Technologic Decline In Health Care: Good News, Though, Robotics To The Rescue (eventually....)

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The Disease Management Care Blog has been delighting in the geopolitical lessons of George Friedman's book The Next Decade: Where We've Been . . . and Where We're Going.  While most of Dr. Friedman's work deals with foreign policy (for example, a better relationship with Argentina can serve as an important counterweight to the emerging power of Brazil and its threats to sea lanes in the south Atlantic), there were two unexpected healthcare insights toward the end of the book. 

They are 1) U.S. technology innovation is in decline and will stay that way for years, and 2) the next area of innovation will be "robotics."

First, the technology.

The United States' twin health care challenges are demography and technology. Most DMCB readers understand the demography: there is an aging baby-boomer population that is well on its way to living long enough to develop degenerative diseases that will sap the available labor pool and cause consumption of expensive services to soar. Yet, the problem with the parallel issue of technology, according to Dr. Friedman isn't cost. It's that technology occurs in waves of innovation that have crested and is now in decline just when we need it.

Technological "waves," you ask? Looking back, Dr. Friedman argues that the first great wave in the 80's and 90's was characterized by the advent of increasingly powerful computers, microprocessors and robust data storage.  Think Microsoft.  The second was this decade's massive data transmission and communication.  Think the Internet. Unfortunately, both technology waves ended with an emphasis on expanding capacity and finding new applications for the existing technology.  In the 90's, personal computers plateaued and Microsoft's business model focused on protecting its business models.  While today's Internet is still being rocked by Facebook and Twitter, the fundamentals of "many to many" communication haven't really changed for years.  Productivity gains from technology have peaked and the rest is, in the author's words, a matter of rearranging the deck chairs.

Despite our investment in medical research, that pales compared to the benefits from military research spending.  Ironically, that, not the Institutes of Health, has been the most powerful impetus to new waves of health care innovation, from penicillin to MASH units to remote robotic surgery. All that is now in decline, thanks to the U.S. focus on applying current technologies (the exception being remotely piloted drones) to a limited style of infantry-based land warfare. Another impediment is America's budget woes combined with the unwillingness of the private financial  markets to commit capital to anything other than safe bets. Add it all up and Dr. Friedman argues that it is unlikely that another technological innovation wave is going to occur before 2020.

Now.... robotics.

Dr. Friedman points out that there aren't enough people to care for all the aging boomers. He says that the answer will be devices that he says "change reality," but could be better termed as capable of manipulating the environment.  When the DMCB thinks about this, aren't all those blue toothed glucose meters, remote blood pressure monitors, telephonic heart devices and other "input" devices merely "half" of what is ultimately needed?  The other half will be "output" devices that administer medicine, generate a treatment, give advice or trigger other responses from the health care system.  They may not "look" like "robots" with a pair of flashing eyes or waving arms, but they will definitely "speak" to their masters and will probably be mobile. 

They will need even higher levels of computing power as well as more powerful batteries. We don't have that yet. 

It's no accident that the military seems to be leading the way on the robotics.  Ironically, the DMCB has a new appreciation for that technology and is now cheering it on.  That's because until they come on line, the only answers we have are 1) drugs that may delay the onset of the diseases plaguing the boomers along with 2) providing palliative services.  Neither options seem to be very attractive.

2020 is about when the DMCB and the spouse are going to be in their 60s.

Disease Management: An Important Piece of the Puzzle Lives On

An important supplement to Population Health Management is now available on line. Even better, it's all open access.

Much of the issue is devoted to the good, the bad and the ugly of the hapless Medicare Health Support program. It's good, because long-term follow-up may show evidence of a return on the government's investment in remote telephonic coaching for chronic illness, bad because modern versions of remote and targeted telephonic coaching continue to be dismissed by policymakers, academics and researchers alike, and ugly because CMS' aptitude as a research partner in MHS was sorely lacking

The Disease Management Care Blog immodestly suggests a good summary of both the supplement contents as well as the policy issues can be found here. Basically, the DMCB argues continued industry innovation, ongoing translational research and a more sophisticated understanding of the role of "disease management" has made the traditional interpretation of MHS moot. Remote telephonic coaching has since evolved to become one piece of the puzzle in caring for populations with chronic conditions.

Disease management: both the term and the concept warrant its inclusion as a viable option for the care of populations by providers, insurers, buyers and governments.

How Did the Disease Management Care Blog Do With Its Predictions for 2010?

Calling Dr. Blumenthal's faulty augury to task is one thing, but applying the same exacting standard to itself is another. While other bloggers are making predictions for the coming year, only the brave Disease Management Care Blog dons a retrospectivescope to conduct a post-mortem on its own soothsaying and ask: how did the Disease Management Care Blog do with it's ten predictions for 2010?

This is what the prescient DMCB foretold:

1. Things are not going to change much. When the sun goes up, insurance rates will increase, busts for Medicare fraud with continue, the academic elite will continue to publish clueless articles and the number of uninsured will remain stubbornly high.

The DMCB modestly suggests it nailed this one. Why else would Ms. Sebelius recast herself as a cost-fighting poly-state insurance commissioner, stuff like this is no longer suitable as front page news, the staid New England Journal is unable to stop itself from saying the Feds can do no wrong while the pro-reform Kaiser Health News would let this see the light of day?

2. The battle has only just begun. Whatever bill gets passed, look forward to continuing mortal combat over the regulations that shape the real authority when it comes to the Fed’s foray into its new vistas of health care.

While the DMCB had it right on the regulations and mortal combat, it didn't predict the scorched earth warfare of "repeal and replace," defunding, and the prospect of hostile hearings spiced with a level of partisanship that includes dancing on the graves of your enemies.

3. Disease management will continue to thrive in its niche. Or rather multiple niches, offering a cafeteria-style suite of low cost and mostly remote care management, prevention and wellness offerings for commercial insurers and self-insured companies. Prevention and wellness will lead the way because most insurers and employers want it but few know how to deliver it. They already have the disease management and will want to keep it.

Here's an example of what one insurer is doing, which is what greater than 95% of all insurers are doing. The Care Continuum Alliance is still going strong and had a 2010 blockbuster meeting. Even the skeptical Vince Kuraitis had nice things to say about disease management.

4. Registries will emerge as a source of new medical knowledge. The rise of terrabyte servers containing all (and the DMCB means all) demographic, claims and medical data will enable startling insights about correlations that were impossible last year and will become routine the next year.

Maybe not routine, but the Institute of Medicine would still agree. The inability to get at the unorganized and largely text data contained within the EHR is one factor that got in the way of succesful multi-source registry development. The DMCB underestimated the EHR's ability to gum this up.

5. The line between insuring and providing will continue to blur. Insurers will provide care services that could be done by the providers in their networks, such as case management and home monitoring. In the meantime, providers will assume partial levels of risk that put them on the financial hook if claims expense exceeds target thresholds.

