Health for life

The Disease Management Care Blog recently attended a physician meeting that keynoted a U.S. Senator.  In his prepared comments, he admitted that he knew little about controlling health care costs.  Unfortunately, that didnt stop him from humbly paraphrasing the testimony of a famous economist:

"Find out what works," said the expert, "and do that."

Maybe some of the physicians silence that followed was an "aha!" reaction to the Senators insightful nostrum.  Some of it may have also been out of respect. 

The DMCB is sure, however, that most of the docs in the room were quietly thinking "You must be kidding me."

Such is the approach of the mandarins leading our federal health care institutions.  "Science and existing literature" says HHS Secretary Sebelius.  "Effectiveness" is the mantra of the Center for Medicare and Medicaid Innovation.  "Improving health care" is now part and parcel of CMS. 

Unfortunately, applying scientific evidence to the economics of health care delivery sounds easy enough until you get down into the weeds.  For a perfect example of that, consider the common condition of painful spinal stenosis among Medicare beneficiaries. According to this JAMA article, there were over 37,000 operations in this population at a national cost of $1.65 billion. 

Which begs the question: does spinal surgery "work," is "effective" and "improves health care?" Can the "science and existing literature" help us decide?

To get an idea of just how complicated the answer is, check out this Agency for Healthcare Research and Quality (AHRQ) research review on Spinal Fusion for Treating Painful Lumbar Degenerated Discs or Joints.  The conclusions from the abstract are:

Overall, limited evidence suggests that spinal fusion compared with physical therapy improves pain and function for adults undergoing fusion for low back pain due to disc degeneration. Because of insufficient reporting and variation in surgical methods used in the different studies, the incidence of adverse events (serious and minor) associated with fusion could not be determined conclusively. The evidence was insufficient to draw evidence-based conclusions for the benefits and harms of spinal fusion for patients with degenerative stenosis or degenerative spondylolisthesis of the lumbar spine. The evidence was also largely insufficient to draw conclusions about the benefits and harms of fusion compared with other invasive treatments or different fusion approaches or techniques.

In other words, there is some evidence that, compared to conservative treatment, surgery helps.  After that, its the stuff of caveats, statistics, evolving technique and myriad study limitations.

In fact, its so complicated that the only way it can be applied is by helping patients understand how the science applies to their unique circumstances and values.  Once the patient understands things, its a matter of letting that patient and doctor jointly decide on the best course of action.

That approach - in contrast to U.S. Senators musing on how we need a one-size-fits-all approach to what works - is called shared decision making and it can be applied to back surgery with considerable cost savings.

"What works?" asks the Senator?  The answer is for you to consider staying out of the way.

...and you can take that to the bank?

It seems no discussion on the Patient Centered Medical Home is complete without a erence to Medicaids Community Care of North Carolina. The states consultants reports on CCNC have been accepted as gospel by the academic community (for example) and have contributed to a widespread consensus that the PCMH saves money. As in billions.

Or does it? For a readable discussion of why CCNC may or may not have saved money, check out this four pager by Joseph Burns appearing in March 2012 issue of Managed Care Magazine. Skeptics point out numerous inconsistencies, including North Carolinas lingering high costs and little change in inpatient utilization. MCM asked analytics impresario Ariel Linden to take a look at CCNC and, after using a time series analysis, he was unable to find evidence of savings.

Nothing new, says the Disease Management Care Blog, which has long been unable to make much sense of the consultants reports either. What is new are the responses of CCNCs Paul Mahoney, founding physician Charles Wilson and advocate Adam Searing. It seems North Carolinas fee schedule is complicated, physician buy-in is high, something must be working because the Medicaid program has avoided making fee schedule cuts and, last but not least, the States legislature never intended the consultants evaluations to meet the exacting standards of the DMCB readership.

The DMCB doubts the controversy will go away.  What we can learn from the CCNC imbroglio is how important it is to think about the analysis early in the planning process. In the meantime, PCMH advocates will probably have to look elsewhere if they want to er to studies that are understandable, transparent and convincing.

Coda: By the way, whatever its imperfections, the CCNC is a good example of a "shared resources" approach to nurse care management. As the DMCB understands it, in CCNC, the primary care sites do not hire their own nurses.  Rather, the costs of the nurses are regionally supported and the nurses are, in effect, loaned out to the clinics. 

The DMCB argues that there is little difference between this and hiring a disease management/population health service provider. To paraphrase Comrade Deng again, the color of the cat may be different, but it still catches mice.

Paying for it is a whole new kettle....

Now that the U.S. Supremes have confirmed the Affordable Care Act as the law of the land, the Next Big Step - as the Disease Management Care Blog predicted - is the move from insurance orm to payment orm. While its politically easy to broaden entitlements to cover everyone, figuring out how to pay for it is a whole new kettle of financing fish.

