Disease Management and the Medical Home Podcast

The Disease Management Care Blog is in a podcast? That DMCB first is thanks to the DMAA posting the audio from a November 25 keynote panel held at the Hollywood Florida Forum 08 Meeting. The topic was a DMCB favorite: the patient centered medical home and disease management. Hundreds listened in on the presentation and this is your chance to share in the knowledge.

The link to the audio is here. In it, you'll hear the real stars of the show, Lisa Latts MD of WellPoint, Paul Wallace MD of Kaiser Permanente and Ricardo Guggenheim MD of McKesson. These experts know of which they speak. So, if you must eat your lunch at your desk, the DMCB suggests listening to this will make your left-over turkey, lettuce n' mayo sandwich that much tastier.

A summary prepared by the DMAA eNews is below in case you don't have the time to listen right now.

'The panelists generally expressed optimism about the medical home model, but cautioned that questions remain about the fundamental design, payment mechanisms and patient engagement strategies. Dr. Wallace suggested that the patient-centered medical home might be better positioned as one component of a more complex "medical neighborhood" with a diversity of providers and a care delivery infrastructure supported, in part, by population health improvement. He also argued for greater patient involvement in health care decision making as the best path to a successful medical home. "Patient-centeredness is something we can do," he said of physicians. But "'personalized' is something that we can only do together with the patient. I think we have to trust the patient to help us find that spot." Dr. Guggenheim noted the need to include hospitals in the "medical neighborhood" concept. Success, he stated, will depend on the ability of the population health improvement industry to provide actionable, real-time data; IT tools to facilitate the care management process; and consumer-focused service.

Dr. Latts noted the challenge of providing additional payment to primary care physicians for medical home services with a limited pot of money that also must fund specialty care. She emphasized that, to succeed, the medical home must be simple to administer for primary care practices, with a coordinated approach to working with multiple vendors, including those providing population health improvement services. Dr. Guggenheim also spoke about the challenge of finding an acceptable payment model for the medical home, calling it "the biggest hurdle" to change. "I think the biggest problem that you have with changes in payment structure is that everyone wants them but nobody's that eager to sign up for them," he said.

Dr. Wallace said that payment reform is achievable, but must include "some accountability in the process for what patients care about." Patients, he said, "care about cost, they care about service and they also care about health. And I think that that's really the dilemma about how we align that incentive. I think that's where managed care and we came up short in the '90s." He also said the medical home must encourage the primary care provider to serve as a gateway to appropriate specialty care rather than as a gatekeeper to limit access to specialists.

Dr. Wallace sounded a positive note for population health, saying that the industry's expertise in reaching out to patients will underscore its value in a care delivery model centered on patients' needs. "I think that's why I'm hopeful for this industry, because this industry has survived only because it has figured out how to connect with patients," he said. "The challenge here is how do we take that connection with patients and align it with the rest of the delivery system?"'

Coda: Next year's meeting Forum '09 Sept 20-23 in San Diego. Mark your calendar.

the day my life changed

I had an echocardiogram today. They are a pretty routine part of my life; I have them every few months to make sure that the Herceptin isn't damaging my heart. So far, so good.

It's kind of boring lying there, so I started to play a little game with myself. When I lay down at the beginning of the test, my resting hear rate had been 65 bpm (beats per minute), when I worried about my results, I noticed that it had shot up to 75 bpm (I could also see on the screen that my heart was whooshing away but I couldn't tell whether it was doing it's job efficiently). I took a few deep breaths and my bpm dropped again. I remembered that I have only bought one Xmas present and my rate went back up into the 70s. Up and down it went (I hope that I didn't affect my results by doing this).

And then it occurred to me that today is December 2nd.

Exactly three years ago, I found the lump in my breast. That day, the world tilted on its axis (I felt it do that as I stood in front of my bedroom closet not quite believing I had this big hard mass on the side of my right breast) and my life was irrevocably changed.

