Sarah Palin on Health Care--A Free Market Republican

Republican vice-presidential candidate Sarah Palin has very little on her health care policy resume from her short time in office as Alaska's Governor but what she does have fits right in with Senator McCain's strategy to use the market more effectively in bringing down America's health care costs and improving access to the system.Her health care efforts have focused on two things in Alaska:

"US Healthcare on the Edge: A Prescription for Cure"

Jonathan Lorch and Victor Pollak, two physicians with plenty of experience and accomplishments in America's health care system, have suggested the steps they think will go a long way toward making our system work.I am pleased to post a brief description of their plan and a link to the full proposal.US Healthcare on the Edge:A Prescription for Cureby Jonathan Lorch and Victor PollakThe US

we clean up nice

But could we get one pic where all of us were looking at the camera and smiling? Um, no.
Updated to add this cute pic of D. and my nephew, in their matching ties. S. had a matching one, too.

McCain-Palin

Who?Well the self-described maverick surprised everyone this morning.While many kept saying it would be Romney, I never believed it. First, they don't like each other. Second, a Romney pick would have flown in the face of the McCain health care strategy ( If McCain Picks Romney He Will Never Again Be Able to Criticize Obama's Health Plan).Governor Palin would seem to be a conservative Republican

Comment on the Proposed NCQA Measures for Disease Management Programs

Readers of the Disease Management Care Blog (and anyone else for that matter) have been invited to click on over to NCQA and comment on its proposed measurement specifications for disease management programs. Do that and you will be able to revel in a host of diagnosis & procedure codes, numerators, denominators, continuous enrollment windows and pharmacy claims.

The DMCB understands the adage that a) quality cannot advance without measurement and that b) the NCQA methodology has resulted in untold jumps in quality and lives saved. Kudos to the NCQA for taking this assessment hammer to a new set of nails.

Yet, the DMCB has three concerns about the proposal:

Well executed disease management raises all boats: While DM programs can always do a better job of documenting and reporting their clinical outcomes, the DMCB believes effective population-based coaching programs that successfully engage patients in self care will spin off increases (for example) in A1c testing in diabetes, appropriate prescriptions for asthma and flu shots when chronic heart failure is present. The opposite is not true: prompting patients to get process-based lab testing, prescriptions or flu shots will not necessarily promote optimum self care. After these specifications are finalized and approved, the DMCB hopes disease management organizations will resist the temptation to issue (for example) a directive to its nurses to stop educating and start directing, to coach less and document more.

The definition of the 'medical record is changing: In true NCQA fashion, many ‘numerator’ criteria rely on traditional medical record documentation or insurance claims to fulfill criteria and obtain credit. Yet, the DMCB believes registry data collected by disease management organizations in the course of their outreach are also a resource. Patient self reports, documented by a DM nurse outside of claims or physician encounters, are a measureable and auditable source of measurement that are going untapped by much of the proposed NCQA methodology. While patient self reports are prone to error, so are insurance plans with pharmacy deductables. What’s more, what happens if the personal health record really takes off? Why not aggressively include patient self-reports in the numerators?

Patients may reasonably elect to not comply with NCQA criteria: Consider this scenario: a fully coached and empowered patient with chronic illness reviews the recommended menu of preventive services, understands the benefit of each, gauges at his or her needs, the doc’s recommendations, the out of pocket expenses and reasonably decides to forego recommendation “A” and adhere to recommendation “B.” This DMCB thinks that is not unreasonable not only because it happens in primary care clinics everyday, but because all medical interventions are not created equally. Why not include empowered patient refusals in the numerators?

The DMCB will be providing a link to this post over at the NCQA site. Readers can too, but the DMCB recommends you check the methodology out for yourself and comment. You have until Sept 3.

wow. this makes it so real

My sister found this when she googled me the other day.

It's funny how something can be simultaneously extremely cool and utterly terrifying.

That's not the final title and it's not coming out until the spring of 2009. Even so, I am embarassed to say how many times I have clicked on this link, just to prove to myself it's still there.

eating cake and the 20 second update

I have been out of town for a couple of days, spending time with friends at their cottage. We were four adults, four boys ranging in age from 17 months to 11 years and five dogs of various ages and sizes. It was barely controlled chaos and absolute bliss.

I am home now. In a few minutes I will turn off the computer and go curl up with a good book and a slice of my friend M.'s divine lemon pound cake (it contains an entire cup of butter and six cups of sugar. That's before icing) Perhaps I'll even have a ice cold cider with the cake.

In other news, I have a new post up at MyBreastCancerNetwork.Com, called "The Challenge of the Twenty Second Update."

This past week end, I went to a beautiful wedding with my family. In attendance were relatives I hadn’t seen in many years, lots of people I had never met and one of my favourite teachers from grade school.

I always feel a bit of awkwardness at these kinds of events, as I brace myself for the inevitable questions, “What are you up to these days?” or “What do you do?”

No one wants to drop the c-word at a wedding, least of all me.

You can read the rest of this post here.

I hope you are all enjoying summer's last gasp with your own cold cider and lemon pound cake. Or whatever it is that makes you happy.

Bridging the Divide Between Policy Blogging and... what are they called... Oh Yes, Patients.

Why Blog?

