Health for life

Even the modest Disease Management Care Blog has to agree that its recent Patient Centered Primary Care Collaborative webinar on supporting care coordination within the medical home was a huge success.  Not only did it get to learn about the impressive work underway at North Shore-Long Island Jewish Health System, but the questions from a record 522 listeners helped the DMCB sharpen its focus.

Here’s one of the better questions that was emailed after the webinar was concluded:

What shared savings arrangements can happen on a small scale, for example a 4 doc office?

The (gently edited) DMCB reply:

None.

The month-to month variability in the insurance claims (think 95% confidence intervals) from a small practice makes it practically mathematically impossible to confidently compare an observed dollar amount to a target dollar amount. 

There are methods that can be applied to diminish the variability (such as censoring “excess” claims and using “risk adjustment”) but, at the end of a fiscal year, a lack of documented savings could be the result of either a) poor care coordination or b) an “underpowered” or mathematically suspect claims analysis.  The skeptical insurer will say it was the former and the screwed docs will say it was the latter.  When that happens, docs lose.

This is an example of the “law of large numbers” and why the shared risk arrangements in Medicare ACOs have to be based on a minimum of “5000” persons. By having that many observations, the variability is blunted and measures of central tendency hold up in an actuarial basis.

And then there are the two policy implications.  First of all, shared risk contract involving a relatively small practice is perilously close to the bad old days of capitation and HMOs, vs. the approach of spreading accountability across a large system that is armed with all the requisite care coordination resources  A four person group can’t match that.  Secondly, the insurers have little interest in putting together a payment system that could financially cripple a four person clinical practice, especially if its primary care.

The DMCB will examine accountable-like arrangements for a small group practice in a future post.

Data is in there somewhere!

Remember the Physician Group Practice Demonstration?  Its results were used by CMS to justify Accountable Care Organizations (ACOs) with the luster of millions of dollars in shared savings and the thrill of being a "partner" with the worlds largest health insurance behemoth, intent on "achiev[ing] a transformed and modernized health care system."

The Disease Management Care Blog has never been all that impressed by CMS bluster.  It became less so when it checked out this short video by a physician leader from one of the Group Practice Demo participating organizations.

Its an interesting story. After being confronted by suboptimal quality scores in the first year of the Demo, the provider organization naturally responded with corrective programs.  However, there was also an 18 month delay in CMS ongoing provision of the quality measures.  Since too much money was riding on meeting the CMS performance threshold, they had to develop their own internal reporting systems. Without them, they would have been flying blind and unable to gauge whether they were making any progress.
 
Another lesion from the Group Practice Demo?  If youre going to be an ACO, dont count on the Feds and mistake CMS size or promises for nimbleness or action.  And make sure you have your own data resources and dashboards to manage the quality "real time."

Image from the Lawrence Livermore National Laboratory

Sweet readers! You did it! Using last week’s Ask the Internet column, you jointly refined an okay recipe to be inexpensive, healthy, and totes delicious. Color me excited.

To recap: last week, I posted that I’d been having problems with a new dish, Parmesan Polenta with Spinach and a Fried Egg. The polenta was dry, the spinach left a funky aftertaste, the texture was mushy, and it lacked overall oomph. Based on your suggestions, I experimented with it three separate times, tweaking the ingredients and methodology a little each time. It kind of went like this:

ATTEMPT #1
Changes: For the polenta: skipped the parmesan, replaced milk and water with chicken broth, increased the amount, and stirred in butter at the end. Added a little more garlic and red pepper flakes to the spinach, and cooked it for a slightly shorter period of time. Left the egg as-was.
Result: Improved polenta flavor and texture. Egg so-so. Spinach and oomph still questionable.

ATTEMPT #2
Changes: Sauteed one ounce of chopped pancetta to start. Stirred it into polenta, and used the leftover oil to cook the garlic, red pepper flakes, and quick-wilt the spinach. Then, used the leftovers to “fry”/steam the egg.
Result: Pancetta an EXCELLENT addition – increased flavor and textural fun-ness. Didn’t need extra fat to cook the egg, either. Spinach continued to be the bane of my existence.

ATTEMPT #3
Changes: Swapped Swiss chard for spinach.
Result: VICTORY, sweet readers. The chard gave it all the scrumptious veggie goodness with nary a fraction of that annoying metallic residue. Now we dance!

