Retail Clinics and Usual Primary Care: Both Respond to Rising Numbers of Unemployed the Same Way

If you, like the Disease Management Care Blog, take the time to read Managed Care Magazine, you already know a lot about Clayton Christensen's view that Retail Clinics are a disruptive innovation in healthcare. Maybe they are, but the DMCB was reminded today of just how similar that business is to 'usual' physician-based outpatient primary care.

Today there was a news release on how Walgreen's Take Care Clinics will be offering free acute care services to persons who can prove they are unemployed and show up between the hours of 11 AM and 3 PM. Remarkable you say? Give them a Gold Star for being socially conscious you say?

Not really. Before the news release described above, the DMCB recently broke bread with some community based primary care physicians and chatted about the bad economy and its impact on their practices. All three physicians described how many patients with 'good' insurance were a) losing their jobs, switching into COBRA and using their insurance to 'catch up' on all that previously foregone testing while it was still covered, b) going onto the Medicaid rolls or c) becoming uninsured. The DMCB asked if the docs were tempted to 'drop' the patients without good insurance from their practices. Their response was not surprising, when you think about it.

The answer was 'no.' All three physicians were seasoned businessmen who had been through previous economic downturns. They had seen this before. Today's patients with no or non-remunerative insurance were not only yesterday's richly insured but tomorrow's also. These providers know that when the economy eventually turns around, these patients are going to join the ranks of the employed/insured. By the way, continuing to care for these patients is the right thing to do, but from a business perspective, this is a loss-leader and an investment in the future. In contrast to Walgreens, there are no press releases.

Press releases aside, the same business logic applies to Walgreen's Take Care. Like the usual primary care providers the DMCB spoke to, Walgreen's is interested in serving today's uninsured, because tomorrow they'll be paying patients who will appreciate what Walgreen's has done for them. The positive word of mouth will help, there will be good press and lastly, while at Walgreens, these patients are likely to buy prescription and over-the-counter meds and while they're at it, print out some photos and pick up some diapers (and, by the way, hopefully NOT be tempted to buy any tobacco products). This is shrewd business sense in the field of primary care. It wasn't discovered by Walgreens.

The DMCB wonders if, with time, the stark differences between Retail Clinics (nurse practitioners using decision support with health information technology to treat common medical conditions) and usual primary care (which will use decision support with HIT to intelligently manage most medical conditions) will fade away. The response of both to the rising numbers of unemployed makes the DMCB wonder if there are more similarities than we've suspected.

"Disruptive?" Maybe not.

The D.C. Health Reform Brackets: Place Your Bets

For reasons unexplained, the non-sports fan Disease Management Care Blog is doing pretty well in two NCAA Basketball bracket pools. Since this random winning streak makes it fancy itself as some sort of hoops expert, it has developed the DCHR (D.C. Health Reform) Bracket for your betting pleasure.

The source of the DMCB's inspiration had less to do with Villanova's clutch shooting or Michigan State's defence than Congress' track record to date in simultaneously managing the banking, insurance and automotive industries. Watch out, healthcare.... you're next!

Pick the DMCB selections at your peril:

a bright light lost

Smart, funny, creative, talented Sara has passed away.

I only knew her as an online presence (although we did once spend more than an hour on the phone together) but I am grieving tonight and for all the people that love her.

I am told that Sara loved red wine and good tequila so if you partake of either of these tonight (and even if you don't) please raise a glass in her honour.

I am going to put on the lava earrings I bought from her (they are my favourites).

Damn. Cancer really sucks.

"Sick Around America" on FRONTLINE

You may remember the FRONTLINE report, "Sick Around the World." It was the best job I have ever seen anyone do summarizing five different national health care systems--the U.K., Taiwan, Germany, Japan, and Switzerland--in just one hour.I recommended it when it originally ran and I recommend it today. You can still see it here.Now FRONTLINE has aired producer Jon Palfreman's effort to explain

"EGMN: Notes from the Road"--A Refreshing and Interesting Look Inside the World of Docs

I just discovered a relatively new blog that might be of interest to you: "EGMN: Notes from the Road."It comes from the publishers of a number of the periodicals physicians read, including Internal Medicine News, Cardiology News, and Family Practice News. Their unique take on the world of health care and policy blogging is to post from medical meetings, press conferences, and policy gatherings

Some Insights, Courtesy of McKesson's Disease Management Programs

The Disease Management Care Blog had a chance to chat with McKesson’s Senior Vice President and General Manager Jim Hardy. The DMCB welcomed the opportunity to talk disease management (DM) with Jim, who oversees his company’s care programs, many of which are serving State Medicaid programs. Prior to joining McKesson, Jim served as Deputy Secretary for Medical Assistance Programs in Pennsylvania’s Department of Public Welfare. He knows of what he speaks.

The DMCB asked Jim about the outlook for traditional old fashioned nurse based, ‘telephonic’ disease management. He replied that while the industry is morphing, their programs will always include a ‘telephonic base.’ Since States typically have tens of thousands of beneficiaries that are eligible for care management, there is no escaping the industrial level efficiency supported by a ‘remote’ telephonic outreach. McKesson is working to make its telephonic care programs better while simultaneously pairing them up with additional community-based, provider-‘embedded nurses’ who in turn become part of the local health care teams (or, if teaming is absent, catalyze its creation). In fact, Jim suspects more and more RFPs are headed in that direction.

DMCB comment: it’s one thing for advocates of the Patient Centered Medical Home to talk teaming, it’s another thing to have a nurse parachute in and make it happen.

The DMCB next asked what explains the disconnect between skeptical public policy and the persistence of State DM programs? Are buyers smarter? Using different metrics? Jim thought that because the States have been doing this for a long time, their measurement methodologies have become more established and that there is often a high degree of mutual accountability. Jim felt Medicaid purchasers are smarter, savvier, more experienced and know how to navigate DM’s clinical and financial outcomes. What’s more, States also are very willing to share insights with each other via learning collaboratives, various formal meetings and other informal communication channels.

DMCB comment: It remains to be seen whether the architects of national health care reform will tap into this knowledge base.

The DMCB also asked about impact of ARRA and the Medicaid supplemental funding on States’ DM programs. Jim replied that since States are having significant budget crises, it’s unlikely that more money will be pumped into new chronic illness, wellness and prevention programs. Rather, the funding will be used to plug budget holes in existing programs. Any money left over may spur investment in programs aimed at controlling the trend in high cost subpopulations. An example may be waiver groups.

The DMCB thinks this is interesting. If the Administration’s economic forecasts turn out to be too rosy, future interest DM programs may be spurred by the pressing need to address uncontrolled costs rather than notions of quality or value.

Finally, the DMCB has about the role ‘risk-based' DM contracting. Jim pointed out that every deal currently has fees that are at risk for both financial and clinical outcomes. This is not going away, but it has stabilized with few contracts having upside gain sharing but most having a floor. In McKesson’s instance, there is enough at risk in most programs that ‘they have our attention.’

