The Canadian Version of the Patient Centered Medical Home: Still Not Ready for Prime Time in the U.S?

If you are interested in the Patient Centered Medical Home (PCMH), you may want to check out this January 6th New England Journal article titled 'Patient Centered Medical Homes in Ontario' by Walter Rosser, Jack Colwill, Jan Kasperski and Lynn Wilson. It describes how the province of Ontario decided to fund 'family health teams (FHTs). Modeled much the PCMH, this Canadian version of government sponsored primary care site transformation-ing was seen as a way to reinvigorate the primary care providers by a) paying extra money for a basket of services, b) provided by a multidisciplinary team.

Docs merely sign a contract. There is no FHT certification or audits. Reimbursement is based on 'electronic data.' The authors estimate at at the present time, there are about 720 physicians in 150 FHTs in Ontario that:

- include nurses, nurse practitioners, psychologists, pharmacists, social workers, and health educators;

- have a defined panel of about 1400 patients. A nurse practitioner is expected to add another 800 patients to the expected practice size;

- receive funding for salaries for the other health professionals and for an approved electronic record system

- are paid using age and sex-based capitation with additional fees for services requiring 'added emphasis' such a visits for infants or patients over 75 years of age, procedures and visits to hospitals, homes, and nursing home visits

- receive bonuses based on prevention goals plus $100 to $300 for every new patient, depending on the complexity.

- forfeits 1 month’s capitation fee when a patient seeks care elsewhere.

Outcomes you ask?

'One study has shown that control of hypertension is better among patients in FHTs than among those in fee-for-service practices. The use of integrative electronic record systems appears to improve efficiency and communication, and we believe that quality incentives have made participating physicians more proactive in providing preventive services and providing care management for chronically ill patients. A full evaluation of this model’s effects on health outcomes, quality measures, and costs will be completed in 3 to 5 years. One effect that is already obvious is an increase of approximately 40% in physicians’ incomes: the average net income for a family physician has increased from $180,000 (Canadian) in 2004 to $250,000 within FHTs, but it has not risen substantially in the fee-for-service sector.'

This makes for interesting reading, but based on this article, the DMCB isn't sure that Canada's FHT is ready for prime time in the Unitied States.

For starters, according to this report, there over 11,000 family physicians in Ontario. Despite the long support of the provincial government, the endorsement of Ontario's teaching hospitals, and the allure of additional revenue, approximately 95% of these physicians have not established FHTs. Why would that be?

In addition, a quick look at the reference that purports to show that FHTs were associated with better blood pressure control seems to indicate that it's an observational study; what's more, the authors credit the control to capitation, not FHTs.

Last but not least, the DMCB isn't sure that it's realistic to believe that the U.S. is ready for 40% increase in physician incomes without more to show for it, such as better access (which was not part of FHTs), accompanying savings (which still remains elusive) or higher quality.

In the meantime, there still appears to be a dearth of data on how the U.S. medical home pilots are going. Has anyone heard anything?

Friday in Baltimore--The Way to Actually Accomplish Something

Intentionally or unintentionally, my sense is that the White House came out of Baltimore thinking they are now on to something, and I hope the Republicans took the same lesson away.Constructive good faith political engagement in Washington actually works.It is just incredible that House Minority Leader John Boehner has had not direct contact with the White House for about a year. A pox on both

The Kubler-Ross Stages of Grief in the State of the Union Speech: Four out of Five Ain't Bad

During its medical career, there were a number of times when the Disease Management Care Blog had to break bad news to patients. Sometimes it was a life-threatening condition, an incurable disease or something that was going to involve a lot of time, money, pain or hardship. During those difficult times, the DMCB also recalls witnessing many textbook displays of the '70's pop psychology Kubler-Ross stages of grief. This says that when persons are confronted by tragedy, coping involves initial denial, followed by anger, then bargaining, then depression and finally acceptance. While these are supposed to serially happen one at a time, the DMCB remembers patients and families not only shifting back and forth, but displaying two or more stages at the same time and sometimes never reaching acceptance.

And so it was during the discussion of health care reform during President's State of the Union Address last night. While the DMCB was distracted by a Supreme's head shaking 'not true' disagreement, the frozen impassivity of the Joint Chiefs over repealing don't-ask-don't-tell and how almost eerily alive Mitch McConnell (R-KY) looked, that didn't stop it from 'medicalizing' the SOTU.

What is the bad news ailing our President? It's the tragedy that landmark and historic legislation is not going to happen. Our President is grieving. The stages of his coping were visible during the speech and can also be discerned in the italicized text of his remarks below.

I didn't choose to tackle this issue to get some legislative victory under my belt. And by now it should be fairly obvious that I didn't take on health care because it was good politics. I took on health care because of the stories I've heard from Americans with preexisting conditions whose lives depend on getting coverage; patients who've been denied coverage; families –- even those with insurance -– who are just one illness away from financial ruin.

To the DMCB, this opening paragraph sure looks like denial. The President did everything he should have done and the facts on the ground support his point of view. How, he asks, could this be? Is there some sort of mistake?

After nearly a century of trying -- Democratic administrations, Republican administrations -- we are closer than ever to bringing more security to the lives of so many Americans. The approach we've taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. It would require every insurance plan to cover preventive care.

This look and it sure sounded like anger over the widespread injustice, the spectacle of insurers getting away with it and the pain of having defeat snatched from the jaws of victory.

And by the way, I want to acknowledge our First Lady, Michelle Obama, who this year is creating a national movement to tackle the epidemic of childhood obesity and make kids healthier. Thank you. She gets embarrassed.

Hey, he points out, I'm willing to include the participation of the First Lady in a very worthy wellness cause. Is this a good will gesture? The start of bargaining?

Our approach would preserve the right of Americans who have insurance to keep their doctor and their plan. It would reduce costs and premiums for millions of families and businesses. And according to the Congressional Budget Office -– the independent organization that both parties have cited as the official scorekeeper for Congress –- our approach would bring down the deficit by as much as $1 trillion over the next two decades.

The DMCB thinks that by reminding everyone of the merits of what he's willing to trade: access and reduced deficits. He is setting the stage for the pitch to follow.....

Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, the process left most Americans wondering, "What's in it for me?"

What's in it for me, indeed. This and the following paragraph continue with the bargaining. He's signalling his willingness to negotiate and once again reminding the listener about what's at stake:

But I also know this problem is not going away. By the time I'm finished speaking tonight, more Americans will have lost their health insurance. Millions will lose it this year. Our deficit will grow. Premiums will go up. Patients will be denied the care they need. Small business owners will continue to drop coverage altogether. I will not walk away from these Americans, and neither should the people in this chamber.

By now, we should be seeing some signs of depression....

So, as temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Let me know. Let me know. I'm eager to see it.

This has been interpreted as a willingness of the part of Mr. Obama to listen to the ideas of the Republican opposition. While that may be true, the DMCB wonder if this rhetorical 'let me know' is the sign of a bitter realization: if they are going to let him know, he's going to have listen and maybe even adopt some of their suggestions. It's well camouflaged, slightly angry, but still a remarkable admission of frustration. That is sad, espeically because the tone suggests he doesn't believe he thinks he'll see anything he'll really agree with.

