Representative Stark Goes By The Numbers In An Attack On The Heath Insurers

The Disease Management Care Blog can put up with U.S. Representative Pete Stark's unrepentant progressivism. It can tolerate his embarrassing partisan bombast. It forgives him for being so easily baited into trading vulgarities with his constituents. However, the DMCB draws the line on the internet posting of monochrome text with simple raw numbers to attack health insurers. Mr. Stark's latest anti-insurer sucker punch describes "hundreds of millions" and "billions" in health insurer profit.

Last but not least, a maroon colored trim? What was the Congressman's staff thinking?

Everyone knows that compared to Congress' health care spending, hundreds of millions and billions are mere chump change. Mr. Stark's faux sticker shock fails to note that the profits only seem high because of the total amount of money under management, most of which is committed to reserves. He also conveniently fails to note that the health insurers' really have an anemic 3.8% net profit margin. Details on Wellpoint's 3.75% and Humana's 1.28% corporate "criminality" can be found here.

Compared to the profits of health information service providers (19%) and medical device manufacturers (12.5%), the real story is that the insurers are being squeezed by the Feds on one side and the provider system on the other. No wonder the newly centrist Obama Administration felt that Mr. Stark's brand of socialism was too awkward and decided to expand funding for Medicare Advantage.

Fortunately, says the DMCB, these inconvenient health care truths can be overcome by smarter web packaging. The helpful DMCB suggests using long-honored below-the-belt content like anecdotes ("until Mrs. Smith decided to buy health insurance after she got sick....") images of circa 1930's dust bowl children and hyperlinks leading to more information extolling the virtues of the Cuban health care system.

And for crying out loud, more "flash," interactivity and, most of all, colors. What are you trying to do, Mr. Stark.... mimic the boring blue-toned CMS website?

All Health Care Is Local. So Are Truly Successful Care Management Programs

If you had to make a wager on care management, would you put your money on local talent and hard work, or blaming inertia and budget shortfalls? Well, thanks to two presentations at the recent Health Canada conference it participated in, the Disease Management Care Blog's betting on the talent and work.

The first was by a physician at a regional hospital that scraped together small amounts of internal and external funding for three interrelated initiatives: 1) hiring a diabetes case management nurse who was shared by 35 primary care clinics, 2) alerting all physicians with "pink sheet" notifications about patient A1cs that are out of range and 3) creating a "standard inpatient order sheet" (an example from another institution is here) designed to combat sliding scale insulin and promote the use of basal insulin. All three led to statistically and clinically significant improvements in blood glucose control.

The second was by a registered dietitian who described how a group health center developed blanket medical "directives" (not to be confused with end-of-life "advance directives") that allowed non-physician professionals to semi-autonomously initiate changes in patients' diabetes care plans while they were interacting with patients via telephone, individually and group visits. Compared to a quasi-experimental control group, multiple measures of diabetes quality (cleverly combined into what was termed a Good Health Outcomes in Diabetes or GHOD score) showed statistically and clinically significant improvements over several years.

Both presentations demonstrated how great programs often have to start with small beginnings, usually involving nimble and dedicated visionaries who understand that good ideas and a successful track record can create its own funding streams, not vice versa. And speaking of a track record, both programs would not have gotten as far as they did without committing considerable resources to recording and analyzing their data on a prospective basis.

Want to start a a) medical home, b) disease management program, c) inpatient work flow solution or d) decision support system but blame the "administration," lack of "funding," colleagues' inertia and other resource constraints? Think you need "support" from the central government, or that you "deserve" square feet and full-time-equivalents and no one will cough it up? It may all be true, says the DMCB, but it was also true for the two presenters above, and they didn't let any of that get in their way. They boot-strapped their way up and were careful to document outcomes along the way. They just "did it."

Last but not least, the DMCB points out that the programs above were far away from the spotlight of academic approbation, policymaker awareness or government support. That is, literally far away, as in the heartland, hundreds if not thousands of miles away. In its travels, the DMCB has found the same has been true in the United States, such as Portland Maine, West Allis Wisconsin, Albany New York, and Boulder Colorado. As we continue to look for good ideas to achieve the triple aim, the Health Canada Conference served as a useful reminder that maybe all we really need to do is look no further than in our own backyards.

i'm fine.

Better than fine, actually. And I have lots of posts stewing in my head (that sounds kind of gross).

But I've had to spend the last few days running around doing all the things I couldn't get to when I wasn't feeling well.

Regularly scheduled (or at least semi-regularly scheduled) programming will resuming shortly.

Insights on Diabetes Management, Courtesy of Health Canada

The Disease Management Care Blog has completed day 1 of 2 of the Health Canada conference on Diabetes Management Programs. While it certainly had much to say in its presentation, the real treat was hearing from the other speakers.

Among the many insights are:

While Canadians are patriots and are loyal to their government-dominated health care system, they readily admit that there are two problems with it: 1) politics intrude in health care policy making and 2) year-to-year clinical program planning can be hostage to year-to-year budgetary funding.

One speaker independently concluded - without having previously read the DMCB - that delivery system redesign with improved scheduling, organization and multidisciplinary teaming with non-physician providers offers the greatest hope for the care of persons with chronic illness. Health information technology and decision support, on the other hand, has little impact on patient outcomes.

One Province allows "stickers" to be placed on the back of insurance cards that are recognized as standing orders by all government labs for regular blood testing, like A1Cs or lipid testing.

While nurse-educator patient coaches are associated with increases in diabetes testing, patients from the same clinics who have not interacted with the nurses also experience increases in testing. The nurses seem to "nudge" changes in physician behavior.

Physicians, clinics or larger systems seeking to achieve outcomes should expect to spend 10% of their budget on data management, analytics and statisticians.

Which diabetes interventions are truly cost saving? You may be surprised by the contrast between how many lead to increased costs and how many actually save money. The global answer, courtesy of the Diabetes Control Priorities Project is here.