DMCB Comment: The DMCB can attest to the motivation and discipline that comes with risk contracting. It wonders when the same approach will be applied to pay-for-performance, the electronic health record and the patient centered medical home.

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

Are you and you company interested in talking to the DMCB? If the topic has to do with population-based care programs, the DMCB is always happy to chat. It and its readers will be better off for it.

The DMCB admits any interview will probably have to be done the old fashioned way. While the DMCB notes with some lust that other blogs are into 'pod casting,' the DMCB has yet to crack that technology barrier. The DMCB spouse suggests it use the blog's Google ad income to pay for any necessary computer upgrades. As that conversation continues, the DMCB will keep readers apprised.

"Take the $600 Billion in New Revenue from Obama's 'Cap and Trade' Climate Change Proposal and Use it To Pay for Health Care Reform"

Last week Senate Majority Leader Harry Reid was quoted as raising the possibility we could take the $600 billion in new revenue projected from a "cap-and-trade" plan to cut green house-gas emissions and use some or all of it to help pay the estimated $1.5 trillion cost for comprehensive health care reform.Energy and climate change issues aside that would be a bad idea--a really bad idea.The

What Are Others Saying About the Disease Management Care Blog?

See what others are saying in this weekly round up about the Disease Management Care Blog:

The Political Calculations Blog includes the DMCB's 'Self Reinforcing Negative Feedback' in its list of important posts as "essential reading." Essentially, many of the proposed health care reforms could lead to the collapse of primary care.

Wenchypoo's Mental Wastebasket also had nice things to say about that posting, noting that it was easily understandable to lay readers and points to an important concern in what could be a universal health care blunder.

"Will CIGNA Remake The Health Plan Marketplace?"--CIGNA Embraces Onsite Clinics

Will CIGNA Remake The Health Plan Marketplace?by BRIAN KLEPPERAmerica’s health plans are floundering. If their job has been to provide the nation’s mainstream families with access to affordable care (let’s leave quality out of it for the moment), they have failed miserably, though they were very profitable along the way, at least until Q1 2008. In 2008, the Milliman Medical Index – an estimate of

The Option of a Public Insurance Plan and the Specter of More Cost Shifting

Advocates for healthcare reform that includes the creation of a publically funded insurance plan are delighting in news that both AHIP (America’s Health Insurance Plans, the trade group that represents health insurers) and Blue Cross Blue Shield (a federation that represent 39 insurers that sport the Blues ‘brand’) have publically thrown in the towel over guaranteed issue in exchange for an individual mandate. Regular readers of the Disease Management Care Blog, however, know this is old news. This issue was examined by the DMCB back in November of 2008. What’s different this time around is that a) guaranteed issue and b) mandates are being mixed up with the c) option of a publicly funded insurer. Reactions seem to range from ‘this is precisely the kind of cudgel we need to bring these obstructionist insurers to the table’ to ‘aha, we have those evil corporate pirates on the run.’

To get to the bottom of this, the DMCB dared tread where few seem to want to go. It actually read the Aetna’s CEO Ron William’s March 24 statement to the US Senate Health, Education, Labor and Pensions Committee. Go ahead, call them obstructionist, evil, the Devil’s Spawn or [gasp, and this is the worst!] for profit, but when health insurers like Aetna speak, we should listen. Aetna, for example, insures 36.5 million persons with $42 billion in assets and a market cap that exceeds $10 billion. There’s no way Congress is going to marginalize these guys by simply passing a law sometime in the next six months.

What does Mr. Williams have to say? Health insurers figured out years ago that their business is no longer about just collecting premiums and paying doctors and hospitals. Their customers are demanding additional value, such as covering medical innovations and technologies, having inclusive provider networks, promoting transparency and offering chronic disease care, wellness and prevention programs. Examples include Aetna’s $1.8 billion investments in Active Health management and their Care Engine. And while the uninsured are a pressing problem, remember employers are successfully supporting health insurance for a whopping 177 million Americans, many of whom appear to be quite happy with the arrangement. The rising cost of their insurance is less a function of companies like Aetna and more a function of the underlying cost of health care. Employers and insurers have been working together on this for years and have had some notable successes in improving healthcare quality, dampening cost trends, increasing consumer choice, promoting transparency and covering wellness and prevention.

And here’s a telling quote.

“An enforceable individual coverage requirement, combined with subsidies and other changes to make coverage affordable, is the best way to ensure that all Americans have continuous access to insurance coverage and high-quality health care. Since 2005, we at Aetna have been speaking out in support of an individual coverage requirement, as we believe it is the critical step for achieving universal coverage.” (year bolded by the DMCB)

So what is the link to the public plan? If there is guaranteed issue and an individual mandate, Mr. Williams suggests a public plan option would be unnecessary. He may or may not have a point about that, but he then raises a critically important issue that has conveniently gone unmentioned by the anti-insurer cognoscenti.

A public plan would probably set provider payment rates akin to those used in Medicare and Medicaid. That’s because the government has the leverage to squeeze low pricing from providers. That in turn would force the providers to engage in even more cost shifting (estimated to already be as high as $88 billion nationwide) from the public insurance plans to the private insurance plans.

There you have it. The private insurers don't fear a public plan would be more honest, just, quality driven, administratively efficient, cost effective or consumer friendly. They think a public plan will simply build on its long history of what amounts to government supported 'heads I win' (non-negotiable fee schedules), 'tails you lose' (hospitals and doctors will make up for it in the private sector) predatory pricing. That's not keeping the private insurer's honest, that's crushing them.

The DMCB has a lot of admiration for care management programs, agile use of information technology, prevention, wellness, consumerism, novel insurance benefit designs, pay-for-performance, the medical home and the electronic record, but NONE of that will help private insurers - even with billions in the bank - compete against that kind of dynamic.

Or maybe that's the intention?

Anybody Know Where We Can Find a Quick Trillion Dollars?

"Irrational exuberance" over the chances for health care reform meet the budget realities.The House and Senate Budget committees have begun work on the federal budget.Last week’s CBO report estimated the Obama budget would:Produce a nearly $9.3 trillion deficit over the next decade.Generate annual budget deficits of nearly $1 trillion in each year from fiscal year 2010 to 2019.Increase budget

There's HIT Dogs and Cats, and Then There Are the HIT Skunks

In the latest New England Journal of Medicine, David Blumenthal, who has been named the new National Coordinator for Health Information Technology (HIT), has a “Perspective” piece on the roll-out of electronic records throughout the healthcare system. It has a brief useful summary of the provisions of ‘HITECH’ (the HIT parts of the recently passed stimulus package). Dr. Blumenthal then goes on to make three telling points about how little time there is, the work necessary to define ‘certified’ and ‘meaningful,’ and Congress’ real intentions.

The first is that the National Coordinator is facing a daunting time schedule. Considerable regulatory and program infrastructure needs to be put in place in the next two years and the clock is counting. The bureaucrats will need to move at relative D.C. light speed.

Secondly, while the stimulus law is aimed at promoting the ‘meaningful’ use of ‘certified’ electronic records, no one is quite sure what that means. Dr. Blumenthal points out that yielding to temptation and setting regulatory bar too high may cause physicians and hospitals to ‘rebel.’

