Not Confirmed, But More Than Just A Rumor?

Check out this line up.

HHS Secretary Kathleen Sebelius
HHS Deputy Secretary Bill Corr
HHS General Counsel Bill Schultz
**CMS Administrator Don Berwick**
CMS Deputy Administrator David Cutler
FDA Commissioner Margaret Hamburg
FDA Deputy Commissioner Joshua Sharfstein

The Disease Management Care Blog says bravo!

Hat Tip HealthHombre.

why yes, i have lost my mind

But I think I look very cute in my new pink cowboy hat (I am told that it's the same one that Julia Roberts wore in Runaway Bride - except hers wasn't pink). It's also really, really comfortable and it makes me happy. So there.

Thanks to Debbie from Journey Bags for taking the photo and emailing it to me. She asked me to let you all know that if you use Promotional Code 1208 when ordering from her site, you can get 10% off.

I think my hat is very Texas. And cheaper than new cowboy boots. And since I passed on the opportunity to go to a real cowboy bar and ride the mechanical bull, I thought I should bring home a little bit of the Lonestar State.

What is Needed to Unravel a Gordian Knot is a Bold Stroke—Access and Coordination

Today, Andy Wallace joins us with some concise advice on how to make our health care system work far better.He comes with a special perspective; a highly regarded physician specialist, a former medical center executive (former CEO of the Duke University Hospital), a former Dean of the medical school responsible for the Dartmouth Atlas and Vice President for Health Affairs at the Dartmouth Medical

random travel observations

I decided when I was on my walk around the hotel grounds this morning that the complaining I did earlier made me sound very spoiled. The truth is that this venue seems pretty ideal for a conference and I am extremely lucky to be here (and I mean that in so many ways). It would be great if it didn't cost $3.25US for a coffee but it is what it is. And I am assuming there will be free coffee once the conference starts in earnest.

Yesterday was a very long travel day. I miscalculated and finished my book way too early in the trip. As a result, my notebook is filled with random observations I made as I sought to fill the time:

I always feel nervous and guilty when I go through security, immigration or customs. I feel like I am going to be "caught." This is ridiculous since I never lie in these situations or smuggle.

There are signs up at US Immigration stating that all travellers will have their hands scanned and photos taken. I only saw this happen to one person. He was an older white guy so not sure if this was random or some new kind of profiling I've never heard about.

You wouldn't know that the North American economy is in crisis, judging by the number of people who are travelling. Both my flights were full, with long standby lists.

My flight out of Chicago was delayed because the plane was struck by lightning. Folks were very upset but I kind of felt that I would rather have a safe plane than one that left on time.

I have never had a sandwich in an airport that didn't taste like cardboard.

One woman seemed to think that the airport was a great place to find a boy friend. In the waiting area in Chicago, I overheard the following conversation:

40ish Blonde Woman (flirtatiously): "Watcha readin?"

Attractive 50 something man: Mumbled title.

Woman: "Is it a Christian book?"

Man: "I suppose it is."

Woman: "That's what I had heard about it."

Man: Silence.

Woman: "You seem really interested. You just keep writing things down."

Man: "Just noting some things."

Pause.

Woman: "Do you live in Dallas?"

Man: Silence.

Woman: Launches into detailed explanation of where she lives. Mortified I get up and leave.

Some time later, after we change gates, I see them again. She is calling out to him, "Don't go away! I'm a catch!"

A few minutes later, she has moved on to another man. From across the waiting room I can hear her talking about going to church.

So - was she prosletyzing or cruising? Or both?

When I am desperate enough, I will read anything. Apparently this includes the in-flight magazine (this month's issue features the NBA) and something called Skymall. I found myself coveting this and this and thinking this was kind of gross. And then I felt guilty that I don't have anything like this to protect my neighbours from my unsightly air conditioner (but what would protect them from all the unsightly dog poo in my yard?). I could go on and on. And the prose in the catalogue was fantastic.

I was too shy to talk to two women I saw at the Chicago end of my flight who I guessed were going to the conference. I redeemed myself by greeting them as we waited for our bags in Dallas. They told me that they have been coming to this conference for six years. They promised me that I was going to have a wonderful time. They also told me that they are expecting 1,000 participants this year. Wow.

The "Networking Opportunity" I mentioned in a previous post is happening now. Time to take a deep breath, gather up my leis and head on down.

Medicare Advantage HMO Stocks Down Big This Week

Matthew Holt, publisher of the Health Care Blog, and I have been in a state of incredulity over Wall Street’s head in the sand view of the Medicare Advantage business for more than a year. See his post today, "I Don't Really Understand Wall Street, Part 98."Why was it that in the wake of a Democratic take-over of Congress in 2006 and Obama’s victory last November that HMO stocks heavily invested

classified

I'm green and orange. As with previous events of this nature, I like to identify others who know what it's like to live with mets. I am also acutely conscious that wearing the orange may be every participant's worse nightmare.

suitcase stowaway

I am in Dallas (or somewhere on the edge of Dallas with only highway and hotels as far as the eye can see. The hotel claims to have seven acres of "park" with walking trails that I have yet to find or check out. Given that the restaurant with the "open air ambiance" is actually in a roped off area of an indoor courtyard and the spa and gym are in a separate building and charge a membership fee, I am prepared to be disappointed). This hotel is huge.

Please note the little friend that I found when I opened my suitcase. He's half of a pair of "sweater monsters" that were given to me by a dear friend. I think D. decided that I might be lonely on my trip. How thoughtful was that?

I am off to find coffee and breakfast. I've been up since 6.

Congressional Budget Office Says Disease Management May Well Be Cost Effective

On February 25 2009 CBO Director Douglas Elmendorf gave testimony before the US Senate on options for expanding health insurance coverage and controlling costs. It's an impressive 31 page document that effectively describes a host of healthcare reform policy options. The Disease Management Care Blog found some statements about - what else - disease management. The most important quotes are below.

Note that overall, CBO is still describing the industry in supportive terms.

'...disease management services can improve health and may well be cost effective - that is the value of the benefits could exceed the costs. But those efforts may still fail to generate net reductions in spending on health care because the number of people receiving the services is generally much larger than the number who would avoid expensive treatments as a result.'

The DMCB agrees that considering the merits of health care interventions based on their ability to 'save money' is less useful than assessing them on how well they deliver value. Contrast nurse-based coaching aimed at achieving an A1c of 7% (which is typically poorly covered outside of managed care settings, if at all) versus stents for persons with coronary artery disease. Both result in betterment. Both cost. One delivers far greater benefit than the other.

As for the dilution of disease management interventions over large populations, organizations in the business of population-based care management have known about this for a long time. In response, they use predictive modeling to target beneficiaries who are most likely to benefit from the interventions. For this to work, however, the Medicare program will need to consider the implications of unevenly applying a benefit to an eligible population. The DMCB has an ironic paraphrased quote to think about in these these days of expanding central government: from each according to their ability, to each according to their need.