In response, a whos who of Obamacaregineers are stepping up with their Phase II recommendations for payment orm.  While you ponder whether the DMCB summary below is enough or whether you need to follow the link for more detail, ask yourself whats missing......

1. Let public and private payers combine forces to "negotiate" payment rates that aim for global spending targets at a regional level.  Embedded costs for research, training and uncompensated care would be carved out and preserved separately.

 2. Use bundled payment methods for episodes of care that span rehab and post-discharge care, starting out with cardiology and orthopedics. Aim to make this payment approach the rule for 75% of Medicares budget within 10 years.

3. Commoditize medical devices, lab tests and radiology services by forcing suppliers to competitively bid for Medicares business.

4. Encourage tiered insurance products, where consumers can pick progressively lower premiums in exchange for higher out of pocket costs.

5. Leverage state exchanges to ratchet down costs on pain of being "delisted" by forcing them to compete on cost and quality.

6. Simplify administrative costs by establishing a single format for all paper and electronic forms. The latter is the default unless the consumer opts for paper.

7. Make the pricing for medical services public and outlaw gag clauses.

8. Allow non-physicians to take advantage of scope-of-practice  laws to practice medicine autonomously.

9. Close the provider self-erral loopholes that allow docs to provide "in house ancillary services," unless its under a global cap.

10 Start all the above with the Federal Employees Health Benefits Program (FEHBP).

11. Use the "safe harbor" of practice guidelines to protect docs against allegations of medical malpractice.

Whats missing is the usual emphasis on primary care and, in particular, the patient centered medical home.  While it could be argued that global targets and bundled payment methodologies will drive the inclusion of higher value/lower cost non-specialists, the DMCB is shocked, shocked that the experts and editors missed usual nod to primary care.

The DMCB will also point out that the proposal is rich in expert councils (to set spending targets), programs (as in Medicare Acute Care Episode to define the bundling), panels (for the competitive bidding and guidelines) task forces (for the administrative simplification), commissioners (to assure transparency) and, last but not least lawyers (expanding Stark to ban self-erral).  Plato, the champion of Philosopher Kings, would be proud. 

In the meantime, Ayn Rand is rolling in her grave.

Image from Wikipedia

Sei Lee and Louise Walter, in this Commentary published in the Oct 5 issue of JAMA, argue that the current  approach to measuring health care quality often leads to unintended harm for many older adults.  Thats because the guidelines-driven and evidence-based measures are "unbalanced."

The Disease Management Care Blog agrees that the state-of-the-art is unbalanced, but its even worse than Drs. Lee and Walter describe. 

First, the Commentary.....

Right now, standard methods for assessing the degree of blood pressure control (typically defined as being less than 140/90) doesnt account for some elders being prone to getting low blood pressure and dizzy when theyre upright. Blood sugar control is a good idea among most persons with diabetes, but for many reasons, older persons are more prone to having dangerously low dips in their glucose levels.  Last but not least, theres also the questionable wisdom of screening for cancer when the likelihood of death from other causes is far greater.

Most nationally recognized clinical guidelines usually have a disclaimer that they are not intended to be used as an inflexible and one-size-fits-all standard of care (for example, read the 4th paragraph of the high blood pressure guideline here).  Yet, in contrast to the flexible guidelines, the all-or-none quality approach to measurement (for example) are inflexible and fail to give "credit" when testing or treating in individual patients are unwarranted. 

Drs. Lee and Walter propose to fix this by reconciling the measures with life expectancy.  If better blood pressure, diabetes or cancer screening can mathematically be expected to result in more years of life, then they should be implemented and only then should credit be given.  While this could get complicated (think life expectancy tables being used during a visit with your doctor or, egads, politically underhanded accusations of ageism and death panels), the authors point out that electronic health records decision support - despite its disappointing track record - could enable life expectancy awareness during physician office visits. Whats more, doctors wouldnt necessarily have to follow the decision support recommendations, but the fact that they were considered could be also be rolled into quality measurement.

What does the DMCB think?

It salutes the authors and JAMA for raising an important point. The idea of accounting for clinical benefit in quality measures is intriguing.  Yet, the DMCB doesnt think the authors go far enough in addressing the imbalance.  It would go one step further and make the measures depend on the on a rather radical patient-centered approach: if the patient was engaged and became aware of the risks, benefits and alternatives to the guidelines-based testing and treatment, was allowed to make an independent, educated and reasoned judgement and gave either active consent or refusal, only then is credit given.  Life expectancy can be part of that shared decision making, but its not the only ingredient.

Novel thought hm?  Its not up to any utilitarian calculation of life expectancy.  Its not up to some buggy computerized decision support algorithm.  Its not up to any expert guidelines.  Its not up to national quality setting organizations.  Heck, its not even up to the physician.  Thats all unbalanced.

Want true balance? Once all the above inputs are understood, its up to the patient.

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.