But the most important point is that Congress is filled with what my colleague, Vince Kuraitis of the e-CareManagement blog, has ably described as HIT ‘dogs.’ Not meant to be pejorative, this is in contrast to the HIT ‘cats.’ The canines believe health care reform aimed at improvements that are facilitated by HIT will lead to greater use of HIT. The felines believe that’s backwards. They favor reform aimed at directly promoting HIT, believing that will lead to greater healthcare quality. While the written law is decidedly cat-like (thanks to direct physician subsidies for adoption via Medicare and Medicaid, reduced fee schedule payments for the laggards and the financing of regional health information exchanges as well as regional technology extension centers), the DMCB gets the doggone impression from Dr. Blumenthal that this is just the opening scene of a far more involved three-fold Federal agenda. Washington is not only rabidly on the trail of 1) bringing costs to heel, b) licking the number of uninsured but (and here’s the dog part) c) taking a bite out of low-quality care. HITECH is a first step in that direction. No wonder there’s been no paws in Congress’ intense efforts to assemble a health reform package.

But enough of cats, dogs and puns. The Disease Management Care Blog would like to introduce readers to a third HIT species: the skunks. Like Harvard’s Drs. Groopman and Hartzband who decry elegant exercises in wishful thinking about HIT in their Wall Street Journal editorial ‘Obama’s $80 Million Exaggeration.’ Like Columbia’s Dr. Armstrong-Coben, who struggles with a clunky interface that impairs doctor-patient relationships in her New York Times editorial ‘The Computer Will See You Now.’ Like orthopedic surgeon Dr. Haig, who points out in a Time Magazine article titled ‘Electronic Medical Records: Will They Really Cut Costs?’ that the answer is no, because they enable docs to document more billable stuff without any commensurate meaningful increase in quality. Like the University of Minnesota’s Drs. Parente and McCullough who point out in an article titled ‘Health Information Technology and Patient Safety: Evidence from Panel Data’ in Health Affairs that electronic records by themselves outside of large institutions will likely have a small impact on patient safety.

The DMCB apologizes in advance to these and other writers that object to being associated with something so… stinky. But think of Looney Tunes’ Pepe Le Pew and his relentlessly inconvenient pursuits of Penelope. While he often failed, he nonetheless succeeded once in a while. More importantly, Pepe will always be remembered for being true to himself and refusing to accept the wrong answer.

The likelihood that Dr. Blumenthal and Congress will find the right HIT answer? The DMCB thinks that remote. However, if they mess this up, there will be no escaping the smell.

author not pictured

Some time between when we pointed the car towards Florida and made our way back (we had a glorious time, by the way. Few photos this year but it's still this beautiful in Siesta Key), my book was published.

The dogs were less than impressed but the human members of my family are all very proud and I am so pleased to actually have a copy to hold in my hands. You can get yours from Women's Press or wait for details of the launches we are planning in Ottawa and Toronto.




And last night, S. won an Honourable Mention in the short story category (for 9-11 year olds) in the Awesome Authors contest, run by the Ottawa Public Library. His story, "The Man in the Photographs" was about how he never wants to seem as uncool as his father. "Pure fiction," he said at the awards ceremony.

Little Ado About Nothing—Part Deux

Last November, the insurance industry offered to do away with pre-existing conditions limitations. This week the health insurance trade associations have also offered to phase-out the practice of varying premiums based on health status in the individual market.From their letter to Congress this week:Specifically, by enacting an effective, enforceable requirement that all Americans assume

Cavalcade of Risk Number [what was it?] is Up!

Yes, the blog is called 'Wenchypoo's Mental Wastebasket' and yes, she has done a masterful and witty summary of posts about 'risk' (insurance, as in health or life). Check out how junket trinkets are drying up, her opinion of the DMCB, whether extended warranties are for you and the new proposed initials for that latest symbol of corporate knuckleheadedness, AIG.

The DMCB has decided it needs to check out this gem of a blog on a regular basis.

Follow-Up on Vermedx

The Disease Management Care Blog is happy to report that it received clarification about the Vermedx study mentioned in a prior post:

• Many of the patients reported in the American Journal of Managed Care article were not involved in the original randomized clinical trial (RCT) in New York and Vermont. It turns out that the physician hospital organization - Vermont Managed Care - indirectly learned of the RCT and installed Vermedx independently. Not all VMC patients had access to Vermedx, which was based on geography, not primary care assignment.

• Yes, it's possible that Vermedx did not, or only partially, accounted for the observed difference in claims expense - an effect described a 'treatment assignment bias.' The authors argue that is less likely because the claims trend prior to the Vermedx install was similar at baseline and then diverged once the intervention was launched.

• The low number of patients was based on the selection of persons with two years of continuous enrollment. Many of the PHO's patients were only newly enrolled and didn't have two years of claims data to draw on.

• Generalizability is being tackled by seeking funding for a repeat study in an environment different from Vermont: inner city with a greater proportion of non-white individuals.

• In the meantime, the larger RCT has been submitted for publication and is underoing review.

The DMCB thanks the folks in Vermont for the feedback and salutes them for their transparency as well as willingness to subject their system to the travails of peer review. The DMCB also thinks the Editors over at AJMC could have done a better job of getting more of the facts into the original manuscript prior to publication.

Based on this additional input, the DMCB would have to say its opinion of Vermedx kicked up a notch. It's possible that the difference in claims expense was due to factors associated with geography and this involved a newly enrolled PHO population. There is still a lot we don't know about the participants in the trial or about the PHO's practice setting. It's also a stretch to believe anything involving a relatively small patient population when it comes to trending. However, this is a good start and the DMCB is looking forward to reading more about Vermedx in the years to come.

Last but not least, the authors are to be commended to simultaneously a) initiating a care system and b) studying the impact with an appreciable amount of scientific rigor. This is what is necessary if we're going to understand how initiatives like this work in the real world and is an important lesson for the disease management/population care community.

Does This Diabetes Registry Reduce Health Care Costs?

Sometimes the Disease Management Care Blog thinks healthcare is one big ‘journal club,’ where we get huddle over interesting policy and scientific reports from the medical literature. It’s not sure if this Vermedx article would pass muster as particularly worthy of a lot attention, but given colleagues’ emails about the media attention this has received (here and here for example), the DMCB decided to take a closer look at this paper and the technology it represents.

Here’s the facts: Vermedx is an privately owned information system that receives lab results on a daily basis, stores the data in a registry and produces physician reports that include flow sheets and recommendations along with letters to patients. Overdue labs generate patient and physician reminders.

Vermedx was subjected to a ‘randomized clinical trial’ involving over 55 primary care practice sites caring for 7,000 patients across New York and Vermont. Primary care sites, not patients, were randomized to either use of Vermedx or to usual care. While the results were never published, it was observed that there was no impact on ‘glycemic control, cholesterol level, blood pressure and self-care behaviors’ for the patients in the Vermedx sites. Yet, patients’ self reports seemed to indicate that health care utilization had declined. If true, this would suggest Vermedx ‘saved money.’

