More On the "Call for Comments" and Here's One From JD Salinger's Fat Lady

The Disease Management Care Blog has gotten some terrific one sentence 'messages' in response to its "call for comments" to share at an upcoming U.S. medical school lecture. If your submission has not appeared anywhere among the DMCB's vast array of web portals, fear not: it's in there. Your comments are being compiled with others, dropped into PowerPoint and will likely appear in a future DMCB posting.

Comments are still being accepted through early next week. This is your chance to educate, impress and influence a roomful of future doctors. Posts here, email, tweet, Facebook and LinkedIn are all accepted.

By the way, the DMCB is **NOT** going to teach about, let alone mention, "disease management." Rather, the lecture will deal with various approaches to health care financing and risk transfer.

The DMCB is planning to conclude the lecture with a comment that touches on a favorite topic borrowed from J.D. Salinger's literary masterpiece Franny and Zooey. That would be the "Fat Lady," or how contemplation, reverence, submission and service can can light up the universe that lingers just beyond the reach of rational thought. This is the astonishing insight from brother Zooey that pulls the gifted radio star Franny Glass out of her nihilistic funk.

Physicians are especially privileged because they have a leg up on discovering their own personal Fat Lady. She exists in every patient and she calls to us. And she is now telling us that, while diagnosis and treatment are still "Job One," we docs are also being called to apply new skills in reconciling ethics, financing, public health, health literacy, lifestyle issues, socioeconomic status and third party meddling:

Zooey's explanation to Franny:

[I was told] to shine my shoes...I was furious. The studio audience were all morons, the announcer was a moron, the sponsors were morons, and I just damn well wasn't going to shine my shoes for them... I said they couldn't see them anyway, where we sat. He said to shine them anyway. He said to shine them for the Fat Lady. I didn't know what the hell he was talking about, but he [had a] ... look on his face, and so I did it. He never did tell me who the Fat Lady was, but I shined my shoes for the Fat Lady every time I ever went on the air again -- This terribly clear, clear picture of the Fat Lady formed in my mind. I had her sitting on this porch all day, swatting flies, with her radio going full-blast from morning till night. I figured the heat was terrible, and she probably had cancer, and -- I don't know. Anyway, it seemed goddamn clear why [I had to] shine my shoes when I went on the air. It made sense.

And now the Fat Lady is telling physicians that while morons abound, understanding the principles underlying risk transfer and how insurance works is important because will help you get your patients the care that they need. In other words, knowing how and why health care services are financed and what can be done about it at the individual patient level is no longer the job of that lady sitting on that porch.

Here's the DMCB comment: Docs need to shine those shoes.

Another Reason Why the Health Reform Town Halls Are Not Failing to Disappoint

The Fat Lady points out that the historical and religious tension between population based care versus one-on-one care may be one ingredient in the health reform Town Hall brouhahas.

Recall it was the ‘Old’ Testament that proscribed certain dietary practices and contact with persons with communicable disease. While the basis of these laws are myriad and include public health as well as holiness, they strike the Disease Management Care Blog as being among the earliest examples of population based care: the care shown by God for a chosen people blessed by a special covenant.

Contrast this community-based hygiene with the 'New' Covenant of Jesus’ ministry in the New Testament. While He certainly personally followed Jewish law, His controversial appeal to his past and present followers seems to have less to do with the collective fate of peoples and more to do with the personal salvation of individuals. To the DMCB’s knowledge, Jesus didn’t come up with a means to diminish the prevalence of leprosy, schizophrenia, blindness or paralytic syndromes. Instead, He cured individuals one at a time. How inefficient. And how wonderful.

Say what you like about the role of the Bible in modern society, the Fat Lady thinks it continues to give great insight into today’s human condition. The insight here is that when it comes to illness, persons don’t want to have the likelihood of future complications from their chronic conditions to be diminished, they want to be cured. That was the health care gold standard uncovered approximately 2000 years ago - and it remains with us today.

Which may be part of the problem underlying the August health reform doldrums and the Town Halls discussed in yesterday’s DMCB posting. After being thoroughly pressured cooked by the dense Boston-based academosphere of D.C. health policy, our elected representatives have emerged from the Capital building spouting opaquely dense terms like ‘access’ and ‘primary care provider’ and ‘bending the curve’ and “preventative.’ They want the public to buy into quality assurance, comparative effectiveness and actuarial predictions.

The Fat Lady says good luck.

Part of the Town Hall dynamic may certainly include political grandstanding, unreasonableness, partisanship, manipulation and public inattention. However, the DMCB also thinks many persons want to hear how the electronic health record, how comparative effectiveness research, how the public plan option, red pills-blue pills, better attention to living wills and subsidies for health insurance will help cure people. Anything less just won’t do, especially if it’s going to cost $1,000,000,000,000.

