Telephonic Disease Management "Opportunity for Savings" in Body of the Article, "Does Not Save Money" in the Title?

Readers of the Disease Management Care Blog may have missed this provocatively titled article, "Telephone-Based Disease Management: Why It Does Not Save Money" that was published in January 2011 the American Journal of Managed Care. The DMCB not only didn't miss article, it quietly wrote a Letter to the Editor. It was only a few weeks ago that it learned that it had been scooped by a better letter.

The DMCB decided to bide its time.

In the original AJMC article, former Healthways researcher Dr. Motheral reviewed the early promise of telephonic disease management (borrowing from programs aimed at reducing readmissions) and the bitter disappointment that followed once the industry matured and underwent greater scrutiny. Reasons for the stumble, according to the author, were 1) numerous econometric studies that showed most preventive treatments do not reduce costs, 2) numerous econometric studies that showed most specific chronic illness care interventions do not reduce costs, 3) dawning awareness that the financial impact of increased utilization (for example, pharmacy) can exceed other program savings and 4) the non-generalizability of published positive studies versus the real world, where program content or the measured outcomes were often modified.

Yet, Dr. Motheral points to four lessons learned since then: 1) applying disease management to vulnerable patients "may provide opportunity for cost savings," 2) some commercial disease management programs work better than others, 3) face-to-face interactions are more potent than telephonic ones and 4) transparent peer reviewed studies trump enthusiastic marketing gimmickry.

The letter mentioned above has recently appeared on-line and was authored by former LifeMasters CEO and current ZOLO Consultant Christobel Selecky. In it, she points out that disease management has evolved in response to Dr. Motheral's criticisms, uses many of the approaches that have also been shown to reduce readmissions and that it's not its fault that the market is demanding costly preventive and care interventions. She also asks why no other sector of the health care industry (like physicians) has been asked stop providing services because it doesn't "save money." Rather, she argues, the future of disease management, and, by the way, health care in general, lies in generating value and continuing to build on what has been shown to work.

The AJMC Editors gave Dr. Motheral an opportunity to reply (same letter link). She notes that assessing value generally means politically thorny and intellectually complex cost effectiveness studies and that the industry, with one exception, has been remiss in showing that it can reduce readmissions. Finally, she asks, if the industry is evolving, why are employers still paying for millions of persons to get questionably effective phone calls?

Ouch.

So does this tempest in a disease management teacup diminish the disease management industry? The DMCB doesn't think so. Such is the nature of medical publishing, where authors vigorously debate competing approaches to care, heap scorn, score points and draw blood. In the end, issues are clarified, new areas of investigation are opened up, medical science is more precise and patients are better off.

As for the eternal debate over "saving money," it not only makes for interesting reading but great bloggery. Over its history, readers will recall that the DMCB has practically made and addressed all of Dr. Motheral's concerns, including the disconnect between prevention and savings (also by linking this article many times), the dubious value of some diabetes interventions, why disease management can work despite cost-effectiveness naysaying, the complicated nature of pharmacy in disease management, the difference between efficacy and effectiveness, the benefits from targeting vulnerable patients, combining disease management with face-to-face care, the limits of cost-effectiveness studies and the need for the industry to invest in peer-reviewed research.

As for the observation that some disease management programs work better than others, isn't that the point in a competitive marketplace? By the way, isn't that also a lesson for our faith in clunky government run demos and health care programs?

When it wrote its letter to the AJMC, the DMCB saluted Dr. Motheral for an insightful review but questioned why the editors allowed the author to use such a contentious title. After all, the body of the paper suggests costs savings are well within reach and expertly describes what the industry can do to "bend the curve."

As we know, the DMCB letter was not accepted for publication, but the question remains: why not a title worthy of a fine, balanced and supportive review, like...

"Telephone-Based Disease Management: Why It Will Save Money" or....

"Telephone-Based Disease Management: Why Cost Savings Are In Reach" or...

A DMCB favorite: "Telephone-Based Disease Management: Why The Disease Management Care Blog Has Been Correct About An Approach to Care That Can Save Tons of Money."

Are Primary Care Bundled Payments for Chronic Illness Really An Answer?

In this enlightened era of "evidence-based" medicine, you'd think that the progressive academics, viziers, and mandarins who are cluttering the policy making commentariat would pay more attention to what was tried before. That should be doubly true if those lessons come from that health care nirvana called Europe, where enlightened central bureaucracies wisely allocate health care for its caffè sipping, plaza strolling and beret adorned citizenry.

Case in point is "bundled payment," which has been underway for several years in the Netherlands. Thanks to this timely New England Journal Perspective from Jeroen Struijs and Caroline Baan, readers can get some insight about what is and isn't known about the topic.

