Another Reminder that Integrated Delivery Systems Are Not All That

The Disease Management Care Bog is not in the habit of handicapping health care legislation, but it did check in with one of the information markets. The prospect of passage seems to be less than the prevailing spin would suggest.

If one rationale of health care reform is to disseminate the superior performance of integrated delivery systems (IDS), readers may want to check out this largely underreported study in the latest issue of the American Journal of Managed Care. While the 'definition' of a delay in radiation treatment following surgery for breast cancer remains hazy, two months not only 'seems' like a long time but there are data that suggests it can affect survival. According to Taffet Gold et al, IDS' overall rate of a 14% delay of two months or more is no better or worse than what has been reported in other settings.

Of course, this is just one study and there is considerable literature in support of IDS. Ultimately, however, we still don't know if the importation of IDS into areas of the U.S. that are struggling with high cost or low quality or high variation would be the panacea some would like. The American Journal of Managed Care article above reminds us of that inconvenient truth.

Image from Wikipedia Commons

Musings From A Drive Home From Washington DC About Democracy and Health Care: Are They Incompatible?

The Disease Management Care Blog was on Capital Hill for the last two days. While staffers' cards are being held close to the chest, it really appears that no one has any idea if health reform will pass.

Democracy in action, especially when the nation’s health is at stake, shouldn’t be so difficult, should it? While there are real policy issues around the role of government and the use of our treasury, the process should be aided by common-sense changes involving primary care, population-based care, insurance benefit designs, premium subsidization, expansion of current programs, rigorously assessing new technology, not paying for mistakes and stopping insurance abuses. Instead, a faction of Congressional Democrats are not playing nice, the Congressional Budget Office keeps coming up with inconvenient truths, key leaders are missing in action, key supporters are being undercut by their rank and file and momentum is decreasing. Delay means opponents will have the summer recess to sink reform with bail-out fatigue, fear of Federal deficits, cap n' trade second thoughts and what's-in-it-for-me politics. The ever-wise information markets are down to a 35% chance that the U.S. will have a government run health insurance plan in place by the end of December.

And yet, that great shining light on the hill is still there: the vaunted Integrated Delivery System (IDS), where hospitals and physicians align their incentives, concoct best practices, charge less, work more, use EHRs anyway and stomp out complications in a paradise of access, efficiency, value and innovation.

It was just in such a setting years back that the Disease Management Care Blog and some of its colleagues were engaged in what can be generously described as a vigorous dialog with a nudnink of a Chairman. The clinical and revenue issues at stake were also common sense and the Chair was simply not going along with our logic. Unable to achieve consensus, the Chair concluded with the meeting with a telling observation: ‘This is not a democracy.’

Indeed. The DMCB cautions, based on personal experience and lots of gossip with other colleagues, that while on the outside IDS’ may appear to be enlightened institutions that use the most modern approaches to capital allocation, use of human resources and clinical program design, inside they have more than their fair share of internal strife. In fact, the past issue wasn’t important and the DMCB suspects the Chair was right. What’s important is that the Chair and other centers of power in IDS’ are always right because they don’t function as democracies.

Which may be why the well-meaning Madam Speaker is having so much difficulty. The DMCB wonders if good health care delivery, in addition to being evidence-based and market-driven with good incentives and a strong mission and all that stuff, is also something of a dictatorship. Congress’ misbehaviors, competing factions and wonky debate remind the DMCB of its dysfunctional yet halcyon IDS days. Perhaps the critical missing ingredient inside the beltway is what IDS’ possess: central command and control that can suspend the exercise of democracy.

The DMCB suspects the odds of passage may need to be rated at less than 35%.

Integrated Delivery Systems Disappoint Again

Check out this article in the Archives of Internal Medicine by Smith and colleagues. They studied the impact of a two mailings designed to promote the long-term use of beta blocker medications among survivors of a heart attack. They found the intervention had a modest impact, but that’s not the point.

During the course of planning the study, the authors received feedback from patient focus groups suggesting ‘they would be most likely to open and read a letter if it came from the clinician; resource constraints prohibited this goal, but the letter did come from a health plan physician administrator’ [italics mine].

Wait a minute. Closer reading reveals this study was conducted ‘prepaid integrated care delivery’ sites in the Kaiser system, at Harvard Pilgrim and at HealthPartners. Aren’t Integrated Delivery Systems (IDS) already supposed to have the resources necessary to coordinate care around the most appropriate physician?

