how he moves in the world

My baby turned 8 on Friday. I love him so much.

Disease Management and Wellness in the Post-Reform Era (book) Is Out!

Check it out

Interested where population-based disease management is going?  Want to learn about its role in wellness programs and the medical home?  Are you curious about the impact of behavioral economics, Medicare's quest for value, out vs. insourcing, behavior change and social media?  Are you wondering why the term "disease management" just won't go away?  Do you thirst for even more Disease Management Care Blog blathering?

If the answer to any of those questions is "yes," then you may want to buy the just-released 164 page book Disease Management and Wellness in the Post-Reform Era.  There are 15 insightful and individually authored chapters that will yield insights on topics that range from the medical loss ratio, consumer incentives, return on investment, Medicare Advantage and worksite wellness.  Chapter 8 on "Social Networking and Population Based Health Management" is a particular DMCB fav.

No company library, office bookshelf, C-suite desk, wish list, office reception area, summer reading list, bridal registry, night stand, cubicle, bathroom or porta john is complete without it.  You can also order through Amazon (though it looks like we'll have to wait for the Kindle edition).

The Seven Ingredients Necessary To Successfully Combine Health Care and Insurance Risk

Basic Ingredients

Versions of PowerPoint have been swarming through the Disease Management Care Blog's computer thicker than physicians on the plaid pants at a country club pro shop sale.  That's because it's been busy polishing the April 29 Care Continuum Alliance sponsored presentation on "Accountable Care Organizations: A Toolkit for Success."

And just what will the perspicacious DMCB actually say?  You'll need to either register or get your hands on the post-webinar recording to experience the full monty, but much of it will be shaped by the emerging nexus between a) clinical care and b) insurance risk.   Are you an organization that wants to take on risk and end the year with a surplus? Are you a managed care insurer, an accountable care organization, a capitated multi-specialty clinic or a hospital with "service guarantees?"

Well, says the DMCB, in addition to the full suite of medical services, going to need some, or preferably all, of the following:

1) an ability to collect, compile and act on patient surveys that measure care gaps and the likelihood of an avoidable expensive future event, such as an admission to the hospital.

2) access to high-end predictive analytics that can draw on multiple databases and find correlations between today's patient characteristics and tomorrow's avoidable hospital admissions, emergency room visits or high claims expense.

3) a willingness to use all means necessary to incent patients to enroll and participate in clinical initiatives, from making an appointment to see the primary care provider to using high-tech home-based physiologic monitoring.

4) knowing how to reconcile one-size-fits-all national treatment guidelines with the realities of busy clinic settings, still evolving IT decision support and state-of-the-art shared decision making (SDM).

5) the courage to unleash non-physicians who can appropriately practice at the top of their license under clinical protocols with the support of physicians independent of location or level of care.

6) understanding of a "shared services model," in which some clinical programs are centrally funded and distributed through a provider network.  "Build" or "buy" works equally well.  If you're in a hurry, the DMCB says go long on "buy."

7) robust ongoing measurement tools that repeatedly assess not only clinical and economic outcomes, but quality of life and health behaviors.

The Latest Health Wonk Review Is Up!

Don Taylor Austin Frakt and Aaron Carroll have compiled examples of an unintentional - yet happy - outcome of health reform: smart bloggers doing their best to inform, educate and opinionate.  Such is the Health Wonk Review, a periodic hosted compendium of the latest policy insights that are unavailable in the mainstream news media.  Enjoy!

Shared Decision Making: A Timely Review Courtesy of Health Affairs

"Let's go over your options...."

If you're a lawmaker, policymaker, academic, health executive or other health care expert, you may want to take advantage of this handy review of "shared decision making" (SDM) by Floyd Fowler, Carrie Leven and Karen Sepucha that apears in the April 2011 edition of Health Affairs.  After reading it, you'll be able to confidently use the acronym "SDM" in your meetings, conference calls and presentations, thereby impressing colleagues, partners, collaborators and coalition members with your health policy chops.

And if you're not a lawmaker, policymaker, academic or executive, but run into them from time to time, the DMCB recommends you spring a "SDM" question on them.

For example:

"Of the 65 quality metrics in the current ACO proposed rule, do you see any role for SDM?"

The answer you get may speak volumes about their expertise.  If you get a blank look, you may want to question their credentials and do them a favor by referring them to the DMCB in general and to the Health Affairs article summary below.

Just because "preference sensitive" health care (for example, elective surgery such as a hip replacement for arthritis, or selection among the various treatment options for prostate cancer) is appropriate or safe doesn't mean it's necessary or desired.  To meet those additional dimensions, patients have to be informed and involved (or what the population health and disease management industry refers to as engaged).  That means that the physician-patient conversation over a proposed treatment needs to not only review the evidence but help patients to personally weigh the benefits, risks and personal costs involved - all of which involve trade offs. 

Because patients differ in preferences and values, there is no "right" answer. Since it  the patient who will have to live with the benefits, risks and costs  of a treatment, it should be the patient who should choose among different options.  Yes, patients can choose "wrongly" (which is difficult to define), but it turns out that state-of-the-art patient support makes wacky unreasonableness far less likely than doctors would expect. What's more, there is good science - 55 randomized clinical trials - that shows that patients tend to be remarkably intelligent and conservative in their decision-making.

"Decision aids," which are defined as high quality support materials that assist patient decision-making, have matured to the point where they can be routinely used in mainstream healthcare.  For example, they are used a lot at Dartmouth-Hitchcock Hospital in New Hampshire. State-of-the-art aids have been linked up with EHRs and, even better, don't have to necessarily be individually triggered by busy physicians.  In other words, docs could pre-order thresholds in which the decision aid is automatically delivered to the patient, depending on the diagnosis and other patient factors.

The science of SDM has also developed validated surveys that can assess baseline knowledge, gauge symptom-based "decision windows"  and ascertain what patients want in terms of symptom control or lifestyle. These surveys can help the targeting of decision aids. 

How can SDM be promoted in mainstream clinical practice?  The authors have four recommendations:

1) Accountability:  important surveys such as CAHPS could be modified to assess use of SDM. Other patient surveys are in the works.  Their results can be used to assess clinical performance.

2) Guidelines: if a patient chooses contrary to a clinical guideline recommendation, the physician shouldn't be penalized.