The Disease Management Care Blog’s spouse has asked that several times. In a prior post, it described a recent Kaiser Family Foundation webcast confab on the increasing role of blogs in the formulation of health policy and the DMCB learned its motivations are not unique. First off, it’s an enjoyable way of building a circle of like-minded colleagues. Second, if you’re going to read about developments in your field of interest, writing about them sharpens focus and makes for more disciplined reading – and learning. For physician readers, think of it as a virtual and solo version of ‘Journal Club.’ Alas, for bloggers with spouses, think of it as ‘not impressed.’

The DMCB thinks of itself as a ‘policy’ blog and a small one at that. Heck, while it may think ‘disease management’ is a big topic, it’s a pipsqueak compared to Health 2.0, health insurance or pharma. Unlike the political or celebrity blogs, it doesn’t ‘break’ news, but aggregates and interprets it. Unlike many of the health policy blogs, it tries make liberal use of links to the peer reviewed evidence-based literature. It reluctantly confesses to paying attention to other health policy blogs but avoids the temptation of writing to capture their attention or to engage them in a web traffic-increasing game of point-counterpoint. It would much rather get email or comments, which are really appreciated (hint).

The DMCB reluctantly accepts Google ad revenue because it thinks any conflict of interest is small and that the Google search engines favor blog sites that accept its ads; to date the revenue for that single rotating ad on the right has resulted in $5.19. The DMCB does not participate in product promotion or marketing. For other blogs, ads and promos are big business.

The DMCB shares in the policy blogs’ greatest weakness: a broad disconnect from the persons we claim to know so much about: the patients. And, by the way, patients are also creating diary-blogs that frequently spill into telling observations about the health care system in ways that may be missed by us policy know-it-alls.

Case in point: check out how a parent at the X-Dad site has to process an evolving and complicated insurance and pharmacy benefit for a son with a rare genetic disorder (‘the good, the bad and the drooly’). The premium is high but still comparatively worth it, the new health savings account (HSA) may or may not cover medically necessary services and drugs can go from covered n’ cheap bulk mail-ordered to not so covered n’ pricy-monthly.

We on this side of the blogsphere, including readers, need to remember that health policy, medical technology and benefit changes that supposedly take advantage of the supposedly most modern advances in cost and quality result in real life challenges for real people. Thanks to X-Dad, the DMCB is reminded that the patients’ (and parents’) points of view are the ones that are ultimately the most important.

Another Panel, Another Lack of New News or Insights

The Disease Management Care Blog recommends you don’t bother taking the time to view or read the New England Journal of Medicine 2008 Shattuck Lecture. The DMCB did both. Save time and read this blog instead.

Arthur Miller led a distinguished panel of ethicists, insurers, lawyers, physicians and policy makers, using ‘real-person’ dilemmas to prompt a meandering discussion over the failings of U.S. health care, ways to improve physician payment, the merits of the electronic medical records, the burden of rising drug costs and the path to universal health care. There was no ‘aha’ consensus anywhere. If an erudite group made up of Arnold Epstein, Charles Baker, Arthur Caplan, Karen Davis, Susan Dentzer, Bill Frist, Robert Galvin, Stephen Schroeder, Reed Tuckson, Ruben J.King Shaw, Thomas Lee, Jonathan Oberlander and Sara Rosenbaum were unable to envision a ‘solution,’ the DMCB doubts anyone will be able to. That was the biggest lesson.

What was said that was interesting:

Physician payment will eventually involve a blend of payment mechanisms that will include fee for service. No one predicted that FFS will go away.

Pay no attention to any of the current unreal health care proposals from any corner of the current political debate. The truth of the matter is that a future President will need to decide if he or she* wants to stake political capital on expanding insurance coverage after his or her inauguration. That will depend on a very hard calculus involving the make-up of the House and the Senate, the likelihood of coalition building and how willing everyone will be to accept their second choice. Moral outrage alone over what is right or wrong will not and never has been a factor.

Mainstream working Americans are not feeling sorry for the underpaid and overworked primary care physicians. Not when they are seeing their houses decline in value by tens of thousands of dollars and gas is between $3-$4 per gallon. Welcome to the their world.

The electronic health records have yet to close the deal. Maybe Charles Baker of Harvard Pilgrim summed things up best by saying the EHR vendors and advocates have over-committed and over-promised.

Never mind trying to decide how much a quality adjusted year is worth - or even WHAT it is. How about trying to decide right now if insurance should cover an intravenous anti-cancer drug that costs hundreds of thousands of dollars and maybe results in a few extra months of life? The panelists were stymied over how to cover this - along with the rest of us.

And now for some criticisms:

What was said that was not recycled:

Nothing.

What was not said:

C'mon panelists, we know prevention and wellness has it's limits, especially over the short run. How can health care costs really be controlled?

The best part about this panel was:

Charlie Baker of Harvard Pilgrim. He talked like a CEO that knew a lot, had little to say, but when he spoke, people listened.

The second best thing about this panel was:

No disease management bashing from the academics, no kidding.

The worst thing about the panel was:

Karen Davis: She really needs to get over this notion that the U.S. can stop being 19th out of 19 countries by being like the other 18 countries.

Second worse thing about the panel was:

Arthur Miller. He was insufferably out of his league by rhetorically leading the panelists to too many reductionist, uni-dimensional bromides.

Third worse thing about the panel was:

A continued fixation on the physician as the nexus of how to fix all that ails the health care system.

The question that the DMCB wanted to ask:

If quality and systemness are the key ingredients to cost control, then why isn't No. 1 Harvard Pilgrim leading the way in reducing health care costs and charging less for its services?




