"Healthcare Guaranteed"--A Health Care "Solution" Offered Dr. Ezekiel Emanuel

I just received a copy of Dr. Ezekiel Emanuel's new book "Health Care Guaranteed."I am anxious to get into it as Dr. Emmanuel's health plan has received considerable attention.In the meantime, Maggie Mahar over at "Health Beat" has put together two posts on the plan, "A Fresh Look at Health Care Reform" you might find useful.Dr. Emmanuel creates a voucher system enabling everyone to buy a private

book review*: escape from amsterdam

Escape from Amsterdam, by Barrie Sherwood was a quick, fun and compelling read. And, for a first time novelist, the guy can write.

Any writer who can throw in a reference to reading War and Peace, at the end of a violent scuffle (in this case, to illustrate the length of time spent waiting for the elevator to escape said scuffle) has earned my admiration and caught my interest.

The novel is the story of Aozora, a cynical, bitter university student who is not much engaged with the world around him. He is also deep in debt to a local gangster, after losing too often at the Mah-Jong tables. An inheritance from an aunt may save his neck but to collect the money, he must find his sister, Mai (who has inherited along with him).

Aozora’s search for his sister leads him to the South of Japan, through the red light district and underworld to a gigantic theme park called Amsterdam. Along the way we meet a cast of characters reminiscent of the best of Carl Hiaasen (if Hiaasen’s novels were set in Southern Japan). The action moves quickly and even the most violent scenes are touched with ironic humour.

I didn’t much care for Aozora as a person, but I don’t typically have a ton of patience for the studied cynicism of middle class disaffected youth (although I did warm to him towards the end of the book, as he goes some distance to redeem himself). But I did appreciate his ability to laugh at himself (even after being thrown off a bridge by a pair of thugs or being chased at gunpoint by a gangster who just found him in bed with his girl). However, I appreciated the book’s cast of characters as a whole, most of whom are deeply flawed yet seem to have at least one redeeming characteristic.

The book’s setting is a character in and of itself – modern, tourist-driven, westernized Japan at odds (and yearning) for more traditional times. The author’s descriptive passages were perhaps what I loved most about the book, not overdone but highly evocative.

I also loved his descriptions of people. An old woman is said to have “the face of a dried prune” while a mobster is “a cross between Kim Jong-Il and Liberace.”

I can’t help but wonder, though what a Japanese reader would make of the book. While Aozora is Japanese, Sherwood is not and I don’t know enough about Japan or its culture to judge the authenticity of his voice.

The book is sprinkled with black and white illustrations. I am not sure that they added anything to the narrative and I actually, for the most part, just found them to be unnecessary distractions from the text.

On the whole, I really enjoyed Escape from Amsterdam and I found myself thinking about it when I had to tear myself away. look forward to another novel from Barrie Sherwood.

*This is a review of a book that was sent to me via Library Thing's Early Reviewer Program.

We hope you find the time to read the book and review it on LibraryThing. You are free--indeed encouraged--to put your review on your blog, or wherever else you want, and to talk about it in the Early Reviewers group. I want to repeat that, although writing a review will help your chances of getting more books, the actual content of your review will not.

Aetna and the Fundamentals of Claims Processing

The Disease Management Care Blog doesn't think that an association between the timely payment of claims and smartly using claims data bases to spot quality lapses is incidental. What's more, shouldn't alerts to providers not only go out by phone, fax, mail and smoke signal, but electronically using the same system physicians use to get their money? Executing on all three is probably causal, but which causes which?

Something deeper at Aetna is going on. I quote CEO Ron Williams from the Q1 Earnings Call:

'Through our proprietary active healthcare engine, the clinical database which is an increasingly integral part of our business, we are able to deliver information that helps customers better manage quality and total costs. When combined with our broad array of technology tools for members that provide information about wellness, clinical quality, evidence-based care guidelines and other critical data, you essentially have, what I call our integrated proposition.'

Health insurance claims data bases are notoriously unwieldy, slow and traditionally designed for one purpose and one purpose only: to render a predetermined payment for a covered service for a covered member. The process is typically laborious, requiring a small army of IT and benefits managers using the 'hand-grenade' approach: close is good enough. While there are many anecdotes of unnecessaary provider payment delays and denials, the DMCB knows from his insurance days that the system can also result in provider over-payments.

Getting this right is hard work. It takes huge investments in human talent and information systems. What we're learning is that once the get-it-right foundation is built, the strategic implications are enormous.

Like much of the industry, Aetna is taking an unexciting and commoditized process and turning it into a competitive information advantage. However, Aetna appears to be executing particularly well. Accurate and efficient claims processing is what enables timely payment, quality improvement, patient empowerment, provider alerts, personal health records, pay for performance that doesn't lead the way in catching the ire of State Attorney Generals and competitive disease management programs.

As an aside, does anyone realistically think Medicare as usual can pull this off? Think again.

Maybe the contrast between Aetna's recent earning reports versus competitors Cigna and Wellpoint is not incidental either.....

Time will tell.

this sums it up perfectly

If my life had a mission statement, this would be it.

Image and sentiment, courtesy of Sara, as this week's contribution to Love Thursday.

AHP Announces a Health Care Reform Initiative and Tells All of the Other Stakeholders What They Ought to Do

I'd like to propose a new health care reform rule.You can't announce health care reform proposals unless Part 1 of your plan first tells us just what it is your side is going to sacrifice for the effort.I don't know about you, but I am getting tired of one vested interest after another in the health care system telling the others what it is they have to do to fix the system. Everyone has to

Childhood Obesity--The Washington Post's Five Part Series on an Important Issue

Last week, the Washington Post gave us a five part series on childhood obesity.It made the point, which has been made here a number of times, that for the first time in our history American children are on their way to a shorter life span than their parents.This comes on the heels of a report last month that 20% of American women have already seen a decline in their life expectancy largely

The Disease Management Care Blog Works Hard So You Can Too

The Disease Management Care Blog likes to monitor the matrix of blogs and other corners of the web for interesting insight, trends and anything else that might rescue the DMCB from the spouse's impression that it isn't really being productive. Or useful. Or too busy.