The DMCB nailed that one too. It's called Accountable Care Organizations and shared risk. Care to predict what the DMCB will have to say about the ability of provider organizations to manage risk? Stay tuned!

6. The advent of PCMH Ver 2.0 or rather Ver 2.a-z. The PCMH will remain more of a concept than any implementable or operational model of care. As the return-on-investment bloom comes off this rose in the many national pilots, its architects will appropriately scramble to tweak the model, perhaps by adopting some of the lessons from disease management.

As of this writing, the DMCB is still unaware of any good studies that conclusively demonstrate that a fully configured PCMH consistently, meaningfully and statistically reduces health care costs. That may be one reason why smarter states are looking at shared service designs that borrow heavily from modern versions of disease management.

7. Social media will expand. Docs will ‘tweet’ each other in hospitals, insurers will push all sorts of web-enabled messaging and the disease management industry will find ever novel ways to combine industrial psychology with cell phone communications.

Well, maybe this has a way to go before it becomes routine, but that didn't stop the enthusiastic DMCB from increasing the concept's visibility.

8. Little to no insurer consolidation. Barring the usual short-term hiccups, the fact that it will be a crime to not buy what the health insurers are selling will give all insurers some breathing room.

The DMCB got this right. As of this writing, profit margins are holding steady and only Dr. Renault would be shocked over the insurance industry's silence over the constitutionality of the ACA's insurance mandate.

9. Republican allegations of the unconstitutionality of health reform bill will have legs. Speaking of which, the DMCB suspects there may be an outside chance that the courts will get in the way of a bill that requires U.S. citizens to buy insurance.

While health reform supporters were initially tut-tuting this DMCB scenario, what better evidence of its credibility than Kaiser Health News' publication of this?

10. The Electronic Health Record (EHR) will continue to disappoint.

It's too early to tell if the HITECH luster of tens of thousands of dollars will finally push docs past the digital divide and into buying EHRs, but there is no shortage of illuminating papers like this and this and this despite Dr. Blumenthal's serene confidence.

The Lessons from 41 Randomized Clinical Trials of Disease Management for Diabetes Mellitus

Which is a better gauge of culinary skill? Using only the finest ingredients to concoct the consummate feast? Or, being able to dress up whatever's laying around in the fridge to make everyone full and satisfied?

The latter has always been favored Disease Management Care Blog when it comes to both cooking and research. It likes taking leftover bits of data and assembling them into a coherent meal after the fact. But that doesn't mean there isn't a role for prospectively staring out with randomized controlled clinical trials (RCTs) to make a repast from the ground up. Now that's tasty!

Case in point is this feast of a study that was published online by the CMAJ. Using the Care Continuum Alliance's definition of "disease management," the authors scoured the published scientific literature for only the finest RCT ingredients and found 41 articles. When the data were baked in a "random effects model," the mean absolute difference in blood glucose control between the intervention and control groups, as determined by the A1c, was 0.51%. Patients with poorer control of their diabetes (having an A1c greater than 8%) appeared to benefit the most. Programs 1) that allowed their nurses to "start or modify treatment with or without prior approval from the physician" and 2) with patient contract at least once a month were also statistically associated with better control. If there were adverse events (like hypoglycemia), they were more likely to occur in the control groups.

The Disease Management Care Blog didn't know that there were so many RCTs how well disease management works. A mean drop in A1c of 0.51 is also both statistically and clinically significant. What is particularly savory are the operational implications of the research: glycemic control is more likely if disease management coaches 1) operate at the "top of their license," 2) contact the patient at least once a month and 3) are reserved for patients at greater risk - not every patient needs to be or should be called by the nurses and, when they do get involved, patients are NOT put at risk.

Here's the reference for your quoting pleasure:

Pimouguet C, Le Goff M, Thiébaut R, Dartigues JF, Helmer C: Effectiveness of disease-management programs for improving diabetes care: a meta-analysis. CMAJ 2010. DOI:10.1503/cmaj.091786

Image from Wikipedia

The Disease Management Care Blog Welcomes A New Health Care Trade Association

According to Wikipedia, a "trade association" is a collaborative organization made up of businesses that operate in a similar area of commerce that pool resources aimed at a) public relations (education, advertising and lobbying aimed at influencing public policy) and b) standardization (uniform engineering or technical specifications, criteria, methods, processes, or practices). If form follows function, the December 16 "Innovations Across the Nation in Health Care Delivery" conference was about as trade association as you can get.

The purpose of the day long confab hosted by the folks at Health Affairs was to showcase healthcare organizations "that have innovated at the patient care level, created more highly coordinated patient care systems and improved population health." The showcasing was prominently directed at the leader and staff of the newly established Center for Medicare and Medicaid Innovation (CMMI) who treated the conclave as another one of their many listening sessions.

The Disease Management Care Blog listened in too. Once it got past the enthusiasm, PowerPoints and data, it concluded that much (not all) of the day consisted of reports of strained credibility, generalizability and scalability. The DMCB counted nine presentations relying on unsophisticated "pre-post" methodologies to support their triple aim claims, while four others contrasted their cost savings vs. projected costs of unknown pedigree. Most of the practice settings had unique cultures, economics and leadership styles that would be challenging to export elsewhere. Many also involved a local commitment of financial or organizational resources that seemed out of reach of most provider settings, even with CMMI's $10 billion.

It wasn't until the DMCB made full weekend use of spiritually-based libations to commune with the health service research and policymaking gods that it divined that it was probably the last person in the room to recognize what was really going on. Hidden under the patina of evidence-driven policymaking was a five-fold vision: 1) large not-for-profit provider groups using 2) primary care medical homes in 3) regional care systems driven by 4) an academic government alliance using 5) insurance levers to ultimately control health care. Check out at the videos and the listening will reveal classic "trade associating": a) education really aimed at convincing an already favorably predisposed CMMI coupled with b) an emerging evaluation standard that doesn't include rigorous research methodologies. All that's lacking is name, set of bylaws, a red ribbon ceremony and directors. Perhaps this will make do in the meantime?

While DMCB has been skeptical about CMS' ability to actually "innovate," it likes the "systemizing" of medical practice as well as the reorganization of primary care. The DMCB also knows trade associations are important and that their support by medical journals or government is not unusual. So, it would like to be among the first to welcome the colleagues named in this Agenda to getting the recognition they deserve. May you and yours be blessed with regulatory favoritism and being mentioned in legislation. May the organizations that want to be like you get those 6 or 7 figure grants and thousands of frequent flyer miles earned to and from Dulles-IAD.

In a future post, the DMCB will examine the implications of this in greater detail. It will also cull out the few presentations that had some useful data and insightful lessons for it's colleagues in the population health management community.

Disease Management, ie Population Health Management Organizations (PHMOs): Plan B to Support the Creation of the Patient Centered Medical Home (PCMH)

As the Disease Management Care Blog has previously pointed out, there is is a lot that the disease management industry has to offer the Patient Centered Medical Home (PCMH). That's why it agrees with this webinar summary that appeared in the latest issue of Population Health Management.

