Feedback on DM & PCMH Integration, Where the RNs Come From, Physician Reality Check & the CDE Roles

The Disease Management Care Blog wants to share some email feedback and insights from its recent talk at the Annual AADE Meeting. The email’s author is a registered dietitian with inpatient, large medical group and disease management vendor experience. She now works as a director of a diabetes management center – obviously someone with lots of ground level insight:

In its AADE presentation, the DMCB speculated that the future of population-based health will bring blended versions of disease management and the patient centered medical home. There’s gratifying agreement on that idea but the feedback below also notes there’s no underestimating the role of electronic records:

1. You are on target- that a “combined model”, is where things will go. Some unification of Population Health Management with the chronic care model/medical home would make sense- although the way to make it happen depends on an improved EMR to help with communication, and claims.

Wonder where all those call center R.N.s come from? The DMCB shared anecdotes about nurses being sucked out of local community hospitals. This is a reminder that there are other pools of qualified individuals who, by the way, are also navigating a very dynamic job market:

2. My experience at a “calling center”, early in my disease management career revealed RNs who were employed that would otherwise be on disability themselves or unemployed because they were no longer able to work in the hospital. The physical demands of the inpatient positions were beyond what they could meet. 50, 60, even 70 year old experienced RNs were working in the centers and helping health plan members from the telephone. Your comment about calling centers “sucking” the nurses out of the local hospital staffs was not accurate in my experience- where 70 RNs were in a center. It is also nice for RNs to have alternate career options, and can be productive despite their physical limits. That phenomenon may also vary depending on the geographical area. Hospitals are suffering nationwide & under a fiscal crunch like never before. The “culture” or environment working in a hospital is not the same caring one it once was. Business is in the face of healthcare each and every day. I imagine (because I am not an RN) all professionals in health care need to be flexible and able to adapt to a changing healthcare environment to a degree.

Uh oh, changing environment? As someone with a mom still proud of her son the doctor, the DMCB couldn’t help itself in its AADE presentation. It stressed the physicians’ changing yet still important leadership roles. Here’s a dose of reality: if physicians think they should command status just because they’re physicians, they may need to think again. The world is changing:

3. Historically M.D.’s have made more money on treating the ill vs. keeping people well. Today’s issues are perhaps a reflection of globalization of all economies- including medical care as a commodity. In Israel teachers are paid higher salaries than physicians. Wellness (lower obesity and less disease) in many other countries command a greater percentage of spending per capita than in the US. Other healthcare systems don’t spend too much in end-of-life care and instead invest far more in prenatal care. None of these common-sense approaches require a lot of physician support.

Well, this was an AADE meeting and my hosts were CDEs. But the DMCB was being more than just nice. It truly believes health educators, coaches, teachers, guides, helpers etc. are going to command a higher status (and compensation) in population-based approaches to chronic illness. It would appear, however, that the DMCB should do a better job of including all classes non-physician professionals in its comments. Furthermore, not everyone buys into the CDE certification process. Is there a role for less rigorously credentialed persons if the need for patient education is so pressing and outcomes are not all that dissimilar?

4 . You commented about the CDE as the “top of the food chain” for diabetes education- holding them at the highest regard- and you only included RNs in the reference. CDEs are also registered dieticians, pharmacists, social workers & other disciplines. And there is much literature on the shortage of diabetes educators in a large part due to the RIDICULOUS application process involved in obtaining a CDE, there are real administrative barriers to obtaining this specialty designation. Thousands of experienced clinicians provide diabetes education each day using the exact same teaching models and high quality comprehensive education and care. They should not be valued less in terms of care delivery. There are many people who practice as diabetes educators, have the criteria for applying to be eligible to sit for the exam- but say “why bother,” skills, are the same. My program’s and practice outcomes show my skill and my patient satisfaction scores are high.

