The Lead Investigator Responds

In a prior post, the Disease Management Care Blog raised some questions about a wonderful study about 'PAM' conducted in two LifeMasters call centers.

As readers may recognize, comments in the Google system are buried away from the main blog page: the post itself needs to be accessed and the comments will only then appear at the bottom.

In this instance, the DMCB heard directly from the principal author of the study. Her timely and helpful response deserves greater visibility. It is reproduced in it's entirety here:

Thank you for your review of our recent study. As the lead investigator on the study, I am happy answer the questions you raised about the methodology. You asked if hospitalization risk was part of the propensity score risk adjustment we used to equalize the two study groups. Yes, the risk severity score, based on claims data, was part of the risk adjustment approach. You also asked about the differences in hospitalization rates between the two groups. The analytic approach we used assessed the trajectory of change and examined whether this trajectory was different for the intervention group as compared to the control group. This analytic approach reduced the need to control for multiple factors, because most of the characteristics of the individuals remained fixed and changes that were observed could be attributed to the intervention. However, because there were some key differences at baseline (including their baseline utilization rates), we constructed the propensity weights to equalize the 2 groups. That is to say, after controlling for other differences, the statistical significance in the utilization tables indicates that the trajectory of change significantly differed for the intervention group as compared to the control group. In the case of Emergency Department use, the control group’s trajectory was up, while the intervention group was down. In the case of hospitalizations, the control group trajectory was flat, while the intervention group went down.Finally you asked about a possible Hawthorne effect, with the nurses who were responding to this “observation” rather than the PAM intervention. This is a very unlikely explanation, as both the intervention nurses and the control group nurses knew they were in a study and were being observed, thus the effect of “observation,” would have been the same for both groups of nurses.

President Obama's Speech to the AMA: Masterful, Necessary and Insufficient

The Disease Management Care Blog tuned into online C-Span and watched a part of President Obama's 56 minute speech to the American Medical Association's Chicago House of Delegates' meeting. It was quite the tour du force for a politician espousing greater government involvement in health care to an organization that has always been hostile to the idea. Unable to believe that the AMA interrupted the speech repeatedly with occasionally robust applause (though there was one episode of booing), the DMCB went back and listened again.

It's heard all these arguments before, but found how they were packaged was simply masterful.

What is the template for such a speech? The DMCB kept notes and has outlined them for you below, just in case you're ever called upon to enter a room full of doctors that are reluctant to go along with your brilliant plans. As a medical director, the DMCB has been down that road and wishes it had President Obama's rhetorical skills in past encounters, when the physicians, after listening closely with sketpical frowns and crossed arms, told it to get lost:

Open with vague descriptions of a better future rising out of the ashes of the current adversity. Bond listeners to you by noting their assistance is needed. Be a supplicant: modesty looks good and builds rapport.

Quote some telling and heart breaking anedotes: patients with cancer, doctors with hassles, small businesses with layoffs. Reach for big anecdotes if you can: automobile bankruptcies, the national debt and, what the heck, global warming if you can get away with it.

Call your listeners to action by saying that doing nothing is not an option. Costs will spiral upward, taxes will go up, budgets will be cut. The Huns are almost on the beaches of Dunkirk, now is the time to man the ramparts.

Recognize the fear and challenge listeners to take action under your confident leadership. Give examples of that leadership and take credit for anything you can. Anything.

Repeatedly commend the audience for their courage, good will and intelligence. Disarm them by thanking them for being so smart.

Remind listeners that, while big change is coming, their core issues will not have to be compromised. You're only fixing what needs to be fixed. It's OK to use terms like "hundreds of thousands" or "tens of billions" here.

Leverage the idea that, aside from a few Luddites, "everyone" agrees with your points of view. Cast your perspectives in the most reasonable way possible. Look affably mainstream.

Repeatedly remind the audience of how your plans will make life better for them.

Describe your plans with opening softballs (EHRs, prevention, Dartmouth Atlas) that you already know they agree with and lead them slowly to your more controversial points of view.

Repeatedly commend the audience for their selflessness, dedication and sacrifice. Disarm them by thanking them for being so unselfish. In fact, you'll eventually be able to say that their higher calling obviously makes them willing to forgo any economic rewards - and they won't boo at that.