So here’s a collection of its hard work: some 'research' finds that are so noteworthy, you too can give your co-workers and family the impression that you are doing everything you can to stay abreast of the ever-changing healthcare landscape:

Even Health Affairs has its own blog and, what’s more, will soon be hosting that pinnacle of blogsmanship, a Health Wonk Review. As further testimony to the emerging expansion of the Blogiverse, HA has revealed that even the Kaiser Family Foundation is jumping in with a Blog Watch summary twice a week. Only twice a week? If it were more frequent, perhaps the DMCB would have a chance of being mentioned…..

‘Hat-tip’ to the Cleaner of the Augean Stables of the Health Care Debate over at healthcarebs, who in turn HT’d Kevin MD for discovering the piercing satire of Extormity web site, the electronic health record Megacorp.

We’re all aware of the pernicious effects of testosterone and its effect on behavior across many species. What else could account for this?

Speaking of testosterone-ness, that doesn’t mean Mr. T is all about smash-em-ups. He’s also about curing coma.

And last but not least, whacky Ron Paul may have no hope when it comes to snagging a nomination, but his handmade campaign signs are still all over central Pennsylvania. Maybe because he’s a Duke U Medical School grad. Maybe because he has some strong ideas about health insurance. Or maybe because he’s got some serious coolness. Ho-ya!

Wonkery Incurred AND Reported....

....at the InsureBlog. Check out the insurance perspective of Hank Stern on much of the bloggery tackling the health care issues of the day.

Norwegians, Depression and Lifemasters' New Depression Program

Yes, that is a disturbing painting, isn’t it? 'Madonna' is by the Disease Management Care Blog’s fellow Norseman Edvard Munch, who is probably best known for his infamous 'The Scream' (or ‘Skrik,’ better translated as Shriek). Based on these and his other artworks, the DMCB suspects Edvard was not a very happy person. In fact, art historians have pointed to his family history, traumatic childhood, likely alcoholism and recurrent depression as major forces that shaped his artistic genius.

And why not? Edvard was born in Norway, which is rainy, cold and dark for half of the year. In addition to the weather, turn of the century Scandinavian culture is not known for its party animals. Or, maybe there’s something in the water or the genes. So it was with some interest that the DMCB noted LifeMasters’ latest entry into a population that may include some of Edvard’s descendants. We’re talking about Minnesota, the land made famous by widespread disdain for Christopher Columbus, deserved admiration for the stoic Norwegians that inspired Garrison Keillor’s Lake Wobegon and the inexplicable persistence people who still eat lutefisk.

But seriously, suicide rates in Norway are lower compared to other parts of the world and Minnesota’s depression rates are not comparatively high either. The DMCB interprets this to mean that programs that improve the detection and treatment of depression are needed as much in Minnesota as anywhere else. That’s especially true considering how ‘usual medical care’ performs in this area and the considerable literature that supports the use of disease management.

According to the press release, the disease management company LifeMasters has used some newly infused money to build a depression program. One buyer is Preferred One Health Plan in Minnesota. Along with other managed care organizations, Preferred One has case managers that are tasked to depression care in its network. Lifemasters provides the telephonic care.

Interested in learning more, the DMCB contacted Lifemasters. They will also perform claims analyses and predictive modeling to identify Preferred One enrollees at greatest risk. Accordingly, patients will be recruited into the program; patients may also self refer and physicians can also. Depending on clinical need and severity, patients may be followed by the case managers or the Lifemasters nurses. There will also be hand offs, depending on how well the patients are doing. This program is in its earliest phases, just having gone through a pilot phase. There’s no information on Lifemasters’ web site, but ‘more information will be made available in the future.’ As for peer review publications so the DMCB can help its readers assess the impact on outcomes, ‘not yet.’

The DMCB recalls that physicians may chafe over the prospect of their patients being ‘cold’ contacted over a possible condition of depression using claims, pharmacy or other relatively inexact data. Some patients are undoubtedly destined to be upset also. However, depression is prevalent, burdensome, costly as well as treatable. Disease management has a track record of success. 'Nuff said.

Lastly, this is another example of an emerging pattern of collaborative integration of program components that blur the distinction between carve outs, carve ins, managed care, provider networks and disease management.

The DMCB wishes Preferred One and Lifemasters good luck on this. Hopefully we’ll hear more on how this initiative is progressing and how Edvard’s relatives and the rest of the clan are doing.

May 31: In the original post, the title ascribed the new program to Healthways. It's obviously Lifemasters. The DMCB regrets the error.

First Year Results in Massachusetts' Health Care Reform Undercut Barack Obama's Health Care Reform Strategy

The Massachusetts health care reform plan is coming up on its first anniversary.Its costs are now officially out of control.Those of you who regularly read this blog know that I have been particularly critical lately of what I see as a lack of sophistication in McCain's market-based health insurance proposals.But with this news, Obama will have some big health care policy questions of his own to

McKesson Teaches the Disease Management Care Blog About a New Word: Promotores

Over half of the States’ Medicaid programs have myriad disease management programs aimed at the usual illnesses like asthma, diabetes, high risk pregnancy, ASCVD, chronic heart failure, depression and others. Wanting to find out more, the Disease Management Care Blog contacted McKesson’s disease management folks via e-mail and was promptly answered. They have disease management programs in California, Montana, Florida, Illinois, Pennsylvania, New Hampshire, Texas and Oregon.

If you check the National Conference of State Legislatures’ descriptions of the programs as well as the AHRQ ‘how to’ web-site, you’ll note that there is no standard Medicaid template. Once you’ve seen one disease management program, you’ve seen one disease management program. Even with a single disease management company such as McKesson, there is variation. They are fostering assignment of patients to a primary care ‘medical home’ and deploying community based care health workers in Illinois, while in Pennsylvania and Texas, they are deploying a version of pay for performance linked to their programs' recruitment and outcomes.

