Read In Airports and on Planes......

From 'Disease management for chronically ill beneficiaries in traditional medicare' by David Bott, Mary Kapp, Lorraine Johnson and Linda Magno, appearing in Health Affairs 2009; 28(1): 86-98.

Numerous CMS demonstrations - including, but not limited to, Medicare Health Support - have shed an unhappy light on the following premises about disease management for elderly, fee-for-service Medicare beneficiaries:

Acute exacerbations of chronic conditions could be avoided by better day-to-day self-management. This has been difficult to demonstrate and in retrospect, the evidence that exists is based on relatively small studies from academic settings.

High costs associated with chronic conditions stem from ED visits and inpatient hospital admissions for acute exacerbations. Yet, the majority of all hospital admissions have turned out to be for reasons other than the index condition.

Patients with chronic conditions are motivated and able to engage in improved self-management. There is little systematic evidence that this is true. Many patients apparently simply adjust to their condition and fail to see the benefit of additional change.

Periodic contact improves self-management and early recognition of symptoms will avoid hospitalization. Many programs turned out to have a poor rate of contact and there was little correlation between the contact frequency and outcomes anyway.

There is a health care provider who is prepared to respond to alerts by scheduling an urgent visit or coming to the telephone. Not so,unless there were standing orders or protocols. Docs won't come to the phone.

And this paraphrased quote from "Who Killed Health Care" by Harvard academic Regina Herzinger:

There are two 'distinctly differing approaches for reforming our health care system. Those who distrust markets and consumers prefer a single-payer system in which the federal government's excellent, centralized management would wring savings from billions now wasted on the hapless, competitive provate sector health insurance firms and inefficient doctors and use the savings to provide coverage for the uninsured. They would restrict insurance choices, much like an automobile market offering identical cars designed by a technocratic elite. Those who believe in consumers and entrpreneurs opt instead for private sector solutions. This small-is-beautiful camp would open insurance and health delivery market to innovators, ....where doctors are emowered to design better, cheaper care.....'

By the way, O'Hare was pretty empty for a weekday. The economy is definitely not doing well.

Group Practice Demo Results, Questions, Policy and Song

The Disease Management Care Blog likewise extends a hearty congratulations to the participants in the Physician Group Practice Demonstration. Hat Tip to Vince Kuraitis for sharing the news and posting the link-announcement with the details. Looks like the docs got some serious coin.

The DMCB asks a) were the in-house interventions all that different from what is typically done by disease management programs? b) are the lessons in these large groups generalizable to the huge majority of physicians who are outside these kinds of practice settings? c) are the payments enough to cover the direct and indirect costs of implementing the interventions? d) are the payments to the four groups that hit the financial performance targets (translate decreased utilization) enough to cover their losses from avoided admissions and specialty care? Looks like we'll need to await the story behind the story.

But it's time to move on. As mentioned above, the challenge is to drive quality and efficiency in the nation's network of smaller independent physician practices. The details on that demo are coming to light, once again, thanks to Vince Kuraitis who has another post on the topic. It makes for very interesting reading.

Pity CMS. It would be so much simpler if the Group Practice Demo couldn't be used nationwide? If the physicians were assembled into large coordinated socialized entities that assumed regional responsibility for care? Instead, those irksome docs stubbornly cling to notions of running a business, retaining notions of independent professionalism and keeping local responsibility for the care they provide.

With apologies to Led Zeppelin:

Wanna tell you ‘bout some policy y’know
My it sound so fine
The docs only ones that we been schemin of
Maybe someday they won’t be so blind
We wanna tell em how we pay just blows
Their bills are just outta touch
We need to tell em that its outcomes that they really love

We want the doctors, go for risk all day
We want the doctors, drop one-on-one, no
We want the docs, take cap all the time
We said we want the greedy doctors to take upside risk

Sunday mornings when their offices are closed
See the uninsured standin in line
Don’t say they want no pay for their work
But when the A1c’s’ below nine
In the long term yes the payment may be low
CMS don’t wanna to be loved
We call the tune, keep-a- usin RVUs
Only payin if admits’r stayin down

We want the doctors join big groups
We want the docs not use pens no no
We want the docs, go salary big time
We said we want the doctors' mistakes to never get paid

In the halls with the men who pass the laws
Changin, schemin and regulatin’ health care
Our nifty notions are just the trick
Re-tool payment for all time
We guess there just one thing left for docs to do
If they don’t like it move outta the way

Cause we got a worried mind
Budget’s too big undermine
Outcomes savings will fix it we pray

We want the docs take episodes of care
We want the docs practice in IDS yay yay…
We want the doctors let us be in charge
We want the doctors to take R-V-Us!

(Hey hey that’s what we’ll do)

Tell the docs what to do!

(Hey Hey, That how we pay!)

Hey hey that’s what we’ll do

We got the doctors, that’s what they’ll do