By way of background, the Dutch require citizens to buy subsidized private health insurance for "short-term level" services, such as outpatient care and acute hospitalizations; prolonged care and durable medical equipment is covered by public insurance. Their reliance on private insurance has been held up as a role model for the United States.

According to Drs. Struijs and Baan, starting in 2007, private insurers began offering global payments to legally defined physician "care groups" who, in turn, accept the up and downside risk for persons with a chronic condition, such as diabetes, COPD or vascular disease. The single payment is negotiable for a defined bundle of services related to the condition itself. The care groups are typically made up of primary care doctors. They, in turn, provide and arrange for all the necessary care services and, when necessary, contract with other non-hospital providers (for example, labs) or other services. Patients with services falling within the bundle coverage provisions have no out of pocket expenses.

So what happened?

1. Variability persisted. Bundled payments turned out to vary from group to group and cannot be explained by patients' burden of illness or the intensity of services. Other factors that probably played a role were differences in how the bundled coverage terms were interpreted and, thinks the DMCB, the negotiating leverage of the various care groups.

2. Integration grew. Providers became organized with greater attention to coordination, protocols and consultations. There was a greater emphasis on use of the EHR. In surveys, physicians reported that they believed they are providing better care.

3. Transparency increased. Providers were obligated to document and report performance against established benchmarks.

but....

4. Outcomes, you ask? According to authors, "...it is still too early to draw conclusions about the quality of care or the effects on the overall cost of care." There has been no observed impact on glucose control (A1c), lipids, patient satisfaction or cost. So far.

5. Market power increased? Some subcontractors reported that they are being squeezed by the care groups' local market power. What's more, patients' freedom of choice in the selection of subcontractors may have been curtailed.

6. Bundle "boundaries?" The Dutch are still working to define just what services are covered by the chronic care bundle. That's important, because the care groups have an incentive to cost shift.

Most U.S. observers seem to agree that the fee-for-service system is broken. Drs. Struijs and Baan are reminding us that replacing it, despite policy savoir faire of many U.S. europhiles, isn't necessarily going to reduce costs, increase quality or not introduce its own set of unintended consequences.

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The Disease Management Care Blog typically doesn't toot its own blogging horn, but it will take an end-of-the-week moment to reflect on the State of the Union in its small corner of social media. This pause has been prompted by the DMCB YouTube "Setting Up An Accountable Care Organization" video crossing the 10,000 view mark. The DMCB hasn't found much in the way of reliable statistics, but it suspects that puts it in the top 5th percentile. It's also the 2nd most frequently viewed YouTube video on the topic of ACOs. This is probably because viewers appreciate its humor while making some important points.

As for the DMCB site, it estimates, using Google Analytics, that it has had over 16,000 returning visitors over the past year. Among these, it loosely calculates that there are about about 5500 readers that return more than once a month. Based their ISPs, many are from care management organizations, consulting groups, government and academia - a high quality group!

As further testimony to the DMCB's web footprint, there also are approximately "RSS" 400 subscribers, several attempts a day to plant spam in its "comments" sections and it finally hit $100 in Google Ad revenue.

And why does it blog? Because it makes the DMCB think - sometimes correctly, sometimes not - about an important health care issue five days a week 365 days a year. Since it started years ago, there are over a 1000 posts. Until it finds a better way to accomplish that or do something more important, it's going to keep it up.

In the meantime, readers, thank you for giving the DMCB your precious time.

The Latest Health Wonk Review Is Up!

Do you like watching or thinking about baseball? Neither does the Disease Management Care Blog, but it may have to change its mind after taking look at the latest Health Wonk Review. Brainy Glenn Laffel (he is an internist, after all) has assembled the latest high quality health policy bloggery in a marvelously crafted "Spring Training Edition" over at his Pizaazz Blog. Pull up a bleacher and enjoy.

Quotes, Insights and Impressions From The Population Health & Care Coordination Colloquium: Health Reform, "Broken" FFS, Retail Clinics & The Truth

The Disease Management Care Blog scribbled notes while it was at the just concluded Population Health and Care Management Colloquium in Philadelphia. Some are paraphrased quotes, others are insights and others are opinionated impressions. With that caveat, here are some of the better ones in no particular order:

Attendance was high (enough to fill a large hotel ball room), jargon ("engaged patients!" "accountable care!") abounded and enthusiasm was high (makes no difference if health reform is upended by the Supreme Court or an implacably opposed Republican party, there is no going back).

While many speakers prized the intimacy of a primary care doctor-patient relationship, they had little problem with the intrusion of other non-physician "team" members at the local clinic level. While they seemed to think its purpose is to "help" PCPs, the DMCB suspects many of its primary care physician colleagues have a different perspective. They secretly welcome the prospect of the involvement of non-physicians so that they can "outsource" that intimacy. That means that they'll be able to focus on the more interesting complicated medical stuff.