The Cost Effectiveness of Diabetes Management Programs, Courtesy of Our Neighbor to the North

The Disease Management Care Blog is broadcasting tonight from Ottawa, Canada, where it is furiously preparing for tomorrow's Health Canada sponsored conference on the cost-effectiveness of diabetes management programs.

So what will the DMCB have to say?

1. Whoever owns the insurance risk should own the disease management (DM) program. That's because DM is ultimately a strategy to mitigate the risk of chronic illness and reduce claims expense.

2. There is an emerging body of evidence that shows DM reduces claims expense and that the savings can benefit the risk-holders' bottom line. See here, here and here.

3. While the U.S. leads the world in per capita health care costs, the rate of increase (a.k.a. "trend") year over year is remarkably high among all industrialized countries. DM is one evidence-based option among many that can blunt that trend.

4. If a nation, province, state, organization, insurer or provider group wants to sponsor or initiate DM, what should it look for? There are several ingredients that are truly universal:

~ nurses that have experience in primary care, are mobile, are credentialed, can work at "the top of their license," are change agents and ultimately enable patients to participate in shared decision making. Docs can't do it alone.

~ information systems that can identify and recruit optimum patients into DM programs. That's because modifiable risk is not evenly distributed in any population. Some persons with chronic illness are not candidates for DM because they are doing well or because they are too ill.

~ it's not enough to achieve outcomes, it's also a matter of documenting them. "Field" research is well within reach, assuming you know how to do it.

~ if you strike the right balance of keeping them in the loop, making life easier and demonstrating real value, docs often support it. Woe to you if you mess it up.

The DMCB will be keeping notes on what others have to say and report on it tomorrow.

Time To Reform Medical Education (and include instruction on population health management)

The Disease Management Care Blog hasn't had much patience for our nation's medical schools. While there are exceptions, too many of them have imperial Deans, all-powerful Chairs, bloated bureaucracies, huge palatial edifices, and a pernicious skill in overproducing specialist physicians. These medical-industrial blobs continue to be unaccountable and tax-sheltered money machines and their leadership just doesn't get it.

Of course, that isn't going to stop reasonable suggestions on medical education reform from appearing in print from time to time. Case in point is a Perspective article by Mitesh Patel, Matthew Davis and Monica Lypson appearing in the New England Journal titled "Advancing Medical Education by Teaching Health Policy." It's just appeared on line, but that's OK because you read the DMCB.

The authors are proposing that the nation's medical schools adopt a "standardized health policy curriculum." They suggest that it focus on four domains: 1) health care systems (insurance, the safety net, workforce health information technology), 2) health care quality (outcomes measurement, quality improvement, patient safety), 3) safety, value and equity (economics, decision making, comparative effectiveness, disparities) and 4) health politics and law (legislation, adverse events and medical errors).

The authors also point out there are three barriers getting in the way: 1) the canard that there is simply no more room in undergraduate education (there is research that says otherwise), 2) the faculty don't exist (er, the truth is that they haven't been hired) and 3) the best way to teach this hasn't been developed (pending research on the topic, that doesn't mean that excellence should be the enemy of the good).

The DMCB wholeheartedly agrees, but being published in the Journal doesn't mean its going to happen. Perhaps what's called for is a top-to-bottom reform of medical education akin to what happened after the publication of Carnegie Foundation's The Flexner Report in 1910 (that's a pic of Abraham Flexner, circa 1895). The Foundation is still at it and many of its current proposals dovetail nicely with Patel et al. Perhaps it's time to link funding or tax policy to "performance," not the least of which should be an increase in the number of docs pursuing primary care careers.

The DMCB will close with an interesting recommendation from the Carnegie Foundation's list of reform proposals. The parts bolded by the DMCB speak to the importance of including team and outcomes-based principles of population health improvement in the curriculum. As a result, it deserves support by the care management community.

As we move forward with health reform, hopefully medical school reform will move to the top of the list:

To cultivate a spirit of inquiry and improvement in learners and in health care teams; this spirit supports both innovations in daily practice that translate into better service to patients, system improvements and improved patient outcomes as well as the development of larger research agendas, new discoveries, and knowledge building.

Wisconsin Teachers: OK To Rank Health Plans and Physicians, But Not Us?

Raucous citizens refusing to leave public places. Political leaders implacably refusing to compromise. A President's politically crafted statements of support. Greece and Libya you ask? Yes, says the Disease Management Care Blog, but include Wisconsin and its public union travails in that list. And one particularly visible group has been the state's public school teachers, who are fighting against proposed changes in their collective bargaining rights, having to pay more for their benefits and, until recently, merit pay.

On behalf of the health insurers and doctors in the Badger State, welcome to our world, says the Disease Management Care Blog. Prior to Madison's political stand-off, Wisconsin's "Department of Employee Trust Funds" had initiated a "3 Tier" health insurance model in which health plans were ranked according to efficiency and quality. Tier 1 plans had the lowest employee premium, which was engineered to attract the largest number of state employees. The state's insurance commissioner and the Wisconsin Collaborative for Healthcare Quality (WCHQ) have also been rating the plans. Since union member enrollment means income, health plans lusting after that coveted Tier 1 status have been undoubtedly rating their physicians. The WCHQ has joined in and has been naming (practice) names.

The DMCB believes it's doubtful that the 3 tiering system and public ratings would have ever occurred without all of the unions' consent. Ironically it seems, they didn't anticipate that this swell idea would be eventually applied to their own members.

The DMCB recalls some of its physician colleagues wishing that they had a union to counter the ratings. The lesson here is that it looks like even a union ultimately isn't going to help in this fight against city hall and its grumpy voters.

Disease Management: An Important Piece of the Puzzle Lives On

An important supplement to Population Health Management is now available on line. Even better, it's all open access.