Here's what I ask Congress, though: Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done. Let's get it done.

Unfortunately, the DMCB notes that this section of the speech appeared to end on a note of negotiating. That may be the sign of a good politician. However, from an admittedly armchair-ish pop-psychology point of view, the DMCB did not hear a post-defeat and Clintonesque 'the era of big government is over' style acceptance.

Of course, the stages of denial, anger, bargaining and depression may be enough to motivate the White House to get a bipartisan deal done. However, the DMCB found that patients did better once they accepted reality and dealt with it. That may, or may not be true in Washington DC in the coming weeks.

Is four out of five enough? We'll see.

The State of the Union--The President Came to a Fork in the Road and He Took It

As Yogi Berra said, "When you come to a fork in the road, take it."The President came to a fork in the road tonight on health care reform. Would he do what many liberals have demanded--push harder to pass the Democratic health care bills? Or, do as many moderate Dems and some Republicans have called for--work to get a smaller but bipartisan health care bill?Listening to his speech he seems to be

Increase the Medicare Out Of Pocket Costs and Watch Hospitalizations Go Up

Years ago, the Disease Management Care Blog worked with a Medicare Advantage health plan that increased a variety of its outpatient co-pays. It wasn't long before the disease management nurses began to report, because of the increased out-of-pocket costs, that patients were refusing health care services . We suspected this was going to lead to problems, but we never got around to proving it.

Thanks to this article (free download) in the New England Journal, there is now good evidence that the phenomenon is real : a blunt plan-wide increase in patient co-pays - even if modest - can seriously backfire.

Thanks to access to Medicare's information systems, the authors of this study found 18 Medicare Advantage Plans that raised the co-payments for outpatient physicians services (from an average of about $7 to about $14 for primary care vistis, about $12 to $22 for specialty care visit and about $150 to $330 for a typical 4 day inpatient stay) and 18 Plans that were otherwise similar but didn't change the co-payments. Over one year, all the Plans experienced increases in health care utilization, but the Plans that increased the co-pays had much lower increases in outpatient visits and much larger increases in inpatient utilization. In summary, for every 100 Medicare Advantage enrollees who were exposed to the level of co-payment, there were relatively 20 fewer outpatient visits, more than 2 additional admissions and 13 additional inpatient days.

While not a randomized clinical trial, the DMCB thinks this is pretty good evidence that Medicare Advantage enrolles are quite sensitive to increases on their out of pocket costs for health care services. What's more, it appears that the accompanying declines in outpatient utilization lead to declines in health status that, in turn, lead to potentially avoidable hospitalizations - despite the increased inpatient co-payments.

Unfortunately, the authors didn't calculate any bottom line. It may be possible that the transfer of costs to their enrollees still resulted in overall savings despite the increased inpatient stays. In addition, it's important to note that these results may not apply to commerical or employer self-insured plans.

For disease management organizations, this is an important study because relatively mild changes in out of pocket expenses can mean big changes in utilization, including services for chronic illness care. For Medicare, this is an important insight on the direct connection between out of pocket costs and health care quality.

The State of the Union, Health Reform and the Need for a CMS Administrator: The Time is Now

No doubt, at the time of this posting, the President and his aides are huddling over the upcoming State of the Union Address. Barring any more outbursts from the now emboldened Republican members of Congress, the Disease Management Care Blog thinks one of the more dramatic moments of the speech will be the unveiling of Mr. Obama’s reconfigured health policies. Will he go for broke and push for passage of an unchanged Senate bill? Will he go opaque with vague bromides about access and quality? Will he go on a populist anti-insurer bender and announce that there’s a new sheriff in town? Will he grin, turn and high-five with Ms. Pelosi and declare the dream will never die? Will he offer a bipartisan man-hug to the Republicans?

Stay tuned!

And, while all this is going on, there are rumors that an Administrator for the Centers for Medicare and Medicaid Services ('CMS') is about to be nominated.

Finally!

The DMCB appreciates that the folks in the White House may be somewhat distracted with a host of health reform details, but that isn’t going to stop it from giving Team Obama some start-of-the-second-year-of-the-term advice:

It's been too long. It's time to get a duly empowered Administrator to lead the Department of Medicare and Medicaid Services.

While the current Acting Administrator is certainly qualified, let’s face it: if CMS is truly going to be an active partner-participant in state and national efforts at health reform, it needs a leader that not only passes muster with Congress but with the American people. The optimistic DMCB also thinks that the confirmation process could - emphasis on could - be an important opportunity to kick-start a stalled bipartisan dialog on health reform.

What’s more, it appears to the DMCB that, up until now, the White House’s health policies have been largely represented by the very intelligent but, let’s face it, lawyerly bureaucrat, Ms. Nancy DeParle. While she certainly has her capable hands full outside of the public eye, it's been too easy for those of us outside of the beltway to conclude that the President's health reform efforts have gone from disengaged to rudderless. What's more, CMS has been curiously lacking in innovation, flexibility and leadership. Case in point? The Lifemasters fiasco. There has never been a greater need for the Agency to adopt a broadminded approach to modern population-based care management than now.

Here's to a CMS Administrator nomination that showcases a commitment to meaningful health reform and the return of a CMS that is a credit to the American people.

guest post

This past Saturday, friends of ours threw a party for their daughter, who just had her first birthday (I had to miss it because I went to Syracuse, New York to pick up a dress but that's a story for another post). In lieu of more traditional birthday presents, they asked that friends and family bring something to put in a "time capsule" that their daughter would open on her 13th birthday.

I think this is a fabulous idea.

My oldest son, who is 11 years old, wrote the following letter to accompany our gift. With his permission, I share it (un-edited) now with you:

Dear F.,

If you are reading this, we presume you are 13 years of age. The other main option is that you peeked, and that you do not truly deserve to keep this gift. On the other hand, you probably feel you were stiffed present-wise, since all the gifts you received at the age of one were hidden from you until now, countless adults taking advantage of your infanthood because they're your "friends and family."

Well, it's finally paid off. If you are reading this letter, your gift is either in front of you or being handled by your parents, who are about middle-aged by now. Our present is a contribution to the "time capsule" your parents constructed 12 years ago, when you looked more like a little pink thing than a real person. We chose to put comic books in your capsule.

The first item in this package is a graphic novel entitled "Scott Pilgrim's Precious Little Life." It is intended to be read over and over again, or at least once if you don't like it. It is a favourite in my family, and I think you will enjoy it, too.

Second, you will find an issue of "PVP", which stands for "Player Versus Player." This is a reference to video games. In this comic, you will find countless references to the pop culture and technology of 2010. It's also pretty darn funny.

Finally, you will find a copy of the first issue of "Siege." I'm not sure what it's about, but what I do know is that it is a massive crossover event in comics. By the time you receive this, it might be worth something. Keep it in good condition.

Enjoy!

Sincerely,

Your friends, the K-Ws.