And speaking of Texas, how about them promotores. Haven't heard of them until you read the DMCB? Well now you know that instead of relying on pricey, remote nurse-based coaching support, it may be appropriate to turn to an alternate care model that depends on lay-health workers who are recruited from the community, are trained and then teach basic self-management skills in the local neighborhood. McKesson, to their credit, picked up on this model also, which was probably an ingredient in securing an extension of their contract. Different States, different Medicaid programs, different approaches.

The DMCB got to meet a real live promotora not too long ago in north Philadelphia and came away seriously impressed. To paraphrase Archimedes, with enough health care workers like her, we can move some serious HbA1c.

next year

Hopefully, I will be doing this at the 2009 BlogHer conference.

How cool is that?

And how cool is it to be planning for a year from now?

Chemo today. I will try and keep this happy thought in mind over the next couple of days.

A Foray into Avastin, Gliomas and Asking: At What Price?

News about Senator Kennedy’s brain tumor prompted the Disease Management Care Blog to think about the treatment options, with a special focus on bevacizumab a.k.a Avastin. The DMCB has special memories about this particular agent. Back in its earlier managed care days, this incredibly expensive treatment was source of great controversy between us medical directors and the network oncologists. Avastin was under “prior authorization” and without it, the drug was ‘non-approved.’ The oncologists wanted to use it for all kinds of different cancers involving all kinds of desperate patients. If ‘prior auth’ was not granted, patients and their physicians were free to appeal. And appeal. And appeal. The medical directors generally lost.

The topic of 'losing' may warrant a future blog post, but suffice it to say that the argument came down to the obligation of a health insurer to cover anything that is 'medically necessary.' Typical definitions of 'medical necessity' exclude treatments that are 'experimental.' New research involving a limited number of patients with initially promising results could be either experimental or medically necessary. What ended that tug of war, however, was the inevitable intrusion of a more compelling concept: hope is medically necessary.

But the DMCB digresses. Avastin is a biologically manufactured complex protein (an antibody) that binds to another protein that regulates the formation of new blood vessels. Many cancers are thought to grow in part due to their ability to create new “feeder” vessels, and this agent blocks that, causing tumor starvation. It’s typically not given as a single treatment, but as part of a “cocktail” with other drugs. It was originally approved by the U.S. Food and Drug Administration in February of 2004 when a prospective clinical trial involving metastatic colon cancer patients showed Avastin increased survival from 15.6 to 20.3 months. It’s since been approved by the FDA for most types of lung cancer and for metastatic breast cancer. Avastin is NOT approved by the FDA for treatment of brain cancer gliomas, but it is widely used ‘off-label’ for a variety of kinds of cancers.

Gliomas are one of those 'off label' cancers Research in one series of 23 patients with a recurrence of their cancer after standard treatment showed Avastin (plus another agent called irinotecan) led to 'six month progression free survival' rate of 46% and a 6 month survival of 77%. Other studies in 30-50 patients have shown similar results. This was enough to prompt the widely respected National Comprehensive Cancer Network to place Avastin in their approved guidelines as 'salvage' therapy for gliomas that have come back. Aetna will cover it for gliomas also.

Why is Avastin a source of such pain for health insurers? According to this analysis, the Medicare reimbursement for Avastin is about $57 per 10 mg. Recall gold is about $300 per oz. Avastin is over $160,000 per oz. A treatment course involving several doses over several months can cost up to $90,000. To get further perspective, note that the cost for Avastin is over $340,000 per year of life gained, and contrast it with this well written $129,000 article in Time. Yes, it's only money, but health insurers have a role assessing the real value of the services they cover on behalf of their enrollees.

Far be it from the DMCB to ‘price’ a living human being, but $90K is a lot of money for progression free or disease free survival that is typically measured in months. That’s true whether health insurers want to keep that money as a return on equity for their investors - or to make not-for-profit health insurance (where I worked) as affordable as possible.

flurry of activity

The last few days before chemo are always very, very busy.

All day today, I kept thinking of really great blog ideas.

But now I'm too tired.

And my head is full of snot (thank you to D. for that).

So after sitting and staring at the computer for an hour, I am off to bed.

I'll try to come up with something better when I next post on Wednesday.

Chemo tomorrow am.

Good night.

The CMS Website Comparing Hospital Performance Is a Good Step Forward

With much fanfare, Medicare (CMS) has stepped up the publicity for its website enabling consumers to compare their local hospitals' quality of care and cost data.So, I went to it and put in the necessary info for my neighborhood. While a number of hospitals came up, I was able to create a side-by-side analysis for three choices. (I suggest you simply ask for all hospitals within a certain

fond in spite of it all (and he is pretty spiteful)

Remember Eli?

Eli has taken to chasing his tail (and catching it) again, an activity that apparently became an obsession when I was in London (he doesn't have to like me, apparently to miss my presence in the house during the day). Upon my return, it became routine for us to wake up in the middle of the night to the sound of a hissing, spitting cat fight taking place at the foot of the bed (and we only have the one cat).

Last Monday morning, I was sitting in the living room when I heard ear-splitting yowling coming from the kitchen. I ran into a scene straight out of a horror movie, as blood gushed from a three-inch gash at the end of Eli's tail. I simultaneously applied pressure and called the vet.

It turns out that he also had severely impacted anal glands (sorry if this grosses you out, I did warn you, though the blog is "Not Just About Cancer") and is hyperthyroid (this will mean medication for the rest of his life.

Every morning, I now find myself administering antibiotics and thyroid meds, then feeding wet food that has been sprinkled with metamucil to the cat, even before I have had coffee or breakfast.

And we haven't even begun to deal with the crazy (because although the anal glands and the thyroid problem may have made things worse, they aren't really the root of the problem).

OK, so maybe I feel a little sorry for him.


After fourteen years, it's hard not to be a little attached.

And he's always had a certain sociopathic charm.

I've got to go hold him down now, so that my spouse can change his bandages.

Comments About the On-Line Chantix Study, the **Shocking** CBO HIT Report and More Insight on Why the Chicken....

From the front page of today’s USA Today: a report that varenicline (Chantix) is associated with mental status changes and that the Federal Aviation Administration no longer considers it safe for use by active-duty commercial pilots. But what’s interesting to the Disease Management Care Blog was that, according to USA Today, the study was posted on-line because…

‘co-author Curt Furberrg, a Wake Forest University medical epidemiologist said he and his co-authors felt ‘this was too important’ to submit first to a medical journal, which could take six months or more to publish [italics mine].’