...proposals could include specific elements designed to induce individuals to improve their own health or to encourage changes in how disease are treated. Through a combination (bolding mine) of approaches, proposals could try to change the behavior of both patients and providers by promoting healthy behavior,.... expanding...preventive care, establishing a medical home..., adopting 'disease management' programs,... funding research comparing the effectiveness of different treatment options... expanding the use of health information technology... and modifying the system for... malpractice. In many cases studies... studies do not support claims of reductions in health care spending or budgetary savings.

Not quite. Many of the studies in each of the domains above are restricted to just that domain (for example, just the medical home) or to a particular piece of the domain (for example, the use of physician order entry). There are few, if any, studies that examine the impact of any significant combination of approaches (for example, the medical home plus telephonic-based coaching that promotes the latest effectiveness research findings linked to a personal health record). The DMCB thinks combinations of these interventions will be proven to be greater than the sum of their parts. This will be the next frontier for effectiveness research in population based care, Medicare demonstrations and Medicaid waivers. In addition, this is where we'll see innovations in those pockets of the medical insurance market place left untouched by the Federal tsunami.

Mr. President, Aren’t You Just Kicking the Can Down the Road?

Pieces of the health care portion of the Obama budget are leaking out.Based upon published reports, the Obama “down payment on health care reform” will include:$634 billion to help pay for health care reform over the next ten years. $318 billion of that—about half—will come from tax increases that include reducing the mortgage and charity deduction for high income Americans.Charging wealthier

Will Obama's Healthcare Reform Be His Boston Tea Party?

Did you watch Obama’s speech last night? The Disease Management Care Blog did and couldn't discern just what the next steps are going to be when it comes to healthcare reform. It has, however, watched many other past local and national politicians square off on the issue with the same grim determination. The DMCB wishes our President good luck and would like, as bloggers are wont to do, offer some unsolicited and unheard advice.

In the winter of 1773, the British Crown made an eminently rational determination. Since the American Colony’s French and Indian Wars had cost the royal treasury dearly, a special tax was called for. As we all know, a citizen-group in Massachusetts disagreed and held what has been come to be known as the Boston Tea Party.

Fast forward to 2009 and check out this videotape showing a vociferous bunch of Chicago Mercantile Exchange floor traders reacting to the skeptical commentary of a CNBC broadcaster. You’d think these guys should be able to discern the rationale behind the mortgage bailout. As the DMCB understands it, the mortgage mess is torpedoing banks, locking up credit markets, depressing home values and wrecking neighborhoods. Tapping the US Treasury to fix it is also arguably fair and rational. These Chicago traders apparently disagree.

While it cannot judge the merits of the bailout, the reaction of these smart businessmen reminds the DMCB of its own past Tea Party. Yes, we thought that we had a wonderful disease management program destined to improve patient care, reduce physician workload and increase provider income. We spoke to local Chief Medical Officers and VPs and secured their input and buy-in. It was then rolled out in a series of meetings, e-mails and formal presentations. Many physician-colleagues, after listening carefully, told the DMCB to take a hike. Others said nothing, returned to their clinics and turned to both active and passive resistance.

So what’s the lesson? Even if an initiative is 1) needed, fair, rational and well designed, 2) rolled out with an abundance of marketing and education and 3) is directly tied to the self-interest of all involved, everyman Bostonians, Chicago traders and physicians are more than capable of coming up with opinions that are 180° contrary to those of the leaders and experts. Physicians who believe in the merits of one-on-one patient care, based on independent professionalism and scientific judgment may find ‘electronic records,’ ‘team based care,’ ‘populations,’ ‘pay for performance’ and ‘bundling’ to be wanting. As one very bright but oppositional physician explained to the DMCB, he didn’t need any more education. He got it. Want he wanted was to be left alone.

The DMCB also learned something else. The resistance of the physicians wasn’t a function of narrow economic self-interest, intellectual inertia, lack of knowledge or professional dysfunction. They had their own vision, paradigms, ideals, thoughts and opinions. They were being reasonable. Given the circumstances, who can be surprised that the docs concluded that it was their patriotic duty to resist?

In response, we went back to the drawing boards. We addressed some of the concerns, ignored others and set up work-arounds when physician cooperation wasn’t absolutely necessary. We then moved forward and counted on a track record of success to convince the nay-sayers. It took a lot of time and a lot of work.

Fast forward again to the promised release of the Obama Administration healthcare reform proposals. Even if the plan is expertly contrived, even if organized medicine groups’ leaders are supportive, and even if economic self-interest is at stake, the DMCB will not be surprised if a significant number of physicians resist.

The Advice? Don't let healthcare reform provoke a Boston Tea Party. The last time that happened, things really turned upside down.

The DMCB recommends that the Obama Administration recognize that many mainstream physicians will have deep concerns. It should resist ascribing it to unawareness, irrationality, selfishness, the lack of outreach or poor planning. Think King George III.

The DMCB also suggests that if the resistance is significant, the success of healthcare reform may hinge on Washington DC’s ability to adjust and adapt. Avoid being mainframe. Think the Yes We Can Campaign.

"Obama Budget Would Creat $634 Billion Health Care Fund"

Here is what Ceci Connolly is reporting at the Washington Post:President intends to release a budget tomorrow that creates a 10-year, $634 billion "reserve fund" to partially pay for a vast expansion of the U.S. health system, an overhaul that many experts project will cost as much as $1 trillion over the next decade.Obama would pay for the expansion by trimming tax breaks for the wealthy and

random observations

observation #1: I am getting dumber and my kids are getting smarter.

My youngest son is undergoing some tests with a psychologist as part of an educational assessment. After his session, the psychologist showed us some of the non-verbal test questions, which involved pattern recognition. D. picked out the illustrations that fit the sequence in split seconds. I asked if he had seen these particular questions before. He hadn't. He's just quick and very, very bright.

The thing is that he answered these questions much more quickly than I could have, selecting the right answer while I was still puzzling it out.

observation #2: I derive almost as much satisfaction from making lists as I do getting things done.

I am going away tomorrow morning (I got a scholarship to attend the Annual Conference for Young Women Affected By Breast Cancer, in Dallas) for a few days. I spent a good part of the morning making a list of everything I need to get done. I love lists. Having several (what to bring in my carry on, what to pack and what I need to do before I go) has made me feel much almost as though my work is done.

observation #3: I am very anxious about attending a conference where I will know no one.

The truth is that I would rather speak in front of 1000 people than meet 100 people one at a time. The words "networking opportunity" scare me. I have been reminding myself that I need to have an open and friendly demeanor and that it's OK to bail and go to my room when it all gets to be too much.

observation #4: Having worked in communications does not make it easier to promote my own work.

I would rather sell a message or promote someone else then sell myself. I have had the same business cards (lovely ones that my older son made for me) for a year and have yet to make much of a dent in them. I am bringing flyers advertising my book, though and will at least put them on tables, even if I don't have the courage to talk about it.

observation #5: I get very excited at having time to myself and tend to over-estimate what I will have the time to do.