As an aside, even the Fat Lady understands the difference between miracles and medicine. That being said, one allure of today’s medical-industrial complex is its promise of miraculously ‘curing’ diseases like cancer, heart disease and obesity. In fact, she wonders if the continuing business success of the disease management industry is due to its recognition of the U.S. health care system’s core appeal. They quickly changed course on marketing themselves as the best approach to chronic conditions in the 1990s to re-emphasizing their role as a supportive care strategy in the 2000s.

The Magi and What Their Mathematics Discovered. The Fat Lady is Back

While the role of the Bible in modern American society can be controversial, the Disease Management Care Blog still thinks it’s great literature that gives important insight into the human condition. While it is the nature of popular media to substitute “Happy Holidays” for “Merry Christmas,” Santa for St. Nick and happiness for holiness, the DMCB is reminded by the Fat Lady to look for the lessons from the Season.

That’s why it’s been thinking about the Magi. These are the wise men who made a brief appearance in the second chapter of the Gospel of Matthew. These individuals were probably top learned scientist-astronomers engaged in the full time study of the patterns of the heavens. As the lights circled overhead in precise mathematical patterns, this expert class of professional stargazers constantly sought out new insights and even attempted to link them to human events or predict the future.

The DMCB isn’t too sure that the stargazers of that day are not too dissimilar from today’s vast numbers of professional number crunching pattern watchers. The only difference is that their areas of study are no longer confined to the stars. In addition to breathtaking advances in the physical sciences, modern wise men are gazing at humans and their patterns, likewise seeking to link them to other events and predicting the future.

We’re all familiar with these brainiacs. Facile with incredibly complex mathematics, these data-heads can price risk, assess the strength of statistical associations and assign attribution. Some are better than others. The ones that are really good, really lucky and benefitting from the work of others often go on to make incredibly useful discoveries. Some even win Nobel Prizes. This is the work of turning data into insight and information into inspiration. This is the work of making numbers “sing.”

So who were the greatest mathematicians greatest of all time? The DMCB votes for the Magi. Blessed by the work of generations of predecessors as well as the good fortune of being in the right place at the right time, these brainiacs also applied prodigious (and literal) amounts of leg work in the pursuit of explaining new pattern in the sky. And what a thing they discovered.

Is this an endorsment of mystical numerology? Hardly. But the DMCB finds it interesting that mathematicians feature so prominently in this classic Bible story. Once again, something far greater lies at the center of our logical hard wired dependence on what is seen and what is measurable. The Fat Lady reminds us that this calls to us every Christmas season.

A Prayer for the 3rd MCCD Report (Part 3 of 4)

Should prayer for those with chronic illness be covered under Medicare? Such a notion is probably an anathema to many of the level-headed readers of the Disease Management Care Blog. The remainder probably thinks the DMCB is going off on some bender. Yet, many reasonable persons believe in the intercessory ability of humans to either harness or appeal to forces that transcend logic or our five senses. On the surface, a majority of Americans would agree that it’s not that radical a concept, especially since there are some compelling anecdotes.

Leaving aside the obvious religious questions and inevitable legal objections, one way to come up with an answer would be to fashion a Demonstration, prospectively randomizing beneficiaries to control and intervention groups and then assessing the statistical significance of between-group differences in quality, cost and satisfaction. Since believers would argue not all prayer is the same, the Demo would need to test several belief systems involving multiple settings and multiple conditions. Think it silly? There have been several per-reviewed publications assessing the impact of such ‘distance-based interventions.’ All that is lacking is sufficient venture capital.

But seriously, the DMCB is not attempting to equate prayer and population-based approaches to care. However, thinking about the challenges of ‘testing prayer’ is instructive about the limits of scientific inquiry. It is very hard to simultaneously test 1) multiple, 2) interdependent, 3) socially complex and 4) variable interventions like prayer and then rely on unidimensional outcomes (like A1c or PMPM) to gauge success.

The DMCB is not being naive. It understands the similarities between prayer and disease management are a stretch (except maybe for what it will take for DM to be covered by Medicare). There are multi-million dollar disease management companies that want a place at the Medicare trough and the implications of coverage are huge. That being said, the DMCB also wonders if disease management has greater similarity to the health care quilts of community-based institutions, families and religious organizations than the more circumscribed interventions of a drug or an x-ray. Assessing multiple-packaged-interdependent-complex-variable interventions like reassurance, support and encouragement through the narrow aperture of a randomized clinical trial (RCT) just isn’t up to the task of assessing the real values of ‘care coordination.’ It also doesn’t work for other long-accepted approaches like primary care or hospice, neither which has also been evaluated in an RCT. Nor should they be.

