making an adventure

photo: M. Slavitch

Early Thursday afternoon, as I woke up from a nap (I'd been sleeping off the toxins of chemo), my spouse came down from his attic office with an odd look on his face.

"Are you ready for some news?"

"Is it good news or bad news?" I said, attempting wake up.

"Good news, I think." He was giggling and looked a little stunned.

"Remember when you asked me to nominate you for a makeover at St, Laurent Shopping Centre?"

My eyes widened.

"You're in!"

They he told me that I needed to go to the mall for shopping and consultation and then, on Wednesday, I would be going to /A\ Channel to be made over on the air.

In case you missed that last bit, I'll repeat that this is a TELEVISED MAKEOVER.

"There's more," Tim added as I sat opening and closing my mouth like a fish. "It's a holiday makeover. You know, so that you can be ready for all the holiday parties you go to."

I do not go to any holiday parties where I can't wear jeans and a t-shirt. In fact, that's the smartest thing to wear to most holiday parties I might possibly attend.

"She actually used the word 'sparkly'." My dear spouse was by this point, enjoying himself. "And you have to decide today."

When I read on Twitter that St. Laurent was asking for nominations for cancer survivor makeovers, I impulsively asked T. to submit my name. I was confident that I wouldn't be chosen because I figured they'd want someone who looked more like a cancer patient. And if I were chosen I thought I'd just go to the mall, get made over and then have some pictures taken for their web site.

But I did get chosen. And when I went on Twitter and Facebook and asked my peeps what I should do, the answer was unanimous - "Go for it!"

So I'm going for it.

This is all being organized by the Ottawa Regional Cancer Foundation and I do want to help draw attention to the good work that they do.

The St. Laurent Centre has some really great stores and I could end up with some great new gear and a fresh new look.

I could use the lift. It is easy to feel frumpy when you're out of the work force and pinching pennies. And chemo does take a physical as well as emotional toll.

And it could be fun.

So I've decided to approach this with an open mind and a spirit of adventure.

I'll let you know how it goes.

The Latest Health Wonk Review Is Up!

It's officially the Interdisciplinary Nursing Quality Research Initiative, but wonky smart insiders refer to it as "INQRI." That's what you'll be allowed to call it after you check out the multiple blog posts, links and summaries in INQRI's hosting of the latest Health Wonk Review. In addition to gaining further insights on the future of nursing, you can also learn about the mid-term elections, health care costs, technology and a host of other issues. Check it out!

More On the "Call for Comments" and Here's One From JD Salinger's Fat Lady

The Disease Management Care Blog has gotten some terrific one sentence 'messages' in response to its "call for comments" to share at an upcoming U.S. medical school lecture. If your submission has not appeared anywhere among the DMCB's vast array of web portals, fear not: it's in there. Your comments are being compiled with others, dropped into PowerPoint and will likely appear in a future DMCB posting.

Comments are still being accepted through early next week. This is your chance to educate, impress and influence a roomful of future doctors. Posts here, email, tweet, Facebook and LinkedIn are all accepted.

By the way, the DMCB is **NOT** going to teach about, let alone mention, "disease management." Rather, the lecture will deal with various approaches to health care financing and risk transfer.

The DMCB is planning to conclude the lecture with a comment that touches on a favorite topic borrowed from J.D. Salinger's literary masterpiece Franny and Zooey. That would be the "Fat Lady," or how contemplation, reverence, submission and service can can light up the universe that lingers just beyond the reach of rational thought. This is the astonishing insight from brother Zooey that pulls the gifted radio star Franny Glass out of her nihilistic funk.

Physicians are especially privileged because they have a leg up on discovering their own personal Fat Lady. She exists in every patient and she calls to us. And she is now telling us that, while diagnosis and treatment are still "Job One," we docs are also being called to apply new skills in reconciling ethics, financing, public health, health literacy, lifestyle issues, socioeconomic status and third party meddling:

Zooey's explanation to Franny:

[I was told] to shine my shoes...I was furious. The studio audience were all morons, the announcer was a moron, the sponsors were morons, and I just damn well wasn't going to shine my shoes for them... I said they couldn't see them anyway, where we sat. He said to shine them anyway. He said to shine them for the Fat Lady. I didn't know what the hell he was talking about, but he [had a] ... look on his face, and so I did it. He never did tell me who the Fat Lady was, but I shined my shoes for the Fat Lady every time I ever went on the air again -- This terribly clear, clear picture of the Fat Lady formed in my mind. I had her sitting on this porch all day, swatting flies, with her radio going full-blast from morning till night. I figured the heat was terrible, and she probably had cancer, and -- I don't know. Anyway, it seemed goddamn clear why [I had to] shine my shoes when I went on the air. It made sense.