In it, Darren Schulte MD of Alere points out that expectations for the PCMH are very high. Its value proposition includes reversing the decay of primary care, meeting the consumerist needs of an aging population, increasing quality and securing additional practice income. A growing body of evidence suggests that the more successful PMCHs have 1) a dedicated non-physician patient coordinator, 2) expanded in-person and virtual patient access, 3) health information technology that includes a functioning registry and point-of-care decision support and 4) increased practice income. Without these key ingredients, PCMHs have an uphill battle managing a population of patients, building a team-based culture and marshaling resources to change patient behavior.

Enter disease management vendors, although Dr. Schulte prefers to use the politically correct term "population health management organizations" (PHMOs) They have decades of experience in patient education, monitoring, self management, treatment adherence and care coordination. Despite physician skepticism and a cultural bias that favors "build" over "buy," he argues that PCMHs may find PHMOs attractive not only because they're speaking the same language, but because their services are "plug n' play" and highly adaptable across a wide variety of small to large settings. All that needs to be worked is out how PHMO support will be paid for so that the PCMH succeeds.

Enter Dr. Greg Sharp of Ideal Family Healthcare in Woodland Park, CO. He notes that health insurers have a key role to play because they're not only providing the additional monthly payments for the PCMH, but they're being called on to support health information technology solutions and provide work-flow consultation services. Since insurers are very involved anyway, he implies that it's not a great leap form them to also facilitate the sponsorship of PHMOs in the PCMH network. Once that happens, he sees few barriers standing in the way of PCMH team members virtually working with remote or in-person PHMO health coaches, accessing the PHMO's registries and relying on PHMO decision support tools.

The acronym addled DCMB likes this description of how insurer sponsored PHMOs can help PCMHs. For a fiduciary and risk-bearing health insurer, the DMCB agrees that the road to patient behavior change, prevention and savings in medical homes may run through disease management. The DMCB suspects many primary care practices won't necessarily want to create (training the non-physicians in behavior change and coaching?) or be able to afford (buying the hardware and programming expertise to create a fully functioning registry?) all the features of a fully transformed PCMH. Calling it "PHMO" instead of using the scorned term "disease management" will also increase its acceptability.

Smart health insurers will recognize that there will be primary care sites that want to go their own way in establishing PCMHs. That's fine. For those primary care sites that may not have the resources or the inclination to build a fully functioning PCMH, bringing in a "population health management organization" vendor is a good Plan B. That disease management Plan B is a rose that by any other name still smells as sweet in the science of increasing quality and optimizing costs.

The Definition of "Disease Management" (with other definitions)

Thanks to prior postings in the Disease Management Care Blog, readers have had access to handy and literature-based definitions of "patient centered care," "care management" and "value based insurance design." Not only can regular readers quote them with confidence, insert them in company-wide memos, amaze colleagues with deep subject matter expertise, bore the DMCB spouse and use them against know-it-all consultants, the definitions make for perfect verbal swordsmanship at that next staff meeting. For example:

"Er, exsqueeze me Bob, but everyone at this meeting except you knows that care management should also be postured to reduce the duplication of medical services!"

Then it occurred to the DMCB that it had not blogged about the definition of disease management. Now that is an embarrassing lapse. The term may have lost much of its brand luster among the vendors and is no longer de rigueur among the policymaker elites, but the contrarian DMCB still predicts the catch-phrase will eventually make a comeback. In happy anticipation of its eventual resurrection, the DMCB proposes this formal definition:

A package of mutually supportive interventions to improve quality or mitigate the insurance risk of a population defined by the presence of a chronic condition.

This short and efficient definition is good because 1) it emphasizes disease management's multi-dimensional nature, resulting in a synergy that is greater than the sum of its parts, 2) it recognizes that in addition to quality, there is merit to controlling costs and doing so in the context of health insurance; in other words disease management and managed care are inextricably intertwined and 3) it transcends one-on-one care, akin to "applied" health services research that also studies defined cohorts. One other feature that favors this definition as eminently quotable is that it has also been published in the peer-reviewed literature (1).

The DMCB also looked up the old and more lengthy DMAA definition of disease management. For the sake of completion, it's reproduced below. Fortunately, it's also been memorialized in the medical literature (2) for your quoting pleasure:

"A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant:

• Supports the physician or practitioner/patient relationship and plan of care,

• Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and

• Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

Disease management components include:

• Population identification processes

• Evidence-based practice guidelines

• Collaborative practice models to include physician and support-service providers

• Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance)

• Process and outcomes measurement, evaluation, and management

• Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling)

'Full-service disease management programs' must include all 6 of the above components. Programs consisting of fewer components are 'disease management support services.'"

Other definitions have been proposed. There is a list here and a table with other definitions was published here, courtesy of the American Heart Association (2).

As a further service to it's readers, the DMCB has reproduced the definitions of "patient centered care," "care management" and "value based insurance design" below along with the necessary citations. In addition, there is a paraphrased definition of "population health improvement," which has been put forward courtesy of the Care Continuum Alliance (CCA).

Patient centered care any care that is "respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" (3).

Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services (4).

Value based insurance designs are health insurance designs that reduce patient out-of-pocket expenses for covered services that provide important medical benefit relative to costs (5).

Population health improvement is paraphrased by the DMCB as a package of services that identifies a population, conducts a needs assessment of that population, provides health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles, promotes health management goals and education as well as self-management interventions aimed at achieving behavioral changes. routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers with ongoing evaluation of clinical, humanistic, and economic outcomes. the full definition can be found here.

References:

1. Sidorov J, Schlosberg C: Disease management and the Medicare modernisation act: "It's the insurance, stupid." Disease Management December 2005;8(6): 331-338

2. Krumholz HM, Currie PM, Riegel B et al: A taxonomy for disease management. Circulation 2006;114:1432-1445

3. Epstein RM, Fiscella K, Lesser CS, Stange KC: Why the nation needs a policy push on patient centered health care. Health Affairs 2010;29(8):1489-1495

4. Bodenheimer T, Berry-Millett RL Follow the money - controlling expenditures by improving care for patients needing costly services. New Engl J Med 2009;1521-1523

5. Chernew ME, Juster IA, Shah M, Wegh A, Rosenberg S, Rosen AB, Sokol MC, Yu-Isenberg K, Fendrick AM: Evidence that value-based insurance can be effective. Health Affairs 29(3):530-536

Insights from the Care Continuum Alliance Meeting: Federal Planning, Small Low-Overhead Practices, Full Risk Contracting and Social Networking

A number of insights from attending today's Forum10 in Washington DC:

It seems that once D.C. policymakers get armed with Federal health legislation, they like nothing better than to talk-circuit with bubbled, arrowed, jargon-filled and notion-addled PowerPoints. The Disease Management Care Blog witnessed this first hand today, when it learned from a plenary session speaker that our government is developing a national health agenda that will drive measurement and change quality for the better. All well and good, says the DMCB, but the fact is that it's locally developed programs that have always been the source of real innovation, and that they only use the Feds' resources only when they add real value. The conceit was astonishing.

