Medicare Health Support Becomes A 'Black Sheep'

Many families have them. The dysfunctional uncle that was in jail. The disreputable cousin struggling with drug abuse. The lazy n’er-do-well brother-in-law. Furtive glances at the dinner table when they’re brought up in front of strangers. Prefer not to talk about them. They’re the ‘black sheep’ and the disease management ‘family’ now has theirs: it’s called Medicare Health Support (MHS). And like that dreaded 2 AM ‘Hi, I’m in town!’ phone call, MHS is inconveniently dropping in with a 69 page update with an additional year’s worth of data.

Recall this is the largest experiment ever involving classic disease management. It’s a Medicare-sponsored, randomized and prospective trial involving eight different disease management organizations (DMOs). They have been paid an average of $67 to $118 per patient per month to manage tens of thousands of randomly assigned Medicare fee-for-service patients with chronic illness in a mix of urban, suburban and rural settings. To assess the impact of disease management, patients are being compared on satisfaction, clinical outcomes and cost to usual care patents that are serving as controls. Participants have to opt in. The goal is to save money or at least break even by reducing Medicare’s claims expense equal to the amount of the disease management fees.

Participation rates were 74-95%; 4-15% could not be reached and the remainder refused. Participants who opted in turned out to be a healthier and less costly subset. In addition, one year later, CMS offered the DMOs the option doubling down by supplementing their assigned populations with additional ‘refresh’ patients. 7 of the 8 accepted, hoping to attract greater numbers of persons with chronic heart failure. By then, LifeMasters had already backed out, but things unraveled after that. McKesson and CIGNA exited followed by XL Health and Green Ribbon requesting early termination of their contracts.

The data has continued to roll in. And what did the disease management family find when they opened the door to the black sheep this time?

Of multiple measures of satisfaction, only 13% showed a statistically significant improvement.

40% of multiple measures of clinical quality showed a modest improvement of 2-4%.

There were no statistically significant reductions in hospitalizations, rates of readmission, or emergency room (ER) visits between the intervention and comparison groups.

No statistically significant differences were observed in mortality rates.

The claims expense trend rate was not statistically different compared to control patients overall or in individual disease categories. After statistically controlling for the differences that developed after randomization, the lack of any difference in claims expense held up. Including the refresh population didn’t make any difference.

Ugh. But, the Disease Management Care Blog doesn’t exactly think it’s all that bad. It has some black sheep in its family and they’re not THAT bad either. Here’s why:

In an ‘ala cart,’ and free-range system of care, it’s becoming very apparent that it's difficult to control/steer/influence Medicare beneficiary behavior. That contrasts with controlled systems with limited networks and creative/restrictive benefit designs. Disease management works best when it’s a part of managed care which still has a significant role to play. How well physicians are able to do this in the Medical Home - absent a 'gatekeeping' approach - remains to be seen.

Secondly, MHS is testing an approach to population-based care that is already becoming obsolete. New approaches with Ver. 2.0 disease management that are better aligned with information systems, benefit designs, consumerism and primary care are already underway. Disease management has already learned what doesn’t work and is applying those lessons in the marketplace.

Last but not least, the DMCB thinks the market and the Feds decided months ago that ‘disease management’ in fee-for-service Medicare doesn’t have much of a future. This latest report is merely a reaffirmation of that.

Everyone knows about the black sheep. Time to move on.

The Five Myths of Health Care Reform––Health Information Technology, Prevention, Outcomes Research, Pay-For-Performance, and Universal Coverage

The arguments that the widespread use of health information technology (HIT), improving health status, expanding outcomes research, implementing pay-for-performance systems, and covering everyone will make it possible for us to afford comprehensive health care reform are commonly cited by people on both sides of the political aisle.It's all a myth.Undoubtedly, these ideas will be at the core of

"Let's Reboot America's HIT Conversation---Part 1: Putting EHRs in Context"

Last Month David Kibbe and Brian Klepper asked me to post an open letter to the Obama Health Team with their thoughts on how to spend the coming federal health IT money. That letter ended up as the centerpiece of a Boston Globe story with the lead line, "some specialists are warning against investing too heavily in existing electronic recordkeeping systems."Encouraged by the response to that

Disease Management Predictions for 2009

The Disease Management Care Blog believes prophesying about 2009 is so easy because predictions are only remembered when they turn out to be true. Lacking any downside risk, the exercise it makes for a future self-congratulatory post if even one divination randomly hits pay dirt. One prediction the DMCB can make with great confidence, however, is that if even one of its 2009 forecasts is accurate, it will not hesitate to remind readers and DMCB spouse of its prowess as a budding futurist.

So here, in no particular order, are the DMCB Predictions for disease management in 2009:

The death of the Disease Management Business Model will turn out to be greatly exaggerated thanks to:

1) adoption of remote patient coaching as one of many components of population-based care for chronic illness. The disease management organizations will finally be forgiven for acting in the past like they were the only component,

2) genuine belief in ‘disease management’ among Administration and Congressional supporters (with the Congressional Budget Office’s [CBO] lukewarm agreement) of national healthcare reform,

3) expansion of disease management programs in the commercial market as more employers become self-insured and use business assumptions (not scientific certainty) in their benefit designs,

4) continued reliance on successful disease management in Medicaid settings,

5) the realization that good health care doesn’t necessarily save money and

6) the next prediction.

