A brand new and very special edition of the Health Wonk Review awaits you at the grand daddy blog of them all, the Health Care Blog. Written by the widely respected and always insightful Brian Klepper, it casts a sobering light on health reform, thanks to the input of many of the best health care blogs out there.
As early one commentator says, this HWR should also be required reading on the Hill and newsrooms everywhere. Even if it weren't included in the Review, the Disease Management Care Blog would still not disgaree.
Thursday, January 7, 2010
A Great Summary of Where We Are
Good friend Brian Klepper has an excellent round-up of recent blog reactions to the health care bill's progress in a "Special Edition of Health Wonk Review."It is posted on The Health Care Blog.It is really worth your time.
Wednesday, January 6, 2010
Why Would the U.S. Senate Want to Continue to Support the Medicare Coordinated Care Demonstration (MCCD) As Part of Health Reform?
The Disease Management Care Blog undertook another exploration of the U.S. Senate's 'Manager’s Amendment' to its proposed health reform legislation and discovered some interesting language on page 155.It directs the Secretary of Health and Human Services to….
Utiliz(ing) a diverse network of providers of services and suppliers to improve care coordination for applicable individuals … with 2 or more chronic conditions and a history of prior-year hospitalization through interventions developed under the Medicare Coordinated Care Demonstration Project under section 4016 of the Balanced Budget Act (bolding from the DMCB).
Continuing the Medicare Coordinated Care Demonstration (MCCD)? Where did that come from?
Regular readers of the DMCB may recall that the MCCD was something of a disappointment that was spun in a way that would make even Madam Speaker Pelosi proud. Briefly, it was a Medicare demonstration involving 15 healthcare organizations (5 disease management organizations, 3 community hospitals, 3 academic medical centers, 1 integrated delivery system, 1 hospice, 1 long-term facility and 1 retirement community) that randomized their established Medicare fee-for-service beneficiaries with chronic illness and prior hospitalization to usual care versus being assigned care coordinators tasked with increasing patient self-care. Final fees ranged from $60 to $270 per member per month (PMPM).
Of the 14 that completed the demo, only one achieved a statistically significant reduction in hospitalizations. Two programs had a significant change in costs, but in the wrong direction: both went up. Two other programs had non-statistically significant reductions in cost; if outlier costs were deleted from the analysis, one turned statistically significant. The abstract appearing in JAMA included statements like ‘…thirteen of the 15 programs showed no significant differences in hospitalizations…,’ as well as ‘…none of the 15 programs generated net savings…’ and, last but not least, ‘these programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined.’
Does this sound like something that should be continued as part of health reform?
DMCB doesn't blame the 14 centers for using whatever political legerdemain it took to continue the funding of this non-compete gravy train. Based on these data, however, it’s clear that while this particular nurse-coordinator model of care may have some promise, it alone is not enough to achieve the breakthroughs necessary to solve the twin health care challenges of cost and quality.
Utiliz(ing) a diverse network of providers of services and suppliers to improve care coordination for applicable individuals … with 2 or more chronic conditions and a history of prior-year hospitalization through interventions developed under the Medicare Coordinated Care Demonstration Project under section 4016 of the Balanced Budget Act (bolding from the DMCB).
Continuing the Medicare Coordinated Care Demonstration (MCCD)? Where did that come from?
Regular readers of the DMCB may recall that the MCCD was something of a disappointment that was spun in a way that would make even Madam Speaker Pelosi proud. Briefly, it was a Medicare demonstration involving 15 healthcare organizations (5 disease management organizations, 3 community hospitals, 3 academic medical centers, 1 integrated delivery system, 1 hospice, 1 long-term facility and 1 retirement community) that randomized their established Medicare fee-for-service beneficiaries with chronic illness and prior hospitalization to usual care versus being assigned care coordinators tasked with increasing patient self-care. Final fees ranged from $60 to $270 per member per month (PMPM).
