Observations on the Leveling Off and Narrowing Confidence Intervals in the NCQA State of Health Care Quality Report

The NCQA has released its annual ‘State of Healthcare Quality’ report that examines the quality performance of the nation’s participating health insurers. While the NCQA says the big news is that the NCQA is relevant, variation persists, the NCQA is relevant, that many measures are incrementally if slowly getting better, the NCQA is relevant and that Federal programs need to get aboard comparative quality bus, the Disease Management Care Blog was much more interested in the actual numbers and their trends.

Speaking to the currently limits of medicine and biology, less than two thirds of persons with high blood pressure achieve control of their condition, just more than half of persons who have had a heart attack attain low cholesterol levels and about 80% of kids get adequately immunized.

But more importantly, the pace of improvement in many measures – while still showing gratifying increases – is leveling off. For example, check out these trends snipped from the NCQA report on A1c testing among persons with diabetes:

and blood pressure control among persons with hypertension:

Also note that the confidence intervals are narrowing, meaning the spread between competing health insurers is narrowing. This may be a function of increasing numbers of participating insurers or less variation. Either way, the DMCB predicts that with time those point scores are going to cluster even more tightly.

The good news is that if these trends continue, variation will diminish. The bad news is that the insurers will become indistinguishable from each other and have to locally compete on tenths of a percent of improvement. Will this force them to look for ‘breakthrough’ strategies for improvement or will they settle with the conclusion that usual care is reaching the limits of improvement that can be attained in usual settings relying on usual ways of payment?

i am a mass of contradictions

(photo: A. Kaplan-Myrth)

I ran the Run for the Cure for the first time today.

Given that its a fundraiser for the Canadian Breast Cancer Foundation I had some trepidations (check out all the pink crap on their site).

But I have been running with my10 year old son for a few months now and we were ready for our first 5km run.

And I liked that this event was non-competitive.

And CBCN did provide a significant chunk of the funding for the National Conference for Young Women Living With Breast Cancer that I attended last year.

So I signed up (but I didn't raise funds. I prefer to donate directly to my local cancer centre or to groups like Breast Cancer Action).

And I loved it.

It was a beautiful day. The atmosphere was one of tremendous goodwill. I felt good.

And I have to admit, that I got a lump in my throat when I went to the "Survivor's Tent" to collect my pink t-shirt, the one that would mark me as someone who had fought a battle with breast cancer and lived to run with my kid.

I was very touched when I was running along and a group of women yelled, "Go Pink!" as I passed them.

I loved hanging out with my son as we waited to start. I loved singing silly songs as we jumped around to warm up. And I loved holding his hand as we crossed the finish line.

I had planned on running for twenty minutes (the most we have done in our training) and then seeing how my body responded. I had hoped to run a little more than that, walk the rest and finish in under an hour.

We ran the whole thing (almost. We followed the Running Room program of - 10 minutes of running followed by 1 minute of walking - lather, rinse and repeat). A total of thirty-nine minutes from start to finish.

I finished with a huge grin on my face that lasted the whole day.

I am as proud of this run as I was of my half-marathon in 2000 (and I was as sore, tired and hungry afterwards. Bacon and eggs for lunch, pizza for dinner and lots of snacking in between).

Among the crowds waiting to start, there were many people with the names of loved ones on their shirts and the words "I'm running for..."

My son turned to me and said, "Mama, I'm running for you."

I'm so proud of both of us.

Cross-posted to Mothers With Cancer.

Someone Somewhere is Going to Respond

Like you, the Disease Management Care Blog has received countless emails from anonymous hucksters offering hugely profitable schemes involving transactions in the tens of millions of dollars. A humerous version mocking the $700 billion bailout has made its appearance and the DMCB thought.... why not?

+++++++++++++++++++++++++++

Dear Citizen,

I am the next President of the United States, sourcing for services of Population Health Manager Enterprises (PHMEs) to manage the actuarially precise sum of US$90 Gazillion, more or less, this amount representing an over utilized amount of money from services that was dedicated to countless elders of a major sovereign 50 State conglomerate newly invested in mortgages, investment banking, Iraqi electricity generation plants and cooking oil-powered transportation vehicles.

