Employed Physicians and Their Political Leanings

Reporting for work!

Read this "Doctor's Inc" article in the New York Times, and it's easy to get the impression that the absence of employed physician support for the Republican Party translates into their active support for the Democratic Party.  Times reporter Gardiner Harris implies this shift is somehow responsible for waning doc interest in liability reform, greater support for public health issues such as consumer safety and the American Medical Association's decision to back President Obama's health reform agenda.

Don't be so sure, says the Disease Management Care Blog.  While it has opined on the  generational "Millennial" shift and what it means for population health management and the practice of medicine, it's not convinced that that means that the physicians will experience a meaningful political shift.  There's little reason to believe that they'll trade their country club memberships, tasseled shoes and Fox News habits and for professional soccer season tickets, pinot grigo at a Sheryl Crow concerts and Pelosi twitter feeds. In fact, midway through the article, Mr. Harris points out that there are no surveys that objectively track physicians' political leanings or can correlate it with employment status.

There are several reasons why the DMCB doubts that things are so simple:

1.  During its multi-decade career as an employed doc, the spectrum of opinion among its employed colleagues spanned the political spectrum  This was not a granola crowd. 

2. There are many instances of mutual support between organized private practice physician groups and large employed physician groups.  This is a good example.  There are others.  

3. It's not unusual for large employed physician groups to cover the dues of membership in County and State medical societies, as well as the AMA.  This is one example.  That's because 1) some docs want to join organized medicine 2) these professional organizations do much of the "political heavy lifting" in areas such as provider reimbursement, 3) at a local level, they've generated a lot of community good will, and 4) can they aid in physicians' professional development.

The DMCB also thinks its unfair to assert that the AMA changed its stance or that the liability reform is no longer a hot button issue.  The AMA had long established principles for national health reform, and it arguably attempted to make a reasonable compromise over what they regarded as an "imperfect" Democratic proposal.  Many of the States have instituted liability reform (here's a good example) precisely because organized physician groups, employed physicians and their employers were unanimous in their agreement that the current tort system is broken.

While there may be something to the notion that being an employed physician makes it easier to be politically unengaged, the DMCB agrees with Health Affairs' John Iglehart that it's too early to tell. It's possible that after a few years, a significant number of employed physicians will have second thoughts.

President Clinton Listens To The Other Side On Health Reform

Blasting away?

According to Kaiser Health News, President Bill Clinton "blasted" the Ryan health reform proposal because it is wrong, will saddle seniors with unaffordable costs and do little to blunt medical inflation.  Questioning KHN's portrayal of a centrist Democrat known for co-opting Republican ideas, the Disease Management Care Blog accessed Peter G. Peter Foundation video library and viewed the next to the last 2:17 Clinton video for itself.

What Mr. Clinton really said is that Mr. Ryan is "wrong" to to believe that taxes shouldn't be touched and that his Medicare proposal is "wrong" "on the merits" because there is no reason to believe it will restrain health care costs.  If costs continue to rise, said Mr. Clinton, people will avoid care and be at risk for premature death.  The President also stated that Medicare is part of a health system with a "toxic" inflation rate that is blunting pay raises and harming America's global competitiveness. He also said he "applauds" Mr. Ryan for the suggestion -  even though "it doesn't work."

Hardly a "blast," scoffs the DMCB.  At least President Clinton, unlike many of his colleagues in his party and the liberal media, is actually listening.

And speaking of listening, the DMCB, thanks to a specially chosen vintage, endured a broadcast of Lady Gaga's "Monster Ball" HBO Concert Event.  While it was mystified by much of the spectacle, the music prompted the DMCB to adapt an old adage about tequila.  Lady Gaga's music, Federal efforts to control health care pricing and tequila all share some key attributes: they're all only suitable when they're really dressed up, or when it's late and there are no other options.

in translation

The cancer centre has implemented something new. When patients check in for treatment, we're asked to fill out a questionnaire related to our well-being (it has some acronym but I can't remember it). We're given the option of filling it in on a central computer but I'm really squeamish about germy public terminals. I always ask to fill the thing in manually (furthering my feeling that I am more of a Luddite than some of my seniors).

Filling out the form involves reading statements such as "I am in pain" and then circling a number between 1 (no pain) and 7 (excruciating pain - or something like that). Most of my numbers were very low except for the ones about my emotional well being and sleep habits. My answers resulted in the following conversation with the well-meaning nurse who checked me in for treatment:

Nurse: 

"You're depressed. Why?"

Me: 

"I'm just a little blue. Five years of doing this is a long time." (Translation: "I'm pissed off and fed up and I have survivors' guilt.") 

"I'm seeing someone at the psychosocial oncology centre." (Translation: "I don't want to talk about it with you, in front of the all the strangers in the room"). 

"The crisis is over and now it's all hitting me." (Translation: "I think I have PTSD. Did I mention that I'm pissed off and fed up?")

Next time, I'm stuffing the damn form into the bottom of my purse.

kitchen conversation (he's so, so right)

My spouse (after listening to lengthy rant #342 yesterday): "Not to excuse that person's bad behaviour, but a lot of things piss you off these days."

Me: "True."

Spouse: "Oh! We forgot to put the compost out!"

Me: (String of expletives, unprintable in a blog my children might read).

Spouse (Meaningful silence)

Then we both burst out laughing.

I need to get some perspective.

But at least I can still laugh at myself.

A Defense of the Current Accountable Care Organization (ACO) Proposed Rule Takes Things From Bad to Worse

The future of standard FFS Medicare?

From time to time, well-meaning attempts to help just make things worse.  One telling example is when Republican Governors, Congressmen and Senators extol the virtues of marital fidelity.  Another is when the Disease Management Care Blog tells the spouse that mini-gargoyle statues could enhance the living room decor. 