3) Research and CMMI:  If this isn't a topic worthy of CMS' interest in promoting high value innovation, what is?  The ACA has other myriad funding mechanisms that could be deployed.  This may also something worthy of comparative effectiveness research.

4) The Patient Centered Medical Home:  It's time to make SDM a feature of PCMH Ver. 2.0.

The DMCB would note that there is widespread agreement that health insurers are generally justified in limiting coverage of treatments not backed by "evidence."  Perhaps a more enlightened approach is for insurers to not cover treatments that haven't been offered to a patient using SDM.  While that may sound radical, the DMCB wonders if that isn't a better alternative to the controversial 15 member Independent Payment Advisory Board.  If someone has to choose, why not insist that the patient chooses?

The DMCB also finds it curious that the authors didn't mention "disease management," especially given the close association between SDM and companies that offer that service.  The point is that doctors, in the course of patient care don't need to be routinely involved in SDM.  They can rely on non-physicians to also provide that service.

By the way, more on SDM, courtesy of AHRQ, here.

ACO Tithing and Putting Clinical Inertia Into Perspective. Good News There's a Toolkit That Can Help!

To the rescue!

While the health establishment's shakers and movers spin on axis over all the wonderful things ACOs will do to transform health care, the Disease Management Care Blog has been asking experts closer to the clinical trenches what they're hearing. It's not enthusiastic.  Skepticism aside, why shouldn't they take a pass? Recall that the upside gainsharing gives the first 2% to the Feds, leaving ACOs 60% of what follows.  So, if claims savings are, say, 5%, the DMCB calculates that ACOs get to keep 1.5% out of that 5%.  1.5 divided by 5 is 30%, leaving 70% for Uncle Sam.  Not even God takes that much.

And one of the things that ACOs are supposed to do is usher in a new era of evidence-based medicine.  The DMCB has its doubts about that too (more on that below), but for something completely different, check out this JAMA Commentary by Dario Giugliano and Katherine Esposito on "clinical inertia."  It turns out that there are a number of peer-reviewed diabetes, hypertension and cholesterol studies that cast doubt on the wisdom of striving for universally low A1cs, systolic blood pressures and LDLs.  While our leaders tut-tut the medical establishment's failure to achieve 100% compliance with academic-expert opinion (or its benefactors), Drs. Guigliano and Esposito wonder if some physicians could have a very reasonable doubt about the evidence or may be reacting with justifiable uncertainty.  If they're right, clinical inertia may be more of a patient safeguard than generally appreciated.

Yet, while the DMCB is being an ACO weenie, that hasn't stopped it from trying to be of help.  That's why it participated in the development of this Care Continuum Alliance "toolkit" titled "Achieving Accountable Care: Essential Population Health Management Tools for ACOs."  You can download this expertly edited and heavily referenced review here. 

In the toolkit, readers will be able to learn about the many other interventions necessary to successfully manage that all important "attributed" population.  That includes using health risk assessments (HRAs), taking full advantage of risk stratification (predictive modeling), maximizing patient enrollment in clinical programs, putting clinical guidelines into perspective with targeted decision support and shared decision making (the answer to the conundrum described above), leveraging nurse-led care management programs, really taking advantage of health information technology, measuring everything and working with third parties to build programs.  Do all these things, says the DMCB, and your ACO will have a much better shot at making a real difference.  It might even make some money.

As a reminder, the DMCB will be discussing this more fully in a CCA hosted webinar later this week.  Registration info here.

Social Media and the Road to Patient Empowerment (and why stop there: disaster preparedness, Google and governance...)

More Than Just A Techie
Communication Tool?

The Disease Management Care Blog has two kin who recently went through major surgery. After being surprised by significant post-operative symptoms, they were told by their providers that the side-effects they were describing were "common."  In retrospect, there was little in the informed consent, the peri-operative discussions, documentation, education materials or discharge instructions that provided adequate warning.  In both instances, the response of the well-meaning, harried and overworked nurses and surgeons was the same....  gawrsh, we should include your insight in our education materials, so we can warn other patients!

Knowing how hospitals, nurses, doctors and educators compile these materials, the DMCB thinks the likelihood that actual patient feedback will be used is about as high as their VP-Administrator agreeing to forgo this year's bonus so the hospital can afford to give the case managers a raise. 

Everyone is just too busy.

The DMCB appreciates that NCQA, Consumer Reports and CMS are doing their part for post-op patients with the HCAHPS survey (more here).  There is also a large body of science on the topic that helps us understand the need for patient input, includes other more detailed surveys, shows it's possible to clutter patient awareness with too much information and confirms that many hospital workers know there is a problem.  What's more, poorly prepared patients appear to be part of a much bigger problem in a clinical domain that's been dubbed "transitions of care": after all, if the doctors can't get things straight with each other, where does that leave the patients?

Figuring the issue isn't going away, the DMCB wonders if "social media" and, in particular, patient-authored education wikis that uses online collaboration to taps into the wisdom of crowds is an answer. After a quick Google search, it appears to the DMCB that there aren't many of these kind of hosted wikis out there. Given the hospitals' overall performance in this field to date, maybe that's not surprising.  This may be something that, like Like Patients Like Me, will ultimately be up to health care consumers themselves.

This may be an area ripe for the leadership of the population health and disease management companies.  Maybe this will be the next step in the evolution toward greater patient empowerment.  Or maybe someone should develop it and sell it to a company. [Note to self]

But the DMCB Isn't Stopping There: Disaster Preparedness and a Looming Disaster for Google? 

And speaking of social media, the DMCB continues wonder where its potential will end.  For example, Japanese earthquake victims relied Twitter, Facebook and texting in the days following the disaster to get information on escape routes and shelter.  And by the way, which would you believe about radiation exposure risk: "tweets" from your trusted circle of known contacts or announcements from a government spokesman?

And if disaster preparedness isn't enough, how about the threat to that multi-billion company called "Google?"  Check out this (lightly edited) quote from an NPR report (with DMCB bolding)

But the story's not over yet. Daniel Roth from says what if people just start searching the web without Google. That kind of messes up the game for all the players.

Mr. ROTH: I know, speaking personally, I read a lot from what I see from my friends on twitter.

CHACE: Roth says your social network might be the next search engine. And it's still pretty hard to game the system of hearing directly from your friends.