The weather will be warm in Dallas. And my hotel (we got great discounted conference rates) is far from anything touristy to do. It does have nice grounds, a nice gym, several pools and an outdoor restaurant, so I plan to pretend that I am at the spa in the hours before the conference starts. I am bringing knitting, books and workout gear. Lots of all of it.

observation #6: Homeland Security is going to have a field day with my suitcase.

Circular knitting needles (joined by flexible cables), pins (for blocking or shaping finished scarves on my extra bed) and a bottle of hair mousse. I might as well paste a sign on my suitcase that says "suspicious contents!". The Yarn Harlot says that her suitcase is opened and checked every time she goes to the States. Mine was only opened the one time I packed knitting in my suitcase. I think knitting needles look suspicious on x-rays.

Off to make some tick marks in my to-do list now.

I may blog while I'm away, if I can find free wireless in the hotel lobby. Can someone tell me why the cheap chains give you free wireless but the fancy hotels charge extortionate rates for slow access?

The Latest Cavalcade of Risk is Up!

Russell Hutchinson excellently hosts this week's blogmos roundup of all that deals with health risk and the financing of health risk for the latest version of - what better name could there be? - the Cavalcade of Risk. Take a look, or risk not being up on the 'best' and being some sort of knucklehead.

For the Obama Administration Health Care Reform Will Require Really Tough Cost Containment—Coming and Going

The President has made a powerful argument—America cannot get its economic house under control without comprehensive health care reform. The cost of existing entitlements—public and private—and any new ones are just too big a ball and chain on our short and long-term economic health.The President has also argued that there could be no better time to fix this mess than now—when it is so critical

The Latest Population Health Management Journal Is Out!

Oh joy! Isn’t it great when you open your mailbox and find a goody like the latest issue of Population Health Management? Sure, you want to thumb through every page, ponder every word, examine every graph and review every citation but…. you don’t have time. But unlike your colleagues, you also regularly read the Disease Management Care Blog. That is your secret weapon. Scan the summaries below and then decide which needs to be read right away and which ones can wait. As an added bonus, the DMCB helps you impress your co-workers with your erudition by rustling up some key quotes. Use them to impress the boss at those upcoming conference calls and business planning meetings.

Dominick Esposite, Erin Taylor and Marsha Gold: Using qualitative and quantitative methods to evaluate small-scale disease management pilot programs.

Heard of the Medicaid Value Program? Neither did the DMCB, but this involved having 10 organizations use a variety of care interventions for Medicaid beneficiaries with multiple chronic conditions. Using a combination of qualitative and quantitative research, the authors found the implementation, competing priorities, provider buy-in and local leadership commitment to be the key ingredients associated with success. This is must reading if you’re going to use some of that Federal stimulus money to quickly rustle up a new Medicaid-based program.

Key quote you could use at an upcoming meeting “According to Esposito’s article in PHMJ, a smaller than expected number of eligible beneficiaries and lower than expected patient engagement rates are not uncommon.”

Iver Juster, Stephen Rosenberg, Deeptimayee Senapati and Mayur Shah: “Dial-an-ROI?” Changing basic variable impact cost trends in single population pre-post (“DMAA Type”) savings analysis.

In a prior post, the DCMB delighted in a review of chronic vs. non-chronic trends to derive what the cost of health care would have been absent a disease management program. If you think that’s simple, read this paper from a DM Jedi Master and his colleagues and find out just how complicated it can be and why, in the end, you’re going to need an actuary to ascertain whether you’re really reducing claims expense.

Key quote you could use at an upcoming meeting “According to Sensai Juster’s article in PHMJ, the length of the look-back period, the length of claims runout and the number of months of enrollment are important determinants of trend!”

Jason Cooper, Lakevia Hall, Angel Penland, Andrew Krueger and Jeanette May: Measuring medication adherence.

Read this and you’ll not only know the operational definition of medication adherence (the days supplied divided by the days prescribed) but how to handle claims runout and disenrollment when it comes to assessing whether a population is taking their meds. You’ll also get benchmark adherence rates in a commercial population (depending on the condition, mostly between 75% and 84% - bile acid sequestrants unsurprisingly are lower). Kudos to Accordant for making the data available.

Key quote you could use at an upcoming meeting “According to May’s article in the PHMJ, our medication adherence rates are already running at [insert ‘more’ or ‘less’] than what’s been reported in the literature!”

Kejian Niu, Liming Chen, Ying Liu and Herman Jenich: The relationship between chronic and non-chronic trends.

Sorry, but there’s no escaping this chronic and non-chronic trend stuff. In this paper, the authors stress-tested the DMAA methodology in a stable population without a disease management program and compared the chronic and non-chronic trends over time. It turns out the two were similar if there is satisfactory statistical adjustments and persons are annually requalified.

Key quote you could use at an upcoming meeting: “Good thing our actuarial consultants are using the DMAA methodology to assess the impact of our disease management program. According to Niu’s article in PHMJ, that approach has considerable merit!”

Thomas Kotsos, Keven Muldowney, Griselda Chapa, Eric Margin and Antonio Linares: Challenges and solutions in the evaluation of a low back pain disease management program.

This is even more evidence that the DMAA approach is taking root, since this article also relied on that methodology to assess a condition of great interest to employers. There appeared to be savings, but the subpopulation with simple mechanical low back pain apparently experienced an increase in claims expense. Everyone else experienced decreased utilization. One lesson may be to leave the simple back pain patients out of the program.

Key quote you could use at an upcoming meeting: “We’re already doing the top 5 chronic diseases, so let’s tackle a new one – like low back pain. Kostos in PHMJ showed that a telephonic nurse support intervention can make a difference!”

Al Lewis: How to measure the outcomes of chronic disease management.

Exhausted by all this high falutin actuarial stuff? The remarkably insightful father of disease management comes at the topic from another point of view by giving you 5 Important Questions that should always be asked when you are attempting to assess whether your disease management program is working.

Key quote you could use at an upcoming meeting: “You’re right of course, but how do we estimate the amount of co-morbidity reduction that has also taken place? According to Al Lewis (and everybody knows his name), that is a key question that must be addressed!”

And then there’s an editorial by … the DMCB. Called ‘Disease Management Grows Up,’ it points out that the sophistication of the literature above reflects an evaluation-science sea change underway in the disease management industry. In fact, the growing sophistication of measurement in population-based programs could well turn out to be the benchmark for other healthcare reform initiatives, including the patient centered medical home.

Key quote here: ‘Gosh, if the company I work for isn’t a member of DMAA, we should join. Not only would we get the PHMJ, we could get involved in future iterations of how to measure outcomes in population care management programs!’

women with real influence

My youngest son came to see me in the kitchen this morning, while I was making school lunches (By the way, has there ever been a more thankless task in the history of parenting? I don't thinks so).

Me: "Your face is so clean! Great job!"

D.: "I washed my face!" (He shows me how he did it, miming vigorous rubbing.)

Me: "That's great!"

D.: "And I brushed my teeth. And I even flossed." (He mimes brushing and flossing.)

Me (impressed): "That is amazing. You are awesome."

D.: "I did it because at day care we are learning about the importance of good hygiene."