If physician income is no object, it's possible to set up a small, low-overhead, limited panel clinical practice and still take good care of patients. It may mean that the docs escort the patients back to the single examining room themselves, draw up and administer their own immunizations, carry a cell-phone 24-7 and create their own primitive records on desktop PC's. That was not surprising to the DMCB - what was interesting was the physician-speaker's assertion that doing all that gives that clinic a head start on getting NCQA recognition as a medical home. Will "concierge practices" add claims of also being a medical home to their other supposed virtues?

Conduct one big study of a disease management/telephonic care management program that shows a big return on investment. Check. Get it past peer review to make sure that what you think you've found is correct. Check. Conduct a bunch of similar in-house studies involving other clients that show the same thing. Check. Then, and only then, can you be confident enough to go to market with that program with a guaranteed, full-risk contract option. To do otherwise would be foolish.

Did you know there are 105 million Twitter users? 400 million on Facebook? That there have been 6.5 billion views on YouTube? Yet, while the telecommunications, computer, specialty retailers and the food industry have all tapped into this "social networking" phenomenon to great effect, the health care industry is still looking at it as an answer that's in search of a question. While there are some health care examples of social networking like hospitals (that use it to market and get patient feedback), patient communities (an example is PatientsLikeMe) and the Centers for Disease Control and Prevention (podcasts and videos are out there extolling the virtues of influenza immunization), this has yet to truly fill it's potential. Consumers are worrying about privacy and they'll only use social networking if it yields better information than a simple Google search. As you ponder this for your company, think about issues involving 1) identity (how much personal information must users share?), 2) authenticity (is this really good from the users' points of view?), 3) accessibility (you cannot afford to have your site go down), 4) reputation (users may not trust managed care-run networking, no matter how well-meaning) and 5) reciprocity (this is two way). These and other insights are courtesy of Deloitte. You can read more here.

What Can Baseball Teach Us About the Return on Investment (ROI) of Disease Management? Nothing, Actually.

Growing up in New York City and then living outside of Philadelphia, you’d think that the Disease Management Care Blog would have a better appreciation for major league baseball. It likes the stadium spectacle (and food), but league standings, box scores, individual player statistics and television game play is as soporific to the DMCB as looking at the aortic valve “Mercedes Benz” sign on an echocardiogram. Try as it might DMCB cannot understand what gets baseball fans and cardiologists so atwitter.

Maybe it's because the DMCB thinks because baseball is so linear. The entire game consists of a series of singular events involving individual players surrounding one ball occurring over the time dimension of nine innings. Sure, there are other moving parts, enormous talent and high drama and but the game has a compelling degree of compact simplicity.

To each their own, says the DMCB, which is one reason why it tried to compact the moving parts, talent and financial drama of disease management (DM) into a (curvi)linear display. This is an admittedly very simplistic and not-drawn-to-scale graph of what financially happens to the return on investment in an ideally executed one-year DM contract:

The black line represents the typical accumulated savings of a well run disease management program over time. Thanks to the use of health risk assessments and predictive modeling, the patients that initially get recruited in the program are those that are a) most vulnerable and b) most amenable to care management coaching and outreach. They’re “rescued” from unnecessarily visiting emergency rooms and being unnecessarily admitted to the hospital. Note that savings grow rapidly. With time, additional patients at lower risk are recruited, but since they’re at less risk, the savings curve begins to flatten out. As more patients get recruited, it’s possible that savings can erode, because the low risk/low utilizing patients can ironically be prompted to seek out additional care services.

The red line represents the cost of the disease management program over time. Initially, there are steep and fixed start-up costs which then slow down over time but never flatten. As additional patients get recruited, more personnel and infrastructure are required for coaching and follow-up. If the program pursues each and every additional patient with multiple attempts at outreach, costs can accelerate.

The small yellow area displays when the savings exceed the cost. That means the "return on investment" (ROI) is positive. That doesn’t happen early in the program and it doesn’t happen late: it's in the middle. Early and late in the program, there are losses. Also note that the ROI is a moving target that changes that as more patients get recruited. This also explains why a positive ROI can be achieved when far less than 100% of patients are engaged in DM.

Of course, this is very rudimentary and doesn't take into account the moving parts of the baseline utilization patterns, the enormous talent of the nurse-coaches and the high drama of how costs and savings are actually calculated.

Every baseball game is arguably unique, but DM is far more complicated. It's sort of like baseball, but all the players have bats, there are 100 balls, pucks and Frisbees in play and the bases move as the game goes on. That's one of the reasons it's so much fun.

The Playbook Used by the Food & Beverage Industry to Avoid All Blame for the Obesity Epidemic, and What Disease Management Can Do

The Disease Management Care Blog thinks that the disease, care and population health management providers deserve a lot of credit for leading the way in our national battle against obesity. This industry "gets it." It's more than just "consumer education" and go-see-your-PCP about starting a diet. While those elements are certainly necessary, disease management also knows about consumerism, engagement, overcoming barriers, behavioral theory, relationships, life-style management, being realistic and follow-through. These vendors are getting far more savvy about studying outcomes and using those data to continuously improve. They are participating in coalitions, joining public health initiatives, off-loading overburdened physicians, establishing partnerships, leveraging community resources, and formulating a compelling business case. They can do all that and still end the day with a tidy profit.

The DMCB also figures the disease management (DM) industry is also well aware of the cynical speciousness of the food and beverage industry's public posture about obesity. At the same time it's intentionally packing calories and salt into servings are both unhealthy and excessive, the food and beverage manufacturers have somehow escaped being lumped with tobacco and pharma. Something is terribly wrong with this picture.

That's the topic of an October 6 JAMA paper by Jeffrey Koplan and Kelly Brownell aptly titled "Response of the Food and Beverage Industry to the Obesity Threat." It's worthwhile reading for those combating the obesity epidemic. It gives special insight on how that industry combats greater scrutiny and regulation as well as why overweight patients desiring to lose weight can be so misinformed. This is important to know about so that patients can be better educated, know what they're up against, overcome barriers and better manage life-style choices.

Drs. Koplan and Brownell's report on the food industry's strategy is summarized below for DMCB readers that may not have full access or lots of time:

Associate with a widely respected health organizations: this gives the casual observer that the industry's wares are good for you.

As the DM industry's role in the crusade against obesity grows, it should probably resist any affiliation with the businesses that profit from making people fat.

Associate with a widely respected connotation: this generates the impression of wholesomeness. The authors mention featuring svelte exercisers on the packaging and in TV commercials, but the DMCB thinks claims of being "green" are also part of the mix.

Ironically, a disease management care plan with overemphasis on exercise as a cure for obesity is playing right into the food and beverage industry's hands. That has a role to play, but the key thing remains smart food choices and long term calorie restriction.

