The Incremental Approach to Disease Management: Hare or Tortoise Approach?

The Disease Management Care Blog made its acquaintance today with a SGIMite (which is always a pleasure because they're really smart) internist-physician who led the creation of a Canadian regional nurse-centered disease management program. His story had an important insight about the creation of disease management/care management population-based programs.

They take time.

As the DMCB understands it, this physician approached a regional home nurse agency years ago with a proposal: dedicate a small number of nurses to a new initiative called disease management. He had a small budget that reimbursed the agency for a part of the cost of the nurses' salary and benefits. These nurses were then tasked with conducting patient outreach involving a limited number of primary care sites. The physicians were suspicious, but with time, the nurses gained acceptance. There were adjustments, but preliminary success led to additional funding in small amounts from various public and semi-private sources, which led to the hiring of additional nurses, the involvement of more physicians, with greater success which led to more funding....

While the DMCB will be finding out more details behind Calgary's Disease Management Program (it will hear a formal presentation tomorrow), the story is consistent with other successful "build your own" care management programs that the DMCB has seen: it takes years.

This approach, of course, contrasts with classic carve-out commercial care management programs, which can implement full programs in a matter of months. While that's an important strength, the DMCB wonders if gradual intrusions into a physician network in a slow one-nurse-at-a-time manner is a 'hare versus tortoise' case study. Making the countless local adjustments, achieving physician buy-in and easing in adequate funding from multiple sources may ultimately be a better approach than dropping a one-size-fits-all program on an unsuspecting physician network with a sticker-shock multi-million dollar budget. All health care is local and physicians need time to adjust.

This may account for some of the travails of some of the for-profit disease management programs with grumpy physicians and gimme-a-one-year-ROI Chief Financial Officers. It may also account for the success of the disease management programs of the large integrated delivery systems, who are in this for the long haul.

The key to physician support may come down to simply taking your time. Launching a big pre-fab disease management program isn't necessary a bad idea, especially since many of them do a good job of anticipating local practice patterns and culture. However, the Canadians are teaching the DMCB that go-slow approach may have better staying power over the long run.

The Latest Health Wonk Review Is Up!

D. Brad Wright of the Cecil G. Sheps Center for Health Services Research (where the DMCB did a fellowship program) keeps a blog called Wright on Health and does a simply outstanding job of hosting the latest Health Wonk Review. Titled the Kabuki Theater Edition, it is an ably written summary of the best of the best of the recent health policy blogging out there. If you agree that you can't rely on mainstream media to give you the insights you need to understand health reform, you owe it to yourself to check it out.

A Summary of the Latest Population Health Management Journal

The Disease Management Care Blog is broadcasting live tonight from Ottawa, a beautiful city that reminds the DMCB of a private U.S. college campus, only with more traffic. When it passed through Canadian customs, it had three key items in its possession: 1) a U.S. passport, 2) a declaration form and 3) the latest issue of the Population Health Management Journal.

The DMCB knows many of its readers travel also, but they have to use the time trapped in planes, trains, automobiles and airports participating in conference calls while perusing spread sheets, business plans and policy changes. The DMCB feels your pain and comes to the rescue with this very efficient summary of the latest PHM contents. Check it out and decide which articles deserve a closer look when you have the time......

Burton WN, Chen C-Y, Schultz AB, Edington DW: The Association Between Achieving Low-Density Lipoprotein Cholesterol Goal and Statin Treatment in an Employee Population. This study tapped the database of 1607 employees of a large unnamed financial services company who underwent 'executive physical examinations' between 1995 through 2004 that included blood cholesterol testing. 150 of these individuals had filled at least one prescription for a cholesterol lowering drug in the year preceding their last executive examination. While the authors found an unsurprising association between the 'medication possession ratio' (or MPR) and the 150 subjects' cholesterol levels, the most interesting statistic was that only 68% of these individuals filled enough prescriptions to achieve a MPR of 80%. Once again, the science of population-based care management demonstrates that it takes more than a) a doctor telling you to take your pills and b) economic well-being to take full advantage of a medication class that saves lives.