By the way, the DMCB doesn’t think Medicare should ‘cover’ prayer, but not for the usual reasons: it’s already freely available.

Unfortunately, the acolytes of care coordination and disease management (and the Medical Home, by the way) have to play with the cards they’ve been statutorily dealt. If the path to explicit inclusion in the Medicare benefit is lined with RCT demos like MCCD and Medicare Health Support, it looks like the population-care industry is going to have a tough time. Medicare beneficiaries will be worse off for it.

What’s the fix?

Fashioning Richer Studies That Ask How, Not What: Don Berwick tells us that we need to do a better job of assessing how interventions work best. The MCCD, for example, tells us that in-person care coordination seems to have greater success than remote approaches. Duh. We already know that, but we sure could do a better job of understand the circumstances It’s doubtful that an RCT will be able to sort that out.

Assess Value, not Savings: Is it possible that in the Medicare FFS Program, care coordination strategies add cost but with comparatively greater gains in value? Suppose we found a version of disease management, inclusive of fees, that cost $50,000 per quality adjusted life year (QALY). That’d be a deal, but it wouldn't be cost saving.

The DMCB is having trouble finding the 3rd report on line. If that keeps up, it'll have to figure out how to post it here. Email if you want a copy.

What Angels Teach Us About Announcements from the Disease Management Industry

The season reminds the Disease Management Care Blog that healthcare is more than just outcomes or trend. It’s also about the Fat Lady and not living on bread alone. Consider that Jesus’ life-story was bracketed by angels announcing His birth and resurrection to persons subsisting at the lowest socioeconomic rungs of the day: shepherds and women. I leave it to the reader to interpret the significance of what happened between the angels’ visits. Whatever the conclusion, it should remind our industry to always consider the relevance of our multiple announcements for those struggling at the margins of today’s modern society.

Pay for Performance (P4P) & Disease Management

In keeping with the season, the Disease Management Blog wanted to bracket this week with a famous bit of verse from the 4^th Chapter of Matthew:

The tempter came to him and said, "If you are the Son of God, tell these stones to become bread." Jesus answered, "It is written: 'Man does not live on bread alone, but on every word that comes from the mouth of God.”

At the time, most of the world was preoccupied getting enough to live on, not dying prematurely and securing as much power as possible. In dealing with these Three Great Temptations, this itinerant carpenter succinctly pointed out that mankind deserved better and that our greatest potential in every aspect of our day-to-day existence was built on something far greater.

Our effort to shape the delivery of health care is no different. I think the “bread alone” issue is what annoys many stakeholders about “pay for performance.” Patients wonder why physicians should be paid to “do the right thing,” while physicians distrust the use of pieces of silver to shape their profession. Both parties know "bread alone" falls short. As testimony to this, not too long ago I watched a respected colleague practically tear up a check at a Departmental meeting in disdainful disgust.

That’s why I was very interested in this telling videotape of Bob Margolis MD, the CEO of HealthCare Partners, discussing how P4P works in California. It’s about 40 minutes long and well worth watching. Kick back, get your lunch and enjoy.

It was not what you might expect. I thought Dr. Margolis was going to suggest that paying docs to do the right thing was bread enough. I was pleasantly surprised. Among his many excellent points is that paying docs to do the right this is all well and good, but more importantly:

• This is also a function of not paying for the wrong thing.

• The exercise in creating P4P generates measurement, which – independent of the bread - is a critical ingredient in the improvement of health care delivery.

• P4P draws stakeholders to the table and gets everyone to talk about quality.

• Because physician groups are large and many of the docs are salaried, they haven’t necessarily seen any increase in pay for their performance. Rather, the pay is used to invest in systems of care that promote performance. Important distinction.

The key lesson is that P4P may deliver more dollars to the doctors (since I'm a doc, the the disease management blog supports the idea), but when it's done right, it can be a catalyst that brings out other more important positive forces. I'm not necessarily saying this is a key to heaven, but there is something to be said for appealing to dimensions of health care that have nothing to do with self-interest.

As an aside, I’ll point out that the lessons are important for the disease management industry, which should also strive to live by more than bread alone. I’ll leave the broader dimensions of this to another blog, but at a more discreet level, check out McKesson’s AccessPlus P4P (more like Pay for Participation) for Medicaid in Pennsylvania (special attention to page 8). Just like the potential of a combined Medical Home-Disease Management approach, there may be merit to a combined P4P-Disease Management approach. McKesson deserves a lot of credit.

