A Summary of the Latest Population Health Management Journal

It's that time again. The latest issue of Population Health Management is out and you'd read it if you weren't so busy with other stuff. After all, PHM is your window into the latest goings-on in the disease management community, its information gives you and your company a competitive advantage and quoting from it impresses policy makers, bosses and colleagues. Good thing you read the Disease Management Care Blog: it has the information you want in a format you can quickly use.

Check it out and decide just which articles you really need to read and which ones are just FYI. So, without further ado......

In this ‘Point of View,’ the veteran Robert Stone of Healthways discusses the maturation of the disease management industry with a special emphasis on the insurers' eternal choice of ‘build or buy.' According to Mr. Stone, insurers want mutually supportive and broad-based health, wellness, prevention, case and disease management on one platform that are all built to last and are adequately capitalized. For those that are foolish enough to think about building, he cautions the availability of tools is not synonymous with an ability to use them. A telling quote: ‘Price is not the best indicator of ultimate value.’

In this article, Harry Leider of Ameritox, David Mirkin of Milliman and Christobel Selecky of LifeMasters reminisce about the recently concluded Ninth Population Health and Disease Management Colloquium. Harry pointed out there were presentations about conditions that have been largely ignored by the industry, such as chronic pain, autism, migraine and psychiatric conditions. David reviewed how unsettled the science is of using actuarial trends to estimate the economic impact of disease management programs. Christobel detailed how there is a growing emphaisis in her company and among others in maximizing patient activation. Good quote from Ms. Selecky about trending: “I wonder if people arent’ just shell-shocked with trying to come up with a methodology – once you think you have it nailed down, something squirts out the other end.”

Thomas Foels, Sharon Hewner: Integrating pay for performance with educational strategies to improve diabetes care. This describes how Independent Health of Western New York State compensated physicians (60 to 70 cents PMPM plus CME) to conduct reviews of their own charts for diabetes care quality. Physicians were then provided summary data that included an estimate of the patient’s overall burden of illness along with suggestions for improvement. 84% of the physicians participated, and over time there were at least 10 percentage point gains in the usual measures of blood pressure (less than 130/70), LDL (less than 100) and A1c (less than 7). The authors say – with very little detail - that they saved money. The DMCB thinks this is was an interesting article because this was more of a pay for ‘quality improvement program’ (? P4QI?) than a typical pay for performance (P4P) program: that seems unique. Kudos to the authors for this quote: ‘There were several limitations to this study, thanks to the lack of a control group, a small sample size per practice site, underrepresentation of rural and small practices and the selection of patients used in the survey based on a claims profile.' The DMCB says this is promising and some more research is needed.

George Ioannidis, Alexandrea Papaioannou, Lehana Thabane, Amiram Gafni, Anthony Hodsman, Brent Dvern, Eleksandra Walsh, Famida Jiwa, and Jonathan Adachi. Family Physicians' Personal and Practice Characteristics that Are Associated with Improved Utilization of Bone Mineral Density Testing and Osteoporosis Medication Prescribing The authors used a physician questionnaire from 225 Canadian docs to assess personal and practice characteristics and then correlated those results to the likelihood of ordering osteoporosis testing and treatment. Being female, not having hospital privileges, not being a recent medical school graduate correlated with ordering bone density testing, having an electronic health record was associated with treatment for osteoporosis. Best quote: ‘This is not surprising…..’

Susan Robinson, Robert Baron, Bruce Cooper and Susan Janson: Does health service use in a diabetes management program contribute to health disparities at a facility level? Optimizing resources with demographic factors. These researchers from the University of California followed 315 persons with diabetes for 18 months. Since all had equal access to the clinic, the authors were interested in knowing whether demographic factors correlated with healthcare utilization. Persons with Medicare and Medicaid as well as persons of Hispanic heritage used the emergency room more frequently. Women were more likely to be hospitalized and Hispanics less so. Telling quote: Clearly ‘disparities in utilization’ of health care services continue to exist within demographic subpopulations.” And we thought disparities hindered access to care.

