Health for life

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bushs gut instincts over Iraqs weapons of mass destruction versus Barack Obamas disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isnt too sure how TEDTalks Dr. Iyengars suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldnt have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.

Nothing like academic fisticuffs to capture the Disease Management Care Blogs interest. The well timed punch that exposes a methodologic weakness.  The counter punch that quotes past research.  The bob and weave of spin and framing.  Misquoting blows below the belt. Statistical pokes in the eye.  The DMCB says its better than foreign politicians brawling, Kill Bill sword fights and lurid professional wrestling.

Which is why its enjoying a big dust-up over the Community Care of North Carolinas medical home initiative in the "Letters to the Editor" section of the January 2013 issue of American Journal of Managed Care (AJMC).

Regular readers may recall this early 2009 DMCB alert about the CCNCs actuarially derived claims of savings with its medical home.  Al Lewis of the Disease Management Purchasing Consortium eventually caught-up the the DMCB with his own three-fold roundhouse of a punch directed at CCNC that was published in August 2012 AJMC:

1. Claims of $250 million in avoided hospitalization costs on a baseline 2006 cost of $114 million is very unlikely,

2. Outside data indicate that Medicaid admissions in the state only fell from 36 to 34 per thousand, which also makes any claim of hundreds of millions in savings suspect, and

3. Two neighboring states without a medical home initiative experienced the same modest declines in hospitalizations without the same savings.

Well, the actuaries involved in the original Community Care report have jabbed back:

1. The baseline that was used was an actuarial projection of what costs would have been, based on prior trends, not 2006

2. The observed savings were never ascribed to avoided hospitalizations

3. The medical home initiative had been in place for many years, which could explain its impact.

The CEO of Community Care also penned his own counter-strike.  He argues:

"Evaluating complex programs is a difficult and evolving science, but [the] approach to estimating CCNC’s impact is reasonable, measured, and up to the latest standards in the field. Its analysis plays by the same actuarial rules as everyone else—including disease management vendors calculating a return on investment and insurance companies setting rates."

.The rest of the letter uses terms like "disturbing," "facile" "erroneous" "mistakes" "misrepresents" "circular erences." Ouch.

The DMCB fully expects the spat to continue and looks forward to enjoying its ringside seat.  In the meantime, its sticking to its original point from more than 3 years ago: the CCNC analysis was an opaque actuarial analysis that was never subjected to the scrutiny (and editing) from independent peer review.  If it had been, the reviewers would have spotted many of Mr. Lewis concerns and forced the authors to be more transparent with their methods.

Lesson learned.

Lets fix it!

While noisy media leprechauns dispense blame and declare winners in the government shutdown imbroglio, the Disease Management Care Blog remains focused on the next steps for meaningful health orm. So are JAMA authors Jack Lewin, Lawrence Atkins and Larry McNeely who, other than one lapse in their editorial, get it mostly right.

Their important insight is that the Bipartisan Policy Center, Brookings Institution, Commonwealth Fund, Kaiser Family Foundation, the National Coalition on Health Care, Partnership for Sustainable Health Care and Urban Institute all have a remarkable degree of overlap in their recommendations for the next phases of health orm. 

Most of these expert organizations agree on the merits of value-based payment as well as insurance orm (pay for quality), information technology, competition, tort orm, evidence-based benefit design (paying when theres evidence that it works), workforce changes (greater efficiency), orming Medicare, changing tax policy (the exemption for health insurance) and instituting regional or local caps (stick to a budget or theres consequences).

The DMCB wholeheartedly agrees and hopes that the bipartisan consensus evident among these think-tank institutions leads Congress (if not this one, the next) and the President (if not this one....) to use these ingredients to build on the successes and correct the many deficiencies of the Affordable Care Act.

And the lapse? 

Jack Lewin et al were missing one thing. The DMCB looked in each of these organizations web sites and found that there was also considerable support for population health management.

To wit:

The Bipartisan Policy Center - while the emphasis of this report is on health information technology, the real dividends are pretty clear when it mentions "population health" 14 times:

This plan should address the development and adoption of policies and standards needed for the delivery of care, the empowerment of individuals, and improvements in population health based on national health and health care priorities.

The Commonwealth Fund:

 Effective population health management requires fundamental change in care delivery that must be supported by changes in payment.

National Coalition

Real orm means engaging consumers in their own health and health care choices. In both Medicare and too many private plans today, benefit design neither supports self-management of chronic disease nor distinguishes between care that is effective and care that is not.

Partnership for Sustainable Health Care - see page 22:

Federal nurse education funding should be ocused to equip registered nurses to assume the roles of case manager and population health coordinator.

The Urban Institute - see page 17 on the topic of Medicaid orm:

States can start in select geographic areas or specific population groups (adults and children or specific chronic conditions), and then incrementally expand them after learning from experience and making program improvements and adjustments. Broader efforts typically mean additional stakeholders, increased collaboration and communication.