Much of the issue is devoted to the good, the bad and the ugly of the hapless Medicare Health Support program. It's good, because long-term follow-up may show evidence of a return on the government's investment in remote telephonic coaching for chronic illness, bad because modern versions of remote and targeted telephonic coaching continue to be dismissed by policymakers, academics and researchers alike, and ugly because CMS' aptitude as a research partner in MHS was sorely lacking

The Disease Management Care Blog immodestly suggests a good summary of both the supplement contents as well as the policy issues can be found here. Basically, the DMCB argues continued industry innovation, ongoing translational research and a more sophisticated understanding of the role of "disease management" has made the traditional interpretation of MHS moot. Remote telephonic coaching has since evolved to become one piece of the puzzle in caring for populations with chronic conditions.

Disease management: both the term and the concept warrant its inclusion as a viable option for the care of populations by providers, insurers, buyers and governments.

scoped

I once had a colleague who was a former Fleet Street journalist. I can't remember his name but I do remember a story he told over a particularly boozy dinner.

"The worst kinds of press releases," he said, "keep all the best bits for the end. That's just not how it should be done. It's like reading a news story that says 'A crowd gathered at Buckingham Palace today. There were also fire engines and ambulances. The corgies were brought out to safety. The Palace burned to the ground. The Queen is dead."

As I went on to work in communications, I kept that anecdote in mind and tried to make sure that the most important facts were kept in the lead of my news releases.

But this is not a news release and I can tell my story in way that pleases me.

I had an endoscopy yesterday.

I wasn't terribly worried when the secretary at reception couldn't find any record of me. I credit the Ativan for that. You still feel the anxiety but it's further away. Almost like it's someone else's anxiety.

She must have found me in the end, because I was called into the endoscopy unit, given an id bracelet and told to change into a robe.

The endoscopy unit at the Civic Hospital could use a facelift. The paint was peeling off the walls in the waiting room and the beds in the prep and recovery area are separated by curtains. My neighbour and I learned a lot about each others' medical histories and bowel movements.

Every nurse I spoke to was very taken aback that I should have metastatic breast cancer at my age.

Every one of the nurses was really kind.

The nurse who took my history and prepped me for the anesthetic noted my "crappy veins" but she got the vein accessed in one poke, so major kudos to her.

My bed was eventually wheeled into the room where the procedure would be done. At this point, I met Dr. A. for the first time. There was another doctor with him who introduced himself so quickly that I didn't catch his name. This second doctor, who I assume was a resident (why don't they introduce themselves as such? Residents always say, "I work with Dr. So and So." They never say "I am learning from Dr. So and So. Do they think the patients can't be trusted with this information? This really bugs me because I can always tell they are residents and I would be much more forgiving if they were honest with me) began to very rapidly list off all the horrendous risks of the procedure and then handed me a waver to sign. 

It's a good thing that I had done tons of my own research (and that I had taken the Ativan) because I might have demanded that they wheel me out of there.

Dr. A. asked me if I had signed the waiver and if I had any questions. I said, "I just want to get this over with."

I mentioned my strong gag reflex to Dr. Resident. He instructed the nurse (pompously? Am I being biased?) to give me some extra shots of the anesthetic spray for my throat (I had the distinct impression that the nurse was going to do this anyway but perhaps I am biased). Then they hooked me up to the drip, placed a plastic frame with a hole in it in my mouth and shoved a tube down my throat.

I then proceeded to gag, choke and gasp for breath. Tears streamed down my face. 

I'll never forget the nurse who gently held my head and spoke comfortingly to me.

It's amazing how big the endoscopy tube looked to me. There's no way it could have  been that big in real life.

I heard Dr. A. say something about how studies had shown that the gag reflex was greatly diminished when Fentanyl is administered.

I heard Dr. Resident sound surprised.

A nurse administered Fentanyl via my IV. And then I was really, really stoned (I just read that Fentanyl is 100 times more potent than morphine and I had a cocktail with other sedatives).

Not sure if I passed out or not but I was pretty woozy. I know they called T. to come and get me. And I know that one of the nurses suggested I try and get dressed.

I sat up and nearly puked. The nurse got me to lie back down again.

Lather, rinse and repeat a few times.

One of the nurses gave me some apple juice, which helped.

I asked what drugs I had been given. A nurse looked that up and said with surprise that I had been given a drug in the Valium family and Fentanyl. She said, "No wonder you're so wasted."

I heard someone mention Gravol (known as Dramamine in the US). I now understand why they give it to me each time they give me Demerol at the cancer centre. They gave me a barf bag.

I texted T. to see why he still hadn't arrived. He texted back that he was in the waiting room. I told him to come get me. He said that the secretary wouldn't let him past the waiting room.

If he wasn't allowed past the waiting room and I wasn't allowed to leave without him (nor could I walk on my own), we were kind of stuck.

One of the nurses went to get him.

Before I left, Dr. A. came to talk to me. He said that I am to come to his office in around four weeks, at which time I will get my results. He also told me that there were no visible tumours (see what I mean about burying the good stuff under a whole pile of details?).

I went home and slept for 6 and a half hours. It would have been longer if T. hadn't come into the room to check on me. I was pretty dopey all evening (giving all my online Scrabble opponents an unfair advantage) and hit the hay before 10.

My throat hurts today and I'm still kind of tired but I did get out for a run (it's 10C here today that's 50F), so I guess I'm recovering pretty well.

In a months time, I'll find out if the biopsies revealed any pre-cancerous cells. Or if I have celiac disease. And Dr. A. promised that if they don't find anyting, he's going to want to do a colonoscopy.

What fun.

Provider versus Payer Centric Shared Decision Making Support: There's A Big Difference

By Bob Tavares

In its post “What Can A Hockey Game Tell Us About Shared Decision Making?”, the Disease Management Care Blog may have missed the important difference between physician-centric versus payer-centric models for patient decision support. While efforts to support shared decision making (SDM) have largely been driven by payers in the past, it is now possible for physicians to “prescribe” patient decision aids and track patient compliance directly from their electronic health record.