Reframe the issues: instead of addressing the merits of caloric excess, the idea here is to move the focus onto caloric neutrality (a serving of broccoli can be equal to a side order of fries), "in versus out" caloric balance (hence the intrusion of exercise as a fix for being fat; think about that the next time you watch Biggest Loser), keeping collateral societal costs out of the discussion ("even though half of all obesity related costs are paid for with public funds") and trumping free markets (we have a constitutional right to be fooled into making bad decisions).

At the individual patient level, part of the strategy of coaching is to help patients keep their eye on the caloric ball. Thanks to its growing visibility at various policy-making levels, the DM industry should continue to step up and shine a light on those collateral costs and take a greater leadership role in figuring out ways to help people make right decisions. Kudos, by the way, to the Care Continuum Alliance for doing its part.

Deceptive advocacy: this is setting up faux grass roots groups that are allegedly against regulation and taxation.

Hey, it's free speech. The DM industry needs to fight fire with fire.

Deceptive science: consisting of sponsoring biased studies and creating hollow self-regulating standards based on those biased studies.

The DM's industry's long tradition of tapping into vetted guidelines has been an important counterweight in its care for millions of Americans. It needs to stick to that tradition and educate policymakers and politicians about what works - and what doesn't.

Product formulation: it may still be the same air-filled puffs of fructose and fat, but add some vitamins or fiber and "voila!" the overwhelming impression is that it's now good for you.

In its day to day interactions, this and other attempts at caloric camouflage need to be countered one patient at a time. It may be that no patient coaching is complete without addressing that particular falsehood.

Go on the attack: it's not enough to deny any harm. Rather, get a stable of loyal talking-head scientists, lobby heavily, fight every unfriendly public health measure and label opponents as enemies.

The DMCB is looking forward to the day when a member of the DM industry is attacked by the food and beverage industry or one of its lackeys. They we'll know we're getting somewhere.

Millennial Generation Physicians and Disease Management

Oh, those "Millennials." Also called "Generation Y," this is the American demographic group born during and after the '70s, that was vicariously raised by "learning is fun" Sesame Street and became accustomed to getting awarded for any effort. They don't know about bomb shelters, walking to school, tape decks or having to get up to change a TV channel. Well, they're now entering the workplace and their informality, disregard for rank, fun-addled lifestyle and astonishing career expectations are making management rather interesting for their Boomer bosses. They're also the medical students, residents and young physicians who are shaking the health care culture up by a novel expectation about working to live, not vice versa.

The Millennial non-attitude about status or rank has implications for the hierarchical command and control that, up until now, has has been overseeing health system. No longer will a VP for Medical Affairs be able to assume young physicians will readily agree to taking "call" in evening outpatient clinics to off-load unnecessary emergency room visits. If a Grand Rounds speaker lacks sufficient eye-candied edutainment in PowerPoint, all the more reason for those young docs to skip out, grab some tofu and surf some YouTube. White coats will be optional and these docs will default to a first-name relationship with their patients.

While that topic may be worth a post in the future, the Disease Management Care Blog thinks there is a far more important trend afoot: the Millennials' "paradigm" is good news for disease and population-based care management.

Witness the Institute of Medicine's report on The Future of Nursing (summary here), which points out that "scope of practice" laws are not necessarily aligned with the profession's skill set, that nurses can be partnered with physicians for mutual benefit and that they can help meet the United States' burgeoning demand for health care. While physicians have been traditionally dyspeptic over the "hot button" issue of independent practice and the intrusion of nurses into the doctor-patient relationship, the DMCB has a prediction about a far more mundane issue: when it comes to non-physicians and disease management, the coming generation of docs will be far less worried about issues of rank, credentialing or licensure and far more flexible over relationships, skill sets and outcomes.

It simply won't concern them. They won't even think the IOM Report is all that noteworthy and they won't mind if a care management nurse is semi-autonomously involved in the care of their patients, just so long as it works.

What's more, they're far more likely to be comfortable with the idea of "virtual" patient interactions involving calls, e-mails and social media. The Millennials have never lived without e or voice-mail and they're the ones that powered texting, Twitter and Facebook.

Last but not least, if a nurse care manager can help them get done by 4:30 PM so they can go to little Johnny's soccer game, even better.

The arrivals of the Millennial physicians are another reason to be bullish on disease management.

In Further Defense of the Term "Disease Management"

We have much to be thankful for in that curious mix of popular mainstream media, 24/7 news cycles and the Internet. In addition to making us so much brainier, our unending connectedness is also helping us to establish new cultural standards. Examples include Lady Gaga's recent meat and greet fashion trend (fans could really see her in the flesh, adding a whole new dimension to the notion of girding one's sirloins... with beef briefs), the totally unexpected SHOCK of the New York Jets' sexist buffoonery when a woman appeared in the team locker room, the laudable courage of State politicians' ability to command improvements in healthcare with the mere stroke of a pen and the use of, er... lawn sausage as a popularity baseline. Case in point is the smart Vince Kuraitis' recent e-CareManagement blog post that reviews the non-merits of the term "disease management" (DM).

Vince brings up the usual criticisms of DM: in this politically correct age, persons really have health challenges, not "disease," while "management" is contrary to our notion of consumer-patient centeredness that is really the province of providers, not physicians. Let's also face it: the DM industry was too uppity. When it stumbled, physicians and the CMS staffers took their just revenge, sealing the comeuppance an eternally negative brand and droopy vendor stock prices. It only makes sense, then, to look beyond the DMCBs use of mere Google page counts and compare the term disease management to established mainstream cultural standards, as Vince has so ably done.

Lesson learned. In fact, the DMCB will stop feeling good about its thousands of weekly hits and compare its web footprint to something that really matters, like the traffic to this YouTube video of a hand-fart rendition of the Star Wars Imperial March.

Why, then, would the wonky and web savvy DMCB remain so blindly loyal to the term disease management?

1. The physician DMCB thinks diabetes, asthma, heart failure, atherosclerosis, hypertension, obesity and other chronic conditions are ultimately diseases. Caring for them involves a combination of treatment approaches that can be packaged into a state-of-the-art management. Nothing about that precludes the patients' participation with their doctors' help. Disease and management may not have cachet but it's still a good description of the reality. What's more, the term is still used in C-suites, national meetings and strategy sessions.

2. While, at its peak, disease management was an all-things-to-all-people panacea, greater market discipline has led to a more precise definition: the use of a package of mutually supportive interventions to improve quality and/or mitigate the insurance risk of a population defined by the presence of a chronic condition.

3. There is plenty of recent peer-reviewed science that is still using that term to describe impressive outcomes. Examples include this and this.

4. While eCareManagement has correctly noted that 1,300,000 Google pages using the term "disease management" is er..... comparatively modest, the term "patient centered medical home" has appeared in 121,000 pages, and the term "accountable care organization" has appeared in 37,700 pages.

