Why Health Reform's Medicare Prevention Provisions For Diabetes Are As Inadequate As Octogenarian Moon Walking

The Disease Management Care Blog often invites feedback from the DMCB spouse. With her usual discerning eye, she critically appraised yesterday's Part 2 post and characterized it as "bleh bleh disease management blah prevention blah blah blah Medicare personalized prevention plan bleh Pam Anderson bleh blah prevention."

Guilty as charged, but the DMCB forges on with this Part 3 post on the topic of prevention and health reform, while drawing more inspiration from another Dancing With The Stars contestant, Buzz Aldrin. The octogenarian, former jet pilot and moon-walking astronaut did a remarkable job of competing against a much younger field, but his future appearances on that show are numbered. The DMCB agrees with judge Bruno Tonioli: he moved like he still had his moon boots on.

And so does Medicare when it comes to prevention. The DMCB explains.

In the (allegedly off-topic) prior post, it was pointed out that the published science takes a dim view of 1) physician-led and 2) non-selective exercise and obesity prevention programs. That doesn't mean that ALL programs are a waste of time, as amply demonstrated in employer based programs and by Silver Sneakers.

What makes them different than the plodding non-evidence-based approach now included in Federal health reform? They a) don't rely on the patient-physician dyad and b) target their interventions.

Consider the need for preventing diabetes mellitus, where is good news. This randomized prospective New England Journal of Medicine study published back in 2001 showed nutritionist-led "detailed" dietary advice with food record review, along with regular, supervised and tailored exercise sessions reduced the incidence of diabetes in persons at risk to 11%, versus a 23% in the control group, over 4 years.

And check out this Diabetes Prevention Program study that was published the following year, also in the New England Journal. Persons at risk for diabetes were randomly allocated to either a) "life style recommendations," b) receipt of the same recommendations plus taking a drug called metformin (which was thought to possess some preventive potential) or c) a far more rigorous "intensive program of lifestyle modification." The latter arm of the study was designed....

"....to achieve and maintain weight reduction of at least 7 percent of initial body weight through a healthy low-calorie, low-fat diet and to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week. A 16-lesson curriculum covering diet, exercise, and behavior modification was designed to help the participants achieve these goals. The curriculum, taught by case managers on a one-to-one basis during the first 24 weeks after enrollment, was flexible, culturally sensitive, and individualized. Subsequent individual sessions (usually monthly) and group sessions with the case managers were designed to reinforce the behavioral changes" (bolding from the DMCB).

After just less than 3 years, the incidence of diabetes was 4.8% in the intensive group versus 7.8% in the metformin group and 11% in the life style recommendations group. A follow-up study showed that the beneficial effect continued after ten years. That's pretty impressive with a number needed to treat of about 20 to prevent one case of diabetes.

So what can be concluded from the success of employer based wellness programs, Silver Sneakers and these New England Journal diabetes prevention studies?

1) Employer based programs succeed because they typically focus their interventions on segments of the population that stand to gain the greatest benefit. They use health risk assessment surveys to identify those persons at risk and to ascertain willingness to participate. The DMCB thinks it may be possible for physicians to also do this during a 1-on-1 personalized prevention plan encounter, but - based on physicians' lack of confidence and perceptions about their patients described in the prior post - that'll be the exception and not the rule.

2) Silver Sneakers succeeds without requiring a physician office visit as a condition of participation. Patients show up at the gym and there are fitness coordinators that tailor programs, much like the interventions described in the New England Journal.

3) The diabetes prevention studies described above, Silver Sneakers and employer-based wellness programs succeed by relying on non-physicians such as nutritionists, fitness trainers and case managers to do the "heavy lifting" of patient engagement and supervision.

And finally, it should be pointed out that fee-for-service Medicare still doesn't cover the actual preventive care by nuritionists, fitness experts or case managers. As of yesterday's health reform signing ceremony, the only that's covered is the physician-based "planning."

Which is why the admiring DMCB regretfully thinks dancing Buzz Aldrin is symbolic of an aging and plodding Medicare. In their prime, Buzz and Medicare were truly remarkable. As the years have gone on, both still deserve utmost respect but let's face it: neither are up to their assigned tasks. This latest bill's prevention provisions is much like Buzz's shuffling moon walk last night: decades late and unable to adapt to the rhythms of a modern age.

In the last installment of this series tomorrow, the DMCB will speculate about what could be done in health reform to take full advantage of what science tells us about prevention. As for Buzz, there is little the DMCB can do, but it wishes his coaching dance partner much luck.

