and other things, too

From Slate's Daily Dose of Doonesbury (click on image to enlarge)

A Penny for the DMCB's Thoughts on Healthways' Earnings Miss

In a prior post, the Disease Management Care Blog promised follow-up on Healthways’ last quarter earnings report. Even though there was a considerable jump in income accompanied by an earnings increase from 31 to 49 cents a share, earnings per share still missed the Street’s expectations by one cent. That's right, a penny. That was enough to reward the company with a continued stock price slump into the $10 range, where it’s been languishing plus or minus a dollar since ever since.

Does this fine company deserve to be hammered over such a small earnings misstep? Maybe not, but reports on Healthways (here and here) seem to be using the penny as chance to fret over the long term prospects for the company:

• With Democratic control of the Presidency and Congress likely, Medicare Advantage plans are destined to get squeezed. As a result, they’ll have less to spend on disease management.

• The bad news from Medicare Health Support lessens the short term likelihood of a Medicare contract and could batter Healthways’ ability to assure its commercial customers that it truly has the goods to reduce claims expense.

• Health Plans have the ability to bring programs in house, further undercutting Healthways’ long term business prospects.

• The balance sheet is described as highly leveraged with considerable debt vs. cash on hand.

As an aside, the DMCB notes Healthways has also brought in a new chief operating officer. Is that an indication that management or the Board of Directors is happy with the course of the company?

While it agrees with most of the points above, the DMCB also thinks companies like Healthways may be struggling because they haven’t adjusted their business model to being better, faster, cheaper or complementing the medical home, helping patients navigate increasingly complicated insurance benefits (like CDHPs), tackling pharmacy issues, integrating their information systems with electronic health records and being fully transparent about showing what works and what doesn’t work.

The DMCB disagrees, however with the notion that Health Plans have a ready ability to bring disease management (DM) in house:

First off, the number of telephonic health coaches (usually nurses) and accompanying IT support represents a considerable expense. Outside full service DM companies can scale DM far more efficiently. If DM can cut their costs and lower their prices – which they’ve resisted to date – health plans will find outsourcing to be the better alternative. The likelihood of this will grow with increasing regulation of insurers' administrative expenses.

Secondly, health plans are first and foremost insurance companies. In most managed care organizations, clinical programs like ‘disease management’ hold a second fiddle to core activities such as building surplus, meeting State regulatory requirements, underwriting, managing claims and managing the ‘float.’ Leaders in health insurance have little loyalty to programs that many feel should be borne by the health care system and are outside their management comfort zone.

And this will get worse. Because of the advent of health savings accounts, insurers like Wellpoint want to also be banks. According to Federal Reserve and FDIC, a mix of insurance and banking with clinical services are permissible just so long as ‘subsidiary’ companies (like HMC, wholly owned by Wellpoint) don’t pose a substantial risk to their parent companies. Increasing expense or distraction from managing these subsidiary functions over the long run may well prompt insurer/bankers/financiers to spin this off or return to outsourcing it.

Ultimately, the DMCB thinks insourcing and outsourcing DM will continue in faddish waves. Right now, Plans seem to be more interested in insourcing. There is no guarantee that will continue, especially if the DM industry can adapt to these changing times and respond with a more efficient modern approach to chronic care for populations at a more attractive price point.

unrelated thoughts*

My weekend was very inspiring. But although I did take good care of myself, I am exhausted (a combination of all the activity and the lateness of my arrival last night). Coherence eludes me, so here is some random content from my brain:

First stray thought:

We have lost our digital camera. I'm pretty sure it must be somewhere in our tip of a house but its disappearance means that not only did I not have a camera on my trip but we couldn't take any pictures on Hallowe'en! We are relying on the kindness of friends to transmit, so I can share.

If I had a camera, I could also embarrass myself by posting photos of my ill-groomed, excessively hairy dog.

Second stray thought:

One of the speakers at the conference addressed the inequities in the American health care system. He mentioned that social workers, who help patients navigate the system, are always the first to get cut when cutbacks occur.

Cancer care is extremely complicated (so many ways of treating and so many different health care professionals and staff to deal with). As a cancer patient, I have to advocate for myself on a regular basis at every stage of care (I was reminded of this today, as I followed up on the fact that I haven't received confirmation of my next chemo appointment. Turns out it was never booked and now I have to chase down my oncologist to make sure that happens). I am educated, middle class and pretty enfranchised. I can't imagine how challenging treatment would be if I were unable to understand the system, communicate my needs or were affected by a mental illness.

Third stray thought:

Homeland security left a little note in my bag to tell me they had opened it and rifled through my underwear (OK so that's not exactly what they said I did but that's the part that gives me the creeps). This has never happened to me before.

The Yarn Harlot has written that it happens to her on almost every trip. This makes me wonder if the search was provoked by knitting needles.

I usually bring only one project and carry it in my purse. I knew I was going to have some down time on Friday, I had a big suitcase that was only half-full and I couldn't make up my mind, so I packed a second project in my suitcase (socks, with lots of little pointy needles).

Fourth stray thought:

The cliche about absence making the heart grow fonder must be true. My littlest, with whom I have been locking horns of late, was extremely happy to see me. He crawled into my bed this morning with a very satisfied, "Mama!" and told me that he had missed me "very, very much."