Fayssoux R, Goldfarb, NI, Vaccaro AR, Harrop: Indirect Costs Associated with Surgery for Low Back Pain - A Secondary Analysis of Clinical Trial Data. 150 patients with unremitting back pain were randomly assigned to one of two surgical options: a standard anterior lumbar interbody fusion with a 'cage,' versus a "Charite" artificial lumbar disc. In this analysis, while the authors had a passing interest in comparing the clinical outcomes of the two groups, what caught the DMCB's attention was how long it took for the participants to return to employment. The bottom line is that 55% of individuals were working prior to surgery, this dropped in the weeks following the operation to about 24% and then slowly climbed over two years to about 63%. If you've paid any attention to what workman's compensation experts say, you won't be surprised that regression analysis showed that the greatest predictor of returning to work was being employed prior to surgery. By the way, the DMCB also points out that other studies have shown conservative non-surgical treatment generally results in the same outcomes over the long term. The DMCB thought this article was a good example of how collecting more than traditional "clinical" outcomes data in patients like this can yield rich insights about the expected time to recovery. To employers and patients, these are the outcomes that count.

Bolge SC, Joish VN, Balkrishnam R, Kannan H, Drake CL: Burden of Chronic Sleep Maintenance Insomnia Characterized by Nighttime Awakenings. The sleeping pill manufacturing pharmaceutical industry has been conducting and sponsoring research for years showing that there is an association between sleep disturbance and quality of life. This is such a study, based on a web based survey called the 2006 U.S. National Health and Wellness Survey (NHWS). Of 62,833 respondents, 2% had 'chronic insomnia characterized by awakenings' or CINA. These insomniacs, compared to persons reporting no sleep problems, had more emergency room visits, days in the hospital, visits to physicians, greater unemployment, higher levels of absenteeism and greater 'activity impairment.' None of this is surprising to the DMCB, but it still isn't sure of the directionality: does insomnia "cause" greater insurance claims expense, or does being ill with greater insurance claims expense cause insomnia? Based on this study and others like it, the DMCB still thinks that managed care organizations have reason to be skeptical that disease management sleep programs and/or liberal pharmacy benefit coverage of sleeping pills will help "bend the curve."

Diette GB, Orr P, McCormack MC, Gady W, Hamar B: Is Pharmacologic Care of Chronic Obstructive Pulmonary Disease Consistent with the Guidelines? The authors in this study looked at the claims data base of a "large managed care organization" with 2272 individuals with at least one claim for a provider visit for COPD. Physician prescribing of the various types of inhalers and pills used to treat this condition were all over the map, so the answer to the title of this article is quite consistent with what other studies have shown: "no." Of special interest is a potential benchmark statistic for those of us working in this field: of the persons with a history of one or more exacerbations of their disease that required a course of oral corticosteroids (the last line of defense before putting someone in the hospital), only about 63% had filled a prescription for an inhaled corticosteroid medication. This class of drugs, otherwise known as "ICS," has been showed to prevent the kinds of exacerbations that lead to oral corticosteroids in the first place. This may be the Holy Grail of COPD disease management: getting 100% of patients with "bad" COPD to regularly use their ICS so they don't have to be exposed to the risks of taking oral steroids.

Elliott JP, Desch C, Istwan NB, Rhea D, Collins AM, Stanziano GF: The Reliability of Patient-Reported Pregnancy Outcome Data. If you are running a disease management program and, like all good disease management programs, you want to follow outomes, should you go to the time and expense of requesting and going through copies of the medical records, or can you get away by simply calling the patient and asking what happened? Well, when it comes to pregancy outcomes, this study of 285 high risk moms showed having a nurse call and interview the patient yielded a high 'kappa statistic' when matched up against the patents charts. Yet, while it works in pregnancy outcomes, the DMCB isn't too sure the same is true for other conditions. In addition, the advent of electronic health records and functional registries may eventually lead to another question: does relying on remote electronic access of provider records perform as well as the relatively time-consuming patient interview?

Goldberg SW, Mulshine JL, Hagstrom D, Pyenson BS: An Actuarial Approach to Comparing Early Stage and Late Stage Lung Care Mortality and Survival. Count on those crazy actuaries to examine lung cancer death statistics in the Surveillance, Epidemiology and End Results (SEER) database to come up with a new point of view about early lung cancer detection and survival. When segmented by age, gender and race and compared to persons without lung cancer, it appears being lucky enough to have an early diagnosis of your cancer is associated with a significant survival advantage. The authors also accounted for 'lead time' bias in their analyses to stand by their conclusion that early detection of lung cancer could lead to saving 70,000 lives a year. The DMCB still isn't too sure because a) the article isn't easy to read and b) in addition to lead time bias, some tumors are slow growing, not necessarily detected earlier. When you sit down to read this one, be prepared to go over it several times. The DMCB is going to read this again on the flight back home. It's just not sure if the accompanying beverage will contain caffeine or ethanol.

