Health for life

Measuring ROI

In yesterdays posting on Al Lewis book Why No One Believes the Numbers, the Disease Management Care Blog pointed out that the measurement of population health management (PHM) outcomes remains an inexact and still evolving science. While that can be a source of endless fascination for the DMCB, the inability of the industry to rustle up credible "return on investment" numbers has prompted some observers to condemn PHM as a waste of money.

The search for simple answers explains much of the appeal of this book.

According to author, one important solution is the "dummy year analysis" (DYA). This relies on repeated year-over-year measurements of utilization that use multiple comparison pairings of all patients with the condition of interest. When thats combined with a "plausibility" check list, Mr. Lewis says purchasers of the Patient Centered Medical Home (PCMH), disease management or wellness programs should be able to get a better fix on whether they saved any money. You can a sense of that perspective here.

The DMCB isnt too sure about that because a) other factors that have nothing to do with population health management can also impact utilization during and after the dummy years, making it difficult to assign an attributable ROI and b) entire health plan populations can likewise regress toward a regional or national mean.

The DMCB also sees three additional reasons why there may be less to this books methodology than meets the eye:

1. When employers, health plans, accountable care organizations or other buyers have a list of names that have been through a care program, they typically want to understand the outcomes for the individuals on that list. If thats the case, the challenge is to find an adequate comparator that portrays what would have happened in the absence of the care program. Multiple options for identifying a parallel comparator have been used in published science for decades. Thats difficult, imperfect, but not broken.  It remains an option.

2. While the book is replete with examples of "actuaries behaving badly," it is impossible to underestimate the influence of actuarial science and trending on premium rate setting, statutory accounting, and the regulation of insurance. As a result, if the actuaries say money is - or is not - being saved, health system leaders ignore their insights at their peril.

3. Isolating the impact of PCMH, disease management or wellness program out of all the other "noise" of a changing economy, evolving consumerism, benefit changes, electronic health record databases, medical advances, inflation and the news media is a function of an increasingly sophisticated and changing statistical sciences and computational technology. Its ironic, but one outcome has been a better description and measurement of the uncertainty surrounding a result.
 
To the authors credit, Why No One Believes the Numbers is not being promoted as the single best methodology that will lead PCMH, disease management and wellness programs to outcomes certainty. Rather, it is one option among many in asking whether a program had any financial impact.

Ultimately, theore, thats why the DMCB advises that measuring outcomes in PHM - absent an ironclad methodology - comes down to using multiple approaches to triangulate on the truth. After reading Why No One Believes the Numbers, some readers may choose it as one of those approaches.

Changing opinion from right to left

Has marriage made the Disease Management Care Blog a better person?

While it and the spouse heartily agree on the ultimate answer, using hard numbers to prove it to a skeptical mother-in-law is a different matter. To definitively answer the question, the affable DMCB came up with some proposed measurement approaches, such as:

1. Pre vs. Post: comparing past beer guzzling to present-day chardonnay sipping;

2. Actuarial: actual vs. projected appreciation for the leather-clad vampire vixens of Underworld;

3. Comparison to a Control: the DMCBs willingness to take direction on shrubbery trimming, versus that of more docile hubbies;

4. Randomized and Prospective: (the DMCB has wisely opted to not go there).

While the DMCB continues to work on the complex methodology of marital outcomes, it is reminded of a key paradox: while we live in an "Information Age," other pressing questions - such as the extent of the Eurozones influence on GDP, the merits of vouchers in public education and the link between the Presidents approval rating and his governing by remote memo - likewise defy conclusive measurement.

Whats more, frustrated by our worlds complexity, we ironically want fewer answers. The DMCB suggests this search for simplicity partially explains the luster of a balanced budget amendment, laws on minimum medical loss ratios, Newts bombast, Obamas rhetoric, blanket coverage of birth control and, last but not least, single approaches to assessment of population-based programs.