Of the 14 that completed the demo, only one achieved a statistically significant reduction in hospitalizations. Two programs had a significant change in costs, but in the wrong direction: both went up. Two other programs had non-statistically significant reductions in cost; if outlier costs were deleted from the analysis, one turned statistically significant. The abstract appearing in JAMA included statements like ‘…thirteen of the 15 programs showed no significant differences in hospitalizations…,’ as well as ‘…none of the 15 programs generated net savings…’ and, last but not least, ‘these programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined.’
Does this sound like something that should be continued as part of health reform?
DMCB doesn't blame the 14 centers for using whatever political legerdemain it took to continue the funding of this non-compete gravy train. Based on these data, however, it’s clear that while this particular nurse-coordinator model of care may have some promise, it alone is not enough to achieve the breakthroughs necessary to solve the twin health care challenges of cost and quality.
Better to use the MCCD's lessons by building an initiative (and please, not another ‘demo’) that takes what is known to work and not work from this as well as other demos and programs inside and outside of government to fashion a multi-pronged approach to population-based care. This should include the best of remote and face-to-face disease management, the medical home and other care coordination and physician led strategies. What’s more, the DMCB thinks it be smart to open this to other entities with fresh approaches. There should be a special emphasis on collaborative partnerships involving multiple players including the primary care doctors. Not only does this hold greater promise of ‘generating net savings’ and ‘having favorable effects on quality of care,’ but it’s the most likely to work in multiple settings across the country.
Monday, January 4, 2010
More on the "C" Word: This Blog Had It All Wrong About Capitation
This Disease Management Care Blog welcomes this alternate point of view from a veteran health insurance insider. While this was orginally a reply to a prior posting, the DMCB thought the points being made deserved special attention.+++++++++++++++
In a previous posting, Jaan Sidorov criticizes the supporters of accountable care organizations (ACOs) by using the supposedly ugly ‘C’ word. That’s right: ‘capitation,’ which is another way of setting a global budget that would incent providers to work together.
Is that really such a bad thing?
If the resistance to capitation and ACOs is that people don't like "the same old bag of tricks" then that's fine as far as it goes. But if the skepticism purports that these "tricks" have the net result of lowering quality care or failing to lower costs, what is the evidence?
There isn’t any consistent evidence that the quality of care went down in the mid 90's when the managed care approaches to increasing quality and lowering cost inflation were at their peak. There is certainly strong evidence that they helped lower costs. Capitation emboldened insurers in their negotiations with providers, bringing about a flatlining of cost trends during those years. Is it any accident that this was also a time of significant business growth that helped the Clinton Administration to erase the Federal deficit?
The single article that was cited in the posting about the abuses of capitation doesn't support the claim that capitation is necessarily bad or that it’s bad when providers are responsible for costs. Nowhere does the casual reader see evidence of lower quality care, higher mortality, etc.
Instead, this is what the authors of the study really said:
"Groups rarely denied requests for referrals and tests. Seventy-seven percent of groups indicated that they infrequently (less than 10% of the time) denied high-cost procedures and tests (cost greater than $500), and 86% infrequently denied low-cost procedures and tests ($200 or less). Patients or providers appealed an average of 17% of denied requests, and the groups reversed an average of 35% of these decisions."
Given Americans' over-utilization of questionable services, the fact is that there is reasonable evidence that utilization of high-end care doesn't have a significant impact on the outcomes that count. While unfettered capitation is not the ideal solution, other approaches to care, such as integrated delivery systems with salaried physicians may be an idea whose time has come. That, of course, is a steep uphill climb in most of America.
keeping it specific in 2010
It's time to dip my toe back into the regular writing of this blog by letting you know that I have scaled way back on the New Year's resolutions this year.
In 2008, I had a list.
Last year, I resolved to "treat my body as well as I treat my mind." Since I gained at least 10 pounds (I'm afraid to get on the scale) and even more than that since my breast cancer diagnosis in early 2006, abandoned yoga and did no strength or core training, I was inclined to view this year as an abject failure on the resolution front. But then my spouse reminded me that I rode my bike pretty much everywhere between April and the first snow. Also, I ran regularly throughout the summer (this was brought to a halt by H1N1 but I'll start again) and cooked more than I ever have in my life.