And in the same vein,  Paul Ginsburg, writing in the latest New England Journal, ineptly praises the first rendition of the controversial CMS Accountable Care Organization (ACO) regulations.  Despite some political signals that CMS will show some flexibility and change the proposed rule, he hopes they stick to their guns in four key areas. That's because he believes that, when it comes to health care reform, this time the Feds really really mean it.  He thinks that's a good thing. Yet, while extolling the proposed rule, he is simultaneously alerting the DMCB and its readers to some troubling aspects about ACOs and Medicare's payment reforms.

1. Retrospective attribution?  Cost savings will be calculated by looking back at the Medicare claims for the population at the end of the contract instead of the beginning.  This has the advantage of ensuring that all beneficiaries are treated equally.  Dr. Ginsburg says its not a problem because CMS will "provide extensive data on beneficiaries on the beneficiaries who could have been attributed to an ACO."

In other words, the success of the retrospective approach will strongly depend on CMS' ability to provide timely data to the participating ACOs.  Anyone paying attention, especially regular DMCB readers, knows that CMS' track record of data support has been decidedly spotty (here and here).  This is an ACO vulnerability that is bigger than was appreciated by the DMCB.

2. Shared savings?  Benchmarks will be locally based, meaning that historically inefficient organizations will have an easier baseline to beat, giving them an out-of-the-gate advantage in their pursuit of shared savings.  Dr. Ginsburg says that's good, because those inefficient organizations need to change and should be recruited as ACOs anyway. 

What alarms the DMCB, however, is Dr. Ginsberg's carrying this logic forward to what could turn out to be an ultimate zero-sum game.  He notes that if ACOs succeed, "evolution toward national or regional benchmarks is inevitable, and already efficient ACO providers will then get larger rewards."  The DMCB believes it's far more likely that a fiscally strapped Washington DC will ratchet down the national or regional benchmarks, ultimately assuring that all ACO providers get smaller rewards.  In other words, ACOs give the Feds one more tool to squeeze the docs.

3. Quality of care?  Dr. Ginsburg notes that CMS's quality measures will evolve over time.  He correctly notes that ACOs would benefit from some stability in the quality measures. 

The DMCB didn't realize that organizations that commit to ACOs may be forced to shift measurement gears during the life of the contracts.  Egads.

4. Mission over margin or... no margin?  Yes, the up-front investments and the high bar on gainsharing make it possible that the return on investment for participating organizations will be too small to make it worthwhile.  Too bad, says Dr. Ginsburg, because the ACOs are in the vanguard of a transition to value-driven payment and that it is inevitable that fee-for-service payments will go away.

So, in other words, some ACOs will succeed and others may go belly up but all the other providers will watch their Medicare incomes vanish as the Feds innovate their way to value-based purchasing.  This is not changing Medicare as we know it?

generation gap

On Tuesday, as I waited at the Heart Institute for my regular echocardiogram, I had the following brief conversation with the older gentleman sitting beside me.

Me: Is that a Playbook?

Him: I don't play! This is an ipad!

Me: Oh. I was just curious about the Blackberry version of the tablet.

Him  (scornfully): Do you have a Blackberry?

Me: I do.

I didn't bother explaining that I don't find touch screens to be intuitive and that I prefer an actual keyboard for sending emails and texting. Instead, I pulled out my knitting, thus eradicating all doubt that I was the Luddite in our conversation.

The Latest Health Wonk Review Is Up!

If the folks at Health Affairs Blog ran the latest HWR, would you expect anything less than a superbly written summary with links to the best that the health care policy blogs have to offer?  Well, readers will not be disappointed and it's well worth the time to check it out.

Primary Care and the Weak Correlation with Quality and Costs (and Costs Go the Wrong Way?)

Correlation

One of the common assumptions in the unending health reform debate is that a revitalization of the primary care workforce will lead to cheaper and better care.  The Disease Management Care Blog is reexamining that premise in light of the just published JAMA study "Primary Care Physician Workforce and Medicare Beneficiaries" Health Outcomes" by Dartmouth's Chiang-Hua Chang, Therese Stukel, Ann Barry Flood and David Goodman.

This was a cross-sectional study that looked at the correlation between statistically representative samples of Medicare beneficiaries' 2007 costs,deaths and preventable hospitalizations vs. the density of primary care physicians within zip-code assigned "primary care service areas."  There were two measures of primary care density: 1) the AMA "Master File" which uses mail physician survey data to count the type and location of doctors (the DMCB remembers completing these surveys), and 2) an estimate of 'full time equivalents" (FTEs) practicing primary care that was inferred from the types and numbers of claims submitted to Medicare.

After controlling for known statistical sources of bias in the service areas, the authors found that the number of "physicians" were lower than the number of "FTEs."  Across service areas, the former ranged from 17 to 81 per 100,000 beneficiaries, while the latter ranged from 65 to 103 per 100,000.  There also appeared to be low correlation between the physician and FTE measures, suggesting that there were many physicians who were not self-identified as primary care but were still providing primary care services.

The authors then sorted the service areas into physician and FTE quintiles, ranging from high to low.  Expecting to find progressively lower hospitalization rates, deaths and costs among the higher quintiles, the authors instead found:

Death rates (overall about 5.4%) did not meaningfully vary across the physician quintiles but dropped slightly among the FTE quintiles,

Preventable hospitalizations (ranging from 75 to 80 per thousand) were weakly correlated in that the highest quintile beat the lowest by 5 to 8 points for physicians and FTEs, respectively,

Costs seemed flat (around $8700 per beneficiary) across the physician quintiles but were elevated (about $8850 per beneficiary) in the  highest FTE quintile.  That trend, however, did not achieve statistical significance.

