Submit That Report To Population Health Management: Here's Why

Have you created a novel care management program? Developed a unique approach to wellness? A groundbreaking approach to analytics? Performed a literature review with some new insights?

Have you already committed your findings to paper with tables and figures and, with some additional effort, could turn them into a real manuscript? Does the idea of sticking all that hard work on some shelf or letting it languish in the C-suite upstairs annoy you?

If you are in the C-suite, do you want to advance the career of some key employees?

If so, do you want to simultaneously advance the science of population-based care to the benefit of patients everywhere, hone your findings with rigorous and insightful peer review, contrast your evidence-based program with the take-our-word-for-it fluff of your competitors and bask in the envy of your colleagues and enemies?

If so, you may want to seriously think about submitting a paper to Population Health Management. Instructions for authors are here.

Benefits include....

• Publication in a highly respected peer-reviewed journal
  


• Rapid, high-quality peer review—average time to first decision 19 days
  


• Fast-track publication online within 4 months
  


• Global readership in 140 countries
  


• High Impact: 90,000 downloads from the journal in 2010
  


• Visibility: Publisher gives special promotion to important papers including e-promotions and press releases
  


• Author-friendly manuscript submission system
  


• Indexed in Medline, Current Contents, and all key indexing services worldwide
  


• Probably being mentioned in the Disease Management Care Blog

a Summary of the Latest Population Health Management Journal

Like you, the Disease Management Care Blog has been busy. Yet, it finally managed to find some time to crack the latest issue of the Population Health Management Journal. What's more, the DMCB kept some notes for your quoting pleasure. Check it out and if any of the articles catch your interest, you can access the abstracts here.

Michael French, Jenny Homer, Shay Klevay, Edward Goldman, Steven Ullmann and Barbara Kahn: Is the United States Ready to Embrace Concierge Medicine?

This is a very detailed review of an emerging kind of primary care where, “in exchange for a retainer or membership fee, patients receive same day or next day appointments for non-urgent care, access 24 hours a day and preventive medical services not usually offered through health insurance.” Here are some facts that caught the DMCB eye: concierge medicine started in 1996, up to an estimated 5000 physicians are CM docs and the retainer fee is typically not covered by insurance. The practice has spawned its own not-for profit trade/advocacy association (http://www.aapp.org//). While you might think the phenomenon is limited to small physician-owned clinics, there are companies that employ physicians in concierge practices. The retainer fees range from $1500-$3600 per patient. Docs typically have just under 500 patients in their panel, allow about 10 visits per day and enjoy incomes as high as $800,000. The authors suggest this could crowd out regular primary care and further strain access. There is precious little research on quality or outcomes Last but not least, Medicare specifically prohibits billing beneficiaries for services that it already covers, which could lead to some physicians becoming ensnared in accusations of double billing. In light of all the attention concierge practices have received, the DMCB is surprised at the low numbers and the emergence of concierge "chains." It asks if and when there will be tipping point and wonders if the SGR will play a role.

Iftekhar Kalsekar, Samantha Record, Karly Nesnidal and Bruce Hancock: National Estimates of Enrollment in Disease Management programs in the United States: An Analysis of the National Ambulatory Medical Care Survey (NAMCS) Data.

The authors used data from the NAMCS to estimate the level of participation in disease management (DM) programs. Their bottom line estimate is that 21.3% of eligible patients are enrolled in DM. While the DMCB would have guessed that chronic heart failure is the chronic condition that the highest penetrance, the answer is that it's chronic renal failure at 40%. The other usual conditions range between 16 and 29%. In reading the methodology for this article, the DMCB couldn’t quite understand how the authors got at the DM enrollment information. Since it trusts PHM’s peer review process and the authors quote other studies that have similar figures, the DMCB finds the numbers credible. Assuming they are correct, they point to the considerable upside growth potential of the disease/care/population health management industry.

Richard Feifer, Laurie Greenberg, Sandra Rosenberg-Brandi Ellen Franzblau-Isaac: Pharmacist Counseling at the Start of Therapy: Patient Receptivity to Offers of In-Person and Subsequent Telephonic Clinical Support

100 consecutive patients who had just started a new medication for a chronic condition were contacted for disease management. Prior to the counseling, the authors used a short survey to ask these patients about their experience when they first picked up their prescription at their community pharmacy. 58% didn’t recall being offered counseling, 11% refused it and 12% couldn’t recall getting useful advice. While it’s difficult to generalize from such a small survey involving a small number of patients, it confirms the DMCB skepticism about the notion that retail pharmacy windows can be retrofitted to deliver disease management. The DMCB also better understands why its own personal chain pharmacy gets its sign-off on a mechanized offer of counseling - which it never gets and doesn't want.

Justin Schaneman, Amy Kagey, Stephen Soltesz, Julie Stone: The Role of Comprehensive Eye Exams in the Early Detection of Diabetes and Other Chronic Diseases in an Employed Population

The research database of Human Capital Management Services contains a vast amount of demographic, employment, compensation, medical claims, pharmacy claims, disability, workman’s comp and work absence information on millions of employees from across the United States – including, maybe, you. Do not, however, be paranoid, because the authors looked at persons with either specific check-box notification of, or, a claim consistent with a screening eye exam that was subsequently followed by the appearance of new claims for diabetes (N=620), hypertension (N=1558) or high cholesterol (2824). When that happened (eye exam, followed by insurance claims), the authors assumed that the eye examination discovered the condition, which then led to a referral for care. These persons were compared to 2,668 persons who also had new claims for diabetes (2668), high blood pressure (17,112) or high cholesterol (12,059) but without the preceding eye exam. . The authors found the eye exam group, compared to those without the exams, appeared to have a less costly course of care. What’s more, the eye exam was associated with less disability and lower workman’s comp claims and a lower likelihood of being terminated. It all added up to more than $4.5 million in possible savings. The authors correctly point out that there may be unidentified sources of bias that could account for the differences and that this may also be a classic example of lead-time bias. The DMCB also points out that association doesn’t mean causality.

Jeanne Clark, Hsien–Yen Chang, Shari Bolen, Andrew Shore, Suzanne Goodwin, and Jonathan Weiner: Development of a Claims-Based Risk Score to Identify Obese Individuals

These Johns Hopkins researchers had concurrent access to the self-reported height and weight data from health risk assessments (HRAs) as well as insurance demographic and claims data from seven Blues plans of over 71,000 individuals. Logistic regression was used to determine which kinds of insurance claims data could be used to predict the presence of obesity in the absence of an HRA. Armed with such an “obesity risk score” tool, commercial plans could presumably use this to recruit patients that appear to have obesity into disease management programs. While the sensitivity and specificity of the modeling was far from perfect (the area under the ROC curve ranged from .67 to .73), this study shows, once again, how health plans can infer important conclusions about their enrollees based on claims data. It should be no surprise that the regression equation it self with the weights were not reported, presumably because that will only be available if you pay for it.

Manjiri Pawaskar, Steven Burch, Eric Seiber, Milap Nahata, Ala Iaconi and Rajesh Balkrishnan: Medicaid Payment Mechanisms: Impact on Medication Adherence and Health Care Service Utilization in Type 2 Diabetes Enrollees

According to the Kaiser Foundation, about 45% of Medicaid recipients nationwide are enrolled in “capitated” Medicaid plans. Are taxpayers getting their money’s worth and are these patients being care for properly? To find out, the authors looked at the claims data from between 1999 and 2005 of 8581 adults age 18 to 64 years with diabetes who were newly started on an oral anti-diabetic medication from 8 unnamed Medicaid managed care plans. 3763 patients were enrolled in “capitated” plans (where most medical services were paid for on a capitated basis) and 4818 were in fee-for-service plans. Logistic regression demonstrated that being in a capitated plan was statistically significantly associated with a greater likelihood of hospitalization and a lower frequency of outpatient visits and a lower likelihood of getting prescriptions filled. Hm, says the DMCB: maybe Medicaid plans should use disease management to make up for these shortfalls.

Nasiya N. Ahmed and Shannon Pearce: Acute Care for the Elderly: A Literature Review

Ever hear of Acute Care for the Elderly (ACE) Units? These are small 10-20 bed inpatient settings that are specially configured for the special needs of elderly persons with acute illness. It involves specialized geriatric care and interdisciplinary teaming all configured to maximize the likelihood of returning the patient to independent living. The authors summarized all the published literature on the topic and conclude that the clinical trials that do exist seem to show that ACEs, compared to usual care, generally lead to a shorter length of stay, have a lower likelihood of readmissions, end up with fewer transfers to a nursing home for longer term care, result in less functional decline, have a lower risk of delirium, reduce the chance of polypharmacy and experience lower cost. The authors caution the literature, while promising, is relatively limited and more research is necessary.