5. Health care advances generally also have their own life cycle of high enthusiasm, followed by an over-reacting crash of bitter disappointment and disdain followed, in turn, by intelligent adoption. The Disease Management Care Blog thinks DM has climbed out of the trough into being a standard part of most insurance plan networks. The Medicare FFS benefit exclusion is the exception and certainly not evidence of Medicare's leadership in this area; rather, they're behind the times. By the way, the PCMH and ACOs are almost certain to follow the same glide path.

6. Plus the DMCB doesn't want to go through the hassle of changing its name,

and, last but not least....

7. When the term "disease management" makes a come-back, the DMCB will be well positioned and be able to continue to share the health policy limelight with e-CareManagement

Disease Management: A Rose By Any Other Name

In its moments of fancy, the Disease Management Care Blog likes to imagine that it's one of the uncommonly reasonable voices in the healthcare wilderness. Because it links a lot of the peer-reviewed scientific literature, it fancies itself as an island of insight in a sea of evidence-poor rhetoric. Maybe it's better thought of as a narcissistic wannabe that needs to rethink its dreams of vast blogging revenue. Whether the thousands of regular DMCB readers plus one spouse agree with any of those assessments remains an open question, but one thing is clear: the DMCB is one of the remaining intellectual redoubts that's still loyal to the term "disease management."

It wasn't too long ago that acclaim was awarded to to anyone with those two words on their lips. The term's appearance on marketing materials guaranteed fat contracts. Including "disease management" in the title of a manuscript or as a proposed MeSH term was scientific journal editor catnip. That and its inflated jargon (engagement! outcomes!) was enough to prompt a HHS Secretary to turbocharge an industry. Health insurer execs coveted disease management more than their ability to deny life-saving transplantations in children. Budgets doubled, titles inflated and careers were launched.

We all know what happened next. The downward spiral of incredulity reached critical mass when the debacle called Medicare Health Support transpired. When the depths of physician hostility became apparent, it was almost a near death experience. Recriminations led to corporate retreats, which then revamped business models and refreshed branding. Among the many outcomes was that the moniker "disease management," like Britney Spears, partially hydrogenated fats and Teletubbies, lost its luster. Even the "Disease Management Association of America" dropped its name in favor of "DMAA, The Care Continuum Alliance."

But seriously, change happens and, to paraphrase a famous bard, a rose by any other name still smells as sweet. While newer versions of remote coaching services for chronic illness are still going strong, end-to-end and interlocking care programmatic interventions in wellness, prevention, workplace health promotion, behavioral health, technology-enabled care, pharmacy and complex care management are providing a potent mix of patient services to the vast majority of self and fully insurance programs plus the Medicaid insurers. If its big and it's tackling quality and cost in cohorts, networks, populations or books of business, it makes little difference what you actually call it.

It should be no surprise, then, that the DMAA has just changed its name again, erasing all traces of those two words. The newly stamped Care Continuum Alliance represents a huge multi-dimensional industry with a critically important role to play as health care continues to evolve. You can read all about it here.

Call it a foolish loyalist, but the steadfast DMCB is sticking to its guns. Do a Google search on the phrase "disease management" and you'll find that the number of web pages appearing with that term in the last year number over 1.2 million. Perform a search for peer-reviewed published literature using the term "disease management" in the last five years, and you'll find there are more than 7000 articles. Finally, there are over 500,000 blogs that have used the phrase.

In fact, the DMCB predicts the term "disease management" will make a comeback. And its not because of Healthway's hot-off-the-presses release about its achievements in that watershed Medicare Health Support pilot mentioned above.

In a future post, the DMCB will explore why it thinks the phrase "disease management" may still have legs.

In the meantime the DMCB is proud to announce that it's come up with it's own logo. Good bye flamingo eyes.

Disease Management and the Patient Centered Medical Home: Moving the Entire Curve

With all the usual reservations, the Disease Management Care Blog basically buys into the prevailing Dartmouth Atlas belief that the United States has a problem with both over and underutilization of health care services. So do the Feds. For years, Washington has been pursuing areas of underutilization, for example, with programs to reduce disparities and support critical access hospitals. And thanks to the insights of Dartmouth Atlas, overutilization is now being tackled with programs that, for example, bundle payments and deny coverage of unnecessary services.

Both approaches, however, can be criticized because they're all about "chasing the tails." Whenever any performance data are arrayed from high to low, they'll generally follow a Gaussian Distribution. Most hospitals, physicians and other service providers generally cluster around an average, with both high and low outliers at either ends of the curve. In thinking about this, the actions of the Federal government described above are all about attacking the extremes of the curve, i.e., the outliers.

All well and good, says the DMCB, but it prefers care approaches that address the entire curve, since that approach benefits everyone. Low end critical access programs and high end bundled payments aren't really going to do much for persons with satisfactory access to hospitals with middlin' levels of utilization. The patients in the middle deserve better.

Which is one of the reasons why the DMCB likes population-based care and disease management. When credentialled non-physicians start coaching patients, the entire curve can shift in the right direction and the outliers move toward the middle. The DMCB hasn't seen much published on this specific topic, but when it conducted an in-house analysis on the impact of disease management some time ago, that's precisely what it found.

How could this work? In a diabetes population, persons on the "low end" who haven't had an appointment with a provider would be prompted to do so and directed to the nearest clinic with access to care. Persons on the "high end" who are on multiple medications and who are seeing multiple providers could be directed to a primary care provider. In the meantime, patients and providers in the middle would be prompted to foll0w cost-effective and high quality clinical guidelines.

Problem solved.

By the way, the DMCB thinks this is an under recognized benefit of the Patient Centered Medical Home (PCMH).

If any readers are aware of any peer review or in house studies that examine this phenomenon, please share.

Star Wars' Master Yoda Advises President Obama on Health Care Reform: Communicating, The Role of Experts & Top 100 Lists

The virtual Disease Management Care Blog has learned to navigate the duality that bridges particles and waves, channel dark matter and access the cosmic video game that governs humankind's Sim-like existence. It is in that polymension that the DMCB discovered that President Obama and Yoda have communicated.

This exchange was plucked from a bosonic mimetic string and is shared as a DMCB exclusive for your reading pleasure.....

Mr. Obama: Master, my poll numbers on health care reform are in the crapper. I've blamed the insurers and the conservatives again to try to generate better support, but it's not working. What is your advice?

Master Yoda: As wily Cato described has, using the Force is the product but the pitch not. To recognize the flaws in the Affordable Care Act and seek to correct them, you need, young knight!

Mr. Obama: But, Master, I don't have time for that. Midterm elections are a less than a parsec away. What do you think about giving some more speeches in a tour of the heartland, like the Great Communicator?

Master Yoda: The difference learn between communicating and oratory, you must. Yes, hmmm.

Mr. Obama: But President Reagan....

