Up and Down Side Risk Proposed In the CMS Notice of Proposed Rulemaking on Accountable Care Organizations (ACOs)

The Allure of Risk!

The Disease Management Care Blog has been culling through a variety of documents that were released today by CMS on the Accountable Care Organization "Notice of Proposed Rulemaking."  What follows is an initial reaction and "first-read" summary that focuses on the proposed payment methodologies.  The DMCB will use the wisdom of crowds in sister blogs to update and correct as necessary.   

CMS proposes to forgo the upside-only "gainshare" and offer ACOs two tracks that have upside as well as downside insurance risk on a prospectively attributed population.

Track 1: Upside gainsharing for two years with two-sided risk on the third year. ACOs that opt for this track will get 50% of the upside savings that is capped at 10% of the benchmark.

Track 2: Upside and downside risk sharing  for all three years. ACOs in this track get 60% of the upside savings, while the downside is capped at 5%, 7.5% and 10% for years 1, 2 and 3, respectively.  Payment is capped at 7.5% of the benchmark.

CMS proposes that the upside risk payment only occur when two things happen:

1) a savings threshold ("minimum savings rate") is exceeded.  ACOs in Track 2 will need to get above a 2% savings versus a calculated benchmark.  Track 1 ACOs, especially those that are smaller or in rural or underserved areas, have both good and bad news.  The good news is that their benchmark can be as low as 0% (especially if they are in underserved or rural areas) but the bad news is that may need to achieve a higher level of savings over that benchmark.  The DMCB read that level may go, depending on size, as high as 3.9%   The smaller population, the greater the statistical variation that can plague the measurement of savings; 3.9% over the benchmarks increases the statistical likelihood that the observed savings are real.

 2) a composite measure of more than 60 clinical quality performance measures is met or exceeed.  Exceeding them can earn extra shared savings: up to 2.5% for Track 1 above (adding up to a max of 52.5%) and 5% for Track 2 (adding up to a max of 65%).  Achieving these measures can also blunt the downside losses.

It appears that CMS also proposes to hedge against future downside adverse risk development by holding back 25% of any bonus.

Next stop: figure out how the benchmarks are determined and what will go into the risk adjustment.

If the DMCB has any of this wrong, please comment!

i'll take it.

No nausea.

No bad taste in my mouth.

No rage or sadness.

No aches and pains.

I'm just very, very tired.

I'm not complaining.

Health Wonk Review Is Up!

While all of us waiting for the ACO regulations to get released today, readers may want to check out the Healthcare Economist's Health Wonk Review - Opening Day Edition.  Just who is on first, what is on second and I dunno is in the bullpen.....?

third row from the top, second from the right

"gleeBE the Musical is the story of a group of talented, ambitious young people vying to get into the fictitious Arts Sanctuary school in the Glebe. GNAG’s spring theatre production, tells the story of their quest for this all-too-often elusive goal."

(Note: The Glebe is a neighbourhood in Ottawa, Ontario).

Seven Reasons Why "Better to Best" Could Have Been Better: A Look at the PCPCC Paper on the Value Driving Elements of the Patient Centered Medical Home (PCMH) and ACOs

From Better to Belly-Up?

What happens when you assemble a roomful of academic and Washington D.C. policy experts who have already bought into a core set of assumptions about the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs)?  Toss in a tape-recording facilitator-consultant and what you'll get is a 48 page impressively titled document called Better to Best - Value-Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations.  The good news is that this is a highly readable, richly quotable and well-referenced "must-read" for ACO wannabes.  The bad news is that, while the title is certainly bodacious, the document ignores a host of critically important issues that are falling outside the participants' closed information loop.  By recycling and repackaging the same old assumptions and biases, the authors have made Better to Best necessary reading, but it is far from sufficient.  The paper was sponsored by The Commonwealth Fund, The Darmouth Institute for Health Policy and Clinical Practice and the Patient Centered Primary Care Collaborative (PCPCC). 

Don't want to deal with 48 pages?  Good thing you regularly check the Disease Management Care Blog.  Thanks to the DMCB, you don't have to read the entire document to know that it describes a set of conclusions from a choreographed, day-long and invitation-only (but the DMCB is not bitter) meeting on the role of PCMHs in ACOs.

Better to Best looks at four areas:

1) the PCMH promises to increase patient access thanks to better     off-hours, telephonic and electronic access, timely appointments, a personal relationship with a provider and reductions in health care disparities;

2) the PCMH is a key and central ingredient in the creation of a "medical neighborhood" that, in turn, leads to the high-value coordination of all those specialty, home care, pharmacy, workplace, home and community-based services.  Come to think of it, a medical neighborhood and ACO are practically synonymous;

3) the interconnections of health information technology (HIT) can optimize engagement, coordinated care and support value - assuming "critical gaps" in functionality and meaningful use criteria are overcome;

4) this is going to need money that could be packaged as some combination of fee-for-service, case management fees, payment for episodes of care or case rates and comprehensive global payments with or without bonuses at the primary care or ACO level.