Twells LK, Knight J, Alaghebandan R: The Relationship Among Body Mass Index, Subjective Report of Chronic Disease and the Use of Health Care Service in Newfoundland and Labrador, Canada. The DMCB suspects, thanks to Canada's health care system, that patients with chronic illness ar more likely to be 'funneled' to a primary care provider and experience queues when it comes to specialist and hospital services. That appears to be the case in this population-based Canadian Community Health Survey (with an impressive reponsive rate of 85%), which found our neighbors to the north have a 17% obesity rate, that those individuals had a greater burden of chronic disease, see primary care physicians more often but don't necessary access other parts of the system with greater frequency. This study would appear to confirm what we already know about obesity and health 'systemness.'

Six Reasons to Think Twice About Hospital Payment Bundling and the Role of Population-Based Care/Disease Management

The peripatetic Disease Management Care Blog decamped to the back of the Philadelphia Marriott Conference 4th Floor Room Franklin 9-10 and sat in on the final event of the Disease Management Colloquium today. This last session was a wide ranging panel discussion that addressed a number of hot reform topics, including the ingredients that comprise state-of-the-art primary care, the role of Washington DC in the regulation of health insurance premiums, physician liability insurance reform and provider payment systems. It was all great stuff, but it was the talk about money that really made the DMCB’s ears perk up, especially because it dealt with a topic that has largely gone unexamined in this blog: ‘bundled’ hospital payments.

Readers may recall this notion arose largely in response to the problem of an average 20% readmission rate for Medicare beneficiaries who have been discharged from a hospital. Since hospitals can financially benefit from those readmissions, the concept of ‘bundling’ was invented. The good news is that bundling pays for a hospitalization and for all the necessary post-discharge care for a period of time (for example, 30, 45 or even 60 days). The bad news is that the bundling doesn’t pay for a readmission if that becomes necessary during that same period of time. Fans of bundled payments like it because the up-front extra payment should incent hospitals to dedicate resources to helping reduce avoidable readmissions. That's why bundling is one ingredient in the Democratic health reform proposals.

The details of bundling are important. The DMCB points out that the fair calculation of the amount of the bundled payment should include 1) the cost of the original admission, 2) the cost of the extra hospital resources (for example, case management and home monitoring), 3) the post-discharge provider care (such as the physician appointments), 4) some reasonable profit margin and, 6) last but not least, the cost of the unavoidable readmissions. The DMCB suspects a lowest a readmission rate can go to is around 8% of hospital discharges (if anyone knows of a lower rate, please share)

With that as background, readers may think this is a grand idea and another reason to support the Democratic vision for health reform. That may be true, but until the Colloquium, the DMCB hadn’t heard the arguments against the idea, which are outlined below. They’re not only worth consideration, but they're a handy way to upend any smug friends, family or colleagues who believe that Mr. Obama’s proposals represent an unassailable intellectual achievement with no unintended consequences:

1. Most hospitals just don’t have the necessary data management infrastructure: building or buying the post-discharge care in its myriad forms, managing the underlying risk transfer, understanding the co-morbidities of the patients and appropriately configuring all the interventions in a complex ecosystem of outpatient services is a very information-intense exercise. This is simply out of reach for the average hospital Board of Trustees, CEO, Director of Nursing and Chief of Staff.

2. Most hospitals also don't have the personnel or the expertise: even if they understood what needed to be done, the how behind creating and maintaining care management programs (job descriptions, work flows, policies and procedures etc) and building provider alliances would be very daunting.

3. This presupposes that the original admission was necessary in the first place: there is enormous regional variation in the decision to admit to a hospital. Bundled payments would simply enable more of the same shenanigans.

4. This could easily fail: there is a very real possibility that abundant optimism combined with budgetary shortfalls could lead to a public payer ‘perfect storm” that squeezes bundled payments and leaves vulnerable hospitals in the lurch. A potentially good idea could be set back years if it had to be repealed.

5. Actuarial neutrality: This was only brought up indirectly in by the Panel, but the DMCB thinks that the sausage making of bundled payments will end up somewhere between covering only the necessary services and nothing more on one end and covering what is happening anyway on the other end. Since this may ultimately just be a reshuffling of the money, the panel pointed out that post-discharge care coordination works well enough as a stand-alone initiative (for example, here, here and here). Why not just pay for it and be done with it?

