not done yet: sassymonkey's entirely unbiased review

I need to start with a little disclosure. Sassymonkey and I have become friends over the last few years and since she has moved to Ottawa, we have spent quite a few hours (we have our own little table at a bar in Little Italy), knitting and talking over pints.

This review really moved me.

"Laurie writes about life. There are times when the book will make you laugh, and other times where you’ll want to kick someone in the shins on her behalf. There are moments, both good and bad, that take your breathe away. Laurie shares the tough stuff but she also shares the soft side of her life, like the song by Daniel on May 8, 2007 that starts, “I love my mama and she is so beautiful.”...

...I’ve learned so much from Laurie, both from her blog and from reading her book. I have a hard time putting it in words but the best I can sum it up is this - she’s taught me more about living life with grace than I ever could have hoped to learn. Life isn’t about the big stuff. Life is lived in the in-between moments. It’s the walk to the library on chilly fall morning, the skate on the canal in the winter. It’s cooking dinner. It’s afternoons with friends. It’s pints and knitting and books."

I feel very honoured to have my work described in this way.

You can read the rest of the review, here.

A Tale of Commercial Disease Management

The intrepid Disease Management Care Blog hunter found signs of disease management company game in the private health insurance market. The footprints tell an interesting story.

Kathie Bracy is a retired elementary room classroom teacher who keeps a blog that acts as a forum for participants in the Ohio teachers’ Health Care and Retirement System (STRS). Several comments on Kathie’s blog about disease management prompted the DMCB to track the STRS’s involvement with a company called... LifeMasters. That’s when things became interesting.

Among its many services, STRS provides health insurance to active employees and retirees. It is funded by enrollee premiums, employer contributions and investment earnings. Like many employer-based insurance plans, STRS has been grappling with providing affordable health care coverage:

‘Rising health care costs, increased utilization and the loss of healthier enrollees are depleting money available to subsidize STRS Ohio retirees’ health care premiums at a rapid pace. Changes in the delivery of health care will need to occur at both the state and national levels. In the meantime, the Retirement Board remains focused on ensuring the long-term stability of the pension plan, while working to create a dedicated revenue stream to fund the health care program’

The forensically minded DMCB checked out the posted minutes of STRS’ governing Retirement Board. They and Kathie’s Blog are an instructive public-domain case study on the workings of a typical commercial disease management contract and the search for savings and quality. Search the STRS website first and readers will find some interesting information:

STRS initially contracted LifeMasters August of 2002 for $2.5 million. The deal included a guarantee that STRS would save more than the fees in insurance claims expense or LifeMasters would rebate 80%. The other 20% was also guaranteed, but half of that (or 10%) was based on ‘clinical measures’ improvement, while the other 10% was contingent on satisfaction. In 2003, STRS estimated it had 6956 enrollees, which calculates to a fee of $30 per member per month. In addition, ‘88%’ of this group were actively participating in what the DMCB suspects was an opt-out program. On April 15, 2004, an unnamed independent auditor confirmed there were 6,125 (or about 88%) persons enrolled with LifeMasters, that there was an 18% reduction in the number of hospital admissions and ER visits and an overall 6.9% reduction in claims expense.

As of December 2004, the STRS Board heard there were ‘5,831’ participants in the disease management programs. Observed savings were $8.6 million vs. the $2.5 million in fees and 92% of participants rated the program ‘excellent, very good or good.’ Based on the results of the program, the Board authorized its Executive Director to negotiate a three-year contract renewal with LifeMasters beginning July 1, 2005.

In May of 2005, there was more good news: STRS noted that among the approximately 6,900 people who were diagnosed with congestive heart failure, diabetes, coronary artery disease or chronic obstructive pulmonary disease, total health care expenditures (medical and prescription drug) were $17.65 million lower than expected. After accounting for the fees paid by STRS Ohio, the net savings was $15.32 million (the fees therefore calculate to $2.3 million). This time the independent auditor was identified: Health Data Management Solutions.

In Feb of 2006, the stakes increased. STRS reported that it was solvent until 2018 and a 3% premium increase was necessary. Instead of contemplating a 12% premium increase, the 3% was based on anticipated cost savings of $47 million between 2007 and ­2009, a 1% employer contribution, Medicare Part D subsidies of $33 million per year and an 8% return on investments. Those $47 million in savings were based in part on a prescription drug management program called the ‘Prescriber Advisor’ as well as – you guessed it - LifeMasters disease management.

Kathie Bracy’s blog has feedback from individuals in the STRS plan who are not happy with LifeMasters. One individual wrote that STRS retirees were being ‘signed up against their will,’ subjected to personal intrusive phone calls and that it was up to the person to indicate that they do not wish to be part of the program. Another, who also heard about multiple ‘pushy phone calls,’ questioned just how the savings were calculated and charged this was a ‘waste of the teachers’ contribution money.’ There are minutes on the STRS website that reflect the Board was aware of some persons’ concerns about being able to opt out and whether the information is confidential.

Insights for the DMCB?