That brings us to this paper, which was published in the American Journal of Managed Care. The authors sought to confirm that there were savings by looking at the claims experience of a subgroup of patients in “Vermont Managed Care,” a physician hospital organization (PHO) that apparently participated in the randomized trial described above. This PHO has just over 31,000 covered lives. 153 patients from the primary care sites that used Vermedx were compared to 870 persons with diabetes that were cared for by the PHO physicians without Vermedx. A comparison of ‘trend’ (the rate of increase in health care costs) after Vermedx was implemented favored the Vermedx primary care site patients: trend was observed to go down in the Vermedx patients so that at the end of one year, the per member per year difference in claims expense was just over $500 and at four years it was just over $3500. The study was financed ‘in part’ by an external grants (making the DMCB wonders if the rest was financed by Vermedx).

The DMCB thinks this is instructive because it helps us remember to ask certain fundamental questions when reading studies like this:

Was it the intervention (in this case Vermedx) or could something else have accounted for the observed improvement (in this case, claims expense)? Since these sites had to voluntarily agree to use the system ahead of time, the DMCB wonders if they may have already been inclined to take good care of their patients with diabetes. Readers may ask ‘who cares?’ so long as it worked, but the DMCB thinks it’s important to know if it was Vermedx or if it was Vermedx combined with especially motivated physicians.

Is the (870 person) comparison control population adequate? In this case, the patients that served as the comparator were drawn from clinics staffed by other physicians in the PHO. There is no description of the other physicians, many of who may not have been primary care physicians or had patients interested in a primary care-centered relationship. In other words, it may not have been the absence of Vermedx in this control group that drove up costs, but the kinds of patients and their physicians - which would be unaffected by Vermedx. Why didn’t the authors report claims from a group of patients from the PHO clinics that agreed to participate in the original randomized clinical trial but were not assigned Vermedx?

Are the results generalizable? In other words, readers need to know if the results are likely to be replicated in their clinical settings. Note that in this Vermont PHO, there are about 31,000 PHO enrollees, yet only about a thousand persons with diabetes were included in this study. Given the overall prevalence of diabetes, the DMCB thinks that may be low. The DMCB wonders how a ‘diabetic’ was defined in this study (in fact, the percent of Type 1 and Type 2 are not disclosed) and if this represents the definition of a person with diabetes in say, Omaha. This is especially true because the savings were based on a relatively small number of persons. The average health plan has tens of thousands of persons with diabetes. In addition, there is no information in this report about the source of the savings: inpatient vs. emergency room vs. other types of healthcare utilization were not reported.

The authors deserve credit for being open to the possibility of unmeasured differences between the two groups. This was brought up in their discussion of the results.

Conclusion? There isn’t enough here for the DMCB to believe the press reports. If these results can be repeated and more transparently replicated as well as more completely described in other settings, there may be merit to this information system. As noted before, the DMCB believes the solution to chronic illness care management ultimately resides in an interlocking system that includes electronic records, the medical home, disease management, smarter physician reimbursement, better insurance benefit designs, consumerism and registries. Vermedx and the approach it represents may - or may not - be a step in that direction.

Note: The DMCB emailed 'infoATvermedx' as well the principal author of the published study asking for more information about the possible limitations described above. After one day, there was no reply.

What If Disease Management Nurses Ran Chronic Illness

Nurse: OK patients, let's pay attention.

Becker, know your blood pressure? (Yes)

Callahan..... Callahan!..... {silence} [Babeep!] Engagement confirmation on Callahan

Disease Management Clerk: Dropped an HIPAA compliant letter 12 days ago

Nurse: [Babeep!] Phone number....

Enrollment Clerk: No sir, no change for Callahan

Nurse: [Babeep!] Primary care site.....

Primary Care Site: No Callahan, but I did find a a person with diabetes.

Nurse: No emails from Callahan......

Nurse: [Babeep!] Folks we need a 20 on Callahan!

[screeching tires] Got him!

Nurse: [Bapeep!] Reroute him straight to primary care, telephone him twice a week to make sure he's taking his medicine and get him a blood pressure cuff with remote monitoring

Reform Medicare. Appoint Guardians. Next?

The Disease Management Care Blog likes to check out what’s new over at the Health Affairs blog. It’s a good example of the emerging spread of traditional ink-based medical media into the blogsphere. While print publications still beat web posts in terms of prestige, the DMCB isn’t too sure that counts for much when timeliness is at stake. Apparently Bob Berenson and Len Nichols agree. With health care reform proceeding apace, they have a big incentive to let Health Affairs post a quickie cliff notes summary of their 199 page New America Foundation “Making Medicare Sustainable” report.

Knowing how busy readers are, the DMCB has created this even shorter cliff notes summary of the Health Affairs cliff notes. The DMCB also found and includes some other nuggets of interest:

• It’s the costs of health care, not the lack of insurance coverage.
  
  
• Change Medicare and everything else follows. Medicare leads the way.
  
  
• Elimination of waste and inefficiency should take precedence over tax increases.
  
  
• The path is clear: a) value-based purchasing in lieu of fee for service, b) physician accountability in lieu of routine payment, c) Congressional oversight and evidence-based coverage in lieu of micromanagement and wide physician leeway and finally d) driving a coherent policy in lieu of dealing with multiple agendas.
  
  
• Value based purchasing is the use of multiple tools that lead to the right kind and mix of services, of desired quality, at a reasonable cost based on the total population’s needs instead of individual interventions aimed at individual diseases. Nugget: there is precious little in the original Medicare statute that prohibits value based purchasing. Rather, regulations that promote it have never been successfully promulgated.
  
  
• In order for Medicare to take advantage of value based purchasing, it will need to be reformed.
  
  
• One ingredient for reform: creation of a new “entity” that is insulated from day to day lobbying. It can free Medicare to strategically and tactically pursue value based purchasing with integrity and the public’s confidence.
  
  
• Persons in the new entity are “Guardians” and they decide which coverage and pricing can be made by CMS and which can be made by Congress. Guardians are subject to Senate confirmation and have term limits. Nugget: Guardians” are selfless stewards of government modeled after Plato’s Republic.
  
  
• And finally the original report points out that value based purchasing can include traditional disease management.

The Latest Health Wonk Review is Up!

...and it's from David Harlow over at HealthBlawg, the Health Care Law Blog. Click, jump, hop and 'spring' on over and delight in the best of the latest health care policy blogs!

Want Your Healthcare To Be Like the Post Office? So Does the DMCB and Here's Why

Nicholas Kristof of the New York Times implores us to rethink our reliance on 'The Daily Me' by regularly sampling media that is contrary to our beliefs. The Disease Management Care Blog endorses that point of view entirely, which is why it pauses regularly on HBO's swarmy smirking Bill Maher whenever it can. The DMCB thinks he uses Mad Money's Jim Cramer's playbook: try to be taken seriously but if called out, refer to yourself in the end as an 'entertainer.'