*interpret that however you like

News and Commentary About Healthways: Lead or Follow?

Uh oh. That regular ritual known as the ‘earnings forecast’ has precipitated some chaos in Healthways’ stock price. If you go to the Healthways ‘News and Events’ site, an otherwise ho-hum press release announcing a change in the fiscal year to a calendar basis and on-target expected price earnings for this year concluded with this telling paragraph [bolding added]:

‘Healthways today establishes its guidance for earnings per diluted share for the three months ending November 30, 2008, in a range of $0.34 to $0.37, which would represent an increase of 13% to 23% from the three months ended November 30, 2007. Mr. Leedle added, "While this guidance anticipates solid earnings growth from the comparable prior-year period, the sequential-quarter performance reflects a decline in revenue due to the impact of certain contract renegotiations, reduced revenues associated with the winding down of a previously discussed contract terminating at the end of calendar 2008 and the full-quarter effect of small contract losses due to health plan consolidation. This earnings guidance also anticipates incremental costs associated with the implementation of contracts scheduled to begin on January 1st.’

According to the flurry of news reports hitting the Disease Management Care Blog’s in-box, the expectations of earnings of 34 to 37 cents per share for the quarter ending November 30 contrasts quite unfavorably with the street’s expectations of 46 cents a share. Shareholders got grumpy and sold sold sold, provoking a 20% stock price drop, to its lowest level since the fall of 2003.

In scanning the news reports, shareholders apparently believe face-to-face care models are in the ascent and strapped insurers are ironically pushing back over the pricing of Healthways’ suite of services, especially ‘optional’ wellness and prevention programs. While overseas contracts may be a bright spot, they just ain’t enough to overcome the spectre of lower pricing and commoditization. Investors are looking for fatter return on their capital.

On the other hand, the Disease Management Care Blog notes that one quarter does not a long term investment make, and that the November 30 quarter is being buffeted by the an unfortunate combination of contract terminations and new program installs. The DMCB’s prior posts have been generally bullish on the folks from Franklin. However, that long (really long!) bullishness is based on three predictions - that the DMCB is still hanging tough on:

a) the population-based disease management ‘story’ is still being told and it'll take many more quarters-chapters before we know how this will sort out, and

b) once the high-touch medical home pilots show just how hard it is to reduce costs, disease management will look more attractive because…

c) models that combine the best of remote behaviorally-based disease management and clinically centered medical home will emerge, especially as synergistic insurance benefits are created (a naive yet conceptually simple example: waived co-pays for care of chronic illness) and the EHR finally shows demonstrable value (simple example: automatic test ordering and notification for all persons meeting tailored criteria for the diagnosis of a chronic condition).

The question for the leadership at Healthways: do you want to lead the way or follow in developing new links in the quality-cost value chain? The slump in your share price suggests so far that investors suspect it's the latter.

Image from Forbes

when boring is good

This is an excerpt from a post I wrote for MyBreastCancerNetwork.Com. I wrote it last Tuesday morning, before chemo:

When I am done, I will crawl off the bed a lot more slowly than I climbed onto it and my friend will take me home. For the next few days, I will feel like I have the flu. As my physical symptoms improve, my mood will worsen. By Friday, I will have to keep reminding myself that my rage and my sorrow are temporary.

And then Saturday will come and I will feel (more or less) like myself again.

If all goes well, things will continue like this over the next few months. Chemotherapy every four weeks. Clean scans every few months. And my echocardiograms will show that my heart still beats strongly and with regularity.

I am left with little to tell about my life as a cancer patient that is earth shatteringly new. But, as my spouse is quick to point out to me, when you have metastatic cancer of any kind, boring is very good indeed.

You can read the rest of this post here.

Individuals Recognized for Leadership in Disease Management

The Disease Management Care Blog extends a hearty congratulations and 'job well done' to the following individuals, who will be recognized in a Sept 7 issue of Managed Healthcare Executive for their leadership in disease management.

George Bennett of Health Dialog

Paul Bluestein ConnectiCare

John Castiglia Premera Blue Cross

Terry Crowson HealthPartners

D.W. Edington University of Michigan Health Management Research Center

Jay Feldstein AmeriHealth

Judith Frampton Harvard Pilgrim Health Care

Ron Geraty Alere

Bob Ihrie Lowes

Joan Kennedy Wellpoint

Barry Lachman Parkland Community Health Plan

Ben Leedle Healthways

Harlan Levine Towers Perrin

Dijuana Lewis Comprehensive Health Solutions Business Unit of Wellpoint

Ariel Linden Linden Consulting Group

Pam Menard Independent Health

Tracey Moorhead President,DMAA: The Care Continuum Alliance

David Nash Jefferson Medical College

Gordon Norman Alere

Michael Norris Great-West Healthcare

Harold Picken Blue Cross Blue Shield of Rhode Island

David Plocher Blue Cross Minnesota

Jim Prochaska Cancer Prevention Research Center

Michael Quilty Matrix Medical Network

Emad Rizk McKesson Health Solutions

Richard Safeer CareFirst BlueCross BlueShield

Chris Selecky Lifemasters

Kara Trott Quantum Health

beautiful faces

Updated to say that my spouse thinks I should have edited my leg out of the second picture. I am feeling extremely lazy today, so I can't be bothered. I think it looks fine, as it is.

Updated again: A very nice reader of this blog cropped the pic for me and I concede that it really does look much better.