Surprised by the changing relationship of medical science and print or web-based media? Don’t be. After all, you read the Disease Management Care Blog.

And the Congressional Budget Office continues its reputation as a parade raining, party-pooping sourpuss by releasing a report that sheds doubt on the financial assumptions of the habitués of the Health Information Technology cool-aid. The DMCB is shocked, shocked.

Last but not least, many readers of the Disease Management Care Blog have probably gotten the Ver. 2 updated ‘why did the chicken cross the road’ joke email from family or friends. It starts out:

BARACK OBAMA:
The chicken crossed the road because it was time for a CHANGE! The chicken wanted CHANGE!

JOHN MC CAIN:
My friends, that chicken crossed the road because he recognized the need to engage in cooperation and dialogue with all the chickens on the other side of the road.

HILLARY CLINTON:
When I was First Lady, I personally helped that little chicken to cross the road. This experience makes me uniquely qualified to ensure -- right from Day One! -- that every chicken in this country gets the chance it deserves to cross the road. But then, this really isn't about me.......

The DMCB thought it would expand on the theme:

HEALTHWAYS:

Numerous peer review studies have conclusively demonstrated that when chickens are ready to change, they can be coached by Healthways colleagues to cross the road with maximum outcomes. At baseline, the chicken was on one side of the road. At follow-up, it was on the other side of the road. We obviously caused that to happen with an ROI of 2 to 1.

HEALTH DIALOG

Our proven predictive modeling and patient engagement strategies help chickens decide how and when to cross the road. After we commenced our personalized intervention, road-crossing behavior measurably, consistently increased. The ROI was 2 to 1.

MEDICARE

Unless more chickens cross the road at lower cost budget neutrality compared to other chickens that didn’t cross the road, you can forget about Phase 2 in Medicare Health Support.

DMAA

It’s not chickens. We announced at our last annual meeting that they are barnyard feathered fowl.

PHYSICIANS

Stay away from our chickens.

ACTUARIES

The vector observed that describes chicken road crossing is typically associated with food seeking behavior, avoiding automobiles, avoiding predators, attraction to roosters, stupidity and random behavior. We can say with 64% confidence that it was one or more of these causes.

ALERE

Because a remote monitoring device ascertained the chicken should seek out the other side of the road. The recent acquisition of Matria brings even more value to that chicken, the road and our shareholders.

ECAREMANAGEMENT BLOG

Because only chickens would be dumb enough to do that for the .35 relative value units (RVUs) that the American Medical Association/Specialty Society RVS Update Committee thinks is enough for a Medical Home.

CATO INSTITUTE BLOG

To escape from the inane health policy recommendations of the Commonwealth Fund

DISEASE MANAGEMENT CARE BLOG

To avoid having to take the spouse to any movie starring Sarah Jessica Parker.

teaching and learning about persistence

Part One (in which running is harder than walking)

Yesterday, my oldest son and I went running.

He is a couch potato and I want him to get fit and get moving.

I used to be a runner but stopped shortly before my surgery in 2006 and have not run since.

S. balked at this proposal at first but I stood firm. Then we saw Run Fatboy Run and he came around (he adores Simon Pegg. And the 'slacker turns long distance runner and gets the girl' theme really appealed to him. Whatever works, I figure).

We did Week One of a beginner's run/walk programme. We ran for one minute and walked for two minutes for a total of twenty minutes (we also did ten minutes of walking to warm up and cool down on each end). Even though I walk almost every day (and sometimes quite briskly), I really felt it (I was also running in a pair of really crappy old shoes which I threw in the garbage when I got home). It's hard to imagine that there was a point in my life when I was able to run for more than an hour and that I once finished a half-marathon.

And S., who had started by saying that he can walk faster than I run (which is true), was panting pretty hard at the end and asking "are we done yet?" Every few seconds.

Still, we both agreed that it was hard work but not overwhelmingly so (I even think that S. was a little proud of himself) and that we would keep at it. I told S. that I expect him to finish the programme with me (in ten weeks we will be running for twenty minutes in two ten-minute increments) and then he will be off the hook.

By then, I am hoping that we will both be addicted.

He was asking yesterday about running a marathon. I think it would be fun to do a 5k together.

We'll see.

On Friday, we will go out and do it again.

Part Two (in which I am pretty)

It was well past D.'s bedtime last night when he asked if he could 'do' my hair. I couldn't resist.

Ever since I was a little girl, I have loved having my hair brushed. This hadn't happened for a very long time. My hair hasn't really been long enough for years and when it was, there wasn't anyone in my life who was interested in brushing it.

D. set to gently brushing (he was standing on the bed as I sat on it). As he worked, he would make comments:

"Tell me if I hurt you."

"S's hair tangles because it is curly."

"Your hair is like mine and S.'s is like Papa's."

"In the light, your hair looks golden."

and

"I like your hair, Mama."

After brushing, it was time to add some adornments. We both loved the end result:


I have been growing out my hair since it started growing back after the Adriamycin. What you see is the result of almost two years of persistence (I am sure that the current treatment regimen has slowed progress, too).

Recently, I have been thinking of giving up. I had very short hair in the months before my diagnosis and I keep coming across photos of myself with short hair in which I think I look pretty good.

But after last night I don't want to cut it any more.

And I've invested in all these cute little clips. Who knew I could wear them all at the same time?


Update on my heart situation: I just got off the phone with my oncologist. He's not really worried about the drop in my ejection fraction. We're going to proceed with next week's treatment as planned and he is going to book an echo cardiogram for me and see if it gives the same results.

People who would know have been advising me that such tests can produce inconsistent results and it seems that my oncologist agrees.

Cross-posted to Mommybloggers.

