on being brave

My family and I went to a little party for brunch on Sunday. This would not have been a big deal except that it was going to mostly former co-workers in attendance and since the cancer returned I have been avoiding these kinds of events.

But this brunch was different. It was a surprise in honour of a friend and former co-worker who is in ongoing breast cancer treament (she is also one of the women with whom I am involved in a writing project and that I wrote about in my post entitled "the building." There is a new building now but my friend still works for the organization). She has been treated quite shamefully by her employer (a supposed advocate for "workplace accomodation") who has consistently refused to accomodate her need for regular time off for treatment. The case will be decided over the next two days by an arbitrator and I knew I needed to overcome my trepidations to show her my support.

And I had a great time. There were so many people there who I was happy to see (I think it is a testament to my friend C. She is a wonderful person who attracts wonderful friends, all of whom wanted a chance to show her how much we love her). The food was great. I loved being there with my boys (all three of them). I always enjoy showing them off and they made me very, very proud just by being themselves.

I am so glad I went, despite my fears. I always tell myself that I avoid these things because it will be awkward and sad. But I don't think that I have been giving people enough credit. The truth is my tendency to experience social anxiety (which predates the cancer) has been exacerbated by spending so much time on my own (something I quite enjoy). I think I use the cancer as an excuse.

From the moment I stepped in the door, and saw all these people I genuinely like, I felt happy and excited and I know that my face and body language expressed that. It was lovely to catch up with people and easy to put them at ease. I know that going did me a world of good.

This post was inspired by "Do It Afraid" by Lahdeedah, one of my co-bloggers over at Mothers with Cancer.

One another note, I urge you to go read a post by Andrea Collins-Smith, who faced the ultimate fear with tremendous grace and courage. Andrea (who wrote as Punk Rock Mommy on her own blog and at Mothers With Cancer) passed away on July 5th, after succumbing to inflammatory breast cancer. She leaves behind six children and a loving spouse. I only became aware of her blog shortly before she made the decision to stop treatment and go into palliative care. She moved and awed me with every post. This last one was written a short while ago, to be posted after her death. It is terribly sad but also hopeful. I hope to one day face death as bravely.

Brace yourself.

Medicare Fee Schedule Cuts, Private Fee For Service, the AMA and Hand Gestures

The Disease Management Care Blog thought Karen Ignagni had cornered the hand gesture market. Ms. Ignagni’s classic two-handed chops, sweeps and grabs in her speeches not only help emphasize her points, but remind the DMCB of a martial artist's kata. Observe Ms. Ignagni’s interview here (once the initial question is over) and this classic kung-fu exercise and see if you can tell the difference.

Well stand back, because Nancy Nielsen, MD, President of the AMA has her own repertoire of jabs, pokes and pushes that accentuate her organization's considerable annoyance at the U.S. Senate’s recent failure to cancel a scheduled 10.6% fee schedule cut by transferring the necessary funding from the private fee for service (PFFS) Medicare plans. Dr. Nielsen and Ms. Ignagni obviously stand on opposite sides on this issue, and the DMCB recommends someone get these two experts together not only for what would be a hugely educational discussion but for an equally entertaining hand gesture smack-down.

Want to learn more about this Republican-Democrat health care kerfuffle? In the opinion of the DMCB, the best summary can be found here at the Health Affairs blog site.

But the DMCB wanted to learn more about hand gestures. This is an excellent article from Scientific American that explains speech and hand gestures are hard wired together in humans. For example, babies who have not yet learned to speak use gestures, while persons with damage to the brain’s ‘speech centers’ lose their ability to interpret gestures. In addition, humans (and primates) are vicariously endowed with ‘mirror neurons’ that are not only activated when we perform a movement but when we observe another person performing the same movement. Numerous studies that have shown speech plus gestures results in far better communication than speech alone.

In fact, this hand-speech connection may be so hardwired, that having your mouth say one thing and your hands do another can be a telling clue to an audience that something is amiss. Unsurprisingly, the best medium for observing this mismatch can be found in politics. Not getting this right can make all the difference in a contender’s career, which is why considerable time and effort may be needed to tie a speech and the movements ‘naturally’ together.

In the meantime, the DMCB has trouble understanding what the Medicare physician fee schedule has to with Medicare PFFS. It has to admit, however, that tying them together and forcing the PFFS supporters to vote ‘against physicians’ was a stroke of partisan genius. Too bad it’s also another example of the manipulative gamesmanship that can get in the way of real health care reform. To the folks in Congress, here’s a gesture from the DMCB to all of you.