Which brings the DMCB to Al Lewis $10,000 challenge, in which he dares anyone to come up with a more accurate approach to measuring disease management return on investment. 

Al is a luminary in the disease management firmament who leads the Disease Management Purchasing Consortium. He was there at the founding of the Disease Management Association of America, led the attack on the vendors past lazy outcomes reporting and has been instrumental in questioning the conclusions about North Carolinas Medical Home Program. He now claims to offer the only approach to accurately measuring the financial impact of disease and population health management.

Maybe, but the DMCB would like to humbly offer up an alternate perspective.

Check out this DMCB paper that simultaneously deployed three uncomplicated methodologies to assess the claims expense impact of a chronic heart failure disease management program. While all three gave different answers, they all pointed in the same direction.

That was enough for the DMCB boss to continue the programs funding.

This same overlapping and multi-layed approach also underlies the Care Continuum Alliances Outcomes Guidelines Reports, which recommend a suite of measurement approaches that pivot on important determinants such as population characteristics, the influence of confounders as well as bias and the resources available to answer the question.

None of this should be any surprise to seasoned and prudent health administrators, physician leaders, clinical program architects or DMCB readers. They know that good actuaries use complimentary and overlapping approaches to come up with the right premium. They understand that good medical researchers demand caution, skepticism and multiple research studies before reaching any conclusions.

In other words, there is no one-time and one-size fits all approach in outcomes assessment.

All this adds up to the fact that optimum outcomes measurement triangulates on the truth. The measurement approaches advocated by the DMCB, Care Continuum Alliance members and health system leaders have been around for years, are within the reach of standard statistical software, are familiar to researchers and are highly adaptable to the circumstances of 99.99% of disease management programs, not to mention the medical home and accountable care organizations.

The DMCB says that when multiple, competing, overlapping, repeated and adaptable measurement methodologies point in the same direction, thats when regulators, consumers, purchasers, buyers, providers and patients and mothers-in-law can be really confident that they have the answer they need.

Image from Wikipedia

The Disease Management Care Blog is reconsidering the wisdom of agreeing to host the Cavalcade of Risk #140. The links below are a unpleasant reminder that disasters are lurking everywhere and that there is no escape.  Being a contrarian physician-blog that dwells on health care and insurance, your DMCB was confident that it could intellectually digest the topics below.  After writing this Cav of ubiquitous hazards, however, the DMCB now wants to digest some Xanax and PeptoBismol.

Who knew that so much could go so wrong out there?

Ever heard of the "Terrorism Risk Insurance Act" (TRIA) of 2002?  Neither has the DMCB, but readers can learn more about it at the Insurance Regulatory Law Blogs post on Quantifying the Unquantifiable: Some Perspective on Terrorism Risk.  It turns out the U.S. government is providing "reinsurance" (insurers can buy their own insurance) for a host of commercial companies that have to deal with a threat that is hugely expensive, quite rare and non-random, which is the very antithesis what the usual market needs to function well.  And by the way, TRIA is set to expire 2014 and it looks like it may not be renewed.  Seems some sort of budget issue has come up.

If being reminded about terrorism isnt enough to rattle you, how about cyberwar?  Thats tackled by the Risk Management Monitor Blog in this post on how UK Infrastructure Providers Accept an Unexpectedly High Level of Risk of Cyber-Threats, and the National Response Is Fractured and Incoherent.  It appears, lacking a coordinated response by their government, that the Brits businesses and banks have decided to deal with this risk on their own.  Unfortunately, theyre not dealing with it very well.  Not only have some companies been slow off the mark, others have decided to accept the inevitability of an intrusion and plan on simply dealing with it then.  How many other key industries worldwide have adopted the same cavalier attitude, asks the DMCB?