That's it. Even my stray thoughts have escaped me...

...except to say that I feel so incredibly fortunate that Jacqueline and John came to visit me (and Jacqueline came up with a brilliant idea for the cover of my book!). This is only the second week end I have spent with them and yet I felt as comfortable as I do with old friends. And they are such smart, creative people. They really do inspire me.

* this post brought to you courtesy of NaBloPoMo.

The Top 20

Thanks to hundreds of regular readers and RSS subscribers that want to keep up on the useful peer review literature, policy proposals and commentary on all those wacky acronyms like MCOs, DM, CDHPs, PCMH, CCM, EHR, PHR, MH, MA and P4P - plus all the ones that are going to be invented once the elections are over - the Disease Management Care Blog is in the Top 20 of the Wikio Health Blog Ranking!

A Look at the New England Journal of Medicine Article on Childhood Anxiety

In the movie Ordinary People, Timothy Hutton plays a deeply anxious and depressed young man named Conrad Jarrett who ultimately finds redemption thanks to the intense counseling provided by a therapist played by Judd Hirsch. The Disease Management Care Blog agrees Robert Redford deserved the Oscar for this wonderful movie, which not only portrays the malignant impact of mental illness on an seemingly ‘ordinary’ family but has a pretty good score of Pachbelbel’s Canon in D.

The message is that it’s hard to underestimate the burden of mental illness on the individual and people and community around them. It wasn’t just Conrad who taught that to the DMCB, but many years of clinical practice. This was tough, very tough to manage.

So when the New England Journal of Medicine publishes an “on-line first” randomized clinical trial consisting of 488 Conrad Jarretts, it pays close attention so that you don't have to. Briefly, 488 persons aged 7-17 years (average age about 11 years) with anxiety or phobia were randomly assigned to either 1) a series of 14 sixty-minute counseling sessions or, 2) the SSRI sertraline ('Zoloft') with 8 sessions to assess response to therapy or 3) placebo with 8 sessions to assess response to therapy or 4) both the 14 counseling sessions plus the SSRI. Psychological scales were used to assess progress in all four groups over 12 weeks. The persons performing the psychological assessments were unaware of the treatment. While the children on just drug or placebo (groups 2 and 3 above) weren’t sure what they were getting, the children getting the therapy plus drug (group 4 above) were aware that they weren’t getting a placebo.

The bottom line? At 12 weeks, 81% in the combination therapy group were significantly improved vs. 60% and 55% in the active drug and counseling groups, respectively, vs. 24% in the placebo group. Adverse events were assiduously tracked and no particularly significant pattern stood out.

What are the DMCB take aways? They fall in three categories:

Confirmation of what is known: Previous studies over the past decade have shown that psychotherapy and drug therapy in depression share the same success rates and that both have a higher success rate than either alone. In addition, a top success rate 80% is consistent with some previous studies on the topic. So this particular NEJM piece is not that newsworthy other than the confirmation of the same findings for anxiety. It does remind us, however, that there is a ‘hard core’ 20% minority of persons who don’t get better. Think the character Karen in Ordinary People. She didn’t do well.

Criticism of the study method: Persons in the combination therapy group knew they were getting active drug. It is possible that this knowledge contributed to their improvement – not because the anxiety was any better but because they thought they were going to get better. In addition, the study was not powered to detect any meaningful difference in adverse effects between the groups, so the fact that nothing showed up doesn't mean nothing is there. At any rate, in this age of SSRIs, the DMCB wonders if Ordinary People would have a chance of being made into a movie today. Not much of a plot when Conrad is taking his daily medicine and doing fine.

The impact on day-to-day clinical practice: The DMCB doesn’t think it will be a lot. Many readers assume that young people with anxiety are probably getting offered drugs more often that psychotherapy. That’s because that course of therapy is cheaper (one month of sertraline is relatively inexpensive under most insurance benefit plans) and it doesn’t use up to 14 hours of valuable time otherwise spent in school or at home, not mention 14 individual co-pays. While an 80% chance of improvement with combination therapy ‘beats’ the 60% with drugs alone, the DMCB thinks most parents and physicians will continue to opt for the drug therapy first and then add counseling if it drugs don’t work.

Finally, there is far more to the modern treatment of depression and anxiety disorders than just drugs or psychotherapy. This excellent article in JAMA reminds us about the role of collaborative care strategies, quality improvement activities, case management, pharmacist-provided follow-up, and decision support. And oh yes, the same principles of disease management that has conclusively been shown to work for depression may also help in the area of anxiety disorders.

relieved

I dreamed that I said the following to my spouse:

"I don't regret the dogs. I sometimes regret the cat. But I really, really regret the rhino."

a post is a post

Happy November!

I stole this badge from Sara.

I will be attending my conference all day today and I may have something interesting to say once its over.

I'm hoping to hang out with Jacqueline and her husband John this evening (and tomorrow, too), though, so it make take me a couple of days to post anything substantive.

I just counted. I've brought three of Jacqueline's garments with me, one of her pieces of jewelry and her Songbird Scarf. And I have more at home, too.