Plan B—There Isn’t One—But There Could Be

As the State of the Union approaches Democrats are considering their health care policy options. There are lots of reports about “Plan B”—pushing through the Senate bill with a parallel corrections bill that could be passed in the Senate using reconciliation rules.That’s as dead as the original House and Senate health care bills. Moderate Democrats have no stomach for such a legislative stunt in

Value Based Insurance Designs Can Break Even, Possibly Save Money: Here's the Details

While the Disease Management Care Blog anxiously awaits seeing just how the President is going frame health reform in his State of the Union Address and whether 24's Jack Bauer can control his psycho-girl partner, it turned its eye to this 'Web First' report in Health Affairs. The authors include disease management veterans Iver Juster and Mark Fendrick, along with a host of other stars. The title says it all: 'Evidence That Value-Based Insurance Can Be Effective.'

Hundreds of faithful DMCB readers already know the NEJM-approved definition for care management. Thanks to checking in again, you can quote this definition for another important concept called 'value based insurance' (VBI) that likewise bears an academic imprimatur:

VBIs are health insurance designs that reduce patient out-of-pocket expenses for covered services that provide important medical benefit relative to costs.

Note that VBI is not necessarily an exercise in cost reduction a.k.a savings. Rather, this is an exercise in lowering the economic barriers to treatments that are cost effective. It's safe to say that interest among employers in VBI as one of many approaches to population-based chronic illness management, particularly pharmaceuticals, is growing.

The introduction part of this study makes for a good mini-review, backed up by lots of references from the medical literature. The authors point out that it's unclear if VBI should be extended to all insurance enrollees or to just those who exceed a certain risk level. That's because extending VBI over a larger populations, even if it's at nominal individual cost, can be costly. This approach could exceed any downstream savings from reduced claims expense. Further complicating this is the fact that foregone revenue from reduced co-pays at the 'front end' is easily calcuated, while the calculation of the savings on the "back end' is ultimately an exercise in estimating what doesn’t happen. Last but not least, VBI can paradoxically increase the use of drugs or preventive services, which can represent an additional cost.

Unfortunately, the study methodology itself does not make for an easy read. That's because 'preliminary statistical analysis of the spending data indicated considerable uncertainty surrounding estimates of the impact of the value-based insurance intervention on aggregate spending.' In response, the authors conducted a 'break-even analysis.'

And just what is a break even analysis? If you're interested, read on. Otherwise, skip to the next paragraph so you don't need to read that BEA solves a set of simultaneous equations to identify the assumptions necessary to justify the belief that the intervention broke even by calculating the ratio of adherer to non-adherer costs (adherence effectiveness) that would allow the firm to break even by simultaneously solving the equations for the following: (1) pre-VBID cost, (2) post-VBID cost, (3) the percentage who adhere post-VBID, (4) an effectiveness impact equation that produces dollars spent on adherers, and (5) increased drug cost.

This particular VBI study involved one employer that reduced copayments for the five classes of drugs that truly reduce the morbidity and mortality of a number of chronic diseases: ACEs, ARBs, beta blockers, diabetes medications and inhaled corticosteroids. Generic medications in any of these classes were free and the co-pays for 'preferred' and 'non-preferred' brand drugs were discounted by 50% to $12.50 and $22.50, respectively. Eligibility for a drug discount was defined by any past or current use of any of these medications; anyone that appeared to be eligible was sent a letter announcing that the VBI medication discount program was underway. The program was implemented by ActiveHealth Management, a 'comprehensive, telephonic, nurse-staffed program' that is an independent Aetna subsidiary.

The authors calculated the outcomes associated with a 3%, 4% and 5% increase in drug use in response to the better prices and found that there would be a 9%-17% decrease in individual 'nondrug' health care services, leading to at least a break even. Given how relatively "blunt' the intervention was (it wasn't limited to patients most likely to benefit and wasn't accompanied by co-pay increases for low value items), the authors argued VBI has the potential to generate significant savings.

And kudos to the authors for pointing out the limitations of their study: the calculations didn't account for the portion of ActiveHealth's fees devoted to administering the VBI, for patients that may only take some of their medications and for assuming all other cost drivers would remain stable during the period of study.

What can the DMCB conclude after reading this?

First off, value based purchasing is one of many options underway in the commercial insurer market. Not only does this speak to the ability of this health care sector to look for novel approaches to addressing health care costs, but is a role model for government health insurance programs.

Second, this is another telling example that the industry is not your old 'disease management' anymore. Telephonic nurse-based management programs are being synergistically paired with other sophisticated interventions - such as novel health insurance co-pay designs - that result in approaches that are greater than the sum of its parts.

Third, this is an excellent demonstration of how important it is for disease management organizations to not only measure and document their outcomes, but to put their findings up for peer review. Kudos to ActiveHealth for not only running a business but doing their part to advance the science of population-based care (even if it's curiously absent from their web site). When it comes to medicine, this is the price of doing business.

Lastly, the DMCB wonders if the growth of tying 'value' to consumers' out of pocket costs will lead to corresponding increases in the out-of-pocket costs for services that are deemed less cost effective by insurers and patients. Could this mean that the prognosis for business-as-usual provider 'cost-plus' fee schedules has decreased somewhat? Will comparative effectiveness research catch up to what the market is already doing, or will it accelerate it or have no effect at all? Time will tell.

Image from Wikipedia

An Association Between Medical Marijuana and an Unreasoning Commitment to Universal Coverage? You Be the Judge!

In the wake of the 'Scott heard 'round the world' comes the news from California about the resurrection of legislation to introduce Statewide universal health care that even supporters concede 'could cost tens of billions a year.' This is from the State that barely missed a budget disaster thanks to raids on county and city rainy day funds, one-time accounting gimmicks and issuance of scrip.

At the same time, the California Supreme Court struck down a provision that limited the amount of marijuana individuals could possess for medical use, assuring the Golden State's preeminence in the national use of weed.

Hmmmm. Could there be an unidentified link between these two trends? It sure looks that way:

Regular readers of the Disease Management Care Blog understand the limits of associations between potentially independent events (just because two things happen at the same time doesn't mean they are interrelated - it could be accidental or random), sources of bias (there may be one or more other events causing both observations) and the direction of causality (which causes which?). For example, this association between 'DDE' and diabetes could be random. Skin color shouldn't be be associated with diabetes, but both are correlated with other genetic determinants and culture, which act as biases. Obesity causes diabetes, but maybe diabetes can cause (the treatment can) obesity, which is an example of two-way positive feedback loop.

The DMCB is out of its depth in divining the political calculus underlying the State's marijuana laws and the enthusiasm for universal health care in the face of deep voter skepticism and gaping budget deficits. Short of some formal research protocol, it can't tell if the association is real and if so, if there is some political undercurrent that is driving both. Perhaps über health policy insights in Sacramento has led to a truly enlightened version of reefer madness.

Or maybe it all comes down to a simple question: just what are the political leaders out in California smoking?

('’)

a perfect evening

The kind when conversation flows easily along with the wine, all accompanied byexcellent food. Where all the kids get along and the adults are left to talk about books, movies and travel. The kind of evening when three and half hours goes by like five minutes and the time to go comes in what feels like the blink of an eye.

And you have your boots on at the door by 9:06pm.