This brings up three important questions:

1) Can traditional disease management firms re-invent themselves to support provider groups (including Accountable Care Organizations) as they assume more risk? If the answer is “yes,” that will probably mean moving from 30 mega payer contracts to 300 small provider contracts - just to keep revenue flat with smaller margins.

2) Can providers who want to build shared decision making themselves really cobble together all of the pieces? The most advanced medical homes have EMRs, registries, and patient portals but many are still very crude as it relates to population health management (PHM).

3) Will a new class of population health management (PHM) firm emerge that doesn't have the baggage of the legacy firms? That's my bet. There are new PHM companies that have traditional disease management execs at the helm who are building a provider centric solution from the ground up. Business rules are being built to ensure that every patient is connected to the appropriate level of decision support across the continuum of care.

My company is working with over 100 hospitals, many of whom are embracing SDM and positioning themselves to be ACOs. We have a long way to go before SDM becomes the standard of care, but providers are further along than you may think. We estimate we’ll be providing decision support programs to approximately 1 million patients this year.

Time To Share Your Good News

Thousands of Disease Management Care Blog readers have come to recognize that it's possible to launch robust population-based care management programs and simultaneously study and manage the outcomes. That methodology also means that you can also share your results with your colleagues at scientific and industry meetings.

Case in point: the Care Continuum Alliance annual meeting called Forum11. There is still time to submit an abstract. Not only will you and your company get the recognition you so richly deserve, but it will be a great excuse to network and learn at a great meeting. You may even get to see the DMCB in person!

The Latest Heath Wonk Review Is Up

Life IS a box of chocolates, especially when you open up this latest Valentine's Edition Health Wonk Review. Sample the best and brightest of the wonky opinionating - all assembled in one place for your learning pleasure at the Colorado Long Term Care Insider blog. Enjoy!

A Tale of Two Insurers

And it befell in the days of President Obama, when he led the Administration and so reigned, that he held a mighty siege against a great alliance of health insurers. Using a great and wondrous rhetoric, he issued forth with a mighty host and wonderly portrayed health insurers as corporate rabid dogs that should slain'd by a forcefull and enlightened federalism. And a law dubbed The Affordable Care Act was passed.

And so the Disease Management Care Blog hearkens back to Anno Domini 1999, when Independence Blue Cross (IBX) in the towne of Philadelphia was locked in desperate and mortal unpleasantness with hospitals, with the force of two-way lawsuits with many accusations of unrighteous and monopolistic pricing at both small community hospitals and great premier academic centers. The DMCB tells of IBX's then CEO and Duke, Fred DiBona, by the faith he owed us and of pleasant countenance, the crying of his many consternations as a very unjust deed of arms. He personally fell passing sore into disrepute, unable to make joy at any public function without news-bards, city-royalty or clergy laying upon him to cease the ungracious slewing of hospital profitability. And the CEO and Duke DiBona retreated to his castle grievously wounded. And a consensus rose up in the land of "hospitals one, insurers zero."

And yet, while the IBX and other insurers throughout the land were put to flight, policy has made a passing change. Forced into unending jousting tourneys defending The Act unto a host of wrathful Congressional Knights, even the fearsome and noble Sebelius has become a new found believer in State autonomy and putting limits on coverage. For inconvenient political and fiscal reality has rendered onto the Administration a great many insights on the basics of health insurance.

Yet, that is not foremost in the possible undoing of Mr. Obama's carefully laid planning. For IBX has obtained a greatly ironic revenge after the passing of so many years. For now, Massachusetts Blue Cross Blue Shield in Boston is set upon smoting Partners Healthcare, while the populace of that honored land has been of unhappyness over hospitals' billion dollar capital campaigns, hand-off errors and many unsavory business tactics.

Which is why the DMCB so asks if the lay-public now holds a more favorable countenance upon the insurers and is less passing glad with their hospitals. What else can explain the continuance of the Massachusetts Blue Cross Blue Shield campaign? Health insurers are not as angels, but the field of battle now seems of more even level. For the people may be coming to see the insurers as being innocently obliged to pass through the vexsome cost increases, are often blessed with not-for profit status, are preserved by the Affordable Care Act and, of greatest consequence, are seen as - perhaps - unfairly and woefully set upon by the mighty Obama.

more small changes, harder than you'd think

I'm still struggling with working on my small changes in 2011.

This is how I've been doing:

Week 1: Weigh in and record my weight every Monday. 

I was late last week but I have been faithfully doing this. I'm down 5lbs since the beginning of the year. Not sure if there is any causal relationship or if this is due to my ongoing (ahem) gastrointestinal issues.

Week 2: Begin doing strength training exercises developed for cancer survivors. Work up to about thirty minutes, three times a week.

I got off track last week. It's hard to do core work when you have weasels chewing on your innards. I need to stop using this as an excuse not to work my arms and legs, though.

Week 3: Drink no more than five alcoholic drinks per week.

The weasels have helped me with this one.

Week 4: Drink more water. My nutrionist recommended drinking as many ounces as half my weight in pounds.

I've certainly been drinking more water, most days. I think half my weight may be an unrealistic goal, leaving me bloated and running to the loo all the time. I think I need to keep the goal but adjust the amount of water I'm expected to consume.

Week 5: Meditate every day. Start at five minutes and work my way up to twenty.

I have not meditated every day but I have at least half a dozen times in the last couple of weeks, which is around half a dozen times more than I ever have in my life. I still have to fight the monkey brain but I've worked my way up to 8 minutes. It's one way to make time slow down.

Week 6: I decided not to add anything to my plate.

Week 7: Always sit down to eat.

You'd think this would be no big deal but just a few minutes ago, I went to get myself a snack and caught myself eating sunflower seeds, while standing in the kitchen and thinking of wriitng this post. Clearly  I need to work on mindful eating.