Think retail, convenient care walk-in and strip mall style nurse-run clinics are going to take off? Maybe, but three veterans from different corners of the country all agreed that they're only profitable when a) their services are covered by an insurance benefit (this is not a cash business) and b) they're closely aligned with a provider network and can refer patients. Otherwise, they're a loss leader. Primary care physicians seem to have little to fear from these bad boys.

Other speakers tut-tutted a "broken" fee-for-service system that "pays" for medical errors. What's wrong with that says the DMCB? When it buys a defective consumer product, it generally pays for a repair unless there is a guarantee (and that's built into the purchase price) or buys up to a warranty that's available for an extra fee.

Business owners are skeptical that health reform will work. The promises are old and there's no new money. Maybe that's because some of them read the DMCB.

Long term "central" intravenous access has been the subject of considerable research. Ask women who've been through it, however, and many will tell you that a major patient concern is its annoying proximity to their bra straps. The problem is that they haven't been asked. What else haven't we asked, and why not?

Speaking of which, one speaker from a national quality standards setting organization agreed with the DMCB that classic "evidence-based" medicine is just one of many windows onto the "truth." Others include observational data bases, effectiveness studies and qualitative patient surveys. Just like "disease management," or the "medical home" or the "electronic health record are not individually "the" solution to achieving high value health care.

Apple products have a high penetration among patients, but a downside is that it also doesn't use Adobe "flash" to support on-line movie viewing. One consumer health education company described how hundreds of Mac and "i"patients under contract were unable to access an interactive patient education video.

Talk to the average doc about the active participation of patients in developing their care plans, and they'll think this is all about "informed consent," in which patients sign all the necessary forms giving permission for surgery. They don't know there's a difference between informed consent and informed choice.

Those repugnant "death panel" scares may have prompted some patients to question the big deal over Dartmouth Atlas-style health care variation. They believe "more" is truly "better."

It is possible to roll publicly available demographic, health and income data up by zip code and assign a local "needs" score that can assist in population-based care planning. The DMCB has always been tempted to define "disease management" as "applied public health." Maybe that is more accurate than it appreciated.

A Summary Of the Population Health Management Journal

The Disease Management Care Blog's travels have been taking it back and forth to the Population Health and Care Coordination Colloquium. It's been taking copious notes at that meeting (more on that in a future post), but the travel-down time has been a DMCB opportunity to curl up and take notes on the articles in the latest issue of the Population Health Management Journal.

Brief article summaries posted below.

Yi Zhou, Robert Unitan, Jian Wang, Terhilda Garrido, Homer Chin, Marianne Turley, Linda Radler: Improving Population Care with an Integrated Electronic Panel Support Tool

In this study, the authors set out to study the impact of an electronic health record “integrated technology application” called the "Panel Support Tool" at Kaiser Northwest in Oregon and Washington state. The “PST” provided on screen point-of-care reminders, supported a patient registry and generated performance feedback using individual patient screen shots and practice panel summaries. Physicians were subjected to lab, medication and screening “care gap” reminders based on national guidelines, HEDIS measures and organizational priorities. To perform the study, the authors measured a series of cross sectional “care performance percentages” that consisted of the number of completed care recommendations (the numerator) divided by the number of indications for a total of 13 quality measures. These were obtained every 4 months for 20 months for 207 practice teams that collectively cared for over 263,000 patients. At baseline, the roll-up measure was 72.9% and it gradually increased to 80% at 20 months. During the study, there were no other "care gap" interventions, so even though this is pre-post, the authors believe the PST was responsible for the 7% improvement. Hardly a breakthrough, says the DMCB. But then again, nothing is.

Dahlia Remler, Jeanne Teresi, Ruth Weinstock, Mildred Ramirez, Joseph Eimicke, Stephanie Silver Steven Shea. Health Care Utilization and Self-Care Behaviors of Medicare Beneficiaries with Diabetes: Comparison of National and Ethnically Diverse Underserved Populations.

The authors used the "IDEATel" telephone survey to compare urban versus rural diabetes care for persons living in two medically underserved areas. 755 respondents (75% and 28% self identified themselves as black or latino) from northern Manhattan or the Bronx were compared to 867 respondents in rural upstate New York (35% and 17% reported black or latino). To be included, respondents had to be Medicare beneficiaries, be age greater than 55 years, diagnosed with diabetes and live in a “federally designated medically underserved” or a “federally designated health professional shortage area” in New York State. The survey was conducted from December 2000 to April 2003 and took respondents approximately ½ hour to complete. Compared to the rural group, the urban group had worse general health (11.6% vs. 5.1% self-rated their health as “poor”), more inpatient days (a mean of 3.48 vs. 1.53), more ER visits and more difficulty with a variety of self-care activities. The DMCB finds it difficult to generalize these data to the rest of the U.S. and wonders if the urban vs. rural differences were the result of other sources of unidentified bias.