Or, do they frequently turn out to be some version of same old managed care?

Hospitals, P4P, Non-Payment of Medical Errors, Performance Guarantees and Disease Management

While the disease management care blog has been aghast at Dancing Priscilla’s botox overdose and egregiously bummed over Robert Plant’s decision to tour with Alison in lieu of Jimmy, at least it has a 2008 Yes Tour to look forward to. In the meantime, it will make do with CBS’ on-line streaming of March Madness, which includes a video player with “boss button.” Click it and a spreadsheet will cover your screen.

The DMCB thinks bosses should be pleased if their employees regularly log onto this web page, so no boss button is necessary. Read on, leave it up and be proud. In fact, forward the link to the big guy: you'll be thanked.

Speaking of CBS, it has another interesting bit of news video that describes a medication error involving the newborn Quaid twins. While the pharma's tone deafness in a separate video makes for creepy viewing, readers may be more interested the implications of what CBS offers up as one solution: hospital package pricing with “performance guarantees” for an the episode of care that extends beyond the initial hospitalization. If the patient needs to be readmitted, that cost is generally covered. For those readers interested in methodology, this has been described in one publication using a pre-post study design in a setting of dubious generalizability.

What’s more, the lack of detail makes the DMCB suspect performance guarantee contracting is actuarially neutral, i.e., priced to account for an expected rate of complications. That may be one reason there hasn’t been a stampede among health insurers to adopt the guarantee approach. Rather, they seem to prefer sticking to their pre-existing fee schedules and turning up the heat with more blunt approaches of carrots (P4P bonuses) and sticks (non-payment for medical errors).

The DMCB asks: who cares? Hospitals will need to improve their in-house care processes but that alone is not sufficient. There is considerable literature showing better patient preparation prior to an elective admission is important and that post-discharge planning often goes awry. Enter the disease management companies which can add value across a wide number of inpatient conditions and their associated episodes of care. For example, they have resources that may be of use prior to surgery in helping patients choose their best treatment options ahead of time, and they have a track record of reducing readmissions once patients are discharged. This may not apply to all conditions treated all ways in all hospitals in all settings, but there is some merit to this approach.

As the pressure grows to increase quality and avoid errors, hospitals may soon turn out to be another customer of disease management companies. In other words, in the opinion of the DMCB, these companies may be able to help secure the bonus, avoid the unnecessary readmission or fulfill the guarantee.

The GAO, Physician Group Practice (PGP) Demo Summary and Implications for the Chronic Care Model

The Government Accountability Office issued a report on another “demo” titled the “Physician Group Practice” (PGP). While news that only 2 of the 10 participating organizations were successful is old, the report makes for an interesting read for those of us interested in “disease management.” Much thanks to my colleagues in the Pennsylvania Chapter of the ACP for forwarding this.

First a summary and then the disease management blog will weigh in:

A summary:

The demo tested “Pay for Performance” among 10 large (at least 200 docs) physician groups. The “performance” used by these groups had everything to do with the approaches used in classic disease management. It included patient education, post-discharge programs, medication reviews, case management, interactive voice response and care coordination. Most of the groups also had an electronic health record.

The “pay” was used to either 1) develop or 2) expand preexisting in-house DM programs. The number of programs per physician group ranged 2 to 9. The pay was also a “gamble”: the groups had to front much of the money in hope of qualifying for the payment bonus at a later date

In order to get the pay, the 10 organizations had to perform by 1) reducing overall spending among its assigned Medicare beneficiaries by more than 2% (making this a gainshare) and 2) achieve improvements in 10 NCQA-pedigreed diabetes clinical process measures. The comparator was a group of Medicare beneficiaries that were retrospectively assigned.

Most of the groups achieved most of the diabetes improvements in the first year, but the only ones that got a gainshare were the Marshfield Clinic and the University of Michigan Faculty Group Practice (calculated at $4.6 M and $2.8M, respectively). One other unnamed group achieved 2% savings but didn’t exceed it (sucks to be you). Marshfield and Michigan also seemed to benefit by being measured against comparator beneficiaries that experienced very high Medicare spending.

Marshfield had only two programs: 1. telephony for heart failure and 2. anticoagulation management. The University of Michigan also had only two programs. They were monitoring and self-care education by care managers for 1. frail patients with many co-morbidities and 2. those with a recent inpatient stay.