They have good teachers at the day care. And, apparently, their words carry more weight than mine do. Maybe I could ask them to talk about "the importance of being polite to his parents" or "the importance of cleaning up his toys."

Here’s a new number for you to memorize from Health Affairs: $2.4 trillion. The one that should scare you? 6.2%

***A DMCB early release***

Mr. Obama will be giving an address Congress tonight and the Disease Management Care Blog will be all ears. It hopes to learn more about the Administration’s coming plans for healthcare reform. The tone surrounding those plans may be gaining urgency thanks to a curiously timed if highly informative release of a Health Affairs web exclusive by actuaries from the Centers for Medicare and Medicaid services.

They’ve rendered up two numbers you may want to listen for tonight or in the coming days: 2.4 trillion and 6.2%. The former may make it into the speech. The latter probably won’t. The former is big and makes the stimulus package pale by comparison. The latter sounds small. Don’t let that fool you, however. 6.2% is really really scary.

The first number is the amount of money that will be spent on health care in 2008. As testimony to the huge size and strength of our economy, we can currently afford to spend that on ourselves every year. Unfortunately, we can’t afford the second number. That’s the rate of spending growth that is projected over the coming years. It contrasts with the 4.1% growth projected for the gross domestic product (GDP – or the sum of all goods and services produced in the course of a year). The mismatch means that year over year, more and more of both our individual income and taxes will be spent on our own and others’ health needs. Right now, that is about 16% of GDP. It could grow to a total of 20% in less than 10 years.

6.2% is known as ‘trend.’ While us mortals think about absolute numbers, actuaries lay awake at night worrying about the rate of growth. Successful insurers recognize that increases in the rate of health care costs are part of the business. Their job is to predict those increases and advise what the health insurance premium should be. The DMCB is no actuary, but it bets the Fed’s actuaries are telling their bosses that this kind of trend is this.

The number 1 and 2 drivers of the cost inflation is ‘medical prices’ and ‘growth in the use of services,’ which accounts for about 2/3 of the growth rate – not the aging of the population. Interestingly, the ‘administrative costs’ of private insurance are projected to continue to decline from over 13% to 12%, making it less likely that insurance company’s ‘profiteering’ can be blamed for our cost woes. And the DMCB doesn’t understand how spreading unsustainable health care costs over the uninsured is going to help either.

Right now, all we know are increased money going to the States for SCHIP/Medicaid and less money for Medicare Advantage. That’s easy. Now comes the hard part - where we see the difference between oratory and reality, bombast and bipartisanship, gimmicky delay versus the day of reckoning.

2/25/08 addendum: The Wall Street Journal points out that the numbers above were calculated without the additional spending in the current stimulus package. Yikes.

FCCCER: An Unfortunate Acronym. Hopefully, It Won't Stick

There they go again. Invective. Hyperbole. Partisanship. Un-niceness.

Read this editorial and you’d get the impression that the Feds are using health care as a Trojan horse to strip us of our freedoms. Listen to this guy and you may want to don your war paint and dump some tea into Boston’s Harbor. No… wait! It’s the other side that’s evil. They’re vicious, ignorant fear mongers who should just sit down and shut up. Because, this is Good and Righteous. It's Very Good.

And so it begins.

What’s got everyone so riled up? ‘Comparative effectiveness research’ and the ‘health council.’ Confused, the DMCB went to the original language of the stimulus bill (p. 63 of this 407 page behemoth) and found language that states $1.1 billion will go to the National Institutes of Health (NIH) and the Secretary of Health and Human Services for ‘comparative effectiveness research’ that measures ‘clinical outcomes, effectiveness and appropriateness’ of ‘items, services and procedures that are used to prevent, diagnose or treat.’ The money can also be directed to encourage the use of registries, clinical data networks and electronic health data that can be used for outcomes data. The money can be granted to ‘appropriate public and private entities.’ $1.5 million is allocated to the Institute of Medicine to decide on priorities for the research.

There will also be a ‘Federal Coordinating Council for Comparative Effectiveness Research’ (FCCCER) (page 73) which will be made up of 15 individuals who ‘foster’ coordination of the research as well as advise, assist and report. This Council will not be allowed to mandate coverage, reimbursement, or other policies for any public or private payers such as clinical guidelines for payment, coverage or treatment.

Like factcheck.org, the DMCB is not worried. But it’s not all that impressed either. Here’s why:

In its days as a managed care medical director, we were constantly scouring the peer-reviewed medical literature to help us divine insurance coverage decisions. We found no matter how carefully crafted, even the best studies leave unanswered questions and are riddled with exceptions. Recent case in point? The rigorously performed SYNTAX trial, which found open surgery bypass had better outcomes compared to the use of stents among persons with severe coronary artery disease. You’d think case closed until you read how these two experts differed in their interpretation of the findings. What they agreed most strongly on was the need for more research. More research begets more research.

In addition, the DMCB isn’t sure that the current insular medical-industrial complex is prepared to conduct the kind of comparative research we need today. We need speed, we need community-based studies, we need to simultaneously implement promising interventions and we need to ask not only ‘if’ it worked but ‘how’ and ‘why’ and for who and under what special circumstances. It’s not just the DMCB that feels that way.

What’s more, clinical effectiveness research won’t answer many important questions – even if money isn’t an issue and even if everyone in Washington DC would like to ethically advance cost effectiveness. Should hundreds of thousands of dollars be spent to prolong the life of an elderly man with advanced brain cancer? What should ICU physicians do in the face of overwhelming but not absolute odds of dying? Is State by State variation due to physicians and is it necessarily bad? Even if we know something doesn’t work, would we still pay for it?

And how about FCCCER? Assuming ‘advise’ and ‘assist’ and ‘report’ are really action verbs, does it have any hope of navigating through the hugely bloated DC bureaucracy? Note that many of its members will be from AHRQ, CMS, NIH, FDA and the VA. Think members of Congress won’t be calling them on behalf of their constituencies? Think again.

Last but not least, FCCCER is an unfortunate acronym. Quite.

Summary: It’ll take years before results appear from traditionally conducted effectiveness research. It won’t answer the important questions. Medical directors will still need to use clinical judgment in deciding coverage issues. It’s not a Trojan Horse and it’s not a panacea. Hopefully, if it has any negative impact, my medical colleagues won't use their own FCCCER-like action verbs to describe its performance.

A Tale of Two Reports. Commonwealth Fund and Milliman.

Want to think some more about reducing healthcare costs? Neither does the Disease Management Care Blog but, nonetheless, two reports deserve your attention. One is a retread of some unproven policy notions swirling about Washington DC. The other makes for a refreshing read from an actuarially sound point of view.

The Commonwealth Fund report on a High Performance U.S. Health System would naively spread the costs of an out of control healthcare system over a larger payer base. By forcing more persons to join, the average cost of the insurance premium may drop but overall costs will continue to grow. The DMCB also continues to be amazed over the faux certainty that the medical home, health information technology or patient-centered-care will measurably increase quality or reduce claims expense. The DMCB also doesn’t understand the difference between The Commonwealth Fund’s support for capped premiums and Nixonian price controls, or if either are reasonable in a real world risk-transfer environment. That being said, there are some other meritorious ideas, including bundled payments. Look it over for yourself and decide.