As you might expect, in addition to cheerleading the merits of transformed primary care and more money, the document is replete with jargon like "policy action items...", "support federal funding..." "involve consumers....."  "create measurement sets...." "research collaboratives..." and "align payment models...."  It then closes with a set of consensus statements about 1) keeping the focus on Dr. Berwick's cherished Triple Aim, 2) measurement, 3) payment model change, 4) learning collaboratives and 5) the continuing role of health plans, providers, academics, employers, federal players, consumers and others.

So what does the DMCB think about findings of this medical home meeting, this transformational talk-fest, this sagacious summit of the select?

There were seven shortcomings:

First off, kudos to the rather contrarian leader of the discussion about interconnected HIT. McKesson's David Nace seemed to be refreshingly skeptical about electronic health records and information exchanges.  Contrary to the HIT groupies magical thinking, Dr. Nace pointed out that this technology won't transform health care, its job is to enable it.  In fact, the Better to Best document strongly implies that HIT has yet to meet its potential. Dr. Nace sensibly recommends measuring the impact of HIT using yet-to-be-defined metrics, adjusting the "meaningful use" criteria to support the PCMH and aligning the MU measures of HIT with those of the PCMH accreditation organizations.  Too bad Dr. Nace doesn't go far enough in worrying that overemphasis on HIT could distract ACOs from the real work ahead.

Speaking of magical thinking, the Best to Better participants seem to be assuming that the ACO pilots are a just a learning exercise on a success-lined path that is preordained to lead to certain adoption of the PCMH.  They may wish to reconsider their hubris.

Thirdly, aside from some standard clichés familiar to any reader of the New England Journal or Health Affairs, there was very little real-world focus on the patient.  Sure, the PCMH, medical neighborhoods and payment reform will benefit patients, but where is mention of the tailored care plans based on the patients' values and preferences that take full advantage of self care, the support of family and the nuturing of community?  Where is the shared decision making that - to paraphrase one extremist - transcends Outcomes Ver. 1.0?

Fourth, the summiteers assume that a "personal physician relationship" combined with better after-hours and remote communication will increase access, while failing to note that the published literature on the PCMH supports reductions in the standard 2200 patient physician panel size (Group Health's PCMH program reduced physician:patient ratios from 1:2327 to 1:1800, it's 1:1200 at the VA's version of the PCMH and this review quotes an average  22% panel size reduction).

Fifth, there is no recognition of the physician-hospital tension that will certainly underlie ACOs.  To be blunt, if the PCMH is the key to ACO success, the primary care docs in those PCMHs have to have a meaningful say in day-to-day-operations and be able to direct where the money goes.  If the physician-hospital relationships doesn't go well, ACOs will not go from Better to Best but from "Better to Belly-up."  'Nuff said.  The image tells it all.

Sixth, speaking of which, who says sufficient numbers of docs can or, come to think of it, want to transform their practices into full PCMHs - especially when you read some of the docs comments at the bottom of this ACO article.  To wit: "another flavor of HMO"..."lower provider revenue"...."dubious ethical validity"..." pit the doctor against the interest of the patients"..."black box"... "alphabet soup"..."regional healthcare  monopoloy"..."place physicians at the mercy of the hospitals"...."ACOs are more dangerous than HMOs"...."ration care through ACOs."  It may be presumptuous to assume that all docs will buy into the notion that a PCMH-ACO is a win-win no-brainer.

Seventh, or last but not least, there is no recognition in Better to Best of the existence of a huge group of organizations with two decades of experience in patient education, promoting evidence-based medicine, extending the reach of physicians, mitigating (and accepting) insurance risk, delivering on outcomes-based (including gainshare) performance guarantees and delivering versions of the Triple Aim in commercial and government health insurance programs.  While the Best to Better conference participants have the luxury of their theoretical nostrums PowerPointed in one day meetings, the statutory fact is that ACOs will need to be launched in about nine months, while it can take "three to five years" to create a PCMH.  As noted previously, there is good evidence (here, here and here) that other care approaches that can be used to support or even backfill the work flows of ACOs without a fully functioning PCMH network.

Bottom line: the DMCB likes the synergies of the PCMH and ACOs and believes that both will be more likely to succeed with each other than alone.  That being said, this is no time for wishful thinking.  Hard work and significant challenges lie ahead to make this work for physicians AND, most importantly, for their patients.

By the way, if you're interested, here's more reading on the combination of Patient Centered Medical Home and ACOs.

Yes Or No Or It Depends To The Medical Loss Ratio (MLR)?

Does every person in imminent danger of being massacred by an oppressive regime warrant U.S. intervention?  Should every person in the U.S. own a home?  Should every teenager attend college?  Should every person buy health insurance?  Does every husband chased from a home by a knife-wielding spouse probably have something they did to deserve it?

The Disease Management Care Blog spouse agrees that the answer to almost all of those questions is "it depends."  A one-size-fits-all "yes" or "no" answer involving whole countries or millions of Americans risks the extremes of a) prolonged foreign entanglements versus isolationism, b) Fannie Mae-powered housing bubbles versus putting the hope of home ownership out of reach for millions, c) loan defaults and "for-profit" colleges, versus putting higher education out of reach for millions and, d) the twisted pretzel logic of a "penalty" designed to protect the private insurance market versus a death spiral.

