Health for life

Getting ready for another announcement

Cornered by the politically inconvenient utterings of members of his Administration, President Obama threw election-year caution to the wind and stepped away from his "evolving" gay marriage perspective into an logorrheic gay marriage perspective: 

"At a certain point Ive just concluded that for me personally it is important for me to go ahead and affirm that I think same sex couples should be able to get married."

Sensing that wordiness may be that secret ingredient that turns feckless dodging into political determination, the public service-minded Disease Management Care Blog would like to offer the White House similarly crafted talking points in support of population health management.  These can be deployed by the President as the need arises at any time:

"After reading the science, Ive have reached a level of belief that warrants an individual decision to think that its important to conclude that population health management should be affirmed as a good thing."

"At a certain level, Ive just decided that for me, after regularly reading the Disease Management Care Blog, to support population health management and discern that the time has arrived in a manner that should prompt a level of commitment that Im willing to provide at this time."

"As the evidence reaches a degree of credibility that for population health management, I agree that a decision should be made in favor of incorporating this as a important option to consider as a worthwhile approach to care in the various programs supported in some manner by CMS."

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

But wheres the money?

The Disease Management Care Blog has always been leery of the "return on investment" (ROI) metric in health care. It knows that there are precious few health care interventions that actually "save" money. Many prevention, wellness and disease management programs     - depending on the analysis -  can cost money since they a) add additional resources to a system with already high fixed costs with b) a short one-year time horizon.

Yet, the good news is even if a program isnt successful in slowing the rate of cost inflation (or "bending the curve," which represents the savings), it can still represent a great value.  Thats because the additional benefit represents significant benefit for each additional dollar of spending.

Thats the message in this recent JAMA Viewpoint editorial Assessing Value in Health Care Programs authored by Kevin Volpp, George Loewenstein and David Asch. They offer up a thought experiment. Consider, they say, a state-of-the-art medication compliance campaign for heart attack victims that avoids a number of costly hospitalizations.  The price tag at $2000 has a positive "ROI" because the investment is less than the avoided cost of the hospitalizations.  However, if the price tag is $3000 and the investment is now greater than the cost of the hospitalizations, the ROI is "negative" even though the same number of patients didnt have to be hospitalized.

The DMCB recommends readers keep this manuscript/link handy the next time some Finance weenie demands an "ROI calculation."

Speaking of readers, the DMCB is happy to announce that it just hit 500 Twitter followers.  Thats in addition to more than 500 "RSS" subscribers, 461 Google Reader subscribers and thousands of return visitors per month.  The DMCB knows each was earned one person at a time.

Are you helping your e-patients?

(The Disease Management Care Blog welcomes the Nursing and Physician Leadership Congress attendees.  By the way, heres the link it mentioned.)

The Disease Management Care Blog got to hear a compelling conference keynote presentation by Dave deBronkart, a.k.a. "e-Patient Dave."    Think of this as an ePost from the eDMCB about the eBusiness implications of ePatients.

By the way, a more suited moniker may be "Remarkable Dave." Hes survived Stage IV kidney cancer thanks to a an interleukin based treatment regime that he wouldnt have known about if it werent for his use of the internet.  Thanks to his laptop and a remarkable degree of determination, he was able to network with similarly "empowered, engaged, equipped and enabled" cancer patients.  Now a multi-year survivor, hes a go-to patient advocate for the Washington DC cognoscenti, is a co-founder of the Society for Participatory Medicine and a tireless advocate for acor.org.

While the DMCB could never capture the scope of e-Daves presentation in this blog, there were some insights that may be of use to the disease management and population health management service community:

The "Soup" of Information: As more medical information becomes available on-line, patients, families and friends will be "swimming" in social networks that will yield more insights about possible diagnosis and treatment options than an average physician could ever know about.  This is not about reading on-line content.  This is the two-way sharing of information in community networks of like-minded individuals who spend a lot of time and effort becoming experts.  They ultimately produce value, not consume it.

Population Health Management (PHM) Implications: ePatients with chronic conditions are going to be unlikely to settle for the recommendations in your pre-fab care plans.  Be prepared to accommodate new inputs that will complicate and enrich self-management.  If a e-patient asks about an unknown treatment option out of "left field," the best answer may be "dont know, well find out more and get back to you."