The Latest Health Wonk Review Is Up!

Ahhhh, you hear the surf and can feel the sand between your toes as you anticipate another lazy day at the beach curled up with a good book and lots of high SPF cancer preventing UV blocker....

OK, you can't. Admit it, you are a workaholic.

Julie Ferguson understands. She and the Disease Management Care Blog agree that if you MUST be in front of your computer, why not head over to her Worker's Comp Insider and at least bask in some blogshine. Enjoy the bestest writings summarized and linked in the latest edition of the Health Wonk Review.

Harry and Louise Should Be Talking About Chronic Illness

Sorry, but the Disease Management Care Blog isn’t impressed by the latest Harry and Louise caper. America’s Healthcare Couple have been brought back to highlight the plight of folks such as Lisa’s husband. If you go to the harryandlousiereturn web site, you’ll learn the advocacy groups in Lisa’s husband’s corner are the American Cancer Society, the American Hospital Association, the Catholic Health Association, Families USA and the National Federation of Independent Businesses. For a misanthropic summary of these and other special interest groups’ use of money and power in the healthcare policy debates, check out the healthcareblog here and then decide it's best if Mr. Smith reconsiders ever going to Washinton.

What struck the DMCB was the relatively narrow focus of this anecdotal ad. While too many persons are caught between jobs with catastrophic illness, Lisa’s spouse isn’t necessarily a good summary of the big ticket and politically correctable ailments of the U.S. health care system. So, as a public service, the DMCB offers up some Harry and Louse Ver. 2.0:

Harry: Health care costs are up again. Small companies are being squeezed by the cost of chronic illness

Louise: Tell me about it. You know Betty’s obese husband just found out he has diabetes.

Harry: But he’s changing his diet and exercising, right?

Louise: No, he just joined a start up and says he can’t afford the time.

Harry: Too many people are unaware of what they can do reduce their risk.

Louise: Whoever the next President is, chronic illness should be at the top of the health care agenda. Bring everyone to the table and at least make THAT happen.

food meme

Recovering from chemo always provides me with an excuse to spend time online getting caught up on the blogs that I love. I am stealing this meme from Average Jane, who also posted the following instructions:

1) Copy this list into your blog or journal, including these instructions.
2) Bold all the items you’ve eaten.
3) Cross out any items that you would never consider eating.
4) Optional extra: Post a comment at www.verygoodtaste.co.uk linking to your results.

It took me a while to do (I cut myself some slack when I am in my jammies for days on end) but it was fun.

And I have the following observations:

1- I don't know as much about food as I thought I did. I had to look a lot of these things up.

2-I am not as adventurous as I was in my younger days. Not sure that I would eat frogs' legs now. Or that I would have turned down head cheese, had I been offered it when I was younger.

The VGT Omnivore’s Hundred:

1. Venison

2. Nettle tea

3. Huevos rancheros

4. Steak tartare

5. Crocodile

6. Black pudding

7. Cheese fondue

8. Carp

9. Borscht

10. Baba ghanoush

11. Calamari

12. Pho

13. PB&J sandwich

14. Aloo gobi

15. Hot dog from a street cart

16. Epoisses

17. Black truffle

18. Fruit wine made from something other than grapes

19. Steamed pork buns

20. Pistachio ice cream

21. Heirloom tomatoes

22. Fresh wild berries

23. Foie gras

24. Rice and beans

25. Brawn, or head cheese

26. Raw Scotch Bonnet pepper

27. Dulce de leche

28. Oysters

29. Baklava

30. Bagna cauda

31. Wasabi peas

32. Clam chowder in a sourdough bowl

33. Salted lassi

34. Sauerkraut

35. Root beer float

36. Cognac with a fat cigar

37. Clotted cream tea

38. Vodka jelly/Jell-O

39. Gumbo

40. Oxtail

41. Curried goat

42. Whole insects

43. Phaal

44. Goat’s milk

45. Malt whisky from a bottle worth £60/$120 or more

46. Fugu

47. Chicken tikka masala

48. Eel

49. Krispy Kreme original glazed doughnut

50. Sea urchin

51. Prickly pear

52. Umeboshi

53. Abalone

54. Paneer

55. McDonald’s Big Mac Meal

56. Spaetzle

57. Dirty gin martini

58. Beer above 8% ABV

59. Poutine

60. Carob chips

61. S’mores

62. Sweetbreads

63. Kaolin

64. Currywurst

65. Durian

66. Frogs’ legs

67. Beignets, churros, elephant ears or funnel cake

68. Haggis

69. Fried plantain

70. Chitterlings, or andouillette

71. Gazpacho

72. Caviar and blini

73. Louche absinthe

74. Gjetost, or brunost

75. Roadkill

76. Baijiu

77. Hostess Fruit Pie

78. Snail

79. Lapsang souchong

80. Bellini

81. Tom yum

82. Eggs Benedict

83. Pocky

84. Tasting menu at a three-Michelin-star restaurant.

85. Kobe beef

86. Hare

87. Goulash

88. Flowers

89. Horse

90. Criollo chocolate

91. Spam

92. Soft shell crab

93. Rose harissa

94. Catfish

95. Mole poblano

96. Bagel and lox

97. Lobster Thermidor

98. Polenta

99. Jamaican Blue Mountain coffee

100. Snake

Health Wonk Review is Up

Julie Ferguson hosts the latest edition of Health Wonk Review over at the "Workers' Comp Insider."She has a great list of recent posts from the world of health blogs suitable for beach reading. Just turn up the brightness on that screen!