The first reports from the multiple insurer sponsored pilots on the patient centered medical home (PCMH) will be a mix of

1) reality-checking reports that show modest gains in quality and disappointing lack of savings,

2) failures,

3) lack of uptake among many of the non-entrepreneurial primary care sites that have either a) tight cash flows and simply can’t afford a practice redesign today based on tomorrow’s revenue or b) an existing successful business model that minimizes overhead, maximizes patient throughput and can still afford that Lexus, and

4) lack of support from specialist physicians who believe primary care physicians were supposed to be 'medical homes' all along.

The rise of Disease Management Lite (defined by the DMCB as any remote intervention that doesn’t principally rely on expensive nurses) thanks to:

1) pushback price pressure in an insurance industry having to make due with fewer member months

2) the emergence of price competition among disease management organizations,

3) the unwillingness of DMOs to cut prices on their traditional U.S based nurse coaching offerings,

4) adoption of technology solutions that are otherwise prohibitively expensive at the provider level but attractive at a PMPM level

The Medicare Medical Home Demonstration will lumber along and will ironically slow adoption of the PCMH as an ingredient in health care reform because a) we have to wait for the results and b) the CBO's lukewarm non-support.

Blogs will become even more important in the shaping of health care policy. Policy makers will monitor and try to shape their reactions in the evolving healthcare debate, start their own blogs and build alliances with existing like-minded bloggers. Ask the health policy bloggers how many times they’re detecting 'U.S Senate Sergeant at Arms' or 'Centers for Medicare Services' in their daily traffic. It’s not small.

Early reports of health care reform will be tempered by vexing unhappiness over lack of progress for the middle class. Testy impatience will drive a political/policy mandate to include all that looks good, including disease management (and electronic health records).

Lacking any credible short term fixes, primary care shortages will spike. Not only will appointments for new patients continue to evaporate, but appointments for old patients will be squeezed. The continued unraveling of primary care will make disease management services even more attractive to policy makers.

i love the internet!

I now know what the t-shirt says!

The process by which it was figured out was as interesting as the answer.

There was lots of speculation and many interesting guesses. And Flippy identified it as Japanese kana (as opposed to perhaps more familiar kanji).

Then my friend Mamabunny (who I met at the now defunct Maya's Mom) forwarded the link to her sister, Mikan, who studied Japanese in college (and who writes a great food blog). Mikan was able to provide the answer:

'It basically says "I love" or "I love you" but it's using "degozaru" which an older form of "degozaimasu". It's just an indication of politeness. My roommate likened it to "I love thee."

It may or may not be inspired by Rurouni Kenshin, a Japanese comic, in which the main character is constantly polite to the point of being annoying.'

I guess it's something like the French "Je vous aime," as opposed to the more familiar "Je t'aime."

So the verdict on the t-shirt is that it can be warn whenever S. wants. After all, the world could use a little more love.

I Read It in the Disease Management Care Blog

One of the unique features of the Disease Management Care Blog is its liberal use of references with links to the peer review medical literature. Unfortunately, the DMCB has grown to well over 300 blog postings and some postings have multiple links to scientific journals. As a result, a posting months ago involving an important topic may have a link that you need today.... but cannot find. Was that article quoted so sagely by the DMCB in the New England Journal of Medicine? In Health Affairs? In the Archives of Irreproducible Silly Results?

Should you search by DMCB by topic in the search box upper left of the page and scan the links one by one? You could, but the DMCB has once again exceeded its readers expectations and created a whole new blog page that has many of the scientific references used in past posts!

They are arranged by topic, are typed up in the AMA Style (for your copying convenience), have a short DMCB description and a link to either the abstract or (if available) the full article.

Many references used in the past are still missing because the DMCB hasn't gotten around to them yet. This system is still imperfect because readers can't search within the page.

On the other hand, this is a start. A work in progress. Suggestions from readers on format or increasing usability will be MORE than welcome. In addition, if you find an article that should be included, don't hesitate to ask the DMCB about it.

happy new year!

2008 and was a pretty good year for my little family.

I remained in remission for a full year. I now have six clean scans under my belt.

I travelled to Florida with D. and to London with S. I spoke at BlogHer this year in San Francisco and attended a terrific breast cancer conference in Philly (where Jacqueline and John came to hang out with me).

I finished my book. It's now into production!

I started writing fiction and (gasp!) am working on a novel.

Lucy came to live with us.

T. took on a new client and is really enjoying the work and the people with whom he is working.

S. is happier than he has ever been. This year his teacher and the kids from his class entered a Lego Robotics competition. They worked very hard and won an award for their teamwork.

Five year old D. is reading now, with great fluency and expression. He also loves sports and has an active social life.

My sister got married to a wonderful man. They've bought a house that is walking distance from my home.

Barack Obama was elected President of our neighbour to the South.

We have food in our bellies, a roof over our heads, clean water to drink, good schools in our neigbourhood and more material things than we need. We are very lucky people.

I wish you all a very healthy and happy 2009.