Under the Garbage Theres Gold: When you consider that as many as 1 in 5 romances start with an on-line dating service that involves hundreds of options and many poor fits before couples find each other, it should be no surprise that much on-line medical information is likewise ill suited to an individual  patients circumstances.  Thats OK, because if patients keep digging, theyll find that key piece of information that they really need.

PHM Implications: An emerging value proposition: being a trusted advisor and catalyzing ePatient information networking and mining.

Wisdom of Crowds on Steroids:  The best source of that information?  Other patients who, unlike many of their physicians, have a lot of time and motivation to do "deep dives" in personally relevant research that would otherwise take years to enter mainstream clinical practice.  Theyll also share their personal experiences with each other.

PHM Implications:  Have you thought about not only helping your patients find an on-line community but hosting one?

Vaccine Airheads: Yes, there is a lot of potentially harmful information on the web but much of it is the fault of the medical community.  The spurious link between vaccines and autism, for example, was the result of fraudulent research and faulty peer review.  Compare the "death rate from Googling" to the "To Err Is Human" death rate of 98,000 per year, and you get the picture.

PHM Implications: As you accommodate an on-line community, expect some crazy points of view.  Thats the price of doing business.

Jerks Google Also:  If a hateful (maybe a less provocative term would be difficult) patient is using the internet to torpedo a doctor-patient relationship, chances are theyd torpedo the relationship without Googling.  Use of the web is an innocent bystander.

Some other DMCB take aways:

There is ample research on shared decision making (plus a good article here) that shows that when patients get all the information they need, most not only choose wisely, they choose conservatively.  While some may chose the "wrong" option, thats the price of patient empowerment.  From a population-based level most of the curve shifts to the left. The good outweighs the bad.

Once again, we are witnessing the breakdown of "credentials" that separate knowledge-based professionals and self-trained amateurs.  This is a disruptive innovation that represents an important threat to "cognitive" physicians.

Electronic health records that rely on a walled garden to try to capture patients will lose.  Electronic health records that can accommodate the messy world of eDaves will survive.  Electronic records that can enable it will win.

The ePatient movements benefits outweigh harms, is self-enforcing and impossible to regulate.  That doesn mean that someone is going to try to do it.

One last closing insight from eDave: If you are reading this, think about what would happen if you developed a serious or life-threatening condition.  You would start searching the internet. 

You are already an ePatient.

Image from an HHS web site

Anyone who regularly attends a house of worship is certainly aware of how preachers make a point of regularly visiting parishioners while theyre in a hospital. Since the Disease Management Care Blogs recent hospitalization involved an inconvenient distance (hour and a half drive) and time (6:30 AM), the DMCB pastor adapted by texting a prayer message. The DMCB took some comfort in what its colleagues euphemistically er to as "faith healing."

Which is one reason why the DMCB paid attention to this interesting peer-reviewed abstract. 170 obese persons were randomly assigned to either monthly emails or daily "personally relevant and interactive" text messages. There was no difference in weight loss at 6 and 12 months of follow-up, but persons who were "adherent" to the text messages had statistically significant greater weight loss and greater activity levels.  Satisfaction levels were also high in the text message group.

And then theres this other study that randomly assigned obese college students to text messaging plus Facebook, Facebook alone and a "waiting list" control group.  In the limited follow-up of 8 weeks, the text messaging group lost a significantly greater amount of weight (2.4 kg.) vs. the other two groups.

Is texting an option for weight loss in particular and for population health management (PHM) in general?  These two studies would indicate the answer for both is "perhaps."  A better answer may be that texting plus other PHM interventions is better and that texting for persons who per it is best. 

The DMCBs Fat Lady might also approve of texting. If its good enough for the prayerful among us, who can argue against it?

Image from Wikipedia

A physician welcoming the patient back to the hospital

Years ago, the Disease Management Care Blog had to readmit a recently discharged elderly patient back to the hospital.  It paged the colleague who originally discharged the patient and she offered up an important insight: the patient was so ill and feeble that it was remarkable that the patient made it out of the hospital in the first place.

Later, when the tut-tuting hospital quality assurance nurses started to swarm, the DMCB provocatively informed them that readmissions were the price of doing business.

Thats why the DMCB liked this New England Journal of Medicine article that questions the overall wisdom of Medicares national focus on reducing readmissions. Authors Karen Joynt and Ashish Jha make some good points:

1. What is the evidence? While a "readmission" is widely viewed as a failure of not having gotten it right the first time, in-depth chart reviews of readmitted patients reveal that only 12% - 25% are truly preventable.