Which brings the DMCB to the topic of the  Affordable Care Act's minimum medical loss ratio (MLR) rule (information from CMS here).  Readers will recall the idea was to make sure that 80 to 85% of every insurance dollar is spent on health care.  Now that the rule is kicking in, authors Jean Abraham and Pinar Karaca-Mandic, in a study published in the American Journal of Managed Care report on potential impact on the individual insurance market.  Using data from the National Association of Insurance Commissioners (NAIC), they show that about a third of the 6.7 million persons nationwide is in an insurance plan that is failing to meet the rule.  This is bad news for regulators, who may have surmised that the number of vulnerable individuals was about 3 or 4 million.

Unfortunately, our political class, working in the intrusive glare of a polarized 24 hour news cycle, tend to yield to the temptation of easy "yes" or "no" policymaking.  Unwilling to let markets sort out all the complexities and thanks to the twin toxicities of dogma and playing to a political base, the MLR rule was passed with the apparent assumption that waivers would be granted few if any times.

The AJMC authors point out that insurers can respond by reducing administrative costs, reducing profits, increasing fee schedules, reducing premiums or exiting the market.  Unfortunately, individual plans have higher administrative costs (there are fewer economies of scale), lower profits (individuals are more likely to have high claims expense) and are therefore poorer risks. That leaves the threat of market exits, which prompted CMS to grant a waiver to all of Maine's health insurers, with New Hampshire under active consideration and possibly four more states to follow.  And thanks to the insights from AJMC report, it appears the pressure on CMS to grant even more waivers is likely to grow.

Is every health insurer with a less than an 80% MLR abusing its beneficiaries, being administratively top heavy or deserving to be put out of business?  The complexity of the issue, the numbers of persons involved and the law of unintended consequences is making the answer to that question also "it depends."  The DMCB wishes the good folks at CMS a hearty "good luck" in sorting all that out.

what if nothing changes?

Today is a treatment day.

For the first time ever, I will have Herceptin on its own (if you don't count the Demerol and Gravol I get to keep the shakes and fevers at bay).

Some people have almost no side effects with Herceptin. Some feel like they have the flu.

Will the fact that my body has such a strong response to Herceptin mean that I feel more of its side effects?

The break from chemotherapy is meant to help me heal and rebuild - physically and emotionally.

The break from chemo is also a risk.

Here's hoping it all works out for the best.

Nurses: The Secret Sauce for Disease Management, the Patient Centered Medical Home (PCMH) and for Accountable Care Organizations (ACOs)

The Disease Management Care Blog has made no secret of its opinion that the secret sauce underlying the success of the many iterations of disease management and the patient centered medical home is nurses.  While various pundits and commentators may assert that it's some latest electronic record tweek or a novel form of provider payment, the DMCB knows better. Once you pull it all apart, there's usually a trusted nurse in there using that EHR or finally getting paid to keep patients out of the emergency room with a special nurse sauce of advice, education, expedited appointments and an unwillingness to take "no" for an answer.  Find a news report or a scientific publication claiming that "DM" or the "PCMH" increased quality or reduced costs and you'll find mention of nurses in there somewhere.  They're the mortar holding those bricks together.  

A recent case in point is this article appearing in today's Wall Street Journal that describes the multi-specialty group Atrius Health Care.  In addition to apparently having solved every known problem there is in U.S. health care, these guys purport to being the Known Universe's First Successful Accountable Care Organization (ACO).  Read through the article, though, and you'll see it - as predicted:

"Atrius Health also uses case managers, who help patients with chronic conditions coordinate care using multiple doctors and medicines"

Which brings the DMCB to three points.

1.  As far as the DMCB knows, there aren't any prospective, randomized and blinded trials that compare nurse-centered disease management or medical home with usual physician-encounter care.  As a result, it's difficult to figure out causation: are high functioning clinics, that are already destined to do well anyway, more likely to hire nurses, or are the nurses responsible for making these clinics high functioning?  The DMCB suspects its more of the latter but it's possible both are happening at the same time.

2.  Which begs the question:  is it possible that an unmeasured "nurse impact factor" is not only responsible for the early achievements of the medical home but that these professionals will turn out to be one of the key success factors  for Accountable Care Organizations?  If that is a strong possibility, should CMS carefully examine whether there is sufficient nurse-support when it finally starts reviewing ACO applications?

3.  While it's mentioned in passing in the WSJ article, the DMCB has learned from personal experience that these nurses are fundamentally unable to "flex" their commitment to patients based on the insurance benefit.  As a result, patients with insurance that doesn't "cover" diseasse managment (for example,Medicare fee-for-service) who are being cared for in clinics with a large commitment to nurse-led disease management typically end up seeing these nurses anyway.  So, while Medicare doesn't pay for disease management, the irony is that its beneficiaries in Atrius and in other health systems are still receiving disease management services in what is another example of cross subsidization of government health care by the commercial sector.  For clinics without broad multi-payer support for their nurse medical home/disease managers, the hidden cross-subsidization of other payers is the price of doing business and could hamper adoption of the patient centered medical home.

small changes: two steps forward...