I remember when Friday nights out didn't get going until after 11:00 and a 1:00am curfew seemed completely unfair. When we danced until the music stopped and got up to the kinds of things that make me dread my own children's adolescence.

It's one of Mother Nature's little ironies that by the time we are mature enough to behave responsibly our definition of a late night (and of a perfect one) has been irrevocably changed.

Hypertension, HEDIS, Excessive Blood Pressure Lowering, Polypharmacy and Implications for Care & Disease Management

Just what do the two numbers in a 'blood pressure' (for example, 120/80) really mean? What happens if the pressures are too high? Suppose just one number is high... how should it be addressed? How should the quality of care be measured among persons with an elevation in just one number? Can overzealous pursuit of high blood pressure lead to bad outcomes and, if so, how should that be measured in populations?

Thanks to a recent publication in the American Journal of Managed Care, your Disease Management Care Blog addresses the controversy.

The DMCB thinks of the two numbers as the highest and lowest measured pressures in the body's arteries that are generated by each heart beat. When the heart muscle contracts, the pressure increases until it peaks. Then the heart relaxes to fill with blood for the next pump. The blood pressure falls during this time until the heart begins to squeeze again. Therefore, think of 'blood pressure' as the peak increase and bottoming out of the pressure that is generated by each heart beat. Most of the time, a person's blood pressure is in between the top number (the systolic blood pressure) and the bottom number (the diastolic blood pressure). We're constantly bouncing between the two extremes.

It's been known that most people seem to have a peak or systolic blood pressure of 120 millimeters of mercury and a bottom or diastolic blood pressure of 80 millimeters of mecury. When those pressures increase, there is increased wear and tear on the inside walls of the arteries, leading to heart attack, strokes and kidney disease. Among persons without diabetes or kidney disease, decades of research have shown that a blood pressure of more than 140 systolic or 90 diastolic (the short hand being '140/90') results in significant enough damage to warrant treatment. If diabetes or kidney disease is present, the treatment threshold numbers are even lower at 130/80.

Which brings us to today's population-based care management conundrum: what should patients and treating health providers do with the category of high blood pressure where there is an elevation in only one of the two blood pressure measures? The reason that is important is because treating one high blood pressure number may cause the other to become dangerously low. For example, (when diet and exercise are not enough) pursuing a systolic blood pressure of 130 or higher with drugs in a person with diabetes could result in their normal diastolic blood pressure going below 70. According to this paper (the info is summarized on Figure 1), that can lead to an increased risk of heart attack and stroke.

This is not just a question for patients, providers or disease/care management organizations. It's also an important wrinkle in the national pursuit of health care quality. For example, a strict interpretation of the National Committee for Quality Assurance (NCQA) HEDIS® measures for successful blood pressure control suggests all persons with diabetes should have blood pressures less than 130 systolic and less than 80 diastolic - with no allowance for the unlucky patients with a 'successfully' treated systolic pressure that is less than 130, causing a concurrent diastolic blood pressure below 70.

Another criticism of the hypertension NCQA HEDIS® measure is that it doesn't recognize that sometimes blood pressure pills simply don't work. Most clinicians stop prescribing additional medications when the patient is on three. Once a patient reaches that point, additional pills are unlikely to work but are more likely to cause side effects.

This can be a problem, because 'all or nothing' blood pressure quality like less than 130 and less that 80 metrics - while well meaning, relatively simple to measure and based on the science - fail to capture the more subtle realities of of hypertension care that are also tied to outcomes (like excess heart attacks) and quality of life (medication side effects).

Which is why this paper published in the latest January 2010 American Journal of Managed Care is important. The authors looked at nine community-based general internal medicine clinics' patients 'of an unnamed academic healthcare system,' thanks to having access to an 11,000 person registry that captured the blood pressure (BP) readings of each and every patient. Two pools of patients were studied: 125 with diabetes who had a recent BP that did not meet the HEDIS criteria of less than 130/80 but were less than 140/90, and 125 patients with BPs or 140/90 or greater. In examining their electronic medical records, they found there were 31 (or 25%) patients in the first pool that were taking three blood pressure prescription medications and/or had a diastolic blood pressure less than 70; there were 43 (34%) patients in the second pool on three or more prescription medications and/or had the low diastolic blood pressure. Among those aged more than 65 years, the numbers were even higher: 58% in the first pool and 60% of those in cohort B took 3 or more antihypertensive medications and/or had the low diastolic pressure.

From a pure unrefined HEDIS® measurement standpoint, having a quarter to one thrid of patients with 'out of control' blood pressure would look bad. DMCB readers have long known there is more to the story. This AJMC study helps us understand the problem better.

The NCQA's Executive VP Greg Pawlson and Partners Healthcare's Thomas Lee would seem to agree. They penned an accompanying editorial in the same issue of AJMC that explains that when it comes to quality measures like those used by the NCQA, '100% performance is not the goal... that clinical judgement should be used' in applying the measure to populations and not be used to 'dictate the care of any individual patient.' They also suggest that the NCQA is open to modifying its measurement guidelines and look forward to the day when real time registries can provide more detailed measurement options.

Hear hear says the DMCB.

What does this mean for disease management organizations (DMOs)? Since DMOs also typically maintain high performance registries, they should already have access to the level of detail that can not only report the standard 'blunt' HEDIS® measures but also gauge the level of polypharmacy over-treatment or excessive BP lowering. Being able to educate your customers about these subtleties and report these data will be a competitive advantage, especially if the NCQA modifies its HEDIS® criteria.

in other news

I was felled by a yucky stomach bug this week and really didn't feel much like blogging. It's the price I pay for a weakened immune system. My older son is home sick today, too. Not sure what his excuse is.

Also, my spouse is in Florida. As far as I know, he's not sick.

To compensate for my bitterness at having been struck down during a week of single parenting (I know, some of you have to deal with this kind of thing all the time), I thought I would show off a little.

Here is my latest clapotis. I made it for my mom.



She thinks she's not very photogenic but I think she's lovely.

I made this thing on tiny (2.75mm, if you care about these things) needles and a laceweight (read very fine) yarn. It nearly killed me.

I was working on it during chemo one day and one of the pharmacists, herself a knitter, shook her head and exclaimed, "You must really love your mother!"

I do.

And while I wouldn't necessarily recommend doing this as a laceweight (not just because it takes forever but because fixing errors is a painstaking process) but I am very pleased with the end results. The yarn is an alpaca and silk blend from Knit Picks and the scarf is soft, airy and has a lovely drape.

I think I am addicted to the clapotis. Although I'll do it in a thicker yarn and on bigger needles (the original was done in my much thicker yarn). Doing this on sock yarn will feel like a breeze.

And did you note the state of my walls?

I have been stripping wallpaper. It's part of a project that a friend is helping with (I know that should be "with which a friend is helping" but that felt awkward. Just want you sticklers to know that I am aware that I'm taking liberties). She offered to "paint a room" in my house in exchange for a bunch of kids' stuff we'd outgrown.

I definitely got the better end of that deal. We got a bunch of stuff out of our house and she has already devoted two afternoons to scraping the wallpaper in my hallway - on two floors and up the stairs.