State of California "Fearful" of Enforcing $1 Million Fine Against Wellpoint/Anthem Blue Cross for "Illegal" Health Insurance Policy Rescissions

Crazy as it sounds an AP story on Thursday reported that the California Department of Managed Care "didn't even try to enforce a million-dollar fine against health insurer Anthem Blue Cross because they feared they would be outgunned in court."Last year the department announced that it would fine the insurer for improperly rescinding individual heath insurance policies in the midst of the

rising above it

A few years ago, back in what seems another lifetime, I had a co-worker who was driving me crazy. He was incredibly insecure and often sought to make himself look good at others' expense. He was also lazy and very willing to let others slog away at the grunt work, grabbing the tasks for himself that would gain recognition from the leadership of our organization.

I started to obsess about the unfairness of this. I wanted something to be done. And I began to vent my spleen to anyone who would listen. Even when relaxing after an intense project, I found myself returning to this subject like a dog worrying a bone.

One friend in particular would listen sympathetically but he also seemed kind of amused. And he would, after listening patiently, gently try and get me to move on. He was very supportive and encouraging but he hinted that perhaps I should stop putting so much energy into being angry.

I remember thinking at the time that this guy just didn't understand the seriousness of the situation.

I have a different perspective now.

This particular friend is a cancer survivor and perhaps that's what led him to understand what I now see more clearly. It is much healthier (and better in the long run) to focus on what really matters and to save our anger for situations when we can actually hope to create real change.

I have recently become somewhat reluctantly involved (and only peripherally) in a situation where it seems that a group of people, for whom I have great respect, have lost sight of a common goal. They have become bogged down in a morass of pettiness and are choosing to express some legitimate frustrations in ways that are destructive. And some individuals are being badly hurt in the process.

I can't help thinking that life is way too short for this.

I think, in situations like this it is crucial that keep ourselves focused on what's important. I always try and ask myself what my goals are and whether my actions will move me towards it. And if I am acting out of anger or frustration then I am likely only contributing to the problem, not to solving it.

Anger and confrontation certainly have their place but they are not ends in and of themselves. We need to ask, yet again, what organization we want to build, be honest about the things that aren't working and take concrete measures to fix those things.

And we need to treat one another with a little more compassion.

Never Mind Massachusetts' Reform Efforts, Check Out What's Happening in the Keystone State

While all eyes are on Massachusetts, the Disease Management Care Blog’s home state of Pennsylvania has been busily involved in its own home health care reform efforts. Our larger-than-life Governor, who is not known for small ideas, has launched an ambitious package of proposals aimed at expanding the availability of health insurance to the under and uninsured, increasing access and reforming health care delivery. Part of the reform effort was the creation of the ‘Chronic Care Management, Reimbursement and Cost Reduction Commission,’ which was charged with developing recommendations for the ’78% of health care costs…traced to about 20% of patients…’

In February of 2008, the Commission released its ‘Strategic Plan,’ which included the ‘dissemination of the Chronic Care Model to primary care practices across Pennsylvania.’ To make this happen, the Commission sponsored a series of regional ‘learning collaboratives’ that focused on diabetes mellitus The first region was south eastern Pennsylvania, in which teams from 33 independent primary care sites involving more than 150 physicians serving more than 200,000 patients were invited to a series of ‘education and support’ sessions in May of 2008. The next will be south central Pennsylvania.

The American Board of Medical Specialties, thanks to funding from the Robert Wood Johnson Foundation is lending support to these sessions. The Pennsylvania Academy of Family Practice was successful in securing ‘Improving Performance in Practice (IPIP) grant support from ABMS, which is being used to coach the participating practices and help them ‘stay on track and implement the changes.’

According to the Philadelphia Inquirer report linked above, the south east learning collaborative has garnered the financial support of Philadelphia’s dominant health insurer, Independence Blue Cross as well as Aetna, CIGNA and others – all to the tune of $13 million. The money will be used to reimburse physicians for attending the training sessions, meeting certain standards involved in establishing the chronic care model, such as implementing supporting information technology (such as registries and decisions support and adding the necessary staff. According to another news report:

‘A typical four-doctor family practice that achieves all standards levels within two years, could potentially earn an additional $275,000 to $480,000 a year.’

That’s some serious coin.

A host of other Pennsylvania entities are lending their support also, including the PA Dept of Health, the University of Pittsburgh, Penn State’s School of Medicine, the Pennsylvania Medical Society, the Hospital Association of Pennsylvania, Lehigh Valley Hospital, Temple, Jefferson, Geisinger and the Jewish Health Care Foundation.

That's some serious support.