It's high time I reported in on my plan to make small and lasting health-related changes in my life this year. 

It turns out that a small change every week is too much to expect, so I'm going to stop numbering them that way. It makes me feel like less of a slacker.

First change: Weigh in and record my weight every Monday.

My scale is broken and I have yet to have it fixed or replaced.

Second change: Do strength training exercises developed for cancer survivors. Work up to about thirty minutes, three times a week.

I've done these exactly six times in the six weeks since I last updated. It's too easy to talk myself out of doing the exercises. On run days, I tell myself that I'm too tired or don't have time and on non-run days I either don't think about it or don't want to do the exercises in my street clothes. I'm lacking both structure and discipline.

I've been pondering going swimming. I also did something last week that I may live to regret. I bought a twenty class fitness pass from a local gym. It only cost twenty dollars, and I have two years from the first class to use up the pass. It's pretty low risk but I'm worried I'm going to hate it.

At least it addresses the structure question.

Third change: Drink no more than five alcoholic drinks per week.

I seem to be better at breaking old habits than starting new ones. I've had no problem with this goal.

Fourth change: Drink more water.

My original goal was to drink around ninety ounces a day. That was unrealistic and made me feel hungry,jittery and even a little nauseated. Also, I was constantly running to the bathroom. Instead, I am now aiming for the more realistic eight glasses a day. This is no problem for me.

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

I suck at meditating. I just can't seem to still my brain, even if only for a few minutes. I find myself making lists, wondering what to do next, even mentally writing blog posts about how hard it is to meditate.

I suppose I should keep trying, as lots of folks I respect tell me how much they gain from their daily practice. It's a struggle though. I'm comfortable with silence. I don't tend to listen to my ipod when I go for walks or running but I do find sitting still and silencing my thoughts to be hard, hard, hard.

And see above re "structure" or lack thereof.

Sixth change: Always sit down to eat.

It's a very interesting experience to notice how often I pop food into my mouth while standing up. Sometimes, I only think about my plan to change after I'm done. But it's a good habit to break and I'm glad I'm doing it.

And announcing...

Eighth change: Take all my vitamins and supplements.

A while ago, I became so overwhelmed with the amount of vitamins and supplements that had been recommended for me that I just stopped taking any of them. The bottles were taking up way too much room in my kitchen cupboard and I couldn't find a vitamin box big enough to accommodate them all. I everything up in a box and put it in the bathroom in my basement.

Last Thursday, I found a giant pill box and spent half an hour on the week end getting organized. Yesterday, I took most of the vitamins (at different times throughout the day) and had raging heartburn by early afternoon. 

Today, I have yet to take any. 

I have recently re-connected with my nutritionist and we're going to review the supplements I'm taking, at an appointment two weeks from now. I'm also confused about interactions. Some vitamins should be taken with others and some shouldn't. Some taken with food and some not. Is it any wonder I put them all in a box in the basement?

Perhaps I should be setting priorities. What should those be? Calcium? Vitamin D? Fish oil? 

Anyone else out there have the problem of getting heartburn when you take vitamins?

As always, I welcome your thoughts and feedback. What changes have you made for your health in the last while? How's it working out?

Disease Management for COPD.... Kills?

Can disease management for chronic obstructive pulmonary disease (COPD) kill?

Until now, that question, thanks to this classic 2006 Canadian study that was published in Chest, would have never crossed the Disease Management Care Blog's mind. In that study, 191 recently hospitalized COPD patients were randomly assigned to either usual care or a self-management program with ongoing care management that included home visits and telephonic counseling. Using the perspective of a "health care payer," the economic analysis showed a per patient savings of $3,338 vs. an expense of $3,774. However, that was based on a caseload of 14 patients per nurse per year. The authors calculated that if that number was increased to a more real-world standard of 50-70 patients per year, the savings would exceed $2000 per patient. The DMCB likes to reference this Chest study in its publications and quote it in its lectures because it was randomized, statistically rigorous (all costs were detailed) and targeted (resources were focused on high risk and recently discharged patients).

And the DMCB was feeling even more confident about the benefits of COPD disease management thanks to this recently published American Journal of Respiratory and Critical Care Medicine study. This one was conducted at five U.S. VA hospitals involving 743 patients with a history of COPD-related hospitalization or an emergency room visit, on chronic oxygen or using systemic corticosteroids. The control group patients received usual care while the intervention group got a single education session, an "Action Plan" for self-treatment of exacerbations and monthly follow-up calls from a case manager. After 1 year, COPD-related hospitalizations and emergency visits was 0.82 per patient in usual care group versus 0.48 per patient in the disease management group. The difference was statistically significant.

While common ingredients include tobacco cessation, flu shots, giving patients basic information about COPD and teaching breathing, coughing techniques, lifestyle modifications as well as energy conservation for day-to-day activities, the DMCB thinks the secret sauce of COPD disease management is the "Action Plan." It's mentioned as an option in the Global Initiative for Chronic Obstructive Lung Disease or "GOLD" guidelines (113 pages can be downloaded here, you'll find it mentioned as "B" evidence on page 71). An Action Plan typically consists of a ready-to-go and "shoot-first-and-ask-questions-later" patient initiated package of antibiotics and glucocorticosteroids that are started if there is a sudden cold, infection, cough, shortness of breath or other disease exacerbation.  Both of the studies mentioned above included this in the intervention group.

