Here Comes Ted Kennedy! Implications for Disease Management

Here comes Ted Kennedy (D – Massachusetts) and he's looking remarkably trim and energetic. Details on his health care reform legislation are not being reported in the media, but it's clear that he’s getting ready to unveil something that will be ultimately aimed at universal coverage.

You may recall that Mr. Kennedy was one of four Senators who wrote to CMS Administrator Kerry Weems about continuing the Medicare Health Support initiative. Will he continue this support when his legislation is introduced? The ever optimistic and naive Disease Management Care Blog hopes the answer will be yes, because.....

1. There are few patient friendly interventions out there that have any hope of blunting health care cost inflation. Disease management is one of them. (Looking at this contrarian post and scrolling down to November 13 may make you think that the EHR is not necessarily a cost savings slam dunk either)

2. Disease management - either as a carve-in or a carve-out - is embedded in most commercial insurance plans. Why not build on their optimism about the value of this approach?

3. Widespread support for the unproven medical home is not incompatible with support for disease management. In fact, this is a chance to craft language that recognizes their complementary nature and supports innovative insurance benefit designs that capitalizes on the value of both. This is a theme in the Baucus Plan.

4. Legislation aimed at major health overhaul could use all the help it can get, which means inclusivity rather than exclusivity. A big multi-dimensional problem requires a big multi-dimensional approach with the support of a host of stakeholders.

5. President Elect Barack Obama has voiced support for disease management. His HHS Transition includes the anti-tobacco and primary care center-experienced William V. Corr and former SGIMite (they are smart people) Nicole Lurie, who, by the way, has written about disease management and is familiar with the good:

'While numerous studies described such interventions, we found only 45 studies that formally evaluated their effect and only six that contained any information on the cost of the intervention or the savings it achieved relative to the no-intervention baseline. All six of these studies, all
on disease management for asthma, found the interventions to be cost effective. One intervention that provided 60- to 90-minute, one-on-one educational sessions was even found to have produced annual net savings of almost $2,000 per patient.'

and the not so good:

'However, a recent RAND review of the effectiveness of disease management interventions found no conclusive evidence that disease management for asthma can reduce direct medical costs. To summarize, we found insufficient evidence to try to answer our questions on the cost of reducing the gap in quality and the return on investment for programs that attempt to close the gap.'

6. A major highly regarded disease management organization is headquartered in Massachusetts.

The DMCB looks forward to learning about the Kennedy approach in the not to distant future. By the way, considering the news coming out of Tennessee, it suspects Healthways hopes inclusive reform is put on a fast track: time may be running out.

A Round Up of Baucus Plan Commentary - Part 3

The Disease Management Care Blog compared the Baucus Blueprint to its own Principles for Reform. Maybe Senator Baucus didn't read them when they were first posted, but the DMCB suspects the Senator and/or his staff used much of the same underlying logic. There's the overlapping approach chronic illness care, ramping up primary care payments outside the RUC, bundled payments and recognition of the worksite, schools and community as the best locus for wellness, prevention and obesity care.

The DMCB believes the Baucus plan at this time is just a functional stalking horse. That being said, it yields up some interesting insights into the thinking of a leading US Senator, which is probably shared by many of his colleagues; think of this as some important market intelligence.

The two biggest issues for the DMCB?

1) While forcing more persons into the risk pools will lower the average health insurance premium (the same amount of insurance risk is being spread over more persons), as it stands now, it has little hope of controlling health care costs, and

2) The proposed Independent Health Coverage Council is a huge grab of power away from the States and the market.

The DMCB hasn't seen any reaction from the Republicans, but if this proposal gets any legs, it expects the wily Mitch McConnell to raise questions about the affordability and the Council. Let the games begin.