A Summary of the Latest Population Health Management Journal

It's that time again. The Population Health Management Journal (PHMJ) has arrived and it's full of your competitors' published findings on wellness, prevention and care and case management. Good thing you read the Disease Management Care Blog. It's saving you time with this handy PHMJ summary so that you can quickly and efficiently scan the contents over your low fat, weight controlling lunchtime yogurt and fruit snack. You'll know which articles deserve closer attention. The result will be better market awareness, enhancement of your professional development, heightened competitiveness for your company, advancement of the science of population care management, fewer Americans with chronic illness and reduction of the national debt. And that's just for starters.

Without further ado:

Impact of Online Primary Care Visits on Standard Costs: A Pilot Study by James Rohrer, Kurt Angstman, Steven Adamson, Matthew Bernard, John Bachman and Mark Morgan

Do “on-line” visits save money? It depends on your definition of saving money. These researchers from the Mayo Clinic pulled the records of 391 patients who were “served online via a secure patient portal” and compared them to 376 consecutive patients who were seen at a “same day clinic at a downtown location,” all of whom were served/seen during a six month period in 2008. The online visit used branching logic to solicit the patients’ history and then forwarded it to a physician for his/her review and reply. In order to use the online option, patients had to have a Minnesota primary care provider and be willing to pay the $35 if their insurer didn’t cover it. “Outlier status,” defined as being outside the 75% national percentile of total costs ($219) over the next 6 months, was used to assess cost savings. 28% of the "same-day clinic" patients met outlier status versus 21% of the "on-line" patients; median costs for both groups were $131 and $87, respectively. Both differences in median costs and outlier status held up as statistically significant even after controlling for baseline utilization. The DMCB thinks that much of this depends on the portal software (“Medfusion”), so we don’t know how generalizable this is. That being said, the DMCB is intrigued by the novel definition of cost savings that is based on an "outlier status." The DMCB also wonders if the next and even more cost-saving step is to have non-physicians handle much of the on line review and reply, oh wait, that is already being done in many population-based care management programs....

Disease Management to Promote Blood Pressure Control Among African Americans by Troyen Brennan, Claire Spettell, Victor Villagra, Elizabth Ofili, Cheryl McMahil-Walraven, Elizabeth Lowy, Pamela Daniels, Alexander Quarshie and Robert Mayberry

In this study, primary care physicians and their patients with an Aetna insurance claims history were randomly assigned to either 1) a high intensity, multi-modal and culturally competent nurse-support program with blood pressure monitors and instructions on how to use the monitors or 2) a “light support” program that included just the instructions and the monitors. 5932 persons were approached for participation and 320 were eventually assigned to the high intensity group while 318 were assigned to the light group. Patients were telephoned to self-assess and report their baseline and 6 month follow-up blood pressures. Mean baseline pressures were not different between the two groups at the start of the study, but at 6 months the high intensity group’s mean systolic pressure was 124, while the light group was 127. While an approximate 3 point difference may seem small, this is what is typically seen in the science of successful blood pressure control. What’s more, the difference was statistically significant. The DMCB likes this study because it’s directed at a population that suffers from disparities in access to care and it shows that additional patient support trumps skinnied-down home blood pressure monitoring. Kudos to Aetna for supporting this study.

Do Case Management Programs Save Money? by Donald Fetterolf, Albert Holt, Travis Tucker and Nazmul Khan.

After reading this article that describes how Alere thinks about it, you may still not know the answer. The good news is that you’ll have a better appreciation for the highly variable nature of patients that are typically entered into case management and how their care is prone to overuse, underuse, misuse and abuse. You’ll also learn that the cost and utilization patterns in this group speak to the problem of health system variation. While this is consistent with the policy message of the Dartmouth Atlas, the broad baseline confidence intervals also can get in the way of statistically proving that case management “works”; the authors used a standard power calculation for a typical cohort of case management patients’ cost patterns and found that more than 30,000 patients would be needed to conduct a research study on return on investment (ROI). Their common sense suggestions to assess the impact of case management include 1) assess and infer from other process, operational and clinical outcomes, 2) look at other pertinent markers of utilization, such as nursing home days per thousand, 3) apply known savings that have been demonstrated in clinical trials to the smaller population of interest and 4) measure quality of life, patient and physician satisfaction and use self-reported anecdotes. Unfortunately, grumpy purchasers may not appreciate how difficult this is and insist on other measures such as 1) estimates from the case managers on individual client savings that are, in turn rolled up (but fail to capture other costs), 2) propensity matching (but also prone to no achieving statistical significance) 3) a “book of business” approach that’s described in the DMAA Guidelines III Document. After all that, the best business approach to case management is to 1) document methodology, case mix, the impact of variation on “ROI,” 2) educate clients about the limitations, 3) agree on directional estimates in lieu of point values, 4) use “performance corridors,” 5) limit only small amount of any performance guarantee on “ROI” and 6) plan for the likelihood that any calculation of program savings may show a loss. The DMCB says this is "must" reading if you're in the case management business.

Wellness, Hard to Define, Reduces Trend up to 4 Percent by Cyndy Nayer, Jan Berger and Jack Mahoney.

This is a title that says it all. The authors conducted a series of open ended and multiple choice surveys of a group of companies that had been selected by the “Center for Health Value Innovation” as particularly innovative and dedicated to wellness among their employees. Innovative respondents 1) seemed to have broader and more inclusive definitions of just what comprised "wellness" and 2) reported that they believe their cost trend was only 4%, compared to national trend of 8 to 10%. The DMCB agrees there is an association between wellness and trend but it still struggling to ascertain whether this is causal and if so how much. If it is, does being blessed with a low trend enable companies to be squishy over wellness?

Comparring Diverse Health Promotion Programs Using Overall Self-Rated Health as a Common Metric by James Rohrer, James Naessens, Juliette Liesinger and William Litchy.

In this study, employees who completed a health risk assessment (HRA) and had four or more “risks” identified were assigned to one of four telephonic coaching programs aimed at weight, exercise, stress or nutrition. Over six months, participants were asked about eating patterns, weight, levels of exercise and degrees of stress, as well as an additional single question: in general would you say your overall health is excellent, very good, good, fair or poor. Of the approximate 48,000 who took the HRA, about 16,000 agreed to participate in coaching, 10,500 were eligible and 2855 enrolled. Drop outs were significant, with 1.5% to 26.7% completing the six months. Improvement in the single question about overall health appeared to correlate with weight loss (an average of 4 lbs.) and exercise levels (increased by an average of 43 minutes a week). The single question did not correlate with stress management practices or healthy eating. The authors suggest that weight loss and exercise programs may have an beneficial impact on the perception of overall health compared to stress management and nutritional interventions. If this holds up, the DMCB wonders if weight loss and exercise programs can reduce overhead by limiting their data collection to a single question. Alternatively, the single question approach may not be adequate enough to detect well-being among stress and nutrition program participants.

Improved Blood Pressure Control Among School Bus Drivers with Hypertension by Joseph Dozy, Tina Severance-Fonte, Elizabeth Morandi-Matricara, Jenifer Wogen, Feride Frech-Tamas.

There is no reason to believe that commercial driver’s license (CDL) holders should be any less prone to hypertension. The pharma-company developers of the “BP Downshift” program don’t think so either, so they created a tailored program made up of multiple educational mailings and a website, BP kiosks that were available in employee areas, free dietitian advice and free gym memberships. The developers showed up at an unnamed school district’s annual orientation for their CDL-holding school bus drivers. 208 entered the study by undergoing a blood pressure screening. 120 had a follow-up blood pressure screening at the close of the school year. At follow-up, systolic and diastolic pressures decreased by 9 and 4 points respectively. Among those that completed surveys, there also appeared to be an increase in health behaviors, and personal health perception. Bravo to the authors for recognizing in the discussion that their study was limited by a lack of a satisfactory control group, lack of generalizability, possible selection bias, the possibility of regression to the mean and temporal factors leading to bias. The DMCB doesn’t think the authors – or the school district – were out to win a Nobel Prize here; rather may be better suited to being thought of as a feasibility study. The next step is to perform a more vigorous study to see if the school district and its taxpayers are getting their money’s worth.

There is also an editorial by Chris Behling named "The Ghosts of Disease Management Past." He laments the persistent haunting of population-based care management by the threefold perception 1) that disease management is all about five chronic diseases, 2) is really all about telephonic coaching and 3) that it's disconnected from primary care. He dispatches each specter with some compelling arguments and recommends the industry leverage it's corporate infrastructure, measure measure measure and "extend and enhance the reach of physicians while filling the gaps that exist in the current delivery of care. Hear hear, says the DMCB.

A Summary of the Latest Population Health Management Journal

The Disease Management Care Blog is broadcasting live tonight from Ottawa, a beautiful city that reminds the DMCB of a private U.S. college campus, only with more traffic. When it passed through Canadian customs, it had three key items in its possession: 1) a U.S. passport, 2) a declaration form and 3) the latest issue of the Population Health Management Journal.