Administrative Costs and the Individual Health Insurance Platform for Health Care Reform

A new study by the "Center for American Progress Action Fund" says that Senator McCain's health reform plan based upon individually owned and controlled health insurance would increase administrative expenses by $20 billion.The Center is an organization headed by former Clinton chief of staff, John Podesta. So, they clearly have an agenda.But they also have a point.As I have said many times

Pharmacy Benefit Managers and Disease Management

'Hello Mrs. Smith. This is John the pharmacist calling to ask how it's going with that new medicine you're taking for diabetes....'

Why is this announcement noteworthy?

The Disease Management Care Blog suspects Pharmacy Benefit Managers (PBMs), which act as intermediaries between (seller) pharmaceutical manufacturers and (buyer) managed care health insurers, will be finding it more difficult use arbitrage, volume or generics alone to maintain profitability. In this case, volume didn’t appear to meet expectations, making investors skittish about possible over-reliance on that part of the business. Hence, the PBMs’ interest in using disease management as another additional way to bring value to their customers and defend their market cap.

And why not?

Pharmacists know a lot of medical science and are trained in patient education in the course of their career. PBMs have plenty of them. It makes good sense to task a portion of them to coaching patients who are using medications for chronic illness. Plus, that’s less cost for the partnering disease management company.

What’s more, the claims turn around for pharmaceutical agents is far quicker than for medical claims (which have a ‘claims lag’ up to 3 months), are potentially more accurate and organized in huge well-run registries. That means indentifying and intervening more quickly. Disease management companies will like that, since having access to drug data for predictive modeling and to drive outcomes translates to a competitive advantage.

This is also one more example of the growing approach of a modular coordinated approach to population-based care. While this particular PBM-DM partnership looks like it’s for keeps (both companies are huge and are likely to share many clients in the future anyway), the big picture is that the PBM is now being increasingly “inserted” in the population-based care machine as one more important component.

You have to wonder why it took so long.

thumpity thump (or rather, whoosh, whoosh)

Last week, my appointment with my oncologist was cancelled. Apparently, he was very sick with a high fever. Having a cancer patient's selfishness, my first thought was, "Oh! It's good that I won't be coming into contact with him then!" Then, my more empathic self remonstrated and I wished him well, poor man.

The nurse who works with him was kind enough to confirm my CT results. The tech who did the scan (or rather her radiologist boyfriend) was right. My scan was clean and there is still no sign of cancer on the liver.

However, the nurse also told me that my heart scan revealed that my ejection fraction (the measurement of my heart's ability to pump blood) was down to 48%. Fifty-five per cent is considered normal (before I started treatment, my EF was 56%), so this is not as bad as it sounds. It is however, a fairly significant drop and likely an indication that the Herceptin is putting a strain on my heart (a common side effect of this drug).

This is not the first time this has happened. Adriamycin (the 'red devil') was also very hard on my heart, so we waited a couple of months to start the Herceptin, in order to give my heart a chance to rebound.

According to my oncologist, it is easier for the heart to recover from Herceptin than from Adriamycin. We've discussed the possibility of taking a break from Herceptin (while continuing with the chemo) if damage should occur, so I am confident that this is what he will suggest when I speak to him tomorrow.

I am really reluctant to stop the Herceptin, since it has worked so well for me. There is a voice in my head (one of several. You have them, too. Don't lie) yelling, "Don't mess with what's working!" But the truth is that it's not working if I need to start taking heart medication or worse, end up with heart failure.

So, if my oncologist suggests doing chemo only for the next couple of months, I will agree (what choice do I have?). I will wait for my heart to rebound (it's weird because I don't feel any different, really).

But I am just a little nervous.

And chemo won't be as much fun without the Demerol.

McCain's Lost Opportunity

Joe Paduda has a great post today over at "Managed Care Matters" on the McCain health plan.Barack Obama is vulnerable over health care because his plan will cost a lot more than the $50 to $65 billion a year he has estimated--maybe twice as much.McCain rightly points that out regularly on the campaign trail.But what McCain and his advisers are missing is that his plan scares people in its own

Senator Kennedy's Illness

News that Ted Kennedy is seriously ill sent shock waves through the capital and the country yesterday.Many think of him as the "liberal lion"--and that is true.Less well known outside the beltway are his incredible instincts and skills for "cutting a deal."I know the notion of liberals and conservatives finding a way to come together drives some people on the far right and left nuts but it is in

Senator Kennedy's Diagnosis and Oncology Disease Management

The Disease Management Care Blog is reporting from Boston tonight. The Celts’ and BoSox festooned apparel of the folks sharing the T to the North End suggests its citizens are preoccupied with some very successful basketball and baseball franchises. However, the really big news tonight is Senator Kennedy’s recent diagnosis of a malignant glioma involving the left side of the brain. The local news is going non-stop.

The DMCB knows enough cancer medicine to recall that the prognosis here is very difficult to ascertain. There aren’t many published studies involving persons in Senator Kennedy’s age category, and gliomas are very heterogeneous tumors with varying degrees of malignancy. As the testing and staging continues, the DMCB offers his prayers along with millions of other Americans.

Yet, the Senator Kennedy announcement led the DMCB to think about general oncology disease management. Many cancers are turning out to be non-curable if treatable chronic illnesses. While the physician colleagues in the oncology community may disagree, many patients with cancer may also benefit from organized population-based approaches to care. Standard oncology treatment is often accompanied by prodigious nursing and social service support. Since that is the standard of care, what additional value would a disease management vendor have to offer?

In the opinion of the DMCB, there are four areas of benefit:

Many patients have difficulty knowing everything they need to know about their condition and the treatment options. While physician-oncologists do an excellent job of education, it’s not unusual for patients to be overwhelmed by the usual counseling, and then there are issues of framing and unintentional bias that can sway the patient toward one treatment versus another. Disease management has a long history of helping patients achieve an unbiased level of lay-expertise in their diseases. Cancer is no exception.

While there is a lot of support in an oncology clinic, the DMCB thinks additional emotional support from DM nurses not only will not do any harm but, for many patients, add considerably to patients’ quality of life. That’s especially true when patients are out of the treatment cycle and aren’t returning to the oncology clinic as often.