While the authors' study was complicated by having to reconcile two measures (doctors and "FTEs") of primary care physicians, they ultimately found only a modest correlation with primary care and lower mortality and hospitalizations, but higher spending.  The conclusions were stronger when they counted FTEs vs. physicians.  Things can be nicely summed up in this quote:

"If all areas' primary care FTEs (in the United States) increased to the highest quintile, the model suggests that this might lead to 48 398 fewer deaths and 436 002 fewer hospitalizations, but would cost $13.8 billion more in total Medicare program spending. The higher spending is from more spending in clinician spending (Part B, $36.4 million more) that is more than the reduction from lower spending in acute care facilities (Part A, $22.6 million less)."

Disappointed?  So is the DMCB but it's not all that surprised.  It's suspected for quite some time that the impact of primary care physicians on health care utilization is somewhat limited.  In looking at the actual numbers in the Tables of the JAMA study, death rates are varying by decimal points and the shift in costs per beneficiary is in the range of about a hundred dollars.  Primary care is hardly the solution to the twin U.S. health care challenges of costs and quality.

It's also important to note that this paper is all about association, not causality. Based on this study alone, the DMCB cannot conclude that moving primary care physicians from high to low density service areas will cause costs to go up or death rates to go down.  That can be implied, but it's also possible that primary care physicians prefer to practice in areas that with spending patterns that translate into higher incomes.

That being said, this is worrisome for Accountable Care Organizations, which are supposed to secure an adequate base of primary care physicians.  Based on a potential cost differential of $100 per beneficiary, this suggests having a high number of PCPs in the ACO network could increase costs and hamper the ability of these organizations to obtain the upside gainshare. 

Earth to Republicans: You Are In Big Political Trouble Over the Ryan Medicare Plan

It should now be clear to Republicans they are in trouble over the Ryan Medicare plan.Yesterday, they lost a seat in a solid Republican New York House district. Their candidate had benefited from lots of money and House leadership attention. The big issue was the Ryan Medicare plan.All month, Republican Presidential candidates have been walking a tightrope over the Ryan plan--don't embrace it but

More On The Synergies Between the Patient Centered Medical Home (PCMH) and Remote Telephonic Disease Management

One criticism of the Patient Centered Medical Home (PCMH) is that its officially endorsed definition is operationally vague.  While organizations such as the NCQA and URAC have developed detailed specifications, it's still possible to meet a minimal number of them with varying degrees of implementation and still claim official credit as a PMCH.  That lack of preciseness not only leads to the PCMH meaning different things to different people, it also makes it difficult to include it in a defined insurance benefit or craft supporting legislation.  Even the PCMH's supporters agree that the PCMH is unfinished and still needs to evolve.

With that as background, suppose the Disease Management Care Blog described a new PCMH arrangement, where a third party conducted a mass recruitment and education campaign consisting of a mailing over a PCMH physician's signature, followed by phone calls from non-physician educators?  While that classic "disease management" approach might be familiar to many DMCB readers, it probably would also run afoul of chronic tensions underlying the "ownership" of all the team-based elements that make up the PCMH.  Accordingly, will the continuing evolution of the PCMH ever lead to the inclusion of remote telephonic care management?

According to PCMH advocate Thomas Bodenheimer's editorial in the latest issue of the Archives of Internal Medicine, the answer is now "yes."  Likening the PCMH to a diaphanous "Holy Grail," he argues its concept now allows for the assignment of routine and chronic care tasks to non-physician care coaches working within "teamlets" linked to the larger collaborative teams with physician oversight.  He says that can help physicians refocus on all patients instead of just those with appointments while "delegating" care tasks to non-physicians.  If physicians can do this, he implies, the Holy Grail will finally be found and medical care will become righteous and pure.

And what is the basis for Dr. Bodenheimer's conversion?  His editorial is in response to a published study by Karen Lasser and colleagues appearing in the same issue of the Archives.  465 patients cared for in 15 Boston community centers who had no record of colon cancer screening were randomly assigned to usual care vs. a mailing combined with "centrally" based "navigators who made as many as 11 attempts to telephone their patients and engage them in the cancer screening.  After one year, 34% of the intervention patients vs. 20% of the control patients had screening, difference that was statistically significant.

In the Lasser study, the navigators were not located in the 15 clinics, were trained separately and work autonomously. This introduces a "virtual" dimension to the PCMH that is similar to traditional disease management programs. The DMCB doubts the physicians in the 15 clinics really cared all that much, just so long as more patients got the care they deserve. 

It appears Dr. Bodenheimer supports that assessment and agrees that remote telephonic support by non-physicians is a good thing for the still evolving PCMH.

Engineering Our Way to Clinical Perfection?

Put breathing tube 'A' into patient 'B'

The Disease Management Care Blog recently had the pleasure of listening to a presentation on reducing medical errors.  The speaker was dually expert in medicine (a superbly trained surgeon) and engineering (NASA).  We also had a chance to chat over lunch.  But for a "systems" approach to patient flows in emergency rooms and operating suites, he said, hospitals would be safer, better and cost-effective havens of evolving clinical perfection.

Which is why the skeptical DMCB was interested in the Health Affairs article on "How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts."  Adding to the luster of "integrated delivery systems," the narrative describes how a dedicated expert team stomped out unwarranted, costly and pernicious variation in prostate, gallbladder, hip, open heart and pacemaker surgeries as well as the care of acute respiratory distress syndrome (ARDS) and "community acquired pneumonia."

After creating the requisite data systems, Intermountain discovered that, while the patients were similar, the physicians' approaches to them were not.  Despite that insight about the providers, the team was unable to discern any statistically significant outliers.  That led them to blessedly leave the individual docs alone and focus on over 1400 clinical, support, patient satisfaction and administrative "processes."  This, in turn, prompted the creation of modified guidelines and care protocols that supported higher quality and lower costs. It worked.  The authors argue this fits hand-in-glove with the Affordable Care Act, puts the docs in charge (in lieu of 'distant health insurance companies') and aligns economic incentives.

The DMCB also learned:

• Intermountain's earliest data systems missed 35-50% of the data necessary to track the care processes described above.

• While there are 1400 work clinical work process, 104 account for 95% of the care delivery at the bedside. Sixty are now being captured, studied and managed.