Mr. ROTH: When they suggest a story, I'm way more likely to click on it, because it's already been vetted. So I spend less time on aggregation sites, and I spend more time looking to see what my friends are aggregating for me. And how do you win in that game? I think you win in that game by writing stories that people really want to read.

And Governance?

And if social media can be a threat to multi-billion dollar companies, how about being a threat to governments?  National security experts are undoubtedly sorting out its role in the fall of Egypt, the threat to Iran and China and the continuing turmoil in Syria.  Yet, it remains to be seen if Western-style governance will also remain immune. While 24-7 global access to multiple information streams isn't necessarily the basis of our economic and political discontent, we also don't know if old-fashioned representative democracy is the fix for the Middle East's turmoil. The Internet in general and social media in particular seem to be making any kind of governance anywhere on the globe difficult for both tyrants and elected officials alike.

There Aren't Enough Rich People To Pay For Medicare And Medicaid!

I hear more and more of my progressive friends arguing, in the context of deficit reduction, that we should be raising taxes before getting aggressive about reducing the cost of Medicare and Medicaid -- as well as Social Security.To a point, I agree.This country is in such a hole that it is senseless to deny that at least some new taxes will be needed to pay for all of the nation's bailouts and

CMS' Physician Quality Reporting Initiative (PQRI): It's a Little Bit (And Taxpayers Are Not Getting Their Money's Worth)

2%

$234,292,572.02 sure seems like a lot of money, doesn't it?  If you were told that's what the Feds put on the table to promote health care quality among Medicare beneficiaries in 2009, you'd be impressed right?  Too bad for CMS' mandarins that you read the Disease Management Care Blog and know better. 

The DMCB explains.

Background

That $234 million was dispersed under the 2009 edition of the "Physician Quality Reporting Initiative" (or "PQRI")  This was passed into law in 2006 as part of Congress' interest in transitioning Medicare away from pure fee-for-service toward a greater emphasis on "value based purchasing." As the DMCB understands it, physicians submit additional claims codes to Medicare in the course of their routine billing that documents various quality measures.  If enough claims codes are submitted, the provider can get an incentive calculated at - depending on the year -1% to 2% of that year's Medicare payments.  The bonus doesn't depend on the quality, only that the quality was reported to CMS.  That's why it was called a reporting initiative.

PQRI is sill ongoing and participation is completely voluntary. When the program kicked-off in 2007, physicians were given the option of submitting codes in 74 different areas that they could select based on their specialty and interest.  2009 PQRI's 132 measures ranged from diabetes to skin cancer to open heart surgery to management of pain.  You can see the list here.  The 2009 bonus was set at 2%.

How many claims codes did physicians have to report to CMS?   They had four options: 1) at least 3 individual quality-data measurement codes among the 132 measures for at least 80% eligible patients, or 2) all measures in one of the six  "measures group" packages (consisting of "preventive care," "diabetes," "back pain," "chronic kidney disease," "perioperative care," and "rheumatoid arthritis") for at least 80% of eligible patients with a minimum of 30 patients during the period, or 3) the "group" approach, but with a 6-month period of July 1 through December 31, 2009 and a minimum of 15 patients, or 4) the "group" approach for 30 consecutive patients.

The Results

So, what happened?  While the 2007 PQRI kick-off was rocky, the 2009 data have been released and CMS seems quite happy with the program's progress.  Download (and unzip) this report and you'll see the $234 million went to 119,804 "eligible professionals" with an average per physician pay-out of $1,956.  CMS estimates that the percent of Medicare-participating professionals has grown from 15% in 2008 to 20% in 2009. The DMCB calculates that an additional 90,775 providers submitted claims but didn't get the bonus - probably because they incorrectly submitted their data sets. ER physicians led the way with a 62.8% participation rate, while 16.1% and 15.5% of family practice and internal medicine physicians participated, respectively.  These primary care physicians' "average potential incentive" payments were $1,126 and $1,924 respectively.

While the physician bonuses didn't depend on any improvement in measured quality, CMS reported that, for those measures that were in place from '07 to '09, there was a median increase of 1.3% in the quality measures.  Some measures increased dramatically (diabetes eye care, for example by 41 points) while others decreased (beta blockers for MI decreased by 30 points).  That probably has more to do with the influx of new physicians with new data than any real change.

Implications

So, with that as background, what does the DMCB think?

1. While this program isn't exactly "pay for performance" (yet), variations of insurer-sponsored P4P have been in use for years by the majority of U.S. insurers.  It took a (Bush era) law to make that happen and CMS is late to the party.

2.  And the party may be starting to thin out, thanks to better understanding of the limits of P4P, the potential for unintended consequences and growing appreciation that one size doesn't fit all.  If this pay for reporting is a prelude to pay for performance, there doesn't appear to be much in the way of the innovative sophistication that CMS purports to embrace.

3. The DMCB is also struck by CMS' reliance on self-reporting, which is a different approach compared to commercial insurance settings.  In the latter instance, it's up to the insurer to take the time and expense of obtaining the data, even if it means paying individuals to go to the clinics and perform chart reviews.  While CMS' adding an extra claim line in the course of normal billing doesn't seem line an imposition on physician practices, this is one more of a thousand cuts involved in running a clinical practice.

4.  While CMS doesn't touch on this in its reports, the DMCB suspects that the provider groups best positioned to take advantage of this are larger groups with the infrastructure that can take on the additional reporting task.  As a result, the PQRI payments probably went to the larger clinics and therefore probably functionally discriminates against small provider-owned practices.  That may be further evidence of CMS' policy preference that small individual physician practices should go away and become "integrated" in "systems."   As further irony, the DMCB doubts the payments that were awarded to the large clinics went to the individual physician's pockets.

5. Um, "return on investment?"  Are self-reported data from a self-selected group of physicians of any use in truly assessing national quality trends and is that worth $234 million?  Is it even worth the amount we are paying to the Chinese in interest?  Will this lead to $234 million in reduced claims expense to the benefit of the U.S. taxpayer? 'Nuff said.

6. And finally, while close to $2000 may seem like a lot of money, it isn't.  While the DMCB's spouse would welcome a check made out to that amount, by the time overhead takes it's toll, any remaining money that percolates down to the physician might be able to cover the weekly staff donut run. 

Every little bit helps, but that's the problem. When put into perspective: this is a little bit. 

Oh Happy Day!

The Disease Management Care Blog Speaks on Accountable Care Organizations!