Or how about a P4P plus Medical Home plus Disease Management approach? Anyone know of any examples?

Moses, Linearity & Singularity: Here It Comes!

Given the season, this is a good time to consider this Bible passage from the 34th Chapter of Deuteronomy:


“Then Moses climbed Mount Nebo from the plains of Moab to the top of Pisgah, across from Jericho. There the LORD showed him the whole land……Then the LORD said to him, "This is the land I promised on oath to Abraham, Isaac and Jacob when I said, 'I will give it to your descendants.' I have let you see it with your eyes, but you will not cross over into it."

It’s telling because it portrays a critically important insight about human existence. At that time, most of humankind lived and thought “circular.” It fit nicely with the eternal cycling of the seasons and the motion of the stars. If Simba needed knowledge, it could be found by looking to the past; if an answer couldn’t be found, the right question wasn’t being asked. The upstart Jews adopted a radically novel point of view: they discovered human existence was linear and, what’s more, led to a richer future that mattered a great deal – if not to us, then to our descendants. This is one of the greatest intellectual achievements in history and it is still with us today. Some would argue it must have been a divine gift.


Fast forward to the present day portrayed by a “Blue Man Group” concert. If you have a chance, this PVC-pipe percussionist spectacle is well worth the price of admission. However, I was drawn to its portrayal of a virtual “post-biologic” hyper-tech world that was not only humorous but starkly linear. The Blue Men reminded the audience that we are still very preoccupied with the future.

In fact, our race to reach it may soon result in what futurists have described as “singularity.” Increases in processing speed, access to huge stores of information, rates of new discoveries in energy, transportation, education and yes, health care, will have profound implications for our sense of self, roles, social status, interests and occupations. When the doubling cycle for the rate of change shortens to zero, change will become infinitely rapid and permanent. It is possible that that point could occur sometime in the next ten years.

What does this have to do with disease management? Well, my blog, so I can still post whatever comments I want. But seriously, the disease management sector in health care is not immune and could help lead the way. The field is getting wider, encompassing more conditions, as well as deeper, using new approaches to identifying populations, quantifying their risk, incenting change and deploying interventions. As change accelerates, it will become even more difficult to run clinical trials: results will be antiquated by the time the trials are completed. In fact, print journals themselves will become obsolete (and blogs will become more important). Consider the possibilities that traditional face-to-face provider visits will become virtual and old fashioned telephony much richer. In fact, access to organized information has huge implications for the role of a physician, which is largely dependent on unequal access to medical knowledge. I don’t profess to know just where disease management will fit in the future, but it seems the possibilities are infinite.

Scary stuff. Those Jews must have felt the same way about their Promised Land.

Later this week, I'll touch on another Bible passage.

Where's the Fat Lady?

Fans of J.D. Salinger may remember the Catcher in the Rye, but the Disease Management Blog thinks Franny and Zooey was J.D.’s finest work. In it, the college-attending, 1950’s heroine, Franny, becomes disillusioned by her meaningless life. Lacking access to the answers offered by our more modern age, like attending a rave or the joys of body art, she turns to repetitive prayer. It’s up to her elder brother and precocious radio-star Zooey to get her to snap out of it. After giving the reader a literary bus tour of the Upanishads, Zen Buddhism and Christian mysticism, Zooey finally hits pay dirt when he reminds his sister about the Fat Lady. Franny’s anxieties are eclipsed by the satori-provoking metaphor of lifelong service to this least-of-us child of/symbol of God.

Heavy stuff indeed. So what does this have to do with anything? Well, my blog, my posts. But seriously, the Disease Management Blog recently had the pleasure of touring a disease management call center, which was an industrial-strength, football-field sized, white-noised cubicle farm of nurses telephonically “engaging” persons of chronic illness. When I was invited to sit in on an HIPAA compliant “outbound,” the nurse took the time to show me a simple hand-made present and a handwritten thank-you letter sent to her by one of her diabetic patients. While she appreciated the small gift, it was gratitude in that note that was memorable for the two of us. Its value will never be captured in a per diseased member per month transaction.

There are several lessons here. The first is that Franny and Zooey is a good read if you're a JD fan and like that sort of book. It’s an option for that next plane trip. The second is that the sheer scale and complexity of these call centers is remarkable. Don’t turn down an opportunity to see one. Third, the remote coaching telephony from a good nurse to an interested patient is not automatically the Vytorin of health care: it can make a remarkable difference in individual patients’ lives. Fourth, the nurses that work these centers are good. Really good. And finally, while it’s fun to cross swords over what to do about the national cost and quality of chronic illness care, the Fat Lady not only appreciates the disease management nurses. She also writes to us from the center of our healthcare policy debate.