"Lipstick on a Pig"--The McCain Campaign is Defining the Fight

The quickest route to a political loss is to let the oppostion define the fight.Anyone who listened to just 10 seconds of the Obama "lipstick on a pig" sound bite knows he wasn't talking about the Alaska governor.But what this whole dust-up tells us is that the McCain campaign is defining the debate and the Obama side can't get their message out.Not that long ago the Obama campaign was

a random kind of day

I'm sitting on the couch with a coffee as both dogs snore beside me. I seem unable to focus on any one thing today so it seems like a good time for another "random" post.

1. I pressed send on the latest round of changes to my book on Monday afternoon. That felt pretty good, I can tell you. And I have only had to send three different versions of the acknowledgments as I keep finding mistakes.

2. When I went to pull together the photos that I want to include in the book, I discovered that they are gone. Apparently, when we backed up "My Documents" to a hard drive before re-formatting my computer, it copied everything but the "My Pictures" folder. Many are on Flickr and the blog but the resolution is not so good. And, what's more, there were hundreds of photos that I have never posted anywhere. I am heartbroken.

3. I forgot to tell you about this post, called 'The Empowered Cancer Patient' that I wrote for MyBreastCancerNetwork.Com. I need to start remembering to link back to this blog in those posts.

4. I rode my bike to an appointment yesterday (30 minutes) and home again. This involved what felt like an enormous hill (up Carling, just before the Civic Hospital, if know Ottawa). And aside from my bag flying off the carrier twice (I have since figured out a better way to secure it), I did pretty well. I feel pretty proud of myself. And my ass is only a little sore today.

5. On the ride home, the skies opened up and it started to pour. One of those weird rains with really big, cold drops and the sun still out. As I cut through a park, pedalling furiously, I passed a young guy, dressed all in black (including his hat) who had stopped his bike just off the path to enjoy a smoke. He seemed oblivious to the torrential rain. Some day, I am going to incorporate him as a character into a short story, I think.

6. My poor little puppy has a cold. Her nose is runny and she is sneezing a lot. Otherwise, she seems more or less unaffected. The vet has put her on a course of antibiotics, in case this viral infection puts her at risk of something bacterial (given her developing immune system).

It doesn't seem to have affected her energy level. She still sleeps all morning and then revs up later in the day. She likes to pick things up and carry them around the house, especially stuffed animals and shoes.

She hasn't destroyed anything (both the late lovely Emma and J-Dog chewed their way through many a shoe and other items when they were puppies. J-Dog ate a camera) but she likes to take the shoes and boots out of the closet (no, I didn't put them away in the spring) and leaving them strewn around the house. As I type this, my slipper is sitting in the middle of the living room. I have no idea where to find its mate.

I have also really fallen down on the grooming and she's looking pretty scruffy. Although not as ratty as these photos, taken at my in-law's cottage last month, would suggest.




This is Stella, Lucy's litter-mate. Don't let her diminutive size fool you. She is the alpha in this equation.


The puppies' breeder captioned this one, "Whatcha wanna do now?"

Note how my pup appears to be a hulking monster beside her sister.

I will try and take a pic of her looking her best, if I ever get around to bathing and brushing.

7. Have you noticed that my photos have been a little washed out of late? I am not sure if it has been handled too roughly or dropped too many times but I find that my pics all look like they were taken in the 1960's. Any thoughts on how to fix this?

8. I have been seeing a 'Life Coach' since January and the process has been transformative. I had a great meeting with her yesterday. And she suggested that I give myself some time before jumping into the next project. I need to create a little space to breathe for a while.

We agreed that this is not so easy. I do have kids, dogs, an elderly cat and a sink full of dirty dishes. She challenged me to do what I need to do but do one thing at a time and do it well. I also need to spend time less time in "avoidance" activities ( You know what I mean - when you stay in bed with the covers over your head when you're really not sleepy or when you engage in junk internet surfing, googling obscure terms or reading celebrity gossip blogs. Or maybe that's just me) and make the time to do the things that fill me up and inspire creativity.

I need to report back to her in two weeks about how I've managed to achieve this.

I'll let you know how I do, as well.

The Patient Centered Medical Home for Chronic Illness: The DMCB Asks (and Answers) in Health Affairs: Is It Ready for Prime Time?