In contrast, the average number of clinical programs for all of the physician groups was between 4 and 5 (Billings Clinic led the way with 9 of them) with total program costs among the participants that ranged from just over $400,000 to as high as $2.9 million. Interestingly Michigan had the lowest total program costs and Marshfield had the highest costs.

In their report, GAO noted the approach was “reasonable” but disappointing. It urged caution in interpreting the data because they are from the 1^st of a 3 year process. In addition, only one participant had all of its programs up and running for the first 12 months of the demo.

To make matters worse, there were delays in getting claims data from CMS back to the physician groups. It was also hard for the physician groups to interpret the data dumps once they arrived. As a result, the participants were “flying blind” without the kind of feedback necessary to “tweak” their programs. GAO has recommended this be fixed, which may make a difference in the future.

The Disease Management Care Blog weighs in:

Even the GAO noted that large physician groups account for less than 1% of all physician care in the U.S., making the lessons learned here practically inapplicable to the other 99% of health care delivery in the U. S.. Smaller physician groups will never be able to implement any of the approaches used in the PGP demo because they don’t have access to the necessary capital, have yet to implement an EHR and have little experience with P4P programs. Last but not least, if large physician organizations are as efficient as they say they are, the outcomes to date gives them every incentive to avoid such schemes. Based on the results from this demo, they can expect to spend more than they gainshare in the first fiscal year.

And now for something completely different:

1) Given the random distribution of claims expense, the disease management blog wonders if the data spread in the above graph has nothing to do with the interventions hatched by the participants. I can’t see any correlation between the intensity of the interventions, the money invested and the savings that were achieved. Toss a bunch of numbers in the air and some will come back lower or higher. Based on the report, Michigan and Marshfield may have been lucky, not smart.

2) One reason for the lack of performance could be because large physician groups are fundamentally postured to seize every dollar of revenue in a FFS environment. One fat DRG beats 5 well-intentioned case managers.

3) This wasn’t disease management. It appears to me that the best interpretation is that these physician groups used programs that met the definition of the Chronic Care Model. Just like the COACH heart failure study, the programs for each of these groups were under the leadership of and had proximity to physicians, used patient self management support interventions, used computerized clinical data bases/registries/EHR, relied on teaming, used clinical guidelines and had supportive reimbursement. I am very confident that if we had asked, the leaders at each of the participating physician group practices would have denied that their interventions were "disease management," and that what they were offering was distinctly different.

Let’s hope future outcomes in this demo show that CCM is not a bust. Or is inconsistent with other negative disappointing literature on the lack of cost savings in CCM.

Are Integrated Delivery Systems really all that?

Speaking of population-based health care, how about those Integrated Delivery Systems (IDS)? Their fans fawn over IDS’ aggregation of healthcare services in an efficient, social-mission minded, mutually supportive panoply of consumer-friendly, one-stop primary, secondary, tertiary and quaternary and insurance for the cure and coverage of whatever ails all persons or populations. They do have a lot going for them.

Hm. Are they really all that?

So, knowing that a crippling writers’ strike is on the verge of turning much of our popular media from eye-candy to a yawnfest, I’ve decided try to help out. Here is my “Top-Ten” list of why IDS’ could always remain the health care solution of the future:

10 Indisputably better patient safety and health care quality at the same or lower price?

9 Liberal policy wonks like them.

8 Stultifying miasmic bloats of overlapping mid-level Assistant, Associate, Senior and Executive VPs, Directors and Managers. Check out this redacted/altered press release from a household-name IDS

“….has been named (title) for hospital operations and support services across the (institution) campus and outlying medical office buildings with responsibilities including working closely with (others) in the planning, coordination and execution of operational strategies to improve quality, service and financial performance at (Name) in (Region). ….will be the senior administrative officer responsible for materials management, facilities, radiology, anesthesiology, laboratory, perioperative/surgery, patient care services, and ambulatory care.”

7 Go ahead, try to close that stand-alone, major employer, community-based Hugh G. Deficit Memorial Hospital.

6 Um, what does IDS stand for again? A lot of my physician friends have idea none.

5 Its share of black eyes. Oops!

4 And just how are they different than the for-profits?

3 Reverting back to “eat what you kill” physician compensation means "why not keep what you kill" physician compensation.

2 “We discussed management’s preference vs. the doc’s preference and decided to compromise. We’ll do it management’s way.”

1 And the majority of exciting, cutting edge innovations in P4P, insurance benefit design, disease management, the Medical Home and the EHR are mostly coming from where?