taking care of my body in 2009: part 6 (or you have to be ready)

First of all, let's review the goals I set for myself last month:

1-Walk VIGOROUSLY for an average of one hour, five times per week (300 minutes a week).

This is a good place to start, since I did well, accomplishing this goal and exceeding it. Next month, I may think about doing something to ratchet up the intensity.

For now, I am also riding my bike around town. As a result, I have a sore rear end. I am sure this will get better.

2- Do either 10 minutes (at least) of strength training or yoga with the Wii Fit or abdominal exercises every day (chemo recovery days excluded).

I did this only 4 times. I also hurt my back this month, pulling my suitcase down from a shelf on the train. I was in a hurry and not paying attention. It was a bit of a wake-up call about the need to improve my core strength.

To that end, I saw my physiotherapist again on Monday. She surprised me by saying that, when it comes to my back, the stiffness in my hips is a bigger problem (she actually said, only half-joking that she is surprised that I can walk). She said it she hasn't seen anyone as stiff as I am in a long time.

So, I now have some stretches that I need to do regularly in addition to the core strengthening.

3-Go to yoga once every week.

I didn't go at all in May. And despite the fact that my physio says that she sees "a lot of yoga in my future" I think that I may not go again until the fall.

It's becoming harder to find a class I can attend regularly (and this will only get worse over the summer, with fewer classes and the kids around more). And I don't really want to go back to the class I have attended the most regularly (the timing is good but the teacher, always more impatient than most, actually yelled and swatted another student the last time we went. It was a bit of a turnoff).

Besides, I feel that I have a lot on my fitness plate right now.

4- Take my vitamin D and calcium supplements daily.

I didn't do this in May either but I am 2 for 3 in June. And going to take them with lunch, I promise.

Now for the big change. I have decided to start doing the Weight Watchers thing again. It's a program that has worked for me before (I lost almost 50 lbs after D. was born) and I feel ready to do it again.

I know I said this last year but this time I have a support group, comprised of two good friends who also would like to get down to their pre-breast cancer diagnosis weight. For four weeks now, we have been weighing in every Monday. They are both doing WW and I have just been reporting on exercise and my quest to eat more veggies.

Then, on the weekend, I admitted to myself that I have the best success when I write everything down that I put in my mouth. And I also realized that I am ready to do this. It wouldn't have done me any good to start earlier in the year. I am ready now. And it feels like the right thing to do.

I did check with my doctor. The conversation went like this:

Me: "I am thinking of making some changes to try and take off some of the weight I have been putting on since my diagnosis..."

Dr.: "Have you considered Weight Watchers?"

So, clearly I have the green light to do this now. And I don't have the discipline to do this any other way than really slowly.

This process will also help me reach these goals:

5-Cook dinner at least once a week.

Easier to count points if I know what went into dinner. Easier to stretch those points out if I prepare lower points options for all of us.

6-Cut down on refined sugar.

I really don't want to waste points on empty calories.

7-Eat seven servings of fruit and veggies a day.

Conversely, filling up on fruit and veggies makes those points go further.

As you can see, I have all the zeal of someone on the third day of a diet. And I'm hungry.

I need to make vegetable soup today.

What goals did you set for yourself this year? How are you doing?

Proof vs. Assurance on the Medical Home: Lessons from Hollywood

In the science fiction-action film Aliens, Ellen Ripley (played by Sigourney Weaver) returns to deep space with a contingent of brave Marines to face her fears and do battle with a race of mucousy, parasitic, acid-blooded and poly-mandibular lizards. The TV remote wielding Disease Management Care Blog, to the lingering disappointment of the spouse, cannot resist the genre and will always pause on that movie (at least when the plentiful action scenes are being shown; it surfs on when insufferably precious Newt starts shrieking. Puh-lease).

A favorite scene? When the brainy and and equally clueless Marine Lieutenant sends his tough men and women into harm's way, only to watch his battle plan unravel over multiple data feeds. Ripley cuts through the clutter, discerns the brewing disaster and saves many of the humans with astronomical pluck and a cinematic disregard for planetary speed limits. Take that, Evil Aliens!

