Health Wonk Review

It's my turn to host Health Wonk Review--a synopsis of some of the best recent posts from the world of health blogs.HWR founder Joe Paduda starts things off with a post critical of investment analysts handling of a recent Coventry Health earnings conference call with his assertion that "the analysts blew it." First the analysts helped HMO stocks hit historic lows this year and now seem to be

Physician-Focused HEDIS Is Not Enough

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

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

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

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

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

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

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

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

When should policy makers start working on this? ASAP.

What is Plan B?

The Disease Management Care Blog admits that it draws its inspiration from both good and bad cinema. Speaking of the latter, remember Harry Stamper (played by Bruce Willis), the ‘Armageddon’ driller-astronaut who is recruited to land on an errant killer asteroid and save the Earth? No, the DMCB doesn’t remember much of it either, but there is a scene where Harry asks the NASA administrator about the ‘Plan B’ should the landing not work. He is taken aback when he is informed that there is ‘no Plan B.’

While the fate of the earth is not at stake, there is a lot riding on the Patient Centered Medical Home (PCMH) pilots and the upcoming Medicare demo. And the DMCB doesn’t discern a Plan B. According to the Patient Centered Primary Care Collaborative’s Purchaser Guide (see page 9), there are a total of 18 studies on variations of the PCMH showing reduced care use/costs and 9 studies ‘negative for reduced care use/costs.’ That works out to 1:2 odds that a Plan B will be needed, or that 33% of the pilots will not show health care savings. If the Medicare Medical Home demo is one of the 33%, the PCMH - and the hope it offers for chronic illness - is in trouble.

Which reminds the DMCB of another movie: 'Terminator 2.' Arnold Schwarzenegger plays a good android defending the heroic John Connor and his mom Sarah from an evil liquid-metal android. Remember that one scene in which, while on the run, Arnold the Android describes to Sarah the series of events leading to the future (‘Skynet’) downfall of mankind?

With apologies to fans of the Terminator series:

The German Accented Patient Centered Medical Homeinator: ‘The Chronic Care Funding Bill is passed. The system goes on line August 4th, 2009. Demand for specialty care, hospitalizations and access to technology are not removed from highly variable human decision making and inevitable demographics. Chronic illness costs continue to grow at a geometric rate. Congress never develops self-awareness and repeatedly votes to suspend consideration of the Medicare funding warning trigger. It's clear that things will go belly up at 2:14 AM Eastern time August 29 2019. In a panic, they try to pull the plug on Medicare bankruptcy.’

Sarah Conner: [darkly depressed, sporting a firearm] 'The medical industrial complex fights back.... '

The Homeinator: 'Yes. Medicare gives up on the role of primary care and launches price controls, specifically targeting Miami, Phoenix and New York City.'

Sarah Conner: 'Why not vote them out of office in Washington DC? Aren’t they responsible for this?'

The Patient Centered Medical Homeinator: 'Because Medicare knows the medical-industrial counter-attack will eliminate any hope of compromise. There is no Plan B.'

The Patient-Centered Primary Care Collaborative's Purchaser Guide

The Patient-Centered Primary Care Collaborative has released an 18 page ‘purchaser guide’ on the patient centered medical home (PCMH). It can be downloaded here after you let the PCPCC know your name and email. It has 29 authors including Paul Grundy of IBM, Greg Pawlson of NCQA, Dennis White of the National Business Coalition on Health, Ronnie Goff of the National Business group on Health and Tracey Moorhead of the DMAA. The four sections make for interesting reading.

The 1st section is a summary of the history behind and principles of the PCMH along with a description of the NCQA’s recognition standards. It notes that the recognition may fall short of addressing behavioral, care coordination, multidisciplinary and shared decision making dimensions of the PCMH and hints recognition standards will be revised, including a public comment period ‘scheduled for 2009.’

The second section discusses why purchasers should support the PCMH: quality isn’t good, purchasers have a stake in employer-based insurance and primary care is in decline. ‘But for’ better access to turbo-charged primary care, quality would soar and costs would decline. What’s more, increased numbers of young physicians would pursue a career in primary care.