Think You Know Everything You Need To Know About Measuring Quality? Think Again

Fast on the heels of this recent Disease Management Care Blog post on a serious shortcoming of mainsteam quality measurement (the routine failure to account for patient preferences) comes this more far reaching and eye-opening JAMA commentary titled "Sudden Acceleration of Diabetes Quality Measures." Authored by Leonard Pogach and Avid Aron, it efficiently summarizes what’s wrong when it comes to trying to do the right thing for populations with diabetes. Thanks to checking in with the DMCB, you’ll do yourself right by familiarizing yourself with the handy summary below on the downsides of our current mainstream approach to “outcomes.”

While readers may believe that only nincompoops and ne'er-do-wells would dare to second guess the National Committee for Quality Assurance’s (NCQA) and Leapfrog Group’s approach to quality for diabetes mellitus, Drs. Pogach and Aron assure us that’s not the case. The Diabetes Quality Improvement Project (DQIP) and its successor, the National Quality Improvement Alliance (mentioned in this AHRQ summary) also reviewed the science of diabetes control and concluded there was insufficient evidence to warrant recommend an A1c of 7% or a blood pressure of less than 130/80. In the years that followed, they may have turned out to be correct. The ACCORD study showed that an A1c of 6.4% resulted in an increased death rate (here) and a blood pressure of 119 systolic was ultimately no better (here) than a blood pressure of 133 systolic.

So, how did the NCQA get it wrong? According to the authors, measuring quality in populations demands a more nuanced, conservative and go-slow approach. To wit, what is needed is a measurement methodology that:

is continuous - right now, most measures are "binary" i.e., measures are boiled down to meeting a single measurement threshold. Since benefit and risk are non-linearly associated with diabetes control, quality assessment should recognize that there is a difference, for example, between an A1c of 7% versus 8% versus 9% and higher.

accounts for selection bias - not all populations that selected for measurement are the same, so comparisons of quality between groups may be prone to bias.

is amenable to case-mix adjustment - if any known sources of bias are present, they should be statistically accounted for.

accommodates patient preferences - take the DMCB's word for it, a significant number of highly informed dabetes patients do not want a low A1c or blood pressure if it means taking more pills.

minimizes measurement variability - blood pressure measurement is very operator dependent and even blood tests can also vary.

is not used until potential harms like hypoglycemia (low blood sugar reactions) and polypharmacy (too many pills) are fully accounted for.

The authors recommend that the Agency for Healthcare Research and Quality take things over. They're more likely to be accountable, take other viewpoints into account, be fully transparent and would probably agree to have everything televised before any quality measure is formalized for widespread use.

The DMCB isn't sure that it necessarily agrees with blowing things up and starting over, especially if it involves a government agency. While it thinks this through, one common sense suggestion may be for the science of quality improvement to adopt the principles above for the NEW measures that are coming out. Hopefully, the NCQA is paying attention.

feeling better

Because I've been able to go out for walks and for runs with the dog.

Because I had a really nice weekend and a very nice Valentine's Day (especially for someone who doesn't really celebrate it).

Because I have so many wonderful people in my life.

Because some of my symptoms have improved considerably (and they most definitely did not improve at all before I was diagnosed with the recurrence of cancer).

Because I have survived experiences that have been far more physically traumatic (like giving birth. Twice) than an endoscopy could possibly be.

I am feeling better today.

Will the Congress Change the Health Care Law During the Next Two Years?

No. But I expect the Patient Protection and Affordability Act to be “relitigated” in 2013, to one degree or another.I recently posted on the controversy over the individual mandate. I suggested a number of alternatives to the mandate—including my own ideas.I was asked if I really thought the Congress would change the individual mandate in the short term.As I have posted before, it will be the

Capitatation, a.k.a. Bundled Payments a.k.a Monthly Coordination Fees: So...Why Are They Such A Good Idea?

The Disease Management Care Blog's world is filled with unanswerable mysteries. Is Lady Gaga an eggample of musicianship or has she become some type of bad yolk that's no longer funny? Do modern presidents never dye or do they just gray away? Are bundled payments really the answer to the physicians' income needs?

Lady G and the President resist analysis, but the DMCB thinks of bundling as a version of capitation, where providers are paid with a fixed periodic global payment (per "caput" or head or person) on a periodic (usually monthly) basis. Its purpose is to reimburse the doctor for a packaged suite of medical services. Under "full" capitation, docs are obliged to rely on the payment for practically all services such as office visits or check-ups. While capitation results in a steady cash flow whether patients are seen or not, the downside risk is that the patients' costs may exceed the monthly payments. As a result, physicians may have an economic incentive to withhold services.

More modern versions of primary care provider payment are trending toward a mix of fee-for-service (FFS) and capitation. In other words, physicians are free to bill the patient (or the insurance company) for each face-to-face encounter (where a fee is generated for each service). But over and beyond the FFS, physicians can get an additional per person payment that covers the cost of a suite of additional services, such as other communication (like emails), patient education and coordination of care. This hybrid payment model isn't referring to it as "capitation" but euphemistically describes it as a "monthly care coordination payment" or a "bundled care coordination fee."

What seems to really get the DMCB's physician colleagues excited is the prospect of "risk adjusted" monthly payments. It's complicated, but the idea is to shift more capitated dollars toward patients who require more services based on characteristics such as advanced age or the presence of co-morbid conditions. So, while the monthly payments can range between $5 and $30 per patient per month (PMPM) it makes sense to remit the higher payments for older patients with conditions like diabetes or, for example, those who have been in and out of hospitals with heart failure.

Sounds good, right? Docs can have their FFS cake and eat the capitation too!

The DMCB doesn't think it quite works out so simply because:

1. Insurers rarely find "new money" in its premium dollars. A common approach is to take any scheduled premium increases and use them to pay the PMPM fees instead of increasing the fee-for-service payments. In the end, the physician community isn't really being paid any more. Some are being paid more (thanks to risk adjustment) but that mathematically means others are being paid less.