In addition to Sigourney's edgy sexiness, the DMCB likes the scene because of what it teaches us about the contrast between data versus determination, between analysis versus action between doing what's correct versus doing what's right. Ripley's interstellar derring-do portrays that classic right vs. left brain human struggle well enough: it earned $86 million out of the gates in its 1986 release.

For an excellent discussion of a more slow motion and real life example of this tension between knowledge vs. faith, check out Brady Augustine's Medicaid Front Page blog. He's come up with a wonderful dimension on the debate about the patient centered medical home. Legislators are going to have to work their way through the same judgment about what the science tells us about the medical home versus a gut-instinct call on whether it's worth billions of Federal largesse. The information is very spotty, opinions abound on both sides of the debate and Aliens are lurking. Do we continue to watch the monitors and wait for more pilot data or for another demo, or do we crash the gates and just pay for the damn thing? Mosh pit indeed.

Keep in mind that making a gut call in favor of action isn't necessarily that good either. If you haven't seen Aliens, you should know that the Marines were ordered to not use explosive ordinance in their space-guns because it would precipitate a runaway nuclear reaction. Fearing for their safety, they disregarded orders and ironically showed how the hapless Marine Lieutenant was right all along.

It sort of reminds the DMCB of a saying from a former star-crossed Defense Secretary about going to war with the equipment that you have, not with the equipment you wish you had. Physicians have to make judgments on the likelihood of disease and the risks and benefits of treatment based on an inexact science and poor information all the time. Businessmen frequently have to assess quirky market conditions and fickle consumer confidence. Sometimes the professionals sit tight, sometimes not.

So, welcome your Congressional Representative and Senators to the club. They are going to have to decide if PCMH data about cost savings are insufficient and if that is reason enough to pause further and see if things unravel, or take a page out of Ripley's Book on How to Deal with Aliens. Both sides of the debate will use the data to justify their judgment calls, but don't let that fool you: they are going to have to guess.

i have excuses (no, the dog didn't eat my blog posts)

I'm back.

I didn't intend to keep Will and Billy and the boys at the top of the page for so long. I keep meaning to post but I never seem to get around to it. I wanted to assure those who have expressed concern that all is well.

It's time to re-commit to regular updates and to begin, please let me explain my absence:

The last round of chemo was kind of hard. I'm not sure if I was hit with an additional bug but I experienced some really gruesome side effects (I'll let you use your imagination), especially last Friday, when I should have started to feel better.

The truth is, that I am taking longer to recover every round, these days. My oncologist has suggested that I skip a treatment this summer. I plan on taking July off so I can go to BlogHer (Did I mention that I got in? I was so disappointed when I came back from Florida to find that the conference had sold out. I can't really afford this but when I learned that there was a space for me, I hesitated for only a couple of hours before taking out the credit card. After all, my book will be there, I want to be there with it!)

I'm going to ask my doc if I can take August off, as well. It can't hurt to ask, right?

When I have felt well, I have been running around a fair bit. I have had a bunch of appointments (among other things, I have returned to physio and lymphatic massage, after taking a long break), errands and other commitments.

Last week end, for example, my spouse and I took D. to the Cumberland Heritage and Power Festival. There were so many cool things there, a steam powered rock crusher, water-powered toys and little tiny steam trains on which you could ride. I wish I had brought my camera. The photos would have made a great blog post.

I blame Twitter. I find sometimes that I have begun to compose my thoughts in 140 characters. For example, I tweeted about my brain MRI results but I see that I didn't write about them here (I think this is a common problem. I remember Average Jane citing Twitter as an excuse for not blogging). They were great results, by the way with absolutely nothing suspicious in evidence, or as I reported to my spouse, "There is nothing there."

I have had BSG to watch knitting to do.

Promoting my book, while fun, has left me kind of uninspired. But I am getting past that. How many more times can I say, "Please buy my book?" or "Don't forget about the Toronto launch on June 11?"

The truth is I haven't been doing much writing of any kind lately. And I miss it. I just seem to have fallen out of the habit.

But the only way to make something a habit is to do it.

So here I am.