The 3rd section describes strategies on how the PCMH agenda can be advanced including convincing your regional insurer to participate in a PCMH ‘pilot,’ asking about support for some or all elements of it in Requests For Information or Proposals (RFIs or RFPs), offering to pay for it, educating local stakeholders, incenting employees and seeking inclusion of the PCMH in any carve outs.

The 4th section has Case Studies. This is followed by Appendices that include a description of the NCQA standards, suggested contract language, an RFI template and a description of pilots currently underway.

This is must reading if you’re interested in the PCMH. The Disease Management Care Blog also salutes the authors for doing a good job of being complete as well as honest. This is a well-referenced document that not only includes information on how elements of the PCMH have succeeded, but how they sometimes have fallen short on reducing health care costs and how much of the information is still preliminary. The marketing side of disease management industry has something to learn here.

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8-4-08: Thanks to a correction from an anonymous comment, the DMCB has an addendum about the true authorship of the Purchaser Guide: Kudos to Michael Bailit and Christine Hughes of Bailit Health Purchasing, LLC and Rohan Beesla, The ERISA Industry Committee (ERIC) and Dennis White, National Business Coalition on Health (NBCH).

Health Care Reform, the Federal Deficit, and the Bush Tax Cuts--A Very Counter Productive Combination

Readers of this blog have been very fortunate this week to hear from Brian Klepper and Maggie Mahar on the subject of just how realistic is it to expect any kind of meaningful heath care reform in the next year or two.They have both made excellent points--and both hope real health care reform will happen.But there is a big bucket of cold water we all have to factor into such a discussion.While

In the terse style of KevinMD Blog

More aggregation. No graphics. Read and run. The DMCB tries it out:

Opting out Brit style

Stormy seas for Health Dialog in the North Atlantic.

Registries. Really really big registries.

Speaking of Health Dialog, disease management and chronic care improvement. What does RHIO stand for again? Medicare and its cutting edge technologies can't, um, be far behind.

Let’s rethink that business model.

HT to the Wall Street Journal Blog. Mr. Reality, may I introduce you to Mr. Revolution. Oh, and look there is Mr. PHR, let’s go over and talk to him and his buddies next.

Health insurers never leave money on the table.

Co-pays go to the PROVIDER. Hmmm, have to wonder at the motivation of the Minute Clinics. It's such a good idea, DMCB is waiting for the physicians to also do the same.

Disease Management's Ace in the Hole

Regular readers of the Disease Management Care Blog know it is looking forward to future - and better - combined versions of both 'disease management' and the 'patient centered medical home.' DM brings remote multi-channel coaching, scalability and an understanding of performance guarantees in an inflationary insurance market. The PCMH leverages the physician-patient relationship, 'high touch' engagement and is one of the ingredients in the resuscitation of primary care. In the opinion of DMCB, each makes up for the weaknesses of the other. Combining both makes a lot of sense.

Yet, even the DMCB admits PCMH is in ascendancy: it's lost track of all the pilots underway, the support of academia and policy makers is deafening and a big Big BIG Medicare demo is in the chute. Feeling confident, PCMH advocates appear to be in little mood for modification of their care model. Who can blame them?

Just wait. The DMCB suspects PCMH's life cycle is about 5 years behind disease management and rapidly reaching the red dotted Peak of Inflated Expectations. After the pilots demonstrate blunted quality improvements and just how difficult it is to reduce claims expense, disillusionment will give way to dialog that is focused on building better approaches to population care.

We're only weeks away from the college football season and its lesson that there is nothing like early season losses to bring players and fans back to the reality of planet earth. My colleagues on the PCMH 'side of the aisle' believe well intentioned doctors and nurses, because they ARE doctors and nurses, can 'educate' patients into doing the right things. The disease management organizations and their nurses moved beyond this years ago. The DMCB predicts once gravity intrudes, we'll be able to focus on new approaches to population-based chronic care that focus on even more effective versions of patient coaching that interlock across the care delivery spectrum.

If you haven't read this fascinating article by Linden and Roberts, you should. Think about taking these approaches and mixing them with the kind of viral consumerism described in books like Buying In and its abundantly clear that we've only begun to scratch at the surface of patient behavior change.