2. Multiple causes: Not getting it right the first time is less of a cause than absent families, poor community supports and lingering poverty.

3. Death is the most effective solution: Hospitals that perform well in keeping patients with end-stage illness alive are ironically destined to have higher readmission rates.

4. Priorities: Trying to reduce readmissions will consume hospitals time and resources better spent on other patient safety initiatives. 

Drs. Joynt and Jha have two good recommendations:

1. Focus on those readmissions occurring within 3-7 days.  Those patients are more likely the victims of poor discharge planning that is under the hospitals control.

2. Alter diagnosis related group payments to include a "warranty" that covers the likelihood of readmission within a few days of discharge.

And, as is common among the health care academia, one good recommendation was missed:

3. Medicare should learn how to adopt, incent and pay for "best practices" from population health management interventions like this and this that lead to meaningful decreases in readmissions for the patients who are at greatest risk.  Whats more, the DMCB believes that if hospitals (and their spawn, ACOs) can "outsource" this to a third party who can provide this on a turnkey basis, they can better devote their attention to other critical patient safety needs.

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.

The right definition was there all along!

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over "population health."

The Disease Management Care Blog says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing "population health" for an entire geography. 

Between the here of "improving chronic care" and the there of "population health," Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term "population health" in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

In short, they dont believe ACOs, as currently configured, are up to the new task.  Thats because ACOs would need to collaborate with social service organizations, be responsible for a geographically defined service area and improve long term public health outcomes.  According to the authors subtitle, the answer to the question "should they try" is "no."

The Disease Management humbly disagrees.  Thats because Drs Noble and Casalino, the editors of JAMA and the manuscripts peer reviewers seem to be ignorant of the the correct definition of population health. Its right there on the Care Continuum Alliances web site, in this longstanding page that describes the "population health model of care."  When the DMCB did a simple Google search on "population health definition," it had little difficulty finding the link.

The CCA helpfully describes population health as:

a delivery model characterized as a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.

Was that so hard?

And how is that accomplished?  According to the CCA, the ingredients to that make for population health include:

• Population identification strategies and processes;

• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;

• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;

• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;

• Self-management interventions aimed at influencing the targeted population to make behavioral changes;

• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;

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

Accordingly, if an CMS-contracted ACO can identify its assigned Medicare population, perform needs assessments, promote awareness of health risks, offer education as well as support, increase self management, use data feedback and evaluate outcomes, its offering "population health."  By using that playbook, an ACO will capitalizing on the experience of a community of population health service providers that have been doing precisely this for over a decade.

This vision is far more compact than the overreaching, misinformed and muddled definition of "population health" offered in JAMA.  It is also, if ACOs invest in the right resources and partnerships, well within reach.

The DMCBs answer to the question "Should they try?" is "yes."

Too-big-to-fail JP Morgan is losing billions of dollars. Greece is getting ready to prop up their banks with devalued drachmas. Facebook is getting ready to monetize your personal data. Dozens of health care organizations are jumping into shared financial risk arrangements. The good news is that while nothing is standing between utter disaster and the U.S. stock markets, the Euro or your privacy, physicians have this handy Care Continuum Alliance resource titled "Population Health Management: A Road Map for Primary Care Practices."

Thanks to this well written, extensively erenced and evidence-based report, primary care leaders can learn how to align population health management (PHM) with their primary care physician network to reduce risk, maximize savings, achieve efficiencies and minimize any disruption of their physicians work flows.  The rest of the world may be going to hell in a hand basket, but docs will be far better positioned to bend the cost curve and be rewarded with that fat end-of-year reconciliation check.

The report discusses:

1) how health risk assessments (HRAs) can be used to gauge the risk of those patients you dont know about;

2) the role of predictive modeling in stratifying the risk of your attributed population;

3) how to recruit and engage patients at greatest risk

4) how clinical guidelines can be best applied at the point of care

5) why care managers can assume responsibility for identifying and recruiting at risk patients and advocating on behalf of the guidelines.

How can the Disease Management Care Blog be so confident that this report is all that and more?  It helped write it.

And the best part is that the document download is for free.

An echocardiogram of the heart

The shortness of breath just wasnt going away.