Thanks for taking time to read this- & ps- my older son (age 14) wants to be a surgeon …

The DMCB thanks Eva Gonzales for the fabu email and the permission to share it. As for being a surgeon, the DMCB will share an anecdote: When a world famous internist came to give Grand Rounds at an even more famous medical center, the internist opened his erudite presentation by telling the audience a little bit about himself. ‘My grandfather was a surgeon,’ he said. ‘My father was a surgeon too, as was my uncle,’ he added. ‘My brother is a surgeon. But I pursued a career in internal medicine. You can see, therefore,’ he added after a pause, ‘that I was the first person in my family to be a doctor.’

completely random

1. When it comes to John Edwards and his affair, I am just about completely indifferent. Elizabeth, however, remains my hero.

2. I realize that I never did blog about meeting her at BlogHer last year. I'll have to do that.

3. I looked up the live-blog of my session at this year's BlogHer and found this. It feels a bit to me like she wasn't at the same session as I was. I remember lots of laughter and a mostly hopeful message. Am I being over-sensitive? Also, I thought live-blogging was meant to be straight-up recording not editorial comment. Feel free to set me straight on this.

4. I have been running with my ten year old son and my big dog. We are now at the place in our program when we run 8 minutes and walk 1 minute (twice) and then run for two minutes (for a total of 18 minutes of running). When I was diagnosed with mets, I threw out my running shoes, so sure was I that I would never do this again. I am so proud of myself and so happy to be running with my son.

5. Yesterday, in my son's absence, I decided to initiate the puppy to running. I had the big dog tied around my waist and held the leash for the little one in my hands. I looked like the crazy dog lady. I know that we have to be careful not to push puppies too hard but I am a VERY slow runner and I kept checking to see if she was flagging. After the run, I took her to the dog park and she tore around some more. I don't think that I pushed her too hard.

6. Today, a big dog walked up to me in the dog park and peed all over my legs and my nice red sandals. The owner was barely apologetic. I would have been mortified.

7. My spouse and I are giving his cousin some wine as a wedding present. We have been using this as an excuse to do our own wine tasting. We currently have three open bottles, going to vinegar.

8. When I won the DS at BlogHer, I thought I would just give it to my kids. Who knew there were such fun games for adults? The game came with a crossword game (I am hooked on the anagrams) and I got two more brain enhancing games for my birthday. It turns out that I am not very smart. And I am having to ration my game time.

9. I wanted Katee to win So You Think You Can Dance. Joshua was my second choice, though, so I'm OK with that. I started watching by accident when they were at the Top Ten. I was quickly hooked. I hadn't actually watched any TV in months.

10. My book just came from my editor. It's time for my last crack at revisions. She was happy with it, thank goodness. I have been glad for the break from it and feel ready to get back at it.

11. What I really feel like doing is walking the dogs, knitting, eating and reading. Oh and hanging out with my family, too.

12. Thanks for all the birthday wishes. It really was wonderful. I slept in, ate lots of goodies and spent time with some people I really love. Great day.

America's Uninsured. A Reality-Based Six Point Counter Proposal

In a prior post, the Disease Management Care Blog reviewed an Annals of Internal Medicine report by Wilper and colleagues on the 25% prevalence of chronic illness among America’s uninsured. An accompanying editorial (subscription necessary, but don't bother - you'll see why soon) by Marshall Chin of the University of Chicago's Land of Make Believe dismisses the idea that extending health insurance to this group as necessary but insufficient.

Drawing on the science of quality improvement, reports from the Robert Wood Johnson Foundation and experience from the Health Disparities Collaboratives from community health centers, Dr. Chin recommends instead that every practice, every hospital and every health plan also 1) analyze quality performance data by race, language and socioeconomic and insurance status, 2) implement training programs in responding to diverse populations, 3) routinely measure reductions of inequities of care, 4) adopt clinic-based models of care that have been shown to improve care for vulnerable patients, 5) smartly align incentives that reward providers and organizations for providing care to vulnerable populations 6) allocate the resources by paying providers, especially those have a disproportionate share of uninsured persons, including ‘efforts to create and certify patient centered medical homes….’