• One guideline (the one or ARDS) required over a hundred changes to better adapt it to what was going on at the bedside.

• It was one thing to achieve change in single clinical settings, but something else entirely to generalize them through a system made up of 23 hospitals and 160 clinics

There are no descriptions of how how Intermountain did the calculations, but they claim hip surgery costs decreased from $12,000 to $8000.  That plus other cost savings added up to $30 million, which was enough to "bend the cost curve."

Key lessons for the DMCB? 

• The authors contrast Intermountain's systems approach with the ham fisted and statistically inept "spot the bad apples" and name-blame-and-shame-the-providers approach favored by many payors, including parts of Medicare.  The point of safety systems in planes is to make it hard for otherwise good pilots to make an error, and the same should be true in today's enlightened hospitals.

• Nationally published "clinical guidelines" were found wanting and had to be further modified.  What's more, they had to be modified by the front line physicians.  While this could be criticized as changing the position of the goalposts, this really suggests that much of "evidence-based medicine" still may not be ready for prime-time in the trenches of patient care.  It also confirms that unless the docs are involved, it won't happen.

• If organizing the inpatient care of rather "standard" surgical and medical conditions in hospitals is stressing information systems with dozens of "work processes" - many of which still defy measurement - think of the hubris it takes to believe that this is possible among free-range outpatients with complicated conditions like diabetes mellitus with multiple co-morbid conditions, varying insurance designs, social supports, cultural inputs, educational levels and competing priorities. 

That last point above is why the salad-fork armed DMCB pointed out to the NASA-doc that the merits of hyper-engineered systems didn't reach all into all corners of the health care system. Overconfident advocates of "disease management" made that same mistake.

We never really came to an agreement on the issue, but then again he's a surgeon.  Which reminded the DMCB of an old joke:

What's the definition of a double blind clinical trial examining the merits of competing approaches to the care of a surgical condition?  Any study involving two or more surgeons.  Ouch.

More On Disease Management Savings and Its Rationale in Risk Contracting

An early Disease Management Care Blog's scientific reaction to the Schwarzenegger imbroglio was to think of the Governor's ten year dalliance as a natural experiment, demonstrating that past anabolic steroid abuse doesn't necessarily necessarily interfere with long-term male fertility.  The DMCB spouse points out that the experiment also demonstrates that steroids have little impact on male intelligence. 

In keeping with the science theme of today's posting, the DMCB wanted to alert readers to the recent publication of two noteworthy studies:

1. Eapen and colleagues were interested in knowing if heart failure disease management programs make financial sense under a bundled payment system. Assuming a baseline readmission rate of just over 20% and a cost per readmission of about $2300, the authors calculate that a program cost of $477 per patient is the break-even point. The authors found 5 studies on the topic and determined that 2 would increase costs while 3 would be cost saving.  The DMCB suspects the disease management service providers will find charging less than $477 to be well within reach.  Hospital systems that are rushing into shared risk arrangements with insurers (including ACOs) that are asking the question poised by Eapen et al. now have their answer.

2. de Bruin and colleagues performed a systematic review of the recently (from 1/09 thru 12/09) published literature on "disease management" that included two or more components of the Wagner chronic care model.  31 papers were included (14 diabetes, 4 depression, 8 heart failure and 5 COPD).  21 of the 31 reported on costs and 13 showed cost-savings.   The authors concluded the range of cost shifts, ranging from +$3305 to -$16,996, indicates the evidence of cost expenditure reduction is "still inconclusive."  The DMCB thinks differently, noting that a "13" out of "21" saving money translates to about 2 out of 3.  To paraphrased Jack Nicholson's portrayal of the brave U.S. President Land in that DMCB cinematic fav, Mars Attacks!, "the people should know that two out of three ain't bad."  Indeed.

has anybody seen my boob?

As anyone who has ever been to my house can attest, the place tends to be a total disaster pretty cluttered. We lose stuff all the time, only to find it months or even years later, after it's already been replaced.

But I have to admit that never in my wildest dreams did I ever think I'd find myself typing this sentence: 

I can't find my prosthetic breast.

We've actually been making some inroads in terms of beating back the clutter. But some rooms are getting worse before they get better. And our bedroom is complete tip.

Now admittedly, I don't wear my prosthesis all that often. But there are days when I want to fly below the radar. There are clothes that just look better when they're symmetrical. And I haven't seen my fake breast for weeks.

Could I have absent-mindedly stuck it in a drawer that I haven't checked?

Could it have become mixed up in the bags of clothing destined for donation?

Could it be under the mounds of clothes yet to be sorted?

Could I have left it somewhere?

It's a mystery.

If you find it, please let me know. 

Or just leave it in my mail box.



Update May 26: We found it! It was in a suitcase. In our bedroom. From a trip on which neither I nor the boob were in attendance. I think I took it off one night and too lazy tired to put it away, popped my bra with the boob still in it, in the open suitcase. Then, the suitcase was closed and left. Three weeks later, when my love finally unpacked - he found my prosthesis. Mystery solved.

Run, Mitch Run Ver. 2.0

Indiana Governor Mitch Daniels continues to be coy about throwing his hat into the race for President.  Yet, the prediction markets are currently rating the odds of seeking the Republican nod at greater than 50% and, given the current desultory field of official declareds at this point, Mr. Daniels entry would shake things up.

Like Mr. Brooks of the New York Times, the Disease Management Care Blog may end up liking the prospect of a "President" Daniels.  It would need to know more about his positions on health care, but Mr. Daniels already has a head start with the DMCB.  That's because it met the future Governor many many years ago.

Back when Mr. Daniels was involved with pharma, the DMCB and some of its colleagues had a chance to sit down with him and chat about quality, costs and disease management.  He described health care as a "blank white page," of which a small corner could be represented by the traditional health care system.  Much like using a pen to darken that corner, he said we were expending far too much time and effort to completely fill it in.  The real solution to health care cost and quality, he said, was examining new solutions that could be drawn on the rest of the page.  