What Happened to the Health Care Issue?

An interesting article in today's Chicago Tribune.Readers of this blog know we've been having a spirited debate recently on the question of just how likely health reform will be in 2009. Brian Klepper and Maggie Mahar have added to this discussion with some interesting posts and comments.The Trib headline:Health care no longer primary ailmentEconomy, price of gas, war in Iraq have surpassed

The American College of Physicians Says the Patient Centered Medical Home Needs Further Research

The Disease Management Care Blog wishes it could give the topic of the Patient Centered Medical Home (PCMH) a break. It was planning to view and comment about the NEJM’s on-line Shattuck Lecture, but was waylaid by the well-written, if formulaic, JAMA commentary on the PCMH by the ACP’s Michael Barr. The DMCB cannot let this one go by.

In the opinion of the DMCB, this well written piece should now serve as ‘the’ reference on the topic of the PCMH. Just two pages long, here is where you’ll find the concepts, the jargon and the key citations to meet the needs of any college paper, RFP, literature review, manuscript, press release, research proposal or business plan. The editorial also follows a now-standardized recipe useful in any health care policy kitchen:

First, describe the heartbreak of unwarranted variation, the ruination of runaway costs, the unfavorable comparisons of U.S. medical care in other civilized countries and the moral bankruptcy of an inequitable, ineffective, inefficient and unsafe health care system. Set aside and preheat to 350°.

Second, in a large mixing bowl, darkly explain that despite the association of strong primary care networks with efficiency and quality, it is being buffeted by poor reimbursement, an inability to attract medical students and a failure to meet the present and future needs of the elderly boomers.

Third, add a hefty helping of the learned and unprecedented unity of the organized primary care groups over the concepts of the medical home and the chronic care model. Then unwrap the term ‘Patient Centered Medical Home.’ Next, depict the unstoppable alliance of the physicians and large employers and its sponsorship of countless Learning Collaboratives. Imply the likely success of the Medicare Medical Home Demonstration Project and then add many other commercial demos being performed with input from health services researchers that will measure quality, cost, patient experience and satisfaction. Combine all ingredients together in a large accommodating and receptive pan. Bake until done.

Fourth, sprinkle with the NCQA Recognition program and the glowing reviews of entities like the Commonwealth Fund. Serve up with a demi-glaze of dissatisfaction with the current system, fiscal non-sustainability, the shame of persistent health disparities and the uninsured, the impending collapse of primary care and the irresistible luster of new improved models of health care.

But seriously, while Dr. Barr followed the standard recipe, this stellar article not only updated the reader on the favorable features of the PCMH and its progress to date, it also made two excellent points:

The first is the PCMH still warrants testing, not implementation. While the entire editorial (as well as the title 'The Need to Test the Patient-Centered Medical Home') speaks to the need to thoroughly evaluate the PCMH, this particular quote says it best: ‘However, it is imperative to test the model in a credible and transparent way in different environments.’ Hear hear. The DMCB especially likes the idea of transparency.

The second is a confirmation of yesterday’s DMCB ‘rest in peace’ post on P4P and its transfiguration into the PCMH. Once again, this quote says it best: “…payment based almost solely on the volume of care provided – even with a small performance-based component based on measures of quality – will not attract medical students and residents to primary care [or] provide the necessary incentives or capital for physicians to invest in practice enhancements, systems of care or health information technology.’ Enter PCMH.

However, the DMCB still wants to know:

1. By starting off with a litany of all that ails U.S. health care, advocates for the PCMH imply that it is a panacea for cost, quality, access, the uninsured and health care disparities. Recalling that there is much to criticize about the disease management industry’s past missteps, why aren’t the PCMH devotees also learning about the perils of over-promising and under-delivering?

2. While traditional ‘primary care’ is associated with lower cost, higher quality and less variation, what evidence is there that a fully implemented PCMH in the same primary care network will lead to even lower cost, even higher quality or even less variation? Why not seek to simply replicate the good primary care we know works into areas of the U.S that need it?

3. It is implied that the PCMH is not only necessary but sufficient for the resurrection of primary care. While it enjoys the widespread support of physicians, where is the real world evidence that a fully implemented PCMH translates into a meaningful improvement in the average PCP’s personal economic well-being? If there is improvement, where is the evidence that it is enough, considering all the other dimensions of the health care system, to make the average medical student chose a career in geriatrics and not dermatology?

4. No system of care, including the PCMH, can ever afford to remain static. Like disease management, it is destined to evolve, especially if testing (and the market) reveals what works and what doesn’t work. Does the ‘need to test’ the PCMH include recognition that a flexible approach to unforeseen and potentially fundamental changes in the seven principles of PCMH may be necessary?

vindication

One of my least favourite of household chores is the making of school and day camp lunches. It is an entirely thankless task, one in which I often see the results of my efforts returned at the end of the day.

And, ten year old S., in particular, has told me on more than one occasion that the lunches I make are not nearly as good as those of his peers. I am not sure if this is because white bread, sugary drinks and most highly processed treats are off the menu, if his perception is distorted or if my lack of enthusiasm for the task is reflected in the end product.

At any rate, I have not had to pack him a lunch in a while and I haven't missed it.

However, S. has spent the last couple of weeks staying with his Grandma and attending a day camp at the Royal Ontario Museum (an animation camp. They are making movies!). On the first day, Grandma asked S. what she should make him for lunch.