Now that we’re into July of 2008, the DMCB sought an update on how things were going from the Executive Director of Pennsylvania Chapter of the American College of Physicians. Here is his report. In a nutshell, the project has the support of the physicians, who believe the prognosis for success is very high:

Physicians in Philadelphia, Pennsylvania recently launched an innovative Pilot to improve the care offered to patients with diabetes. It is a chronic disease that is the subject of the Southeast PA roll-out of the Patient-Centered Medical Home Project.

This Pilot is part of Governor Ed Rendell’s RX for PA. It was designed by the Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission. Ralph Schmeltz, MD, FACP, FACE and Eric Gartner, MD, FACP, two leaders in the Pennsylvania Chapter of the American College of Physicians (PA ACP), have been active Commission members and are helping to spearhead the initiative.

PA ACP, in conjunction with PAFP and PAAAP, obtained a $150K grant for IPIP from the Robert Woods Johnson Foundation, thus making Pennsylvania only the third state enrolled in the IPIP program. IPIP, or Improving Performance in Practice, will support practices by focusing on improving diabetes care.

What Do We Need to Do to Fix the Medicare Physician Payment Problem?

Whenever the subject of Medicare physician fee payments comes up on this blog, the reaction from physicians, particularly primary care docs, is predictable: "You can't cut us, we haven't had a Medicare raise in years, we are already dramatically underpaid, and if Medicare cuts our payments we are going to stop taking Medicare patients."There is no doubt that doctors have a point--particularly the

The Innovator's Dilemma, Bundled Payments and the Prognosis for Disease Management

Many years ago, the Disease Management Care Blog was involved in a doltish exercise in planning how to prepare specialist physicians for careers in primary care. As part of this work, we faux experts predicted an oversupply of physicians in light of the rationalizing of medical services thanks to ascendant managed care. Boy, in those heady pre-backlash days did we ever get it wrong.

However, one trend became apparent to the DMCB at that time and it still holds true: the increasing ‘upward competency’ of health care providers. We assumed, thanks to technology and market demand that the expertise and skills required of specialists could be acquired by non-specialist physicians and that primary care physician expertise and skills could in turn be acquired by non-physicians. Think of it as a medical form of the ‘innovator’s dilemma.’

We are seeing versions of this trend today. For example, invasive cardiac surgery performed by intensely trained cardiac surgeons has been supplanted by stents from cardiologists, while highly accurate coronary artery imaging that could only be obtained via a cardiologist-performed catheterization can now be obtained directly by primary care physicians in the form of multi-slice CAT scanners. In the meantime, many of the traditional diagnosis and treatment roles of primary care physicians have been taken up by professional non-physicians, while at the end of the line, we’re finding that patients can assume many of the day to day duties of education and management. Patients aren’t ready yet to remove their own appendices, but the trend in many areas of health care – including chronic conditions – is definitely there.

Unfortunately, the ‘defined benefit’ of typical fee-for-service (FFS) insurance has trouble keeping up with these shifts in physician competencies. That’s because the coverage of any given service typically hinges not only on the nature of the intervention itself but on the entity or physician performing the service. Approval of the physician is often contingent on their credentials, which are reviewed by the ‘credentialling’ process of health insurers. Not credentialed to bill for a service = not covered.

What can change this pokey nature of FFS style health insurance? The DMCB likes an editorial from our friends at MedPAC in the July 3 2008 New England Journal of Medicine (and it's not online at the time of this posting). Hackbarth and colleagues describe the MedPAC recommendations about the use of bundled inpatient payments by Medicare. They argue that global payments that include the hospitalization itself as well as all the physician services and several weeks of post-discharge care will lead to better coordination or services, higher quality and lower costs. This is a limited version of Porter and Teisberg's recommendations for payment for 'episodes of care.'

The DMCB thinks this is a good idea. If the global payment approach fulfills its promises and physicians do not end up being disenfranchised (think backlash Ver 2.0), similar payment approaches for the outpatient management of chronic illness may eventually follow. Simplistically thinking, if there is a similarly contrived reimbursement for the ongoing care of chronic conditions, it would be up to the specialists, primary care providers, non-physicians and even the patient to sort out who does what with the resources at hand. Services within the care episodes would move to the appropriate level of care without having FFS process and financial disincentives get in the way. Given its efficiencies and effectiveness, the DMCB is confident versions of disease management would be sought out as one component of a coordinated delivery system (a.k.a. Dr. Casalino’s ‘accountable care organization’) for chronic illness, leading to the emergence of partnerships between physician-organizations and vendors. The upward competency/innovator’s dilemma wouldn’t need to wait for fee schedule updates from health insurers.

The DMCB agrees this sounds naively utopian but there’s something to this. Cheers, MedPAC.