It's a shrewd image and the DMCB has repeatedly used it (with appropriate attribution) in many of its public presentations.  While persons can read whatever they want into the part about the "rest of the page," Mr. Daniels has grasped that the solutions to the twin challenges of cost and quality lie outside the traditional medical-medical complex. 

Not a bad insight for someone with no real hands-on experience in patient care.  It also stands in contrast to the current "red pill-blue pill" occupant of the White House.  The DMCB is not endorsing Mr. Daniels, but is hoping he enters the race so that we can have some real substantive discussions on the next steps for health reform.

"none of us knows when we are going to die"

On April 25th, Alaina Giordano lost custody of her children. A North Carolina judge ruled that her two kids need to move to Chicago to live with Giordano's ex-husband. She based this decision, in large part, on the fact that Giordano has Stage 4 breast cancer.

Visit msnbc.com for breaking news, world news, and news about the economy

I can't be articulate about this story, except to say that I work very hard to make sure that my kids will be all right- no matter what happens. I wish I could protect them and all those who love me from the realities of cancer. But do I think that cancer makes me a less fit parent?

Not on your life.

Want to read more?

I first read about this on BlogHer, where Jenna argued very articulately that anyone who has ever been ill or ever might be should care about this story and the frightening precedent it has set.

My friend Judy (from Mothers With Cancer) wrote a beautiful response called "We Are All Terminal." 

You can read Alaina's own words on her blog, Beauty in Truth.

I couldn't find a single post or comment by anyone who agreed with the judge's ruling.

For that, I'm grateful.

"Upgrading" the Independent Payment Advisory Board As a Way to Control Costs?

In yesterday's post about "risk transfer" as Medicare savings "in drag," the Disease Management Care Blog mentioned and linked a largely favorable New England Journal summary article about the Independent Payment Advisory Board (IPAB).  Describing it as a very complicated part of the Affordable Care Act (ACA), author Henry Aaron notes the 18 member IPAB will be seated in 2013 and start issuing recommendations to Congress on ways to reduce health care costs for 2015.  By law, none of the IPAB recommendations  can result in any “rationing,” changes in premiums, increased cost sharing, benefit limitations, physician fee schedule adjustments or alterations in Medicare's eligibility standards.  While there are other services that can get "whacked" (for example, dialysis centers, Medicare Advantage and the Part D prescription program), it looks like the IAPB - for now - will be relying on data from comparative-effectiveness studies, approaches to bundled payments, value-based insurance designs, health insurance exchange-based competition and ACOs for most of its recommendations.

Yet, asks the DMCB, suppose Medicare's costs continue to rise despite vague promises about risk pools, innovation and quality while there are dozens of inconclusive demos and pilots?  What if providers find comparative effectiveness rules, bundled payment arragnements, insurance designs and ACOs burdensome and figure out how to circumvent them?  What happens if the electronic health record craters, like it did across the pond? 

The DMCB thinks it's remotely possible that a frustrated Congress and a President could choose to further "upgrade" the IAPB so that the 18 member board does have the power to change payment rates or other aspects of the Medicare program.  While unlikely, the alternative - having to vote to increase taxes or cut benefits - is also difficult to imagine.

Hmph, you say?  Check out this quote from the U.S. House of Representatives Ways and Means Committee Chairman Camp's letter to the President:

"President Obama discussed giving more power to the IPAB, but didn't share specific details regarding how it would reduce Medicare Costs.  The Chairman's letter asked "What specifically do you mean by 'giving the IPAB additional tools to improve the quality of care reducing costs, including allowing it to promote value based benefit designs?  Would this require a statutory change, given that the IPAB is not currently allowed to consider changes to the Medicare benefit package?"

Based on the scenario above, the DMCB thinks it knows the answer.

Risk Transfer: Cost Reduction in Drag for Medicare

Health policy titans debating the actuarial links between clinical quality and cost trends.  Presidential candidates struggling to find the best "gotcha" Medicare catch-phrase to use against their enemies.  Progressives and conservatives in a death struggle over competing health care "visions" on the role of government.  Yet, underlying all this political cacophony is general agreement that Washington DC's involvement in health care and insurance has increased.

Except, says the contrarian Disease Management Care Blog, that is less true than meets the eye.  That's because in one key respect, Federal involvement in the world's largest health insurance program called "Medicare" is actually decreasing. When viewed through the lens of "risk transfer," there is an ironic bipartisan agreement that Medicare's risk needs to be transferred elsewhere.  The only real disagreement is over where it should go.

Recall that insurance is a contractual agreement to exchange "risk" for "money" a.k.a. risk transfer.  Insurance is a business that accepts and "pools" risk and uses collected premiums to cover the cost of the bad events among the individual contract (or "policy") holders. As the likelihood or cost of a bad event (such as, for example, a death of a wage earner, a home fire, car accident or unexpected illness) increases, the cost of the insurance premium to fix, or "make whole" the bad event also increases. 

Basically, the Medicare program accepts risk in exchange for FICA taxes.  Medicare's problem is that both the likelihood and the cost of illness among its beneficiaries are turning out to be unaffordable.  Unable to increase the premium or decrease the cost of illness, the logical response is to transfer that risk (along with its inadequate levels of money) someplace else.

There are three non-exclusive risk-transfer options that the DMCB thinks are being proposed and implemented at the Federal level:

1) Transferring the risk (and the money) to commercial insurers.  That program is called "Medicare Advantage," which has been criticized for transferring proportionately too much money for the level of risk.  Another approach is Medicare's "secondary payer status," forcing any other active health insurers to pay first when there is any overlap in coverage.

2) Transferring the risk (and the money) back to the Medicare beneficiaries.  Variations of this is a recurring theme among the U.S. House of Representatives Republicans, who are proposing variations of a "defined benefit"  approach, such as capped premium support payments and vouchers.  If the cost of illness exceeds a threshold, it's ultimately up to the person, not the government to eat the economic difference.