I have to admit that I have never undertaken this kind of project before and I'm actually enjoying it. On our second afternoon we used "Concentrated Wallpaper Remover" from the hardware store and the hard-to-scrape stuff just melted off. Very cool. I hope it's not too terribly toxic. There didn't seem to be any fumes. It kind of smelled like dish soap.

There's another hour of stripping to do and then I gather everything has to be washed, then primed then painted. And then it will all look so good that the rest of the house will seem really dingy in contrast.

Finally, I feel like I can't conclude this post without mentioning the horrific situation in Haiti. Please give what you can, to a reputable organization.

When the Yarn Harlot sent out the "knit signal" last week, I was prompted to direct my money to Médecins Sans Frontières (Doctors Without Borders). They are already set up to help and do excellent work aroun the world.

Click here to donate in Canada, the United States or everywhere else in the world (find your country in the menu on the left). The Harlot mentioned in her post that it is most helpful if you direct your donation to "Emergency Relief" or "Greatest Needs" instead of to a specific project.

A Smaller Bipartisan Health Bill? What It Could Look Like

In the wake of the Massachusetts vote, Democrats are scrambling to find a way out of the health care political mess they are in.Right now they are in a daze standing by waiting to see if any of the "trial balloons" they have launched gain any traction. So far, ideas to ram though the now toxic Senate bill in the House in one parliamentary form or another are falling flat.Last night, the President

Welcome to the "Tree of Blogs": An Avatar Movie Inspired Health Wonk Review

Welcome to the Health Wonk Review, a hosted compendium of high-quality health policy blog postings with insights you don't typically see anywhere else. And how fitting, given how the January 20 deadline for submissions for inclusion in this HWR also happened to be the one year anniversary of the Obama Presidency.

What a year it's been. Even the most logorrheic bloggers are having trouble finding the superlatives that come close to describing the tumultuous events of the last 365 days. The health reform imbroglios, drama, debates and politics has been much like the 'fix' of internet donations to a member of Congress: hard to fully grasp but immediately addictive.

Even with so much going on, your humble and solicitous host, the Disease Management Care Blog, had little trouble identifying the most important, the major, the most significant event in the last year that could serve as a HWR theme. That's right, it's the Avatar movie inspired HWR.

The Disease Management Care Blog proudly presents The Tree of Blogs*.

Just in case any readers' disdain of popular culture or unwillingness pull away from C-SPAN prevented them from seeing this marvelous cinematic work, the DMCB salutes your discipline and provides this quickie synopsis: a nice and disabled ex-soldier Jake Sully goes to Planet Pandora, which is being strip-mined for highly valuable unobtainium by the greedy human race. Jake's mind is remotely synched with a genetically contrived and partially human avatar that is designed to infiltrate an indigenous race of blue-skinned humanoids called the Na'vi. Don't you know, Jake's central nervous system does not belong to a military dolt: romance with warrior babe named Neytiri and a series of mind-melds with a shimmering glow-in-the-dark 'Tree of Souls' mends Jake's brain of his evil ways.

In this HWR, readers are likewise invited to open their minds and commune with the accumulated wisdom of this interconnected and timeless Tree of Blogs. Mind meld with these important issues that likewise span Pandora and Earth. The voices that speak out of the mists of the blogmos are just as powerful, just as compelling and just as much fun......

Who best fits the role of the downtrodden Na'vi: the underdog Republican-Conservatives or the reform-minded Democrat-Liberals?

While the Republicans may have won the latest round in health care reform, Brad Wright takes them to task for their past willingness to countenance commentary that is emotional, alarmist and baseless. Using contrasting 'word clouds,' he compares two conservative commentators' rhetoric and demonstrates that one shows it is possible to be reasonable. while the other shows how easy it is to be everything that liberals detest. Now that the Republicans seem to be on the ascendancy, they can start by banishing the obstructionist angry 'you lie' style politics and embrace Pandora-like harmony: at least pray over your victims after you kill them.

John Goodman of the National Center for Policy Analysis points out that many of the Democratic health care reform proposals have been curiously devoid of any identification of just 'who' in particular is supposed to transform the disembodied ideas of health reform into specific actions. Like an elementary school teacher, he notes the presence of verbs without subjects not only makes for incomplete sentences, they make for incomplete policy. John's grades this an 'F,' despite Mr. Obama's December 2009 self-grade of a solid B+.

As we know, the majority of Massachusetts' voters would seem to agree with John Goodman's grade. But never mind what all the experts have to say, check out a series of quick interviews of Massachusett's voting citizenry during last Tuesday's special election by Tinker Ready of Boston Health News. The good news is that folks are paying attention and have a grasp of the issues. The bad news for our politicians is that folks are paying attention and have a grasp of the issues. Like the Na'vi Clans, they are assembling for this time of great difficulty and tribulation.....

We know, however, that legislation always includes favoritism for selected constituents. Just who ends up being favored is always interesting. Case in point: Senator Schumer (D-NY) proposed exemption of the religious Amish from the health insurance mandate. John J Leppard IV uses the Senator's own words against him when he examines how Mr. Schumer ironically saluted the Amish's thrifty self-sufficiency as a reason for the exemption, while the Senator was simultaneously proposing to penalize others who might refuse insurance for the same reason. While the DMCB thinks the Amish community has an effective and very informal form of insurance, it also appreciates the political art of making exceptions to every rule.

Is the planet being strip mined of its health dollars?

Jeff Goldsmith, writing in the Health Affairs blog, doesn't think so. Citing the 'inconvenient' statistics of the annual CMS' actuary's report, he describes how overall health care spending has been blunted for several years, thanks to the tapping out of consumer borrowing and the relative lack of any recent 'must-have' big dollar medical technology or pharmaceutical advances. The only entity that's continued to have an out of control 10.4% appetite for health care services is the government, probably thanks to a build up of toxic levels of Medicaidium and entitlementium. And here's an interesting thought: consumers were so battered by out of pocket health care costs that the resulting financial squeeze may have actually helped to fuel the recession. Like Pandora's bio-botanical network, we are all interconnected.....

Even if non-government health care costs may be moderating, that doesn't stop Louise of the Colorado Health Insurance Insider from arguing that objections to a commercial insurance mandate is misguided. After all, banks require their mortgage customers to buy homeowner's insurance and, if a house burns down, it's not up to the rest of us to cover the rebuilding costs. In addition, there are other key policy considerations, including the need to fairly spread risk and mitigate individuals' personal risk of financial ruin. The DMCB gets it, but also worries that the Democrats will conclude that their recent setbacks were the result of poor communication/education on these issues, not poorly constructed policy that failed to pass muster with a skeptical and savvy public.

No argument on the point about mandates from Anthony Wright of the Health Access Blog and, apparently, from Rush Limbaugh. Recall this conservative talk show provocateur was recently hospitalized with chest pains while in Hawaii. After heart disease was ruled out and he was discharged, Mr. Limbaugh had nothing but accolades for the medical treatment he received and held it up as evidence of a health system that really works. Anthony points out that the Hawaiian health care system is operating under an employer mandate to provide health insurance for workers. Alas, the resemblance between Hawaii and Pandora is only superficial: without a mask to shield him from the toxic vapors of government interventionalism, Rush would surely die.