After years of being treated for persistent asthma, Dr. Smith (name changed) found his usual mix of inhalers and pills was no longer working.  Unable to comfortably sleep at night and finding he couldnt hustle as quickly up and down his clinics hallways, he decided it was time to see the Disease Management Care Blog.  After a quick look and a listen to his heart and lungs, the DMCB tapped its heuristics and made a shortcut bet that this wasnt asthma.  The echocardiogram that was obtained that afternoon proved that it was right: Dr. Smith had heart failure.

Heart failure is the leading cause of hospitalizations in the elderly and is a huge cost to the U.S. health care system.  Theore, if docs like the DMCB on an individual basis - or the U.S. on a health care policy basis - could prevent heart failure, that would be a big deal.

"Natriuretic Peptide–Based Screening and Collaborative Care for Heart Failure - The STOP-HF Randomized Trial" that was just reported in JAMA may be a step in that direction.

The DMCB explains.

First off, there is a hormone that is made by a stressed heart (yes, the human heart secretes hormones) called "naturetic peptide" (or NP) that signals the kidneys to excrete more salt and water. "BNP" is one type of naturetic peptide that can be detected using a simple blood test.

The STOP-HF trial set out to examine whether BNP levels could identify otherwise well-appearing persons with stressed hearts who were at future risk for the development of clinically evident heart failure.  By catching these persons early and getting them into treatment, the hope was that these patients wouldnt turn out like Dr. Smith.

39 practices in the catchment area of Dublin Irelands St Vincents Hospital erred patients who were older than 40 years and had one of the following cardiovascular risk factors: high blood pressure, high cholesterol, an obese body mass index, documented (by an angiogram or a known heart attack) coronary artery disease, history of stroke, peripheral vascular disease, diabetes, arrythmia or heart valve disease.  Persons with known heart failure were excluded from the study.

After entry into the study, patients had a BNP level drawn and were then erred to either a "control" (observation only) group or to an intervention group.

In the intervention group, patients with an elevated BNP level of 50 pg/ml or more were erred to a cardiology service and had a cardiac function study using echocardiography. In addition, any of the cardiovascular risk factors were aggressively managed with medications and a specialist nurse-coach.

In the control group, physicians and patient were not told about the BNP level and were cared for on a routine basis.  Patients were not erred for any cardiology care unless another reason supervened.

1374 patients were randomized, 697 in the intervention groups and 677 in the control group. High blood pressure was the most prevalent risk factor and most patients had two risk factors. 263 (38%) and 235 (35%), in the two groups respectively, had BNP levels greater than 50 pg/ml.  Average follow-up was 4.2 years and all patients eventually had an echocardiogram to assess their heart function

During follow-up, 8.9% of the control group patients and 5.3% of the intervention patients developed heart failure as determined by echocardiography.  That difference was statistically significant and was due to a higher level of treatment with drugs that help control risk factors and prevent heart failure. When the DMCB uses a number needed to treat analysis, the works out to 28 patients needing to be screened and treated for an elevated BNP to avoid one case of heart failure.  Thats not bad, even if you compare it to aspirin and heart attacks.  There were also fewer emergency room visits and hospitalizations in the intervention group.

The DMCBs take:

1. This is classic population health management: This study was not only about using BNP to find patients at risk for heart failure, it was about relying on nurse coaches to manage the underlying clinical drivers, such as high blood pressure or underlying coronary artery disease.  If the DMCB suggests a better title for this article would have been "Population Health Management to Screen and Treat Patients with Elevated BNP at Risk for Heart Failure."

2. An appealing value proposition with a return on investment: Given a NNT of 28 and the future costs of heart failure, combined with statistically significant reductions in emergency room use and hospitalizations, the DMCB expects population health management service providers as well as medical homes to use BNP and non-physicians to screen and treat patients to prevent heart failure.

3. Still imperfect: Despite aggressive management by a specialized team, 5% of patients in the intervention groups went on to develop disease.  We have a ways to go. 

Image from Wikipedia

Whats the one issue that drives the most doctors crazy?  The Disease Management Care Blog suspects its persons who use basic vaccinations.  Thats because physicians are inculcated from the first day of their education with triumphant stories of how basic science and public health joined forces to banish many common and fatal infectious diseases. 

Not getting your shots is crazy.