So I've decided to tell myself that I did OK.
But this year, I have decided to be very realistic and specific in my goal. This year, I resolve to make soup.
Yesterday's soup was lentil carrot, from "Cooking With Foods That Fight Cancer."
Soup-making is creative and provides right-brain stimulating repetitive motion. Soup is generally healthful and inexpensive to make. But really, I just feel like making soup.
I'm going to make soup at least 20 times this year (every other week, less in the summer).
Have you made any goals for 2010?
Ten Predictions About the Organization of Health Care for the Coming Decade
While other blogs have their Top Ten past year in review or next year’s predictions list, the intrepid Disease Management Care Blog is going one log-step further with a series of predictions Call it Thoughts on the Looming Teens, Divinations on the Coming Decade, Augury Ver. 10-19, or.... mere speculation, the DMCB offers up these trends for your consideration:
1. The Democratization of Medical Information – We are getting to the point where data storage and processing is about to hit us like a Gutenberg Bible.
Persons will not only be able to obtain, review, store and modify their personal information, they’ll have the final say over the use of their data for growing need for applied health services research. For many reasons (including their personal benefit and less concern about privacy), the majority will willingly opt-in (or elect to not opt-out) and participate.
What’s more, thanks to the demand of lay persons for useful insights about their health and disease as well as the increasing number and sophistication of multiple media outlets (including blogs), complex research information and analyses will be made understandable to non-professionals. In fact, medical journals that fail to cater to this audience will find themselves sidelined to serving insular niches of pyknotic academia.
Last but not least, the granularity of this perfect information storm will enable society to drive a stake through the heart of a crumbling mainframe medical approach of managing to the average outcome. Subgroup analyses, confidence intervals and genetic information will facilitate a far more personalized and distributed approach to care. Let's hope we figure out how to pay for it.
2. Classic Health Economics Fades to Black – The lingering inability of ultra-specialized academic economists to adequately explain the interplay between the demand and the use of health care services will be altered by the lifeblood infusion of the sciences of anthropology, sociology and psychology. If you want to succeed in this field, now is a good time to be a well-read non-specialist. If you're a medical journal, now's the time to think about the make up of your reviewers and editors.
3. Whither medical devices? Unable to shake our morbid fascination with gadgets and using them to cheat death, the increasing use of internal and external devices, monitors, pumps, stickers, probes, wires and radios will drive their alliance with an army of professional non-physicians who will advise, coach, text, prompt and educate. Think Batman Utility Belts and Dick Tracey Radio Watches unrestrained by notions of size or the presence of a skin barrier, especially since 99% of us will be permanently tethered to the internet. This will power old fashioned disease management.
4. The demise of 'single line' primary care – Yes, this is painful thought, but thanks to the emergence of cheaper better faster options such as self care, remote care, eVisits, convenience clinics, health information technology support, nurse practitioners, physician assistances, nurses and community health workers, my primary care colleagues are going to get sidelined. Outside of Number 10 below, the PCP's options include geriatric medicine, tatoo removal or writing to their Congressman. Only one of these options will pay well, and the sooner they - and policy makers - realize it, the better.
5. The fading of subsidies and rise of government costs – Despite the generosity of the current Congress and a landmark healthcare bill, the inexorable demand for health care in the face of limited resources combined with a failure to restrain costs will force a future and more conservative government to turn to the old tricks: higher eligibility thresholds, higher out of pocket costs, caps on benefits, co-pays and denials of coverage over notions of medical necessity. There will be law suits over interpretations of the entitlement language, Congressional hearings, more Czars and the growth of a unwieldy. overlawyered and hyper-regulatory blob. Think today's commerical insurers have too much overhead? You ain't seen nothing yet.
6. Black Swans – the health care system will be rarely but severely rocked by unexpected stresses. Examples include a new pandemic, an act of terror or the election of Sarah Palin. Equally unpredictable will be how society responds by altering the health care system. If severe enough, this is how single payor advocates will finally get their wish.