In the meantime, in addition to thinking about it's own blog, the DMCB likes to scan the other postings out there to see what they say. This is another version of market intelligence and it found some interesting stuff:

The 'insiders' line up over at the National Journal Expert Health Care Blog, including conservative John Goodman of the National Center for Policy Analysis (“a rehash… a start”), Len Nichols of the New America Foundation (it takes many paragraphs for him to say he likes this, and lots), Nancy Nielsen of the AMA (they look forward to ‘working with’ Mr. Baucus, like, er, they have any choice), Karen Davis of the Commonwealth Fund (she endorses the ‘building block’ approach and thankfully spares the reader from mentioning how swell healthcare is in Denmark), Ed Howard of the Alliance for Health Reform (is saying the Baucus plan is 'thoughtful, comprehensive and coherent' code for supportive or non-supportive inside the beltway?) Rich Umbdenstock of the American Hospital Association (‘good ideas,’ he says, but the DMCB thinks they'' ultimately like the notion of getting out of the business of charity care), Ted Kennedy (lauds the 'bipartisan' potential - uh huh, sure) and Henry Aaron of the Brookings Institution (he likes the Connector). The DMCB likes quoting all of this and giving the reader that he’s familiar with all these brainy think tanks.

The asute Robert Laszewski notes the proposal lacks detail on a) the size or source of the premium subsidies, b) controlling health care cost inflation, c) getting buy in from the specialist physicians who would be affected by a re-tooling of the Sustainable Growth Formula or d) finding the money to pay for this beast.

For an example of the intricacies of twiddling the knobs on the impossibly complex tax code to change human behavior, see this over at the Wonk Room. Tools of this trade include excluding premiums, income sliding scales, deductions, marginal rates, subsidies and exemptions.

As mentioned in a prior post, the health insurers AHIP and Blue Cross and Blue Shield issued short terse statements. They're still thinking this over.

How about the DMAA? Well, funny you should ask. No statement from them. Ditto the Patient Centered Primary Care Collaborative.

The American College of Physicians Blog (internists are primary care docs that treat adults) asks about the politics of taking money from other specialists and mentions the luster of a sustainable growth rate fix. The KevinMD blog (also from an internist) likes what he reads ("almost sounds like something I could have written") and curiously echos the question about the cooperation of the specialists. The DMCB asks if the internists are spoiling for a public fight inside the House of Medicine as a means to engage their otherwise busy membership?

There's also no underestimating the physicians' distrust of the RUC committee. Medrants likes the Baucus plan proposal to move decisions about primary care reimbursement out from the under the RVS process.

The Liberals you ask......?

Nobel Prize winning liberal Paul Krugman hopes that Obama will agree that the means justify the end in “do[ing] the right thing” and break the campaign promises he made about not supporting mandates. Keeping your word is apparently optional for the conscience of a liberal.

Maggie Mahar savors each morsel in the Baucus plan in delicious detail for the sweet and the bitter and finds it an ultimately tasty but vague dish. Her biggest fear is that this will lead to legislation that resembles the U.S. version of Chinese food: tasty but unfilling.

Folks over at the California-esque Health Access Weblog imply the Executive branch's President Elect Obama should welcome help from the Legislative branch's Senator Baucus. They also distrust the inclusion of any individual mandate in a health care plan, thinking it's better to make one big risk pool. Curiously, they include the failed California Schwarzenegger – Nunez template as some sort of example of how things can go well.

The Physicians for a National Health Program are also uncomfortable with anything less than one big risk pool. Otherwise, if Senator Baucus' position takes us closer to a single payor system, they're for it.

And if you're from Massachusetts and involved with their Health Connector, you gotta like it when the Feds believe in your idea.

Finally, what's liberalism and blogging without Ezra Klein? He points out that it looks like Mr. Baucus is throwing some elbows to establish court dominance under the health care reform basket. He also provides a solid outline of the Senator's proposal and summarizes the principles, including the mantra of if you (are crazy enough to) like your (overpriced for profit) plan you won’t have to change (yet). In addition, the proposed Health Coverage Council would make most of the hard decisions (for you). Interestingly he predicts the Wyden plan is “dead in the water”

How about the Conservatives.....?