DMCB readers are probably aware of how childhood U.S. vaccination rates are dropping.  While we continue to wonder just how any parent or guardian could let that happen, heres a handy summary on the story behind the story: the New England Journal has an article on Improving Childhood Vaccination Rates:

Total U.S. rates of vaccination remain greater than 90%, but there are some pockets of the country with rates just over 50%. Thats where there have been outbreaks of disease leading to some pointless deaths.

Parents (or guardians) opposed to vaccination are unlikely to change their minds.  Thats why high vaccination rates among the remainder of children are important to create herd immunity.

There are four approaches to achieving high vaccination rates:

1. Make shots free and think about paying parents to have their children immunized.

The DMCB likes the idea but wishes the authors had pointed out that in the context of value-based insurance, this is hardly a radical idea. 

2. Make it really difficult to attend school without proof of vaccination.  Getting an exemption should demonstrate that the parents are serious and not shuffling by on lax enforcement.

The DMCB grew up in New York City and recalls being immunized against polio in the schools cafeteria.  Is it time to bring this back as a first-line strategy?

3. Confront the anti-vaccine community with counter-education campaigns that rely on more than facts and figures.  Anecdotes and trusted public figures should also be used.

Whither social media?  And, at a traditional marketing level, the DMCB thinks that maybe its time to partner with the pharma companies that do such a good job of convincing TV viewers to take lipid-lowering agents and anti-depressants.  Nothing against the colleagues in public health, but theyre not known for their marketing savvy.

4. Physicians need to step up one patient at a time and, while theyre at it, make sure theyre up to date with their shots.

The DMCB did a literature search on "shared decision making" and "vaccination" and found no useful information.  Given the success of aids and engagement strategies that enable truly informed decision-making, the DMCB thinks its time for the population health management community to step up and offer their services.

(One last thought: Newts been lampooned for his moon-base wackiness, but as the DMCB understands it, his recommendation is really based on an X-Prize approach, which he contrasts with the discontinued Shuttle program.  The DMCB wonders if such an approach couldnt work in those areas of the country with critically low childhood vaccination rates: a 5 figure prize to any outfit that can move it to 90%.  Why not?)

Image from Wikipedia

The Department of Health and Human Services (HHS) has launched a "Million Hearts" campaign that is designed to prevent a million heart attacks and strokes in the next 5 years.  You can read about it in the New England Journal here or in Circulation here.  There is also more detail here at the HHS gov web site.

The campaign is crafted to address the "ABCS" a.k.a. aspirin, blood pressure control, cholesterol control and smoking in the U.S. population. The Feds propose to 1) consolidate just how ABCS will be specifically measured in any population, 2) remind and help manufacturers as well as users of EHRs that they can be tasked to addressing ABCS, 3) initiate a "pharmacist-led campaign.... (to) facilitate counseling about hypertension control," 4) launch an anti-tobacco marketing and community-based campaign, 5) push for food labeling in restaurants and 6) increase the measurement of sodium and fat consumption.  Details are in this table.

"Bravo!" says the DMCB.  When it reads about Million Hearts, its clear that the Feds are identifying population-based strategies, basing their interventions on demonstrated needs, increasing awareness of health risks, using patient-friendly education, helping consumers make the right choices and figuring out how to assess outcomes on an ongoing basis with a feedback loop.

If you agree on the DMCBs assessment of what the Feds are up to, you also agree that theyve they have launched a huge population health improvement (PHI) initiative.  The DMCB isnt making that up: if you compare the Care Continuum Alliance description of PHI here with the fundamentals of Million Hearts, youll see that the overlap is almost 100%.

Whats different is that the Feds are also using Million Hearts to 1) further justify the Affordable Care Act and the EHR meaningful use initiative, 2) leverage some potent government entities like AHRQ, CDC, CMS and the FDA, 3) distribute hundreds of millions in community grant money, 4) create a coalition that includes The Y, AHA, Walgreens, some professional pharmacy associations and AHIP, and 5) say some nice stuff about Mrs. Obamas childhood obesity program.  

All that makes perfect sense from a governmental as well as political process, but its still PHI.

"A hearty welcome to the fold!" says the DMCB.  HHS has finally decided to give millions of Americans access to PHI that combats atherosclerotic heart disease.  Better late than never, but based on what we know about the science of PHI in multiple other settings and assuming the government can pull this off, the DMCB is confident that a million lives being saved is within reach.  