2. Risk adjustment is a notoriously inaccurate both inside and outside of primary care. As the DMCB understands it, much of risk adjustment is mathematically based on "binary" functions (for example, there is diabetes or there isn't; it fails to account for poorly controlled vs. well controlled disease) and doesn't to account for other conditions that aren't easily detectable that may also drive utilization. As a result, only a fraction of utilization is accounted for, leaving the physicians to deal with the rest.

3. Last but not least, risk adjustment is subject to the same downward pressures that are being applied to all those other good ideas making up the payment systems such as DRGs, RVU conversions, the SGR and even the notorious fee-for-service payments. The DMCB suspects that the bundled payments may seem like a bonanza now, but just wait. The money will dry up faster than Dr. Berwick's admiration for the British health care system. Physicians will be squeezed between trying to make a profit by withholding care or depleting their inadequate capitated fees by providing substandard care.

So why are bundled fees and partial capitation payments systems such a good idea? The DMCB will continue to go ova this this but it isn't expecting to make much headway.

What Can A Hockey Game Tell Us About Shared Decision Making?

The Disease Management Care Blog attended a professional hockey game this weekend and it must say it was quite the spectacle. While the athleticism on the ice was quite remarkable, the real wonderment involved the hometown fans. Questionable referee calls prompted thousands of all ages to chant phrases that the DMCB has not recently read in any medical journals, while the willingness of grown men to display, in stereo fashion, obscene gestures was only last witnessed by the DMCB during an early morning ER shift.

Given their apparent fondness for calorie dense foods and various carbonated beverages, it was also clear to to the DMCB that wellness, prevention and chronic illness management was not at the top of most the hockey fans' agenda. Since there is a ready availability of high quality health care providers surrounding the hockey venue, the DMCB suspects most if not all of the gluttons on display were well aware of their downsides of their risky lifestyle.

So, is that their doctors' fault?

While the DMCB was at the American Medical Association's National Advocacy Conference, it was repeatedly reminded that the preferred physician answer is "hell no." While the DMCB's colleagues recognize the key to control of chronic illness is patient education, the sense of powerlessness over this issue was telling. Doctors talk, patients listen and, when the next visit rolls around, nothing has changed.

Enter "patient centeredness." This has been defined by the Institute of Medicine's Crossing the Quality Chasm report as any care that is “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." So, if a physician provides whole person care, comprehensive communication, coordination, support, empowerment and access on Friday afternoon and the patient washes three jumbo dogs and a plateful of nachos down with a pair of brewski's that Saturday night, is that a breakdown in a physician-owned care process?

Common sense says no, but our systems for quality improvement have yet to catch up with this reality. Ultimately, says the DMCB, patients should be able to fully participate in shared decision making and decide for themselves whether an ideal body weight, an A1c less than 7% or taking extra blood pressure pills is worth it. Assuming they've been apprised of all the risks, benefits and alternatives, that should be their decision to make. Given their behavior at the hockey game, patients certainly enjoy making full use of their right to make bad decisions.

Which leads the DMCB to three recommendations:

1. In addition to measuring "process," and "clinical," "economic," and "other" outcome measures, perhaps its time for the health care system to start learning how to measure "shared decision making" outcomes including counting the number of times patients at risk (the "denominator") participated in a state-of-the-art risk reducing, engagement seeking educational session (the "numerator"). The DMCB has little doubt that when this is done right, variation will diminish and the quality curve will shift toward the better. Physician buy-in will also increase.

2. Physicians should be free to assume personal responsibility for the task of seeking patient engagement during all the free time they have (not) during their face-to-face patient encounters. A more reasonable alternative may be to outsource this, either to the other team members in a patient centered medical home or to a companies (like this) that can scale this from one to thousands of patients.

3. Finally, hockey fans should recognize that persons unengaged in personal health improvement or risk reduction who also have no redeeming physical characteristics are not helped in their appearance by wearing a foam replica of an oversized hockey puck on their head.

Alternatives to the Individual Mandate—Some Are A Lot Better Than Others

With Constitutional challenges to the individual mandate now threatening the very life of the new health care law, Republicans aren’t the only ones that would like to see it jettisoned and replaced with something better.And it isn’t just the Constitutional challenges that are prompting a second look. The mandate doesn't work politically and it doesn't maintain the integrity of the market because

when Google is not your friend

So I've been having some (ahem) gastrointestinal issues for a while. Last spring, I was diagnosed with GERD. Things got better after I made some amendments to my diet and started taking meds (so much better that I got lazy about the diet and just took the meds). But now the issues are back in spades, along with abdominal discomfort and a feeling I can only discribe as "weasels chewing on my innards."

A couple of weeks ago, I went to see my GP who doubled my dose of the meds, ordered some blood tests and other (ahem) samples and put in a referral to a gastroenterologist. She told me that it would likely be a six month wait.

I had chemo on Tuesday, February 1st, which means I should have been feeling more or less like myself on the week end. I did not. By Saturday, I was still achy, weak, nauseated and the stomach weasels were out in full force. On Sunday, I felt no better.

On Monday, I went back to my doctor. 

She examined me and, to my enormous relief, reassured me that my liver is where it should be (not swollen and tender like it was when I was diagnosed with liver metastasis. She also said that I should  take comfort from the fact that my blood counts, taken less than a week before had shown all my liver functions to be perfectly normal.

We discussed the possibility of me having contracted a parasite or a virus (I certainly know enough people who've been ill, including my two kids. My suppressed immune system - from the chemo - makes me susceptible to every passing illness) or that anxiety could be playing a role in my physical condition.

My doc is a great advocate, though, and she picked up the phone while I was still with her and left a message for the gastroenterologist, asking if I could be seen more quickly.