Open your more controversial proposals with the options that are most likely to be supported thanks to your audiences' economic self interests. Yes, it may be more work but more work means more compensation.

Your audience is now ready: hit them with the items that they may not cooperate with. Now is not the time to let up! Sprinkle in more anecdotes that demonstrate why your ideas warrant their support.

Repeatedly recognize your audience wants to do what's right and that they have great expertise. Disarm them by recognizing that they are the trustworthy experts.

There is always something your audience wants. Don't give it to them (and expect the boos now), but now is the time to give something close to it in exchange for their support. Explain why your compromise bauble is a) is still worth having and b) is better than nothing at all.

Repeatedly commend the audience for their helpfulness and assistance. Disarm them by thanking them for their help. Admit that we're all in this together.

Point out that you recognize the core values of your audience.

By now, close to 40 minutes have elapsed. Attention is waning. Now is a good time to raise additional controversial recommendations.

Recast any disagreement as 'healthy debate' and 'legitimate concerns' that you 'welcome.' If there were prior mistakes, point out that you're not responsible... for any of them. Now is a good time to good-cop-bad-cop: mention that you're shielding your audience from others that are more radical than you are.

Identify a common enemy. Take sides with your audience against that enemy. Be firm. Look resolute.

Bring up the example, if you have one, of a family member or close friend, that would have done better if your ideas had been adopted years ago.

Your audience is more tired now. You can quote any economic statistics you like at this point. They are more likely to be believed.

Wrap up: unless you agree NOW this deal with disappear faster than primary care physicians taking Medicare.

No doubt the President will get good grades for this speech. However, the DMCB has a caution for the Administration. With time, it learned, on its own with lots of trial and error, to use many of the approaches mentioned above. As a result, it often also achieved the verbal support of its audiences. Weeks or months later, that support often waned unless there was continuous dialogue, feedback, reaching out and more face-to-face visits.

Mr. Obama has given a necessary speech, but he and his advisors need to know that it was far from sufficient. There is still some way to go.

Just Which $2 Trillion Were They Talking About?

Just two weeks after putting $2 trillion in health care cost reductions on the table, the response to President Obama's plan to cut the health care providers by a total of $618 billion over the next ten years ($305 billion in his original budget and another $313 billion this week) is startling--if not in the final analysis predictable.Given that, at present trends, we are on our way to spending

It’s NOT the Prices Stupid!

Out here on Kent Island, the federal government says that I like to watch the Baltimore TV stations and therefore forbids my satellite provider to give me access to the local DC channels. (We’re about an hour from both Baltimore and DC.)There is reason number one never to put the government in charge of any more than absolutely necessary.While my new digital converter box had been working just

So, What Is a Health Insurance 'Cooperative?' and Five Reasons Why Senator Conrad's Idea is a Realistic Option for Health Care Reform

If you've been following developments in Washington's attempts at health care reform, you may have read how the concept of an 'insurance co-op' was "pitched" by Senator Conrad (D - N.D.). See him describe it here. It's a compromise offered to bridge the disagreement over just how the Feds should sponsor a public option.

Senator Baucus (D-Mont.): “I am inclined, and I think the committee is inclined, toward a co-op”

Senator Grassley (R - Iowa): "there was a thing suggested that would be kind of a private-sector option along the lines of co-ops."

Senator Rockefeller (D - W. Va) is "dubious."

Senator Hatch (R - Utah) "I'm totally opposed"

When the Disease Management Care saw the term 'insurance cooperative' bubble up in its news feeds, it was confused but, unlike our Senators, didn't offer up any snap judgments. Instead, it did its homework. At first, it thought a 'co-op' was a large carbon footprint air-conditioned store filled with baguette-laden wicker baskets where boomer earth mothers and natural-foodies drive their hybrids to buy over-priced asparagus. That plus high end Chardonnay. Thanks to some web-enabled detective work, the DMCB found out they don't necessarily involve hybrid automobiles and that the concept of a co-op can be applied to the purchase of health insurance.

So, exactly what is this thingie called an 'insurance cooperative' and what is its potential for meaningful health reform? Because you regularly read the DMCB, you'll find the answer to this question well before you can finish that lunch you've been eating at your desk.