The DMCB has just learned Clay Aiken is gay? John Edwards is trying to make a political come-back? Diane Sawyer believes Elliott Spitzer's prostitute is a newsworthy interview? On top of all that shocking ... SHOCKING news, the über right Health Care BS blog (which is curiously never mentioned by the New York Times or Kaiser’s weekly blog round up) decries the Baucus bureaucrats and their dysfunctional price ceilings. He suggests docs oughta be allowed to charge what they damn well please.

The home of the father of health savings accounts isn't THAT far behind and predictably decries narrowing choice, unaffordability and growing government interference.

And to continue this conservative theme, CATO points to far darker implications of the Bauchus proposal for the Republican right. Man the barricades! This is not health care, this is a plot that will win over portions of the South and the West into the Democratic camp with a new public program that promises and improvement of the social safety net.

The Baucus Blueprint for a Call to Action for Healthcare Reform, Part 2

How about chronic illness? Even if the Senator Baucus' Call to Action never sees the light of day, this document gives some useful insight on a prevailing attitude in Congress. In this post, the Disease Management Care Blog pays special attention to the Baucus Blueprint (BB) chronic illness recommendations. No reproduced quotes here about the growing prevalence of disease, stubbornly poor quality and unsustainable costs. DMCB readers already know that stuff and want the bottom lines:

Hanging by a thread but there’s hope: This is rather important, so the DMCB pulled this quote verbatim (italics added): ‘Vendor-based disease management programs, which typically involve phone-based care planning and follow-up by nurses, have found some success in the private market but have not fared as well in recent Medicare demonstrations. While these approaches should not be jettisoned without consideration of new evidence from state and private payer programs, it remains an open question whether Medicare should make direct payments to vendors outside of a comprehensive care management model, such as the medical home.'

To the DMCB this means that under the BB, 1) all insurers except Medicare are free to include disease management (DM) in the benefit if that's what they prefer, 2) there is still time to pursue new evidence about what works and what doesn't, and 3) there is less support for traditional 'stand-alone DM' versus an integrated approach that uses DM as part of a broader care management care system.

Medical Homes remain the darling, but ‘require ongoing evaluation: The BB describes the medical home is described as a 'work in progress' and expansion will require 'ongoing evaluation.' An interesting twist is that the measures have to be meaningful to consumers, not academics, editors, the NCQA, economists, policy makers, partisans, advocacy groups, physicians or politicians. Can the Medical Home consistently bend the trend and reduce claims expense? Until it succeeds where DM has not, the BB urges that coverage not be automatic.

Bundled payments! That's right, the BB mentions 'episode groupers.' In fact, it states Medicare should develop its own 'open-source technology platform' that includes information on both episodes of care and per-capita resource use. This will presumably help ensure that episodes of care are both necessary and efficient. What isn’t mentioned is how this is a first step on the inevitable road to bundled payment. By the way, the DMCB adds, this will also pave the way for no-pay for inpatient readmissions, because they’ll be rolled into the global payment.

And bundle the providers too: The BB praises the assembly of providers into 'Accountable Care Organizations' such as hospitals that employ their own physician staff, academic medical centers and their affiliated faculty practices, multispecialty group practices, physician hospital networks or independent practice associations, and primary care physician groups able to identify the other providers from whom their beneficiaries receive their care. It suggests there should be an ACO pilot in communities and regions where meaningful integration does not yet exist — such as in rural areas and small group practices.

If you don’t measure it, it doesn’t happen: The Blueprint would give the Independent Health Coverage Council described in the prior Part 1 post the ability to set standards for chronic care management and quality reporting. Insurers would be responsible for collecting and reporting the performance of providers in their networks. Presumably, patients would make better decisions about their own care.

Value-based insurance benefit: Out of pocket expenses for recommended preventive services will be dropped.