Micah Throp, Jessica Weinstein, Jason DeVille Eric Johsnon, Amanda Petric, Xiuhai Yang, David Smith: Comparison of renal replacement therapy and mortality using 1 versus 2 estimated glomerular filtration rates. Using data from their electronic health record (EHR), these Kaiser researchers found that when when physicians ordered an ‘estimated glomerular filtration rate’ (eGFR)and found evidence of chronic kidney disease, the appearance of a second eGFR in the order data sets predicted a worse outcome. If you use the electronic record to find patients for a CKD disease management program, you may want to use this signal as evidence of a higher burden of illness. The bottom line quote: For the purpose of disease management, it is less important that the second low eGFR demonstrate [sic] an independent prediction of mortality…. Disease managemer can take advantage of its superior predictions….”

Yiduo Zhang, Timothy Dall, Yaozhu Chen, Alan Baldwin, Wenyua Tyng, Sarah Mann, Victoria Moore, Elisabeth L Nestour, William Quick: Medical cost associated with prediabetes. Using a ‘Cost of Diabetes Model,’ NHANES, Census Bureau Data and the Ingenix Research DataMart, these Lewin Group researchers ultimately estimate there is a total cost of $25 billion or $443 per person with prediabetes, mostly due to increased outpatient utilization, not from emergency room or inpatient care. What's more, 'these cost estimates understate the true cost of prediabetes to society...[due to] increases in missed work days and lower productivity.' The DMCB says use this paper when you want to market your metabolic syndrome disease management program.

Yaozhu Chen, William Quick, Wenyua Yang, Yiduo Zhang, Alan Baldwin, Jane Moran, Victoria Moore, Navita Sahai, Timothy Dall: Cost of Gestaional diabetes mellitus in the United States in 2007. This is another fact-fest from the Lewin Group who, this time, relied on discharge data to that gestational diabetes to estimate that the cost is $636 million, or $3,305 per pregnancy.

What It Would Take to Really Make America's Health Care Costs Affordable and Sustainable

Most health care experts agree the reason our system is so unaffordable is because of all of the waste and unnecessary care—up to 30% of what we spend.I will suggest that it will take the genius of individual creativity to separate the 70% of this health care system that is the best in the world from the 30% that is waste.So far, the Congress has focused more on entitlement expansion then

free to a good home

It's not the kind of thing I'd want to advertise on Craigslist or Kijiji.

I can't set it out on my front lawn and hope someone takes it away.

I doubt the Canadian Diabetes Association or the Ontario Federation for Cerebral Palsy would want it as part of their drive to collect use goods for re-sale.

But I have a perfectly good prosthesis, worn only a handful of times that I'm sure someone could use, even if it was wrong for me (and I have replaced it with another one I don't seem to be wearing much).

The government covers about two thirds of the cost of a new prosthesis. That balance must be prohibitive for many who don't have private insurance to take care of the rest.

How do I find someone who can use it though?

Maybe someone at Breast Cancer Action would know.

Of course, I could always use my prosthesis to make art, the way Jacqueline did.

I think my inclinations might be a little more violent, though.

Thoughts?

Health Care Reform Should Mean Health Care Reform--A Proposal for Real Change

CMS says that we will spend 17% of GDP on health care this year and we are on our way to having 22% of our GDP being spent for health care by 2018.The stated goal of the President and all of the Congressional health care reformers is to accomplish health care reform and have it be deficit neutral.Deficit neutral means we wouldn't reduce our costs one bit. We would have no assurances that we would

and then it just got even more canadian around here

photo: A Kaplan-Myrth

Because every Canadian finds a Mountie on their front lawn on Canada Day.

The food was good, the beer was cold and their was maple syrup in the salad dressing. Now the dogs are being driven crazy by the fireworks.

It's been a good one.

The $440 Billion Question for the Value of Cancer Treatment Such As Erbitux Gets More Complicated

It seems the contrast between the often staggering cost of treatment and the modest yield in life expectancy caught the attention of the editors and academics over in the Journal of the National Cancer Institute (JNCI). The DMCB thanks them for confirming an issue raised previously in this blog. How so, you ask? Read on.