The DMCB knows many of its readers travel also, but they have to use the time trapped in planes, trains, automobiles and airports participating in conference calls while perusing spread sheets, business plans and policy changes. The DMCB feels your pain and comes to the rescue with this very efficient summary of the latest PHM contents. Check it out and decide which articles deserve a closer look when you have the time......

Burton WN, Chen C-Y, Schultz AB, Edington DW: The Association Between Achieving Low-Density Lipoprotein Cholesterol Goal and Statin Treatment in an Employee Population. This study tapped the database of 1607 employees of a large unnamed financial services company who underwent 'executive physical examinations' between 1995 through 2004 that included blood cholesterol testing. 150 of these individuals had filled at least one prescription for a cholesterol lowering drug in the year preceding their last executive examination. While the authors found an unsurprising association between the 'medication possession ratio' (or MPR) and the 150 subjects' cholesterol levels, the most interesting statistic was that only 68% of these individuals filled enough prescriptions to achieve a MPR of 80%. Once again, the science of population-based care management demonstrates that it takes more than a) a doctor telling you to take your pills and b) economic well-being to take full advantage of a medication class that saves lives.

Fayssoux R, Goldfarb, NI, Vaccaro AR, Harrop: Indirect Costs Associated with Surgery for Low Back Pain - A Secondary Analysis of Clinical Trial Data. 150 patients with unremitting back pain were randomly assigned to one of two surgical options: a standard anterior lumbar interbody fusion with a 'cage,' versus a "Charite" artificial lumbar disc. In this analysis, while the authors had a passing interest in comparing the clinical outcomes of the two groups, what caught the DMCB's attention was how long it took for the participants to return to employment. The bottom line is that 55% of individuals were working prior to surgery, this dropped in the weeks following the operation to about 24% and then slowly climbed over two years to about 63%. If you've paid any attention to what workman's compensation experts say, you won't be surprised that regression analysis showed that the greatest predictor of returning to work was being employed prior to surgery. By the way, the DMCB also points out that other studies have shown conservative non-surgical treatment generally results in the same outcomes over the long term. The DMCB thought this article was a good example of how collecting more than traditional "clinical" outcomes data in patients like this can yield rich insights about the expected time to recovery. To employers and patients, these are the outcomes that count.

Bolge SC, Joish VN, Balkrishnam R, Kannan H, Drake CL: Burden of Chronic Sleep Maintenance Insomnia Characterized by Nighttime Awakenings. The sleeping pill manufacturing pharmaceutical industry has been conducting and sponsoring research for years showing that there is an association between sleep disturbance and quality of life. This is such a study, based on a web based survey called the 2006 U.S. National Health and Wellness Survey (NHWS). Of 62,833 respondents, 2% had 'chronic insomnia characterized by awakenings' or CINA. These insomniacs, compared to persons reporting no sleep problems, had more emergency room visits, days in the hospital, visits to physicians, greater unemployment, higher levels of absenteeism and greater 'activity impairment.' None of this is surprising to the DMCB, but it still isn't sure of the directionality: does insomnia "cause" greater insurance claims expense, or does being ill with greater insurance claims expense cause insomnia? Based on this study and others like it, the DMCB still thinks that managed care organizations have reason to be skeptical that disease management sleep programs and/or liberal pharmacy benefit coverage of sleeping pills will help "bend the curve."

Diette GB, Orr P, McCormack MC, Gady W, Hamar B: Is Pharmacologic Care of Chronic Obstructive Pulmonary Disease Consistent with the Guidelines? The authors in this study looked at the claims data base of a "large managed care organization" with 2272 individuals with at least one claim for a provider visit for COPD. Physician prescribing of the various types of inhalers and pills used to treat this condition were all over the map, so the answer to the title of this article is quite consistent with what other studies have shown: "no." Of special interest is a potential benchmark statistic for those of us working in this field: of the persons with a history of one or more exacerbations of their disease that required a course of oral corticosteroids (the last line of defense before putting someone in the hospital), only about 63% had filled a prescription for an inhaled corticosteroid medication. This class of drugs, otherwise known as "ICS," has been showed to prevent the kinds of exacerbations that lead to oral corticosteroids in the first place. This may be the Holy Grail of COPD disease management: getting 100% of patients with "bad" COPD to regularly use their ICS so they don't have to be exposed to the risks of taking oral steroids.

Elliott JP, Desch C, Istwan NB, Rhea D, Collins AM, Stanziano GF: The Reliability of Patient-Reported Pregnancy Outcome Data. If you are running a disease management program and, like all good disease management programs, you want to follow outomes, should you go to the time and expense of requesting and going through copies of the medical records, or can you get away by simply calling the patient and asking what happened? Well, when it comes to pregancy outcomes, this study of 285 high risk moms showed having a nurse call and interview the patient yielded a high 'kappa statistic' when matched up against the patents charts. Yet, while it works in pregnancy outcomes, the DMCB isn't too sure the same is true for other conditions. In addition, the advent of electronic health records and functional registries may eventually lead to another question: does relying on remote electronic access of provider records perform as well as the relatively time-consuming patient interview?

Goldberg SW, Mulshine JL, Hagstrom D, Pyenson BS: An Actuarial Approach to Comparing Early Stage and Late Stage Lung Care Mortality and Survival. Count on those crazy actuaries to examine lung cancer death statistics in the Surveillance, Epidemiology and End Results (SEER) database to come up with a new point of view about early lung cancer detection and survival. When segmented by age, gender and race and compared to persons without lung cancer, it appears being lucky enough to have an early diagnosis of your cancer is associated with a significant survival advantage. The authors also accounted for 'lead time' bias in their analyses to stand by their conclusion that early detection of lung cancer could lead to saving 70,000 lives a year. The DMCB still isn't too sure because a) the article isn't easy to read and b) in addition to lead time bias, some tumors are slow growing, not necessarily detected earlier. When you sit down to read this one, be prepared to go over it several times. The DMCB is going to read this again on the flight back home. It's just not sure if the accompanying beverage will contain caffeine or ethanol.

Twells LK, Knight J, Alaghebandan R: The Relationship Among Body Mass Index, Subjective Report of Chronic Disease and the Use of Health Care Service in Newfoundland and Labrador, Canada. The DMCB suspects, thanks to Canada's health care system, that patients with chronic illness ar more likely to be 'funneled' to a primary care provider and experience queues when it comes to specialist and hospital services. That appears to be the case in this population-based Canadian Community Health Survey (with an impressive reponsive rate of 85%), which found our neighbors to the north have a 17% obesity rate, that those individuals had a greater burden of chronic disease, see primary care physicians more often but don't necessary access other parts of the system with greater frequency. This study would appear to confirm what we already know about obesity and health 'systemness.'

A Summary of the Latest Population Health Management Journal

Now that the holidays are over, it's back to work. E-mail boxes are overflowing, meetings are in full swing, budgets are being reviewed, spending is still being restrained and business opportunities abound. If it's not a memo, RFP or business plan, you're probably not going to have the time to read it.

Of course, like thousands of others in the care management business, you do take the time to read the Disease Management Care Blog. While there are plenty of reasons to do so, one important feature is its quick-read summaries of the latest issue of the Population Health Management Journal. You get to keep up to date with the latest peer review literature, see what the competition may is looking at or writing about and quote science to the amazement of your colleagues and business associations.

So, without further ado......

Martin Chung, Peter Melnyk, Donald Blue, Donald Renaud, Marie-Claude Breton: Worksite Health Promotion: The Value of the Tune Up Your Heart Program.

A Canada-located Chrysler automotive plant and the auto workers’ union agreed to add a ‘Tune Up Your Heart’ cardiac risk-lowering program to its other worksite wellness programs. Employees took a Framingham-based 10 year risk survey and those with ‘above average’ risk were invited to participate in an intervention. This consisted of a package of programs, including seminars, access to an 800 number, newsletters, a body mass index calculator, newsletters, written materials, nurse visits for individualized goal setting and, depending on the degree of risk, follow-up monitoring and medication review. Of 1078 employees, 580 were ‘invited,’ and 343 participated. 18 months later, average Framingham risk went from 10.7 to 9.3, average systolic blood and diastolic pressure dropped by 7 mm. and 1 mm. of Hg, respectively, total to HDL cholesterol ratios dropped by .2 and the BMI dropped by 0.2. Knowledge and satisfaction were high and cost-modeled per person per year (PPPY) savings were 793 Canadian dollars. Unfortunately, there was no control group, so this article's conclusions may be undermined by regression to the mean. There also is no description of the non-participants, so the reader can’t rule out the possibility of self-selection bias. What’s more, the DMCB found the economic cost modeling difficult to understand and the nurse intervention was not well described. This double whammy was important because, according to the model, almost 75% of the savings was based on nurse-driven medication changes in this Pfizer-funded study. The DMCB also wonders how there were no drop outs. The authors, to their credit, warn the reader at the end of the article about the possible biases and the questionable generalizability of a study from a single payor system to the U.S. market. Despite the assertion that this program was unique, the DMCB is aware of other workforce programs that utilize the same principles.

