A New Cavalcade of Risk Is Up!

This one is ably hosted by newbie Nina Kallen, a lawyer specializing in insurance law. She does a great job of summarizing some important topics that make for interesting reading. As an added bonus, she doesn't disagree with the DMCB.

It's worth a look so check it out.

speaks to me

Thank you xkcd.

The Definition of "Disease Management" (with other definitions)

Thanks to prior postings in the Disease Management Care Blog, readers have had access to handy and literature-based definitions of "patient centered care," "care management" and "value based insurance design." Not only can regular readers quote them with confidence, insert them in company-wide memos, amaze colleagues with deep subject matter expertise, bore the DMCB spouse and use them against know-it-all consultants, the definitions make for perfect verbal swordsmanship at that next staff meeting. For example:

"Er, exsqueeze me Bob, but everyone at this meeting except you knows that care management should also be postured to reduce the duplication of medical services!"

Then it occurred to the DMCB that it had not blogged about the definition of disease management. Now that is an embarrassing lapse. The term may have lost much of its brand luster among the vendors and is no longer de rigueur among the policymaker elites, but the contrarian DMCB still predicts the catch-phrase will eventually make a comeback. In happy anticipation of its eventual resurrection, the DMCB proposes this formal definition:

A package of mutually supportive interventions to improve quality or mitigate the insurance risk of a population defined by the presence of a chronic condition.

This short and efficient definition is good because 1) it emphasizes disease management's multi-dimensional nature, resulting in a synergy that is greater than the sum of its parts, 2) it recognizes that in addition to quality, there is merit to controlling costs and doing so in the context of health insurance; in other words disease management and managed care are inextricably intertwined and 3) it transcends one-on-one care, akin to "applied" health services research that also studies defined cohorts. One other feature that favors this definition as eminently quotable is that it has also been published in the peer-reviewed literature (1).

The DMCB also looked up the old and more lengthy DMAA definition of disease management. For the sake of completion, it's reproduced below. Fortunately, it's also been memorialized in the medical literature (2) for your quoting pleasure:

"A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant:

• Supports the physician or practitioner/patient relationship and plan of care,

• Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and

• Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

Disease management components include:

• Population identification processes

• Evidence-based practice guidelines

• Collaborative practice models to include physician and support-service providers

• Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance)

• Process and outcomes measurement, evaluation, and management

• Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling)

'Full-service disease management programs' must include all 6 of the above components. Programs consisting of fewer components are 'disease management support services.'"

Other definitions have been proposed. There is a list here and a table with other definitions was published here, courtesy of the American Heart Association (2).

As a further service to it's readers, the DMCB has reproduced the definitions of "patient centered care," "care management" and "value based insurance design" below along with the necessary citations. In addition, there is a paraphrased definition of "population health improvement," which has been put forward courtesy of the Care Continuum Alliance (CCA).

Patient centered care any care that is "respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" (3).

Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services (4).

Value based insurance designs are health insurance designs that reduce patient out-of-pocket expenses for covered services that provide important medical benefit relative to costs (5).

Population health improvement is paraphrased by the DMCB as a package of services that identifies a population, conducts a needs assessment of that population, provides health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles, promotes health management goals and education as well as self-management interventions aimed at achieving behavioral changes. routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers with ongoing evaluation of clinical, humanistic, and economic outcomes. the full definition can be found here.

References:

1. Sidorov J, Schlosberg C: Disease management and the Medicare modernisation act: "It's the insurance, stupid." Disease Management December 2005;8(6): 331-338

2. Krumholz HM, Currie PM, Riegel B et al: A taxonomy for disease management. Circulation 2006;114:1432-1445

3. Epstein RM, Fiscella K, Lesser CS, Stange KC: Why the nation needs a policy push on patient centered health care. Health Affairs 2010;29(8):1489-1495

4. Bodenheimer T, Berry-Millett RL Follow the money - controlling expenditures by improving care for patients needing costly services. New Engl J Med 2009;1521-1523

5. Chernew ME, Juster IA, Shah M, Wegh A, Rosenberg S, Rosen AB, Sokol MC, Yu-Isenberg K, Fendrick AM: Evidence that value-based insurance can be effective. Health Affairs 29(3):530-536

Another Wellness Program Demonstrates Value

On the heels of this Health Affairs publication on the economic value of employer sponsored wellness, we now have this "on-line" report from Population Health Management. You know it's going to be an interesting when it simultaneously involves a care management company (HealthMedia), an academic institution (University of Michigan) and a health insurer (a subsidiary of a Blue Cross Blue Shield Plan).

The manuscript is titled " The Economic Value of a Wellness and Disease Prevention Program" and was authored by Steven Schwartz, Caryn Ireland, Victor Strecher, Darren Nakao, Chun Wang and Deborah Juarez. It makes for interesting, if difficult, reading.

The Disease Management Care Blog will try to summarize.