Disease management: check.

Action plan: check.

Which is why this news is so counterintuitive (hat tip to KevinMD). According to this article, the VA's Bronchitis and Emphysema Advice and Training to Reduce Hospitalization "BREATH" COPD disease management trial, which was started in 2006, was halted early in 2009 because of higher all cause mortality rates in the intervention group.

The DMCB went to the clinicaltrials.gov website to find out more. BREATH was a two phase study. The first part was a twelve month "feasibility" study performed at six VA sites that targeted a recruitment of 180 patients, followed by a second phase expansion at 8 other sites targeting the recruitment of an additional 780 patients. In reading the protocol, the DMCB thinks the intervention group received the standard mix of disease management services, including the education, telephonic follow-up and an Action Plan.

The trial was stopped in 2009. According to news reports, a manuscript in the works and should be published in the coming months. Until the paper gets published, the DMCB can only speculate about the cause of the increased death rate in the disease management intervention arm of BREATH. If it had to guess, however, it would wonder if the Action Plan play some sort of role - perhaps the antibiotics led to microbial resistance or the steroids hampered immunity.

Stay tuned.

(late post - Google formating wouldn't work)

giving in to the monkey brain

Herceptin

I think I'm happy with the outcome of the brouhaha over Herceptin in Ontario. For those of you outside the province or outside the loop. Jill Anzarut, a 35 year old woman undergoing treatment for breast cancer made the news last week when she announced that the province had to pay for Herceptin because her Her2+ tumour was less than one centimetre (that's about 1/4 inch) in diameter.

The province initially refused to budge but eventually caved after a massive campaign played out in the social and traditional media. Access to Herceptin will now much more room for discretion when it comes to providing access to the drug.

I feel good about this. It's not that I think that every drug should be funded for every person. Her2+ cancers are very aggressive and, as best put by Stephen Chia, chair of the British Columbia breast-tumour group, “In HER-2 positive cancers, it’s not the size that drives it; it’s the HER-2 gene that drives it.” 

Election

Canadians are once again going to the polls. I am not happy about this. 

I'm sad that the long overdue Bill C-389 protecting the rights of transgendered people will die before it gets the chance to be thrown out by the Senate.

I'm worried that we will end up with a Conservative majority.

I have election fatigue. There was a time in my life when an election would make me feel excited and hopeful. Now I just think, "Ugh."

Presents in the mail

Did you see my scrabble pendant in yesterday's post? My friend Leslie sent it to me after I told her I'd like to have on with my initial on it. It made me very happy to open the envelope that held my surprise.

The bad with the good

Last week, I received my author's copy of the current issue of Canadian Woman Studies. The theme this quarter is Women and Cancer and I have a poem that is part of a piece called "Seven Reflections on Breast Cancer by Seven Women Who Worked Together." I'm happy about that.

I'm far less happy about another piece I stumbled on when I was leafing through the issue. It's called "The Private/Public Split in Breast Cancer Memoirs." It was written by a woman who came to my book launch in Toronto and asked for permission to speak in order to seek contributions - something to which I readily agreed. She also asked me to contribute to the issue, which prompted me to reach out to my writing group.

I had no idea that she planned to write a scathing deconstruction of my book - but that's what she did. I know that all writers get bad reviews but I found her comments to be very critical of me as a person (I guess you can't seperate the analysis of a memoir from its author) and quite unfair. 

I'm sure how to respond or react, or whether I should do so at all. I've actually been unable to finish reading the article. With a distinct lack of maturity, I threw the journal onto the living room floor and it stayed there for several days. I only just picked it up, in order to write this post.

I'll let you know what I decide to do. Meanwhile, I'm pasting my very own contribution below. It's a very small part of a greater whole (and not the strongest piece by the seven of us by any stretch) but it's mine and, like all my writing, expresses a little bit of what has been in my heart.

Snap shots

December 2^nd, 2005.

When I close my eyes, I see myself as I was then.

Short dark hair and boots with heels.

Irritable and excited in equal measure.

I knew big change was coming. And it did. But it was not what I expected.

I was getting undressed when I found the lump.

July 1^st, 2006

I close my eyes and see myself as I was then.

Round, bald and bloated. But happy.

Chemo is behind me. Or so I expect.

I am self-conscious but also hungry.

I eat two burgers at the barbecue.

December 24^th, 2006

I close my eyes and see myself as I was.

I rallied for Christmas Eve but in the end the pain got the best of me.

My liver was riddled with tumours. And I had waited too long for the morphine.

My mother had to put me to bed. That comforted me.

And so did the drugs.

June 25^th, 2007

I close my eyes and I can taste

The strawberries on my tongue

The sensual pleasure of the whipped cream

And the Niagara ice wine as it slid down my throat.

I knew I would soon have something to celebrate.

December 16^th, 2009

I close my eyes so I can think.

I have now been in remission for 30 months.