A nationalized complicated proposed wellness, prevention, medical home, disease management and chronic illness pan-initiative effective January 20 that makes available the invoiced sum shall be immediately printed up in $10,000 bills in the US Mint and safely be set aside in a special Medicare account managed and monitored by the top officers of the US Health and Human Services, in charge of the day to day running of accounts and finance section including an ‘OIG’ department and have almost perfected and read all documents and regulations to back up the payment, which makes the transaction 100% risk free, unless a duly elected body of representatives or their regulators decide otherwise at any time for any reason.

My request is your assistance in achieving a peer-reviewed reduction in claims expense using a secured risk corridored account that is able to receive such funds and thereafter invest it for a period of 1 or 2 or 3 or more years on behalf of qualified individuals subject to quality measures ascertained in a one-way partnership basis. In recognition of your initial investment, a suitable and mutually rewarding return shall be realized, which can be returned greatly to the US Treasury.

Sundry and unforeseen expenses incurred by both parties in the course of this transaction will be deducted after due calculation by a 3rd party under our employ. I have noted your honesty and ability to protect the highly exalted positions of the officers herein discuss. On your acceptance to assist, we will first draft an RFP to be signed by both you and the group in a meeting that will be arranged at your instance before the processing of the payment, which will pass through the relevant authorities for purpose of authentication before a transfer to the account you will provide for this purpose.

As an administrative officer I was mandated to seek your indulgence on this matter, if this is acceptable to you, contact me strictly by email stating the private phone numbers of your investors and their willingness to participate in this critical transaction.

Yours Sincerely….

dvd review: "visions for cancer recovery"

I was asked to review this DVD "written and narrated by Mary Hallman, who researched and and developed this program based on her experiences during her recovery for fallopian tube cancer." She is also a registered nurse.

The full title of the DVD is "Visions for Cancer Recovery: A Guided Visualization and Health Meditation." It's 20 minutes long and divided into four sections: "Introduction", "Begin Body Relaxation", "Stress Release/Deeper Relaxation" and "Healing On A Deeper Level: Cancer Cell Elimination."

The DVD uses "scientifically rendered scientific imagery." I also learned a new word, "apoptosis." It's the scientific term for "cancer cell elimination." Cool, no?

What I liked about it:

• The music chosen as an introduction was appropriate and set a relaxing tone from the beginning.
  

• There was a disclaimer at the beginning of the DVD cautioning that the program is to be used in conjunction with, not instead of, more conventional cancer treatment. I very much appreciated this.

• The voice-over (by Mary Hallman) was very relaxing and reassuring.

• As I watched, I was taken from very familiar (and soothing) scenes of nature, all the way into space. We then returned from space, to think about the cells working within our bodies. I liked placing myself in context this way and enjoyed that imagery.

• I enjoyed imagining imagining any cancer cells in my body being absorbed and eradicated by the healthier ones.

• The messages repeated at the end were ones that really did speak to me and that I could see myself repeating throughout the day: "Cancer cells are not surviving...Only healthy cells survive....the body does what it needs to do."

What I didn't like:

• I couldn't get into watching a guided meditation on my television or computer screen. When I relax, I like to close my eyes. Just as I would find myself getting into the program, the voice would remind me to "keep your eyes on the screen." It just didn't work for me.

• I didn't find the visual imagery used to be very effective. The nature images were pretty but I would have enjoyed imagining my own relaxing locations much better. The other images didn't work for me at all (and there was an image of a coil that I actually found weirded me out).

The production values on the DVD seemed to me to be quite high. And it was obvious to me that the person who developed it was knowledgeable and thoughtful. Perhaps this DVD would be more useful for those who are having trouble conjuring up relaxing imagery or imagining what cancer cells look like. Or maybe some will find it soothing to have the visuals provided for them. I think, though, that I prefer audiotapes.

Or my own imagination.

When It Comes to the Pharmacy Benefit, You Get What You Pay For: An Examination of Dr. Brewer's Wall Street Journal Editorial

Did you know the Disease Management Care Blog was a former Medical Director in a not-for-profit HMO? In that role, it often got to experience first hand the ‘other side of the story’ when a physician ordered a drug that was subject to utilization review.

To read Dr Brewer’s side of the story, he is being unjustly second guessed by a faceless health insurance company more interested in saving $120 per month than doing right by his long-term patient. He argues these hassles lead to the unecessary use of his and his office staff’s precious time. This is wrecking his margins and ability to accommodate more patients.