I left her office feeling almost euphoric, with all health related anxiety pushed to the back of my mind (there was enough other anxiety to take up all the space in the forefront).

Then yesterday, I got a call from my doc's office, telling me that I have an appointment with the gastroenterologist - and an endoscopy - scheduled for February 17. That's really soon.

I've heard that endoscopies can be really traumatic experiences, so I Googled "endoscopy" just to reassure myself (seriously, that's what I told myself).

Well, not only do I not feel reassured (they shove a camera down your throat to look at your innards! I have a very strong gag reflex) but I am now freaking out about the test and about exactly what it is they might find down there. It could be nothing. Could be something relatively benign. Or it could be...well I'm trying not to think about it.

I haven't been for a run in more than a week because of chemo and the (ahem) gastrointestinal issues. But I think I might risk it.

The Affordable Care Act Mandate: It Comes Down to Optics

Early in the course of the Disease Management Care Blog marriage, the spouse would target an important non-optional purchase for the DMCB spawn and tell her husband to hand over the cash. Provoked by a loss of control and a spike in circulating blood testosterone levels, the annoyed DMCB would resist. After listening to its sputtering claims that it was better suited to evaluating the merits of said purchase, the shrewd spouse relented.

After listening to very smart dueling lawyers (Simon Lazarus of the National Senior Citizens Law Center and Ilya Shapiro of CATO) at the AMA National Advocacy Conference, the DMCB decided that a key part of the debate over the individual mandate is the tangled DMCB-spouse-spawn purchasing relationship writ large.

The debate over the mandate (which, by the way, has been supported by the AMA for years) comes down to the "optics" on whether there is a difference between:

a) the spouse (government) collecting the 'hand-overed cash' (taxes) to make a purchase necessary for DMCB spawn upkeep (health care insurance),

versus

b) the DMCB (a citizen) being obliged (mandated) to spend its own cash to make the necessary spawn-upkeep purchase (health care insurance).

Supporters of the mandate point out that the Feds can use payroll taxes to force us to purchase Social Security. It can also use its taxation powers to purchase Medicare Advantage on our behalf. The only difference in the mandate scenario is that the Feds-spouse are taking themselves out of the middle. In the end, it's the same outcome.

Opponents of the mandate make an important distinction between it and taxes. While taxes are as certain as death and can be used by the spouse-government to buy anything on our behalf - examples include Fannie Mae (mortgages), GM (cars) and AIG (insurance) - it shouldn't necessarily be able to oblige DMCB-citizens to buy the stock of Fannie Mae, GM or AIG, even though that's what is happening anyway. It also can't require citizens to buy their mortgages, cars or insurance products either.

Supporters say a key distinction is that health care is unlike mortgages, cars or insurance because it's not optional. Opponents retort neither is food and shelter.

And so it goes.

The DMCB has previously examined the Affordable Care Act's (ACA) "individual responsibility" and "penalty" language (as an aside, to its knowledge, the word "mandate" never appears in the Act itself). It recalls a craven Congress wanted to avoid the political atmospherics of a "tax" while simultaneously supporting a private health insurance market. It turns out that the legislative cure may have been worse than the disease.

As an aside, during Q&A, the DMCB asked about fast-tracking the ACA-mandate legal challenges to the Supreme Court. The panel pointed out that the appeals process will allow both sides to sharpen their legal arguments, enable a better review by the Supremes and, ironically, prompt Congress to start thinking about "Plan B." Good points but, then again, they're lawyers.

By the way, as the years have passed, the DMCB just hands over the money.

the dog ate it

My 12 year old has been asking for a Blu-Ray player. 

We've informed him, many times, that given our current need for fiscal restraint, this kind of luxury is not in the cards, for the time being.

This morning, he and I were cuddling with the dog and talking about how much we love her. S. asked about her ongoing skin issues and when she's going to start her latest hypoallergenic diet. 

Me: "When the new food arrives at the vet."

S.: "Poor Lucy."

Me (sensing a "teachable moment"): "We had another big vet bill this week. Enough to pay for several Blu-Ray players."

S.: "Really?"

Me: "Yup. She's not the reason that finances are tight but she's one of our priorities. We love her and we have a responsibility to take care of her. The food, medicine and tests - it all adds up."

S. (grinning affectionately at Lucy): "So the dog ate my Blu-Ray."

He's a good kid.

A Hearty "Good Luck" To Two Victims of the Affordable Care Act

While the health reform hand-to-hand combat continues, the Disease Management Care Blog had a chance to see two features of the Affordable Care Act (ACA) up close and personal.

The first was courtesy of the AcademyHealth National Health Policy Conference, where there was a breakout session on how employers will have to cope. It wasn't pretty. The speakers, who were experts on the ACA's wording and the likely supporting regulations, described an emerging horrid thicket of employer and employee tax credits, penalties, fines, benefit design rules, assumptions, subsidies, gaming, audits, reporting requirements and what-if calculations. The DMCB figures that companies that want to buy health insurance for its employees will eventually need to hire a small army of tax and benefit consultants and, despite trying to do the right thing, will still risk being in violation of some rule some where. It's so complicated, the DMCB predicts that it won't be the "money" but the indirect costs, administrative burdens and hassles that will lead to businesses bailing out, paying the fines and pushing their hourly employees into the individual market health exchanges. The DMCB heard that the ACA's architects ultimately wanted employer-sponsored insurance to waste away, and it looks like they'll get their wish. Despite this, however, the message was that the employers liked some features of the ACA and were patriotically planning to comply.

The DMCB wishes our nation's employers good luck.