"Mama always makes me a ham and cheese sandwich with butter and a little bit of hot sauce."

Perhaps my efforts have not gone entirely unappreciated after all.

"Chastened and More Sober, Harry and Louise Return"

Brian Klepper joins us again today on the subject of just how realistic health care reform will be in the coming year.Chastened and More Sober, Harry and Louise Returnby Brian KlepperYesterday Ron Pollack of Families USA led a call with bloggers - unfortunately, I couldn't be on it - to discuss a new health care reform campaign sponsored by 5 prominent organizations: the American Cancer Society's

Patient Centered Medical Home (PCMH) and Pay for Performance (P4P): Are the Similarities More Than Just Skin Deep?

The Disease Management Care Blog recently had an interesting lunch conversation with the Chief Medical Officer (CMO) of a regional health plan. After investing more than a million dollars in per year in ‘pay for performance’ (P4P) over the last few years, progress has stalled. As a result, the focus in this organization has shifted from P4P to the Patient Centered Medical Home (PCMH). This health insurer, like many others, is planning to invest in a PCMH project in the coming months. The CMO I spoke with cited two reasons why the PCMH was in many respects displacing P4P: a) the emerging realization doctors ‘can’t do quality alone’ under 1^st generation P4P only -- even if considerable economic incentives are available -- and b) the PCMH promises a reduction in claims expense for persons with chronic illness within 1-2 years.

One would think that P4P would have led to local investments in practice redesign required to achieve the outcomes (performance) necessary to achieve the added revenue (pay). In this CMO’s experience, that simply didn’t happen. Apparently, the physicians’ pay wasn’t used to buy EHRs, hire additional care managers, or invest in decision support. Instead, the docs simply ‘added’ quality activities whenever they could in the course of business as usual. Perhaps the added revenue was used to offset the declining primary care payments we’ve been reading about. Another interpretation is they kept the P4P money and ran.

Has P4P’s less-than-perfect track record added to the growing luster of the PCMH? While any association between P4P’s disappointment and PCMH’s acclaim may be spurious, the DMCB wonders if there is more to it. In fact, the DMCB is struck by an underlying similarity between P4P and PCMH. Much like P4P, PCMH involves additional ‘pay,’ but the performance measures have changed from process and outcome measures to 'systemness' measures: for example, it’s not LDLs but referrals, not A1cs, but registries, not medication management but self management and it’s not cancer screening but clinic teaming. For the average CMO, those underlying similarities and available money make the transition from P4P to PCMH intellectually and operationally easier.

There are some interesting messages here:

1) while advocates of PCMH may suggest that managed care organizations should consider redirecting resources away from disease management to the PCMH, one has to wonder if the monies being used are being redirected from P4P and,

2) once again, much of the hope for PCMH is riding on its ability to reduce health care costs. If PCMH is going to survive in this CMO’s health insurance plan, it better deliver and quickly.

i'm too busy to have cancer

I have far too much on my plate right now to go to chemo.

But I must.

See you on the other side.

Meanwhile, I have a post up at MyBreastCancerNetwork.Com.

Ten Good Reasons To Go To The Annual DMAA Confab

Other than this simply being a great learning experience for anyone interested in populaion-based health improvement, here are ten other reasons to click here:

1. Hear about successful market-based real world advances in population based health outcomes that you’ll never see in most peer reviewed academically dominated print journals.

2. Watch individuals and organizations get a DMAA Awards and say to yourself, “Hey, I’ve done more than that. Next year I’m nominating myself/organization for that award.”

3. You’ll meet the growing number of medical school faculty that ‘get it.’

4. Hear and meet the unsinkable Tracey Moorhead.

5. Endless intrigue: Will Gordon Norman sport facial hair when he becomes Chair? Will DMAA change its name again? Will the Kaiser Family Foundation site mention any policy findings from this meeting? Can you get to the wine without stopping at a booth?

6. Meet and Greet the DMO CEOs COOs CMOs and countless other Cs. Find out for yourself that they really spend a lot of time worrying about quality and cost.

7. Watch the DMAA staff swarm into customer expectation-exceeding action.

8. Toast the Greenie’s doom and gloom predictions of hurricanes along the Florida coast with an umbrella’d drink poolside at the sunny host hotel.

9. You may get mentioned in the Disease Management Care Blog.

10. Hear Drs. Bagley and Grundy talk about the Medical Home.

Group Practice Demo Results, Questions, Policy and Song

The Disease Management Care Blog likewise extends a hearty congratulations to the participants in the Physician Group Practice Demonstration. Hat Tip to Vince Kuraitis for sharing the news and posting the link-announcement with the details. Looks like the docs got some serious coin.

The DMCB asks a) were the in-house interventions all that different from what is typically done by disease management programs? b) are the lessons in these large groups generalizable to the huge majority of physicians who are outside these kinds of practice settings? c) are the payments enough to cover the direct and indirect costs of implementing the interventions? d) are the payments to the four groups that hit the financial performance targets (translate decreased utilization) enough to cover their losses from avoided admissions and specialty care? Looks like we'll need to await the story behind the story.

But it's time to move on. As mentioned above, the challenge is to drive quality and efficiency in the nation's network of smaller independent physician practices. The details on that demo are coming to light, once again, thanks to Vince Kuraitis who has another post on the topic. It makes for very interesting reading.