While the DMCB sympathizes with Dr. Brewer, here are some inconvenient facts:

Medical Directors in most health plans have the ability to approve tests, procedures and drugs on the spot and to do it quickly – literally with the stroke of a key. The DMCB would venture to guess that 99% of Medical Directors, when presented with the facts in Dr. Brewer’s article, would approve the drug. Dr. Brewer’s travails, while vexing, are the exception and not the rule for most health plans most of the time.

Managed care review of drugs like Celebrex are based on same decision support tools that populate electronic health records. Ironic, hm?

Pharmacy programs that use utilization review (UR) cost less per month than pharmacy programs that don’t. That's because they work. Whoever was buying his patient’s Celebrex-needing insurance benefit probably had the choice of purchasing the more expensive option and did not - despite the physicians' discomfort. That’s because they are less affordable. That means pharmacy programs that have UR are cheaper and more affordable and more accessible.

While the DMCB would probably trust Dr. Brewer, it has had reason to not trust many of Dr. Brewer’s colleagues, who like to prescribe potentially dangerous drugs like Celebrex when a cheaper substitute has been shown to work just as well. That speaks to the fiduciary responsibility of health insurers, which they take very seriously.

It is precisely the angst of physicians like Dr. Brewer and their patients that has caused many insurers to retreat to a tiered benefit design. More expensive drugs like Celebrex can be liberated from the tyranny of UR by a Faustian bargain: hooking them up to higher out-of-pocket cost for individual consumer who really needs drugs like Celebrex.

Finally, the DMCB asks readers to ask why drugs like Celebrex cost $120 per month and if it’s the health insurers’ fault.

shifting prioirities

I have a new post up at MyBreastCancerNetwork.Com. It will also be my last for a while:

I am very grateful for the opportunities I have had here at MyBreastCancerNetwork.Com to further extend my reach, to share my stories and reassure so many women that a diagnosis of metastasis is not without hope. For so many of us, metastatic breast cancer is treated like a chronic illness, one that must be managed but through which we can live active, healthy lives.

However, as I have written before, when metastatic breast cancer is well managed, the stories one tells can start to be repetitive and even boring (Another clean scan! No new signs of cancer! Today, I felt like a normal person!). And while I vigorously embrace the lack of drama in this part of my life, I also find myself lacking in inspiration.

As I have said often to friends in the last few weeks, blogging about my life with metastasis means to be constantly tapping the same vein. I am feeling a bit drained (I also just finished the final edits on my book, “I’m Not Done Yet,” which is being published by Women’s Press and due out in the spring of 2009, and that has no doubt contributed to my ‘cancer fatigue’).

It’s time to spend more time writing about other parts of my life (my blog is called Not Just About Cancer for a reason) and even to play at making stuff up, along with other creative pursuits. I have a puppy that needs training. And I need to spend more time on the activities that nurture my body, as well as my mind.

After I wrote this post, I had my spouse proof read it (he proofs almost everything I write before it goes online). He said that it was fine. Except that I mention the puppy and not my spouse or kids.

He said (while laughing at me), "It's like saying, 'I'm retiring to spend more time with my dog.'

I chose not to change that line. In my defense, I have have not been neglecting the needs of my family to write for MyBreastCancerNetwork.Com. I did, however, have to remove the puppy from the dining room table, as I wrote yesterday's post. I clearly need to invest more time in training.

You can read the rest of my "goodbye for now" post here.



An example of the 'other creative pursuits' in which I wish to engage. Taken at the a family Bar Mitzvah this past week end (photo: A. Wayne).

Cross-posted to Mothers With Cancer.

happy october

October, as you most certainly know, is breast cancer awareness month.

You won't find any pink ribbons here.

Instead, I give you links to my previous posts on this subject:

not in my name (October 2007)

not enough to think pink (October 2006)

And, if you want to read more, please check out Parade of Pink: Why BCA Is Concerned By Cause-Marketing For Breast Cancer. Breast Cancer Action also includes a list of "six critical questions" to ask before buying pink ribbon products so that you "support the cause, not cause-marketers."

(I stole these links from an excellent post by sprucehillfarm, over at Mothers With Cancer.)

So as, I said, you won't find any pink ribbons here. Red boas, on the other hand, are perfectly acceptable.


(photo credit: A. Wayne).