Check out the video below and decide if this is serious policy or merely entertainment.:



The DMCB appreciates the point, but isn't sure a 42 cent stamp is a good comparison. It may be possible to get the note cross country in an even shorter period of time, but we can't assess that because of the United States Postal Service's (USPS') monopoly on standard postage items.

But how about larger packages that, like patients, vary in size, weight and delivery needs ? Unlike Mr. Mahar, the DMCB has had personal experience in standing in line at the local post office with a large package versus going a little further down the road and using Federal Express on one side versus using United Parcel Service on the other. It thinks there's a big difference. The DMCB isn't alone either: according to Consumer Reports, the post office isn't the no brainer choice that Mr. Mahar makes it out to be.

The DMCB also suspects the USPS' willingness to take credit cards, provide shipping boxes on site and accomodate other special requests is thanks to the competition from the likes of FedEx. That's why there may be merit in the idea of a 'Medicare like' public insurer as a part of health reform - but not for the widely accepted rationale.

To paraphrase the Wall Street Journal editorialists, the Healthcare 'Political Class' would tell you Medicare For All is needed to provide competition to the private insurers. The DMCB thinks they have it backwards. If a public plan passes as part of heatlh reform, it is the private insurers that will, like FedEx and UPS, force the public option to be a better health plan.

Hat tip: The Health Care Blog

The Newest Health Care Reform Arithmetic--Unbelievable!

"A coalition representing 30 health care organizations on Monday asked lawmakers in the House and Senate to suspend pay-as-you-go rules when drafting and passing health care overhaul legislation, saying much of the savings introduced by such a plan would be realized beyond the rules' 10-year budget window."That paragraph from last week's Kaiser Daily Health Policy Report caught my eye.I don't

An Idea for Health Care Reform: Target It at Making America Number 1

When an expert contacts the Disease Management Care Blog, it pays attention. That's especially if that person is Robert Stone, co-founder of Healthways and a past President of the DMAA. Bob is no stranger to the ways of Washington DC and has more than his fair share of health policy mojo. Bob pointed out that he had shared his perspectives on health reform during Day 2 of the recent Disease Management Colloquium titled Changing Times, Changing Solutions. He made a transcript of his comments available to the DMCB and they make for interesting reading.

As the DMCB interprets it, Bob warns that we are headed down the same path of wrongly talking about the wrong things when it comes to health care reform. Various fixes, while creating meaningful and measurable micro improvements, have not been sufficiently robust to create the macro changes at which they were aimed. While everyone agrees – again – that reform is urgently needed, vague nostrums like “equitable,” “accessible,” “affordable,” “quality” and “transparent” abound. Each stakeholder imbues those words differently from every other stakeholder while working hard to keep their share of the health care economic pie. The result has been a sorry record of tinkering around the edges based solely on a combination of self-preservation, the prevailing political winds and whatever ideology in vogue at the time. Given the lack of any coherence, opponents to some or any elements of reform can derail the entire process.

So what should we do? While Newt Gingrich loves to quote Eisenhower, Bob does also, but he uses a better one: "We succeed only as we identify in life, or in war, or in anything else, a single, overriding objective, and make all other considerations bend to that one objective." Like any seasoned healthcare executive, he knows that if you don't measure it, it doesn't happen. He also knows that most successful businesses have to choose a limited set of measures and manage to them. Using that compelling logic, he proposes that at some agreed to point in the future, with milestones along the way, that the objective be to make America rank #1 in the world in an overarching, comprehensive and easily understood measure of health status. If adopted, three things would likely result: 1) we’d meaningfully divert resources toward keeping healthy people healthy, 2) we’d see funding dedicated to helping people mitigate or eliminate the health risks associated with unhealthy lifestyle behavior choices and 3) the provision of evidence-based care to those who are ill would increase.

The DMCB finds the concept intriguing. It's outcomes based. Once we know what we are 'managing to,' what should and what should not be included in healthcare reform would become clearer. Overall health status measures are well within reach (examples are here - despite problems with how the WHO measures are collected and how they're interpreted - and here) and can be assembled either as a single score or in a 'dashboard.' Once established, Congress would be paying attention to conditions like this instead of worrying about nonsense like this.

Which brings the DMCB back to Newt. The other Eisenhower quote is "If a problem cannot be solved, enlarge it." Forcing healthcare reform to land on an overarching measure and manage to it certainly makes it visible, focuses it like a burning platform, would seem to promote bipartisanship and will make our elected representatives far more accountable than they are now.

Want a copy of Bob Stone's address? You can email him here.

Physician Payment Reform--Time for Hard Choices

I recently authored a guest editorial in the February 15th edition of Family Practice News--"The Leading Independent Newspaper for Family Physicians."Many years ago, the Congress established the Sustainable Growth Rate Formula (SGR) to control physician spending in Medicare. The concept is simple, if Medicare physician costs grow at a pace beyond affordability, next year's payments get cut to

The Population Health Impact Institute Wants You

In a prior post examining the not so good, the very bad and the downright ugly of disease management company white papers, the Disease Management Care Blog mentioned the Population Health Impact Institute (PHI Institute or just PHII for short). DMCB colleague Tom Wilson tried to post a response but was stymied by Google blog's log-in process, so he emailed directly. The DMCB thought the thoughts were so good that they warranted a separate posting.

PHII is a non-profit, 501c3 organization made up of individuals who believe that transparency of methods in disease management and other population-based approaches to care will lead to a) better methods of attribution, b) better programs, and c) better overall health care in the country. For more than a year, dozens of volunteers at the PHII have discussed and debated, debated and discussed, and finally emerged with a set of "methods evaluation process" standards that are practical, easy to use and 'evidence-based.' They can be applied to virtually ANY of the varied methodologies used to assess population health programs today.

This is a new era of 'take a second look' before buying anything. As a result, we believe that programs that are willing to open up their black box of methods - in a structured way - will have competitive advantage in this new marketplace. This does not mean that proprietary processes used in interventions necessarily need to be revealed. Under the PHII process, these business assets can remain top secret. A disease management organization's revelation of attribution methods in our structured, peer-reviewed way can be accomplished in a private reconciliation between buyers and sellers, in a public white paper, or a peer-reviewed journal. In fact, we've found that even peer-reviewed papers can be flawed – especially in the methodology sections where eyes gloss over for many readers -- and that this structured process should be beneficial there as well. In sum, the PHII approach can help buyers closely examine the claims in these manuscripts and separate fact from speculation.

Check out our web site to learn more. You are also invited to attend one of our educational workshops at meetings held in conjunction with two other non-profit organizations: Institute for Health and Productivity Management (April) and Case Management Society of America (June).

If you find any of this really interesting, we are always open to new volunteers. Feel free to email us.