6. Bad behavior: This wasn’t brought up by the panelists, but the DMCB wonders if hospitals could end up with a financial incentive to deny inpatient care for patients that genuinely need to be readmitted to the hospital. After all, bundling sure looks like a form of capitation and we know how the physicians responded when they were forced to accept bad incentives. Could a hospital send someone home from the ER with advice to take two aspirins and call in the morning?

The DMCB also notes that much of the downsides described above can be amply mitigated by population-based care management. In fact, any literature search on post-discharge care coordination is likely to yield multiple articles that include the term 'disease management.' The DMCB says why not? Once again, non-physician professionals to the rescue with remote or in-person tailored interventions that can help persons and their family become experts in self-care. 'Nuff said.

The good news is that that the Democratic Senate bill appears to either 'pilot' or 'demo' the bundled payment concept. The DMCB hopes, after listening to this panel, that if health reform passes, that these six cautions and the role of population-based care management are closely examined before the HHS Secretary decides to implement it nationwide.

Selected Quotes From the 10th Population Health & Disease Management Colloquium

The Disease Management Care Blog spent a very long but intellectually rewarding day listening to speakers at the Population Health and Disease Management Colloquium. It was much like a health care policy mall with something for everybody. While the DMCB is still digesting it all, here are some eminently quotable insights with attribution (whenever possible) that may be of interest:

"Right now, care coordination is only available if there is a specific condition and the person is insured by a specific plan, or if the person is part of a public health program or an experiment." So said Richard Wender, MD, Chair of Family Medicine at Jefferson.

"Good transitions of care involve not only the safe movement of the patient, but the successful hand-off of all their information also." This is courtesy of Thomas Wilson, Ph.D of Trajectory Healthcare, who is also working on how to measure this (hint: structure, process, outcomes and attributon).

"It's not 'health information technology' anymore, it's health improvement technology." Dennis Schmuland, MD, National Director at Microsoft who also showed us how a computer controlled avatar can be capable of holding a spookily real "live" conversation with you, such as the problem of an elevated blood sugar and how to treat it.

"It's all about C4 healthcare ecosystems (convenient, connected, coherent and cost-effective) with P4 (predictive, personalized, preventive and participatory) care for E4 (equipped, enabled, empowered and engaged) consumers." That's from Gordon Norman MD of Alere.

"Whatever happens with health reform, wellness and prevention are underway." So says Fred Goldstein of U.S. Preventive Medicine, who believes it's reached a tipping point.

Then there is this piece of insight from a wise colleaque during a hallway conversation: "Self-pay health consumerism is going to take off because of a) impatience with and b) distrust of commercial and government-run insurance programs."

"The liklihood of health reform passing is 60%." This prediction is from Susan Dentzer, the Editor of Health Affairs. The DMCB wonders why the intrade information market says otherwise.

When asked about physicians that are reluctant to transform their practices into patient centered medical homes, the same Gordon Norman (linked above) offered this astute solution: "Fine, let the nurses do it." The silence in the hall was telling.

Lance Lang, MD of Health Dialog pointed out "that the population-health/disease management companies can fulfill the role of extension agents" extolled in Atul Gawande's article on transforming primary care practice.

And finally Sean Sullivan of the Institute for Health and Productivity Management looked forward to the day when companies "will not only report cash flows, profit and losses as well as balance sheet data, but will also report on the health status of their human capital," perhaps by using this metric.

After the Failure of Reform

After the Failure of ReformbyBrian Klepper and David C. KibbeThe stalemate in the bi-partisan health care summit was cast the moment it was announced. Republicans demanded that the reform process start anew, and Mr. Obama insisted on the Senate bill as the framework going forward. The President may now offer a more modest reform bill that can demonstrate some progress on the health care crisis,

quality of life

I just returned from the 10th Annual Conference For Young Women Affected By Breast Cancer in Atlanta.

I am so tired I can barely see straight.

It was a terrific experience and I really learned a lot but I'm feeling too brain dead to share any of the many stories swirling around in my brain.

Instead, I'll share some notes I took from a presentation by Dr. Julia Rowland, director of the National Cancer Institute's Office of Cancer Survivorship, called "Living Fully Is The Best Revenge."

In particular, Dr. Rowland shared with us the "factors associated with quality of life outcomes" - the things that need to happen for those of us who have had cancer to live long and well. My editorial comments are in brackets.

1. Accessing state of the art care (well, yeah).

2. Social support (having it and using it).

3. Finding or having a sense of purpose or meaning in one's life.

4. Learning to express oneself.

I think that these factors apply to quality of life for anyone, not just someone going through cancer treatment.

I'll be back on the other side of chemo.