Master Yoda: Silence young one! Speak the name of the greatest Jedi Knight that ever lived, do not. A rare Gladwell Academy Outlier he became.... spent decades writing and giving speeches training his superb communication talent. Many thousand hours at Earth poultry dinner gatherings helped him his skills hone. Just a rookie novice you are. Yeesssssss.

Mr. Obama: Hey, let me remind you that you're just a mix of green latex and computer animation, while I'm President of the United States and Number 1 on this list of the 100 most powerful people in health care.

Master Yoda: Silly, are you. Other insider insurance execs, ivory tower policymakers, politicians and bureaucrats in a closed information loop on that list, see you, hmmm? A way to retread old news and generate web traffic, "Top 100" lists are. Little green droppings on them, I leave. Blah!

Mr. Obama: Hey, now you're sounding like the party of no that got us in this mess in the first place!

Master Yoda: Work on me, your tired rhetoric will not [whack with weenie cane here]. Advise to jettison your mistaken notions into deep space, you I do. Best find advisors who on that Top 100 list are not.

Mr. Obama: But my administration's policy making is being formulated by the brightest folks this country has to offer!

Master Yoda: Of great danger, over-reliance on experts is. Commune exclusively on Planet C-SPAN do they, pretending that Federal healthcare Jabba the Hut is not. Lack day-to-day understanding of patient care, they do! Publish in journals that are read by few. Instead, hologram message view you must from New York Times about the future of publishing, using the wisdom of crowds this is.

Mr. Obama: You are truly wise, Master Yoda. My last question is how I can get the First Lady to don Princess Leia garb.

Master Yoda: Ahhh, brazen young pilgrim. Eternally wise DMCB also frequently that asks. Thinks its spouse looks better than a new star drive when sport she twin buns of hair, says it. When the answer to that find, a true Force become, shall you!

More On Those "Right" Patients for Disease Management In the "Middle"

Thanks to everyone who requested a copy of the Disease Management Care Blog PowerPoint slide describing those "right" patients "in the middle." As regular readers may recall, the DMCB argued that care management may be best reserved for the relatively lower number of health insurance enrollees that fall within a more moderate risk profile.

The DMCB also got some great feedback. The most insightful was from an email by Bob Stone of Healthways, which is (mostly) copied below:

I would be comfortable with that conclusion if it was caveated to reflect the growing understanding that they’re the group to target for short-term improvement and return. The evidence is also abundantly clear, however, that next year’s middle and high risk patients are most likely to come from the lower risk profile groups. Most studies – including the ones you cite – don’t run long enough to capture that dynamic.

Exactly, says the DMCB. The "logic of the middle" only works in economic environments where care/disease management contracts with their performance guarantees extend from one fiscal year to another. As one seasoned nurse executive taught the DMCB, the irony of that approach is that after three years or so, it's typical for the "return on investment" from these programs to trail off. Risk can be managed within a year, but it seems insurance beneficiaries have a habit of living year after year after year....

Bob Stone takes the irony one step further. He points out that the disease management programs that use this "middle" business model are ultimately the product of a myopic "sickness" care system that fails to deliver what patients really want and what society really needs: better wellness and prevention programs that function many years further upstream. Until America achieves that, we're going to spend precious treasure figuring out how to spend less of it.

Good point.

Increase Government Involvement in Quality/Cost of Health Care, Watch Public Trust Go Down. Here's Why

It would be ironic, wouldn't it? While the federal government's involvment in health care is increasing, the level of public trust is likely to go down.

The Disease Management Care Blog explains.

Remember the Patient Self Determination Act (PSDA)? When it was passed twenty years ago, the federal requirement that institutional health care providers and managed care insurers provide information about "advanced care directives" was largely a non-event. At the time, there was very little government visibility over issues of quality and cost, so there was no basis to doubt the Feds' intentions. Consumers and voters interpreted the PSDA as righteous and noble thing. Hospitals and insurers complied and that was the end of it.

In the meantime, however, managed care insurers were meddling in the thousands of quality/cost decision points involved in benefit design, adjudication of the benefit, determining medical necessity, precertification, concurrent review, network development, denials of coverage and appeals. As readers will recall, that often boiled down to denying coverage. Healthcare consumers quickly learned to distrust their insurers because they discerned that there was a huge conflict of interest between making a profit (by denying coverage) and serving a patient (by paying for medically necessary treatment). Through it all, Medicare and Medicaid were the role model and above suspicion: they paid for everything.

Things have obviously changed. From President' Obama's red pill/blue pill remarks, to the Fed's interest in "comparative effectiveness research," to the fixation on the Dartmouth Atlas to rising concern over ballooning deficits, the government's insistence on showing leadership over quality and cost has a down side. Just like with the commercial insurers, persons now have a reason to question the intentions of the Affordable Care Act's (ACA) evolving laws and regulations that could - correctly or not - be interpreted to mean that saving dollars will come before saving lives.

This is why the DMCB thinks the lingering radioactivity of the "death panels" controversy is unlikely to go away anytime soon, and why trying to bend the cost curve by decreasing spending in the last year of life is dead in the water. While the President's supporters can blame underhanded partisan politics, unscrupulous Tea Baggers, AM radio talk shows and poor messaging, an under recognized ingredient is the inevitable link between having to manage cost/quality and consumer suspicions that you're doing it at their expense.

On behalf of all health insurers out there, the DMCB wishes CMS a hearty welcome to their world.

Medicare and Payment Innovation

The Disease Management Care Blog is very much looking forward to participating in a closing afternoon panel discussion in Washington DC this July 20. It'll be at the 6th Annual Leadership Summit on Medicare. The DMCB will be fortunate to be sharing the dais with Stuart Guterman of the Commonwealth Fund's Program on Payment System Reform and Len Nichols of George Mason University's Center for Health Policy Research and Ethics. By the way, the DMCB is also pleased to recognize both institutions' blogs (here and here) presence among the blogmos.

Is the DMCB anxious about being on a podium with such obviously smart speakers? Absolutely. Especially when the topic is "payment innovation in Medicare," including the coming pilots and demos, the mechanics of state and federal partnering, what's working and what's not and, last but not least, what the future holds.

To prepare itself, the DMCB has developed a kinder and gentler version of the sometimes obnoxious "talking points memo." It'll probably print out a copy of this blog and refer to it during the proceedings.

1. Does Quality Always Mean Lower Costs? Underlying much of D.C.'s interest in "innovation" is the assumption that clinical and organizational quality and efficiency inevitably lead to reduced claims expense. Unfortunately, while the notions certainly make intuitive sense, proof in many corners of the healthcare system has remained remarkably elusive. That's because a) measuring savings is a difficult exercise in measuring what doesn't happen in a "statistically noisy" environment of rising costs and b) any savings that are achieved may be exceeded by the direct, indirect and uncategorized costs of delivering the intervention in the first place. Reconciling this may be out of reach of even the Center for Medicare and Medicaid Innovation.