The DMCB thinks the editorial itself is well intentioned yet insufficient. Here’s why:

While the devil is in the details underlying the content and delivery of any quality improvement activity, its impact on (for example) provider behavior, diabetes control or quality of care for the elderly is far from a sure thing. The DMCB also had little trouble finding references here and here suggesting the impact from 'collaboratives' outside of community health centers is less of a slam dunk that its advocates would have you believe. The other recommendations above are worn out nostrums of dubious evidence based on an antiquated focus on physician-centric care.

Disappointed yet undaunted by the inability of my academic colleagues to cross over from their parallel universe of contented salaried physicians, grants and tenure tracks, the DMCB would like to offer its own, if admittedly politically naïve, 6 point approach to meeting the goal of the Annals editorialist: improving care and outcomes of uninsured persons with chronic disease….'now’:

1) Develop a stripped down insurance benefit that covers that which is patently medically necessary. One could start by covering services recommended by the U.S. Preventive Health Services Task Force along with a representative standard benefit, probably with mental health parity. Assuming local or regional insurers take this on, the Feds or some other entity may need to help with reinsurance.

2) Pull out all the stops of utilization management including pre-authorization, concurrent review and denials of payment for services that require approval, specifically targeting the usual suspects: those notorious outpatient procedures, high dollar radiology and the biologicals.

3) Accept the high likelihood that extending insurance coverage to a group with a 25% prevalence of chronic illness is likely to result in costly health care utilization that will be borne by the taxpayer or add to deficit spending no matter what you do. While this is a stretch, Governor Rendell of Pennsylvania teaches us that taxpayers will accede if a) you’re up front with them and b) they believe they are getting their money’s worth.

4) Deploy disease management programs, especially ones with the years of experience in Medicaid, to temper the inevitable demand for health care services by coaching patients to use the most cost-effective care options, including self-care. And face the ugly truth: the patient centered medical home is just getting off the ground and doesn’t have the mass or scalability to carry this out. Helloooo, it's also being 'piloted' everywhere because it's unproven.

5) Start out by paying the primary care physicians, and we're not talking penurious RVUs either. Since primary care is in short supply in many areas of the United States, programs that offer alternate levels of care including non-physician practices and retail clinics will be necessary. Without it, emergency room use for persons with their new-found insurance will not only increase, it will go through the roof.

6) This is an area ripe for trying even more novel approaches to care such as upside gain sharing, combined disease management-patient centered medical home strategies, community-based lay educators, consumer incentives and private-public partnerships.

No Silver Bullets, Lots of Shortcomings

Goodness gracious. If you think you have a good idea when it comes to solving the twin dilemmas of cost and a quality for chronic conditions, ‘tis the political season. While the Disease Management Care Blog thinks the short term prognosis for meaningful health care reform is poor, that doesn’t mean it’s not smart to get your proposal out there and on the table in the next 85 days. Just in case.

As a public service, the DMCB would like to offer these two Rules for Promoting Your Good Chronic Condition Care Idea:

1. Cast It As A Leading Domestic Policy ‘Silver Bullet.’ Yes, we know chronic illness care is an impossibly obscure tangle of insatiable demand, State and federal regulations, complex actuarial principles, relentless demographics, burgeoning technology and county-by-country variation. That complexity combined with an impatient hunger for reform is the perfect setting for the simplistic Good Idea that offers to cut through the clutter. For examples outside the health policy sphere, think ‘school vouchers,’ ‘flat tax’ or being willing to ‘take a paternity test.’

Examples of Chronic Care Silver Bullets: The electronic medical/health/personal record, pay for performance, single payer system, disease management, health savings accounts, patient centered medical home and an individual insurance market.

2. Do Not Mention Shortcomings (other than cost): Not only will you tarnish the Good Idea and diminish its chance of adoption, we all have a limited attention span that is simply unable to tolerate it. It is OK, however, to mention the cost of [insert a number from 1-100 here] [insert prefix of bil, tril or gazil here] lion dollars because we’ve become used to similar-sounding amounts being spent on Iraq, mortgage lenders and botox.