It's one thing to write about Accountable Care Organizations, but what about speaking on the topic with new insights plus the opportunity for live audience feedback?  The intrepid Disease Management Care Blog will do exactly that when it leaves the relative safety of the blogmos and opens itself to your criticisms and insights at a Care Continuum Alliance Webinar one week from today. 

You can register here. It's worth every penny.

During the presentation, the DMCB will be joined by the smart Andrew J. Baskin, MD, Aetna's National Medical Director, Quality and Provider Performance Measurement and the insightful Elizabeth W. Hoy, MHA, Vice President, Strategic Development, Cheyenne Health Services Management. Michael Raymer, General Manager, Health Solutions Group, Microsoft Corp will act as moderator.

Listen in and participants will learn about many of the underrecognized population health and care coordination tools and strategies that are "mission critical" for the success of ACOs.  The webinar will also unveil a unique ACO toolkit designed to help policymakers and health system leaders as they deal with the many details of beating that risk-adjusted baseline.

Last but not least, this valuable and affordable educational opportunity is pre-approved for 1.5 hours toward Chronic Care Professional (CCP) certification.

Additional ACO Insights: Won't Make Money, Physician Leverage, Year-to-Year Patient Attrition & It's Not the PCPs, It's the Hospitals and Specialists

"What about concurrent versus prospective
risk adjustment?"

The Disease Management Care Blog listened in on the Opal Events' "CMS ACO Regulations Debriefing" webinar that was held as a follow-up to its Austin Texas conference.  The speaker confirmed much of the DMCB's darkly suspicious bloggery, but there were lots of additional and noteworthy insights:

It's the providers that are "participating" in ACOs, not patients. Patients aren't really "assigned" to any ACO, but their data are.

There's a reasonable chance that the January 1, 2012 start date will have to be delayed.

Why would a provider organization even want to be an ACO? It could be because it wants to be better positioned for the eventual demise of fee-for-service payment systems so it can take on risk. Or, this could be a way to achieve greater clinical and economical integration. Or maybe it just believes this is the right thing to do. While all of these fit with CMS' proposed ACO regulations, wanting to "make a lot of money" is a lousy rationale. That's because the ultimate point of the program is to have millions in efficiency and quality bonuses make up for the loss of millions in billing revenue combined with the investment of millions in care and data management systems.

Speaking of provider participation, it doesn't appear there is anything in the proposed regulations to keep them from abandoning the project midway through the contract period.  The DMCB foresees this leverage being used not only if there is impatience over the return on any financial rewards, but if there is dissatisfaction with the ACO's leadership. 

It's not uncommon for up to 25% of Medicare beneficiaries to switch providers (and health systems) from year to year.  That's why CMS' proposed "retrospective attribution" is both good and bad news.  The good news is that the participating organizations will only be held retrospectively accountable for the patients that were actually cared for in the system.  The bad news is that risk adjustment will be calculated off a baseline year using a population is likely to change considerably by the time the attribution is performed and the results are tabulated. 

While a strong primary care network is important, the economics will really depend on how well hospitals deal with "never events," hospital acquired conditions, readmissions, preventable admissions and cheaper alternate levels of care (like 23 hour stays, avoiding the intensive care settings and transferring patients to skilled nursing facilities instead of rehab centers). In addition, it will be up to the specialists to opt for more conservative (and less remunerative) treatment options.

Any communication from providers to patients about the "ACO" will need to be approved in advance by CMS.  So, if in the name of efficiency and quality, a physician wants to encourage his or her patients to contact the clinic in lieu of going to an emergency room, that letter may have to be submitted to CMS for their review.

i could lose myself in this.

Actually, I have.

Someone posted a link to Hyperbole and a Half on Facebook this morning and I was so tickled (and so willing to procrastinate that I got sucked right in. I now have no time to write but I think you'll enjoy her more anyway.

It's The Money That Matters

Let's face it: when it comes to reining in the cost trends for Medicare and Medicaid, it's going to be either 1) really painful or 2)  really experimental.  That's how the Disease Management Care Blog summarizes Meredith Rosenthal's New England Journal review of the "hard" versus "hopeful" ideologies underlying the Republican Ryan versus the Democratic White House approaches to deficit reduction. 

An easy-to-read table that compares the two can be found here. Dr. Rosenthal points out that hard evidence that Republican "premium support payments" will control costs is weak and that, under such a system, consumers may not always make wise choices.  Alternatively, it's also questionable whether the Feds are really up to the task of implementing the Dems' complicated reforms in an unwieldy health care system. 

The biggest commonality in both approaches is that it's the most vulnerable patients who are at highest risk.  Under the Ryan Plan, patients with the greatest needs may be stymied by increased out of pocket expenses.  Under the White House Plan, unintended consequences of global or performance-based payments could result in provider "gaming" or denials of care reminiscent of old fashioned capitation.

It's depressing to read that while both the White House and the Ryan Plans have downsides, the one thing that they don't have is overlap.  It's hard to see how an Independent Payment Advisory Board (Dems) could be reconciled with greater consumer choice (Republican), or how commercial competition for enrollees (Republican) could be combined with a regulated insurance benefit (Dems).  The good news is that the two options make some credible approaches to cost control.  The bad news is that there doesn't appear to be much room for compromise.

When the DMCB is confronted by difficult choices, its angst is eased by breaking out into song.  Given the fraying of our social contract, maybe that message from the 80's - that it's really money that matters - has greater wisdom than US taxpayers generally appreciate.  That or big hair......

Home Blood Pressure Monitoring Plus IVR Plus Pharmacist Results In Blood Pressure Control

Add patient, IVR and pharmacist?

Thanks to a plethora of disease management studies on diabetes and heart failure, the Disease Management Care Blog is always on the look out for its application for other chronic conditions.  That's why this particular piece on A Multimodal Blood Pressure Control Intervention in 3 Healthcare Systems caught the DMCB's eye.   

David Magid and colleagues recruited study participants who were on four or fewer drugs with persistently high blood pressures from the electronic health records of three Denver health care systems: 1) the Eastern Colorado VA  Healthcare System, 2) Kaiser Permanente Colorado and 3) a county safety net system called Denver Health and Hospitals.  3083 patients were screened, 338 were chosen to participate and 283 completed the study.

