A New Term: Coordinated Delivery Systems. Better than Integrated Delivery Systems?

In a prior post, the Disease Management Care Blog described how Boeing was ‘assembling’ a medical home initiative. In thinking about this some more, the DMCB wonders if Boeing is assembling something far greater with important implications for population-based health care.

Large employers are increasingly becoming self-insured. To manage their insurance risk, they use a standard benefit, rely on a provider network, have wellness programs, may use prior authorization and/or concurrent review, contract an outside disease management vendor and, as Boeing demonstrates, are starting medical home projects. Considering the spectrum of need in an insured population, this is a reasonable approach, right?

The approach of employers (and many mainstream insurers, by the way) is not only to have those components but to sponsor interlocking combinations of wellness, prevention, episodic care, primary, secondary and tertiary care, chronic illness care management, complex care coordination and catastrophic illness care. In some areas of the country, a single source can provide the full spectrum of services. They are called ‘integrated delivery systems.’ In the remainder of the country, however, IDS are simply not available.

None of the above is necessarily news. What is news is the advent of an ‘outsourced and modular’ approach to health care that resembles the modern industrial processes. As mentioned before, many manufacturers in the U.S. have foregone ‘owning’ the entire factory and are instead relying on global network of suppliers who provide the ‘just-in-time’ components made to precise specifications. The result, in the case of Boeing, is a jet that really consists of parts (according to Wikinomics) that are practically ‘snapped’ together. The approach to health care isn’t turning out to be all that different. Employers are ‘assembling’ outsourced care components.

Note that in a typical supply chain, failure to deliver the components means giving up the business. The DMCB has watched employers literally fire health care entities and ‘insert’ new ones, much like swapping a turbine made by GE for one made by Pratt and Whitney. These employers are more than willing to ‘swap out’ hospitals, physician groups, disease management vendors and wellness entities based on price and outcomes. While the fired vendors have protested that this disrupts patient care, the vendors taking their place claim to have processes in place that will minimize the disruptions. In looking at the processes, they have a reasonable point.

The DMCB isn’t sure all this is necessarily bad. Integrated delivery systems’ transfer pricing and loyalty to their own systems don’t consistently translate into the best value for the health care consumer. Maybe an alternate approach is 'coordinated delivery systems' typified by the Boeings of this world. A quick Googling didn’t define ‘CDS’ in this new context: the DMCB would say these are organizations that hold the health insurance risk, have fiduciary responsibility for their enrollees, have separate access to all the components normally owned by an integrated delivery system and can force a market dynamic, mutual interlocking and substitution of the components in their health care purchasing decisions.

If Boeing is not alone in this new trend, the Disease Management Care Blog suspects CDS' (or what ever they are best called) will be a force to be reckoned with.

Physician-Patient Virtual Visits Part 2

In a prior post, the Disease Management Care Blog touched on the topic of 'virtual visits.' Check out this report from Spain. Teens are using Second Life to access health care advice. Wow.

The DMCB remains a fan of virtual visits. It suspects that in this instance, the physicians are already fairly compensated or, even better, providing the service as a public service. This looks reasonably user friendly. It may be one approach to health care disparities but IT access would be a barrier in the U.S. The visits are appropriately limited to a single topic area, making formal IT-based decision support & teaming less necessary. The lack of formal links to a medical record is what is sought by the users (obviously), which is not unheard of in this corner of public health. If this grows, expect ongoing studies to help us better understand its value.

Maybe the value proposition could be extended to chronic illness. As this evolves, the DMCB is really looking forward to seeing how Linden dollar fee-for-service or capitation would work. The spouse thinks her physician-husband should consider it when we have a Linden mortgage for the roof over our heads or can live off of Linden groceries.

The Disease Management Care Blog Interviews a Full-Risk Physician Group Medical Director: Does Disease Management Work?

The Disease Management Care Blog had the opportunity to chat with the medical director of a >300 doc California-based physician group that, aside from some high cost conditions like transplants, accepts full capitation from most of the state’s insurers.

It was an interesting conversation.

• Much of his day is spent in technology assessment, dealing with an insatiable appetite among his specialist staff for the purchase of new medical devices so they can perform gee-whiz procedures. He frequently has to say no.
  

• About 10% of his primary care physicians’ compensation is based on “pay for performance.” He has no doubt that it leads to physician behavior change. The P4P measures are all driven by the insurers and the extra revenue is in turn shared with the docs. He is aware of other groups that make 30% of the provider compensation ‘variable.’
  

• The DMCB asked about that thingy called ‘disease management.’ This physician group has it and the medical director is convinced it works. They’ve hired the nurses that deploy remote telephonic coaching to help them manage their capitation risk.
  

To put this into perspective, check out this article from more than 10 years ago in the Annals of Internal Medicine. What was true then is still true today: when physician groups take responsibility for the cost of health care, they often adopt the hard-nosed approaches ascribed to managed care. Disease management is a late arriving but powerful equal-opportunity intervention agnostic to the insurer-physician divide. In the population-based health care business, whoever provides the service with the best outcomes for the lowest cost to the consumer should win.

Let the games continue.

The Disease Management Care Blog Ver. 1 dot zero and a third

Disease Management Care Blog has been struggling with its HTML code. Google alerts pointing to the author or the blog itself have been curiously silent lately and attempts to ‘engage’ Google through its webmaster help boards have failed to exceed the DMCB’s customer expectations. However, at great risk, new code has been copied into the template and it will hopefully make some difference. Expect more changes in the future including search functionality and feedback surveys.

