician professionals can do more efficiently and cheaply. They all come around, which is the real insight from the note that "personalized coaching" has started. Smart move.

The Latest Cavalcade of Risk Is Up

David Williams of the Health Business Blog hosts the latest Cavalcade of Risk #122. If you plan on sharing lotto winnings, having a stranger take out your life insurance, using payday loans, anticipating global leadership deficits, opposing raising the national debt, getting internet insurance, buying a safe car, repealing the ACA, learning more about ACOs and understanding the nuances of risk and more risk, you should check it out. Enjoy!

The Tucson Shootings: Representative Giffords, Predicting Violence Among Schizophrenics and Our Partisan Craziness

The Disease Management Care Blog's prayers go out to U.S. Rep. Gabrielle Giffords and the other victims of the senseless Arizona shooting. So far so good for brain-injured Ms. Giffords' post-operative recovery: consciousness and language seem intact. The bad news is that the neurosurgeons are keeping mum on how well Rep. Giffords is moving the (opposite to the injury) right side of her body.

There is also little information on the underlying motivation of the shooter, who impresses the medically-minded DMCB as seriously disturbed. Yet, while this loon turned out to be especially lethal, it seems he was not all that dissimilar from the borderline functional persons often seen in physicians' waiting rooms. Assuming the media's reasonable conjectures about the presence of schizophrenia are correct, the DMCB points out that it's difficult to predict which persons like him are prone to violence. Concurrent drug abuse (as apparently was the case here) appears to increase its odds. In addition to drugs, this remarkably detailed study of close to 1500 schizophrenic persons also found a prior history of arrest or crime, childhood "conduct" problems, greater severity of mental illness, being homeless and being "nonviolently victimized in the prior 6 months" to be among the more risk factors. Violence prone schizophrenics may also have a different brain structure. When the DMCB adds it all up, it unhappily concludes that the science has not progressed to the point where it can be used to prospectively identify persons at special risk.

Speaking of bad brains, DMCB readers are undoubtedly aware of how the shooting has prompted widespread media commentary on the need to tone down our partisan vituperation. The contrarian DMCB doubts the behavior of persons with significant mental illness are influenced by the likes of Rush Limbaugh or Keith Olbermann; instead, that special pathology seems to be restricted to our political class. The vulgarity of conservatives being linked to crazy anti-government violence has prompted them to brand their liberal-progressive foes with politically motivated opportunism. And so it goes on and on.

The DMCB has a far more benign explanation for its left-leaning friends' perspective in this matter. Whenever it debates the modern role of government with them, many are simply unable to comprehend the DMCB's general tilt toward markets and federalism. Stymied by an obliviousness toward enlightened government and social justice, liberal-progressives can only conclude that the DMCB is evil or suffers from some sort of mental insufficiency. Since the DMCB's bonhomie obviously rules out evil, liberals half jest but also half wonder if it and others like it are "crazy." Given the pervasiveness of that illogic, who can blame some for succumbing to the temptation of painting schizophrenic shooters and conservative opponents to such fine ideas (like health reform) with the same broad brush?