‘Studies’ and ‘Demos’ remain a fav: The BB asks for a ‘study’ to identify the various federal programs that can help prevent the development of chronic disease and suggests options to more effectively coordinate efforts going forward. There are lots of the standard goodies such as “demonstrations’ for obesity, and grants to nudge local governments, employers, schools, health care systems, communities and individuals to work together and support healthy lifestyles.

And the DMCB offers closing thought about the physicians. As Governor Rendell is discovering in Pennsylvania, if you're going to change the system, it sure helps to have the physicians on your side. The BB has two features going for it: 1) the support of primary care physicians who believe anything is better than the status quo, especially if they get paid for the medical home, and 2) a promise of permanently repairing the Sustainable Growth Rate formula used to threaten all physicians with deep fee schedule cuts.

The Baucus Blueprint for a Call to Action for Healthcare Reform, Part 1

Readers of the Disease Management Care Blog will probably want to pay attention to that ‘Sleeper of the Senate,’ Max Baucus (D – Montana), Chair of the all powerful U.S. Senate Finance Committee. He’s released his own Call to Action, a.k.a a ‘blueprint for healthcare reform’ ahead of any proposals by President-Elect Obama or Reformer-Select Ted Kennedy (D - Mass.). It’s not a legislative proposal but a flexible outline backed by a prodigious number of peer-review references that is intended to guide an ‘investment’ intended to improve healthcare quality, reduce costs and put the system on a ‘more sustainable path.’ There won't be any reform without his input, so when he speaks, Capital Hill listens. So should you.

It promotes employer-based insurance, relies on guaranteed issue of ‘actuarially equivalent’ plans, offers up a publicly financed Federal Insurer, uses a Massachusetts style Health Insurance Exchange (HIE) to match insureds with insurers, temporarily lowers the Medicare eligibility age to 55 years (if you can afford the premium that is designed to be cost neutral until the HIE kicks in) and lowers the income eligibility of generic Medicaid to 100% of the Federal Policy Level. It envisions a new governmental oversight entity called the ‘Independent Health Coverage Council' that will be made up of individuals nominated by the President and confirmed by the Senate ’

The DMCB offers up these observations about the insurance implications of the Baucus Blueprint (BB).

Think of this as play or pay with a tax credit sweetener. The theory is that making all persons buy-in will expand the risk pool. By forcing more low-risk players into the DMCB’s ‘risk transfer arena,’ the average price of transferring risk will drop. That should theoretically should decrease the cost of health insurance but the DMCB points out a) that has yet to happen in play or pay Massachusetts and b) the reason insurance is so expensive is because healthcare is expensive.

A Federal Insurer could be either/both a) an insurer of last resort (designed to avoid 'crowd out' by being a little bit more expensive than the other carriers but, in the end, it will cover you) or b) a competitor that forces the other plans to offer lower prices so that they avoid losing the member months of revenue. The BB appears to favor the latter but uses the former.

The BB's guranteed issue and uniform benefit would force all insurers to compete on price. While unstated, the DMCB suspects that this will increase the insurers' efforts to squeeze savings from the health care system; how well this will succeed remains to be seen. There are oodles of other proposals pertaining to quality - more on that later.

To give you an idea of the scope of the Independent Health Coverage Council, it would define what comprises ‘insurance’ and just what ‘affordability’ is. Big problems command big solutions, but that is an astonishing amount of power. This may be a key stumbling block in the filibuster prone Senate.

The Blues have been cautiously not unsupportive of this and AHIP is mulling this over. The DMCB suspects health insurers are grappling with the prospect of a) more premium revenue thanks to more persons being signed up and b) many smaller regional plans going out of business because they can't afford guaranteed issue. Health insurers will ultimately have to decide if resembling regulated utilities is all that bad.

In its next post, the DMCB will discuss the BB's chronic care proposals and some of the implications for disease management. Hint: things are hanging by a thread and the business model needs to evolve.