unrelated

photo: J. Sussman

"It is one of the ironies of the creative life that while drama is part of what we make, it has almost no place in how we make it."

Julia Cameron
Walking In This World.

The Ironic Conundrum of the Preference Sensitive Measures, P4P and HEDIS Criteria

The Disease Management Care Blog received this posting from a primary care physician who prefers to remain anonymous. It speaks to the good intentions of applying HEDIS measures in the real world of primary care practice involving real physicians and real patients:

Most readers are familiar with the Oracles of Dartmouth and their numerous reports touting the opportunities from reducing variation around preference sensitive care. In the ideal world of measurement around the average, it all seems so logical and even warm and fuzzy. However, practitioners in the real primary care world are having a tough time fulfilling its promises in day to day practice. Is the problem the art and science of medicine, or is the problem with the logic underlying the measurement methods?

As a family doctor I am constantly being measured by HEDIS criteria and compared to my peers' average measures. This is how I am graded by most of the health insurers I contract with and my pay for performance (P4P) dollars are often based upon them. Yet, no matter how much my patients prefer – after careful, physician-delivered full disclosure of why this should be done - not to have a colonoscopy, not to schedule a diabetic eye examination or not to take a statin for coronary artery disease, it is the physician who is penalized for not obtaining one. When charts are reviewed, and documentation is read, informed choice is not a consideration for HEDIS.

In my opinion, HEDIS criteria are unreasonable, static, inflexible and fail to account for patient preferences. It measures physicians by the same unforgiving yardstick that expects all patients to be the same. It fails to account for the degree of patient preference care that’s been described in other care settings in the Dartmouth Atlas.

The only way to incorporate flexibility of choice in the P4P system is through the use of multiple individualized clinical pathways. Yet, each of the multiple clinical pathways are also inflexible and ill-suited to the special circumstances of each patient. Here’s the conundrum: If I am offering flexibility to my patients through multiple inflexible options, how can I properly inform them flexibly?

Good point. The physician points out that the current blunt force approach to HEDIS in managed care networks is based on a) comparing physicians to an ill-suited average measure that fails to capture the uniqueness of each practice setting that has a population of unique individuals, b) doesn't incorporate patient preferences and c) is demoralizing because it fails to give physicians credit for trying. The physician also doubts that health information technology and decision support will ever be up to the task of overcoming the special perspectives of any individual healthcare consumer. Last but not least, the DMCB is fascinated by this portrayal of the flip side of 'patient sensitive care' which, according to the Dartmouth Atlas, is prone to overutilization.

The DMCB doubts managed care medical directors will care much about this point of view, partially because they've been brainwashed by regular attendance at the Church of the Holy HEDIS and partially because their bonuses often depend on it.

living with it

I have just come back from an echo-cardiogram appointment (I have regular echos to make sure that Herceptin isn't damaging my heart) or rather what I thought was an echo appointment. It had previouslybeen scheduled for Thursday, February 26 (when I was travelling to Dallas for the Conference for Young Women Affected By Breast Cancer) and I'd had to reschedule. I had entered the appointment (I use Google Calendar) for Friday, March 6 at 3pm. It turns out the appointment is for Tuesday, March 10th, at 3pm.

Since I was told about the appointment over the phone, I have no idea where along the channel of communication the mistake was made - as it came out of the caller's mouth, or as it went through my (increasingly sieve-like) brain. I guess it doesn't really matter, though (and next time, I will call to confirm).

I did find that it made me feel a lot better to get out of the house (both physically and mentally). Can you remind me of that next chemo cycle, please? I don't know why I am still figuring these things out.

I am still all aglow from the conference (even if I have been too tired to write about it). It was a truly supportive, joyful atmosphere, despite the shared circumstances of the women in attendance. I had been hoping to learn (and I did). I had been hoping to get a chance to talk about my book (and I did). I had been hoping to meet a few nice people (which I really did). I did not anticipate how very inspired and hopeful I would feel on my return. I am so grateful that I was able to attend.

There were some excellent sessions on practical and medical issues (I mentioned the session on nutrition in yesterday's post and I will write a post on Monday about the medical stuff) but also workshops and speakers that addressed what it means to live with cancer.

Here are some of the comments that resonated with me:

From Advanced Breast Cancer: Living With Uncertainty, a workshop led by Mary K. Hughes, a nurse who helps cancer patients cope with anxiety and depression-

• Instead of focusing exclusively on what we have lost, it is important to "find new meaning in what you can do."

• There is a difference between depression and the grief we all experience as women living with metastasis.

• People often tell us we are brave. We don't generally feel brave, just that we are doing what we need to do.

• It's hard to explain to people that we will never be "done with treatment."

• "Coping is temporary. Adapting is permanent." This is so true.

• Talking about our cancer "takes the power out of it. It's like deflating a balloon."

From Happiness In A Storm: Embracing Life Through And After Cancer, a keynote address by Dr. Wendy Harpham, MD, FACP and multiple cancer survivor, speaking about her own experiences:

• When she was first diagnosed with cancer, she had a busy practice and two kids. Cancer felt "like a storm had descended." I can really relate to that metaphor.

• A "healthy survivor" is one who gets good care and lives as fully as possible. Good health is a "wholeness of body and mind and not dependent on biology." Dr. Harpham advised us to "make your life the best it can be, whatever the circumstances."