Let’s face it: oncology drugs are complicated frightfully expensive and, for many patients with recurrent disease, may not appreciably offer much benefit. Helping patients – and sometimes their doctors - choose the right treatment for individual circumstances based on high quality guidelines is not only cost effective, it’s the right thing to do. Given formulary considerations and cost sharing issues, disease management may also have a role to play in helping patients navigate through the insurance benefit. In addition, if treatment is underway, some meds may need to be taken at home. Remote support may help patients be more fully compliant.

And last but not least, many patients need end-of-life support. While hospice is valuable, many patients choose not to have it or don’t qualify. Enter remote support from disease management. As an aside, one Medical Director from an oncology disease management vendor informed the DMCB that a useful measure of quality in this field is the percent of patients still receiving treatment in the weeks prior to death. Too low and you can surmise the physician is not being aggressive enough, while high numbers suggest the physician is being over aggressive with treatment. The Medical Director indicated these data showed high variability. Disease management may have a role to play in reducing that variation by sharing those data with oncologists and encouraging the use of evidence-based treatment protocols.

Senator Kennedy will not suffer for lack of any support. Yet, his interest in health care has helped millions of other just-us-folks Americans also not suffer for lack of care, including disease management. He deserves a lot of credit. The DMCB wishes him well in this latest battle.

a bad idea, going badly

It seems that the Canadian Border Services Agency (CBSA) 'snitch line' is attracting a lot of frivolous calls.

According to an article in today's Globe and Mail, the agency logs between thirty and forty calls to the hotline a day, the bulk of which are irrelevant or even downright malicious:

As one log demonstrates, many callers don't quite grasp how the immigration system works: "Caller would like to deport a couple of people from Canada and she would like the website address to fill out the proper forms. Advised caller that it is not her decision who gets deported. Caller does not care."

Another person calls the watch line from prison - where he is serving time for assault and forcible confinement of his girlfriend - to report his girlfriend is engaged in a paid marriage of convenience. "There is a small concern about his credibility," a CBSA employee notes.

Um, yeah (I really love the understatement here. No doubt most CBSA employees would agree that their time could be better spent than answering and logging these kinds of calls).

The snitch line was an ill-conceived plan and one that exploits the basest of human tendencies. Encouraging Canadians to spy on their neighbours is distasteful and unproductive (to continue with the understatement). I think our tax dollars could be spent infinitely more wisely.

"Caller states he has a problem. His wife's family is interfering with his marriage and he doesn't want them to come to Canada," a watch line employee writes.

"Advised him to speak with his wife."

I have a new post up at Mommybloggers! It's about my boys playing hide and seek.

Read the Disease Management Blog and Keep Up with the Peer-Reviewed Literature on Diabetes and Chronic Heart Failure

Holmes AM, Ackermann RD, Zillich AJ, Katz BP, Downs SM, Inui TS: The net fiscal impact of a chronic disease management program: Indiana Medicaid. Health Affairs 2008;27(3):855-64

The Disease Management Care Blog would expect nothing less than a prospective randomized trial on disease management from one of the Gods of General Internal Medicine. Thomas S Inui is among the authors of such a study recently published in Health Affairs. His prodigious biosketch can be found here. Note that he is a former President of the very academic Society of General Internal Medicine (SGIM), which has been curiously mute on the exciting and controversial developments in real world population-based health care. More on this in a future blog.

But let’s turn our attention to the study at hand. It was about the economic impact on disease management (DM) in an Indiana Medicaid population. Indiana has been looking at the role of DM for quite awhile. As patients were randomly enrolled in the program, they were followed over time and compared to patients who had not yet been enrolled, otherwise known as a staggered implementation. Over 800 persons with either diabetes or chronic heart failure were studied with an average of 21 months’ worth of data. Cost of the program (excluding start up) ranged from about $20 per member per month (PMPM) for telephonic care up to about $57 PMPM for nurse care management. High risk persons were assigned to the nurse care management, while low risk patients were assigned to telephonic care.

AmeriChoice ran the call center. The Indiana Primary Health Care Association provided the nurse care management

For CHF:

High risk PMPM savings vs. controls: $150 – not statistically significant

Low risk PMPM savings: $247 – statistically significant

For Diabetes:

High risk PMPM savings: - $144 (more expensive in the intervention group) – not statistically significant

Low risk PMPM savings: $3.80 – not statistically significant

The authors concluded that disease management was cost saving for the low risk heart failure group. They were unable to show savings in the high risk heart failure group or in either group with diabetes.

What does the DMCB think?

Once again, it’s possible to do credible research outside of research settings.

What’s true in Medicaid doesn’t necessarily apply to populations with other types of insurance. For example, a similar study in a commercial population showed diabetes disease management was associated with savings, while in an integrated delivery system, low risk heart failure disease management seemed to not result in savings. Go figure.

In their discussion, the authors expressed surprise that there were savings for low risk persons with CHF. For the DMCB, that’s still not that counterintuitive. Moderate amounts of disease may be more amenable to intervention. Persons with mild disease will do well no matter what you do, while those with advanced disease will have problems despite the best of care.

The authors also noted that the baseline characteristics of the control and intervention patients were imperfectly matched, which could have skewed the results. It’s also possible that higher numbers of participants may have achieved statistical significance. The DMCB also wonders if the protocols used to identify the 'high risk' versus 'low risk' patients could have been responsible or if the nurse protocols to manage the high risk heart failure patients or the diabetes patients weren’t up to snuff.

More on Coordinated Delivery Systems

The Disease Management Care Blog truly appreciates any and all written commentary on prior posts. The best so far is an insightful observation from Anne. She doubts a modular approach to social services has much merit. Unlike the manufacturing of planes or computers, she argues these services can’t be ‘widget-ized’ at several levels. It obscures accountability between the provider and the contractor. Health care providers are not necessary postured to manage administrative and oversight roles. Finally, the modular approach doesn’t have a very good track record; while lead paint in toys is one example, another could be the recent heparin catastrophe.

Anne’s perspective has a lot of merit. However, the DMCB isn’t sure that the current system doesn’t also perpetuate the same lack of accountability. Lapses in care are common among persons with chronic illness and it’s even hard to figure out who the responsible doctor is. Enter the government, employers and insurers who are out to fix the lapses by coordinating care, working with/for the PCP, helping patients choose self care and bringing back versions of capitation with clinical and financial performance guarantees.