And now the Fat Lady is telling physicians that while morons abound, understanding the principles underlying risk transfer and how insurance works is important because will help you get your patients the care that they need. In other words, knowing how and why health care services are financed and what can be done about it at the individual patient level is no longer the job of that lady sitting on that porch.

Here's the DMCB comment: Docs need to shine those shoes.

Shame on AARP For Their Response to the Deficit Commission Co-Chairs' Report

The Co-Chairs of the President’s Deficit Reduction Commission are out with their preliminary recommendations.They’ve done a great job—they’ve offended about everyone!But we have a nearly impossible but unsustainable challenge in front of us if we are ever going to crawl out of this deep hole.It is not so much what is on their list as what this list tells us about just how fundamental the changes

More on the Uncertain Economics of Accountable Care Organizations (ACOs)

In this last post about Accountable Care Organizations (ACOs), the Disease Management Care Blog promised to take a follow-up look at how ACOs will get paid and how they can save money. It's a good thing that it didn't say that it would explain how the economics will work, because it promises to be very complicated. So says the DMCB, thanks to insights gleaned from reading this Integrated Healthcare Association White Paper again. This is a very insightful report that looks at the experience of the California market when it comes to the dizzying mix of fee-for-service, capitation and shared savings medical group contracting arrangements.

First off - and assuming ACOs really do save money - if multiple insurers in a State are all contracting equally with multiple ACOs, no single insurer will experience any lasting economic benefit. That's because the savings from any efficiency gains would be spread out throughout the risk pool and be a one-time event. What's more, if a single ACO attempts to compete on price by underbidding its rivals, it's unlikely that the insurers will collectively see any significant drop in overall costs, which means that consumers won't ultimately see any decrease in their premiums. The DMCB thinks that one way to fix this is to allow ACOs and insurers to enter into semi or fully exclusive contracting arrangements. Unfortunately, this has implications for consumer choice (would patients agree to be locked or incented into using only one ACO's physicians?) and could perpetuate the "most favored nation" contracting dysfunction.

Secondly, organized physician entities and their hospitals have been very reluctant to agree to capitation for their pricier services. As a result, capitation is typically applied to low cost high volume services like primary care. Given how shrewd providers are about the financial risks from capitation, the DMCB suspects that if hospitals readily agree to more modest arrangements like "shared risk" and "gainshares," that will signal their belief that they can get more money from the deal. This increased cost obviously won't translate into lower insurance premiums for consumers, unless providers are willing to accept significant up-front reductions in their fee schedules. That is unlikely.

Last but not least, the organized physician entities and hospitals have only just begun to enter into various performance-based, risk pool and gain share arrangements. This makes it too early to tell how this will work in "real world" markets that exist outside integrated delivery systems. This reminds the DMCB that if the authors of the Affordable Care Act were sure that ACOs really do save money, they wouldn't have set it up as a pilot program.

Given all the uncertainty, the best approach to implementing ACOs may be one of "incrementalism." That would minimize unintended consequences and allow for small changes to accumulate over time. Unfortunately, that would take years. Add to that the time it will take to evaluate the impact on cost and quality, and the U.S will be many years into additional cost inflation, changing political landscapes and new economic challenges.

Bottom line: there are too many economic uncertainties about ACOs. If anyone tells you otherwise, don't believe it.

A Call for Comments

In just over one week, the Disease Management Care Blog will be doing something that only few ever get to experience: it will have the undivided attention of an entire U.S. medical school class for over an hour. It was invited to give a real and honest to goodness lecture. It's been working on the reading list, assembling the lecture content and buffing the slide presentation for weeks. And the DMCB doesn't intend to go into this alone. It would like to take its readers along by offering them the chance to communicate with these young physicians.