Joseph Yaskin, Richard Toner and Neil Goldfarb: Obesity Management Interventions: A Review of the Literature.

Want to know everything, and the DMCB means everything, there is to know about the published good, bad and ugly about the treatment of obesity? Well, you’re in luck because this paper takes the existing literature (99 references) to task and it’s mostly ugly. Keep in mind that the National Institutes of Health (NIH) has established criteria for what constitutes for a successful weight loss intervention: sustained reducton of 5-10% of baseline weight over one year, period. According to the authors, there were too few non-surgical studies that were of the sufficient duration one year duration. The few good studies that exist showed NIH-defined success was achieved only when behavior change (diet, exercise or counseling) was combined with drug treatment. What’s more, NIH-defined success, depending on how the drugs or the surgery were priced, did not actually reduce total costs or ‘save’ money. Instead, the amount of money spent per year of life-saved seemed, compared to other things that are covered by health insurers, justifiable. The authors have much more to say on the debate over the merits of various types of bariatric surgery, the implications of some new bench research discoveries, the role of disease management and the need for better research. Note to disease management organizations that are selling weight loss programs: it’s time to rely on the NIH definition of weight loss success and if you think you have a better mousetrap, you need to prove it by subjecting your results to the scrutiny of peer review.

Scott Taylor and Jack Weiss: Review of Insomnia Pharmacotherapy Options for the Elderly: Implications for Managed Care.

OK, instead of obesity, maybe you’d rather know everything about insomnia in the elderly, including its prevalence (especially in persons with chronic conditions), what the treatment guidelines have to say, the option of non-pharmacologic treatment, the merits of the three classes of FDA-approved prescription drug treatments, safety issues, the potential for drug abuse and how little is known about comparative clinical and cost effectiveness of the many drugs used for insomnia. You’re in luck here. Some important take away messages that the DMCB found interesting: insomnia is a prevalent and hidden problem for probably up to 50% of all those persons enrolled in disease management programs, disease management may have something to offer in making time consuming and first-line non-pharmacologic counseling/treatments available and while direct to consumer advertising suggests otherwise, all sleeiping pill drugs – pending studies that show otherwise - probably have the same success rate: who can blame managed care formularies for restricting choice?

Thomas Sandberg, Amy Wilson, Holly Rodin, Nancy Garrett, Eric Bargman, David Dobmeyer and David Plocher: Improving the Imputation of Race: Evaluating the Benefits of Stratifying by Age.

It can be difficult or awkward for health insurers to collect information about race. Enrollees may wonder if that information will be used to discriminate against them and many refuse to answer the question even if they fill out a survey. On the other hand, insurers have a role to play in reducing health care disparities and that will be difficult to do if its severity cannot be assessed. This paper adds to the science of inferring race from ‘geocoding.’ This is the use of location (county, zip code or street) to estimate the racial make-up of population segments. In addition to location, surname has been used to identify persons of Asian and Hispanic heritage. In this study, the authors took advantage of the observation that African-American households may have younger persons present. Lo and behold, when age was statistically combined in the geomapping mathematical modeling, the positive predictive value increased by 1-2%. It’s not a lot, but every little bit helps. The DMCB, wonders, if this would work outside of Minnesota, so additional studies are necessary.

James Rohrer, Kurt Angstman and Gregory Bartel: Impact of Retail Medicine on Standard Costs in Primary Care: A Semiparametric Analysis.

Don't let the term 'parametric' bother you, the DMCB isn't sure what that means either. 141 persons used a Mayo Clinic sponsored walk-in retail clinic and 137 used regular office care in the same period of time for one of five conditions: pink-eye, sore throat, viral illness, cough or bronchitis. Over the ensuing 6 months, average total costs for persons who used the retail clinic patients were $138 vs. $180 for the regular clinic users. After adjusting for the number of previous visits, age and gender, the difference turned about to be statistically significant. If doubters about retail clinics believe conditions are being ‘missed’ by that style of care, the economics in this study (assuming Mayo runs these clinics like the rest of the industry) would seem to suggest otherwise. The authors do an outstanding job of reviewing the possible sources of bias in this study and appropriately call for more studies. This report should have been this particular Population Health Management issue’s lead study. Read this if you want to see how a well executed study can be combined with economy of wording and scientific transparency.

Kathryn Kash, Smiriti Sharma and Neil Goldfarb. Is Disease Management Right for Oncology?

The DMCB always wondered just what disease management had to offer oncology. After all, these patients have very different types and stages of cancer, varied co-morbidities, complex treatment regimens and heavy physician involvement. Well according to this review of the literature, there seem to be three reasons why disease management may be right: 1) organizations such as the American Cancer Society and the National Cancer Institute have endorsed the involvement of ‘patient navigators,’ 2) patients are living longer and longer beyond the acute stages of their care and 3) there are some commonalities across many types of cancer that are quite amenable to the kind of support available in classic disease management. Those commonalities include the physical side effects of fatigue, nosocomial infections, dehydration/pain and anemia as well as the psychosocial issues of depression, symptom relief in palliative care, facilitating appropriate decision-making about end-of-life-care, coordinating multiple physicians, and managing lifestyle. As readers may surmise, there are not many studies on the cost effectiveness of oncology disease management, but there are two good studies from commercial settings and both appeared to be associated with declines in claims expense.

Don MacDonald, Michael Murry, Kayla Collins, Alvin Simms, Ken Fowler, Larry Felt, Alison Edwards and Reza Alaghehbandan: Challenges and Opportunities for Using Administrative Data to Explore Changes in Health Status: A Study of the Closure of the Newfoundland Cod Fishery.

What happens from a population based perspective when a major industry is closed and a lot of people are thrown out of work? While the moratorium on cod fishing in the Canadian provinces of Newfoundland and Labrador may not have direct lessons for those of us in the United States, the description of the methodologies that were used is instructive. The authors tell an interesting story of how they accessed and reconciled numerous and seemingly unrelated data bases to piece together an insightful snapshot of what happened to the population. The absolute numbers of declined as people moved away but grew older because it was predominantly younger people that were moving. Yet, average health status increased and death rates decreased thanks to the very old also moving out. Educational levels increased and new businesses appeared.

There’s also and editorial by Alan Lyles titled “Improving Long Term Weight Management: Social Capital and Missed Opportunities. In it, he describes how the social “capital” of mutual interpersonal support among like minded persons can act as a power catalyst in behavior change. He notes that social capital has been in decline in the United States over the last few decades. One bright spot, however, has been in the classic 12 Step programs, which includes Overeaters Anonymous. He notes their conspicuous absence in the science of battling obesity and suggests we'd do a lot in the fight against obesity if we learned how to harness this important social force.

The Latest Population Health Management Journal Summary For Your Summarized Reading Pleasure

Better late than never says the Disease Management Care Blog.

Just like yours, the DMCB's latest copy of the Population Health Management Journal has gone guiltily unread. Unable to resist any longer, it broke out the caffeinated beverages, donned it's reading spectacles and jumped in. It took notes and took no prisoners.

Good thing. The holidays are fast approaching, time is tight and you need know which articles are worth a closer look so you can quote them to the amazement of your coworkers.

James Gill, Ying Xia Chen, Joseph Glutting, James Diamond, Michael Lieberman: Impact of Decision Support in Electronic Medical Records on Lipid Management in Primary Care. Clinics that were already using GE’s ‘Centricity’ electronic medical record (EMR) and were members of the ‘Medical Quality Improvement Consortium’ (MQIC) were randomly assigned to either: a) an interactive point-of-care EMR disease management tool (12 clinics with 26,696 patients), or b) usual use of the EMR (13 clinics with 37,454). The tool consisted of an on-screen ‘pop-up’ that included a warning, patient assessment and patient management prompts. One year later, high risk patients (as determined by ATP-III criteria) were statistically significantly more likely to be tested. However, there was no difference in the rates of blood cholesterol levels being at recommended levels or being on lipid-lowering medications. Moderate and low risk patients were no different in both testing and being at recommended levels. Maybe it was the Centricity EHR, maybe it’s because docs don’t like/respond to pop-ups, maybe there are no financial incentives or maybe the EMR just doesn’t have the healthcare mojo the HIT nudninks would have us believe. Heads up Mr. Blumenthal.