In contrast, check out this report from the 100% actuary guys at Milliman. While less likely to attract the attention of the policy elites or the blogmos, the DMCB likes this because it tackles healthcare cost inflation in lieu of recycling policy fluff. Bruce Pyenson et al present a series of options that, while politically challenging, are meaningful long-term goals that will fit into any future payment system, public or private or both.

According to these guys, reducing the rate of healthcare inflation from 16% of GDP to 12% (a 25% decrease) can be achieved by exporting the best practices that are already active in many areas of the United States to the rest of the country. This will shift utilization, without having to change the reimbursement (i.e., cost cutting) per unit of service.

Here's a shortened summary of Milliman's excellent recommendations. The DMCB thinks they make for good benchmarks next time you hear or read others' ideas on how to get health care costs under control as part of our reform efforts:

Reduce overall utilization and variation to levels being achieved at Intermountain Healthcare and Mayo (maybe venture capital is warranted at finding successful ways to align independent health care entities at a regional level?)

Make hospital-based health care services available 7 days a week (don't let a weekend get in the way of performing needed testing and treatment)

Put hospitalists in control of inpatient stays and make specialists readily available for consultations (the DMCB is convinced that hospitalists make for more efficient inpatient stays)

Implement inpatient pathways, order sets, computerized order entry (these are the inpatient parts of the electronic record that have been shown to improve efficiency and reduce complications)

Reduce medically unnecessary admissions from the ER to the inpatient setting (once an ill patient crosses the ER threshold, it's very hard to return them home. It's far easier to admit and move onto the next patient)

Optimize discharge planning (the weeks after discharge from a hospital is a time of great vulnerability. Patients are still sick and may not know what to do to cope)

Routinely get family involved (back in the day, the DMCB asked family to come in and learn how to care for Mom. The nurses were more than happy to help teach. Anecdotally, it works)

For patients already in nursing homes, manage their needs as much as possible there rather than transferring to a hospital (physicians will recognize that nursing homes are a rich source of transfers to the emergency room and that most get admitted to the hospital).

Promote commoditized generic medications, durable medical equipment, outsourced (overseas) radiology interpretation, drug importations and medical tourism (it's called price competition).

Expedite FDA approval process,

Enhance the financial transparency behind drug purchasing (this is a morass of contracting arrangements where everybody wins except the consumer)

Promote skin in the game for patients' medication adherence and persistence,

Capitlize on personalized medicine to target prescribing for maximum outcomes

Allow nurse practitioners to prescribe.

Give up on the notion that health care is local (while the DMCB is uncomfortable with the notion that once size fits all, standards of care can be combined with expected patterning so that a less than 100% fulfillment rate is not only accepted, but expected)

Standardize protocols surrounding patients who are in end-of-life care including promoting home-based care, following advance directives, doing comparative effectiveness research on high tech care options, using hospice as the control arm and focus on comparative effectiveness studies (end of life care is where there are huge cost opportunities).

The Milliman report is also interesting for what it doesn't include, like disease management. It correctly notes that it's role in reducing costs to a significant degree - compared to inpatient care or pharmacy - is limited and still subject to some study.

Raising the Price Before You Put It On Sale—The Obama Budget and His Health Plan

The Obama budget team has made it clear they are going into the next federal budget process playing it straight on many fronts that the prior administration had fudged on.The cost of the wars, the cost of adjusting the alternative minimum tax each year to keep the middle class from falling into it, the cost of disaster relief, and the cost of avoiding the otherwise automatic cuts to Medicare

SavingPrimaryCare.org Doing Good Work

A comment to a recent post caught my attention.There is a new group of primary care practitioners doing some good work that deserves some attention.From their website:SavingPrimaryCare.org is an off-shoot of the Ideal Medical Practices Project that has been running since 2006. This grant funded project supports solo and small practices across the US as they struggled to provide

“Leading Figures in the Nation’s Long-Running Health Care Debate…Appear To Be Inching Toward a Consensus”

Robert Pear, in the New York Times, is reporting that, “leading figures in the nation’s long-running health care debate…appear to be inching toward a consensus that could reshape the debate.”He goes on to write, “While not all industry groups are in complete agreement, there is enough of a consensus, according to people who have attended the meetings, that they have begun to tackle the next steps

when life gives you lemons

A couple of weeks ago (has it really been that long?), Nonlinear Girl, presented me (and a few other bloggers with the Lemonade Award.

What it's supposed to mean is that the recipients have been handed some lemons by life and have gone on to make lemonade. I love Nonlinear Girl's blog. I met her at BlogHer last year and have been reading ever since. She seems like someone I would hang out with if we lived closer to each other (she's in Portland and I'm in Ottawa), except that she's smarter and more talented than I am.

She's also expecting twins in a month or two. I am thrilled for her and in awe.

But back to the award. Recipients are supposed to tag ten other bloggers but I think I am going to follow Nonlinear Girl's lead and just choose a few bloggers I like, who write bravely, humourously and well about their lives and the obstacles they have had to overcome. There is no pressure on any of them to pass this on, I just enjoy them and think you will too.

So the award goes to:

Lene

Princess TinyButt

Sara

The Maven

An Instructive Study Gets Published in the American Journal of Managed Care

Regular readers of the Disease Management Care Blog are already aware that the DMAA took the lead in developing a ‘real world’ approach to evaluating the economic impact of population-based care management programs. Since prospective, randomized clinical trials are not reasonable in business settings and parallel control cohorts may not be available, the ‘DMAA approach’ allows for a pre-post design, including the cost trend of a ‘non-chronic’ population to predict what the cost would have been absent the intervention. It also recommends that the costs measured pre and post be generally based on persons who are ‘requalified.’

Confused? You don't have to be:

The ‘trend of the non-chronic population’ is based on the observation that, from year to year, there is a baseline rate of health care cost inflation. If health care costs among persons without chronic illness climbs 10% per year, then a 9% cost increase in the disease management population from year 1 (pre) to year 2 (post) implies you saved 1%. It may be counterintuitive (versus relying on the trend among persons with chronic illness), but a lot of background work has shown this is a conservative and better approach.

The term ‘pre and post be based on persons who are requalified’ is also counterintuitive. In any insured population, there are persons in the pre or baseline year with one or more insurance claims for chronic illness care and then there are persons in the post or follow-up year with one or more claims for chronic illness care. The 'requalified approach' says that you are only allowed to include the costs of persons with active claims in the year of measurement. So, if a person with a claim for diabetes in year 1 (pre) turns out to not have a claim for diabetes in year 2 (post), that person’s costs are not used to measure cost in year 2. They are taken out.

Which is why a paper by DMCB colleague Soeren Mattke and colleagues (Seth Serxner, Sarah Zakowski, Arvind Jain and Daniel Bold) appearing in the latest issue of the American Journal of Managed Care should be of great interest. It not only is another carefully conducted study of the impact of disease management but it’s a good exercise in what you should look for when you read studies like this. As an aside, it was Dr. Mattke who was responsible for this oft-quoted paper, so when he writes it, the DMCB reads it.