If you didn’t have enough reasons to subscribe to Health Affairs or regularly check their web site, here’s another: the Disease Management Care Blog has landed a publication in that staid prestigious journal. No longer encumbered by a news embargo, the DMCB sallies forth with the announcement about a “Perspective” piece entitled “The Patient Centered Medical Home for Chronic Illness: Is It Ready for Prime Time?” in the September/October 2008 issue. It’s a response to a very scholarly work by the Urban Institute's Bob Berenson and colleagues appearing in the same issue, who present some interview-backed insights on how physicians and Patient Centered Medical Home (PCMH) advocates agree and sometimes disagree on just what the PCMH will accomplish.

In its article, the DMCB notes the PCMH has great promise but has three challenges to address before the health care system should dive in and begin widespread implementation. They are:

1) Varying definitions of the PCMH across real world clinical settings. Close scrutiny of the underlying literature shows there is a surprising degree of variation in the implementation of the medical home and chronic care model in clinical settings. What’s more, there is little evidence that locating all or some of the elements of the PCMH in the primary care site results in better patient care than, say, letting it reside in managed care or disease management.

2) Limited scalability outside of Medicaid programs, publically funded clinics, pediatric or psychiatry setting or integrated delivery systems. In looking at the literature, experience in implementing the PCMH in smaller physician-owned practice settings is quite limited. The evidence that does exist suggests uptake can vary considerably from clinic to clinic.

3) Scant documentation of cost savings. There is peer-reviewed evidence that many of the individual components of the PCMH may reduce claims expense but there is scant evidence that the PCMH as currently conceived will routinely achieve meaningful savings in commercial insurance programs or in the Medicare program.

Until current and future pilots address these three challenges, the DMCB suggests the answer to the above question is ‘not yet.’

Health Affairs will hold a briefing on the issue on Sept 10, 2008 at 9 AM at the Willard InterContinental. The DMCB was invited to go and it cannot resist. More posts on the topic to follow.

Disease Management - Patient Centered Medical Home Collaboration

The Disease Management Care Blog listened in on the DMAA web cast by Paul Grundy MD of the Patient Centered Primary Care Collaborative and Bruce Bagley of the American Academy of Family Physicians.

It liked what it heard.

Dr. Grundy went first and angrily declared U.S. health care purchasers are buying ‘garbage.’ He asserted the U.S. has been dead last in quality and expense in the world thanks, in part, to the 'immoral' disintermediation of the primary care physician-patient bond. Primary care needs to be resurrected. To make that happen, buyer-primary care physician 'covenant' needs to be reestablished. The docs themselves will also need to get some religion about value-based systems of care. That will require a host of blended payment reform interventions that lead to primary care site teaming, electronic data systems and decision support. In other words, it will take the patient centered medical home or PCMH. So far so good.

Dr. Bagley was less evangelical. If primary care is going to be continuous, comprehensive and personal, says he, it will need to adopt:

1) teaming with shared responsibility with awareness of mutual strengths that results in human resources greater than the sum of the FTEs,

2) registries (clinical data bases that monitor essential care elements and facilitates active management)

3) care coordination ‘microsystems’ that foster the right care at the right time,

4) ‘built in’ quality measures and reporting,

5) leverage of community resources including support services, family, disease management organizations and home health

6) self management support, which is NOT education but enabling patients to achieve informed medical decision making free of provider bias.

So far so good, but once Dr. Bagley got past all that jargon, things became really interesting.

He noted that there are physician practices that are immature mom and pop shops with non-professional approaches to finance, human resources and quality. They talk and act like victims, rely on top down command and control, have no clue about process mapping, try harder instead of smarter and have unapproachable physicians. Many other clinics may share some of these features but have a much better prognosis.

That’s where disease management organizations come in. According to Dr. Bagley, DMOs need to move from helping patients become engaged to helping the struggling clinics become expert. In his opinion, this can occur in a number of ways including training office staff in registry and care coordination functions, providing patient self management support, helping with community services and providing 24/7 telephonic support.

During the question and answer period, there was a ‘who’s going to pay’ inquiry about the disease management support. Dr. Bagley didn’t quite answer the question, but this is what the DMCB thinks:

1) if DMOs are ultimately going to paid to deliver outcomes, it stands to reason that physicians are an important ingredient. Why not devote resources their way if it means better outcomes?

2) it seems it’s more than just a question of physician engagement. It’s achieving physician buy in. Outcomes are the 'tangible asset'; physician buy in can be thought of as 'good will.' Maybe it should be monetized. Next.

3) managed care organizations are also struggling with physician engagement and know how tough it is. The DMCB thinks they’d be sympathetic to the idea of partnering on helping primary care physicians, especially if they’re getting impatient over enrollee reach rates or other outcomes.