What’s more, there are the increasingly complicated benefit designs. While the health care consumer is supposed to be ‘empowered’ by the right combinations of deductables, co-pays and Health Savings Accounts, the DMCB thinks patients could use help to navigate it all. Just because that’s not a traditional role for providers doesn’t mean it couldn’t be achieved. That’s especially true if who is ever paying for the care insists on it and health information technology is tasked to assist this.

As for the lead paint theory, the DMCB has seen clinical outsourcing with performance metrics built right into the contracts. While this kind of patient protection is not necessarily perfect, it’s a heluva lot more accountable than usual medical care, which has its own issues with patient safety.

None of the elements above necessarily depend on a modular approach in a coordinated delivery system. However, the DMCB wonders if government, employers (like Boeing) or health insurers couldn't impose accountability metrics on each contracting entity, perhaps assign one entity with coordinating oversight (maybe to a disease management vendor) and pull the contract(s) if lead paint starts showing up in the product.

The DMCB agrees that the coordinated delivery system is untested has a lot of naïve assumptions built in. That being said, there still may be some merit to the notion. Thanks to Anne for stressing the model.

another one for the 'if only' files

First we find out that Vitamin D is thought to prevent breast cancer.

Then came today's news that breast cancer is more likely spread in women who are deficient in the sunshine vitamin (from the Globe and Mail):

Women diagnosed with breast cancer are nearly twice as likely to have the disease spread to other parts of their bodies and are 73 per cent more likely to die from it if they have low levels of vitamin D, according to a Canadian study...younger women tended to have the lowest levels because they generally didn't use vitamin D supplements, which older women often take to prevent bone fractures.

“Vitamin D deficiency is common,” observed Pamela Goodwin, senior investigator at Mount Sinai Hospital's Samuel Lunenfeld Research Institute in Toronto and principal researcher on the study. “It's associated with high-grade tumours, and in our data set, it's associated with an increased risk of [cancer spread] and death.”

"Blendon, Laszewski, And Rovner On Health Care Reform In The Election"

Earlier this week I was part of conference call organized by the new Health Affairs editor-in-chief, Susan Dentzer, on the topic of health reform in the presidential election.The call, and subsequent posting of the transcript by Chris Fleming on the Health Affairs blog, was in connection with the thematic issue of health reform in the May/June Health Affairs.First, congratulations to Susan on

bloggers unite for human rights

May 15 is the day that bloggers around the world unite to speak up for human rights (you can find out what some BlogHer contributors have chosen to write about by following this link).

I have been thinking all day about what I would like to contribute.

I visited the Amnesty International site and added my voice to their campaigns about human rights violations in China and in Guantanamo Bay.

I thought about my friend Eve Goldberg and how she wrote a song and then offered it to Amnesty to use in its campaign to end human rights violations in Burma.

And I thought about my own country where:

Far too many children still go to school hungry.

First Nations Peoples are still treated like second class citizens.

and my government has been complicit in many gross abuses of human rights (here's another example).

And I was thinking today that it's been a while since I have done much to address these injustices.

I vote.

I sign online petitions.

Sometimes I donate money.

And I can talk a good game.

All of these things are important but I think it's time that I resolve to do more. All too often, I let the opportunity to speak out, call my MP or write a letter slip by me. I simply assume that someone else is on top of it.

I resolve to take a little more action, step up and speak out when I get the chance. It only takes a few minutes to call my MP and only a few more to write a personal letter. And I can write more, right here in this blog about human rights at home and abroad.

I'll think a bit more on all of this and get back to you.

And speaking of human rights, good news coming out of California today, no?

Adam Smith says....

.....read the Healthcare Economist blog for marvelous Health Wonk Reviewery or the mercantilists will win!

The Medical Home: More Time, More Patients or More Money. Or More Money Not.

A long time ago, a very wise managed care executive told the Disease Management Care Blog that there are only three things you can give physicians. They are more time, more patients or more money. This trinity may be part of the overlapping three-way theoretical appeal of the 'Medical Home.' An IT-supported, clinic-based care team and a forward thinking health insurer could render up all three.

By (appropriately) transferring some clinical responsibilities to non-physicians, there'd theoretically be more time in the day. That could mean higher quality, longer visits per patient, or the physician could go home a bit earlier for a change. The time could also be used to coordinate care for patients with chronic illness.

Or, that time could alternatively be used to accomodate more patients in the practice. With or without the extra time, seeing patients is what doctors 'do,' and while many primary care physicians are overburdened, many others would still welcome the chance to grow their clinical practices. Efficient practices with the Medical Home could attract more patients - with or without chronic illness.

Finally, more time and/or more patients means more cash flow. Even without the additional time or patients, physicians would also welcome a higher fee per patient. Proposals on financing the Medical Home center around an additional monthly payment in addition to the usual fee-for service.

Yet, all is not well in the money part of this trinity. The DMCB recommends you check out Vince Kuraitis' excellent post (with a promise of more to come) on how the toxic waste of traditional medical payment methodology is threatening to engulf the Medical Home.

As an aside, you may want to also review this article in the Philadelphia Inquirer. It quotes $13 million for 220,000 patients. Sounds like a lot of money, but if you do the math, it's not a lot per patient.

As a supporter of 'disease management,' I'm worried that underfunding of the Medical Home will doom it. In my humble opinion, the Medical Home will turn out to be a key component of future population-based health care solutions for patients with chronic illness. My colleagues in the disease management industry agree with me: if this promising if unproven approach to care suffers a crib death, it'll be a tragedy.