And I will be in treatment for the rest of my life.

Some days I wake up celebrating.

Some days I grieve for what I have lost.

Today is a sad day.

Tomorrow will be better. Or maybe the day after that.

Submit That Report To Population Health Management: Here's Why

Have you created a novel care management program? Developed a unique approach to wellness? A groundbreaking approach to analytics? Performed a literature review with some new insights?

Have you already committed your findings to paper with tables and figures and, with some additional effort, could turn them into a real manuscript? Does the idea of sticking all that hard work on some shelf or letting it languish in the C-suite upstairs annoy you?

If you are in the C-suite, do you want to advance the career of some key employees?

If so, do you want to simultaneously advance the science of population-based care to the benefit of patients everywhere, hone your findings with rigorous and insightful peer review, contrast your evidence-based program with the take-our-word-for-it fluff of your competitors and bask in the envy of your colleagues and enemies?

If so, you may want to seriously think about submitting a paper to Population Health Management. Instructions for authors are here.

Benefits include....

• Publication in a highly respected peer-reviewed journal
  


• Rapid, high-quality peer review—average time to first decision 19 days
  


• Fast-track publication online within 4 months
  


• Global readership in 140 countries
  


• High Impact: 90,000 downloads from the journal in 2010
  


• Visibility: Publisher gives special promotion to important papers including e-promotions and press releases
  


• Author-friendly manuscript submission system
  


• Indexed in Medline, Current Contents, and all key indexing services worldwide
  


• Probably being mentioned in the Disease Management Care Blog

how i fill my days (for better or worse)

Will Accountable Care Organizations (ACOs) Lose Money - and Mimic Disease Management's Medicare Health Support?

Remember the much regaled "Physician Group Practice" (PGP) CMS Demo? Ten group practices (five integrated delivery systems, two free standing, two academic organizations and one hospital sponsored provider network) continued to bill Medicare on a fee-for-service but were eligible for a bonus if they reduced costs. The bonus consisted of 80% of Medicare's savings in excess of 2% - assuming they also met some quality targets. To pursue those savings, the ten groups used a varying mix of care management protocols, registries, provider education, data feedback, HIT, remote patient monitoring, team-based disease and case management programs as well as discharge and palliative care programs.

You can read more here and here but the financial bottom line is nicely summarized here. Six out of ten of the participants met the quality and expense goals. Each was rewarded with at least one bonus during one of the three years which, in all but one case, amounted to millions of dollars.

The PGP observation that providers could organize and use the mix of interventions mentioned above to save taxpayer dollars helped advance the notion of "Accountable Care Organizations" (good summary here) in the Affordable Care Act:

“….with respect to the quality performance standards established by the Secretary under subsection (b)(3), if an ACO meets the requirements under paragraph (1), a percent (as determined appropriate by the Secretary) of the difference between such estimated average per capita Medicare expenditures in a year, adjusted for beneficiary characteristics, under the ACO and such benchmark for the ACO may be paid to the ACO as shared savings and the remainder of such difference shall be retained by the program under this title.”

The prospect of being able to form regional ACOs has provoked an organizing/merger/buy-out frenzy among hospitals and physicians. While the DMCB suspects ACOs will turn out be more about physician vs. hospital control of monopolistic cartels, being able to bill fee-for-service and still get a bonus is too sweet to ignore.

Or is it? While the PGP groups were awarded millions, how much did they have to spend on all those additional care management programs?

Writing in the latest New England Journal, Trent Haywood and Keith Kosel report on a financial analysis they conducted on the Group Practice Demo. Combining data from the Demo reports, the Government Accountability Office and the HHS Report to Congress, the authors created this curve. Based on a mean investment of $737 per provider or $1.7 million per organization, a 13% and 20% margin on that investment is needed for a break-even within 5 years and 3 years, respectively. If that's not bad enough, recall that 4 out of the 10 Demo participants never received a single cent.

And remember how the Medicare Health Support Demo on the topic of disease management was partially tripped up by delays in promised beneficiary data from CMS? The authors note their analysis may be limited because:

"....the participants did not receive provider- feedback reports and bonus payments in a timely manner, which may have negatively affected their ability to perform more effectively and receive greater shared savings."

In response to their findings, the author offer up some cautions for ACO wannabes:

1) This is not about fee-for-service. Think hard about the high cost of those up-front investments in care management and be prepared for a return on investment that may not materialize for five years.

2) Think really hard about doing this if you are a small provider organization with limited access to capital, a short time horizon or an inability to tolerate a 40% chance of this being a complete bust.

The DMCB offers up this third consideration: think hard about taking that money and investing in a broadly diversified mutual fund.

There are also some policymaker recommendations:

1) Limit ACO participation to provider organizations with sufficient financial strength

2) Change the bonus from being based on demonstrations of annual savings to cumulative savings.

The DMCB offers up this additional thought: If there is a chance that ACOs will end up like Medicare Health Support, the good folks at CMS may want to reconsider. The poor design, inadequate data support and the lack of a cumulative time frame was not part of CMS's calculus when they shut down the disease management demo. Here's a Healthways study that shows it was a mistake that set care management back years. It'd be unfortunate ACOs failed not on their merits, but on poor planning and execution by CMS.

where i've been

Update: I've decided that my habit of using initials instead of names makes some sentences confusing and nearly unreadable. Henceforth, I will use my discretion - and mostly use names.