Call for Paragraphs

Have the itch to write but don't want to put up with paper media? Don’t have the time or an understanding spouse to start your own blog? This isn't the traditional call for papers, but paragraphs.

After reading the Disease Management Care Blog, readers should have a sense of the theme, style and possible topics. Send me your 3-5 paragraphs, don’t get mad if I don’t think it’s suitable and don’t mind if I offer some friendly editing – just like it’s done in the print journals.

The DMCB will be happy to consider posting your work and you’ll get as much credit as you desire. It promises not to have your work languish for 3-5 months awaiting interminable peer review and it won’t take 12 months to appear in print. While this won't catapault you into being interviewed for All Things Considered, being invited to speak at some swank D.C. venue or being on the cover of Health Affairs, I’ve seen CV’s with blog authorship listed – this is your chance. Just send an e-mail.

News About Healthways and Minnesota BCBS

If you've been a regular reader of the Disease Management Care Blog, this announcement from Minnesota BCBS shouldn't be a surprise. It's dropping Healthways as a supplier of disease management services. In a prior post (several paragraphs down) the DMCB first previewed the dynamics behind the decision, while in this post, it unveiled the results of a positive pilot involving a Medical Home partnership.

The DMCB still thinks the market is going to move toward various combinations of in and out sourced disease management components. In this instance, it suspects that Minnesota believes it can 'outsource' the more intense care management services to many of the larger physician clinics in its network while keeping the more 'scalable' telephonic services in-house.

It notes the article says the intent is to hire '90' nurses. That's a lot of coin. If that's price competitive with the contract price of Healthways' services, no wonder the disease management industry is thriving. It's also testimony to the cost of doing disease management with the right degree of infrastructure - and speaks volumes to the prospect of physician-groups affording to take on remote coaching.

It also believes there will be no 'single' best combination, since what works in the Twin Cities doesn't necessarily work in Phoenix. One of the major determinants of what combination works best will be the ratio of outcomes to price.

Can Minnesota BCBS execute? Time will tell.

May 12: Addendum. The link in the first paragraph went cold. It's been fixed to lead to another article. In the meantime, this article is helpful also.

How Can Health Information Technology Be Improved in Support of Chronic Illness Care?

It’s not every day that someone from the Department of Health and Human Services emails the author of the Disease Management Care Blog for recommendations, but that’s what happened. The DMCB was asked about enhancements to Health Information Technology (HIT) in the coordination of care for persons with chronic illness.

In this context, the DCMB thinks of HIT as a computerized health record (EMR, EHR or PHR etc) with a registry and decision support. With that simplistic generalization, it is happy to immodestly blog in with a bulleted summary of the recommendations below.

HIT is necessary but not sufficient. Even if near-term fixes in a) interoperability and b) competitors’ willingness to share data succeeds, there still isn’t a plethora of good evidence that upcoming versions of HIT will truly reduce costs or increase quality. Rather, HIT’s greatest potential lays in its support for other quality initiatives, including P4P, the Medical Home, CDHPs and Disease Management. It is the means to an end, not the end. Bottom line: ‘Cornerstone’ it’s not. Think mortar.

One reason why small physician groups have been reluctant to buy into HIT is because they bring their ‘front-line’ skepticism (some may say cynicism) in looking at its true value for their patients with chronic illness. Maybe they know something. CMS can always force the issue by regulatory fiat, but that won’t answer that nagging question: ‘where’s the beef?’ Bottom line: use your fiat power to also ask the HIT community to demonstrate it can deliver a tangible impact on outcomes in small group settings.

Limited (e.g., medication prescribing), cheap (not tens of thousands of dollars), modular (order entry this year, billing next year) and easy (plug and play) is more attractive than single solution, pricy, soup to nuts and complicated. Note that disease management vendors, in their eternal quest to achieve physician buy-in, are betting on the luster of turn-key web-based EMR solutions for their patients with chronic illness. Bottom line: accommodate the KISS concept in HIT.

[Sigh] RHIOs didn’t quite work out. The lesson is that parts of HIT may fail because there is still a market, albeit an imperfect one, that can separate the sustainable from the unsustainable. At a recent conference, the Secretary was heard to mention the interest of the Medicare program in “personal health records.” Uh oh. Bottom line: Keep in mind that the adage ‘don’t just stand there, do nothing’ can also apply to the world’s largest health insurer.

The notion of ‘medical records’ is changing. It’s no longer just provider-encounter and insurer-claims data, but the information being held by employers (e.g., sick days) and wellness (e.g., health risk assessments) and disease management vendors (e.g., the remote telephonic coaches record everything). The solution may be ‘personal health records’ but maybe not. Assuming they don’t achieve 100% penetration or 100% information capture, they’ll probably make things even more complicated. Bottom line: Update the existing HIT policies, requirements and protections to include these other emerging and disparate data bases.

Last but not least, the DMCB returns to the concept of ‘open data.’ Useful parts of beneficiaries’ patient clinical, pharmacy and financial data bases could be placed in the public domain for access by professional and amateur researchers. While this may be a radical concept, desk-top technology and the growing sophistication of researchers outside the traditional mainstream can generate insights on behalf of the public good. This is not an insurmountable concept if a) access is limited, b) if the right kind of patient protections are put into place and c) patients agree to it. Bottom line: join the open data movement.