Terrorism, cyber attacks.... its enough to make the DMCB flee to the country and seek sanctuary on a farm and live simply off the land.  But wait, even that isnt safe, because Lynch Ryans Workers Comp Insider Blog points out that the risk of getting trapped, suffocated or crushed in a grain bin is increasing.  In response, the National Grain and Feed Association has a video on one more reason why our nations farmers deserve a lot of respect.  The DMCB thinks it deserves to flee back to the suburbs.

So it might be best to stay safe and stay at home, right?  Well, if you have a mortgage on that home, the canadianfinanceblog warns that your sneaky bank may try to to sell you "mortgage life insurance."  It turns out this may be a lousy deal, since the premium may not change even as the balance on the mortgage declines.  Better to get standard term life policy.  And when youve done that, you can scrutinize the rest of that small print in the mortgage documents that you signed for some other unpleasant surprises.

After you read all that fine print and discover what youve unwittingly agreed to, you may want to think about property losses from hurricanes, floods, tornadoes and earthquakes. Yes, you can buy a specific insurance policy for each of those possibilities, says the Free From Broke Blog.  On the other hand, given how uncommon hurricanes, tornadoes and earthquakes are, it may make more sense to invest in a sump pump and simply stash away an emergency fund.  The DMCB followed that game plan during the recent flooding from Tropical Storm Lee and now needs a basement mold mitigation fund and a get-rid-of-wet-carpets fund.

Plus, you may want to get "home insurance" against the possibility of a loss from a robbery.  Unfortunately, says the My Personal Finance Journal Blog, the cousins across The Pond are grappling with a daily toll of more than $3.5 million in home insurance fraud.  As a result, the DMCB calculates that honest home owners there are unnecessarily having to add a hidden tax of $1 for every $3 in insurance.

While youre putting bars on your home windows and barricading the doors, it may be smart to take that money out from under that mattress and seek some investment income, right?  If thats your plan, you may want to check out this "101" posting on the fundamentals of investment risks posted at The Financial Literates Blog.  How many things can go wrong, you ask?  "Fifteen" says the FLB!

Or if you want to avoid those 15 dreaded errors, how about an "annuity?"  This lengthy post by the Free Money Finance Blog on Why Do We All Hate Annuities explains that the fine print is perplexing, the sellers are a shady lot, their fees are high, the company (like AIG) could go belly-up, you lose control of your money and theyre still a big gamble.  One option is "laddering."  Another option, says the DMCB, is digging a hole and stashing away some precious metals.

While being attacked, hacked, crushed, ripped off or making a bad investment bet is a possibility, at least we Americans have an enlightened government that is helping us buy health insurance, right?  Think again, says Louise of the Colorado Health Insurance Insider.  She points out the feds online "healthcaredotgov" web site can be misleading.  It appears that the site reports blunt pricing underwriting statistics that fail to capture what is really going on.  While Louise makes the point that brokers can help customers navigate this complicated marketplace, the DMCB thinks that the healthcaredotgov website is a telling lection of the unsophistication of Washington DCs health insurance bureaucrats.  Good grief, and these amateurs actually want to be in charge.

Maybe you should take charge, then, and confront the risk that you may come down with a debilitating, crippling and non-curable condition and need long term insurance.  The curiously named High Yield Savings Accounts Blog  offers up a check list of what to look for in such a policy, such as excluded services, maximum lifetime benefit terms, riders and renewable guarantees.

While were struggling with hazards, perils, dangers, disasters, terrorism and disease, Hank Stern over at the Insure Blog suggests there is a way out from all this danger, at least for the fairer sex. Women may want to have a mid-day tipple because another observational study has shown that there is an association between imbibing and well being.  To that, the DMCB says "Cheers!" and points out if you end up in the hospital anyway, your physicians will know what to do.

"Gulp!" says the DMCB.  While it likes the idea of imbibing to support the DMCB spouses continuing good health, it thinks it should also look into buying an electric generator, firearms and a years stash of fresh water and vacuum-packed ready-to-eat meals.  While its doing that, itll be looking forward to Jay Norris of Insurance Shoppers hosting the next edition of the Cav.