But let us head to the other side of the globe to Connecticut, where that State's Attorney General has filed suit against insurer Health Net. David Harrow of the Health Blawg discusses how the State AGs seem to be more than willing to use their power to enforce the privacy regulations under the "Son of HIPAA" amendments to the HITECH act. Health Net allegedly dawdled in notifying hundreds of thousands of enrollees about a stolen computer containing their personal health care information. Beware, says David, the AGs are prepared to take consumer protection very seriously if insurers fail to be in full compliance with the letter and the spirit of the law. Hm...seems there is even more Pandoran wildlife out there to deal with.

And what's an insurance budget without a pharmacy benefit? Never mind just the blue pills or the red pills, pills of all sizes, shapes and colors, particularly their costs, are examined here by Adam Fein of Drug Channels. This is a multi-hundred billion part of the national health care budget and it's important that we project costs from year to year. Well, according to Adam, CMS isn't doing a very good job of it. The Agency seems to be over estimating the costs year after year, apparently missing the impact of increased generic medication prescribing. Too bad the Administration doesn't appear to be underestimating the size of the Federal deficit.

Employer-sponsored insurance, including the Cadillac Plans: the insurance equivalent of unobtainium?

Feel overwhelmed by economists' jargon and funny mathematical symbols? You can avoid both by looking at Austin Frakt's review of an important analysis of the decision-making that goes into employer sponsored health insurance. There are myriad decision points over the benefit package, type of plan, projected enrollment, the worker/employer allocation of premium payment, the workforce profile, the labor market and the overall business strategy. Oh, and, by the way health care too. And we thought only our President was up to marathon planning sessions.

Joe Paduda at Managed Care Matters understands the ultimate intent of the 'Cadillac' health plan tax: it's supposed to put the brakes on high cost insurance and slow down health care inflation. He points out that if this ultimately goes through, the reality will be far different. Not only will regional cost variation unfairly sweep some high cost plans into the one size fits all tax bracket, it also targets employers that have substituted health insurance benefits for wage increases. He suggests an alternative is to tax plans with an unwarranted cost trend, independent of baseline cost or benefit level. If you think that's too complicated, his rejoinder is Yes We Can.

Merrill Goozner of Gooznews on Health doesn't like the Cadillac tax either. He looks to the future and sees rising insurance premiums resulting in more plans and their enrollees being ensnared by the tax or, worse, employers ratcheting down their costs by skinnying benefits or transferring more costs back to their employees. They could respond by skimping on needed health care. Like buying the blue pill instead of the red pill.

Henry Stern of the Insure Blog also agrees. He has one telling example of a health insurance plan that is up for renewal that would be in the Cadillac Tax bracket. He points out that that's not the result of a richer benefit, but the a) adverse trend of that particular group that is not controllable and therefore unfairly included, and b) the coverage mandates that have been imposed by special interests that are also driving up costs. Cadillac? Hardly. Blasting away at these plans is like attacking the Na'vi Hometree: there are women and children at risk!

Let's not forget that health insurance is not the only dynamic in covering workers. There's also Workman's Compensation Insurance. If you had to guess if younger or older workers are more prone to the kind of work-related injuries that trigger a WC claim, would you guess 'older?' You'd be wrong, because experts like Lynch Ryan of the Worker's Comp Insider continue to remind us that older workers are good WC risks, even if they seem to have longer recovery times. If you want to learn more about this and about the different WC market segments, you should check it out. And remember f you're injured on the job and don't have health or WC insurance, then you might as well pray to the Pandoran god Eywa for guidance. You'll need it.

Avatar characters ride around on the backs of fantastical creatures called Banshees. The health care system rides around on the backs of creatures called Physicians.

The Disease Management Care Blog is all for giving doctors more money in the form of lower medical school tuition, scholarship and load financial support, income supplementation, small business assistance, realistic fee schedules and tax breaks. Since policy makers seem to support tying money to outcomes, Chris Langston of the John A Hartford Foundation suggests loan forgiveness be extended to students that eventually enter a career in geriatrics. A good idea says the DMCB, especially since adoption of that idea by the Administration might further cement its remarkably good relationship with the American Medical Association.

Talking about giving doctors money, how about all that cash for adopting electronic records that meet meaningful use criteria? Resources to help readers better understand this are excellently linked up and summarized by Vince Kuraitis over at e-CareManagement. Shahid Shah steps back and reminds physicians that they should be asking other more fundamental questions about the merits of automation, customer service, other outcomes that really count and the types, formats and accessibility of information that will be required. He offers up a list of shorter term and easier steps that can be implemented by docs before they write an EMR vendor a big check. Elyse Nielsen offers her own thoughts of health system workflow efficiencies at Anticlue. Better hurry up though, Mr. Obama is in a hurry to get this done.

How about doctors spending money? David Williams of the Health Business Blog summarizes an interesting study that reports on a cancer doctor survey about health care costs. The majority are already including cost of chemotherapy in their clinical decision making and would welcome additional information based on comparative effectiveness research. As a cancer patient, he asks, which would you rather have: a coverage or treatment decision based on a hunch or one based on real science? The DMCB has seen oncologists come to the rescue of countless patients. When they walk in the room, it reminds him of Jake riding in on a big orange flying Toruk.

But fear not, my fellow physicians, because Peggy Salvator of the Healthcare Talent Transformation blog recounts a reassuring interview she had with national health information technology coordinator David Blumenthal. The government's enlightened use of goal setting to help you use EHRs is designed to stretch not break you. You may feel the heat like a pulled rubber band, but be of good cheer, when they're done with helping you implement meaningful use, the Planet will be better off for it. So cooperate, OK? If this reminds the DMCB of Pandora character Parker Selfridge, it apologizes.

Jake dreams of being able to walk again, but cannot afford it. Is that the fault of the hospitals' economics, ethics or not using check lists?

The States' tax revenue is pancaking and more persons are out of work. That means a double whammy: less money to support the Medicaid budgets while, at the same time, more persons with low income levels are qualifying for Medicaid. In this post, Mike King looks at how the Georgia Legislature and Governor are thinking about taxing hospitals, especially since the extra money will help the State qualify for additional Federal dollars. The hospitals are unsurprisingly opposed to the idea. The DMCB isn't too sympathetic, since the States want to extend health insurance to more people, which will will only help these institutions' bottom lines. Perhaps one way of dealing with the hospitals that can't make it is creating their own version of cash for clunkers.

Maybe the willingness to tax hospitals could at least indirectly be the result of reports of incredibly unethical and illegal oversight of some of their Boards of Directors? Roy Poses, in this January 15 posting (you need to scroll down or go here and here) describes how bloated compensation packages and self dealing are slowly ruining the public's faith in hospitals' ability to do right. While this may the result of a few bad apples, Dr. Poses points out the crying need for functioning and vigorously enforced ethics policies. Maybe if they wake up and realize how tone deaf they can be, we won't want to tax them like the big banks.