7. Health insurers become regulated utilities – Semi-public and heavily overseen, expect them to become functional regional monopolies (technically they'd be monopsonies) that are brought to heel with paper thin profit levels, public hearings over rates and an occasional stab at competition. Unless number 6 happens, this will be the closest we get to a single payor.
8. Congress will not give up control - A well run enterprise overseen by a smart Board of Directors is typically guided by the adage of ‘nose in’ (ask a lot of questions, give smart counsel) and ‘hands off’ (other than setting policy, don’t run things unless you really really have to). Despite noises about an insulated Federal decision-making body, the various Committees of Congress will continue to behave like a well intentioned activist and meddlesome Board of Directors: nose in, hands in. Heaven help us.
9. Conservatism will become cool again - While this prediction is somewhat dependent on our cultural sine wave, Ron Paul’s run at coolness combined with an inevitable overreach of Washington DC makes the DMCB think that the tweeners will embrace notions of personal liberty, private enterprise, profit motive and capitalism in all things including health care. It will start as a backlash against penalties for unhealthy living -- like failing to eat veggies or brazenly dancing like Matrix partygoers the night before the Machines come.
10. The DMCB Can't Let Go of Unification Theory - After trying every siloed approach to increasing clinical, humanistic and economic outcomes for populations, 'care management' will finally unify the personal/electronic health record, accountable care organizations, the medical home, disease management and pay for performance/partial capitation into synergistic and overlapping approaches to care. Everyone will agree that one cannot exist without the others. Between here (2010) and there (2019), there will be winners and losers.
Finally, the DMCB offers up this freebie. The Next Big Social Issue will be the failure of higher education to prepare college graduates for competition in the global economy. Consumers, parents and elected officials will attack the high cost and poor outcomes of an insular not-for-profit university system that caters to itself. If you're thinking of running for office in four to eight years, it's time to bone up on this. You're going to need it. Come up with solutions and you will be elected.
('
’)Sunday, January 3, 2010
Health Reform, Disease Management, Patient Centered Medical Home and Health Insurance Preditions for 2010
The Disease Management Care Blog is really looking forward to 2010. And why not? Fergie’s ubiquitous media presence is only bound to grow, Washington’s work of fixing all that ails us has only just begun and the DMCB hasn’t made any predictions yet. Well, at least we don’t have to wait for the predictions, because they have arrived. Concocted with a witches’s brew of post-party cogeners, caffeine, ibuprofen and tomato juice, the crystal-gazing and prophesying DMCB offers up these horseshoes of the future, because close is good enough.Without further ado: Here are the DMCB Ten Predictions for 2010......
1. Things are not going to change much. What you say? After the continuous cacophony of talking heads, political duct tape and late night votes, it’s going to be the same old same old? Alas, the parallel with most first-time acts of, er….intimacy will be uncanny: after so much… anticipation, so much… passion, the first insight afterward will be ‘is THAT all there is to it?’ When the sun goes up, insurance rates will increase, busts for Medicare fraud with continue, the academic elite will continue to publish clueless articles dealing with more and more about less and less and the number of uninsured will remain stubbornly high.
2. The battle has only just begun. Whatever bill gets passed, look forward to continuing mortal combat over the regulations that shape the real authority when it comes to the Fed’s foray into its new vistas of health care. Most of us will miss it though, thanks to the news spotlight moving on to really important stuff, like the yet-to-be-discovered foibles of other sports stars and whether Jack Bauer’s bone marrow transplant really cured his Prion Disease.
3. The market has decided. Disease management will continue to thrive in its niche. Or rather multiple niches, offering a cafeteria-style suite of low cost and mostly remote care management, prevention and wellness offerings for commercial insurers and self-insured companies. Prevention and wellness will lead the way because most insurers and employers want it but few know how to deliver it. They already have the disease management and will want to keep it.
4. The growth of registries as a source of new medical knowledge. Sure, the academiverse will continue its infinite expansionism thanks to Federal funding bloat, but the rise of terrabyte servers containing all (and the DMCB means all) demographic, claims and medical data will enable startling insights about correlations that were impossible last year and will become routine the next year.