If you had told me at that moment, how the next couple of years would unfold, I never would have believed that life could be as good as it is right now, despite the cancer. Don't get me wrong. If I could choose to have never had cancer, I would.

I hate having cancer, hate being in treatment, hate the restrictions placed on me as a cancer patient and I do still grieve for all I have lost. There are many, many ways, though, that my life has changed for the better since December 2nd, 2005.

Maybe that's why, when I remembered the date, my heart rate didn't budge.

Whoosh! Whoosh!

Cross-posted to Mothers With Cancer.

book review: "any given doomsday"

I think of myself as a fairly discerning reader.

I've read lots of really good books this year, filled with challenging stories, beautiful prose and ideas that nourished my soul.

Any Given Doomsday, by Lori Handeland was definitely not one of those. And yet, I devoured it.

I requested this book from Library Thing's Early Reviewer Program because it looked intriguing and the publisher (St. Martin's Press) was giving away an unprecedented 1000 review copies. A couple of months passed between when I was notified that I was getting a copy and it's arrival, by which time I had started to hope it would never come. Most of the reviews for the book were scathing (I tried to avoid reading these but the words "piece of trash" did leap out at me) and the average rating on Library Thing is only two and a half stars.

The book is filled with examples of over the top, staggeringly cheesy writing:

"Everything about him was dark - his eyes, his clothes, his heart."

"He'd always had an unbelievable way of looking at things, and when he'd looked at me, I'd wanted to give him everything I had. Back then all I'd had was me."

"I hadn't noticed Jimmy moving closer as we spoke, but now he was too close, trapping me on the cot. If I stood, my entire body would slide against his. If I stayed where I was he'd continue to loom over me, his crotch level with my mouth. I licked suddenly dry lips.
'There's something I have to tell you.' he said, and his voice was rough, as if he'd been running several miles through ice and snow.
I lifted my gaze to his, the movement brushing my chin against the suddenly bulging zipper of his pants. 'Tell me.'"

There are also some inexcusable grammatical and language errors (especially egregious from a big publisher like this one):

"He didn't have to sound like he could care less."

"The less people who know about them, the less chance an un-people might kill them."

"He was thinner than normal, and pale too. I hadn't noticed until now because the usual shade of his skin was so much darker than most." (than most what? white people? human beings? super natural beings?)

The story is mostly good fun, in a gory, completely implausible sort of way. It's pages are filled with every kind of monster imaginable: dhampirs (half-vampire, half human), skinwalkers, berserkers, werewolves, demon killers and even fairies.

The book has a somewhat religious bent, in that heaven and hell are real places and the bad guys are the descendants of fallen angels who mated with humans. The main protagonist, Liz Phoenix is a psychic ex-cop, who, at the opening of the book has a vision that summons her to the side of her former foster mother. When she arrives, she finds that the woman has been brutally murdered. It turns out that Ruthie, the foster mom was a seer and a leader of a movement called "The Federation." Ruthie proceeds to groom Liz as her successor from beyond the grave (Liz hears Ruthie's voice at regular intervals and has entire conversations with her when her dreams take her to a white picket-fenced house in heaven, where Ruthie continues to take care of children). Liz sets out for Arizona and then New York City in pursuit of knowledge and demons. She also learns that she is an empath...the kind of empath who can take on the powers of others but (get this!) only if she has sex with them.

The sex scenes in the book are more than a little troubling, since the Liz is either drugged or coerced into participating (I would warn survivors of sexual assault to stay away). One review I skimmed suggested that the author wanted her character to be scene as "a good girl" and that, if she chose to have wild sex with skinwalkers and the like, she would be tarnished by that. I would have vastly preferred for her to find out that she could gain powers through sex and then set out to have a good time for the greater the good (I was also annoyed when she envied the powers of a female character but wouldn't even consider the idea of sex with her because, you know, she's just not into women).