Hey there.

March has been a busy month for our little household. And last week was March Break. We all drove to Toronto and then our oldest, Sacha, went to visit two of his parental grandparents in Florida. It was his first flight (other than a short hop between Toronto and Ottawa) on his own (and he's now too old to be an "unaccompanied minor"). 

But I'm getting ahead of myself.

It seems that I'm not so great at multi-tasking these days. I have lots of blog posts in my head but before I write them, I thought I'd catch you up on what we've been up to since my last post.

On Saturday, March 12, I ran a bunch of errands and packed for our week away. We also went shopping for new clothes that my 7 year old could wear for a theatre date with his Grandma in Toronto.

He was very pleased with this outfit. The photo doesn't do him justice.

On Sunday, March 13, we drove to Toronto. That evening, Tim and I went out for a delicious Indian meal to celebrate our 20th anniversary (we celebrate the anniversary of our first date because our wedding anniversary is September 7. At that time of year, our lives are so busy. Besides, March needs a reason to celebrate). It's hard to believe it's been that long - and we still like each other.

I started my day on Monday, March 14 by lining up outside the Toronto office of Passport Canada, since we had realized the previous Friday (at 4:30) that our son's passport had expired (I can now safely confess this, as he has been and returned to Florida and you all can know that our parental ineptitude didn't lead to tragedy). I was second in line (well before dawn) behind a woman and her two young children from Northern Ontario who had been turned away from their flight to South Carolina the previous day (the woman's MP had assured her that her son could travel to the US on an expired passport. He could not). Her name was also Laurie and her boys were also five years apart. We bonded, as we stood on the pavement outside the passport building for 90 minutes.

Once the new passport was sorted, Tim and I took our youngest to the zoo (Sacha opted to go check out the  TIFF building with his Grandma). I didn't take any pictures but we had a great time. It's a sprawling place with animals that appear to be reasonably content. At least I hope so. Daniel was ecstatic. His favourite animals were the gorillas and the bats (no photos. I was too distracted and perhaps still groggy).

On Tuesday, March 15th, Tim drove Sacha to the airport in Toronto (I was happy not to go, since I was beside myself with anxiety) and then headed back to Ottawa to work (he was extremely patient with me as I texted him every forty-five minutes for updates).

I was happily distracted by the wonderful company of my friend Andrea We went out for brunch and then spent a few hours at the Purple Purl, one of my favourite places in the world. Andrea's spouse Patchen joined us for dinner and we three had a lovely meal. I was back at my Mom-in-Law's place before my seven year old who had spent the day with Grandma and gone to both a Second City kids' show and Billy Elliott.

On Wednesday, March 16, Daniel and I took the train to Guelph, where we hooked up with some cousins and went to the Butterfly Conservatory. Despite the heat in the building (I looked with envy at the folks who'd worn shorts), we had a great time. Besides the amazing butterflies (a gorgeous blue one landed on Daniel, to his great delight) there were many kinds of birds, fish and turtles.

Daniel and his young cousin Y. had some strong mutual admiration going on.

On Thursday, March 17, was primo cousin hanging out time. Daniel loved being the oldest cousin. Five year old N. (whose two older sisters were in Florida with Sacha) seemed equally pleased to have some boy time. 

I took the boys to see Mars Needs Moms in 3D (great animation, problematic movie) and then we went to a really great park. That evening, the boys entertained each other happily over dinner out (at Swiss Chalet - the pubs were packed with partiers dressed in green) and my brother-in-law and I had the chance to converse in complete sentences (my poor sister-in-law was at home recovering from a very bad case of food poisoning. She was more of a trooper that day than I would have been in her shoes).

On Friday, March 18, we returned to Toronto and I got to spend the afternoon and evening with my dear friend Leslie. We had lunch, browsed the Distillery District, went for a big walk along the Boardwalk and then had dinner at our favourite pub over pints. Meanwhile, Grandma took Daniel up the CN Tower and for a swim at the Y.

We took the train home on Saturday, March 19. We watched far too many episodes of The Magic School Bus  but not once did Daniel say, "How much longer?" or "Are we there yet?"

It was a very good week.

The last couple of days have been focused on re-entry - catching up with friends, going to appointments and making endless lists of things to do. As of this evening, Sacha is safely home. Tomorrow we can return to routine (bring on the fights about homework and cleaning up bedrooms). Whatever form it takes, a break from routine can be a very good thing.

