Where's the Gas When You Need It?

The Disease Management Care Blog confesses that it wasn’t easy learning the differences between an EMR (electronic medical record), an EHR (electronic health record) and a PHR (personal health record). While medicine is certainly riddled with its own complexities and acronyms, health information technology (HIT) seems to have taken it to a whole new level.

There may be one less acronym, however, to worry about. If (and that is a big if) this post from the Health Care Renewal Blog has any basis, there may allegedly be little reason to distinguish HIMSS (a membership organization) from CCHIT (involved in certification of electronic records). Is the DMCB’s buddy Scott Silverman an HIT voice crying in the wilderness? Time will tell but the DMCB will be harkening.

The disease management community, in contrast, seems to have had its act together from the very beginning. The DMCB was there in the early days when several disease management companies earnestly set out to define what set them apart. That’s when they came up with this. Realizing that a distinct brand was emerging, they sought a process that would accredit reputable full-service disease management companies – similar to the track record of hospitals and managed care organizations. They correctly reasoned that the more distant they were from owning the accreditation process, the more credible it would become. Not to mention that their lawyers pointed out that anything less could result in the improper appearance of collusion. It was good business sense and it was also the right thing to do.

It paid off. The highly regarded National Committee for Quality Assurance (NCQA) and URAC have both developed independent programs that are distinctly free of any allegations or even the appearance of conflicts of interest.

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And a now for a non-sequitur: It’s bad enough having to see a dentist, but having him remind you of the striking difference between medicine and dentistry makes the drilling seem comparatively blissful. Grinning through his mask and goggle-glasses, he asked his physician-patient today what he thought of the newly inked ‘stimulus bill.’ By this time the DCMB was immobilized thanks to having to simultaneously guess where half of its face was while French-kissing a latex dome with a mouthful of gruesome metal objects. Not caring to translate my gurgling, he went on, ‘Looks like the government wants to tell you guys how to practice.’ After a pause, he added, ‘And they’re going to get away with it.’

Where’s the gas when you need it?

Observations on the Leveling Off and Narrowing Confidence Intervals in the NCQA State of Health Care Quality Report

The NCQA has released its annual ‘State of Healthcare Quality’ report that examines the quality performance of the nation’s participating health insurers. While the NCQA says the big news is that the NCQA is relevant, variation persists, the NCQA is relevant, that many measures are incrementally if slowly getting better, the NCQA is relevant and that Federal programs need to get aboard comparative quality bus, the Disease Management Care Blog was much more interested in the actual numbers and their trends.

Speaking to the currently limits of medicine and biology, less than two thirds of persons with high blood pressure achieve control of their condition, just more than half of persons who have had a heart attack attain low cholesterol levels and about 80% of kids get adequately immunized.

But more importantly, the pace of improvement in many measures – while still showing gratifying increases – is leveling off. For example, check out these trends snipped from the NCQA report on A1c testing among persons with diabetes:

and blood pressure control among persons with hypertension:

Also note that the confidence intervals are narrowing, meaning the spread between competing health insurers is narrowing. This may be a function of increasing numbers of participating insurers or less variation. Either way, the DMCB predicts that with time those point scores are going to cluster even more tightly.

The good news is that if these trends continue, variation will diminish. The bad news is that the insurers will become indistinguishable from each other and have to locally compete on tenths of a percent of improvement. Will this force them to look for ‘breakthrough’ strategies for improvement or will they settle with the conclusion that usual care is reaching the limits of improvement that can be attained in usual settings relying on usual ways of payment?

Comment on the Proposed NCQA Measures for Disease Management Programs

Readers of the Disease Management Care Blog (and anyone else for that matter) have been invited to click on over to NCQA and comment on its proposed measurement specifications for disease management programs. Do that and you will be able to revel in a host of diagnosis & procedure codes, numerators, denominators, continuous enrollment windows and pharmacy claims.

The DMCB understands the adage that a) quality cannot advance without measurement and that b) the NCQA methodology has resulted in untold jumps in quality and lives saved. Kudos to the NCQA for taking this assessment hammer to a new set of nails.

Yet, the DMCB has three concerns about the proposal:

Well executed disease management raises all boats: While DM programs can always do a better job of documenting and reporting their clinical outcomes, the DMCB believes effective population-based coaching programs that successfully engage patients in self care will spin off increases (for example) in A1c testing in diabetes, appropriate prescriptions for asthma and flu shots when chronic heart failure is present. The opposite is not true: prompting patients to get process-based lab testing, prescriptions or flu shots will not necessarily promote optimum self care. After these specifications are finalized and approved, the DMCB hopes disease management organizations will resist the temptation to issue (for example) a directive to its nurses to stop educating and start directing, to coach less and document more.