While the DMCB can continue to ponder just how and why the DM-PCMH divide can be bridged, the key take away here was that these two PCMH physician leaders welcome the prospect of collaboration DMOs and have some interesting ideas on how that can be pursued.

The DMCB says let that dialog continue.

Comparing John McCain's Health Care Plan to Barack Obama's Health Care Plan

Now that the political conventions are over we are in the final weeks of the presidential campaign. Here is my primer on both of the candidates' health care reform plans and the the big idea difference between them.Comparing Barack Obama's Health care plan to John McCain's health care plan:What's the Big Idea Difference?A Detailed Analysis of Senator John McCain's Health Care Reform PlanA

Is This Any Way to Run a Meeting?

Alas, the Disease Management Care Blog is not posting this 'live' from a meeting site at the DMAA Forum '08. As many readers know, a potential Category 4 bully by the name of Ike presented an unacceptable risk. Even if many of us had been able to get to the meeting, who knows when we would have been able to get out?

In the meantime KUDOs to the DMAA Staff. The DMCB received several 'stay posted' emails in the days leading up to the travel day, a request to update contact information 'just in case we can't get a hold of you,' a very timely cancellation notice and then, on top of it all, a personal phone call just to make sure I wasn't on my way to the airport. I talked to the staffer and she relayed that everyone being called was very supportive. And why not? That's what happens when you exceed the memberships' expectations.

One of the highlights of the Forum would have been a presentation by Bruce Bagley MD, a leader in the American Academy of Family Physicians, and Paul Grundy MD, director of healthcare transformation for IBM and chair of the Patient-Centered Primary Care Collaborative on the medical home and synergy between it and population health improvement interventions. The good news is that the presentation will still go on via web cast today at 10 AM. It should be very informative.

No Requiem for Disease Management

In the August 2008 issue of Managed Care, Blain Bos, Mercer’s ‘chief strategist for health reform,’ is interviewed about emerging trends in health plan benefit designs. Interesting article and worth a look, but there was one quote about the business community’s perception of disease management caught the attention of the Disease Management Care Blog:

‘Disease management has been embraced, and there is general agreement that it is having a positive impact on the healthy and well being of people who have chronic conditions. The questions now are: How can we measure that to be sure we are getting the best return on investment.’

The DMCB thinks this is one other indication that the ‘disease management’ phenomenon is not going to dissipate. Embraced means they’re not letting go. The name may evolve (‘population health improvement’) but the underlying concept has become a fixture in the medical landscape, along with managed care, the NCQA and physician networks. This upstart industry is maturing and is becoming part of the fabric of employer sponsored U.S. healthcare.

And what exactly is that ‘concept’ you ask? Well, even if you didn’t, and, without relying on the usual formula of a list of specific ingredients, the DMCB suggests the following definition (with explanatory notes) meets the marketplace definition of disease management:

‘Any health insurer (can be commercial or a self-insured employer) sponsored (i.e., paid for) package (there is no single silver bullet) of interlocking communication activities (depending on local market conditions, vary from setting to setting) relying on principles that include (and are not limited to) industrial psychology, marketing and consumerism that are designed to a) maximize self care and b) mitigate insurance risk (usually within one fiscal year) for populations defined by the presence of a chronic condition.

A less technical definition may be:

Any package of consumer-focused education activities that help health insurance enrollees with lifelong diseases take better care of themselves and save money.

Note that the definition depends on the insurance concept of 'risk transfer.' The DMCB believes that is generally outside the bailiwick of mainstream clinical medicine (unless my physician colleagues want to get back into taking global cap) and is one of the features that distinguishes it from the Patient Centered Medical Home. This brings up the second point about the definition: while the defintion doesn’t explicitly mention physicians, they are a necessary but insufficient ingredient in the ‘activities’ mentioned above. Furthermore, risk ‘mitigation’ doesn’t necessarily mean ‘has a positive return on investment.’ It means reduce the risk of a loss and increase the chance of money being left over at the end of the year. Last but not least, it makes no apology for inclusion of the ‘fiscal year,’ because that is how insurance, business, budgets and health care are financed in general.

The DMCB believes the employers and their insurers are using a working definition of disease management based on much of the above when they’re thinking about chronic illness. It’s relatively simple and builds on the notion that patient education translates into savings: it’s common sense. Combined with over 10 years of experience, no wonder the business community, according to Mr. Bos, isn’t asking ‘if’ disease management works, but ‘how’ to best measure it and use those measures to extract maximum value.