The authors evaluated the Hawaii Medical Service Association's "HealthPass" program. This includes a health risk assessment (HRA), biometrics (like the usual lab tests, blood pressure measurements, assessments of body mass index plus the age/gender recommended screenings), counseling (which could be one-on-one, group or telephonic) and access to online awareness, education and motivational wellness support interventions with or without financial incentives. In other words, it was state-of-the-art.

In order for HMSA enrollees to be included in the study, they had to be between 18-70 years old, a member for at least 9 months between 2002-2005, not exceed $100,000 in claims per year, not have been in a nursing home and not have remained in a hospital for a prolonged period of time. Of the approximate 384,000 HMSA members, 166,201 (43%) met the criteria described above. Of this group, a total of 11,883 participated in HealthPass at some point (it looks like 11,498 in 2002, 5192 in 2003, 4247 in 2004 and 4060 in 2005, suggesting some individuals participated over multiple years). Age, gender, baseline morbidity and baseline costs were used in "propensity matching" to fashion a one-for-one non-HealthPlass comparator control group for each of the four study years.

Compared to the control group, HealthPass participants consistently had lower total average health care expenditures. What's more, those savings exceeded the yearly HealthPass costs (which ranged between $204 and $236 per year). The net savings was $34 per participant in 2003, $132 in 2004 and $124 in 2005. The calculated total "return on investment"was $1.58 in reduced claims expense for very dollar spent.

In addition, there appeared to be a "dose response" curve: more years of participation led to even greater savings. What's more, persons with higher levels of morbidity appeared to achieve greater savings. Finally, the savings appeared to hold up if two year cost trending was used to project future costs.

When the DMCB was reading this, it found it hard to understand which year's savings was being compared to which year's costs. With that caveat, it thinks this study is part of an expanding body of evidence that supports multi-component worksite wellness programs. The authors also deserve credit for correctly pointing out that there may been been ethnic, educational, psychological, attitudinal, behavioral or other unmeasured factors that were not captured by the propensity matching that could have accounted for the observed differences.

Last but not least, two of the University of Michigan authors (Drs. Schwartz and Strecher) are also affiliated with the HealthMedia care management program. Bravo, says the DMCB. It wishes more if its academic colleagues would get into fashioning and evaluating "real world" programs that are not only doing measurable good but are commercially viable. As an added bonus, you check out this video here of Dr. Strecher explaining his passion for web-based health behavior change. Watch it over lunch with your salad, tofu, yogurt or donuts. You won't be disappointed.

Image from Wikipedia

"Don't Litigate, Innovate." How To Implement A Fully Funded Alternative To The New Health Care Overhaul -- And It's Already In The Law

This post of mine first appeared at Kaiser Health News last week.What if a Republican governor and a Republican legislature had the ability to implement their version of health insurance reform and the federal government would have to pay for it? It's a great idea. And I'm thrilled to say that a bi-partisan bill has already been introduced in the Senate by Ron Wyden, D-Ore., and Scott Brown,

Population Health Management Journal Summarized Again!

It took a while and it needed some much needed breathing space, but the Disease Management Care Blog finally stopped looking guiltily at its unread October issue of the Population Health Management Journal and finally cracked the cover. It knows it's not the only one battling a very busy time of year and that there are holidays to contend with. So, here comes the DMCB to our mutual rescue with this handy narrative summary of each of the PHM articles. Now you can efficiently catch up, find some pearls to quote or decide to take a closer look at an article (your own copy can be found here) that captures your interest.

Dan Kent, Linda Haas, David Randal, Elizabeth Lin, Carolyn Thorpe, Suzanne Boren, Jan Fisher, Joan Heins, Patrick Lustman, Joe Nelson, Laurie Ruggiero, Tim Wysocki, Karen Fitzner, Dawn Sherr and Annette Lenzi Martin: Healthy coping: Issues and implications in diabetes education and care.

What happens when you put some CDEs, PhDs, RDs and one MD in a room and ask them about “coping skills” among persons with diabetes? This article is what happens, which has everything you’d want to know about the topic and more. The DMCB learned that “coping” is among the seven diabetes self-care skills (in addition to healthy eating, being active, monitoring, medications, problem solving and reducing risks) that has been identified by the American Association of Diabetes Educators (AADE). It can be defined as “responding to a psychological and physical challenge by recruiting available resources to increase the probability of favorable outcomes.” It’s difficult to measure, highly dependent on psychosocial factors, vulnerable to depression and should be routinely assessed in the course of patient counseling. The DMCB thinks this is a good article that give readers a different way to think about the coaching that they already know about.

Kavita Nair, Kerri Miller, Jinhee Park, Richard R. Allen, Joseph J. Saseen and Vinita Biddle: Prescription co-pay reduction program for diabetic employees.