The authors used insurance claims data to assess the cost impact of unnamed vendor-owned case management, disease management, medical advice telephone line and wellness programs sponsored by two large unnamed employers. The DMCB thinks the employers were probably self-insured and that the program designs were of the usual type, including HRAs and predictive modeling. Two year baseline costs 'pre' were compared to costs one year 'post' baseline and the programs' own predictive modeling was used to statistically adjust for other factors that could have influenced the numbers.

So, now that you know about the outlines of ‘non-chronic trend’ and the ‘requalification’ method, you probably want to know about that too. The DMCB notes the non-chronic trend was not explicitly mentioned by Mattke et al; rather they used a ‘nonpurchased trend.’ It also appears that there was not a requalification but an ‘intention to treat’ approach that probably means all persons eligible in year 1 were included in the year 2 cost analysis.

Bottom line? The programs in aggregate were associated with a non-statistically significant $13.75 increase in the per member per month (PMPM) claims expense over what was expected, based on (the 'non-purchased') trend. Case management dropped costs by $1.35, disease management increased them by $8.63, the advice line increased them by $21.71 and wellness increased them by $20.14; only wellness was statistically significant and it went in the wrong direction. Ouch.

The DMCB thinks this is a first-rate study for the following reasons:

1. This probably started out as a standard inquiry into the performance of a disease management vendor for a purchaser. It was disciplined, methodologically rigorous and turned out to be not that far from being good enough for peer-review publication. It marries the real world and evaluation science. Bravo. The disease management industry has come a long way.

2. It offers up a template that could be used by purchasers to economically assess the impact of their wellness, nurse-advice lines, disease management and care management programs. Yes, we can debate the merits of the trend that was used and whether the lack of a requalification was important (and it probably is), but the DMCB thinks that can be swapped in or out depending on the preferences of the purchaser and its actuaries. Dr. Mattke and colleagues have given purchasers a public-domain benchmark on how these analyses could be conducted.

Think you don't have the time/resources to bother with publication? The DMCB says that if you perform an adequate evaluation, you should be 90% there. The other 10% is the cost of doing business.

3. Think we'll ever get to a standard methodology to assess disease management programs? Think again. As testimony to this, Mattke et al strengthened their paper by conducting other analyses that had their own merits (and didn't really change the overall conclusions).

4. The DMCB is reluctant to generalize the findings from this single study to the entire industry. Other purchasers are discovering savings, or they wouldn't be buying into these programs. The conclusion is not that disease management doesn't work, but more DMAA members need to publish their findings. And by the way, in addition to quibbling over the methodology, we don’t know enough about the employee population or their insurance benefit design or about the disease management programs.

5. It would appear that the package of interventions purchased by these unnamed employers did not give them their money’s worth. The DMCB says fire the disease management vendor and issue a new RFP – including the warning that another analysis based on the methodology above will be used to assess their performance next year.

Hopefully, that will be shared in a peer-reviewed setting.

bigger than the beatles

So Barack Obama is in my town as I write this. He has had a meeting with the Prime Minister, some lunch and then they took him for a beaver tail (deep-fried flat pastries) in the market.

Why am I embarrassed by this?

I can't help but think, though, that he would have enjoyed the beaver tail more if had gone skating first.

I hope he was advised to have the Killaloe Sunshine and not the Nutella.

Traffic in my neighbourhood is a mess right now, as I live on the way to the airport. I really pity anyone who had a commercial flight out of the city today.

The Latest Health Wonk Review is Up!

The Disease Management Care Blog can't get that Monty Python tune out of its head....'wonderful spam... wonderful spam!' and it's not just because more Americans will to be turning to it in the coming months. It's also because Henry Stern of InsureBlog has cooked up a delicious recipe of Health Wonk Review submissions for your simultaneous gustatory and intellectual pleasure. Learn about cheese balls, comparative effectiveness, mexican extravaganza, COBRA and much more here. You'll also get to use a new term on your colleagues and assocates: 'spendulus.'

Where's the Gas When You Need It?

The Disease Management Care Blog confesses that it wasn’t easy learning the differences between an EMR (electronic medical record), an EHR (electronic health record) and a PHR (personal health record). While medicine is certainly riddled with its own complexities and acronyms, health information technology (HIT) seems to have taken it to a whole new level.

There may be one less acronym, however, to worry about. If (and that is a big if) this post from the Health Care Renewal Blog has any basis, there may allegedly be little reason to distinguish HIMSS (a membership organization) from CCHIT (involved in certification of electronic records). Is the DMCB’s buddy Scott Silverman an HIT voice crying in the wilderness? Time will tell but the DMCB will be harkening.

The disease management community, in contrast, seems to have had its act together from the very beginning. The DMCB was there in the early days when several disease management companies earnestly set out to define what set them apart. That’s when they came up with this. Realizing that a distinct brand was emerging, they sought a process that would accredit reputable full-service disease management companies – similar to the track record of hospitals and managed care organizations. They correctly reasoned that the more distant they were from owning the accreditation process, the more credible it would become. Not to mention that their lawyers pointed out that anything less could result in the improper appearance of collusion. It was good business sense and it was also the right thing to do.

It paid off. The highly regarded National Committee for Quality Assurance (NCQA) and URAC have both developed independent programs that are distinctly free of any allegations or even the appearance of conflicts of interest.

++++++++++++++++++++++++++++++++++

And a now for a non-sequitur: It’s bad enough having to see a dentist, but having him remind you of the striking difference between medicine and dentistry makes the drilling seem comparatively blissful. Grinning through his mask and goggle-glasses, he asked his physician-patient today what he thought of the newly inked ‘stimulus bill.’ By this time the DCMB was immobilized thanks to having to simultaneously guess where half of its face was while French-kissing a latex dome with a mouthful of gruesome metal objects. Not caring to translate my gurgling, he went on, ‘Looks like the government wants to tell you guys how to practice.’ After a pause, he added, ‘And they’re going to get away with it.’

Where’s the gas when you need it?

asymmetry at the songbird branch

I have a post up at The Songbird Branch (a blog started by the brilliant Jacqueline) about my attempt to knit an asymmetrical sweater for my asymmetrical body.

Go check it out and the really beautiful items that have been found and made for the post-mastectomy body.

book review: "the widows of eastwick"*

I have a confession to make. Before The Widows of Eastwick, I had never read anything by John Updike (although, I did see the movie version of The Witches of Eastwick, which is sort of a prequel to this one. I'm not sure how faithful the movie was to the book. Given Hollywood's track record in this regard, I imagine the book and the movie were fairly different).

The Widows of Eastwick, picks up some 30 years after The Witches. As the title suggests, the three witches find themselves widowed, reconnect with each other and (after doing some travelling together) return to the earlier scene of their crimes. The mansion in which they partied as younger women has been turned into condos and they decide to rent one for the summer.