3) Transferring the risk (and the money) to the heath care providers. This underlies the logic of the upside gainshare, ACO "two sided" risk, bundling and no-pay for "never events" as well as "hospital acquired conditions."  The logic here is that providers can mitigate risk through greater efficiency or quality.  By tying in the money that goes with it, Medicare is gambling that the physicians can ultimately "bend the curve."  The amazing thing here is that, following the debacle of HMO capitation in the 1990s, the providers are willing to go along with it.

All three options have the political advantage of obscuring cost reductions for Medicare with the patina of efficiency consumerism, quality and value.  The DMCB thinks of it as savings in drag.

What happens if Medicare's risk transfer legerdemain isn't successful?  Our politicians will have to return to the politically unpalatable options of increasing the premium or reducing costs through unilateral fee schedule reductions.  Alternatively, they can outsource that repugnant task that to a newly created animal called the Independent Payment Advisory Board.

That road could (see slide 36) ultimately lead to a single payer.  More on that in an upcoming post.

selfish (dear loved one)

I'm sorry that my fear becomes yours.

I regret that you get pulled into my panic.

I feel ill when my every cough, ache or bump twists your insides the way it does mine.

I would prefer to protect you.

I want to watch you smile, hear your laugh, feel your heart thump with joy when you pull me to your chest.

I don't want to make you scared, or sad or worried.

But I can't wish you weren't ever scared or sad or worried.

Because I need to share.

Because I need not to feel alone.

Because I need you.

The Malcolm Gladwell Innovation Hypothesis Applied to Multi-Stage Evolution of Disease Management

Who Really Invented This?

While the Disease Management Care Blog doesn't subscribe to The New Yorker, it has pieced enough of the National Public Radio and this on-line summary together to understand the "cliff notes" version of Malcolm Gladwell's "innovation" hypothesis. 

He argues that true innovation is really a multi-stage process that not only involves raw creativity but subsequent insights on how that creativity can be changed, adapted and applied.  For example, it was the Soviet military that envisioned remote digital technology, the Americans who made gadget drones and the Israeli military who used them in real warfare.  Another famous example is the Xerox clunky mouse and Apple's historic success in commercializing a far more compact version.

The DMCB suggests the same may be true of "disease management."  According to this seminal Boston Consulting Group paper, DM's early roots can be traced to the advent of self-glucose monitoring and the groundbreaking realization that patients could actively participate in clinical decision making.  The Big Pharma business model of linking this to higher drug sales was ultimately stymied, only to be replaced by a 2nd wave of entrepreneurs who figured one-size-fits-all disease-specific telephonic advice would lower health care costs.  Good idea, but that was ultimately supplanted by today's far more cost-effective approach of risk stratification with tailored DM targeted at patients who are most likely to respond and benefit.

Unfortunately, too many policymakers and regulators remember the early versions of DM.  Good thing they're not calling the shots on the use of drones in Afghanistan or how Windows operate in today's tablets and laptops.  DM's continued evolution is why it's so prevalent among commercial, Medicaid and employer-run insurance plans. Like the Israelis and Steve Jobs, they know a good thing when they see it.

Mitt Romney's University of Michigan Grand Rounds Presentation On Health Reform: The Rest Of The Story

Loathed by Conservatives, Feared by Liberals?

Years ago, as a cherry-cheeked participant in the AHIP's executive leadership program, the Disease Management Care Blog attended a national meeting keynoted by Massachusetts' Governor Mitt Romney.  Having steered bipartisan health reform legislation through the Bay State's notoriously liberal legislature, the Republican Mr. Romney was widely admired as a conservative centrist that could get things done.  The young DMCB liked what it heard and joined in the polite applause at the conclusion of Mr. Romney's speech.

How things have changed.  Massachusetts' insurance mandate and subsidies were co-opted by the Affordable Care Act (ACA), earning the Governor the enmity of  a grumpy Republican party and its Tea Party allies. 2012 Presidential front runner Mr. Romney now finds himself in the ironic position of being openly lauded by Democrats as the inspiration for Obamacare.

Since the road to the White House now  goes through having to defend "mandates," Mr. Romney on May 12 did what all politicians do when they have a problem: he gave a speech.  Curiously, however, he decided to give a PowerPointed Grand Rounds at the University of Michigan.  Initial reaction seems to be ranging from disappointment to skepticism to outright hostility. Absent in all of the mainstream media, however, is any helpful summary description of what Mr. Romney actually said. 

Thousands of smart DMCB readers want to know if it really is that bad.  Maybe not, says the DMCB.  Decide for yourself.

Mr. Romney's 30 minute presentation is readily viewable on YouTube in three parts (1, 2, and 3).  He readily admits that his stance on "replace and repeal" a federal law patterned "Romneycare" is political millstone, but, soldiering on, he points out that Massachusetts....

1. at the time he was Governor had a State fund committed to cover the costs of approximately 500,000 uninsured.  In the meantime, 94% of the population already had insurance.

2. used its "rights and responsibilities" under the 10th Amendment of the U.S. Constitution to address a "State" problem of "free riders." Several studies showed that many of the uninsured had the means to afford health insurance, yet, thanks to the fund's generosity, opted for free health care by refusing to pay their physician and hospital bills.

3)  The resulting law required "personal responsibility" from the free riders, using the threat of fines to force them to buy insurance. For those unable to afford it, the fund mentioned above was retasked to providing premium subsidies.  And, thanks to that fund, Massachusetts Taxpayer Foundation agrees that there have been no new taxes.