The definition of the 'medical record is changing: In true NCQA fashion, many ‘numerator’ criteria rely on traditional medical record documentation or insurance claims to fulfill criteria and obtain credit. Yet, the DMCB believes registry data collected by disease management organizations in the course of their outreach are also a resource. Patient self reports, documented by a DM nurse outside of claims or physician encounters, are a measureable and auditable source of measurement that are going untapped by much of the proposed NCQA methodology. While patient self reports are prone to error, so are insurance plans with pharmacy deductables. What’s more, what happens if the personal health record really takes off? Why not aggressively include patient self-reports in the numerators?

Patients may reasonably elect to not comply with NCQA criteria: Consider this scenario: a fully coached and empowered patient with chronic illness reviews the recommended menu of preventive services, understands the benefit of each, gauges at his or her needs, the doc’s recommendations, the out of pocket expenses and reasonably decides to forego recommendation “A” and adhere to recommendation “B.” This DMCB thinks that is not unreasonable not only because it happens in primary care clinics everyday, but because all medical interventions are not created equally. Why not include empowered patient refusals in the numerators?

The DMCB will be providing a link to this post over at the NCQA site. Readers can too, but the DMCB recommends you check the methodology out for yourself and comment. You have until Sept 3.

Physician-Focused HEDIS Is Not Enough

The curmudgeonly Disease Management Care Blog recently provided input on some proposed preventive care measures for HEDIS. While it thinks the proposed methodologies are sound, are helpful and should go forward, it remains unconvinced that physician-based promotion and prevention is really really up to the task. Brief counseling makes a difference, but doctors fall short of consistently providing necessary wellness and prevention counseling in areas such as adolescent tobacco use, alcohol abuse, HIV prevention, osteoporosis treatment, cardiovascular disease in diabetes and obesity. What are the docs trying to tell us?

Surveys have demonstrated that individual physicians prefer to independently review the science that undergirds many wellness and prevention guidelines for themselves and, many times, agree to disagree. They may a) not have enough information, b) conclude the recommendations are in error, c) doubt that they have the necessary skills to carry them out or d) believe carrying them out the will make no difference. For some HEDIS measures, that's not unreasonable. Being human, if they don’t practice what they preach, they’ll also not preach.

The fix is not necessarily ‘payment’ as in performance (P4P). Other surveys have shown physicians can be ambivalent about the role of economic incentives and that many don’t buy into the notion that they should benefit if the patients’ outcomes are improved. Physicians may also doubt that commonly used measures of performance capture what is truly important. This dissonance may be particularly acute when they care for elderly vulnerable patients with multiple co-morbidities. No wonder there’s data showing P4P may have a limited impact.

And then there is the problem of trying to figure out just which physician is responsible for what. As pointed out in this article, patients (in Medicare fee for service, and by extension, in commercial PPO insurance products that don’t require a referral) may be seeing multiple physicians, each with a hand in the management of an aspect of prevention or chronic illness. Many people also rarely see physicians. If HEDIS, which is based on insurance claims and chart audits, can’t identify a responsible physician, is it reasonable to make physicians accountable?

There is also the emerging perspective that patients need to be equal participants in medical decision making. A distinct percentage of health care consumers may therefore decide, based on their goals, values and resources, to not follow through on the prevention recommendations of their physicians. Why should their physicians be held responsible if patients make a decision that is counter to HEDIS recommendations? Shouldn’t physicians be given credit for a) informing their patients of the recommendations (via chart documentation or by use of a special code) and then b) honoring their wishes?

What is the fix for skeptical physician-scientists that are human, resistant to blunt economic incentives, are interacting with a complex web of other physicians and letting patients decide for themselves? The DMCB doubts there is a magic mix of resources, incentives and sticks based on HEDIS measures alone that can be aimed at docs and appreciably change their prevention and wellness care patterns. Rather, it's time to invite other stakeholders to the party.

The DMCB recommendation: it's time to determine and accept the upper range of what is typically possible in physician-based prevention and wellness activities in usual clinical settings. Once that is understood, the sometimes successful use of HEDIS can be integrated with the promotion and measure of wellness and prevention in other sectors of the economy such as school districts, employers, communities, disease management programs, wellness providers and personal health record vendors. In the meantime, promoting physician reliance on the Patient Centered Medical Home's approach to 'outsourcing' prevention and wellness to other local team members may help increase clinic-based HEDIS measures.

Based on what we know about traditional physician approaches to wellness and prevention, is this necessary? Yes. Difficult? Yes. Naive? Yup. Outside the typical mandate of HEDIS? Absolutely. Do consumers deserve new approaches that build on the successful track record of HEDIS? Yes.

When should policy makers start working on this? ASAP.