None of these women is very likeable, nor did I find it easy to relate to any of them (not sure if this was in part because I am so much younger - although I have read and enjoyed books with much older protagonists before). I did very much enjoy the writing, although I found that the dialogue was more an opportunity for the women to pronounce on the world, as opposed to really engaging with each other:

Jane looked aged in the harsh desert light, shrunken. Blue veins writhed on the backs of her hands. "There's this stink to the past," she said, "of magic that stopped working. It never really did work, of course. Just gave the priests more power than was good for them."

"If they believed it worked, maybe it did. It made them less anxious. As I remember us in Eastwick, we used to believe that there was an old religion, before men came in and took it over just as they took over midwifing and haute couture. It was a nature religion that never died - women carried it on even when they were tortured and killed."

The book is less about what is happening in the present and more about looking back to the past. The women are motivated by a desire to make amends for their crimes (causing the death, through witchcraft of a rival and of some other people who appear to have been thorns in their sides) and to relive their wild and powerful youth. The whole thing feels more like a padded short story than a full length novel. Some interesting things do happen but I found it hard to feel too interested.

As I was reading this book, I learned that Updike had died. I feel a bit guilty that I can't write a more positive review. I am very confident that this, the last of his novels, was not his best work by any stretch of the imagination. And perhaps I would be feeling less critical if I had read and enjoyed The Witches before reading this one.

Updike must have been grappling with cancer as he wrote this book and there is lots of talk of cancer throughout. The women killed their rival by giving her ovarian cancer and Alexa (one of the witches - the one played by Cher in the movie, I think) is obsessed with cancer.

I didn't hate this book. I just didn't really like it. I was expecting so much more.

Any Updike fans out there? How does this book compare to his other works? I would love to know.

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

The Big Stakeholders and Health Care Reform--No More Happy Talk?

For a number of months I have been beating the drum that there is nowhere near the consensus for health care reform we need to get the big one done and that the key stakeholders are no more ready to give up valuable real estate to make it happen than they have been in years past.I got a call from Maggie Mahar earlier today to discuss an article in yesterday's Chicago Tribune, written by Julie

The Medicare Coordinated Care Demonstration (MCCD) Didn't Work: Conclusion? That the Medical Home Will Work.

You may have seen some dispirited reports (here, here, and here) about the published summary from Mathematica (Deborah Peikes, Arnold Chen, Jennifer Schore, Randall Brown: Effects of care coordination on hospitalization, quality of care and health care expenditures among medical beneficiaries) appearing in JAMA (2009;301(6):603-618) on the federally funded Medicare Coordinated Care Demonstration (MCCD). This involved a total of 15 participating healthcare entities (5 disease management organizations, 3 community hospitals, 3 academic medical centeres, 1 integrated delivery system, 1 hospice, 1 long-term facility and 1 retirement community) serving fee-for-service (FFS) Medicare beneficiaries with one of several chronic conditions. Each of the 15 entities ran their own randomized clinical trial with varying inclusion criteria and risk factors. Patients were randomly assigned to usual care vs. being assigned a care coordinator who, depending on the program, used different types of behaviorally-based patient education programs that were ultimately aimed at increasing self care. Final fees ranged from $60 to $270 per member per month (PMPM).

The Medicare beneficiaries entered into these programs were sick and therefore expensive at baseline, averaging just over $1535 per member per month (PMPM). One program had to drop out because of low enrollment. Of the 14 that were remaining, only one program reduced hospitalizations in a statistically significant manner. Two programs had a significant change in costs, but in the wrong direction: both went up. Two programs had non-statistically significant reductions in cost; if outlier costs were deleted from the analysis, one of the two programs turned statistically significant. Bottom line: Medicare funded care coordination programs for FFS beneficiaries, based on this research, will not reduce healthcare costs.

Those are the facts. But the authors of the report then went on to offer up some subjective impressions, presumably based on their close working relationship with each of the MCCD entities. The Disease Management Care Blog forgives them for going on a speculative bender - but only up to a limit.

Those subjective impressions? The care coordination programs that came close to saving money were:

a) High Touch - care coordination personnel seemed to have more face-to-face time with the patients, even if that meant travelling out to the doctors' offices to meet them. Relying exclusively on the telephone seem to have less success.

b) Not Too Hot, Not Too Cold - patients who had a low burden of disease and patients that were extremely ill continued to use little or high amounts of care, respectively, no matter what intervention was used. Programs that aimed their interventions at the 'just right' patients seemed to do best.

c) Aimed At the Pills As Well As the Ills: helping patients understand why and how they need to take their medicines seemed to be helpful, and

d) All About the Fundamentals: Keying on 1) patients when they got out of the hospital and 2) assigning care coordinators by physician (and not by the patient) kept patients out of the hospital and kept physicians from having to deal with too many nurses.

So where did the authors cross the line? You guessed it: by force-fitting their subjective impressions into an editorializing closing paragraph about the supposed virtues of the Medical Home:

'...the medical home model may be able to replicate or exceed the success of the most effective MCCD programs.'

Really? This is lecturing based on what data? The DMCB believes the statistics showed that care coordination programs failed to achieve statistically significant reductions in healthcare costs. Statistical significance was only achieved in one program when high costs were censured out of the data, which is a luxury that the real world Medicare program does not have. Finally, while the authors' impressions of successful program characteristics made sense, they selectively focused on the one that fit their unfounded admiration for a yet unproven - if promising - care strategy. As an aside, an accompanying editorial by John Ayanian of Harvard didn't do much better.

Message for the disease management organizations? Based on this article, none of this should be any surprise to you. Many in policy circles may not know it yet, but you should keep doing in the market what you've already learned to do, thanks to an ever-growing knowledge base that relies on far more than a hidebound research paradigm: for the right patient, it continues to make sense to rely on nurses that are available for in-person coaching, to use your predictive modeling algorithms to identify patients that are ''high impact,' to pursue medication adherence and persistence,to do everything possible to find and help patients that are recently discharged and to build close relationships with the primary care physicians.

Oh... as for waiting for Medicare to catch up? The DMCB isn't too sure about that. We'll see.

A Kaiser Foundation Misstep on Employer-Based Coverage for Cancer Care

How unfair. But it works.

Want to attack any process with a track record that is pretty good, considering the circumstances and alternatives? Look for individual instances of shortcomings and vaguely generalize them, making it appear that things are far worse than they really are. Given the complexity of insurance benefit designs and cancer coverage, the topic is perfect for this type of gamesmanship. And this is exactly what the Kaiser Family Foundation and the American Cancer Society (ACS) did here. By lining up 20 cancer victims who got tangled up in insurance benefit designs, the unsuspecting reader would conclude that when it comes to cancer, commercial insurance companies are either hopelessly broken (‘individuals may not be protected from high out-of-pocket costs’) or evil (force patients to ‘incur debt in order to pay for care…. or forgo or delay lifesaving treatment’).

The Disease Management Care Blog is not saying that each breakdown isn’t heart breaking or an opportunity to learn from mistakes. While this makes for a good narrative, this is not how to make good policy about the interlocking roles of deductables, cost sharing, out of network tiering, annual limits, lifetime limits and minimal coverage designs in the evolution of healthcare reform.

