Health for life

Years ago, the Disease Management Care Blog tagged along as a minor player to a high level strategic meeting involving a pharmaceutical company and a provider organization. The senior leadership egos on display barely competed with the meeting rooms spacious view of the Manhattan skyline as our group was hosted over yummy pastries and coffee by a good looking, gregarious, gracious, intelligent and obviously "connected" pharma executive.

The meeting progressed quite nicely until a coffee break supervened and the DMCB found itself alone in an anteroom with the host. Caught up in the enthusiasm of the moment, the DMCB parroted one of the meetings nostrums about the internet. The executive turned and hissed at the DMCBs stupidity with dripping contempt, turned and walked out. Minutes later, the meeting restarted as if nothing happened.

That was just one of the DMCBs many encounters with an organizational psychopath. Unable to have experience any interpersonal "connection" with anyone, these soulless persons use the people around them to pursue the more tangible rewards of power, financial gain or amusement.  Excluded from the social web of human relationships, psychopaths cant access a moral compass.  As a result, they turn to social mimicry to charm, shame or bully anyone in the pursuit of their goals.  Everyone that surrounds them is a either a means to an end or,in the case of the DMCB, dirt.

While the more famous psychopaths are sadistic murderers, theyre the exception.  Most of them coldly calculate that they dont need violence to achieve their ends. Deceit, predation and manipulation are more than enough while they pursue their goals in the cubicles down the hall and the offices upstairs.  And as they click along, these Sandusky-esque time bombs are often recognized too late.

Heres the DMCBs four  rules on how deal with organizational psychopath:

1.  That ill-defined "feeling" that you have that somethings wrong with that person? You wonder if its bad parenting, drugs, mental illness, curious flattery or an inflated ego?  Trust your instincts and include psychopathy among the possibilities.

2. Dont be surprised when you uncover the extent of the dysfunction.  The prevalence is at least 1% and their toxicity can bring a team, a department and even an organization to its knees before you realize whats happening.

3. The infamous Milgram experiments found that persons in positions of power can lead decent people to do awful things.  Questioning authority is a good thing. If you do it, you deserve credit. If one of your reports does it, they deserve protection.

4. Stay away, contain and remove, perably the latter - even if it means you.  Warnings and counseling will not change their underlying motivation in any appreciable manner.

The DMCB is happy to report that the meeting didnt lead anywhere and that it was wiser for the experience. 

Thats why, years later, its skin crawled in a medical meeting hotel bar. 

Following a standing ovation for a plenary session presentation by the charismatic CEO of a very successful health care organization on the merits population health, the electronic record and systems integration, the DMCB found itself behind him and one of his minions trying to get a cappuccino. English was not the hapless servers primary language and she struggled with the baristas brewing details. The CEOs cold scorn and hateful disdain were radioactive while his companions nervous silence signalled that more than just impatience was at work.  The guy on stage just minutes before was an impostor.

Yes, it really did happen and yes, hes still out there.

Check out the three page article on "U.S. Health Cares Future" in the Marketplace section of the December 12 Wall Street Journal. Using personal stories of a doc, hospital CEO, insurance executive, human resources manager and a patient, the news piece portrays the blurring business lines between insurers, buyers and providers.  Mainstream readers of the Journal are likely to think the topic is both timely and novel.  Regular readers of the Disease Management Care Blog learned about his months ago.

Who are these five canaries in the health care coal mine, these bellwethers of the insurance business, these oracles of management and what are they telling us?

1. Dr. McCullough, a salaried physician with 28% of his income contingent on quality and satisfaction.  Some measures were imposed by the local Blues plan, which was passed through to the him by his employer.

Message: Purchaser and buyer control of physician reimbursement is already big and its growing.

2. Jim Taylor, a hospital CEO who cannot buy an electronic record system unless he merges with two other hospital systems.  If the merger is approved, the hospital will also be able to take on "warranty-style" payments from insurers.

Message: "Bigger is better" for capital-constrained hospitals.

3. Chris Day, an Aetna executive who got an Arizona health system to share insurance risk.  The main sticking point was the two-way mutual sharing of internal cost and contracting data.

Message: If insurers are willing to share internal pricing data, they must really mean it and think its an important success factor.

4.Robert Jacobs, the HR person, who linked about $10 per week of employees health insurance premiums to healthy behaviors (like tobacco) and quality test results (like blood cholesterol levels).