The Intensifying Collapse of the Health Care System, Why It's Different This Time, and What We Need to Think About Along the Way

The Intensifying Collapse of the Health Care System, Why It's Different This Time, and What We Need to Think About Along the Wayby Brian Klepper and David C. KibbeMore than at any time in recent memory, powerful forces are buffeting the health care sector. We are in the midst of profound upheaval, driven by market and policy responses to the industry's long-term excesses. We can already see

Self-Reinforcing Negative Feedback Loops: A Simplistic Threat to Primary Care

Want to read an understandable explanation of the current economic crisis, but afraid you’ll be blown away by obscure economic phraseology and opaque financial concepts? The Disease Management Care Blog recommends the highly readable and crisply written The Return of Depression Economics by Nobel Laureate and blogger Paul Krugman. Like that highly intelligent college professor who has a knack for explaining things at your level with the occasional dash of sparkle and cynicism, Dr. Krugman brings money supply, central bank interest rates and capital control concepts within the intellectual reach of us non-economist amateurs. He makes it refreshingly simple.

Thanks to Dr. Krugman, the DMCB learned that one of the more damning features of the crisis was the phenomenon of accelerating and self-reinforcing negative feedback loops. Thanks to a peculiar mix of human psychology and highly interconnected leveraging, things logarithmically went from slightly bad to horribly awful in a short period of time.

So what does this have to do with healthcare? The Disease Management Care Blog believes the same accelerating negative feedback loop could occur if the future version of ObamaCare mistreats the primary care physicians.

Let’s assume there are ten primary care doctors in a mid-American county, each of whom has a panel of around 2000 patients. Some patients leave, some patients die, so let’s optimistically assume at any time there is room for 100 new patients in each doc’s practice. Along comes ObamaCare, a government sponsored insurance plan for persons unable to afford private insurance. 1000 county residents that were uninsured now have insurance and seek out a medical doctor. The 1000 persons are distributed among the 10 doctors, resulting in 100 new patients per doctor. All is well, right?

But suppose ObamaCare is perceived by the physicians as having onerous terms: an unattractive fee schedule, an unwelcome return to capitation or high administrative burdens that prompt one physician to close the practice to any new patients. As a result, the newly insured 1000 persons are distributed among 9 remaining physicians. That’s 111 or 11% over the threshold of 100 more patients per doc. That’s tolerable, maybe. But another wavering physician may may see the threat of even more patients seeking access to the practice as a reason to also close it to new patients. Now two physicians have dropped out, resulting in 1000 new persons among 8 physicians. For each doc, that means 125 new persons or 25% more. That may be close to intolerable. That may cause a third physician to bail out. The remainder are left with 142 or 42% over the threshold of 100. If four drop out, that’s a 66% increase. Every time one more physician heads for the exits, the remainder are left with disproportionately more patients to deal with. Faced with a healthcare access version of a run on the bank, all ten will quickly slam their doors.

The point is that a linear decrease in the number of available physicians who accept ObamaCare mathematically results in a non linear greater number of patients pursuing the remaining new slots among the remaining primary care physicians. That’s the accelerating negative feedback loop akin to the one that brought the credit markets to their knees. As the remaining physicians see their practices overwhelmed by higher number of patients with unwelcome insurance terms, more physicians will quickly drop out because they won’t want to be the last practice facing 1000 new patients. That’s the same psychology that also battered the markets. Without any economic incentive to accommodate the new patients, the negative feedback loop will rapidly cause the local primary care access market to collapse.

The DMCB recognizes this is a very simplistic unidimensional portrayal of a very complex system that varies considerably across the U.S.. What's more, it thinks most physicians will continue to struggle to do the right thing and see patients.

That being said, simple isn't necessarily wrong.

The Worrisome Outpatient Trend: What Does Disease Management Have to Offer?

In its last post, the Disease Management Care Blog criticized the wretched state of individual disease management company sponsored ‘white papers.’ Contrast their pale efforts with this study from the McKinsey Global Institute titled “Accounting for the cost of the US health care: a new look at how Americans spend more that would be expected by high levels of wealth.’ It’s an update to a 2007 report that found that $650 billion of the $1.7 trillion spent by the U.S. cannot be explained on the basis of wealth alone. This kind of white paper the DMCB likes. So, apparently, does the White House. And so should DMCB readers, so we can be better informed about where the opportunities lay when it comes to healthcare reform.

Before the DMCB checks out some of the report’s more interesting conclusions, it’d like to point out that McKinsey is arguably so big and famous that it doesn’t have to bother with the peer review process, this particular paper is better thought of as a short book than a manuscript, it was run past a panel of reviewers (‘academics, think tanks and industry stakeholders’), it’s remarkably transparent and has little in the way of any ‘hard sell’. Oh, and by the way, it’s immensely informative. In these respects, it resembles the wide ranging and important white papers released by the DMAA. Like McKinsey, they also transparently draw on the resources and expertise of multiple experts in the industry and keep the marketing to a minimum.

So what does McKinsey say in this particular tome? While there’s a lot here about U.S. administrative costs (surprisingly, growth is mostly in the public, not the commercial domain) and pharmacy (yes, everything you’ve heard is true, we pay a lot more than the French), it was the insights about outpatient costs that caught the DMCB’s eye. That’s right. Inpatient costs are not the villain.

First off, McKinsey compared the United States to other countries in the Organization for Economic Co-operation and Development (OECD for short, consisting of Austria, Canada, the Czech Republic, Denmark, Finland, France, Germany, Iceland, Poland, Portugal, South Korea, Spain and Switzerland). As gross domestic product increases across these countries, the relative per capita spend on health care also goes up in a more-or-less linear fashion. Think of it as a wealth effect: the richer you are, the more you can afford to spend on healthcare. McKinsey extrapolated these numbers to the U.S. and found that we spend $650 billion more than expected over the calculated OECD baseline.

Think this excess is thanks to persons with chronic illness ending up in the hospital over and over again? Think again. It was outpatient care and same day hospital/other center visits that seemed to account for two thirds of this relative excess with a scary year-to-year trend of 7.5%. While it was outpatient physician visits that accounted for the bulk of the cost, it was the high margin (a whopping 25% is not unheard of) outpatient procedures that had the highest trend at 9.3%. This is thanks to a double whammy of more procedures being done plus a higher cost per procedure. This toxic brew is driven by new and more expensive technology (there are no innovations that are decrease costs, each new one is more expensive) combined with the independence of physicians, patient demand rising to meet to capacity and relative consumer price insensitivity (thanks to still widespread employer-based insurance).

Think the shift to outpatient care is an attractive policy alternative to pricey inpatient care? Nope. Since the majority of inpatient reimbursement is based on fixed payments, hospitals are being forced to be more efficient. In contrast, fee-for-service payments in outpatient settings reward doing more with more revenue, which adds fuel to the fire. The DMCB sort of knew that, but it McKinsey pointed out that outpatient care volume is also being driven by increased availability to more people: no longer does that annoying but tolerable hernia or trick knee require a long trip to the hospital with an overnight stay; you can have it done at the new Surgi-Center down the road and be home in time to watch Dancing With the Stars. In fact, inpatient costs, after controlling for GDP, are only slightly above OECD predicted baseline.

Interesting, hm? Hospitals are not the problem when it comes to rising healthcare costs. Since the data suggests fixed payments 'work' for hospital costs, no wonder the Obama Administration is putting such an emphasis on using the same approach for post-hospitalization care.