5. The line between insuring and providing will continue to blur. Insurers will provide care services that could be done by the providers in their networks, such as case management and home monitoring. In the meantime, providers will assume partial levels of risk that put them on the financial hook if claims expense exceeds target thresholds.
6. The advent of PCMH Ver 2.0 or rather Ver 2.a-z. The PCMH will remain more of a concept than any implementable or operational model of care. As the return-on-investment bloom comes off this rose in the many national pilots, its architects will appropriately scramble to tweak the model, perhaps by adopting some of the lessons from disease management. In the meantime, insurers will continue to be simultaneously pressured and stymied in their efforts to create a uniform benefit that includes a ‘PCMH.’
7. Social media will expand. Docs will ‘tweet’ each other in hospitals, insurers will push all sorts of web-enabled messaging and the disease management industry will find ever novel ways to combine industrial psychology with cell phone communications.
8. Little to no insurer consolidation. Barring the usual short-term hiccups, the fact that it will be a crime to not buy what the health insurers are selling will give all insurers some breathing room. For now. In the meantime, the health insurers will stick to their knitting: no new lines of business.
9. Republican allegations of the unconstitutionality of health reform bill will have legs. Speaking of which, the DMCB suspects there may be an outside chance that the courts will get in the way of a bill that requires U.S. citizens to buy insurance. Never mind this article in the oppositionally minded Wall Street Journal. The DMCB wouldn't have paid attention if the Manager’s Amendment didn't curiously have a lot of lot of language (starting on page 67) defending the constitutionality of the bill. Doth it protest too much?
10. The Electronic Health Record (EHR) will continue to disappoint. This one is easy, especially now that the same folks that brought us TARP, mortgage relief and undie bombs are involved.
3. The market has decided. Disease management will continue to thrive in its niche. Or rather multiple niches, offering a cafeteria-style suite of low cost and mostly remote care management, prevention and wellness offerings for commercial insurers and self-insured companies. Prevention and wellness will lead the way because most insurers and employers want it but few know how to deliver it. They already have the disease management and will want to keep it.
4. The growth of registries as a source of new medical knowledge. Sure, the academiverse will continue its infinite expansionism thanks to Federal funding bloat, but the rise of terrabyte servers containing all (and the DMCB means all) demographic, claims and medical data will enable startling insights about correlations that were impossible last year and will become routine the next year.
5. The line between insuring and providing will continue to blur. Insurers will provide care services that could be done by the providers in their networks, such as case management and home monitoring. In the meantime, providers will assume partial levels of risk that put them on the financial hook if claims expense exceeds target thresholds.
6. The advent of PCMH Ver 2.0 or rather Ver 2.a-z. The PCMH will remain more of a concept than any implementable or operational model of care. As the return-on-investment bloom comes off this rose in the many national pilots, its architects will appropriately scramble to tweak the model, perhaps by adopting some of the lessons from disease management. In the meantime, insurers will continue to be simultaneously pressured and stymied in their efforts to create a uniform benefit that includes a ‘PCMH.’
7. Social media will expand. Docs will ‘tweet’ each other in hospitals, insurers will push all sorts of web-enabled messaging and the disease management industry will find ever novel ways to combine industrial psychology with cell phone communications.
8. Little to no insurer consolidation. Barring the usual short-term hiccups, the fact that it will be a crime to not buy what the health insurers are selling will give all insurers some breathing room. For now. In the meantime, the health insurers will stick to their knitting: no new lines of business.
9. Republican allegations of the unconstitutionality of health reform bill will have legs. Speaking of which, the DMCB suspects there may be an outside chance that the courts will get in the way of a bill that requires U.S. citizens to buy insurance. Never mind this article in the oppositionally minded Wall Street Journal. The DMCB wouldn't have paid attention if the Manager’s Amendment didn't curiously have a lot of lot of language (starting on page 67) defending the constitutionality of the bill. Doth it protest too much?
10. The Electronic Health Record (EHR) will continue to disappoint. This one is easy, especially now that the same folks that brought us TARP, mortgage relief and undie bombs are involved.
Subscribe to:
Posts (Atom)