Against Obama, McCain Has a Lot of Ground To Make Up on Health Care

The latest Washington Post-ABC News poll on health care should give John McCain reason to be concerned.The early May poll asked voters, "Regardless of whom you may support, whom do you trust more to handle health care?"The answer was Obama by 55% and McCain by 31%.And this poll was done a few days after his much-publicized week long health care tour.McCain also did poorly on the other economic

Some Unsolicited Advice for the Disease Management Community on the Realities of Traditional "Research"

Ouch. Some ham-fisted dismay about Dr. Mattke’s paper on what the literature has to say on disease management from some colleagues in the for-profit side of the industry. In response, the Disease Management Care Blog has some unsolicited advice:

Getting to the ‘truth’ in health services research (HSR) is an imperfect science and a fickle journey. It can be waylaid by hidden bias, complex statistical analysis and imperfect generalizability. The conclusions are rarely bullet proof. There may be better approaches to asking the right questions, but once you enter this arena, you have to live by its rules.

The rules include having your fellow HSR expert-travelers delight in repartee and swordsmanship. What's more, the many readers of published research are independent-minded scientists who have been acculturated to judge the merits of conclusions with a skeptical and sometimes lethal eye. The best attempt at telling the truth will always be subject to the merciless scrutiny of your colleagues. Getting past peer review and publication is not the end, it is the beginning.

Peer reviewed publication is not one of several marketing ‘channels’ that exists to advertise or brand a product or service for a particular audience. Rather, it is an open and standing invitation for more critical review and even more research. The conclusions may ultimately be unexpected or even unwelcome. That is what truth-finding is all about. Your - our - patients will ultimately be better off for it.

10 lovely years

For the last while, blogging has taken a back seat to a bigger project. I am finally done (at least for now) and have time do a little catching up.

It's been a busy time and there is much to write about but, most importantly, I need to tell you that on May 10, my first born son turned ten years old.

We celebrated him in grand style, with presents, a movie outing, a walk in the tulips, family, Chinese food and still more presents. The next day, we were informed that the only thing he regrets about his birthday is that "it only lasted for twenty four hours." And he slept for eight of them.

It really was a beautiful day and the birth of this child is a wonderful reason to celebrate.

I like to tell the story of the day he was born. He came into the world on Mother's Day, after I had been labouring at home for many, many hours. When our midwife decided that it was time to head to the hospital, we set out along the route we had planned (we were fairly new to the city). We had to find an alternate route in a hurry, though, as our chosen route (and the fastest one) was closed off, due to a "Mother's Day" race. As I moaned in the car beside him, my poor spouse pulled out a map and plotted a new route to our destination, as the runners streamed by.

I also like to remind S. that his birth was a long, hard, drawn out process. But the truth is that it was all worth it. I love him so much and I couldn't be prouder of this smart, loving, creative, funny boy.

10 things S. did this year to make me proud:

1. Helped his little brother to write a series of stories, with titles like, "The Boy Who Got Stuck in the Toilet," and its sequel, "The Boy Who Got Stuck in the Sink." He then directed the movie version of these stories and created the best movie trailer ever.

2. Travelled to London with his mother, where he was mature, flexible, good-humoured, fun, patient, responsible, thoughtful and a terrific companion.

3. Looked out for his little brother, even when the littler one made that very challenging.

4.Learned to knit, demonstrating persistence and patience.

5.Made me laugh out loud, almost every day.

6.Hugged and kissed me whenever he saw me, even in public and even in front of his peers.

7.Proved time and again that he has a compassionate, empathic soul.

8.Learned to forgive and move on.

9.Was true to himself.

10.Gave me glimpses of the man he will become. I will be proud to know him then. I know I will always feel lucky that this terrific human being is my son.

How Did This Article on Primary Care Access Get Past the Editors at Health Affairs?

Check out this article (or abstract) published in the ‘web part of Health Affairs. Dr. Colwill and colleagues tapped into U.S. census data and matched up the projected increases in the nation's various age groups versus the supply of primary care physicians. As you would guess, the authors found that by the year 2025 (or 20 dash 25, see below), the shortage of PCPs will be worse than anyone anticipated.

Colwill et al found the U.S. population will increase by 18% and that the number of persons age 65 years or more will increase by 73%. If the various age segments continue to seek PCP care at the same rate they do today (1.5 visits for those less than age 65, about 3 visits for those older than age 65), it’s projected that there will be a 29% increase in the work load for the average adult care generalist. Unfortunately, the current pipeline of generalists, even with an expansion in the number of medical schools, can only produce an 11% increase.

In their Discussion segment, the authors review the limitations of their analysis and recognize that physician supply is dynamic, that demand could increase if universal health insurance occurs or, alternatively, decrease if the number of uninsured grows.

But it's the ‘policy implications’ section of the paper that is a whopper. Noting that greater 1 on 1 doc-patient efficiency is unlikely, that tapping into the non-physician (NPs or PAs) supply is a limited strategy, that specialists’ track record in primary care is dubious and that concierge medicine limits access, the authors laud the ‘medical home’ as an answer to our nation’s health care dilemma. That’s because, as everyone apparently knows, the medical home is efficient, provides access, increases everyone’s satisfaction and reduces spending.

Oh? Is that why the Medicare Program needs to demo it first? Why insurers are still piloting them? The Disease Management Care Blog agrees the Medical Home has considerable merit but isn’t sure it’s ready for the big time or that it can be held up as a single solution to the looming generalist shortage.

What surprises the DMCB, however, is that the editors of Health Affairs allowed this scholarly work on physician supply to turn into a sparsely referenced mini-editorial on a distantly related topic. It’s also depressed by the lack of equal time for the solutions offered by disease management. Once again, one approach to care that could efficiently ‘off-load’ a segment of chronic illness care away from the overstretched primary care community goes unmentioned by our friends in academia.

Now that the DMCB has gotten that off his chest, it’s time to feel even better by breaking into song. With apologies to Zager and Evans and their 1969 hit 2525…..

In the year 20 dash 25,
If doctors can survive
Medicare can’t deny
They may find…..

In that year 20 dash 25
Ain’t gonna get to see your doc, ain’t no jive
Should have believed that Health Affairs
It's bye bye to my elder care

Oh I fear 20 dash 25
How ‘bout that Med’cal Home, or will I die?
Specialists are bein’ forced on me
My treatments are from just NPs

It just sucks 20 dash 25
Doc just won’t take my call, yet I try
How will I stay alive, oh I’m screwed
Primary care is gone and woe, I lose!