Implications for disease management? While reducing avoidable hospitalizations has been the mantra, perhaps it needs to think more about how it can offer access to better-value and lower cost outpatient care services. In addition, the industry has much to offer patients when it comes to informed decision making about the risks, benefits and alternatives to invasive therapies. Is it time for the industry to focus its efforts on managing the outpatient trend and being one of many answers to the insatiable appetite for technology?? Given the insights from this McKinsey report, the DMCB thinks the answer may be yes.

photojourney

Ottawa, Ontario. March 12th. 10:30 am.


Scranton, PA. March 12, 4:15pm. S. is a huge fan of The Office. We made a detour for this photo.


Harrisburg, PA. March 12th, 6:30pm. T. checks GPS while the boys ham it up.


Port Wentworth, Georgia. March 13th, 10:45pm. He feel asleep with his arm around my neck.

Is A Moratorium on Disease Management Company White Papers Warranted? If Not, Here Are 7 Guideline Rules

What’s up with disease management organizations and their ‘white papers?’ Typically paired with some inflated press release or a laudatory web site, these downloads (also labeled as ‘research,’) are typically engineered to convince the reader a novel and important advance is at hand. Capitalizing on the company’s supposed scientific ‘player’ status, we’re expected to believe that a ‘patented approach,’ or a ‘validated methodology’ or a ‘proprietary system’ backed by ‘industry leaders’ increases quality, saves money, attains physician buy-in and restores karma across the healthcare landscape. Alas, while there may be some exceptions, most of the time, those assertions are not supported by the data..

With the increasing visibility of the Disease Management Care Blog, it is fast becoming the target of company sponsored white papers, analyses, reviews and postings. It has generally avoided commenting on them because it has found many of the papers have astonishingly shallow research designs, truncated bibliographies and self-serving conclusions. Recall how disease management organizations published all that junk years ago? While the reviewers and editors finally caught up with them, like whack-a-moles, this pseudoscience still has a lingering safe zone on the web-pages of and spam-like email attachments from even some of the more reputable disease management companies.

Ah, you say, this is just the plain ol’ marketing, what’s the big deal and everyone does it? The big deal is that the disease management industry has a unique reputation for lousy analyses that have repeatedly violated multiple fundamental statistical and analytic rules. The audience of clinical leaders, policy makers, politicians’ aides, physicians and insurance executives has been sensitized to this and are likely to see these white papers for what they are: the same old garbage. As a result, these glossy faux articles paradoxically cause the industry to lose credibility. And since it’s not hard to find the old white papers out there, the arrival of even more makes the DMCB think there must be a manuscript zombies about, spreading their pestilence thanks to naïve marketing departments, poorly trained scientific writers and high level executives who are impatient with science and the pace of peer review.

The DMCB thinks the blow-back toxicity of the white papers run amok is enough to warrant a moratorium. The DMCB is humbly resigned, however, to the likelihood that the industry will not follow its recommendations. So, it offers up the DMCB Seven - If You Must - Rules to White Paper Management:

1. Think: is the scientific news that your company wants to share really so critically important that you can’t accommodate the peer review process? If it’s that important, many Journals will 'fast track' your findings. If it’s not that important, then it’s probably marketing, not a white paper. Treat it as such and don’t insult the intelligence of your customers by pretending otherwise.

2. There are some outstanding Journals that have an outstanding turn-around time with volunteer expert peer reviewers that can help sharpen the conclusions, spot inappropriate assertions and help you with a high acceptance rate. Your company won’t have to wait long to see its findings in print with all the advantages of a white paper with fewer gaffes.

3. If you must issue a white paper, strive to make it good enough to pass peer review anyway. In fact, it’s possible to submit it to a journal, skip the publication (though that’s very rude if they offer to take it) and use the reviewers’ comments to make the manuscript better.

4. The DMCB calls your bluff if you go with a white paper. Try using your readership as peer reviewers by open sourcing your (HIPAA compliant) data so that others can confirm your findings.

5. While you may believe your company is aided by claims of proprietary expertise, transparency is a stronger suit long term.

6. Minimize the involvement of sales and marketing until after the scientific writing is completed.

7. Think about getting involved with the PHI Institute. These guys have a process that helps companies assure that their in-house analyses follow the basic rules when it comes to correctly attributing causality between your program on one end that the observed outcomes at the other end.

We Don't Have Ten Years

The Disease Management Care Blog confesses that it never learned much in its past gym classes. One thing it did learn was that there was a 'window' of opportunity while running those repugnant laps. As it fell further and further behind, those out ahead eventually extended their lead to the point where it appeared they were trying to catch up with the DMCB. The gym teacher was only rarely foooled but the DMCB liked being momentarily out front.

Alas, that rent in the time-space continuum of Mr. Hottenstein's Universe of Ropes That Could Not Be Climbed, Dodge Balls That Could Not Be Avoided and Laps That Lasted Forever was always short lived. To quote Calvin of Calvin and Hobbes, at the time the young DMCB felt as if 'I was put on this earth to accomplish a certain number of things. Right now I'm so far behind I will never die.'

Neither will the U.S. Congress if it goes along with this wacky idea. According to the Kaiser Daily Health Policy Report of March 10, a coalition of health care organizations wants the legislative pay-go rules to be discarded because reform offsets and savings can extend over ten years or more. Apparently, some on Congress favor the notion and, oh, by the way, pay-go is often ignored anyway.

Well guess what. According to this short, credible, non-partisan and very telling 4 minute video by former HHS Secretary Leavitt, we don't have ten years. In fact, the day of reckoning may fall within the second term of the current administration. Even the body language is depressing.

As the DMCB has pointed out before, it's the costs stupid. Unrestrained spending without tackling the underlying cost inflation will simply make things look like we're ahead on laps, while insolvency is ready to overtake us.

Watch out Ms. Sebelius. The current crisis cautions how easy it is to go from hero to zero.

Hat tip to the National Journal Health Care Expert Blog

The Latest Cavalcade of Risk Is Up!

Warning, warning! Use of ladders can inadvently release excessive gravitational force, causing traumatic injury. Dancing can lead to uneven deceleration, causing some parts of your body to stop before other body parts. Tequila can result a syndrome of torrid midnight madness. The Disease Management Care Blog leaves it to readers to assess the exponentially greater risk of combining any two or all three.

But be not afraid. You can positively harness risk over at Jason Shafrin's warning-laden Healthcare Economist's Cavalcade of Risk. Without the gravity, momentum or fermented Agave plant product, the assembly of some great links will make you more intelligent, help you gain a better understanding of insurance, be wiser about all the bad economic news, appreciate workers comp gaming and 'advance the science of economics.' Just a mouse, a click and some enjoyable reading.

what if?

"We have all the tools to eliminate mortality from Her2 positive breast cancers in the next 10 years."

-Dr. Eric Winer, Director, Breast Oncology Centre, Dana-Farber Cancer Institute (February 28, 2009, 9th Annual Conference For Young Women Affected By Breast Cancer).