This is a call for a short one sentence (or less) statement that can fit with others on one or two closing PowerPoint slides, sort of like the closing credits to a satisfying movie. Angry, abusive, lecturing or depressing comments will be rejected. The DMCB is looking for wittiness, optimism, inspiration and humor.

If you have something important to say to a group of professionals who will be saving lives, spending gazillions of your tax dollars while being in the eye of an unending health reform storm, this is your chance. Email the DMCB at jaansATaolDOTcom, Tweet, or post here, or on Facebook or LinkedIn.

No Relationship Between Primary Care and Deaths from Coronary Artery Disease?

Listen in on the average health care Conference, Meeting or Grand Rounds with health care patriarchs or D.C. brainiacs speaking about "primary care," and it's likely that you'll hear at least one PowerPoint slide's worth of praise for PCPs. It reminds the Disease Management Care Blog of what it's read about about the hollow admiration of the Saudis for their hardy Bedouins, the Norwegians for their rugged Laplanders and the Ben and Jerrys for their Vermont dairy farmers. Sure, these special folks may deserve special regard, but no one actually wants to live in a desert, above the Arctic Circle or close to a smelly barn. All the special attention is of small comfort us PCPs who just can't seem to get any respect.

And now this study isn't helping at all. Titled "Association of Features of Primary Health Care with Coronary Heart Disease Mortality," it was published in the November 10 issue of JAMA. Louis Levene, Richard Baker, John Bankart and Kamlesh Khunti accessed ALL of England's health data on mortality, patient characteristics and primary care delivery to explore the relationship between heart disease deaths and the local availability of primary care. This was an impressive study involving 54.3 million Brits being cared for in 152 of their regional "trusts." Regression analysis was used to determine if there was any statistical correlation between deaths from heart disease versus race, socioeconomic status (a "multiple deprivation" index), tobacco use, weight, diabetes, high blood pressure, number of physicians, staff and practices and pay for performance bonuses that were awarded to the docs.

Based on common wisdom, most persons would think that all of the above factors are independently and statistically significantly correlated with death rates. Thousands of DMCB readers know otherwise. That's because they know primary care is not the panacea for all that ails health care and that the DMCB likes to look at published research that goes contrary to the common wisdom.

It turns out that only five characteristics were associated with heart attack death. The risks were 1) being white, 2) having a low socioeconomic status, 3) using tobacco and 4) being diabetic. Having high blood pressure detected (this is not the same as having high blood pressure: patients can have hypertension that goes undetected) was associated with less risk.

What turned out to have no impact was availability or the quality of primary care. According to the authors:

"Neither provision of primary health care as indicated by the numbers of physicians or staff per 100 000 population, nor clinical performance as reflected by the quality and outcomes framework indicator scores predicted mortality in any year."

This should give pause to the universal assumption that manufacturing and then parachuting more PCPs into areas of the U.S. with a high burden of coronary artery disease and showering them with pay for performance dollars will save lives.

As an aside, that was also the conclusion of this recently published RAND review paper from Health Affairs titled "Primary Care: A Critical Review of the Evidence On Quality and Cost of Care." The authors state:

"....a recent survey of primary care physicians found that those in the highest-spending regions of the Dartmouth Atlas of Health Care were significantly more likely than those in the lowest-spending regions to report more aggressive use of discretionary visits, tests, and interventions. In other words, care by primary care physicians in high-cost areas is not the same as care delivered by primary care physicians in low-cost areas. This finding ....suggests that adding more primary care physicians in regions such as South Florida may increase mortality rates. Such analyses offer evidence that adding more primary care providers in high-spending areas could have deleterious effects if local provider cultures and other system-level characteristics are not simultaneously reoriented."

Of course, there are other studies on the topic that say otherwise and England isn't the same as the United States. Time will tell.

One last point: the good news about the JAMA paper is that the detection of high blood pressure seems to pay off. If population-based detection and pursuit of hypertension is what counts and it's independent of the availability of primary care physicians, there are other population-based solutions available. It's called disease management. Examples are here and here.

Image from Wikipedia