Ultimately, the whole shebang was maybe a tad heavier and a few cents more expensive than I intended. But the former makes it suitable for dinners, and the latter can be easily remedied by buying Swiss chard in season. (Which I did not do. Mine was plated in gold, apparently.) These are minor quibbles, though. Overall, the whole thing rocked my socks. (And I’m not even wearing any. Go figure.)

So, I’m raising a pretend glass of champagne to y’all. Then I’m pretend drinking it. After that, I’m pretend stumbling around and wondering why the apartment is spinning. Finally, Im pretend sauntering downstairs, pretend shoving my face into the fridge, and pretend eating the leftover pancetta raw. Woo hoo!

~~~

If you like this recipe, you might also quite enjoy:

• Grilled Swiss Chard
• Kale with Mushrooms and Polenta
• Swiss Chard with Pinto Beans and Goat Cheese

~~~

Polenta with Swiss Chard, Pancetta, and a “Fried” Egg
Serves 2.
With help from Carrie, Ira, Morgan, Ona, Evelyn, Clea, Michelle, Meagan, Anna N., Claire Dawson, Diane, Katy, Rick, Val, anotheryarn, biankat, wosnes, Happy in Nevada, Katie, Rachel, LaDonna, JohnB, Deeds, Mary Joy, Dana, Elizabeth, Sassy Molassy, Rebecca, and sweet, sweet Anonymous.


2/3 cup corn meal
1 14.5-ounce can low-sodium, reduced-fat chicken broth
1 teaspoon butter
1 ounce thinly sliced pancetta, chopped
1 small clove garlic, minced
1/4 to 1/2 teaspoon red pepper flakes
4 ounces fresh Swiss chard, stemmed and torn into bite-sized pieces
2 eggs
2 teaspoons parmesan
Kosher salt and freshly ground black pepper, to taste

1) In a medium pot, whisk the cornmeal and broth together. Cook over medium heat, stirring frequently, until all liquid is absorbed. This should take 8 to 12 minutes. When finished, turn off heat. Stir in butter until melted. Set aside.

2) Meanwhile, in a large nonstick skillet, cook pancetta over medium heat until it releases its fat and is almost crispy. This should take 8 to 12 minutes. Remove meat from pan with a spoon, and stir into polenta. Evenly distribute the mixture between two serving bowls.

3) Turn skillet heat up to medium-high. Add garlic and red pepper flakes. Cook in pancetta oil until fragrant, 30 to 60 seconds, stirring frequently. Add Swiss chard. Saute about 2 minutes, until just barely wilted. Spoon on top of polenta.

4) Crack two eggs into the skillet, making sure you keep the yolks intact. Add a teaspoon of water to the side of the skillet and cover. Cook 2 to 4 minutes, until the barest white film appears on the top of each egg yolk. Gently place the eggs (one each) on the polenta and chard. Sprinkle each bowl with 1 teaspoon parmesan. Salt and pepper to taste. Serve.

Approximate Calories, Fat, Fiber, Protein, and Price Per Serving
333 calories, 12.2 g fat, 4.4 g fiber, 15.9 g protein, $2.13

Calculations
2/3 cup cornmeal: 336 calories, 1.6 g fat, 6.8 g fiber, 7.8 g protein, $0.30
1 14.5-ounce can l-s, r-f chicken broth: 9 calories, 0 g fat, 0 g fiber, 1.8 g protein, $0.75
1 teaspoon butter: 34 calories, 3.8 g fat, 0 g fiber, 0 g fiber, $0.03
1 ounce thinly sliced pancetta, chopped: 100 calories, 8 g fat, 0 g fiber, 6 g protein, $1.05
1 small clove garlic, minced: 4 calories, 0 g fat, 0.1 g fiber, 0.2 g protein, $0.03
1/4 to 1/2 teaspoon red pepper flakes: negligible calories, fat, fiber, and protein, $0.04
4 ounces fresh Swiss chard: 22 calories, 0.2 g fat, 1.8 g fiber, 2 g protein, $1.49
2 eggs: 147 calories, 9.9 g fat, 0 g fiber, 12.6 g protein, $0.42
2 teaspoons parmesan: 14 calories, 1 g fat, 0 g fiber, 1.3 g protein, $0.12
Kosher salt and freshly ground black pepper, to taste: negligible calories, fat, fiber, and protein, $0.02
TOTALS: 666 calories, 24.5 g fat, 8.7 g fiber, 31.7 g protein, $4.25
PER SERVING (TOTALS/2): 333 calories, 12.2 g fat, 4.4 g fiber, 15.9 g protein, $2.13