• Minor discomforts (hello lymphedema!) can be an obstacle to happiness. She called it "the rubber band syndrome."

• Unpleasant emotions can be "the signal of a problem or the response to a problem." They can sometimes be used "in healing ways."

• "Anger and grief have a purpose."

• "It matters less what you feel than what you do with what you feel."

• "Live until you die." I know that sounds obvious but it is easy to lose sight of the living when all you can see is the illness or the ways in which your life has changed.

• Strike a balance between hope and acceptance - "hopeful acceptance."

• "Setting the stage for hope is a choice."

• "A prognosis is not a prediction."

• "Little problems have become trivial. The ordinary has become marvelous." I have written about revelling in the mundane.

• "Even the hard stuff reminds me that I am alive."

• On communicating with kids - "open the lines of communication and tell the truth. The greatest gift we can give our kids is not to protect them from the world but to give them the skills to deal with what life deals them."

As someone who lives with metastatic breast cancer, I will be in treatment for the rest of my life. I am also in remission and live a full and happy life, despite the challenges I face. It was so inspiring to be around people who really understand this.

The women pictured above were among the nicest I met this week end (the two at the back are from Boston - the same two women I was too shy to approach at the Chicago Airport!) the two in pink are from Orange County and I met them at the cocktail party on the first evening. And then it turned out they were all friends. They enveloped me in their little circle and it made my experience that much better.

Last Minute Thoughts.....

According to the President's remarks at yesterday's Summit (they're here, fast forward to 6:20), healthcare costs lead to a bankruptcy 'every thirty seconds.' Is that so?

The Disease Management Care Blog invites the White House staff to follow its playbook: take the effort to read the underlying science for yourself and measure twice and cut once when it comes to making public conclusions.

And for those who feel left out: the DMCB feels your pain. It wasn't there either.

The Latest Health Wonk Review Is Up!

The Disease Management Care Blog is such a sucker when it comes to cinematic eye candy. Little did it know just how seductive it can be when it is used in health care policy blogging. Excellent case in point: Brady Augustine's Medicaid Front Page Blog, who has assembled a Watchmen Edition. Think of it as brain candy that has assembled the best, brightest and most interesting cast of blog entries from the web's commentology.

An Anything-You-Please, Not Thelma and Louse White House Health Care Summit

The Disease Management Care Blog sat through the C-SPAN health policy video of one of today’s White House Health Care Summit ‘conversation’ break out sessions. There was something for everyone here, and everyone certainly had something to say. The session heard about planned parenthood, low income women, cancer prevention, nurse-patient staffing ratios, the public plan option, research, hospitals, obesity, bankruptcy, coverage doesn’t equal access, shortage of providers in rural settings, food safety, nurse workforce issues, centers of excellence, drug reimportation, interoperable health information systems, end of life care, obstetrical units, pre-exisiting conditions, single payer system, public reporting, Medicare Part D, mandatory coverage, malpractice reform, long-term disabilities, community-based services, the Latino community, immigration reform, stem cell research and comparative effectiveness.

The healthcare reform quote of the day was that things are so dire, it’s not a Harry and Louise moment, but a Thelma and Louise we're gonna drive-off-the-cliff moment. The DMCB thinks it was more like a narrow interest, soapboxy never waste a crisis, anything you please moment.

But it was a comment about employer-based insurance that caught the DMCB’s ear.

General Mills, the maker of Cheerios, Green Giant veggies, Progresso soups, Pillsbury bakery products and Yoplait yogurt has 18,000 U.S. employees in multiple States. Its CEO, Ken Powell, was at the Summit and pointed out that his company and the rest of the Business Roundtable wants to preserve the ability of employers like General Mills to offer health insurance for two reasons: 1) it helps them recruit and retain skilled employees and 2) they’re really good at it.

In addition to a highly competitive health insurance plan with a manageable cost trend, Mr. Powell pointed out General Mills has tobacco cessation and weight loss programs, diabetes coaching programs, pharmacists to help persons understand their medications and access to other venture-capitalist funded, multi-employer supported chronic condition care programs. He hopes healthcare reform allows his and other companies to continue to leverage this strategic advantage when it comes to maximizing its human capital.

The DMCB hopes so too. In a prior post, the DMCB reviewed a highly informative report that pointed out that the distribution of ‘best practices’ from high performing systems, 7-day-a-week hospitals, the right kind of health information technology, controlling admissions, optimizing discharges and other proven strategies across the United States can save billions of dollars. The additional General Mills option, unlike the swirl of other narrow interest group issues listed above, is in the mainstream of health care, it deals with the twin challenges of cost and quality and is within legislative reach this year

The DMCB recommends the reformists listen closely to employers like General Mills. Promotion of their approach nationwide is a key consideration in wellness, prevention and care of populations with chronic conditions.

small changes, small successes.

I had just experienced the first concrete encouraging sign in my journey of small changes.

I tend to spend the couple of days after chemo in pajamas. After spending all day pulling up my pjs, (the drawstring seems to have gone missing) it occurred to me that they might be getting too big. I pulled out a pair of pajamas that my parents had given me for Christmas that had been too tight to fit comfortably. I pulled them up easily and I'm wearing them now.

The thing is, this encouraged me to do something else that was healthy. As a pre-dinner snack, I had been considering toast or a granola bar. Instead, I had an orange.

I am inordinately pleased with these developments.