"Medical Homes Do Not Save Money" says Al Lewis at the National Medicaid Congress

That's a quote from Al Lewis of the Disease Management Purchasing Consortium about a new look at the data from the famous North Carolina 'medical home' initiative, otherwise known as the Comunity Care of North Carolina (CNCC)/ACCESS program. He spoke today at the National Medicaid Congress and the intrepid Disease Management Care Blog was in the audience taking notes for its readership.

As readers may recall, this program's actuarially determined savings of hundreds of millions of dollars are commonly held up as the reason why health reform wouldn't be complete without the patient centered medical home. CNCC was examined by the Disease Management Care Blog back in February; it didn't pass judgment on the savings question because it went to the "Program Impact" part of the CNCC website and looked at all the .pdfs. Not only did the DMCB actually read the actuarial reports, it didn't understand how the calculations were done and, unlike many CNCC's advocates, it wasn't afraid to say so.

Before you think this is some more of the internecine battling between the disease managementroids on one side and the medical homabots on the other, readers should also realize that there has been no more visible critic of the disease management vendor industry than DPMC's Al Lewis. In fact, the Disease Management Care Blog suspects many of its colleagues are somewhat relieved that Al has turned his attention to the medical home. They could use a break from his unrelenting mocking of the industry's opaque, always-positive-ROI, cherry picking and illogical innumeracy. Simply put, Al Lewis is no lightweight and commands the respect of a number of highly regarded Health Plans that rely on him for help and insight.

So what did Al Lewis say? Like the DMCB, he thinks evaluators of population-based care programs should never accept anyone's conclusions at face value and should always perform a plausibility test - especially when savings totalling hundreds of millions of dollars are being claimed. He found the CNCC is quite wanting plausibility-wise. He noted that the data supposedly shows inpatient costs fell by 46%, ER visits by 25%, outpatient visits by 24% and pharmacy costs by almost 11%. In Al Lewis' experience in looking in successful programs, it is practically unheard of for decreases in claims expense for admissions to not be accompanied by a corresponding increase in outpatient physician visits. What's more, in any population, almost half of all admissions are not controllable thanks to trauma and unexpected random illness; in order to mathematically achieve a 46% decrease, practically all admissions for chronic illness would have had to be avoided. Al Lewis smelled a rat.

Things got particularly stinky when Al Lewis told the audience that he had used the Freedom of Information Act to pull utilization claims data for the North Carolina TANF population, which makes up the bulk of their Medicaid population. According to his analysis, physician office visits did go up, ER visits were flat, admissions for heart attacks were flat and asthma admissions went down. While it's difficult to translate events (visits and admissions) into expense data (dollars), Al's rough estimates show very modest savings that are far less than the 'official' numbers and outweighed by the program's expense. In fact, when expenses are included, the program lost money. Sound familiar?

The DMCB looked hard for holes in the analytic logic. There were some minor glitches, but nothing serious. That's for another post.

Al told the DMCB that Senator Kennedy's office is interested in learing more about his conclusions.

What does the DMCB think?

Determining savings in insurance settings is fundamentally a brain cramping exercise in measuring what hasn't happened and then trying to assign a cause. The DMCB doubts there is any 'single methodology' that can answer that question for any commercial or government insurer. Rather, the better approach is to triangulate on the results using a combination of actuarial, epidemiologic, statistical and research methods that may very well include the DPMC methodology. We know have another prespective on CNCC, and for that we should be grateful.

Once again, the real challenge is to find approaches to the care of individuals with chronic disease that use the best combination of care interventions but are reasonably generalizable in multiple care settings. The DMCB has questioned whether CNCC's approach will work outside of Medicaid. So, the question isn't the utility of endless debate over the past of the CNCC but finding the right future combination of disease management, medical home, information technology, payment reform and benefit designs that give patients their money's worth.

In addition, supporters of the patient centered medical home better work hard to get this puppy into the upcoming Congressional health reform bills and passed before there is any more bad news - not only from Al Lewis but from all those other medical home pilots currently underway.

Last but not least, getting news like this is a good reason to keep up with the DMCB.

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