While what has been dubbed "Romneycare" worked in his State, he doesn't think its parallel is working at the Federal level. It has new taxes, upends the Federalist system by increasing D.C.'s involvement in health care, limits choice of insurance plans, is too complex, discourages innovation, repels physicians and kills jobs

So, President Romney would issue an ACA "waiver" to all 50 States while seeking a repeal of the law.  Then, he'd work on new legislation that would

1. return to Federalism with flexible State block grants and DISH payments that support charity-based care, exchanges, other subsidies, private coverage arrangements, chronic illness programs, reinsurance, risk adjusted programs and high risk pools,

2. promote responsibility by giving individuals a tax deduction for purchasing health insurance that is on the same level as what given to US businesses,

3. focus Federal regulation on making sure that insurance is portable, chronic illness is covered, that businesses can form purchasing pools and that insurance can be purchased across State lines,

4. establish medical liability reform with caps on non economic damages, health courts and alternative dispute resolution,

5. enable market reforms, such as health savings accounts that can can also be used to pay insurance premiums, co-insurance, value based insurance products, Consumer Reports style transparency, HIT, interoperoperability, capitated rates and bundled payments.

Mr. Romney's smarter critics readily distinguish between Federal vs. State involvement in health insurance. They condemn him for presiding over a mandate at any level, calling it, for example, a "blunder" in the "philosophy of government."  Opposed to anything other than a free market, they point to Massachusetts' rising costs, queues, and continued State governmental meddling.

All well and good, says the DMCB, but today's critics were far less visible when Massachusetts first passed its law, which even its supporters noted was a work in progress.  Thanks to 20/20 hindsight, the Cranky Conservative Class can find plenty to not like, but let's face it: based on what was known at the time, Romneycare sure looked like a good idea.  President Obama and his allies' mistake was not recognizing its lessons and recklessly doubling down with hundreds of billions of dollars worth of new Federal entitlement programs across all 50 States.  The Conservative Class' mistake is failing to discern that and adding insult to injury by making Mr Romney's affable style of bipartisanship an unforgivable sin.

The DMCB thinks there is no better evidence of just how much the Democrats fear Mr. Romney's ideas than the grins in this softball laden interview between MSNBC host Chuck Todd and current Massachusetts Governor Patrick. This one-two punch of 1) embarrassing liberal endorsement of Governor Romney's reforms combined with 2) attacking the candidate is political gamesmanship at it best, ultimately designed to enable a more right-of-center candidate to win the Republican nomination.  There is no way Mr. Duvall would have given that interview unless Mr. Obama's political handlers loathed the prospect of debating a bipartisan-minded Mr. Romney on the merits of State vs. Federal health care reform.

The Medicare Patient Empowerment Act (MPAE)

While the Ryan Plan has insurance vouchers, how about payment vouchers?  That's how the Disease Management Care Blog thinks about the Medicare Patient Empowerment Act (MPAE).

Right now, doctors that "participate" in Medicare must take "assignment" for all patients and accept its payment in full and not balance bill.  There is a good discussion of how it all works here.  The two page MPEA would change that, allowing docs and patients to directly "contract" for service costs over and beyond the Medicare rates, while the physician could still be reimbursed for the amount amount that Medicare would have otherwise paid.  The proposed legislation requires that the arrangement be spelled out in a formal written contract and protects the patient from being billed for additional payments that are explicitly spelled out in the contract.  The patient would have to agree to things ahead of time and presumably be fully apprised of the out of pocket costs. It also can't be implemented during emergent or urgent care.

The AMA and other MPAE supporters argue that being able to bill for the "balance" of unpaid costs would make it more likely that physicians will continue to see Medicare beneficiaries and  "preserve" patient choice. Opponents point out that the threat of drop-outs is a paper tiger and that balance billing will introduce a two-tier system of haves and have-nots, since patients who are unable to 'contract" could be shut out.

Whatever its merits, the likelihood that this will ever get past the Senate and to the President's desk is about as high as the DMCB getting an apology from Google for wiping out some of its recent posts.  This is simply another wrinkle in the politically stunted debate over Medicare as a defined "contribution" versus the status quo of a defined "benefit" and it ain't going anywhere.  What better evidence of that than this peer reviewed medical evidence that the Republicans have no stomach for the topic.

Thanks to Google blogger being down, the DMCB was unable to post this as originally planned on the curiously ironic date of Friday, May 13.  The DMCB apologizes for the inconvenience.

The Lightweight Romney Health Plan

Mitt Romney has outlined his new health plan. He outlined five key steps in an op-ed in USAToday. Here is a summary:Step 1: Give states the responsibility, flexibility and resources to care for citizens who are poor, uninsured or chronically ill.who are poor, uninsured or chronically ill.Step 2: Reform the tax code to promote the individual ownership of health insurance.Step 3: Focus federal

beautiful eyes

That's what struck me when I met Sarah in person: she had the most beautiful deep brown eyes I had ever seen, with a lovely smile to match.

It was February 2010 and we were both in attendance at the Annual Conference for Young Women Affected by Breast Cancer. We had met online through our online community, Mothers With Cancer.

A short time after we met, Sarah found out that her breast cancer had become metastatic and she began treatment anew. A few weeks ago, she learned that the cancer had spread to her brain and she started radiation treatment. A couple of days ago, she was admitted to hospital with breathing issues. Last night, she passed away.

I won't claim to have known beautiful Sarah better than I did. But I did consider her my friend. And I will miss her.

Here are some things I knew about this remarkable woman:

She loved her three daughters very much and she was incredibly proud of them.

She was happily married.

She was a talented photographer.

She loved animals, especially dogs and horses.

She had an appreciation for good coffee.

She left this world way too soon.

Sarah, you will truly be missed. My heart goes out to your family and to all who loved you.

You can read more about Sarah at her blog, Spruce Hill. Tributes have also been posted by Jenny (cross-posted to Mothers With Cancer), Susan, Nicole, Ree and Mary Beth.

Note: Blogger was down for about 20 hours and when it came back up, this post was gone (as were the comments from my previous post). If you are seeing this twice in a row on the blog, it will be because Blogger has returned it to me.