The truth is that faced with unrestrained medical costs, the vast majority of employers are successfully coming up with creative and functional health insurance designs. Without such creativity, there is either no health insurance for their employees or no staying in business for their customers. While the insurance may thin out, the fact is that for every example described in this Kaiser Foundation report, there are many other unseen examples of individuals who were able to use perfectly adequate insurance to access cancer screening and treatment. That piece of good news went decidedly unmentioned.

Instead, Kaiser and the ACS used anecdotes in combinations of highly unusual and lethal diseases requiring highly unusual treatments under highly unusual insurance designs. Toss in overpriced screening tests, docs cancelling their insurance contracts and rare employer stupidity, and you have biased report tilted away from locally controlled State-regulated or HIPAA protected employer-based insurance. That’s not necessarily bad, says the DMCB, but us citizens can’t rely on biased reports like this one to make an informed decision about the alternatives of a) greater State or Federal regulation, b) developing a tax-payer supported Federal insurance plan with first dollar coverage, no deductables, no coinsurance and no lifetime limits or c) a single payer system.

A rare Kaiser Foundation misstep.

Well, the DMCB to the rescue. It suggests you read the report, but keep in mind the inconvenient truths that follow below. You’ll be closer to getting your head wrapped around the high cost of cancer and how to insure against it.

Pre-existing condition exclusions cause treatment postponement. Many patients with pre-existing conditions preferentially seek insurance after the fact. Forcing coverage under such circumstances would drive up the cost of the premium, forcing even more individuals to forgo insurance.

The individual market screws patients by refusing coverage to persons with a cancer diagnosis. If the individual market were forced to cover individuals with a past history of cancer, all persons buying insurance in the individual market would be forced into higher premiums to pool that added risk.

Out of network doctors lead to medical debt: Many doctors choose to be out of network because they refuse to accept the insurers’ fee schedules, putting patients in the middle.

Annual benefit limits lead to debt: Benefit limits of $2500 to $20,000 to $100,000 are the exception and not the rule. $1 million is common, but when it is exceeded, what is the right limit that Americans are willing to pay for?

Patients need to continue working while getting chemo: In the example provided, the patient’s employer worked with the patient to maintain her employee status. Most do.

Separate deductables lead to debt: Deductables are a standard approach to making insurance affordable. What’s more, in the example provided, the patient was contesting a PET scan’s medical necessity, not the deductable.

COBRA sucks: COBRA was conceived, written and passed by the U.S. government and insurers are following the regulations. To the letter. Which is why the Feds have stepped in with another fix. Whether we can count on government over the long run to continue its support is a question mark because of the next item.

High Risk Pools suck: As the DMCB reads it, it’s the government that is underfunding them, which should make one wonder about the government's ability to manage any of this over the long run.

The Perfect Academic Health Policy Maker Girlfriend

The Disease Management Care Blog sympathizes with its colleagues in the industry, who are constantly striving to engage hostile academic policy makers and skeptical administrative staffers in a constructive dialogue over the role of disease management in healthcare reform. It is such an uphill battle, isn't it? Being shot down, calls not being returned, being rejected.....

While the effort continues, however, the DMCB found, thanks to a tip from a progeny, the dream date for y'all. Her paraphrased comments are below the video window.......

"I like disease management programs who have a little bit shareholders... a little bit profits. I like programs who like to tell me they have good outcomes and charge a LOT of money. This is good thing. If I know there are no savings, I'm not like, oh poor taxpayers, there's no value. This is so silly. I know sometimes they go to, the ehhh... Congress, but that is okay.... I'm not jealous. They can do whateverrrr they want. I mean, I don't care."

Drug Industry Wins Comparative Research Fight in Stimulus Bill

If you are looking for something to do over the weekend I suggest reading the one thousand page final stimulus bill.You can access it here.This past Wednesday, I posted the following regarding the differing health care comparative effectiveness research provisions in the House and Senate versions of the stimulus bill:Comparative research--which drugs or medical devices work the best--makes a lot

Medicare and Applied Health Services Research. It's Time.

The Disease Management Care Blog found two suggestions from its buddy, Sandra Foote, to be interesting options as the U.S. continues to think about healthcare reform. While we know what works, there is a lot we don't know. The evidence-based medical literature only helps us with approximately 30% of clinical practice. While we continue to struggle with financing and shaping the other 70%, Sandy recommends that Medicare develop "a powerful continuous innovation strategy" that draws on the lessons of the private sector. The idea would be to develop "goals, leadership, organizational structures, incentives and processes" that would constantly test innovations. The DMCB thinks of this as "demos" but multiplied on a log scale and placed on steroids.

Paired with this idea is a mandate that's been given to MedPAC to "conduct a study of the feasibility.... of establishing a Medicare Chronic Care Practice Research Network." Sandy reports this would involve creating a standing network of providers that test new approaches to care.

The DMCB thinks of this as "tithing," i.e., giving a portion of your income for service to a greater good. All healthcare organizations, from individual physicians up to large integrated delivery systems have an obligation to assess the content of the care they are providing. The DMCB thinks that in order to do this right, it generally takes about 10% of the operating budget: that's how much time it devoted to data management and reporting in its former life as a medical director.

Think that sounds like a lot? The DMCB argues that one reason the Federal Government is creating a national center for effectiveness research is because mainstream healthcare - outside of academic medicine - has not stepped up to this plate. The good news is that other healthcare organizations, including disease management providers, are also beginning to embrace the value of "applied" health services research. They'd welcome Medicare to this party. Hopefully, Medicare would be prepared to commit sufficient resources to doing this right.

Heads up: the DMCB will have a print editorial on the topic appearing in the not too distant future.

rants and ramblings on a rainy day

Some things make me very, very angry.

Like every new detail coming out about the needless deaths of Robert Dziekanski and Brian Sinclair. Each man could have been saved so many times by so many different people.

Like the fact that the mayor of Ottawa and the leadership of OcTranspo were guilty of several big whoppers around the transit strike (especially about how much money the city was saving and how long it would take the buses to get back on the road).

Some things make me laugh.

Like making silicone breast prosthesis jokes with my sister last night (you really did have to be there).

And going to see a taping of The Debaters with my son and my spouse.

Some things make me smile.

Like getting an email from a woman I have never met who tells me that she loves my blog and seems to be living a parallel life to mine (right down to the kids five years apart and two dogs).

Like the sound of two dogs snoring as I type this.

Some things make me worry about my faculties.

Like the fact that I bought tickets for a show (the above-mentioned Debaters) and then made child care arrangements for the wrong night (thank goodness for my wonderful sister who changed her evening plans so she could still come and hang out with my youngest son).

Like the fact that I woke up one night in a cold sweat in the middle of the night a week ago and double-checked that I had bought the tickets, yet didn't notice that they were for the wrong night.

Some things are good.

Some things are bad.

Some things just are.

Still working, sometimes, on sorting out the difference.