Or maybe folks are fed up with resistance of hospitals to the use of checklists to reduce unnecessary complications. According to Magie Mahar of the Health Beat Blog, failure to do so is contributing to the equivalent of six sold-out 747s crashing every day. Doing the same thing on every patient all the time every time has several things going for it: it's cheap, it works, but most importantly, it's the topic of a book by healthcare golden boy, Atul Gawande.

When the Na'vi refuse to cooperate, it's time to call in the marines. When it comes to a unwieldy health care system, is it time to call in the Feds?

Ken Terry shines a harsh light on the States and kicks it up a notch by asking a fundamental question: do the individual States really have what it takes when it comes coralling health insurers? Can they really run exchanges? Can State Insurance Commissioners really do what is best for health plan enrollees? Is there any entity better situated to streamline this than the Fed's Office of Personnel Management? The answer may ultimately turn out to hinge on how you interpret the Constitutional support for an expanded role for the Federal government.


*You're right, the image doesn't look like it's from Planet Pandora. That's because Planet Pandora doesn't have a Tree of Blogs, silly: that's only present here on Earth. Image from Wikipedia

An Important Health Affairs Article on Savings from Workplace Wellness Programs

None other than healthcare Obamacon rock star David Cutler has an article on the prestigious Health Affairs web site assertively titled “Workplace Wellness Programs Can Generate Savings.” Anyone interested in or in the business of worksite wellness should not only read it, they should email the link, twitter the link, download it and provide printed copies to your co-workers, your customers and your bosses. The enthusiastic Disease Management Care Blog even gave a copy to the DMCB spouse. While her excitement was inexplicably muted, the DMCB is confident that with time, she'll come to appreciate its findings.

Here’s why. Lead author Katherine Balcker, co-author Zirui Song and Dr. Cutler scoured the world’s published scientific literature on worksite wellness and pulled out a surprising number of studies (32 of tem) from an equally surprisingly wide array of employer settings, including financial services, manufacturing, school districts, universities, municipalities, utilities, telecommunications, energy, pharma and consumer product manufacturers. What was not surprising was multiple components of these programs. The majority were kicked off with a Health Risk Assessment (HRA) by an array of initiatives, including self-help education materials, individual counseling, group sessions and incentives that attacked a variety of health concerns with a special emphasis on the twin lifestyle issues of tobacco abuse and weight gain.

When the economic ‘difference in difference’ (pre-post changes over time in an intervention group versus the pre-post changes over time in a control group) are added up across the studies, the workplace wellness programs not only lead to a workforce with lower health care costs, but those savings exceed the cost of delivering the program at a rate of $3.27 for every $1 spent. And if, as a regular reader of the DMCB, you are leery of studies that are non-randomized and could be compromised by a self-selection bias, the authors noted nine of the 32 studies were randomized and showed a return on investment (ROI) of $3.36 for every $1 spent. To ice this cake, the authors also reported on the monetized impact on absenteeism for the 12 studies that had those data and found a ROI of $2.73.

Balcker et al do an excellent job of being transparent about the limitations of their study. Since only programs that are successful would be expected to appear in the scientific literature, there could be a publication bias. Since only larger employers generally have such programs, there is only limited information on whether this would work for small employers. Costs are easy to detect, while savings, especially over the long haul, may be more prone to errors in measurement. All in all however, there is a considerable body of literature from a wide variety of settings that support the economic case for implementing wellness programs in the worksite.

There may be two additional implications:

The DMCB is unaware of the current status of the call for a moratorium on the prohibition of collecting family history information in HRAs under the Genetic Information Nondiscrimination Act (GINA). The finding that the use of HRAs in the workplace prior to the implementation of this part of GINA is associated with savings is another reason for the Administration to reconsider and allow HRAs to collect the information. Family history is an important part of addressing risk, increasing health and reducing cost.

The authors correctly point out that large employers can afford the up front investment costs in worksite wellness and that that is often out of reach of small businesses. Given the degree of savings, however, the DMCB wonders if health insurers should think seriously about offering this in their small business market. It'd be a logistical challenge, but the return on investment could be quite attractive, it's worth further study and there could be a distinct competitive marketing advantage.

Stick a Fork in It! The Democratic Effort to Pass a Health Bill is Dead

Tuesday’s Republican victory in Massachusetts means the current Democratic health care bills will not be on the President’s desk in 2010.Forget the crazy talk of ramming something through—including just having the House pass the pending Senate bill.I’ve talked to lots of people in the past few months that didn’t like the Democratic effort but conceded that the Dems won the 2008 election on a

The Silver Lining in the Massachusetts Vote

The Silver Liningby Brian Klepper and David C. KibbeMassachusetts voters' stunning rejection of Democrat Martha Coakley, in favor of a not-very-impressive Scott Brown, should be exactly the splash of cold water that the Democratic party - and Congress as a whole - needed. The defeat can be understood in two ways: one large and one fairly small.First, the large one. This will probably send reform

Never Mind Waterloo. Obama, Health Reform and Moscow: An Uncanny Resemblance

Back in July, North Carolina's Senator DeMint announced the Republicans were going to use a 'Waterloo' strategy to defeat health reform and 'break' President Obama's aura of invincibility. After watching the liberal Juan Williams sullenly defend the current status of health care reform on a January 17 evening Fox News panel, the Disease Management Care Blog pronounces that plan a failure. It's not a Waterloo, but it is sure looking like a Moscow. Too bad the DMCB didn't think of the allegory first, but it makes sense. The latest news from the front is dismay over unfairly shielding high-cost low-value 'Cadillac' plans from paying their fair share plus a surprise revolt by the Independent voters in Massachusetts.

Recall the Battle of Waterloo was Napoleon's last ditch effort at holding onto power in the face of a coordinated attack by British and Prussian forces in Belgium in 1815. It was a pitched three day clash of the grand armies of Europe involving epic charges, huge personalities and high strategy. When it was all over, there was a clear winner and a loser. With a clear outcome and happy ending, no wonder the tale evokes such lust from political strategists.

Contrast the Waterloo allegory with Napoleon's earlier 1812 star-crossed invasion of Russia and the taking of Moscow. The British were preoccupied by a war with the U.S., Spain refused to submit but was contained, and conquering Russia, for a variety of economic and military reasons, looked like a good idea at the time. Backed by a huge coalition with considerable treasury and hundreds of thousands of soldiers, the French Empire crossed into Russia in June. What followed was a long drawn out campaign of Russian retreats in an increasingly inhospitable terrain with occasional battles and, as the months went by, the arrival of winter. Napoleon's Pyrrhic victory was consummated by a horse ride through the Russian capital's deserted streets. What followed next was a disasterous slow withdrawal through an unpacified countryside. It certainly didn't ''break' Napoleon but it turned out, even though Moscow was taken, to be an epic disaster.

To the amateur historian DMCB, there are some compelling similarities to the present day political landscape. At the start, Napoleon was at the height of his power and was favored by overwelming power (controlling both the U.S. House and Senate). While there were many issues to be dealt with, 'Russia' (health care) emerged as a worthy campaign with a good prognosis of success. However, instead of a single climactic battle, the French were slowly bled by a scrappy enemy (Republicans) and hostile civilians (Tea Baggers) while Napoleon himself seemed hesitant. Even though he could technically claim victory (some sort of bill is likely to pass), the months that followed culminated in a growing disaster in thanks to continued attacks, the lack of support in large parts of the countryside (grumpy approval ratings) and the change in seasons (Winter is still upon us and the 2010 elections loom).