2. Can You Count on the Feds? Medicare has had more than its fair share of fickle behavior when it comes to partnering. Not only have the physicians been whipsawed, but witness what happened to the insurance community with Medicare+Choice in '93 and Medicare Advantage in 2010 That makes two constituencies that have been burned by the Feds. While these may be exceptions, consider the details Medicare's participation in the multi-payor medical home pilot. This may have implications for the prognosis of federal, state and commercial payor partnerships.

3. Is the Road to Being Covered by Medicare Lined with Demos? Many of the high visibility innovations out there, like the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) remain largely unproven outside of government sponsored insurance settings or integrated delivery systems. That's why the Affordable Care Act relegated them to pilots and demonstrations in the first place. While the past performance is no guarantee of future disappointment, Medicare's ability to execute on demos in general have not fared well. In fact, the experience of the disease management industry's star-crossed Medicare Health Support should give pause to the PCMH's and ACO's fans. That may be doubly true since, as pointed out here by one of the DMCB's fellow speakers, there is widespread bipartisan consensus that CMS is generally underfunded, which could hamper CMS' ability to manage the countless details of actually running a multi-site demo.

4. What Do Physicians in the Trenches Think? It is hard to underestimate mainstream physicians' disappointment over the Sustainable Growth Rate's (SGR's) impact on the Medicare fee schedule and the inaction on meaningful tort reform. The DMCB isn't fooled by organized medicine's political support for health reform, which has only obscured the distrust and cynicism in many grassroots doctor's offices. By the way, physicians have always been suspicious of their local hospitals also, so it remains to be seen how much they'll cooperate with the creation of ACOs. Accordingly, the DMCB rates physician discontent as the biggest threat to the future of Medicare's efforts at innovation.

There are two big suggestions that help address all of these challenges. The DMCB didn't think of them first, but that's not to stop it from bringing them up at the July 20 Summit. Those suggestions, my co-speakers' reactions and what the audience has to say will be discussed in greater detail in the next posting.

Smart People Adding Too Much Value

The Disease Management Care Blog is happy to host Kit Gorton, MD. Kit is currently a healthcare consultant who is a former VP of Medical Management at HP Enterprise Services, served as President and Chief Medical Officer of APS Health Care and was Chief Medical Officer of Pennsylvania Medicaid. As someone who has developed and presided over a host of good ideas, this is a professional who knows of what he speaks.

In case you’re wondering why your excellent idea isn’t going anywhere, the good news is that you’re smart. Read on and find out about the bad news……

Why do so many good ideas get so little traction? As a guy whose job has often been to support innovative programs, I find myself thinking about this a great deal. The reasons why ideas languish are of course complex: too few resources, too many competing priorities, too little consensus, too much information out there. All are solid explanations for why smart people I’ve worked with accomplish less than everyone would expect.

I was reading Marshall Goldsmith’s book What Got You Here Won’t Get You There (Hyperion, New York, 2007) as I got geared up for my current career transition and I came across another possible explanation that I hadn’t entertained before. Goldsmith posits that smart people impede their organizations and their own careers through what he characterizes as the bad habit of adding too much value. He observes, “It is extremely difficult for successful people to listen to other people tell them something that they already know without communicating somehow that (a) ‘we already knew that’ and (b)’we know a better way.’” He points out that whatever incremental improvement that the smart person provides to an idea is often overshadowed by the loss of enthusiasm and commitment of the other people in the process.

Perhaps smart people’s ideas don’t get more traction because of the smart people’s behavior? In a knowledge economy, adding our two cents is how the idea guys make a contribution, right? Perhaps not. Goldsmith argues that the more powerful or influential we people become (or wish to become…), the more behavior factors into their success. His premise makes a lot of sense: that it is counter-productive to always try to improve on the ideas of others. After all, the obverse of “I’m smarter than you are” is obviously “You are dumber than me.” No one likes to be on the losing side of that conversation.

The typical approach of smart people to care management solution development and academic research is to design incremental improvements or disruptive changes and then demonstrate proof of concept in either a pilot program or through a research protocol. Adoption is then supposed to be driven by the innovators promoting their ideas through publications, seminars and, to a lesser extent, commercial marketing approaches. Their underlying assumption has been is that good ideas sell themselves. They think their job is to simply to build a better mouse-trap and then explain it to the rest of us.

Goldsmith’s perspective suggests to me that innovation processes that focus largely on coming up with and presenting the next best idea are likely to be ineffective in driving improvements in chronic care management, medical homes or wellness and lifestyle programs. Innovators may not have the interpersonal skills and communication behaviors necessary to promote adoption. By “over” delivering on value and underestimating the response of their colleagues around them, innovation can dissipate.

Clearly there is work to be done in translational research and in identifying control points in the diffusion of healthcare innovation. Still Goldsmith’s observations about human behavior raise the question of how much interpersonal relationships and individual communication may impact the success of transformational change. That is a topic I think is worthy of a great deal of silent reflection.

The Paradox of Workplace Posters in Healthcare Facilities: Don't Mean It? Then Don't Post Them.

The Disease Management Care Blog received this posting from an experienced nurse with a background in clinical and administrative medicine. Ouch!

We’ve all seen them. Those vacuous workplace posters exhorting teamwork, creativity and other forms of inspiration and accomplishment. A version has begun to creep into our nation’s health care facilities. reminding everyone of the need for privacy, how infections can be spread and the importance of patient service. And if my experience is any indication, they can also amply demonstrate to patients just how badly broken the health care system can be.

During a recent visit to a local medical center, I noticed the elevator posters of the really cute child saying “shhh” with a finger over her mouth along with a tag line about patient privacy. As I was waiting for my elevator, I could hear a overhear a resident dictating a surgical summary about a named patient’s a bowel resection, low blood pressure, blood loss and signs of malignancy. Good thing the patient is not my neighbor.

And how about the signs telling patients to remind providers to wash their hands before touching them to help stop the spread of infection? During another visit, my mother's physician seemed was surprised when I pointed out the poster and asked him to wash his.

My primary care physician has a poster that tells me to ask my doctor 3 things before I leave: what is my major problem; what do I need to do to manage it; and how are they going to help me manage it. After my physician’s office staff grudgingly gave me a "sick appointment" for my pleurisy, I had x-rays and a cursory examination. I asked the doctor the 3 questions the poster told me to. He told me we would discuss that the next time I see him. While I wait for the x-rays results, there is no follow-up scheduled at this time and no treatment has been prescribed.

While these and other posters are intended to educate consumers and remind providers, I’m running into doctors who are ignoring them. Paradoxically, these posters are reminding patients of lax privacy, the risk of avoidable infections and lousy customer service.

Here’s a suggestion for you well meaning hospital administrators: until you really fix these problems, don’t inflame things with posters. Put up pictures of what you’re apparently really all about: cash.

Coda: After this post appeared, the DMCB subsequently got an email from a colleague that pointed out that there are other opportunities for poster-addled hospital administrators to display their leadership and patient education skills.