If you scan the literature or the web, getting at the commercial PMPM fees charged by disease management companies doesn’t seem to be all that easy. The DMCB has informally heard global average fees range around $30 per diseased member per month and this seems to confirm it. In addition, the opt-out rate seems to be 12%, which may be another useful benchmark factoid.

Isn't it interesting that the lion's share of the fees' guarantee were based on reduced claims expense? The DMCB thinks it's sad but true: we can talk up 'quality' (which apparently went unmentioned) and 'satisfaction,' (reviewed once) but at the end of the day, this is about the bottom line.

The Board didn’t take LifeMasters’ word for the assertion that there were savings, but brought in an independent auditor. So much for the notion that DM companies are pulling wool over their customers’ eyes by performing their own self-serving analyses.

Despite a 92% satisfaction rate, there often are small numbers of individuals who can noisily protest. The DMCB doesn’t think this is necessarily bad; in fact this helped the Board to re-examine the issue.

If the rather large savings vs. fees are to be believed (without access to the methodology, we’ll have to take their word for it), it is very clear that in 2006, STRS doubled down: it is banking on LifeMasters as a principal means of keeping the teachers’ health insurance premium increases to a minimum. If this is typical of the market in general, no wonder employers are supportive of disease management. The good news is that, based on close to $18 million in savings, STRS thought a 3% premium increase is reasonable. The bad news is that the bet is also based on 8% market returns on STRS’ investment portfolio.

As an aside, this last point has implications that extend beyond disease management. As we know, the markets are not cooperating in generating the kind of investment income that supports insurers and helps keep premiums down. If STRS was not alone in its rosy assumptions, the employer-based commercial insurance market may find disease management is not enough to protect its beneficiaries from steep increases in premiums.

While this may or may not help the disease management industry, how will this stress the ability of employers to continue to provide health insurance? How will it factor into how they react to health reform?

Stay tuned!

buzzing brain

I had a brain MRI today. I'd never had one before and it's a pretty weird experience.

I'm not worried about anything in particular. I just thought it would be a good idea, after hearing an oncologist speak at the Conference For Young Women Affected By Breast Cancer that I attended last February.

It wasn't nearly as bad as I'd feared. It turns out that I am not at all claustrophobic (and I was so relieved that the technician managed to access a vein for the contrast injection on the first try that nothing after that fazed me at all).

But boy, was it loud. And my neck is still stiff from the brace they used to hold my head steady. It's been hours since I left the hospital and I feel like I am still vibrating. It felt like a jackhammer being used right beside my head. My teeth were chattering from the vibration.

And I am exhausted (although that my be from waking up every forty-five minutes again to make sure that I didn't oversleep).

I'm not going to worry too much about the results (although I may change my mind about that in the next few days).

My CT results from last week were good (still no tumours in sight).

And besides, there were several women at the young women's conference who had recently had surgery for brain metastasis. Every month seems to bring more options for the treatment of cancer.

And it's nice outside.

I am either going to take a nap now or go pick up dog poo in the back yard.

And then I'll go for a walk.

"An Open Letter to the New National Coordinator for Health IT: Part 3 -- Certification As The Elephant in Health IT's Living Room"

by DAVID C. KIBBE and BRIAN KLEPPERIn the first and second parts of this series we talked about how and why there is no universal definition for the term "EHR." Instead there is a legitimate, growing debate about the features and functions that "EHR technologies" should offer physicians seeking to qualify for HITECH incentive payments. We explored the layers of network technology, suggesting that

Does Lots of Tests for Patients Generate Lots of Satisfaction? Maybe Not.

There is nothing like a blood test or an x-ray to build patient confidence in a diagnosis. Being able to point to that laboratory report or CAT scan as proof positive that a disease was indeed present (Mrs. Smith, the pregnancy test confirms it!) or absent (Mr. Jones, the scan shows there is no brain tumor!) remains a time-honored part of the doctor-patient journey from uncertainty to reassurance. Never mind Mrs. Smith’s gravidity would be obvious even to a professional wrestling referee or that the likelihood that Mr. Jones’ 20 year history of dizziness could be ascribed to any tumor anywhere is remote, it’s **The Test** that seals the deal.

Is it really that simple though? This study (provocatively titled "Is patient satisfaction influenced by the intensity of medical resource use by their physicians?") by Bryan Down, John Kralewski, Amer Kaissi and Sally Irrgang from the University of Minnesota, Texas’ Trinity University and Blue Cross Blue Shield of Minnesota in the American Journal of Managed Care says otherwise. Using a validated 2002 patient survey that assessed satisfaction with a) overall primary health care, b) adequacy of time spent with the physician and c) likelihood of recommending the clinic to others, the authors sought to correlate the satisfaction with 2001 insurance network and claims data for 62 practices with 2800 patients.

While the actual calculation of claims expense was complicated (‘dollar-weighted resource use’), the bottom line was that there was no statistical correlation between more intensive medical resource use and a) overall patient satisfaction or b) the likelihood of recommending the clinic to others. What’s more, higher levels of use were negatively correlated with satisfaction over time spent with the physician. In fact, the degree correlation looked striking at -0.92. Interestingly, high resource use was not associated with being a busy clinic, prompting the authors to suggest that busy clinics are not trying to substitute tests for meaningful hands-on patient care – something else was going on.