The DMCB always thought that small swings in pharmacy insurance co-pays for medications would translate into big differences in medication compliance. So, when an unidentified “state employer” moved all its diabetic medications to the lowest tier ($10 to $20) co-pay it would have thought that the 589 continuously enrolled persons in this study would have had more than just a 3% increase in medication adherence (defined as filling 80% of chronic prescriptions) in the following year. There were decreases in emergency room and hospitalizations among the 589 persons who were continuously enrolled during the study period. Unfortunately, this was a "pre-post" study and authors are correct when they note that it's difficult to ascribe any of the measured changes to the decreases in the co-pay. The DMCB notes that it really can’t conclude anything after reading this article.

Safiya Abouzaid, Eric Jutkowitz, Kathy Foley, Laura Pizzi, Edward Kim and Jay Bates: Economic impact of prior authorization policies for atypical antipsychotics in the treatment of schizophrenia.

What happens when a research grant from a pharmaceutical company pays for a study that uses a “decision analytic model” to assess the impact of something disliked by pharma: insurer-based medication prior authorization (PA)? The DMCB figures chances are that it’ll show it doesn’t work. While this study showed “only modest savings approximately half the time,” the DMCB lives in the real world and doesn't trust this brew of model inputs, software, assumptions and sensitivity analyses.

James Springrose, Felix Friedman, Stephen Gumnit and Eric Schmidt: Engaging physician in risk factor reduction.

In this study, the authors got three primary care practices with 17 providers to agree to participate in a pay for performance (P4P) and referral program involving 546 patients who, on the basis of a claims analysis, appeared to have coronary artery disease, diabetes or high blood pressure. These were patients with two years of established care who were re-evaluated over the 6 months after the program started. Each "biomarker" improvement in weight, lipid levels, diabetic control or blood pressure control resulted in a $65 payment. Providers were also encouraged to refer patients to a disease management program. Compared to the baseline period, when there were 9 spontaneous biomarker improvements, the 6 month period had 96 pay-outs. Of 187 patients who appeared to be candidates for referral into disease management, 80 were actually referred by the providers and 43 agreed to participate. The DMCB thinks this is an interesting pilot study and the notion that P4P could promote buy-in for referring to disease management to be interesting. More research using a concurrent comparator would be a good next step.

Alex Harris, Katharine Bradley, Thomas Bowe, Patricia Henderson, Rudolf Moos: Associations between AUDIT-C and mortality vary by age and sex.

Screening for alcoholism identifies persons who are alcoholic and alcoholics have a higher rate of death, so do persons with a positive screening test have a higher rate of death? In this instance, from 2004-2005, approximately 225,000 Veterans Administration patients were given the AUDIT-C screening tool. When the 1-12 range (the higher the score, the greater the likelihood of alcoholism) AUDIT-C score was divided into quartiles, women in the highest quartile had an increased death rate, as did men in the higher two quartiles. Male non-drinkers also appeared to have a higher death rate. The DMCB finds none of this surprising and thinks this confirms the need to aggressively screen for alcoholism in the course any care programming.

Urvashi B. Patel, Quanhong Ni, Carol Clayton, Peter Lam, Joseph Parks An attempt to improve antipsychotic medication adherence by feedback of medication possession ratio scores to prescribers.

Missouri instituted a “Treatment Adherence Program (TAP) in four community mental health centers for patients that had been prescribed antipsychotic medications. When these patients failed to filled their prescriptions at 7, 30 and 45 days, an alert email was sent to a responsible provider in the clinic. 78 patients with a record of lapsed prescriptions were compared to a convenience group of 269 patients. Compared to the control group, patients in the intervention group has a small but statistically significant increase in filling their prescriptions over the 6 months surrounding the intervention. This decayed after the alerts were stopped. The DMCB thinks this was a nice try, but more will be needed to help these patients continue to take their life-saving medications than simply alerting their overworked providers.

Ronald Loeppke, Dee Edington, Sami Bég: Impact of the prevention plan on employee health risk reduction.

Three disparate employer groups used a wellness program (including a health risk assessment, blood screening tests, results review with recommendation, an action plan, live and web-based support services and ongoing feedback). 2606 employees completed the entire suite of services. 15 health risk measure categories were assessed over the course of the following year, and they were compared to the "Edington Natural Flow Model" that measures health risks in a population without access to health improvement. If you believe the model, the reduction in 10 of the risk categories achieved statistical significance that favored the intervention group. Close to half of individuals in the overall high and moderate risk categories moved to the next lower level of risk.

The Disease Management Care Blog Gets A Grooming

Thousands of regular readers of Disease Management Care Blog readers will notice that the information, links and other helpful stuff over on the right of its web page have been updated. The DMCB rearranged them into categories such as News and Policy, Journals, Bloggery, Commerical Health Insurer Coverage Policies, Guidelines 'n Standards and created a new one called Not A Waste of Time. Since its humorous videos on ACOs and the PCMH have far exceeded most of the other yawnfest YouTube postings on both topics, the DMCB decided to link them too.

Readers are always invited submit alerts about other links that may be useful to the DMCB community.