Message:  "Dont just stand there," say the employers, "do something."

5. Louis Kandor, an 86 year old man with advanced diabetes, who is being visited by a nurse who, in turn, is employed by a care management service provider under contract by his Medicare Advantage insurer.

Message: One key to mitigating risk for every insurer (except fee-for-service Medicare) is to use nurse-led care management.

While the Journal article doesnt spell it out, the DMCB believes the anecdotes can be distilled down into three useful insights:

1. Stakeholders are scrambling to demonstrate measurable outcomes to an increasingly educated and  skeptical public.  Thats the basis for physician pay-for-performance and premium surcharges.

2) Sharing proprietary insurance data is important.  Is information the secret ingredient that was lacking during the similar - and mostly unsuccessful - insurer-provider collaborations back in the 1990s?  Well see. 

3) For those hospitals that cannot or will not take risk, the next best answer is to merge.  That will mean economies of scale, access to capital and negotiating leverage.

People with heart disease have special needs when it comes to dental care. Here are some tips to consider before going to the dentist if you suffer from one of the following heart conditions.
Dental Care After Heart Attack

Wait a minimum of six months after a heart attack before undergoing any dental treatments. Tell your dentist if you are taking anticoagulants (blood-thinning drugs). These medications could result in excessive bleeding during some oral surgery procedures. Ask your dentist if oxygen and nitroglycerin are available in case a medical emergency should arise during your office visit.
High Blood Pressure (Hypertension)

Some high blood pressure drugs can cause dry mouth or alter your sense of taste. Calcium channel blockers in particular can cause the gum tissue to swell and overgrow, resulting in chewing difficulties. If you do experience gum overgrowth, your dentist will give you detailed oral hygiene instructions and may ask you to make more frequent dental visits for cleanings. In some cases, gum surgery may be required. (A gingivectomy is the name of the surgical procedure performed to remove excess gum tissue).

If your dental procedure requires the use of anesthesia, ask your dentist if the anesthesia contains epinephrine. Epinephrine is a common additive in local anesthesia products. Use of epinephrine in some patients with high blood pressure may result in cardiovascular changes - including the rapid development of dangerously high blood pressure, angina, heart attack, and arrhythmias - and theore should be used with caution.
Chest Pain (Angina)

Patients with angina treated with calcium cannel blockers may experience gum overgrowth. In some cases, gum surgery may be required.

Like patients with a previous heart attack, patients with angina may want to ask their dentist if oxygen and nitroglycerin are available in case a medical emergency should arise.

While patients with stable angina (chest pain that occurs in a predictable pattern) can undergo any dental procedure, patients with unstable angina (new chest pain or unpredictable chest pain) should not undergo elective (nonessential) dental procedures, and emergency dental care should be performed in a hospital or office equipped with cardiac monitoring capability.
Stroke

If you’ve had a stroke in the past, tell your dentist if you are taking anticoagulants (blood-thinning drugs). These medications could result in excessive bleeding during some oral surgery procedures.

If your stroke has impaired your ability to produce an adequate amount of saliva, your dentist may recommend the use of artificial saliva. If your stroke has affected your face, tongue, or dominant hand and arm, your dentist may also recommend use of fluoride gels, modified brushing or flossing techniques, and strategies others can use to assist you in maintaining good oral hygiene.
Oral Health and Heart Failure

Some medications used to treat heart failure (such as diuretics, or water pills) can also cause dry mouth. Ask your dentist about dry mouth treatments, including the use of artificial saliva.

Points to Remember About Dental Care and Heart Disease

    Give your dentist a complete list of the names and dosages of all the drugs you are taking for your heart condition (as well as any other prescription or nonprescription drugs that you may be taking). This will help your dentist decide on the best treatment course for you including medication selection for dental procedures.
    Give your dentist the name and phone number of your doctor(s) in case your dentist needs to speak to him or her about your care.
    If you are particularly nervous about undergoing a dental procedure as a result of your heart condition, talk with your dentist and heart doctor. Your doctors can provide you with information and work with you on strategies for controlling dental pain and easing your fears.


Is There a Link Between Periodontal Disease and Heart Disease?

Various researchers and government agencies continue to investigate the possible relationship between gum (periodontal) disease and heart disease. Some researchers speculate that bacteria in the mouth that are involved in the development of gum disease move into the bloodstream and cause inflammation in the blood vessels - changes that in turn contribute to heart disease and stroke.