Pity CMS. It would be so much simpler if the Group Practice Demo couldn't be used nationwide? If the physicians were assembled into large coordinated socialized entities that assumed regional responsibility for care? Instead, those irksome docs stubbornly cling to notions of running a business, retaining notions of independent professionalism and keeping local responsibility for the care they provide.

With apologies to Led Zeppelin:

Wanna tell you ‘bout some policy y’know
My it sound so fine
The docs only ones that we been schemin of
Maybe someday they won’t be so blind
We wanna tell em how we pay just blows
Their bills are just outta touch
We need to tell em that its outcomes that they really love

We want the doctors, go for risk all day
We want the doctors, drop one-on-one, no
We want the docs, take cap all the time
We said we want the greedy doctors to take upside risk

Sunday mornings when their offices are closed
See the uninsured standin in line
Don’t say they want no pay for their work
But when the A1c’s’ below nine
In the long term yes the payment may be low
CMS don’t wanna to be loved
We call the tune, keep-a- usin RVUs
Only payin if admits’r stayin down

We want the doctors join big groups
We want the docs not use pens no no
We want the docs, go salary big time
We said we want the doctors' mistakes to never get paid

In the halls with the men who pass the laws
Changin, schemin and regulatin’ health care
Our nifty notions are just the trick
Re-tool payment for all time
We guess there just one thing left for docs to do
If they don’t like it move outta the way

Cause we got a worried mind
Budget’s too big undermine
Outcomes savings will fix it we pray

We want the docs take episodes of care
We want the docs practice in IDS yay yay…
We want the doctors let us be in charge
We want the doctors to take R-V-Us!

(Hey hey that’s what we’ll do)

Tell the docs what to do!

(Hey Hey, That how we pay!)

Hey hey that’s what we’ll do

We got the doctors, that’s what they’ll do

Electronic Medical/Health Records: The Looming Information Overload

Here’s an interesting article describing the data-management travails of banking, securities, financial services and technology company executives. Corporate data volume is doubling every two years. Keeping track of it all and handling discovery in the course of litigation is turning out to be a major issue.

Over in the health care industry, electronic information overload at the point of care continues to be an annoyance for individual physicians, who have trouble managing and reconciling electronic prompts during a patient visit. And if you think fixing the human-electronic record interface is easy, think again.

Well, not only do individual physicians have a vexing problem with visit-to-visit data overload, this article warns us that the medical industrial complex and its love affair with the electronic medical/health record is headed for the same problem at a ‘macro’ level. The sheer volume of patient data will not only result in storage and mapping needs, its complexity will make it more difficult to sort out what is important versus merely data versus a key piece of evidence in future litigation.

another incredbible piece of writing

Jenny, who writes at "At Least It's A Good Cancer," wrote this piece, on the change in identity that comes with being a cancer patient:

At first, I wanted so much to maintain my professional identity, to be the smart, strong person who just happens to be going through cancer treatment. I didn't want to be like those grey, wispy, shadowed people sitting in the waiting room in their headscarfs and their wheelchairs. When I had surgery and couldn't wash my own hair, it was hard to accept help because it just drove home my incapability. When I couldn't walk outside for a full half hour at a time, I felt the loss of my physicality more than I had ever felt its presence.

What the writer doesn't say, and what happened too slowly for me to watch, is that you really can go back to something like your old life, and leave that self-loss behind; but it's almost like a projection of your old life, one rendered in all the same colors and moving in the same patterns, but against a different screen, parallel to the old but never quite touching.

I cannot say how much this spoke to me, even though Jenny has completed treatment and mine is ongoing. I have been thinking a lot lately about how strongly I feel about wanting to be seen as strong, vibrant and above all well, that I have even become defensive when anyone implies otherwise.

You can read the rest of Jenny's post here.

The Patient Centered Medical Home Doesn't Necessarily Increase Access to Primary Care

Well, it’s official now. Even though the Disease Management Care Blog has repeatedly noted that providing persons with health insurance is not the same as providing persons with access to care, the the National Association of Community Health Centers, the Governor of Massachusetts and even the pro Massachusetts-style reform folks at Health Care For All have come to that realization.

And nowhere is access more problematic than in primary care. Proposals to increase access have included changing medical education, using non-physicians, expanding retail clinics, increasing physician compensation, using the electronic health record and, of course, pushing the Patient Centered Medical Home (PCMH).

Just how does the PCMH perform in increasing access? Your DMCB took to the peer-reviewed literature and found this interesting quote from Future of Family Medicine Project report on the Personal Medical Home [italics mine]:

‘Because the analysis primarily focuses on the impact of the New Model on physician income under current work hours, it is assumed that any increase in services associated with chronic care patients is offset by a reduction in the physician’s panel size, so that the number of hours worked by a physician remains unchanged.’

Whoa. Reduction in the panel size? The DMCB has experience in primary care and suspects it wouldn’t be unreasonable to believe that there would be neutralizing trade offs. Physicians under the PCMH would have new roles that would mean less one-on-one care, but reliance on non-physician team members should make up for it, right? The DMCB looked at some of the original literature as well as the web sites of the Patient-Centered Primary Care Collaborative, the Commonwealth Fund and the Robert Wood Johnson Improving Chronic Care site for more information about increasing access, and was unable to find any.