Examples of shortcoming to not mention: that electronic records can introduce new types of errors, P4P can incent processes not outcomes, single payer systems are notoriously difficult to modify, disease management may not work for all populations, ‘cost sharing’ may really mean ‘cost transfer,’ patient centered medical homes are being piloted (research), not adopted (covered by insurers), many persons with chronic illness are uninsurable and that cost effectiveness studies rely on unfamiliar concepts like QALYs. Mention these and your Silver Bullet will be tarnished.

Examples of excellent SBNS (Silver Bullet, No Shortcomings) rhetoric (italics mine):

From the McCain campaign:

'By emphasizing…..the use of information technology, we can reduce health care costs.'

‘Those obtaining innovative insurance that costs less than the credit can deposit the remainder in expanded Health Savings Accounts’

‘Families should be able to purchase health insurance nationwide, across state lines.’

And in the cost is no object category:

‘…establish a nonprofit corporation that would contract with insurers to cover patients who have been denied insurance and could join with other state plans to enlarge pools and lower overhead costs.’

And from the Obama campaign:

‘Support disease management programs. Seventy five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease and high blood pressure.’

‘Providers….will be rewarded for achieving performance thresholds on outcome measures.’

‘…establish an independent institute to guide reviews and research on comparative effectiveness.’

And in the insert number, insert prefix category:

invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records

Late Friday Post. Some News Items

Late. The internet service provider failed to exceed the Disease Management Care Blog’s customer expectations today.

Since the DMCB can't quite get to turning off the computer on this Friday afternoon, briefly:

In a prior post, I announced that Vince Kuraitis and I had presented a Webinar on the Patient Centered Medical Home. You can get a summary and a copy of the slides we used at Vince's most excellent e-CareManagement blog.

Speaking of presentations, the DMCB had the pleasure of talking about “Primary Care, Populations and Educators: What You Need to Know” at the annual American Association of Diabetes Educators (AADE) meeting in Washington DC. This was a huge meeting that filled the Washington DC Convention Center. Very impressed with the infectious energy and enthusiasm, DMCB came away with new insights that it’s saving for a future post. If the United States can channel the common sense and ‘can-do’ spirit of this community of professionals, the cost and quality challenges of diabetes can only improve.

Bob Wachter has a July 25 posting over at The Health Care Blog that echoes the DMCB’s prior comments on the emergence of efficient on-line reporting of scientific results versus traditional paper journals and their information monopoly, hidebound review processes and unfair copyrighting. No skepticism here.

Members of the disease management community are well aware of Dr. David Nash and successes of the Department of Health Policy at Thomas Jefferson University in Philadelphia. In recognition of the Department’s considerable accomplishments and the growing visibility as well as importance of population-based health care, the Department has been elevated to School status. Congratulations to Dr. Nash, his colleagues and to the arrival of even more scientifically rigorous and academic disease management. We are all off better for it.

The DMCB confesses to a morbid interest in the recent we-may-have-a-culprit news in the Anthrax attacks. Mainstream print and radio reports may taste great, but the prize for the most filling and complete information fix goes to Barbara Martin’s review of the evidence in this post at Pathophila. SNR markers, types of envelopes, two-not-one spore batches and the likelihood of intentional sabotage certainly put a new light on the assertion of some that the case is not ironclad. The DMCB suspects a jury of scientists would have voted to convict.

And last but not least, you think that because you spend a lot of time on the phone that you're skilled at managing all those buttons? Think again. The DMCB hopes this is not a video of a DM call center nurse with too much down time.

This is What a Real Cost/Quality Decision Looks Like

The UK's National Institute for Health and Clinical Excellence (NICE) has decided in a preliminary ruling that four drugs used for the treatment of advanced kidney cancer are not effective enough and they won't be paid for by the National Health Service.Now before someone just claims this is what single-payer health care plans do all the time, let me be clear that NICE is an organization that has

The Voters Aren't Upset Enough About Health Care--And Why Should They Be?

The health care issue has a history of being named by voters as one of the biggest problems we face--until the problem de jour comes along and pushes it off the list. In 2008, that seems to be happening again with the economic downturn, the mortgage mess, and $4 gas surpassing health care as the big issues.When asked to name the most important financial problem facing families today by the Gallup