Only the Disease Management Care Blog can find population health management lessons from yesterdays Superbowl.

With only 57 seconds left in the game and the Giants in possession of the ball at the six yard line, elite running back Ahmad Bradshaw got the hand-off.  He was only a few steps into the play when he simultaneously realized that the Patriots were purposely not tackling him and that his quarterback, Eli Manning, was shouting at him to not enter the end zone. Thats because Mr. Manning knew that a quick touchdown would turn possession of the ball back to the Patriots and give their star quarterback Tom Brady plenty of time to stage a comeback.

It was the difference between running out the clock and getting points on the board.

Against every instinct, Mr. Bradshaw slowed, turned and tried to sit down, only to end up squatting his way butt-first into Super Bowl history.  Fortunately for the Giants, while the Patriots did get possession of the ball, Mr. Bradys passing game was stymied and the Giants won.

The Actuaries:

The DMCB thinks of Eli Mannings cunning as a demonstration of the actuarial sciences, where the past experience of Tom Bradys passing magic was projected into a future of time-outs plus clock-stopping sideline plays that were calibrated with situational awareness and educated guesswork.  Such is the business of health insurance where the beneficiary population, the mix of services and the cost per service are used to make huge bets on a premium.  No wonder Eli had a some "eye of the tiger" about him when he was standing on the sidelines.

The Providers

The DMCB thinks of Ahmad Bradshaw as an archetype of those elite docs who live to make the diagnosis (with end zone ahead and ball in hand) and cure it (i.e. a touchdown).  Asking a provider to not commit all possible resources for patients ends up like Mr. Bradshaws ungainly scoring: not only isnt it pretty, it seems to happen anyway.  Such is culture of U.S. health care where the latest technology is combined with professional judgement to drive revenue. Last but not least, Mr. Bradshaw was ironically credited with the game-winning touchdown.

As providers transition into assuming more risk with a variety of bundled payment, gainsharing and global budget arrangements, they would be well advised to think about the logic of running out the clock and saving as much on utilization as they can.  If they dont, they may gain plenty of revenue points but will end up losing when the books close on the final seconds of the fiscal year game.

Your bronze plan ticket to health care?

Should patients be forced to reach a spending threshold before their insurance kicks in? At first glance, it makes sense, because health consumers "skin in the game" forces them to think twice before going to the emergency room for a sore throat, or an orthopedic surgeon for simple back pain.

Wharam and colleagues examine the science behind high deductible insurance in this just-written article in the New England Journal.

And the science says there is a lot we do not know.

Once insurance risk is monetized into premiums, policymakers as well as insurers are operating in the dark about calculating the right deduction for a given income level. One example is Cover Oregons $5000 deductible for persons who are at 200% to 400% of the federal poverty level. That means a family with a yearly income as low as $47,000 would have to spend more than 10% of their income on health care before seeing a dime of insurance coverage.

"Egads," says the DMCB.

Given that stark reality, the challenge is to figure out how an up-front deductible influences "buying behavior" once persons get sick. Unfortunately, most of the research out there is on the impact of relatively "small" amounts of out-of-pocket expenses on health care utilization, especially in low-income populations. The bad news is that lay-persons - who are unable to discern the difference between a simple headache vs. a brain tumor - tend to "indiscriminately" lower all utilization as their cost sharing goes up.

There has also been no research on the impact of high deductible plans on mortality or chronic condition control.

Concluding that the U.S. is "poorly prepared" for what will happen under Obamacares bronze high deductible plans, Wharam et al recommend there be more research on the topic.  Pending that, they suggest consumers be educated about their insurance purchases and be encouraged to chose low-deductible plans. They note that the star-crossed insurance exchanges (once theyre fixed) can be configured to help do that. When there is employer-based insurance, employers could be encouraged to make the deductibles more proportional to income. In addition, health savings accounts could also help.

While the authors dont use the words "population health management," they tap this discipline as one solution to this Obamacare problem. They point out that predictive modeling/risk stratification can be used to create "personalized" insurance designs that optimize high-risk patients access to care. Patients in these plans could have access to decision-aids and coaching that help them figure out when its a simple headache and then they should seek medical care.

What did that study show?

In yesterdays post on the role of telephonic disease management for obesity, the Disease Management Care Blog pointed out that POWER was a landmark study that demonstrated that remote lifestyle counseling performed as well as traditional face-to-face counseling.