The DMCB did find plenty of literature on the salutary impact of Open Access scheduling. This is an appointment management system that opens the clinic to patients without requiring them to schedule far in advance. The PCMH includes (but doesn’t require) innovations such as open access but review of the literature shows a) it’s possible to implement open access without the PCMH and b) may not always work (here and here).

What can be concluded? Based on what the DMCB has found, expansion of primary care in general is good when it comes to access to health care, but there is little evidence that expansion of the Patient Centered Care Model among the nation’s currently available primary care practices will necessarily lead to better access. In fact, the PCMH may lead to a ‘reduction’ in physician panel size. Open Access with (or without the PCMH) may (or may not) - help. If efforts to expand health insurance to the nation’s uninsured are successful, it appears we cannot count on the PCMH to address the mismatch between the availability of primary care and the demand for it.

Do any readers have any information that suggests otherwise?

more random

I am feeling a little scattered today so here are so more random thoughts:

1. I have been in such a good mood since my manuscript came back from my editor. I think I am just basically relieved that she didn't say, "This is a piece of sh*t and I have no idea why we said we would publish it." Sometimes it pays to set your expectations really low.

2. I am finding time management or the organization of my day to be a real challenge. No matter what thing I do well on any given day, there are several that I should have done and didn't.

3. I am very sad that Jeremy Hinzman is being deported.

4. I took a deep breath and gave some thought to an email before I wrote it today. In doing so, I realized that the other person had raised some valid points. I think cancer has made me grow up a little.

5. I am very psyched for the Ottawa Folk Festival. It had better not rain (as it has almost every day this summer). We had such a good time last year.

You Really Should Go To the DMAA Annual Meeting

The Disease Management Care Blog would like to point out that the DMAA: The Care Continuum Alliance will reach an important milestone in just a little more than three weeks from now. That's right, this is the 10th annual meeting, which will be held in Hollywood, Fla.

DMAA has evolved along with its members over the past decade, addressing the full continuum of chronic disease care and the changing approaches to health care delivery. At the upcoming meeting, a new track will examine the Patient-Centered Medical Home and population health improvement's contributions to this model of care. A featured keynote underscores this: medical home proponents Bruce Bagley, MD, of the American Academy of Family Physicians; and Patient-Centered Primary Care Collaborative Chair Paul Grundy, MD. Yours truly will be very interested in what they have to say and will resist populationating.

The DMCB will also be presenting in the Pacesetters International sessions on a successful offshore, web-based disease management program. More on this is a later post.

Readers should visit the The Forum site to learn more, wonder if your picture will ever be posted along with these other white male illuminati and to register for this most excellent program. Also note that members of DMAA and several partner organizations, including CMSA and NACDD, can attend at a significant discount.

See you there.

How Disease Management Leaders Can Win the Gold: Learn from Mrs. Phelps

The Disease Management Care Blog has been enthralled along with the rest of the world by Michael Phelps’ stunning 11 gold medal, world-record studded achievements. However, the DMCB couldn’t help also cheering for that indefatigable mom, Deborah Phelps. What’s not to admire about a divorced woman who simultaneously worked, completed graduate school and successfully raised three children, one of whom was diagnosed with ADHD? She’s clearly a force to be reckoned with, not only as a middle school principal but as the worst part of her son’s DUI: Michael reported his greatest dread in that ordeal was the prospect of having to face her.

What a woman. Deborah Phelps reminds us about the ingredients necessary for successful leadership:

Role-appropriate listening and helping: According to an ABC news interview, she said "I've been there not to dictate or guide. I'm there to listen to what he wants to do and try to help him problem-solve and make a wise decision…”

Example for DM: The DMCB observed a physician colleague talk with his company’s data analysts in a two day exercise in systems-level data collection and reporting improvement. The analysts had most of the answers, thanks to a manager who talked with, not to, these very bright people.

Willingness to accept risky suggestions: Michael wanted to stop his ADHD drugs. Deborah Phelps agreed.

Example for DM: The DMCB watched a nurse manager agree to letting her nurses modify a new patient education approach that had implications for a core outcome measure that crossed multiple business lines. There was a lot at stake and it worked out.

Let experts handle the things that experts handle: Michael has access to a number of expert coaches and other advisors. Deborah Phelps stays out of their way.

Example for DM: Nursing protocols underlying patient coaching are very sophisticated. A VP known to the DMCB learned this the hard way when the nurses were instructed to use an old approach for a different patient population all in the name of HEDIS. It did not work out.

Recognize talent and build on it: Michael was not very good at math, but his swimming prowess quickly declared itself. Guess which skill was the focus of Mrs. Phelps?

Example for DM: Dissatisfied with the response rates and data from an in-house wellness survey, one disease management company familiar to the DMCB decided to outsource it. After all, nurse coaching was their core competency.

Stay in the background: Watch Deborah Phelps in an interview and it’s clear that she rarely talks about herself. If forced, she portrays herself as just a mom.

Example for DM: The DMCB thinks the best CEOs give few interviews and stay off the covers of magazines. Instead, they’re too busy giving credit to the folks in their companies.

my 'best of the blogosphere'

Today's blog is brought to you by other people. Only they don't know it yet.

I am behind in my blog reading and even further behind in life but here are some of the best posts I have read this week, the ones that I keep thinking about:

I Don't Want to Be Dooce by Sassymonkey.

Ambulance Chasing by Mary P. Jones (MPJ)

And look what my friend Jacqueline, of Rebel 1in8 has been up to:

the view from here

The internet can be such an interesting place, no?