Kurt Angstman, Ramona DeJesus and Mark Williams: Initial Implementation of a Depression Care Manager Model: An Observational Study of Outpatient Utilization in Primary Care Clinics. This is a retrospective study looking at the impact of an ICSI ‘coordinated’ and creatively named ‘Depression Improvement Across Minnesota Offering a New Direction’ (DIAMOND) project that is housed within two Rochester area Mayo Family Clinics with about 19,000 patients. Two care manager nurses were hired to assist in the care of patients with depression (defined as not only having the diagnosis but a PHQ score of 10 or greater). 38 DIAMOND participants were compared to 49 depressed patients who went without the care managers. DIAMOND patients had a higher number of return visits (averaging 1.24 vs. .69 for any reason and averaging .95 vs. .55 for depression) within a month. However, in looking at the proportion with at least one visit, 66% of the DIAMOND patients had a return visit for any cause within a month vs. 37% of controls (a difference that was statistically significant) and 55% of the DIAMOND patients had a return visit for depression in one month vs. 32.7% of the controls (not statistically significant). While the authors pronounced DIAMOND a success, the inability to find a statistically significant increase in the proportion of patients with follow-up visits for depression – the basis of a key HEDIS measure – makes the DMCB think otherwise about the 'success.'

Tine Hansen-Turton, Caroline Ridgway Sandra Festa Ryan and David Nash: Convenient Care Clinics: The Future of Accessible Health Care – The Formation Years 2006-2008. This is a thoroughly referenced history, description, review and editorial for Convenient Care Clinics (CCCs). If you can get past the marketing infomercial-like framing (the early ‘fledgling years,’ or ‘pleased’ consumers ‘ have ‘driven ….the increase in third party contracting, or ‘the core values’ are ‘quality, accessibility, price transparency and affordability,’ or CCCs ‘resonate with parents’ etc. etc.) you can learn about the Convenient Care Association, Harris polls, the growth of the industry, a RAND study that purports to show CCCs Are A Righteous And Good Thing, the underlying business model and the regulatory challenges.


Jane Stacy, Seven Schwartz, Daniel Ershoff, Marilyn Standifer Shreve: Incorporating Tailored Interactive Patient Solutions Using Interactive Voice Response Technology to Improve Statin Adherence: Results of a Randomized Clinical Trial in a Managed Care Setting. Humana randomized enrollees on statins to either 1) three behaviorally-based highly personalized interactive voice response (IVR) phone calls coupled with personalized mailed materials (N=253) or 2) one IVR call and generic mailed materials (N=244). At six months, the group with the high intensity IVR was more likely to have submitted a pharmacy claim for their statin (implying they were taking their pills) than the lower intensity group: 70% vs. 61%. Other measures of medication compliance were also statistically significantly different. The authors state their intervention consisting of ‘an amalgam of discrete elements borrowed from various evidence-base adherence-enhancing strategies ….based on multiple behavioral theories,’ works, but its vagueness makes it difficult for the reader to assess whether the intervention is truly generalizable. Readers may also wonder why the control group didn’t get three low intensity phone calls: it’s possible it was the calls alone, not the content, that led to the 10% absolute improvement seen in the study population. (As an aside, IVR was used to recruit potential candidates for participation in the research project and ‘73% could not be contacted by the IVR system after three months’ of multiple attempts. Is IVR the blanket communication tool that many believe it is?)


Yujing Shen, Usha Sambamoorthi, Mangala Rajan, Donald Miller, Ranjana Banerjea, Leonard Pogach: Obesity and Expenditures Among Elderly Veterans Health Administration Users with Diabetes. This study used the 1999 Large Health Survey of Veteran Enrollees (LHSVE) and the 1999 Diabetes Epidemiology Cohort (DEpiC) to assess the interplay between diabetes, accompanying obesity and the costs among VA patients who were also enrolled in Medicare. Only 21% had a normal body mass index (BMI); the remainder were overweight (48%), obese (23%) or morbidly obese (9%). While you would think that excess weight would be associated with higher costs, that’s not what was found: a normal BMI had more than $10,000 in yearly expenditures, followed by overweight ($7500), obese ($6600) and morbidly obese ($6700). The authors looked into the categories of claims expenses and could find no simple explanation, summing things up by saying a normal BMI may be associated with ‘poorer health.’ While the findings are counterintuitive, the authors point out there are other studies that show a reverse relationship between weight and costs among elderly persons with chronic illness. Maybe the widespread assumption that there is a ROI from weight loss and that this a reason to include it in care management for an elderly population should be revisited.


Brian Leas, Bettina Berman, Kathryn Kash, Albert Crawford, Richard Toner, Neil Goldfarb and David Nash: Quality Measurement in Diabetes Care. Did you know there are multiple organizations promulgating their own methodologies for assessing quality in diabetes care? Of course you did, but the extent of the problem may be greater than you think. It’s tough enough that different groups (like the NCQA or the National Quality Forum and others) recommend different measures. For measures where there is agreement (for example hemoglobin A1c), there are differing standards over the determination of the numerator and denominator, the target goal or the time frame. After surveying the various quality standards organizations, the authors then asked an expert group of ‘key informants’ if they found the complexity problematic. Short answer: yes. In addition to better ‘harmonization,’ the authors recommend that some missing measures be developed, such as assessments of interventions for ‘pre’-diabetes, ‘population-based’ metrics (not just the patients with a claim or a provider visit with an index condition), better attention to measures in the unemployed or uninsured populations, patient-centric measures and assessments of access to care. Good idea says the DMCB.


Roxana Maffei, Daniel Burciago and Kim Dunn: Determining Business Models for Financial Sustainability in Regional Health Information Organizations (RHIOs): A Review. If you’re interested in boning up on Regional Health Information Organizations (RHIOs), this is the article for you. Reports of their death have been greatly exaggerated but their economics remain murky. Among the few RHIOs that have survived, success seems to be associated with being a free standing organization with a business model predicated on membership fees (local health organizations involved in exchanging data pay a fee to belong, i.e., pay to play) and transaction fees (billing the participating organizations based on the number or type of transactions occurring). This article points out that this is still very much a work in progress. Stay turned.

A Summary of the Latest Population Health Management Journal

It's that time again. The latest issue of Population Health Management is out and you'd read it if you weren't so busy with other stuff. After all, PHM is your window into the latest goings-on in the disease management community, its information gives you and your company a competitive advantage and quoting from it impresses policy makers, bosses and colleagues. Good thing you read the Disease Management Care Blog: it has the information you want in a format you can quickly use.

Check it out and decide just which articles you really need to read and which ones are just FYI. So, without further ado......

In this ‘Point of View,’ the veteran Robert Stone of Healthways discusses the maturation of the disease management industry with a special emphasis on the insurers' eternal choice of ‘build or buy.' According to Mr. Stone, insurers want mutually supportive and broad-based health, wellness, prevention, case and disease management on one platform that are all built to last and are adequately capitalized. For those that are foolish enough to think about building, he cautions the availability of tools is not synonymous with an ability to use them. A telling quote: ‘Price is not the best indicator of ultimate value.’

In this article, Harry Leider of Ameritox, David Mirkin of Milliman and Christobel Selecky of LifeMasters reminisce about the recently concluded Ninth Population Health and Disease Management Colloquium. Harry pointed out there were presentations about conditions that have been largely ignored by the industry, such as chronic pain, autism, migraine and psychiatric conditions. David reviewed how unsettled the science is of using actuarial trends to estimate the economic impact of disease management programs. Christobel detailed how there is a growing emphaisis in her company and among others in maximizing patient activation. Good quote from Ms. Selecky about trending: “I wonder if people arent’ just shell-shocked with trying to come up with a methodology – once you think you have it nailed down, something squirts out the other end.”

Thomas Foels, Sharon Hewner: Integrating pay for performance with educational strategies to improve diabetes care. This describes how Independent Health of Western New York State compensated physicians (60 to 70 cents PMPM plus CME) to conduct reviews of their own charts for diabetes care quality. Physicians were then provided summary data that included an estimate of the patient’s overall burden of illness along with suggestions for improvement. 84% of the physicians participated, and over time there were at least 10 percentage point gains in the usual measures of blood pressure (less than 130/70), LDL (less than 100) and A1c (less than 7). The authors say – with very little detail - that they saved money. The DMCB thinks this is was an interesting article because this was more of a pay for ‘quality improvement program’ (? P4QI?) than a typical pay for performance (P4P) program: that seems unique. Kudos to the authors for this quote: ‘There were several limitations to this study, thanks to the lack of a control group, a small sample size per practice site, underrepresentation of rural and small practices and the selection of patients used in the survey based on a claims profile.' The DMCB says this is promising and some more research is needed.