Numerous studies are being conducted that both support and ute the possible link between these two diseases. One study, published in Stroke: Journal of the American Heart Association, found that people who had fewer than 25 teeth at the start of the 12-year trial (teeth loss is the ultimate end result of untreated gum disease) had a 57% greater risk of stroke compared with patients who had 25 or more teeth.

Another study involving over 4,000 patients and 17 years of follow up showed no evidence of a decreased risk of coronary heart disease if chronic gum disease was eliminated. Based on these results, these researchers speculate that the relationship between gum disease and an increase in cardiovascular risk is coincidental and not causal (that is to say that gum disease does not cause coronary heart disease).

The true role, if there is one, between gum disease and heart disease remains to be determined.

Now that 2011 is gone, this is a good time for the Disease Management Care Blog pause and take stock. How is it doing?

It likes to think of itself as a unique ongoing journal club on the organization, delivery and financing of health care.  If the DMCB was soup, thered be three ingredients:

1) reliance, whenever possible, on peer-reviewed and published evidence,

2) a physicians "real world" experience and

3) a ready dash of skeptical humor.

The DMCB must be doing something right.  Despite a narrow mix of medical science, economics, effectiveness and policy, the DMCB has attracted a relatively large and elite readership.  If youre reading this, that means you. 

Sophistication

When it looks at the ISPs of its many return visitors, the DMCB sees dozens of academic institutions, big and small name news media outlets, publishing houses, trade associations, information technology businesses, Congress, CMS, the White House, state government, foundations, commercial insurers, hospitals, health care consulting organizations and population management service providers. Many are household names.

It doesnt stop there. The DMCB has been contacted by and gotten to know folks from all levels in the health care industry.  Based on those conversations, it knows this a smart group.  The author of this blog is a better person for it.

The DMCB knows each regular visitor, twitter follower and Google subscriber has been earned one person at a time. It knows its elite readers are knowledgeable, active or interested in health policy, population health management, the patient centered medical home or primary care. These are not casual readers.

And you have a lot of company:

According to Google Analytics mix of ISP addresses and cookies, DMCB Ver. 2011 had 29,000 unique visitors with 42,000 visits. A third were repeat (defined as more than one) visits.  While there is no definition of a "regular" reader, the number of visitors with more than 50 DMCB "hits" in 2011 numbered 5153. There were 786 visitors with more than 200 hits. 

The DMCB also has 416 Twitter followers.  According to TweetReach, the DMCB regularly reaches almost 1500 persons with its tweets.  Depending on re-Tweets, that number can exceed 7000. 

There are also 466 Google RSS subscribers. 

These 2011 numbers suggest there are thousands of persons that regularly read the DMCB.  Every individual visitor, follower and subscriber returned or opted-in based on the DMCB content and only the DMCB content. There is no marketing, emailing or use of any services to promote the DMCB. It doesnt have the advantage of a sponsoring institution or explicit link to a big-name business. And its readership continues to slowly grow.

The DMCB Web Juggernaut

The DMCB is regularly lected and linked in many prestigious web outlets, include HealthHombre, Health Affairs, KevinMD, Forbes, and many sister blogs. Its also appeared in the web sites of USAToday, Wall Street Journal, the Washington Post, Dartmouth Atlas, Business Week and the National Review. Its also been linked in the intranet web sites of many insurers, provider organizations, and health information tech companies.

And, by the way, according to YouTube, the DMCBs videos to date have had 33,486 views.

As testimony to its growing web presence, the DMCB is on the first page when the term "disease management" is Googled.  The DMCBs growing web traffic has ironically made its "Comments" section a target by spammers with links to its dubious medical web sites.  With only one unobtrusive Google "Ad" that generates pennies per click, it still got a check for $100 (prompting the derision of the DMCB spouse, but thats another post).  The DMCB has also been offered - and used - cash to provide link backs.  It also had one complaint lodged over copyright infringement over an image (the post has since been removed, with apologies).  Simply put, folks are paying attention.

Last but not least, the DMCB is proud of its four 2011 peer reviewed publications in Population Health Management, Self Care and the Journal of Comparative Effectiveness Research.

And a thank you....

... to the readers who have commented or emailed with feedback, comments and insights.  To the readers who use their precious time and keep coming back.

ACOs at work.