Participants were randomly assigned to a control group,consisting of usual care along with a National Institutes of Health (NIH) patient information booklet, or and intervention group which got the booklet plus additional patient education, a home blood pressure monitor that was paired with an interactive voice response system (BP numbers were inputted using the phone key pad) that was, in turn, monitored and managed by a pharmacist.  The pharmacist made medication changes after discussing things with the patients' physicians.  The study lasted six months, the mean age of the participants was 62 years, one third were female and two thirds were white.  The study was funded by the American Heart Association and the Colorado Dept. of Public Health and Environment.

The average blood pressure for the 138 patients randomized to the intervention group was 150/89,  For the control patients, the average blood pressure was 144/85.  That difference was not only statistically significant, it played a role in the interpretation of the observed outcomes.  At six months, both groups' average blood pressures were lower and essentially the same (137/82).  Because the baseline was higher in the intervention group, the authors found that the change in blood pressure was also highest in the intervention group.  What's more, it appeared that the patients with blood pressures with a systolic (top number) of more than 150 experienced the greatest reduction in blood pressure and therefore derived the greatest benefit from the program.

In the discussion of their results, the authors - like all good scientists - did an excellent job of describing the limitations of their findings. From a statistical standpoint, it's possible that the greater decrease in the intervention group was partially the result of mathematical phenomenon known as "regression to the mean."  The DMCB additionally wondered if the 3 subgroups (VA, Kaiser and County) had different outcomes, which would suggest that the intervention worked better in one setting than another.  Last but not least, the authors did some additional analyses on medication compliance and correlating that with the outcomes.

Lessons for the DMCB:

It's not the pharmacist, or the IVR or the home BP monitor or the patient engaged in self care, it's the combination of all of the above.  The effect is probably greater than the sum of its parts and extends the reach of the physician.  This seems a far more reasonable approach than, say intrusive electronic record "prompts" during a physician appointment, pay-for-performance or quality assurance.  What's more, the model fits classic remote disease management or the Patient Centered Medical Home or both.

Once again, it appears the benefit from interventions like this is not evenly distributed across a population.  Patients with higher blood pressure derived the greatest benefit, suggesting that programs like this should be targeted at patients who are at greater risk or who are mostly likely to respond.  In this instance, it was for patients with a blood pressure that was greater than 150.

Last but not least, while the electronic health record certainly has its limitations, one useful role is helping to find candidates for research trials.


Magid DJ, Ho M, Olson KL et al: A multimodal blood pressure controlintervention in 3 healthcare systems. Am J Manag Care. 2011;17(4):e96-e103.

not about the Beatles

I don't have the energy to write anything of substance today, so I thought I'd share a little bit of silliness from my writing class last night.

Our teacher instructed us to "write about the Beatles" and this is what happened for me:

"When I think of the Beatles, I think of the Rolling Stones. I was a teenager in the 80s and both groups had already passed into iconic status. Which band was better in my mind? The answer, to my adolescent self anyway, seemed obvious.

Paul was cute. John was smart (and tragic) and I couldn't even imagine what the other two guys looked like. But Mick...Mick was hot. With those eyes, those lips, that hair. And those hips.

I couldn't have told you whose music was better, more complex, which group would have staying power. 

I just knew that the Beatles were pretty but Mick made me feel warm in places this Catholic girl wasn't supposed to think about."

What Can An iPad Scrabble App Teach Us About HIT and EHRs?

It sure isn't easy being a President nowadays. Arab potentates have the bad taste to not know when they've been conquered, U.S. Treasurys could be downgraded, the U.S. air traffic control system literally takes naps from time to time and the health care reform debate refuses to go away. ACOs, the centerpiece of the "bend the curve" potential of the Affordable Care Act, may end up not having much of a reach or be readily embraced by physicians.  And in the middle of all that consternation, the Disease Management Care Blog was confronted by an additional lesson on the limits of the Administration's investments in health information technology (HIT).  The DMCB was visited by two of its spawn this weekend, who spent a pleasant afternoon on either side of the living room sipping chilled beverages. Playing Scrabble.  Remotely.  Over the Internet.  Using their iPads.  The only recognizable human interaction was the trash talking.

How... cool.

Which may ironically be more bad news for the Feds' efforts to promote use of electronic health records (EHRs).  Go to this CMS web site and it's clear that the vision underlying EHRs is an encounter-based system involving providers who maintain a central repository of patient-specific information and use that "platform" in "meaningful" ways. The Stage 1 "meaningful use" (MU) criteria outlined here confirm it's all based on a standardized and traditional clinical approach.  In that MU world, key information (problem lists, medication history, health screenings) is  maintained, followed and shared among the providers with a need to know.  It is very specific, measurable, transactional and reductionist.  Instead of an old-fashioned Scrabble board, it's on a monitor - but it's the same old game.

It is also ill-suited to the attitudes and lifestyle of the future patients who took over the DMCB living room.

While experts flittering about the "HIT space" refer to "ecosystems," the DMCB suspects that description may be far more apt than is generally appreciated.  Ecosystems are not linear, they're complex with interactions that are greater than the rum of their parts. This is where denizen patients and providers use multiple technologies reliant on rapidly evolving portable platforms to collaboratively and bidirectionally interact in real time.  Problem lists are jointly agreed to, medications are ever-shifting and health data are being constantly updated.  Docs will not only need to personally interact with their patients, but docs' portable information-devices will be syncing with their patients' while decision logic spins in the background.  Think about seeing a doctor as the two of you initiate your devices and trigger a dedicated and shared "app."  That is a truly new version of Scrabble.

Of course, the IT weenies will argue that EHRs need to learn how to crawl before they can run.  The DMCB agrees, but wonders if CMS' heavy handed involvement is forcing the system to crawl over problem and medication lists, while EHR-enabled interactivity remains the exception and not the rule.

Undoubtedly, minds far more creative than the DMCB's and the government's are already pursuing a new "Scrabble-oid" HIT paradigm. When they achieve a workable model, will the MU's specific, measurable, transactional and reductionist maintaining, following and sharing of problem lists, medication lists and health screenings get in the way? 

bittersweet moment

Yesterday afternoon, my baby fell asleep on my chest.

He's almost 8 now and it had been years since this happened. He had two late nights followed by two early mornings, and he'd been tired and cranky. I suggested we curl up in bed for some quiet time. He had a new book to crack open and he was keen.

But after awhile he grew restless. We talked about putting on a movie. I told him I felt tired and lazy. He said he did, too. After a few moments of lying quietly, his breath began to slow.