George Ioannidis, Alexandrea Papaioannou, Lehana Thabane, Amiram Gafni, Anthony Hodsman, Brent Dvern, Eleksandra Walsh, Famida Jiwa, and Jonathan Adachi. Family Physicians' Personal and Practice Characteristics that Are Associated with Improved Utilization of Bone Mineral Density Testing and Osteoporosis Medication Prescribing The authors used a physician questionnaire from 225 Canadian docs to assess personal and practice characteristics and then correlated those results to the likelihood of ordering osteoporosis testing and treatment. Being female, not having hospital privileges, not being a recent medical school graduate correlated with ordering bone density testing, having an electronic health record was associated with treatment for osteoporosis. Best quote: ‘This is not surprising…..’

Susan Robinson, Robert Baron, Bruce Cooper and Susan Janson: Does health service use in a diabetes management program contribute to health disparities at a facility level? Optimizing resources with demographic factors. These researchers from the University of California followed 315 persons with diabetes for 18 months. Since all had equal access to the clinic, the authors were interested in knowing whether demographic factors correlated with healthcare utilization. Persons with Medicare and Medicaid as well as persons of Hispanic heritage used the emergency room more frequently. Women were more likely to be hospitalized and Hispanics less so. Telling quote: Clearly ‘disparities in utilization’ of health care services continue to exist within demographic subpopulations.” And we thought disparities hindered access to care.

Micah Throp, Jessica Weinstein, Jason DeVille Eric Johsnon, Amanda Petric, Xiuhai Yang, David Smith: Comparison of renal replacement therapy and mortality using 1 versus 2 estimated glomerular filtration rates. Using data from their electronic health record (EHR), these Kaiser researchers found that when when physicians ordered an ‘estimated glomerular filtration rate’ (eGFR)and found evidence of chronic kidney disease, the appearance of a second eGFR in the order data sets predicted a worse outcome. If you use the electronic record to find patients for a CKD disease management program, you may want to use this signal as evidence of a higher burden of illness. The bottom line quote: For the purpose of disease management, it is less important that the second low eGFR demonstrate [sic] an independent prediction of mortality…. Disease managemer can take advantage of its superior predictions….”

Yiduo Zhang, Timothy Dall, Yaozhu Chen, Alan Baldwin, Wenyua Tyng, Sarah Mann, Victoria Moore, Elisabeth L Nestour, William Quick: Medical cost associated with prediabetes. Using a ‘Cost of Diabetes Model,’ NHANES, Census Bureau Data and the Ingenix Research DataMart, these Lewin Group researchers ultimately estimate there is a total cost of $25 billion or $443 per person with prediabetes, mostly due to increased outpatient utilization, not from emergency room or inpatient care. What's more, 'these cost estimates understate the true cost of prediabetes to society...[due to] increases in missed work days and lower productivity.' The DMCB says use this paper when you want to market your metabolic syndrome disease management program.

Yaozhu Chen, William Quick, Wenyua Yang, Yiduo Zhang, Alan Baldwin, Jane Moran, Victoria Moore, Navita Sahai, Timothy Dall: Cost of Gestaional diabetes mellitus in the United States in 2007. This is another fact-fest from the Lewin Group who, this time, relied on discharge data to that gestational diabetes to estimate that the cost is $636 million, or $3,305 per pregnancy.

The Population Health Management Journal, for your quoting pleasure

Today was a good day for the Disease Management Care Blog. That's because any day that includes the latest copy of the Population Health Management Journal in its mail box is a reason to pause, get an extra cup of coffee, put up the feet, crack the cover and sample this buffet of learning from the peer reviewed, population-based care literature.

Many don't have that luxury, but no fear. The DMCB went through each manuscript and culled what it believes you need to know and what you can quote for your corporate-jousting, revenue-enhancing, client-facing, career-laddering advantage. Just another leg up when you join the many hundreds that regularly check in with the DMCB!

Anthony Stanowski: Influencing employees' attitudes and changing behaviors: A model to improve patient satisfaction. ARAMARK Healthcare conducted a national survey of 700 nurses (68%), physicians (11% and other clinical staff (the remainder) attitudes toward clinical support service employees. What follows is a descriptive journey that finds ‘a psychographic segmentation model can form the basis of a messaging strategy to create a collaborative approach with support services and the total patient experience with the health care institution.’ Despite the graphs and the percents, the DMCB was confused by how the author got from here to there, and why the PHMJ published a lead article that seem more attuned to an inpatient care oriented audience.

Amy Wilson, Holly Rodin, Nancy Garrett, Eric Bargman, Lori Harris, Melinda Pederson and David Plocher: Comparing quality of care between a consumer-directed healthplan and a traditional plan: an analysis of HEDIS measures related to management of chornic diseases. Consumer directed health plans have been accused of being the devil’s spawn because they oblige persons to actually participate in the economics of their health care services purchasing. While this may reduce global health care costs, does it also reduce medically necessary health care costs? In this study from Blue Cross Blue Shield of Minnesota, approximately 131,000 consumer directed enrollees’ HEDIS scores in heart disease, asthma, back pain, diabetes, medication monitoring and depression were compared to the HEDIS scores from just over a million traditional health plan enrollees. Ultimately there was either no difference in most of the HEDIS measures. Consumer directed plans actually did better in three of them: back pain, diabetic eye exams and diabetic urine screening. While it’d be easy, based on these data, to conclude that consumer directed plans are not the devil’s spawn, the authors didn't appear to statistically adjust the data for the baseline differences in age or gender. They also didn’t take into account the possibility that persons who chose consumer directed plans are more savvy health care purchasers. To really decide the question, better matching of consumer directed enrollees and health plan members would be necessary. It’s highly unlikely that a prospective randomized trial will ever be done, so the likelihood that the question will be ever be settled to everyone's satisfaction is remote.

John Fortney, Jeffrey Pyne, Jeff Smith, Geoffrey Curran, Jay Otero, Mark Enderle, Skye McDougall: Steps for implementing collaborative care programs for depression. Want to establish a state of the art, evidence based, clinically effective, generalizable, diffusible, CQI-oid, Plan-Do-Study-Act formatted, organizational theory-led implementation plan for the management of depression in your institution? Look no further. Here’s a series of check-listed steps with recommendations, along with a flow chart, for you or your 'team' to follow, all based on ‘lessons learned’ in two Veterans Affairs implementations. The DMCB will leave it to the reader to decide if this approach has any hope of success outside a vertically-integrated and salaried-provider care setting without a 3 month waiting list for non-emergent patients in carve out commerical plans to see a psychiatrist in the first place.

John Knight, Jeffrey Dowden, Graham Worral, Veerabhadra Gadag, Madonna Murphy: Does higher continuity of family physician care reduce hospitalizations in elderly people with diabetes? If you think one purpose of Canada’s health care system is to remind us Americans of the poor job we’re doing, you’ll like this study from the province of Newfoundland. The family medicine physicians’ insurance claims of all persons age > 65 meeting an insurance-based definition of diabetes mellitus (N=1393) were analyzed for the presence of “continuity.” Continuity was based on the patterns of claims that suggested that there was a single family practice provider responsible for the patient’s care. The higher the continuity score, the lower the likelihood of hospitalization in this group. Interestingly, the number of visits with any family practice provider was not associated with a lower hospitalization rate.

William Cardarelli: Asthma: Are we monitoring the correct measures? The DMCB thinks the asthma HEDIS measures were chosen because they’re easier to measure, not because they have any real world correlation with disease activity. It is not alone. This latest review of the literature from Atrius Health/Harvard Vanguard points out that there are several easily administered surveys that correlate quite nicely with the asthma severity as well as patients' quality of life. The author argues that clinical assessments of asthma control should be multidimensional and be partially based on these patient self-assessments. The DMCB also notes there’s a difference between individual patient assessments of asthma activity and population-based assessments of asthma quality of care. Why not, asks the DMCB, also use these surveys to supplement the insufficient HEDIS measures?

Yiduo Zhang, Timothy Dall, Sarah Mann, Yaozhu Chen, Jaana Martin, Victoria Moore, Alan Baldwin, Viviana Reidel, William Quick: The economic costs of undiagnosed diabetes. It makes sense to think that the years prior to a formal diagnosis of diabetes is probably a time when diabetes is present but hasn’t been diagnosed yet. The folks from the Lewin Group and Ingenix/i3 compared total insurance claims for the two years (2004 and 2005) prior to a first time diagnosis of diabetes in 2006 to insurance claims from persons from the same period without diabetes. The authors found the claims expense was comparatively greater. Based on these data, the authors estimate that the annual per person cost of undiagnosed diabetes and its associated complications is $2864. When extrapolated to the United States’ population, that’s $11 billion in direct medical costs, which typically goes unmentioned in all those other estimates of the already huge cost of diabetes.