Her2 is a protein. And it fuels cancer cells. Her2+ breast cancers are always very aggressive and, had I been diagnosed before Herceptin was widely available, I am sure that I would not be alive today. Now, a whole host of new drugs are being developed to attack this breast cancer that affects primarily younger women.

Dr. Winer's words are among the most hopeful that I have heard in a long time.

And then today, I heard a story on the CBC about a man who is being forced to choose between taking an oral chemotherapy drug for his brain cancer or feeding his kids. It's heart-breaking.

And, I can't help but wonder, what if, when the Herceptin stops working, neither my government or my insurance company will pay for the next course of treatment? What happens then?

Dr. Winer also noted that 30-40% of all women with breast cancer metastases will eventually have the cancer spread to the brain. He told us that Herceptin doesn't pass through the brain and suggested that all women with metastatic her2 positive breast cancers have brain scans done every 6 to 12 months. Guess what I am going to be talking to my oncologist about during my next appointment? (Although, vinorelbine, the chemo drug I'm taking is sometimes used to treat brain mets. That's reassuring).

I hope this is making at least a little bit of sense. I have a raging head cold and am feeling pretty muddled. My spouse was laughing at me this evening, reminding me that I am always very stoic about the big things (like, say, having a liver the size of a watermelon) but a garden variety head cold turns me into a whimpering puddle of goo.

I guess I am reminded that, generally speaking, I am very healthy these days. And that, in itself, is very hopeful.

This brings me to my second favourite quote from the conference:

"The best predictor of doing well is doing well."

-Dr. Winer.

Cross-posted to Mothers With Cancer.

Kaiser's Electronic Messaging System and the Implications for Disease Management (and KP's own disease management programs)

The Disease Management Care Blog has been slowly navigating through the latest issue of Health Affairs and wanted to draw readers' attention to the lead article that examines Kaiser's electronic health record (EHR). It's by Catherine Chen, Terhilda Garrido, Don Chock, Grant Okawa and Louise Lian and optimistically titled 'The Kaiser Permanente electronic health record: transforming and streamlining modalities of care.' It describes how office visits dropped at Kaiser Hawaii by 26.2% between 2004 and 2007, coincident with the implementation of an EHR-based messaging system. As office visits declined, telephonic and email visits went up, HEDIS measures didn't appear to decline and an in-house patient satisfaction survey held steady. The total number of encounters, i.e., visits, phone and messaging increased by 8%.

Is the DMCB impressed? It isn't sure. First off, this isn't the first time that Kaiser has claimed that its technology has reduced patient visit numbers. What would be impressive is if the shift from face-to-face visits was accompanied by a decreased in the number of health care providers and/or fixed costs. What probably happened was that the same numbers of doctors and nurses were spending more time on the phone and less time in clinic rooms. So what?

Secondly, this may be a classic demonstration of regression to the mean. In other words, it could be that remote messaging the EHR was implemented during a time of comparatively high clinic utilization prior to 2004 with a predestined decline in the years that followed. Alternatively, there may have been other reasons for the decrease in visits, some of which the authors recognize (including an increase in co-payments and changes in clinic work flows) and some of which may be going unsaid (like some organizational turmoil). But maybe not, since the DMCB found these data which indicated another group of clinics in Hawaii had an parallel increase in patient visits in the 2004-5 time period. Curious that Health Affairs would pick this flawed article has the lead off in an important issue.

That being said however, the total number of encounters increased. If this occurred absent any change in clinic personnel then it would imply that practice efficiency increased.

The implications for disease management (DM)? The DMCB still thinks that when it comes to inbound and outbound electronic and telephonic messaging, the DM organizations are just as and maybe more efficiently able to contribute to a decrease office visits with even lower overhead compared to healthcare settings. The trick is to find the right combination of remote and local clinic nurse support, all designed to keep physicians 'hassles' (i.e., using an expensive resource to manage picayune issues) to a minimum.

What makes the DMCB think that? Well, even Kaiser Permanente would seem to agree that 24/7 nurse availability is a good idea and is making it separately available without having to buy their mainsteam health insurance or clinical services. Interestingly, the service doesn't appear to rely on the clinic based EHR-based messaging system described by Chen et al. They've come up with a better alternative.

Ironic, hm?

The Steal-A-Nurse-FTE Approach to the Patient Centered Medical Home

Quick: what’s better: renting it, buying it, borrowing it or just taking it? Of these four options, the last one – taking it – offers the best deal because you don’t have to offer up anything in exchange. Even borrowing involves trade offs, along with an expression of gratitude.

Which brings us to the Patient Centered Medical Home (PCMH). As the Disease Management Care Blog understands it, the PCMH is supposed to function as a one-stop primary care resource where grateful patients and unrushed providers can manage both prevention and illness in idyllic population-based tranquility. As first-among-equals, the physician presides over a happy band of nurses, educators, care managers and others, all thanks to an enlightened reimbursement mechanism supported by insurers, who in turn are soooo indebted to the docs for saving them oodles of money. That reimbursement typically will probably end up consisting of some combination of fee-for-service, a monthly fee, pay for performance and upside gainsharing.

Then why aren’t the physicians routinely assuming the cost of the nurses, educators and care managers? The DMCB checked out documents from the Southeast Pennsylvania learning collaborative (slide 16), Community Care of North Carolina (a poster child for the success of the medical home), the Rhode Island Chronic Care Sustainability Initiative (slide 11) for three examples of medical home models that rely on nurse care managers being salaried by entities other than the medical home practice itself. In reviewing some of the other pilots underway, the DMCB couldn’t quite tell which programs maintained local physician control of the nurses and which ones didn’t. It suspects there are a variety of approaches out there.

It’s an important issue. The DMCB is less concerned over the issue of nurse ‘loyalty’ being divided between the insurers or the physicians. Hire the right nurses, says the DMCB, and these savvy independent mission-driven providers can be counted on to do the right thing and maintain loyalty to the patients. No, says the DMCB, the reason it’s important is because the successful involvement of outside agencies in supplying personnel to local physician practices is perfectly aligned with an emerging disease management organization (DMO)-PCMH partnered business model. If IPIP, networks or insurers can hire the nurses, so can DMOs.

When it comes to the PCMH and nurse full time equivalents (FTEs), physician practices can 'build' (or buy a nurse and the other members of the health care team), rent (the DMCB predicts entrepreneurial nurses will offer local services at an hourly rate, such as visiting nurse agencies), borrow (even if there are no nurses left in primary care practices, can what are euphemistically referred to as ‘office assistants’ perform the task - thanks to a job description change?) or steal (i.e. take, let the holder of upstream insurance risk make some investment).

The DMCB likes the ‘steal’ model because it suspects many mainsteam small practice primary care physicians are not prepared to assemble, buy or rent all the components of a medical home team. The fact that they’re allowed to steal FTEs in some of the PCMH initiatives and pilots also speaks volumes about the potential of DMO-PCMH collaboration. The ‘steal model’ also increases the likelihood of scaling a standard PCMH benefit evenly across an insurance network. Finally, the DMCB predicts this may emerge as an important option in the upcoming Medicare Medical Home pilots.