Erbitux (generic name cetuximab) is one of several manufactured proteins that in turn bind to a protein component found on various human cell surfaces that regulate growth (called, appropriately enough, ‘growth factors’). When combined with standard chemotherapy for cancers such as lung or colon, Erbitux has been shown to modestly increase life expectancy. Unfortunately, Erbitux is a very sophisticated product that required years of expensive testing and development, demand for the drug is very high, setting prices for medications is very arcane and the manufacturer has a patent.

As a result, it’s not unusual for a treatment course consisting of several IV infusions of Erbitux to cost tens of thousands of dollars. When projected over the number of persons that would qualify for treatment, authors Tito Fojo and Christine Grady apparently (access to the full text is restricted) determined that the total cost to our nation’s health care system could add up to a whopping $440 billion per year.

In our age of printing up trillions in dead Presidents, that’s not necessarily the problem. The addition of Erbitux, according to summary news reports, results in a paltry average of 1.2 months of added life expectancy. This poor value proposition troubles the authors, who recommend that expected cost and life expectancy should be used as a criteria for the funding of future cancer treatment research.

According to the Wall Street Journal, actual patients may disagree. They point out that today’s expensive advance will be cheaper tomorrow, big breakthroughs lead to other breakthroughs, persons can use the 1.2 months as a bridge to other treatments and, well, it’s only money.

For the record, the prescient DMCB raised this issue just hours before the JNCI release and believes Drs. Fojo and Grady are confirming that stomping out ‘waste’ and ‘medical mistakes’ pale in comparison to our need to reconcile the high cost of technology versus the actual yield. The issue has been around for a long time. One old example is this comparison of the expensive clot buster tPA versus cheap clot buster streptokinase for heart attack. As for our chances of reconciling high cost vs. modest yield: good luck, even in today’s reform-minded environment.

However, while the mainstream media have focused on the validity of the $440 billion price tag, the contrarian DMCB thinks ‘1.2 months’ is statistically unfair and does a poor job of reflecting the real issues faced by cancer patients. Check out this real life clinical trial that is available on line. It showed Erbitux resulted in a median survival of 12 months with a confidence interval ranging from about 8 ½ to just over 15 months versus just over 9 months of survival with a confidence interval extending from about 7 ½ months to just under 12 months without Erbitux.

Most scientific studies report confidence intervals to give you an idea of the distribution of the results. In other words, there is a 'plus minus' ‘spread’ around the average in how any population of patients will respond to treatment. That is determined by myriad clinical factors but, once the numbers are added up, it acts in typical random 'Gaussian' behavior. This means the real bottom line in this trial is that getting Erbitux may result in a life expectancy as high as 15 months versus a life expectancy as low as 7 ½ months without Erbitux.

Depending on the real price of a course of Erbitux, that may place it within reach of the standard threshold of cost effectiveness. Put another way, if you were told your life expectancy could double to 15 months for, say, 20 grand, would you go for it? Saying yes at an individual and policy level is not that unreasonable. The DMCB says the JNCI editors' failure to recognize that real world calculus is unreasonable.

Oh, and one more thing: the JNCI authors suggest that ‘oncologists must offer clear guidance for the conduct of research, interpretation of results, and prescription of chemotherapies.’ The DNCB’s experience dealing with oncologists and their drugs as a medical director in a highly regarded health plan taught it otherwise. So does some peer review literature. The JNCI authors are not only also unreasonable, they're being naive.

rhetorical question

Do you know hard it is to keep track of two six year olds in a museum on Canada Day, when admission is free and everyone is dressed in red and white?

So far today I have been to the Museum of Civilization, eaten Vietnamese noodle soup, watched two boys play in a splash pad at a park and taken the dogs for a walk in the rain.

Now that the sun is out, I'm going to join friends on their back deck, watch the kids splash in the pool, eat some barbecued stuff and have a beer or two.

Very Canadian.