Suddenly, he sat up, “Mama, could you stop feeling so lazy. I thought we were going to watch a movie!”

“We could do that,” I answered. “But I thought we were going to have a little snooze first.”

To my surprise, he said, “OK. I'll have a little snooze.” He put his head on my chest, and within seconds was sleeping soundly.

We lay there like that for more than an hour (at one point he woke up, said “Where'd my book go?” I said, “You've been sleeping.” He said “Oh!” and went back to sleep), and I was blissed out. I was happy to have my book within reach but I spent a long time just looking at him, listening to him breathe and loving the feel of his weight on my chest.

As I said, this was the first time this had happened in years. And it was quite possibly the last.

All too soon, he woke and we went on with our afternoon. If I close my eyes and listen to my own slow breaths, I can still feel his weight on my chest.

More Thoughts on Accountable Care Organizations (ACOs) From Around The Web

The Disease Management Care Blog toured the web for some additional ACO insights.  The New England Journal wonders if CMS is going to be as confused as the rest of us by the final regulations.  The Health Affairs blog doesn't like how the odds are stacked, while the widely quoted Bob Laszewski doubts the macroeconomics.  Short blurbs and links below.

Reading between the lines of John Iglehart's latest NEJM Perspective article "The ACO Regulations - Some Answers, More Questions," it's easy for readers to get the impression that CMS' policymakers are unsettled. Rather than creating a new healthcare vision, CMS' Proposed Rule is really an attempt to reconcile long-standing notions of managed care versus fee-for-service as well as closed networks versus open choice .  No wonder that Mr. Iglehard describes the new ACO regulations as "a work in progress" that mixes the best of of capitation, fee schedules, attribution and benchmarking that results in more questions than answers.  It's bad enough that the providers will find the 429 pages confusing, but so will the CMS staffers charged with making this ACO patchwork actually function.  This has implications for the ability of CMS to navigate between primary care, specialists and hospitals, provide timely data feeds, calculate savings and deal with anti-trust concerns.

Even without CMS' intelligent support, however, getting an ACOs off the ground will be daunting says Steven Lieberman in this Health Affairs Blog post.  Start up costs are likely to exceed savings, "two-sided" risk .imposes additional burdens, there are significant capital restraints, the quality reporting standards are numerous and complex, "retrospective attribution" dilutes control, the program is operationally burdensome and the interpretation of the regulations promises to be uncertain.  This promises to be risky.

In the end, says the widely quoted Bob Laszewsik, the prognosis for ACOs, may be limited less by CMS' confusion and by all those burdensome regulations than by enduring interest of the health care industrial complex in maintaining the status quo. Bob asks a fundamental question of economics: he wonders how likely is it that providers will be willing to spend money so that they can ultimately receive less money under a shared savings program?  Good point.

In a future post, the DMCB will be reviewing some approaches to these and other questions.

i can relate to this...

...and so can, I would wager, anyone who has been harassed by  condescended to infantilized by dealt with an insurance company on health related matters.

Especially if you have been on long-term disability for any length of time, you can expect regular correspondence. Blogger Katherine describes this experience:

"But as sure as the swallows return to Capistrano, every March CIGNA sends me information on its Cancer Support program. Last year’s began “Good health is a gift.” This year’s reads like a grade school report:


Dear KATHERINE O’BRIEN:


The American Cancer Society estimates that two men and one in three women will face cancer in their lifetime. Although these are scary statistics, CIGNA HealthCare wants you to know we’re here to help…"

Most of us just sigh, groan, maybe yell a little and then toss the letters into the recycling bin (unless it is one of the letters making demands to send information we have alread sent them SEVERAL TIMES. Then we scream a little louder, call the company, get transferred to voice mail, leave a message and then never hear back, send the info as requested and then get ANOTHER LETTER requesting the SAME INFORMATION and scream some more. Or maybe that's just me.). After years of this kind of correspondence, Katherine decided to write back (CIGNA is her insurance company):

"Dear DOUG:


Thank you for your letter of March 2010! I couldn’t agree more that good health is a gift! I was blown away that you want to help me make the most of it.


It was gratifying to know that “as health care claims are submitted to us, we review them and identify steps you might take to help improve your health.” Gosh. I feel a little guilty. I mean, you are poring over my health claims and I am doing bupkis for you. Maybe I could clean out the coffee room fridge in Bloomfield some time? Police the parking lot? Just let me know.


As you might have gleaned from your research, I have metastatic breast cancer. My doctor says that in 2010, there’s no cure for metastatic breast cancer. Of course that’s what she said in 2009. So I do intend to doublecheck in 2011. I will keep you posted...


...I think it is important to take care of me, too. I see Dr. Gaynor once a month. It might be hard to see her more regularly than that. Unless she wants to join my mahjong group. I will make inquiries."

You can read the rest of the letter and Katherine's post about it on her blog, ihatebreastcancer. Thanks to Anna Rachnel (ccchronicles) of The Cancer Culture Chronicles for telling us about Katherine's letter via Twitter.

Okay, But What Do The Actuaries Have To Say About Accountable Care Organizations?

Braininess

The elites, politicians, economists, physicians and bloggers may have much to say about Accountable Care Organizations (ACOs), but let's face it: we ignore what the actuaries have to say at enormous peril.  That's why it's worth checking out this important report from the brainiacs over at Milliman.  The report helpfully focuses on the many insurance and business risks of ACO's.   Its insights will help you help your bosses, co-workers and teammates as your company grapples with getting that ACO proposal ready for the looming January 1 kick-off date.

For example, think "revenue cycle management" or "fee negotiations" will be enough?  Think again, because CMS is not talking any prisoners on the risk of downside loss. You'll need far more discipline and capital, because Milliman points out that the Feds not only intend to withhold 25% of any savings, but will also require ACOs demonstrate an ability to pay back any losses. 

Milliman predicts that ACOs will need ongoing "service line" performance reports. That's vital, because they'll need to be prepared to redirect their care resources at numerous potential threats, like high readmission rates, high usage of skilled nursing facilities, increased numbers of one-day hospital stays or elevated specialist referrals.  In addition to following those data, it's also important for ACOs to know what level of reduction in any given metric - such as "ambulatory sensitive," "preference sensitive,"  short stay and repeat admissions - is achievable and what that means to the ACO's and CMS' bottom lines.  For example, is a "10%" reduction in ambulatory senstive conditions vs. an adjusted benchmark within reach, and does it get you over the "minimum savings ratio"?  If so, by how much?