Health Reform: Is It a Noun.... Or a Verb?

Google blogger went down May 11 and 12, erasing the original "Noun or Verb" post.  The DMCB apologizes for the inconvenience.

In its continuing war over the Sustainable Growth Rate (SGR), the American Medical Association has sent a letter to Congress recommending that new payment structures be tested over 5 years, using a series of demonstrations that test risk-adjustment and attribution.  Why not, since there has been a plethora of other demonstrations and pilots, including the "Acute Care Episode Demonstration," the "National Pilot Program on Payment Bundling," a "Gainsharing Demonstration," and the "Independence at Home Demonstration."

In the meantime, the Medicare and Medicaid Center for Innovation continues to forge ahead with its commitment to testing and dissemination of new approaches to care and reimbursement with its refurbished web site, lauding continuous change for the better.

All well and good, says the DMCB, but it has its doubts about this burgeoning emphasis on "change."

1.  It kicks the can down the road: a fundamental alteration in the Medicare benefit literally takes an act of Congress.  Since that's so hard, it's easier to park new ideas in "demonstrations" and let them languish there in a twilight zone.

2.  Too much "change management" strains resources, resulting in a distraction away from the real work of running an agency.  For example, the DMCB's physician colleagues would like to hear less about "ACOs" and more about CMS paying bills accurately the first time every time.

3.  It gives the appearance of action when in fact, very little is happening.  Demonstrations and pilots taste great but are just not filling.

4.  Finally, the DMCB is all for innovation but CMS' track record of nimbleness - being able to collect, filter, analyze data and act on it - still remains very much of an open question.  There are just too many people, stakeholders, lawyers and politicians, no matter how well-meaning everyone is.

If the AMA isn't careful, it could end up trading the loathsome SGR for something much worse: being whipsawed by a series of delayed, tentative, frothy and inaccurate payment innovations that introduce an even higher level of uncertainty into its members' Medicare reimbursements.  In other words, payment "reform" will become an unending verb, instead of what the AMA's members want, which is a final noun.

The Latest Health Wonk Review Is (Really) Up

And that will be that after you check out the latest seasonal "Spring" edition of the Health Wonk Review.  This is a linked compendium of insights, opinions, analyses, comments and other wonkery from around the blogsphere, ably hosted by Hank Stern over at the Insure Blog.

Google blogger recently went down, taking the HWR review with it.  Henry Stern has reposted it.

taller than i

My beautiful first born turned 13 yesterday. The cliche is true - it happens in the blink of an eye. He's a good person - smart, creative, caring and funny. We are so proud of the man he is becoming.

Technologic Decline In Health Care: Good News, Though, Robotics To The Rescue (eventually....)

Your new health care provider?

The Disease Management Care Blog has been delighting in the geopolitical lessons of George Friedman's book The Next Decade: Where We've Been . . . and Where We're Going.  While most of Dr. Friedman's work deals with foreign policy (for example, a better relationship with Argentina can serve as an important counterweight to the emerging power of Brazil and its threats to sea lanes in the south Atlantic), there were two unexpected healthcare insights toward the end of the book. 

They are 1) U.S. technology innovation is in decline and will stay that way for years, and 2) the next area of innovation will be "robotics."

First, the technology.

The United States' twin health care challenges are demography and technology. Most DMCB readers understand the demography: there is an aging baby-boomer population that is well on its way to living long enough to develop degenerative diseases that will sap the available labor pool and cause consumption of expensive services to soar. Yet, the problem with the parallel issue of technology, according to Dr. Friedman isn't cost. It's that technology occurs in waves of innovation that have crested and is now in decline just when we need it.

Technological "waves," you ask? Looking back, Dr. Friedman argues that the first great wave in the 80's and 90's was characterized by the advent of increasingly powerful computers, microprocessors and robust data storage.  Think Microsoft.  The second was this decade's massive data transmission and communication.  Think the Internet. Unfortunately, both technology waves ended with an emphasis on expanding capacity and finding new applications for the existing technology.  In the 90's, personal computers plateaued and Microsoft's business model focused on protecting its business models.  While today's Internet is still being rocked by Facebook and Twitter, the fundamentals of "many to many" communication haven't really changed for years.  Productivity gains from technology have peaked and the rest is, in the author's words, a matter of rearranging the deck chairs.

Despite our investment in medical research, that pales compared to the benefits from military research spending.  Ironically, that, not the Institutes of Health, has been the most powerful impetus to new waves of health care innovation, from penicillin to MASH units to remote robotic surgery. All that is now in decline, thanks to the U.S. focus on applying current technologies (the exception being remotely piloted drones) to a limited style of infantry-based land warfare. Another impediment is America's budget woes combined with the unwillingness of the private financial  markets to commit capital to anything other than safe bets. Add it all up and Dr. Friedman argues that it is unlikely that another technological innovation wave is going to occur before 2020.

Now.... robotics.

Dr. Friedman points out that there aren't enough people to care for all the aging boomers. He says that the answer will be devices that he says "change reality," but could be better termed as capable of manipulating the environment.  When the DMCB thinks about this, aren't all those blue toothed glucose meters, remote blood pressure monitors, telephonic heart devices and other "input" devices merely "half" of what is ultimately needed?  The other half will be "output" devices that administer medicine, generate a treatment, give advice or trigger other responses from the health care system.  They may not "look" like "robots" with a pair of flashing eyes or waving arms, but they will definitely "speak" to their masters and will probably be mobile. 

They will need even higher levels of computing power as well as more powerful batteries. We don't have that yet. 

It's no accident that the military seems to be leading the way on the robotics.  Ironically, the DMCB has a new appreciation for that technology and is now cheering it on.  That's because until they come on line, the only answers we have are 1) drugs that may delay the onset of the diseases plaguing the boomers along with 2) providing palliative services.  Neither options seem to be very attractive.

2020 is about when the DMCB and the spouse are going to be in their 60s.