Donald Fetterolf: Long-Term Results Evaluation in Medical Management Programs.

Here’s a solid review paper that tells you everything you need to know about the evaluation of the long term impact of disease management programs. This includes “bending the trend,” the phenomenon of a therapeutic “plateau” once any interventions have reached a steady state and the occurrence of a “step function,” which signals the impact of a one-times savings impact. While you may think savings between programs should be easy to calculate, that’s not the case, thanks to a lack of standard methods, groups not being comparable, a lack of control groups, evolving practice standards and shifting program content. In addition, cost is not the only consideration. There is clinical impact, quality of life, future risk pool effects, branding and employee retention. Once a program has plateaued, it’s tempting to turn it off, risking an upward “rebound” in cost trending. Once again, Dr. Fetterolf takes a complicated topic and puts it within reach of us mere mortals.

Patricia Harrison, Pamela Hara, James Pope, Michelle Young, Elizabeth Rula: The Impact of Postdischarge Telephonic Follow-up on Hospital Readmissions.

This is a study involving 30,272 Medicare Advantage plan members who were automatically enrolled in a chronic disease management program and who had a hospital admission for any reason in calendar year 2008. Any members who were discharged from a hospital were subjected to a “Hospital Discharge Campaign” that notified the provider of discharge, called the patient with 14 days of discharge, reviewed the orders to delete any duplicated or contraindicated prescriptions and made sure the patient understood “proper steps to take,” like participating in a timely PCP follow-up visit. The intervention study group numbered 6773 patients. 23,499 patients who were re-admitted prior to getting the call or who did not get the telephone call comprised the convenience comparison group. In general, being older, male and having an increased length of stay was associated with a 30 day readmission. Admissions were highest 2-3 days after discharge; a third of all admissions occurred within 7 days. While patients who got the call were 23% less likely to be readmitted, the DMCB is concerned about the use of a control group that may not be a good comparator. The observed difference could be due to factors other than the phone call. This is a good start, but better and more research is needed.

Ron Cantrell, Julie Priest, Christopher Cook, Jack Fincham Steven Burch: Adherence to Treatment Guidelines and Therapeutic Regimens: A US Claims-Based Benchmark of a Commercial Population.

This was a “cross sectional and retrospective” study of HEDIS-like and national guidelines-based quality of care measures using pooled commercial insurer claims from the Ingenix Impact National Managed Care Benchmark Database. This contains information from a whopping 45 managed care organizations with 65 million enrollees. The authors focused on 2007 claims with persons who had identifying claims in 2006 (except for new depression) or 2007 consistent with asthma, COPD, CAD, depression, diabetes, heart failure, hyperlipidemia or hypertension. Based on the sample of approximately 5.5 million people with an index condition who had at least 6 months of enrollment the authors discovered most people with asthma don’t refill their inhalers, 3% of persons with COPD will have an exacerbation, the majority of persons with new depression fail to refill their antidepressants, and 44% and 48% of persons with diabetes don’t have an A1c or lipid test, respectively. There is lots of other information here, including tables of the average number of hospitalizations, ER visits and mean claims expense. Shortcomings of the study were listed by the authors and included the limited accuracy of claims, the lack of risk adjustment between MCOs and the potential non-generalizability of the time span that was used. The DMCB didn’t find anything that was surprising, but this paper could serve as a useful benchmark for comparison purposes.

Julie Priest, Ron Cantrell, Jack Fincham, Christopher Cook, Steven Burch: Quality of Care Associated with Common Chronic Disease in a 9 State Medicaid Population Utilizing Claims Data: An Evaluation of Medication and Health Care Use and Costs.

This is the Medicaid companion to the commercial study mentioned above. It too was a “cross sectional and retrospective” study, but this time it used pooled fee-for-service Medicaid claims from nine states using the Thomson Reuters Market Scan Multi-State Medicaid data base for asthma, COPD, coronary artery disease, depression diabetes, heart failure, hyperlipidemia and hypertension. Once again, the authors examined 2007 claims on persons identified with the index condition in 2006 or 2007; dual eligible and persons older than age 65 were excluded. HEDIS-like and national guidelines-based quality of care metrics were used. There were 2.8 million individuals with an average age of about 16 years. Only 23% regularly refilled their prescriptions on time and only about a third of newly diagnosed depression patients filled any prescriptions for an antidepressant. 70% and 63%, respectively, of persons with diabetes had A1c and LDL testing. There is other information, including hospitalizations, ER visits and means claims expense. Once again there was nothing surprising, but the numerous tables could serve as a benchmark.

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