Speaking of which, the Milliman report also has some useful benchmark information on ambulatory care sensitive condition (ASC) admission rates.  The report has some great information that compares the ASC performance numbers of "well-managed" to "loosely managed" insurance plans.

Which indirectly inspired the DMCB to once again to rekindling it's telepathic spiritual bonding with the Great and All Powerful and All Knowing Carnac the Magnificent - someone who was so wise, he was able to divinate answers to questions before he knew the question! 

While the DMCB was writing this post, it mysteriously entered into a trance-like state in which Carnac psychokinetically blessed the DMBC with three insightful and all-powerful answers:

1. Answer:  The Great Plains, Milliman and Wardrobe Malfunction!

2. Answer: A hero and a zero!

3. Answer:  Medicare Advantage and The Republican Deficit Reduction Plan!

It was only AFTER these answers were bestowed that the questions were transmitted to the DMCB from the spiritual realm of the all-knowing Carnac:

1. Question: Name a prairie, an actuary and a mammary.

2. Question: Who is Acting CMS Administrator Don Berwick and what are his chances of Senate confirmation?

3. Question: Give an example of capitation and decapitation.

The Budget Fight: It Will Be A Long Hot Summer, and Fall, and Winter…

The good news is that Democrats and Republicans are finally seriously engaged over the country’s fiscal crisis.And, each side is presenting a starkly different course for the voters to choose from.When it comes to the health care entitlements, Republicans want to cut the health care entitlement benefits and therefore ease the pressure on federal spending.Obama wants to largely leave the programs

The Latest Health Wonk Review Is Up!

It IS a wonderful time to be a wonky reader, especially if you want some additional links with insights on ACOs, the Ryan Budget, Medicare, HIT, journalism, ethics and other parts of health care.  David Williams of the Health Business Blog excellently hosts this week's edition, which can be found here.  Enjoy!

my kids are alright

I had a dream a few nights ago.

My kids were in a giant flash mob, dancing their hearts out, surrounded by dozens of other kids and adults. They were exuberant and focused, their movements fluid and in synch with those around them. My heart swelled with pride and joy.

I learned that the flash mob had been created to drum up excitement over an upcoming performance. In a couple of hours, my kids would go on stage and perform. I could tell they were ready.

Then I was handed a note. My own performance was scheduled for right after theirs. I was wholly unprepared. I hadn't even looked at my script. I was rushing off to find it when my alarm went off.

Sacha was in a play very recently. And they did organize a flash mob a week before the performance, as a form of advertisement. And Sacha performed beautifully. My heart did swell with pride.

In part, my subconscious might have been remembering the play but I choose to believe that I was also sending myself a message.

Life with metastatic breast cancer is filled with uncertainty. But no matter what happens, my kids will be fine. They are smart, talented, resourceful and resillient. They have friends and family who love them. My kids will be alright.

Medicare As We Know It Is Ending Under the Republican and Democratic Proposals

Good bye!

Pssst.  Guess what.  If either the a) the President and his Democratic allies or, b) the resurgent "Path-to-Prosperity" Republicans ultimately win Medicare deficit-funding debate, "Medicare as we know it" is going away.

That's the conclusion of the weary Disease Management Care Blog after reading the text of today's speech by President Obama on reducing the U.S. budget deficient.  More information can be had by checking out this White House fact sheet. 

A previous review of the sweeping Medicare changing Republican Ryan proposal can be found here.  Those are big changes. 

But so are the President's.

In tones that even the New York Times called "partisan," Mr. Obama extrapolated on Congressman Ryan's "voucher" proposal and asserted it will result in "$6,400" in additional out-of-pocket expenses for Medicare beneficiaries. Arguing that it's smarter to reduce the overall cost of health care, the President proposes to instead attack "wasteful subsidies and erroneous payments," leverage Medicare's purchasing power to command discounts and incent doctors and hospitals to prevent injuries and improve results.

Readers may recall that all those audibles are already in the Administration's CMS Playbook. What caught the DMCB's eye was the added proposal to "strengthen" an "independent commission of doctors, nurses, medical experts and consumers who will look at all the evidence and recommend the best ways to reduce unnecessary spending while protecting access to the services seniors need." Furthermore, if "Medicare costs rise faster than we expect, this approach will give the independent commission the authority to make additional savings by further improving Medicare."

That 15 expert member "commission" is a creation of the Affordable Care Act, otherwise known as Independent Payment Advisory Board (IPAB).  It is empowered to bypass Congress with cost-saving changes to Medicare, so long as it doesn't change coverage or quality. What's more, just as the President said, if the changes don't result in actuarially projected savings, IPAB is responsible for generating additional recommendations that must be carried by the Secretary of HHS.  What's new about the President's proposal is that the Board will be charged with striving for even tighter GDP-based global cost targets than previously anticipated.

So, why could Medicare-as-we-know-it end?  Up until now, it has been the style of Medicare to cover all reasonably medically necessary health care services.  In the "real world" of patient care, Medicare beneficiaries - with the exception of some preventive services - get sick and doctors treat and get paid.  Under the Democratic IPAB proposal, it is highly likely that U.S. docs' treatment options will be clinically or economically curtailed to what is officially "evidence-based."  

While that doesn't necessarily sound bad, much of the published science that will underlie the Commission's recommendations simply isn't up to the task.  While certain testing and treatment strategies are superior to others, comparative effectiveness research can be illusory, research results can be less than pristine, outcomes may not uniformly apply to all individuals and they often remain chronically (and thankfully) open to re-interpretation.  Highly trained U.S physicians will wonder - just as they do in their tussles with commercial managed care today - how remote experts use flawed and "succesionist" logic to decide what's best for their patients under their special and unique circumstances.

That's a lot of change.

Even though it's ironic that the solution to CMS' failures to date is even more CMS, the DMCB also wonders if either Congress (with its partisan hearings and tradition of service to constituents) or the Executive Branch (favoring the special interests of key political allies) can really resist the continued political temptation to meddle in a trillion dollar industry.  That won't change.