Timothy Dall, Sarah Edge Mann, Yiduo Zhang, William Quick, Rita Furst Seifert, Janna Martin, Eric Huang, Shiping Zhang: Distinguishing the economic costs associated with Type 1 and Type 2 diabetes. Did you know that it’s not until folks are greater than age 45 years that direct and indirect medical costs of Type 1 diabetes becomes greater per person compared to Type 2 diabetes? By the time Type 1 diabetes reach age 65 years, much of the individual excess costs are associated with institutional care, including year-round nursing homes. Yet, the aggregate costs of all Type 1 diabetics (because there are far fewer cases) are much lower compared to Type 2 diabetes (which comprise 94% of all the cases). The most impressive number in this manuscript is $159.5 billion in total U.S. health care costs for Type 2 diabetes, vs. $14.9 billion for Type 1. That’s a lot of money that could otherwise be spent on, say, bank bailouts.

The Latest Population Health Management Journal Is Out!

Oh joy! Isn’t it great when you open your mailbox and find a goody like the latest issue of Population Health Management? Sure, you want to thumb through every page, ponder every word, examine every graph and review every citation but…. you don’t have time. But unlike your colleagues, you also regularly read the Disease Management Care Blog. That is your secret weapon. Scan the summaries below and then decide which needs to be read right away and which ones can wait. As an added bonus, the DMCB helps you impress your co-workers with your erudition by rustling up some key quotes. Use them to impress the boss at those upcoming conference calls and business planning meetings.

Dominick Esposite, Erin Taylor and Marsha Gold: Using qualitative and quantitative methods to evaluate small-scale disease management pilot programs.

Heard of the Medicaid Value Program? Neither did the DMCB, but this involved having 10 organizations use a variety of care interventions for Medicaid beneficiaries with multiple chronic conditions. Using a combination of qualitative and quantitative research, the authors found the implementation, competing priorities, provider buy-in and local leadership commitment to be the key ingredients associated with success. This is must reading if you’re going to use some of that Federal stimulus money to quickly rustle up a new Medicaid-based program.

Key quote you could use at an upcoming meeting “According to Esposito’s article in PHMJ, a smaller than expected number of eligible beneficiaries and lower than expected patient engagement rates are not uncommon.”

Iver Juster, Stephen Rosenberg, Deeptimayee Senapati and Mayur Shah: “Dial-an-ROI?” Changing basic variable impact cost trends in single population pre-post (“DMAA Type”) savings analysis.

In a prior post, the DCMB delighted in a review of chronic vs. non-chronic trends to derive what the cost of health care would have been absent a disease management program. If you think that’s simple, read this paper from a DM Jedi Master and his colleagues and find out just how complicated it can be and why, in the end, you’re going to need an actuary to ascertain whether you’re really reducing claims expense.

Key quote you could use at an upcoming meeting “According to Sensai Juster’s article in PHMJ, the length of the look-back period, the length of claims runout and the number of months of enrollment are important determinants of trend!”

Jason Cooper, Lakevia Hall, Angel Penland, Andrew Krueger and Jeanette May: Measuring medication adherence.

Read this and you’ll not only know the operational definition of medication adherence (the days supplied divided by the days prescribed) but how to handle claims runout and disenrollment when it comes to assessing whether a population is taking their meds. You’ll also get benchmark adherence rates in a commercial population (depending on the condition, mostly between 75% and 84% - bile acid sequestrants unsurprisingly are lower). Kudos to Accordant for making the data available.

Key quote you could use at an upcoming meeting “According to May’s article in the PHMJ, our medication adherence rates are already running at [insert ‘more’ or ‘less’] than what’s been reported in the literature!”

Kejian Niu, Liming Chen, Ying Liu and Herman Jenich: The relationship between chronic and non-chronic trends.

Sorry, but there’s no escaping this chronic and non-chronic trend stuff. In this paper, the authors stress-tested the DMAA methodology in a stable population without a disease management program and compared the chronic and non-chronic trends over time. It turns out the two were similar if there is satisfactory statistical adjustments and persons are annually requalified.

Key quote you could use at an upcoming meeting: “Good thing our actuarial consultants are using the DMAA methodology to assess the impact of our disease management program. According to Niu’s article in PHMJ, that approach has considerable merit!”

Thomas Kotsos, Keven Muldowney, Griselda Chapa, Eric Margin and Antonio Linares: Challenges and solutions in the evaluation of a low back pain disease management program.

This is even more evidence that the DMAA approach is taking root, since this article also relied on that methodology to assess a condition of great interest to employers. There appeared to be savings, but the subpopulation with simple mechanical low back pain apparently experienced an increase in claims expense. Everyone else experienced decreased utilization. One lesson may be to leave the simple back pain patients out of the program.

Key quote you could use at an upcoming meeting: “We’re already doing the top 5 chronic diseases, so let’s tackle a new one – like low back pain. Kostos in PHMJ showed that a telephonic nurse support intervention can make a difference!”

Al Lewis: How to measure the outcomes of chronic disease management.

Exhausted by all this high falutin actuarial stuff? The remarkably insightful father of disease management comes at the topic from another point of view by giving you 5 Important Questions that should always be asked when you are attempting to assess whether your disease management program is working.

Key quote you could use at an upcoming meeting: “You’re right of course, but how do we estimate the amount of co-morbidity reduction that has also taken place? According to Al Lewis (and everybody knows his name), that is a key question that must be addressed!”

And then there’s an editorial by … the DMCB. Called ‘Disease Management Grows Up,’ it points out that the sophistication of the literature above reflects an evaluation-science sea change underway in the disease management industry. In fact, the growing sophistication of measurement in population-based programs could well turn out to be the benchmark for other healthcare reform initiatives, including the patient centered medical home.

Key quote here: ‘Gosh, if the company I work for isn’t a member of DMAA, we should join. Not only would we get the PHMJ, we could get involved in future iterations of how to measure outcomes in population care management programs!’

Population Health Management Journal Summary For Your Perusing Pleasure

It's that time again! The December 2008 issue of Population Health Management, that journal formerly known as Disease Management is about to land on your desk. But you're busy. Those e-mails are overwelming your in-box. The December '08 let-it-wait-till-January-'09 management decisions are looming. Do you crack the cover of that journal and if so, which articles are of interest to you? More importantly, is there one you can quote or comment on at that staff meeting tomorrow to the amazement of your colleagues and boss?

The Disease Management Care Blog at your service! Plenty of stuff here across the employer, program, behavioral and actuarial settings........

Ron Loeppke, Sean Nicholson, Michael Taitel, Matthew Sweeney, Vince Haufle, Ronald Kessler: The impact of an integrated population health enhancement and disease management program on employee health risk, health conditions and productivity.

Is the company you work at self insured? You’re in luck because your employer can be like DIRECTV. They distributed an employee health risk assessment in April of 2003 with a $15 gift certificate incentive for completion followed by a $300 credit for their health insurance if a) low risk or b) moderate or high risk and willing to participate in up to 6 lifestyle-health improvement programs. The programs included in-person as well as remote coaching. $15 was enough to get a 60% baseline participation rate. There was a follow up survey in 2005. This report focuses on 543 persons that completed both surveys. As expected there was ‘risk’ shifting over time among the low, medium and high risk populations, but the downhill flow of persons from high to medium and from medium to low exceeded the uphill flow. A reduction in risk was associated with a reduction of 3.5 absences per year versus a comparison group. Unfortunately there is little information on the penetration of this program into the entire DIRECTV workforce: is 543 employees enough to make a difference for an entire company? What’s more frustrating, the authors state we need to wait for another publication to find out if health care insurance claims expense was reduced.

Roger Mazze, Margaret Powers, Harry Wetzler, Cori Ofstead: Partners in advancing care and education solutions study: Impact on processes and outcomes of diabetes care.

The International Diabetes Center at Park Nicollet has developed a ‘Partners in Advancing Care and Education Solutions’ (PACES) program based on their Staged Diabetes Management approach to diabetes care combined with an educational curriculum. 40 medical centers were invited to compete for inclusion in a pilot and 10 were eventually selected. Using the NCQA’s Diabetes Physician Recognition Program and the ADA Education Recognition Program criteria at baseline and at follow-up, there was a broad improvement in most of the diabetes quality measures pre-post. In addition, all participating centers ended up being certified by the NCQA and the ADA. The DMCB wonders if the authors chose the centers that were performing at a low level and/or had the highest interest in succeeding. If so, the generalizability of this study may be limited. On the other hand, if you want to turbocharge your institution’s likelihood of getting ADA or NCQA recognition, these guys may be the ones to call.

Ramsey Farah, Kyahn Kamali, Jeffrey Harner, Ian Duncan, Thomas Messer: Random fluctuations and validity in measuring disease management effectiveness for small populations.