The second was at a separate conference a few blocks away, where Acting Medicare Administrator Donald Berwick spoke. The good news is that Dr. Berwick's comments amply demonstrated his smarts, credibility and passion. He genuinely believes in the merits of health system change involving electronic records, self-directed care, team-based coordination, dissemination of best practices and paying for value. He supports the ACA "after thinking about it," avoided any gratuitous comments about his boss and brought a roomful of physicians to their feet in a standing ovation. The bad news is that he naively thinks aggressive Federal activism is a good thing for patients and doctors everywhere, that there is broad political support simply because the Angels of Light are on his side and that the huge expanded Medicare bureaucracy is up to the task of leading and executing on centralized health system reform. Dr. Berwick is a good man, but his challenges are practically insurmountable.

The DMCB wishes Administrator Berwick good luck.

Things Are About to Get Ugly—-Republicans Plan to Defund the Health Bill Next Week

Word is that House Republicans will attach an amendment to the latest federal spending bill that will cut-off funding for the health care bill.The last Congress never finalized a budget for the current fiscal year—the feds have been operating under a series of continuing resolutions. The most recent one will expire on March 4th. If another resolution is not agreed to, much of the government has

The Disease Management Care Blog Proudly Presents the 124th Cavalcade of Risk

Welcome to the Disease Management Care Blog's hosting of the 124th Cavalcade of Risk. Every few weeks, writers like the DMCB get to submit their on-line posts for inclusion in the CoR. Bloggers take turns hosting the CoR by selecting the best, summarizing the posts and providing links back to the original post for further review. Think of this as a virtual convention of writers who blog about risk and want to share our best recent work for your reading pleasure.

The DMCB likes to regularly write about health care, primary care, insurance, health reform and disease management. As a result, it often strays into the topics of measuring, monetizing, moving and mitigating risk. As a result, it couldn't resist a chance to host this CoR.

The DMCB has divided this Cavalcade of bloggery into two categories. The former are of the very high quality "thinking" persuasion that critically examine some new aspect of policy, regulation or the business. The latter are peripherally associated with risk but spill over into money management, employment, credit, value and personal security. They are more "informational" in nature.

Thinking Contributions

Louise of the Colorado Health Insurance Insider quotes the President of a state medical society about comparative effectiveness research (CER) and likes what she hears. Doctors need to be confident about which treatment option among many offers their patients the greatest value, says she. If every doc follows Colorado's example, maybe we'll be on the way to achieving real health reform, not just health insurance reform. The DMCB wonders if anyone has done research comparing health care quality among physicians who believe in CER versus those who don't.

If we're going to have a mandate for health insurance, why not the same for mishaps related to gun ownership? Nina Kallen of the Insurance Coverage Law in Massachusetts blog points out that insurance generally only works for unintentional accidents. She thinks it's a lousy idea. Most shootings are intentional, so it'd be difficult to price and regulate. Yet, thinks the DMCB, health insurance covers intentional injuries and what about the person who knowingly continues with a lifestyle that is harmful.....? Maybe that's why we should have a tax and not a mandate. Maybe that's why health insurance is broken. You can think about this knotty issue here.

Auto accidents, falls, skin injury, being impaled, electrocution, amputations, being trapped in a building, exhaustion, dehydration, heart attacks, lumbago and being gassed are all risks that share one key characteristic. Want to know what that is? Then head on over to Julie Ferguson of the Workers' Comp Insider Blog, who succumbs to the blogtemptation of an informative "Top Ten" (in this case "12") List (Speaking of "cold," the DMCB spouse would have little problem with her husband heading off into space if she were recovering from a gunshot wound to the head. It's his coming back that she'd have the problem with).

Have you heard about the Obamacare "mandate" and "risk pooling," but never quite grasped it? Jason Sharfrin of the Healthcare Economist provides a remarkably clear explanation while dismissing Florida Judge Vinson's controversial decision. The DMCB worries, however, that in both scenarios, the total cost is approximately the same, it's just spread around more people and is less visible. Unfortunately, for Mr. Obama, it appears U.S. health care costs are being spread around and are more visible. Not to worry, however, since lawyers on the Supreme Court will have the answer.

Somewhere in the Affordable Care Act is something called the "Community Living Assistance Services and Supports (CLASS) provisions. This is a voluntary, tax-qualified long-term care assistance program that is administered by the federal government. Henry Stern of the InsureBlog has been closely looking at this from a "nuts and bolts" insurance perspective and doesn't like what he sees. After reading it and checking out its links, you may not either. That was certainly true for the DMCB.

Russell Hutchinson of Chatswood Consulting examines the insurance concepts of the "booster benefit" here and benefit exclusions here. The former is mysterious and the latter is pernicious. Both appear to be situations where it may really pay to have a broker on your side who can explain all this to you. Lacking a broker, another option is to regularly read the Cavalcade of Risk as well as the Colorado Health Insurance Insider, Insurance Law in Massachusetts, Workers' Comp Insider, Healthcare Economist, InsureBlog, Chatswood Consulting and DMCB (via Twitter, Facebook and RSS) every once in a while.

Last and least, the DMCB offers up another public service, informational and humorous video portraying a fictional conversation between an enthusiastic Accountable Care Organization administrator and a skeptical health care consumer. While ACOs are the darling child of President Obama's health reform efforts, there may be less to these details than meets the eye.

Informational contributions:

Indexed annuities. Their complexity is part of their fascination.... and risk.

Parachuting. Here's why you shouldn't.

Think you can beat the markets when it comes to investing? Meet your competition.

Income not keeping up with your job responsibilities? Here's what to do.

If you think $10 is not a lot of money, here's 9 good (along with one bad) reasons to think again.

Lending money to family and friends calls for some tough discipline.

Mixing your 401K and a cash advance loan is risky. If you must.

If you are considering opening or managing your own IRA, here's some facts.

Inflation is lurking out there, so you may consider some hedging strategies.

You: road warrior. Your device: iPhone. Your need: travel apps. Lots.

Credit cards can get you into credit trouble. Ironically, they can also get you out.

Speaking of credit cards, AmEx will extend product warranties with the usual exclusions.

Risk is known, knowable and unknowable. Know why here.

If you are tired of paying too much for routine care maintenance, pop this hood.