A New England Journal of Medicine editorial accompanying the POWER article points out that there may have been an additional factor that explained the results: patient attendance at the in-person counseling sessions dropped off precipitously as the trial progressed (an average of only 2 out of 24 scheduled visits after the seventh month), while the telephonic approach achieved 16 out of 18 scheduled contacts.

The DMCB agrees and suggests this is an additional virtue of remote telephonic disease management.  While in-person counseling may have more of an individual impact, it does little good if  patients no-show.  In contrast, "high volume" telephonic counseling may have more of a population-based effect, because a lower intensity intervention has greater absolute impact if its delivered to more persons.

NIH scientist Susan Yanovskis editorial falls short on capitalizing on that insight.  While it grudgingly points out that POWER shows "PCPs can deliver safe and effective weight-loss interventions in primary care settings," it neglects to mention the two important implications of POWER:

1) non-physician team members acting collaboration with PCPs are an important resource in the national battle against obesity and

2) offering a variety of communication channels increases reach and gives more patients new and effective options to access anti-obesity programs.

Futures so bright, gotta wear shades!

Optimism.  Enthusiasm.  Bullishness.  Who can blame the Care Continuum Alliance for describing the future as "bright" in a ebullient 2012 population health management "Industry Outlook" white paper?  Based on a survey of unnamed "industry leaders,  the CCA found that practically every high visibility health policy initiative out there is relying on the principles of care management.

Theyre right.  Given growing recognition that "health care as usual" cannot continue, companies, vendors and organizations (and blogs) that offer new approaches will thrive.  Have a good idea on reducing chronic illness and improving health and the value proposition will follow.  Have a value proposition and the business model will follow.   Have the business model and an early comfortable retirement will follow. 

The report can be downloaded here.  No company or individual resource knowledge library is complete without it.  The Disease Management Care Blog also thinks that forwarding the report to colleagues, co-workers, bosses, underlings, friends and enemies will demonstrate two key traits:

1) your situational market business awareness is second to none
2) reading the DMCB is a competitive advantage

A DMCB summary review is below

ACOs and Shared Savings: the industry has a host of necessary  risk assessment, predictive modeling, information technology, analytics, patient engagement and condition management tools that can be built and tailored. Provider organizations that seek to make money from "upside gainsharing" ignore these resources at their peril.

Electronic and Mobile Health: remote physiologic monitoring, app based coaching and "pull" style  social media engagement are all reaching a tipping point.  Or rather, are all eReaching an eTipping ePoint. The Disease Management Care Blog, sharing in the eEnthusiasm, has initiated a remote "eSpouse" offering. More on the ePerils of that eBusiness model in a future ePost.

Reducing Readmissions: Come Oct. 1 2012, outlier hospitals with more than their fair share of heart failure, heart attack and pneumonia readmissions can look forward to a painful revenue cut.  "Pay us now or pay later," says the industry, with too numerous-to-count proven care management strategies that have been described at the Care Continuums annual meetings for years.

Medicare Advantage Bonus: Thats right, MA plans will be eligible for bonuses from CMS based on HEDIS inspired commercial insurance outcomes that have been the bread and butter of the care management service providers since the beginning of time.

Dual Eligibles:  This highly vulnerable population has been trapped in a twilight zone of overlapping and uncoordinated benefit plans thanks to a well-meaning but typical Washington-style mishmash of Medicare and Medicaid.  The good news is that the Feds have finally woken up to this and are interested in funding many of the coordination strategies that the population health industry stands ready to offer.

Prevention and Wellness: The Feds have money to put into this and employers are increasingly willing to invest in it.  Medicare covers annual wellness visits and covers obesity counseling.  The controversial ham-fisted involvement of HHS in calculating the MLR has thankfully correctly slotted the cost of wellness programs.  Wellness and prevention are one of the ten essential benefits.  The industry is poised and ready to go.

And what about "build" versus "buy" and the notion that providers already know how to do all this stuff?   The DMCB points to the sine wave of on-again off-again in and outsourcing that has been the norm for the commercial insurer-disease management vendor relationship for years.  The DMCB suspects the same will occur for providers, hospitals, delivery systems and ACOs that have to operationalize complex programs that achieve measurable accountability.  The difference is that, up until now, they havent had to do that at all.  Based on a mix of in-house competencies, interest, speed to market needs and cost comparisons, many will buy. 