Want to know if your disease management program saved money? Well, if the number of persons in the program is small, the ability to spot any meaningful savings is decreased and gets worse as the number of participants goes down. As a result, you may need to a) hire an actuary or b) read this paper or c) do both. If you read this paper, you’ll be better able to understand using 1 vs. 2 standard deviations, 1 or 2 sided testing, admission based savings calculations, truncation at a $100,000 stop loss limit and various external populations for non-chronic trending. After reading this paper, the DMCB thinks you'll need to hire an actuary anyway.

Cynthia Hartsfield, Eli Korner, Jennifer Ellis, Marsha Raebel, John Merenich and Nancy Brandenburg: Painful diabetic peripheral neuropathy in a managed care setting: patient identification, prevalence estimates and pharmacy utilization patterns.

Using claims submitted by physicians to insurance companies to indentify populations with a condition of interest is very much an art and a science. Claims can both “overcall” a diagnosis (be falsely positive) or miss a diagnosis (falsely negative). Thanks to a grant from a manufacturer of a drug meant to treat diabetic neuropathy, the folks at Kaiser used the gold standard of chart audits to fine-tune a claims-based algorithm that had a so-so false positive rate (of about 50%) and a low false negative rate (about 1%) for this condition. They estimate that among persons with diabetes, the prevalence of neuropathy, depending on the criteria used, is between 11-21%. Furthermore, treatment of diabetic neuropathy is very difficult: nothing works very well. As expected, medication claims in this population is highly variable in both the numbers of persons receiving treatment and the types of drugs being used. This is a good paper because the authors provided the ICD-9 codes and the reader gets to think about the good and the bad about using insurance claims instead of chart reviews; many of the lessons here apply to other conditions.

Karen Fitzner, Deborah Greenwood, Hildegarde Payne, John Thomson, Lana Vukovljak, Amber McCulloch and James Specker: An assessment of patient education and self management in diabetes disease management – two case studies.

The wonderful folks at the American Association of Diabetes Educators are pointing out in this review of the literature that there is some evidence that Certified Diabetes Educators (CDEs) can be a valuable asset in diabetes disease management. Yes, there are registered nurses and case managers, but the CDEs can provide an extra level of expertise to patients that need it. They even provide two case studies – one from an integrated delivery system and the other from a for-profit disease management organization – that spell it out in greater detail. The DMCB knows CDEs are an important option in disease management and is glad to finally see a paper that confirms its suspicions.

Thomas Blakely and Gregory Dziadosz: The chronic care model for behavioral health care.

This is a report from an outfit called ‘Touchstone innovare’ who implemented a behavioral version of the chronic care model in their Michigan mental health agency. Frankly, this is a difficult paper to read because there’s no description of the workings of the agency or the disease burden in the population. There was a control group but they were contaminated by being the same agency. That being said, a pre-post analysis showed an improvement in multiple measures of psychological well being and an astounding 39% reduction in inpatient days. This is a good start, but much work needs to be done before we really know how the chronic care model will work in outpatient behavioral medicine.

Read All About It: the Population Health Management Journal is Out!

Quick. Which is more newsworthy? Ms. Lucci’s return to daytime soaps? Ms. Obama’s striking victory night garb? The arrival of the newly named Population Health Management Journal in our mailboxes? The Disease Management Care Blog agrees with you: it IS hard to pick one, but since the Journal was sitting on the kitchen table and its white, green and blue trimmed luster caught it’s eye, the DMCB was drawn to it faster than you can say: ‘Egads, Howard Dean for HHS Secretary?’

Feeling guilty about wanting to read about Ms. Lucci or Ms. Obama rather than page through the Journal? You’re in luck! You can have the dancing, the dress and this disease management knowledge dump by taking advantage of this quick summary - courtesy of the DMCB.

Maio V: Light and Fire, from the Department of Health Policy at Jefferson.

This is an editorial that describes the good (light) and the bad (it burns) of “biologics” or those drugs that are grown in DNA-altered bacteria filled vats. The number of these agents is not only growing, so are their indications. The only thing that is falling is the threshold of doctors to using them. The author suggests that the growing appetite for these miracle drugs will inevitably lead to the discovery of some horrid side effect that was previously unknown. Either that or a batch will eventually go bad and hapless patients will be exposed to curdled biologic. We need head-to-head comparative effectiveness trials that also account for their cost and hassles (IV administration for example), and the sooner the better. The DMCB seconds that motion.

Fetterolf D, Tucker TL: Assessment of Medical Management Outcomes in Small Populations, from Alere

Dr. Fetterolf was an author in many of the DMAA Outcomes recommendations, so when he writes, readers should pay attention. In this review paper, he and Mr. Tucker patiently examine why small numbers of observations are the bane of DMO marketing and salespersons who want to, but can’t say “our results are ‘statistically significant!’” Common approaches to this vexing problem include ignoring the statistics, ignoring the results, or reporting the results with a statistical caveat emptor. But do not fret, Fetterolf and Tucker describe other approaches including cumulative sum plots, passing patients’ data through a series of binary tests and weighted blending of the study population data into those of a larger book of business. Confused? So is the DMCB, but it promises that if you read this article more than once, some of it will sink in.

Serxner S, Mattke S, Zakowski, Gold D: Testing the DMAA’s Recommendations for Disease Management Program Evaluation, from Mercer and Rand (Mattke)

The authors set out to compare an old DMAA method (without requalification), one recommended by the lead author and some other approaches to assess the savings from care management programs. To do this, medical and prescription drug claims from over 200,000 persons over the two years prior to and one year after the institution of a ‘health and productivity management program’ were used to test the role of using 1) a non-chronic trend, 2) a non-chronic trend with statistical adjustments, 3) a non-chronic trend adjusted for relative and 4) absolute historical differences, 5) the client specific trend (which is Sexner’s preferred method) and 6) a national trend. The authors also measured the impact of not having a $100,000 cap, not excluding certain conditions like cancer and extending the baseline out to 24 months instead of 12. The change in the per member per month cost swung from a savings of $153 to a loss of $15. Guess what the author’s conclusions are: baseline trend assumptions have a large impact on assessing program impact. Now are you REALLY confused? So is the DMCB, but the authors raise an interesting point: if there is no clear definition of just what the “truth” is when it comes to analyses like this, perhaps it should be an industry standard to obtain multiple analyses and use them all to make an informed judgment on the effectiveness of a program. The DMCB is aware of other insurance industries that rely on multiple actuarial models to ultimately derive a single best estimate of trend, projected surplus and premium setting.

Glave Frazee S, Sherman B, Fabius R, Ryan P, Kirkpatrick P, Davis J: Leveraging the trusted clinician: Increasing retention in disease management through integrated program delivery, from Care Health Systems and Case Western Reserve.

Care Health Systems has “an innovative methodology” that has the secret sauce in “identifying, contacting, enrolling and retaining patients in DM programs.” The term ‘secret’ is no joke because the “tracking of patient demographic and clinical information, the patient contact and enrollment process, as well as all contacts between the nurse coach and patient were performed using a proprietary DM information system application” that is “patent pending.” The group getting the intervention did indeed have a clinically and statistically significantly higher 12 month participation rate, but without knowing what’s inside the black box, the DMCB stopped rea

Rohrer JE, Takahashi PY, Adamson SC. Age, obesity and medical visits in family medicine, from the Mayo Clinic.

This is a descriptive study from the folks at the Mayo Clinic who used a convenience sample of 1715 patients who were referred out of the Department of Family Medicine for a specialty consultation. The authors were interested in the interplay of age (less than vs. older 65 years), co-morbidities (measured by the Charlson Index) and BMI. Unless there were significant co-morbidities, a BMI greater than 35 was not, repeat not, a predictor of many physician visits among the elderly, but it was among persons that were younger. If visits are a surrogate measure of health, the authors ask if population-based interventions for obesity are really necessary for geriatric patients. Though this was an observational study, the DMCB feels redeemed by recalling that he told many of his otherwise healthy older women patients to stop worrying about being size 20. Maybe the rest of us should not worry if our rotund grandpas enjoy another helping of pie this Thanksgiving.

Duncan I, Lodh M, Berg, GD and Mattingly: Understanding patient risk and its impact on chronic and non-chronic member trends, from Solucia, Schrammraleigh Health Strategy and McKesson.

Whoa, actuary alert! These authors used a data base and from a state Medicaid plan that had purchased disease management services to assess a risk adjustment method to “further assure equivalence between the baseline and intervention period populations” that are requalified under the DMAA methodology. After staring at a paper that had more numbers than words, the DMCB believes the authors set out to statistically neutralize the impact of the varying costs involving extrinsic factors involved in new, continuing and terminating members’ patterns of utilization. Really really confused? The DMCB fears it will stay that way also, but the good news is that this paper is further evidence of the growing sophistication behind the evaluation of disease management programs.

Finally the Journal published a preview of all the upcoming abstracts from the 10th Annual DMAA Forum and the 2nd Integrated Care Summit. Use it to plan your upcoming meeting diet of education, knowledge and insight.