Happy Anniversary Affordable Care Act

About one year ago, the Disease Management Care Blog was watching health reform unfold in all of its toxic splendor. Deconstructing those complex events will happily occupy pundits, pollsters, editorialists historians and bloggers for years to come. The DMCB likewise hasn't been immune from reflecting on some of the ingredients that were mashed into the dreadful sausage-making that ultimately made up the Affordable Care Act. To wit:

~ an emboldened Democratic Congressional leadership determined to govern from the left of their rank and file;

~ the staking of a U.S. Presidency on a huge roll of the political dice - that could still come up snake eyes;

~ speculative projections from health care economists able and willing to portray any scenario based on assumptions built on theories derived from wishful thinking, which still continues today;

~ organized medicine groups being politically boxed in by a) their prior position statements, b) an bum deal over the SGR and c) fear of being thrown under the bus;

~ the astonishing misuse of 'health insurers" as a political piñata for garnering support, deflecting criticism and changing the subject;

~ equating any lack of support for health reform as a lack of education about health reform.

And how do things stand today? For the best example of how topsy turvy things are, check out the disparate perspectives of some Kaiser report "players and experts."

~ State governments are simultaneously opposing and implementing the ACA;

~ Maybe providers and insurers didn't really need federal legislation to cooperate all along;

~ It's not a majority or any broad political coalitions - which remain stubbornly split - but the small "independent" voter block that may hold the key to the long term survival of national health care reform.

~ The private sector still remains the best hope for innovation.

~ It's in the regulations outside of the legislative process where important battles over the MLR, insurance exchanges, essential benefits packages and worksite wellness programs will be won or lost.

~ The direction of national health reform will be decided by nine lawyers - and probably one in particular.

One question continues to perplex the DMCB: Why is the Administration so reluctant to endorse the eponymous flattery and historical legacy of the term "Obamacare?"

Image from Wikipedia

Crossing Over From Medical Home Land: Lessons For The Patient Centered Medical Home (PCMH)

Think Chinese culture is inscrutable? That the laws in Saudi Arabia are alien? That Lutheran Norwegians at a dinner table are weird? That, once you leave the familiar safety of home, life unpredictably becomes more opaque, dizzying and unfamiliar?

Such appears to be the reaction of some of the Disease Management Care Blog's colleagues once they venture outside the borders of "Medical Home Land." Case in point is this essay by Bob Doherty and this heartfelt "I second that emotion" by Dr. Bob at the aptly named Medical Rants Blog.

Inside Medical Home Land, transformed primary care always increases health care quality, reduces cost, increases patient access, attracts medical students, increases patient satisfaction and increases wellness. Inside that protective bubble, the medical home has admiration of PhDs, unquestioning acceptance by fawning medical journal editors and keynote status from pricey conference promoters. It is a nice place to be.

Unfortunately, Medical Home Land is missing one absolutely necessary natural resource. No, it's not statistical significance for measures of claims expense reduction (for example, p=.08 at Group Health, p=.21 at Geisinger and not even mentioned at HealthPartners). Rather, what's missing is money. To get their hands on that, Medical Home Land denizens have to step outside its borders and deal with insurance market skepticism, physician "transformation" inertia and patient-voter apathy.

As the DMCB has previously described, the likelihood that anyone is going to just hand over fistfuls of money to something that is a good idea is nil. Saying the Medical Home is the right thing to do is not enough. But be of good cheer, says the DMCB. While stepping outside of self-reinforcing closed information loops can be traumatic, dealing with reality has its benefits. The Medical Home is still a work in progress. Learning to joust with hard nosed actuaries, insurance execs and CFOs will ultimately help it be a leaner and more effective approach to patient care.

To help the Medical Homeites successfully adapt to being strangers in a strange land, the DMCB offers up some lessons learned by others that have also had to deal with the trauma of crossing over:

1. Once the disease management industry was confronted by data that it wasn't really saving money, it changed. It used its experience in wellness to contract with self insured employers to develop worksite-based prevention programs. It also honed its protocols to target the patients most likely to benefit. The point is that that industry figured out what the naysayers wanted and jettisoned the rest.

2. The electronic health record vendors worked for decades in the shadows of the health system before they finally achieved enough of a critical mass to catch the attention of a U.S. President. Yes, the EHR vendors continue to spout unrealistic bromides, but they were very patient. So should supporters of the medical home.

3. The DMCB learned the hard way that simply publishing positive results seldom achieves stakeholder buy-in or generates change from front-line providers. Recall how slowly physicians adopt any evidence-based medicine? Quoting it may be necessary but that alone will get medical home advocates about as far as quoting a Berwick paper to a Republican US Senator.

4. The pharmaceutical industry figured out how to trump branding for its me-too products. It's not that pill, its being able to ride motorcycles with your chums, blow rose petals at your daughter's wedding and lounge in twin bathtubs with the spouse. The ex-medical director DMCB has had to deal with countless enrollees demanding coverage of me-too lipid lowering agents at $80 a month. It's time for Medical Home Land to figured out how to harness that energy and the cash that goes with it. Which would patients rather have: a "patient centered medical home" or a "concierge?" Figure that out and commercial insurers and Medicare will follow.

5. Think being invited to the White House means anything? Not only does that environment also suffer from its own brand of health care unreality, you'll be asked to take a seat between the Thoracic Surgeons and the the National Association of School Nurses. Good luck with that.

The DMCB says be of good cheer, medical home supporters. Listen to the naysayers and adapt, hang in there for the long haul, figure out how to create patient demand and put publications and the support of fickle politicians into perspective. Good ideas always win out in the end.