According to this Commonwealth Fund Issue Brief, an insurance co-op exists when small employers 'band together' on a regional basis to form a purchasing block that can negotiate better deals with the local commerical health insurers. This efficiently consolidates the decision making, billing and servicing under one roof and often allows for choice among several competing plans. It also allows all the participants to 'pool' their insurance risk, which, in turn, should lead to lower and more predictable premiums. Unfortunately, the track record of co-ops has been spotty, apparently because member businesses are constantly on the look-out for better deals and may exit the co-op, leaving the higher-health risk businesses behind in the equivalent of a death spiral. If they don't keep and maintain a large market share, they can't go toe-to-toe with the commerical insurers.

For a more complete review, this paper from Health Affairs teaches us about a number of pooled purchasing arrangments including the 'co-op.' It seems this has been around for a long time. They typically operate at the state- level, are not for profit, are run by employers, don't have to accept all insurers, carve out the administrative/back office functions to an insurer for an administrative fee, leave it to employees to choose the insurance they want from a list, and, thanks to ERISA, may not be subject to all State regulations.

And if you're wondering if the famous Group Health Cooperative has anything to do with this, the answer is yes. Back in 1947, a multi-member community-based group decided to buy its own clinic to offer health care for its employees. The rest is history.

How would the co-op fit in healthcare reform? According to this link, the legislative outline currently under consideration would require them to be State-by-State or regional, non-profit, provide a coverage option for individuals and small businesses with as few as 2 employees, be subject to State laws and have 'governance standards' that would presumably trump a consumer focus in the Boards of Directors.

The naive DMCB thinks the co-op idea may develop legs:

1. As noted previously on the DMCB, as debate on the public plan option matures and stakeholders realize it's not synonymous with 'Medicare for All,' the focus will shift toward other more politically nimble options that also offer credible health insurance. The co-op is such an option.

2. According to the Commonwealth Brief and Health Affairs articles described above, commercial health insurers don't like co-ops because they force them to compete on price instead of benefit design. The fact that insurers have historically been hostile to the co-ops is telling and could be reason enough for many Democrats to support the idea.

3. Without a government-run public plan, employers will have less of an incentive to drop health insurance for their employees.

4. The very term 'co-op' has the kind of fuzzy appeal - like ''pesticide-free' or 'consumer directed' - that the Democratic majority can spin while it seeks to counter partisan Republican attacks.

5. While the the DMCB has seen little evidence of input from the NAIC anywhere in the healthcare reform debate, it suspects the nation's insurance commisioners would support the co-op as a reasonable compromise between the State and Federal governments over what is a looming intrusion by Washington DC into their space - which, by the way, they think they've done a good job regulating. Recall that Ms. Sebelius is a Past President of the NAIC, so she'd probably understand how her fellow Commisioners could shepherd the State by State co-ops into position.

The articles above are somewhat skeptical about the ability of co-ops' to control costs. While that is a fair assessment of their track records, some of the examples cited occurred during the 1990s, when health care costs were on their way down and employers were disinterested. That's not the case now, so the DMCB thinks their prospects are better. That being said, If the co-op idea moves forward, look to Congress ponder regulations that keep (as in 'mandate') small employers and individuals in the co-op risk pool and keep insurers from poaching away low risk business with side deals.

Here's an Example of a Cooperative Not-For-Profit Health Plan--North Dakota Blue Cross

North Dakota Senator Kent Conrad has proposed establishing not-for-profit cooperative health plans as an alternative to the Medicare-like public health plan President Obama supports.I will suggest Senator Conrad take a look at this one:North Dakota Blue Cross Blue ShieldFrom their website:"More than 65 years ago, Blue Cross Blue Shield of North Dakota (BCBSND) began as two separate pre-paid

Health Care Cooperatives--An Old New Idea--So What's a Blue Cross Plan?

As opposition to a Medicare-like public health plan option grows, there has been a lot of talk about the compromise idea of creating not-for-profit health insurance cooperatives that would compete on a level playing field with existing private insurers. The reasoning goes they would keep the existing insurers "honest" by introducing a new element of competition.That's a great idea.And it was a