While this could rekindle the death panel controversy, this could ultimately turn out to be what the President doesn't want: re-run of the 2010 debate over the role of government in health care.  The blogging DMCB, on the other hand, looks forward to a bloggy-target rich debating environment: do we want the enlightened allocation of health care resources or... do we want to harness the wisdom of markets?  Which is worse: top-down central planning or... forcing vouchers on vulnerable seniors and forcing them to choose between eating, heating or healing?  And finally, which party can frame ("vouchers!" or "premium support!") the debate and deploy the best rhetoric (that $6400 is not a CBO number, is it?) to meet their policy and political ambitions?

vote early, vote often

I watched last night's English language election debate with interest. I was shocked at how quickly the two hours passed, although this was greatly aided by the fact that I wrote and read a steady stream of commentary on Twitter and Facebook (sorry to my followers and friends who don't give a damn about the Canadian federal election!). It helped me to keep watching without blowing a gasket. I felt like I was at a bar with friends hooting and hollering, except that I was in my basement drinking tea with my son and my spouse (another advantage to Tweeting during the debate was that I had to keep looking down at my Blackberry. This kept the orange decor from searing my retinas and Harper's cold eyes from turning me to stone).

I thought that all the opposition party leaders did well. Duceppe delivered the best opening line ("Congratulations, Mr. Harper, for answering your first question from a citizen during this election campaign.") but petered off  towards the end. It's got to be brutal doing a two-hour debate in one's second language. By and large, I find it a pity that the Bloc only speaks for Quebec, as they are so consistenly solid on most social issues. They lose me, however, when it comes to questions of immigration and multi-culturalism. Nationalism and multiculturalism don't go so well together.

Layton was calm and measured and many people with whom I've spoken found his performance to be much stronger than in previous debates. Personally, I would have liked him to be a bit more aggressive, as he left it to Ignatieff to drive home the points that are near and dear to my heart. Kudos to him for mentioning proportional representation and for this seriously funny (but cheap) line: "I don't know why we need more prisons when the crooks seem so happy in the Senate."

I thought the evening, however, belonged to Ignatieff. He stayed on message (although I found "You shut down what you can't control" to be more effective the first time he said it than the tenth) and was forceful and articulate. He hit all the right notes on all the key issues and challenged Harper on gun control, immigration, crime, health care and transparency. He looked positively Prime Ministerial (my favourite Iggy line of the night, "This isn't bickering Mr. Harper. It's democracy.")

Is any of this going to change my vote? Absolutely not. I remember when the Liberals were in power and they were singing from a different songbook then. Happily, my NDP candidate is an incumbent who has done an excellent job, locally and for the country. I'll vote for Paul Dewar and I won't even have to hold my nose.

But if I lived in a riding where the race was one between the Tories and the Liberals? I just might be voting strategically this time around.

Perhaps none of it will make a difference though. All the pundits who did wrap-up commentary last night seemed to agree that Harper had won the evening. Even my beloved Chantal Hébert was unhesitating in her praise of Harper's performance. Did Canadians watching at home feel the same way? Did undecided voters? Do any undecided voters watch the debates?

I can't recall a time when I have felt as strongly about voting. I keep reading assertions that if all eligible voters under 25 and all women voted, Harper would be out on his ass.

Let's make that happen, shall we?

The Patient Centered Medical Home and Diabetes: A Timely Review of the Evidence

Where's that evidence?

After last week's Disease Management Care ACO-Blog-Fest (which catapulted the DMCB onto a highly coveted 'first page' Google "search" status for "Accountable Care Organization"), the DMCB turns its attention back to the Patient Centered Medical Home (PCMH), thanks to this timely hot-off-the-presses review by Trajko Bojadzievski and Robert Gabbay of the Penn State College of Medicine. 

Anyone pondering the many promises of the PCMH is likely to eventually focus on diabetes mellitus.  The condition is not only highly prevalent and costly, but its quite measurable.  Patients with diabetes are readily identified in most healthcare databases and it's relatively easy to measure the frequency of recommended tests and treatments over time.  It could also be argued that diabetes is a "bell weather" for overall quality for providers and insurers.  Solve diabetes and you solve the health care conundrum.

With that as background, Drs. Bojadzievski and Gabbay asked a simple question: what is the evidence that the PCMH reduces costs or increases quality for patients with diabetes?

The authors assembled peer-reviewed published papers as well as all the web-based reports on the PCMH and its impact on diabetes. They identified 41 programs and pilots; three were excluded because of their small size and focus on converting from usual care to a medical home practice, leaving 38. 

Unsurprisingly, the authors found that common ingredients for the PCMH include payment reform (with additional money to pay for new infrastructure, patient coordination and quality bonuses), care management, patient registries, electronic records and expert consultation support. They provide succinct summaries (including a well organized table) of the what the DMCB is coming to refer to as the "Top Eight" PCMH pilots: Community Care of North Carolina, Geisinger Health System, the Pennsylvania Chronic Care Initiative, Group Health, the Rhode Island Initiative, Health Partners, the Colorado PCMH pilot, and the PCMH National Demonstration Pilot.

While their review showed the PCMH was associated with impressive quality gains, the authors' answer to the question poised above was telling:

"Although randomized trials have yet to be performed, the eight Medical Home initiatives reported provide encouraging “before and after” results to support the PCMH as a viable mechanism to improve the quality and costs of diabetes." 

"Before and after?" Once again, the DMCB is left wondering if the enthusiasm for the PCMH will ever be matched by its evidence base.  Recall the following quote from a past 2007 article from the American Journal of Managed Care that critically examined "disease management":

"However, the vendor-run assessments typically do not meet the requirements of peer-reviewed research in terms of the comparison strategy, and adequate control for selection bias and regression to the mean."

Fortunately for the DM industry, they responded by adopting approaches that meet many of the rigor and plausibility requirements of peer reviewed research. The good news for the PCMH is that they can do that also as better data from the pilots are released the coming months.  That being said, the DMCB is also coming to believe that the uptake of the medical home may ultimately hinge less on the pilots than on how well it supports the success of ACOs.  Unfortunately for advocates of the PCMH, that ACO evidence base - and it prospects for profitability - remains an even bigger question mark.

One last important point from the authors was that expert "practice transformation coaches" and "learning collaboratives (meetings to explore and exchange ideas) are a common feature of the PCMH.  If that is one of the factors leading to "before and after" success described above, ACOs that are building medical homes in their networks may be well advised to tap into that kind of expertise.