With Health Reform, Medicare Now Covers a Prevention Visit With A Doctor: A Look At the Scientific Evidence, Part 2

In yesterday's post, the pernickety Disease Management Care Blog contrasted Speaker Pelosi's victory speech description of the newly passed health bill's prevention provisions with the actual legislative language. While her characterization bordered on bombastic, it's clear that there's a lot of grant money and new government being devoted to prevention. What really caught the DMCB's attention, however, was the decision for Medicare to now pay for an annual visit devoted to the creation of a "personalized prevention plan."

Sounds good right? Imagine being ushered in from the waiting room and huddling with your personal physician, Dr. Nowpaidenuf. Dream about reviewing, sharing and discussing how little you exercise, how much you eat and how unwilling you are to get a colonscopy. Then visualize exiting the clinic with a plan, being thankful that your version of Medicare is under the stewardship of an enlightened political leadership and resolving to eat more vegetables. And fruit.

Sound too good to be true? There's plenty of research to say that it probably is.

While there are plenty of studies (for example) that show that physicians could do better when it comes to counseling their patients about prevention, it turns out that lack of payment has been only a small part of the story, compared to other issues, such as their own lack of confidence or patient barriers that include socioeconomic issues, competing medical conditions, and the lack of motivation. If physicians wade in anyway, their advice can be wrong and, even if they're right, the benefit that patients may get typically decays over time. No wonder the U.S. Preventive Services Task Force has concluded there is no evidence that primary care counseling works to meaningfully increase physical activity and that a very thorough review of the medical scientific literature found no evidence to support the notion that counseling alone has any sustained impact on obesity.

While the DMCB is thankful, that's because a certain Ms. Anderson has thrown her hat, plus ample amounts of fruit, into the ring of Dancing With The Stars. Armed with that inspiration, the DMCB thinks it's ironic that, just when Medicare is emphasizing value based purchasing, Congress has created an additional entitlement that, by itself, has little apparent value.

But all is not lost. The DMCB ultimately thinks that there is plenty of value to be had in prevention counseling. More on that in a Part 3 post tomorrow.

The House Passes Health Reform: What Does It REALLY Say about Prevention?

The Disease Management Care Blog watched last night's speechifying that accompanied the House's health reform and was struck by Speaker Pelosi's repeating the 'prevention' refrain:

"...the list goes on and on about the health care reforms that are in this legislation: insure 32 million more people... end insurance company discrimination .....creating a healthier America through prevention, through wellness and innovation, create 4 million jobs in the life of the bill and doing all of that by saving the taxpayer $1.3 trillion dollars" (bolding from the DMCB).

Which begs the question: now that reform is at hand, will our new and improved health insurance system now pay for preventive care?

To find out, the trusting but verifying DMCB blew tanks, dove through the House's legislative language posted here and uncovered this quote:

The CMS Administrator would conduct an assessment of the diseases and conditions that are the most cost-intensive for the Medicare program. The assessment would inform research priorities within HHS in order to improve the prevention, or treatment or cure, of such diseases and conditions. Not later than January 1, 2011, the Administrator would submit the report to the Secretary of Health and Human Services and the Secretary would transmit the report to the Congress.

So, a more more accurate interpretation of the legislation that was passed by the House may be that it would create prevention research for a healthier America.

But then the DMCB paddled back to the Senate's language and looked for more. It found that that creates an Independent Medicare Advisory Board that is charged with making cost-saving recommendations that promote prevention, a National Prevention Health Promotion and Public Health Council to coordinate prevention, a Preventive Services Task Force to make recommendations about prevention, a national private-public partnership to raise awareness about prevention and a web site on prevention. In addition, there are provisions for research grants and contracts that fund health teams so that they can counsel patients about prevention, grants to States to test prevention programs in Medicaid as well as fund community programs, offers of technical assistance to employers for wellness programs and establishment of a "Prevention and Public Health Fund" that would invest in prevention and public health programs. Last but not least, Medicare would cover an annual visit that creates a "personalized prevention plan."

So, a really really more accurate description of this legislative bundle is that it would fund research, contracts, assistance and grants on prevention, create various bureaucracies devoted to prevention and include coverage for provider visits devoted to counseling about prevention.

As its prior posts may indicate, the DMCB has been skeptical about Feds' ability to deliver on their health reform promises. However, 1) it's now the law of the land, 2) all still remains right with the universe because the Orange are hanging in there and 3) some solace was within reach yesterday thanks to this mixed with a version of this. Who knows, maybe some good will come of reform, especially if some of the folks running things in DC read this blog once in a while.

In the meantime, it appears to the DMCB that the short answer to the question at the beginning of this post is that, outside of lots of Federal largesse and bureaucracies, the health insurance system will now cover provider counseling on prevention for consumers. In tomorrow's post, we'll examine in greater detail whether that is really as wonderful as Ms. Pelosi's speech implied.