Could it work out this way? While only those who actually read history are the ones condemned to see it get repeated, the DMCB fears things are getting to the point where victory on passage of a health care bill could result in a lonely Democratic ride through a virtual Moscow.

The DMCB hopes not.

Martin Luther King Day and Health Care Disparities - Much Work Remains

Martin Luther King Day is upon us. The Disease Management Care Blog is using this time to reflect on Dr. King's remarkable achievements on behalf of the disenfranchised. Yet, while his civil rights legacy is indeed a cause for celebration, it's also a reminder that, when it comes to healthcare, much work remains to be done:

Of course we know that socioeconomic status and race are linked. The good news is that it's possible to tease that out and discern when barriers to care are predominantly economic and when they are a function of skin color. Sadly, the science confirms that what Dr. King told us decades ago is till true today: we still have a problem. No, make that a really BIG problem.

While we're all looking for reasons to leave no corner of the health care system unexposed to electronic medical or health records, the Department of Health and Human Services has released a long awaited Interim Rule on the 'meaning' of meaningful use for health information technology. The good news is that it includes a requirement that it be used to reduce health care disparities. The bad news is that that particular issue is being treated as a 'quality of care issue,' along with other care domains such as continuity of care, error reduction and research. If Dr. King were alive today, he'd probably wonder about linking fundamental human rights issue to 'quality'; the Disease Management Care Blog would not only agree, it'd also worry about the prognosis of that approach.

Of course, having an electronic health or medical record is not the same as having a workable registry. Despite the little real world knowledge of just how electronic records address disparities, there is this report on how registries can help define the patterns of care associated with race. The first step to doing something is to measure it, and this sure looks like a good first step, assuming this is built into registries and we are prepared to act on it.

Many may not be are aware that managed care insurers have a long legacy of working to reduce disparities among their enrollees. They're making some progress (see here, here and here), but the flight of employers to self-insured plans could possibly undo things. Going forward, the DMCB thinks Rev. King would suggest this deserves greater measurement and scrutiny.

Last but not least, patient centered medical homes and disease management can reduce disparities. In working with many organizations, the Disease Management Care Blog is proud to report that many take that mission very seriously. It just wishes they'd do a better job of taking their data on this and moving it into the public domain.

The Fat Lady is a fan of Reverend King and brings up this quote from the 25th Chapter of Matthew.

.....Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me....I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.'

While some readers may think the Bible shouldn't have any role in health care policy and planning, the DMCB knows Reverend King would disagree. Even then, we can still be guided by its powerful insights about the human condition and the way forward.

These 'least' are our equals. The sick await. The work remains. We can do better. And the stakes are high.

The Union “Cadillac” Tax Sweetheart Deal

Just when you thought you couldn’t be more cynical about the health care bill.As I have said before, there wasn’t a lot of hope the same administration that ignored the rule of law in granting unions priority over Chrysler bondholders was going to offend them on the “Cadillac” tax.We’ve seen the “Louisiana purchase” giving Senator Landrieu hundreds of millions for her vote, only to be upstaged by

Medical Consequences of an Earthquake in Haiti. Trauma, Crush Injuries, Infectious Disease and Stress Disorders: A Population-Based Care Perspective

Count on the science of medical epidemiology to leave no manmade or natural disaster go unexamined. Examples include the medicalization of nuclear war, inquiries into the risks associated with depletion of the ozone layer and more recent alarming reports on 9-11 and global warming. Given the epic tragedy unfolding in Haiti, the Disease Management Care Blog wondered if a) earthquakes were also a topic in the medical literature and, if so, b) what it could tell us about them from a population-based health perspective.

The answers are yes and lots.

It looks like there are four stages to a disaster like this.

1. In the initial hours, the risk of traumatic death is not only dependent on proximity to the epicenter, but being in taller buildings and on the upper floor. In fact, it's the large structures in an affected area that are the greatest threat. Immediate causes of injury include not only building collapse but falling debris, falls, motor vehicle accidents and burns. Low socioeconomic status, severe mental illness, moderate (not persons with 'severe', because they are being cared for) physical disability or being just having been discharged from a hospital are associated with a higher likelihood of death.

For those victims who make it out, the majority won't necessarily need to go to a hospital - assuming those facilities are still functioning. Instead, survivors are typically treated outside in makeshift stations or individually on the street. Those individuals with life-threatening chest or head trauma often don't get to the hospital on time; if they do make it, it's more likely that that trauma was minor. Instead, what fills the hospitals' emergency rooms, operating rooms and inpatient beds in the first wave are persons with severe limb fractures.

2. What follows next are the crush injury victims who are pulled out of the rubble. Survival with chest or abdominal trauma is relatively uncommon, so once again, it'll be these victims' limbs that require treatment. Laying in one position and being unable to move for hours or days with or without crush injuries can also lead to considerable swelling or the arm or leg, which often necessitates 'fasciotomies,' i.e., surgically opening the skin (explanation and picture) to accomodate the swelling. This allows this edema to run its course without squeezing off the local blood supply. These injuries can also lead to the release of high amounts of muscle protein into the blood stream (called 'rhabdomyolysis'), which is toxic to the kidneys. Avoiding kidney shut-down (failure) involves complicated medical treatment which is often out of the reach of first responders. If the failure turns out to be permanent as the hours to days unfold, the lack of access to dialysis is a death sentence for those victims who are otherwise joyously rescued alive from the rubble.

3) In the days and weeks that follow, there is the specter of outbreaks of infectious diseases. Thanks to overcrowding as persons seek shelter combined with the breakdown of fresh water transport and sanitation, insect borne diseases, contaminated water, measles, respiratory illnesses and meningitis can emerge as a huge threat to the survivors. Vaccinating against measles is important and chlorine, not boiling water, may be a better first line of defense for potable water. This is where the work of establishing camps with adequate shelter, clean water and sanitation, food and nutrition are critical over the longer haul. Haiti's special burden of HIV and tuberculosis (TB) should also warrant special attention to minimize spread to the uninfected. Last but not least, this is probably when the arrival of increased numbers of relief workers results in some of that group also being exposed to injury.

4. Finally, there's the high incidence of post traumatic stress and the increased risk of suicide. The psychological burden can last for years and cannot be underestimated.

Despite the initially insurmountable logistics, this can be the Obama Administration's finest hour. Based on what the DMCB is reading, their planning should emphasize finding, assembling and equipping local 'first responders' who can supply first aid in the streets. In addition, medical experts with knowledge of treating trauma and, in particular, orthopedic injuries are critically needed right now. They should be followed by other surgeons as well as health providers that can manage the rhabdomyolysis and, if possible, provide emergency dialysis. Planning for camps should be starting by now to head off the risk of overcrowding, poor sanitation and communicable disease; vaccines should be on the way and special services for HIV and TB need to be arranged, along with mental health services.

The DMCB hopes and prays for the brave people of Haiti.

The Red Cross is accepting donations, which can be accessed here.

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