The population health industrys outlook is very bright indeed.

Image from Wikipedia

If you were an employer with tens of thousands of employees and dependents and had launched a health promotion, disease management and care management program, how would you assess its impact? If you answered you wouldnt bother with measuring outcomes, youd flying blind.  If you answered that youd call up an academic institution to fashion a comparative clinical research trial, youd be using a lot of your time and money. 

But if you answered youd use a quasi-experimental design, youd be eligible or a Disease Management Care Blog Gold Star.  Thats because business owes it to its employees and investors to not only understand the value of these programs, but also make reasonable compromises on the detail, speed and accuracy of these kinds of analyses.

Thats why this paper by Serxner and colleagues appearing in the American Journal of Health Promotion is a good template for companies that want understand if their health management programs are doing any good.  This analysis involved an unnamed company with over 120,000 insurance beneficiaries. 

The authors decided to focus on 75,475 active employees and COBRA participants who were eligible for the programs.  They included a health risk assessment, lifestyle management, telephonic disease management, a health information nurseline, and health awareness initiatives.  The analysis itself put limitations on the age inclusion (18 to 64 years) as well as continuous enrollment, which further limited the research to 49,237 individuals.

The baseline comparison period extended from January 2003 through December 2004, while the intervention period extended went from 2005 through 2007.  When the programs were rolled out in 2005, participation among the insured beneficiaries grew.  Since not all of the employees participated at once, the authors took advantage of what turned out to be a staggered implementation with concurrent parallel cohorts made up of participants and non-participants. This allowed for the "quasi-experimental" comparison.  Regression modeling was used to isolate and account for the impact of age, gender and the type of medical plan.

In year one, the company spent over $2.5 million, followed by $4.6 million in year two and 5.0 million in year 3 for its programs (including $2 pmpm for the disease management). 

What happened to the companys health care costs?  While they increased for everyone over time, the persons who had enrolled in the program experienced less of an increase in their health care costs. The total gross savings for each of the years were $1.5 million, $15.4 million and $13 million in years one, two and three, respectively. When the savings were netted against the program costs,the first year had an unfavorable return on investment (ROI) of .59:1.  This turned positive once persons were in the program for two and three years, with ROIs of 3.33 and 2.59, respectively.

While studies like this can not rule out the possibility of "self-selection bias" (i.e. persons destined for lower health care costs were naturally drawn to the programs), the analysis passes muster for a large business that needs a reasonable degree of assurance that it is getting its moneys worth.  While the analysis itself may seem daunting, the DMCB suggests that that cost, when compared the millions already being spent, is comparatively reasonable and should be rolled into the price of doing business.

The DMCB suspects dozens of studies like this are being done by employers and insurers, most of which are being used for internal consumption.  Sexner et als study is one that made it into the public domain. 

Heads up, corporate America: your competition is not only investing in their employees health, but using quasi-experimental analytics to understand the return on investment. Its another factor in achieving a competitive advantage.

Diabetes control isnt their top concern

The Disease Management Care Blogs primary care colleagues are undoubtedly aware of how "social determinants" can undermine the best care planning. So, if youre going to rely on the Patient Centered Medical Home (PCMH) to increase health care quality and reduce costs, ignoring the impact of poverty or health literacy could lead to poor diabetes control, worsening high blood pressure or more hospital readmissions.

Arvin Garg, Brian Jack and Barry Zuckerman have written a JAMA "Viewpoint" that offers five lessons from pediatric medical homes that can mitigate harmful social determinants:

1) Include social determinants (for example, community factors, substance abuse, education, malnutrition or poverty) in the creation of national treatment guidelines.

2) Develop and implement screening programs to identify any social determinants that could impact medical treatment.

3) Colocate community resources that address social determinant in PCMHs.  Examples include housing programs, job training programs or food pantries.

4) Colocate "outside the box" social programs in PCMHs also.  This is an area ripe for piloting or researching innovative interventions

5) Integrate visiting nurse programs with the PCMH.  Think of the visiting nurses as an extension of the medical home.

As readers of the DMCB are aware, not all PCMHs can build the full suite of services that make up a medical home. Since health insurers and care management vendors are partnering with primary care physicians to build medical homes, this approach to incorporating social determinants in their programs is worth a closer look.