If some books fill you up like a satisfying meal, then Any Given Doomsday is like a bag of Cheetos (or the no-name copy of Cheetos). Sometimes, I'm just really in the mood for the Cheetos (and sometimes eating the Cheetos makes you feel a little queasy. And, as my older son said, when I told him about this metaphor, you need to go wash up because you have Cheetos all over your fingers).

This book is meant to the be the first in a series. Will I read the next book when it comes out? Probably not. But I may go looking for some more trashy fun.

We Can Save 30% By Getting Rid of the Waste in the U.S. Health Care System—Sounds Like "Groundhog Day" To Me

As we begin the health care reform discussion in earnest, many are pointing out all of the waste in the system and the need to research what works best, provide the incentives to do it, manage the big spenders’ chronic care better, make better use of heath information technology, and encourage wellness and prevention.One of the disadvantages of being at this for more than 20 years is that I feel

LifeMasters Hits One Out of the Park with Florida Dual Eligibles

While the Disease Management Care Blog was at the Hollywood Florida Forum 08 DMAA meeting, it heard the folks from LifeMasters report on the updated results of a three year randomized (in a ratio of 5:2) clinical trial of opt-out disease management vs. usual care for dually eligible FFS Medicare beneficiaries with heart failure, coronary artery disease and diabetes in eleven counties southern Florida.

By way of background, LifeMasters is a privately held company headquartered in Irvine California. Not too long ago, it stumbled during an attempt at a merger with Healthways. It shuffled its leadership, sought out additional financing, reduced its workforce and decided to stick to disease management.

The Florida program started out in January 2005 with a well defined population with a well defined program of telephonic outreach. As the months progressed, it looked like the program was not going to break even. As a result, LifeMasters changed course. It increased its face-to-face recruitment strategies, dropped four of the counties from the program, changed the combination of chronic illness and comorbidities that qualified for program entry, increased the physician marketing and intensified the remote recruitment efforts.

As a result, recruitment (the number of patients who agreed to participate) and engagement (the number of patients that actually participated in the phone calls) rates went up. Among the persons who were engaged, there was a savings of approximately $700 PMPM vs. persons who had been merely enrolled and vs. the control group patients.

Whoa! you say? The DMCB knows what you’re thinking: that a $700 per member per month (PMPM) savings among the persons that were recruited into the program is a classic example of selection bias. While that’s correct, the analysis reported at the DMAA also included a comparison of the intervention vs. the control groups. The group randomized to the LifeMasters program had lower claims expense compared to the control group; it’s just that the $700 persons who were recruited and engaged ‘dragged down’ the average claims for the entire group, which was otherwise flat. The actual overall savings were not shared at the DMAA meeting (pending release by CMS), but Ms. Selecky’s grin and CMS' decision to extend the program spoke volumes about the results.

The message was that once persons with chronic illness are enrolled, savings are achieved. The fix is to launch disease management programs and enroll, enroll, enroll.

make parliament work!

Do you want a coalition government for Canada? Go here now and read how you can help.

Go here to email your MP.

Canadians deserve a government that will work for all of us in these tough economic times.

meaner than fiction (and short-sighted, too)

According to a recent article in the New York Times, soon-to-be-Ex-President Bush is trying to ram through some changes to the Code of Federal Regulations before Obama takes office. Some of the new rules, which have the "force of law" in the US, would:

"make it much harder for the government to regulate toxic substances and hazardous chemicals to which workers are exposed on the job;"

"make it easier to build power plants near national parks and wilderness areas;"

"reduce the role of federal wildlife scientists in deciding whether dams, highways and other projects pose a threat to endangered species;"

"allow coal companies to dump rock and dirt from mountaintop mining operations into nearby streams and valleys;"

give "states sweeping authority to charge higher co-payments for doctor’s visits, hospital care and prescription drugs provided to low-income people under Medicaid."

Despicable.

If a fictional President in a novel or movie attempted to do these things in his last days of power, would we find it believable?