The Disease Management Care Blog isn’t sure what else is going on and the authors didn’t spend a lot of effort discussing the implications of their findings, other than stating that more research is needed. The DMCB wonders if some physicians try to substitute tests for ‘quality time’ independent of how busy they are. The reverse may also be true: patients who are dissatisfied with any amount of time they’re getting with their doctor may end up demanding additional tests. There were two weaknesses in the research design too: 1) in general, these Minnesotans were highly satisfied with their care and Minnesota is the land of low variation to begin with, which may have obscured the ability of the researchers to detect a correlation and, 2) if multiple correlations are performed, one may randomly show up as spuriously ‘significant.’

Whatever the reason, public and private insurers will view these data as one more reason to do something about unsustainable upward trend in medical testing, including high cost radiology procedures. While physicians may claim that their patients ‘demand’ the testing, it didn’t turn up in this research. When policy makers get around to the notion of impeding physician's ability to order tests ad lib, they may want to use this paper to point out that patient satisfaction levels may remain unchanged or - assuming there's a causal relationship - even go up.

taking care of my body in 2009: part 5

Alternative title: "a mixed bag"

Alternative title: "doritos do not make a healthy lunch"

Alternative title: "time to bring in some support"

As my first alternative title suggests, I have had some mixed success this month, in my quest to "treat my body as well as I treat my mind" in 2009.

Let's review, shall we?

1-Walk VIGOROUSLY for an average of one hour, five times per week (300 minutes a week).

I did very well on this front, meeting my goal and exceeding it. I am especially pleased, given that I had such a terrible cold for a while. And I am very proud of the fact that I went for a long walk every day that I was at the Conference for Women Living With Advanced Breast Cancer (near Philly). I walked after checking in at the hotel, at the end of a long day on Saturday and organized a late check-out so that I could walk again before going to the airport.

2-Go to yoga once every week.

I went twice. I can definitely do better. I did have semi-valid excuses (conflicts and a head cold that made it impossible for me to bend down) but really, I can do better.

I'm going Wednesday morning, OK? I'll report back afterwards.

3. Do either 10 minutes (at least) of strength training or yoga with the Wii Fit or abdominal exercises every day (chemo recovery days excluded).

I used the Wii Fit once. I did the abdominal exercises three times (every day when I was away and then not again). Yeah, I caught a cold and then had chemo. But there were lots of days I could have worked at it and didn't.

I think I will lower the bar to 5-10 minutes and try again.

And that's the good news.

4-Cook dinner at least once a week.
5-Cut down on refined sugar.
6-Eat seven servings of fruit and veggies a day.
7- Take my vitamin D and calcium supplements daily.

When it comes to input, things have been a little out of control.

The dinners I "cooked" were as instant as possible.

I have eaten more sugar and fried stuff in the last month than I have in a very long time (Easter, Passover, travelling and my son's birthday provided the excuse). And the volume of food has vastly exceeded my needs.

The whole fruit and veggie thing has been extremely haphazard. I stopped keeping track but I'm probably averaging three servings a day (if I am incredibly generous in my calculation).

I can't remember the last time I took the lid off a supplement.

Clearly, it's time for some more drastic action.

I'm not talking about buying into the beauty myth or wanting to look like Posh Beckham. I just need to take better care of myself.

My lymphedema is worse and has started to be painful.

The bigger pants I bought are becoming tight.

I have aches and pains in my joints.

I feel sluggish and run down.

Now, I know not all of this is attributable to diet (early menopause and chemo are playing a role) but I do have control over what goes into my mouth.

I keep attending workshops on diet and nutrition, as it relates to cancer (went to another excellent one at the conference I have yet to write about) and I have years of Weight Watchers and reading obsessively about diets under my belt.

Going back to Weight Watchers might help (I tried doing the online last year and without a person to hold me to account, it was a bust) but we really can't afford it right now and the idea of dragging my ass to meetings is extremely unappealing.

So, my friend C. (who is feeling much as I have been) and I have hatched a plan. We are going to track what we eat, weigh in weekly and report in to each other. And then we'll have a little mini-meeting about what things are working for us and why other things might not be. My goals for this month aren't changing (no specific weight loss goal and I won't count points) but I will keep careful track of my promises to myself.

This kind of accountability has worked for me when it comes to my writing goals so it can only help on the health front. When I was meeting with my coach in January (without whom I would never have finished the book, started writing fiction or done so many other things that made me feel happy and purposeful in 2008), I set the following goals for the year:

I want to fit back into my pre-diagnosis pants (two sizes smaller than my current ones).

I want to have a strong core.

I want to feel fit and strong.

I think these goals are realistic and achievable. I just need to keep my eye on the prize.

Going to go throw out the empty Doritos bag and weigh myself with the Wii Fit now.

not done yet on toddler planet

"Not Done Yet is one of the good things to come out of this new approach to living publicly, to letting the light shine in on troubles and illness, and it is a very good thing indeed."

Thank you, WhyMommy. I feel the same way about everything you write.