According to this Bloomberg news release, some of Medicares Accountable Care Organizations (ACOs) are already achieving cost savings. Mt. Sinai and Coastal Carolina are reducing emergency room visits while Hackensack is reducing costs.

All three institutions are using two key ingredients:

1) information technology-based risk stratification to identify the persons at greatest risk and

 2) dedicated full-time nurses who perform telephonic and in-person outreach, coordinate care and provide patient coaching that, in turn, is tailored to that risk.

To the DMCB, the good news is that ACOs are using the two approaches that define modern-day disease and population health management. That industrys success will be Mt Sinais, Coastal Carolinas and Hackensacks success.

The bad news is that the news release only addresses half the question: did any savings exceed the institutions cost of the risk stratification and the nurse-FTEs? If the early answer is no, then avoided ER visits and reduced costs could turn out to be much like Governor Christies lap band: so far so good but its still risky and could ultimately be all for naught.

And on an unrelated note, this just-published New England Journal article makes note of "not made in America" health care innovations from overseas that could hold important lessons for the United States. In particular, the authors point out that Germanys DRG hospital payment system includes 30-days of post-discharge care and includes the physician payment. Readmissions within that 30 day window are, with a few exceptions, not covered and physician payment is possible because docs are often employees of the hospitals.

"Interesting!" says the DMCB, but is reminded that Germany is hardly a model for reducing inflationary cost trends.   It also specifically recalls hearing Germanys Minister of Health, Daniel Bahr, express impatience with his countrys DRG system just last week. He criticized it for not advancing enough quality in his keynote address at the HauptKongress in Berlin.

The Disease Management Care Blog was shocked, shocked when it learned that Representative Pelosis political opponents have conspired to fund federal student loan subsidies by "tak[ing] it from their favorite target: womens health" (italics DMCB). The White House has chimed in about this political evildoing, noting defunding womens health could result in "hundreds of thousands of women" losing access to cancer screenings.

Alarmed by this unfair disenfranchisement of half of the U.S. population, the DMCB spouse and a number of future Secret Service agents, the DMCB decided to investigate.

As the DMCB understands it, the House Republicans propose to pay for the loan subsidies by defunding all or some the Sec 4002 of Affordable Care Acts Prevention and Public Health Fund (PPHF). 

Heres the key wording from the ACA:

SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND ....to be administered through HHS, to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs. FUNDING.—There are hereby authorized to be appropriated, and appropriated, to the Fund, out of any monies in the Treasury not otherwise appropriated—
(1) for fiscal year 2010, $500,000,000;
(2) for fiscal year 2011, $750,000,000;
(3) for fiscal year 2012, $1,000,000,000;
(4) for fiscal year 2013, $1,250,000,000;
(5) for fiscal year 2014, $1,500,000,000; and
(6) for fiscal year 2015, and each fiscal year thereafter, $2,000,000,000.
(c) USE OF FUND....for prevention, wellness, and public health activities including prevention research and health screenings, such as the Community Transformation grant program, the Education and Outreach Campaign for Preventive Benefits, and immunization programs.

Unable to find the words "womens health" in Sec. 4002 of the ACA, the DMCB next looked up the Community Transformation grant program and the Education and Outreach Campaign.  There is practically no mention of "womens health" there either.

With further research, the DMCB did find this insight on the mechanics of federal health grant funding in the unbiased and ereed policy journal Health Affairs.  According to Boston academic authors Mariana Arcaya and Xavier Briggs, the institutional complexity of overlapping committee and agency jurisdictions and budgets make it extremely difficult - absent innovation, reorganization and new support mechanisms - to coordinate grant programs like the PPHF and give the taxpayers their moneys worth.

The DMCBs conclusions?

1. Given the size of the U.S. governments deficit, its Congress job to make tough choices. Cancelling one program to fund another is one of them. The DMCB wishes that happened more often.

2. Trading a costly and questionably effective PPHF for a national investment in college education doesnt sound like a bad idea to the DMCB.

3. This is only the beginning. Those of us in the health care industry can look forward to the threat of funding cuts in other federally supported programs.

4. Even in this time of political discontent, Speaker Boehner has a point. Shame on Ms. Pelosi and her allies for their bombast and for the mainstream news media for failing to recognize it.

Image from Wikipedia

1. Using traditional research to detect a "statistically significant" decrease in insurance claims expense is notoriously difficult.

2. Theres scientific statistical proof and then there is a reasonable business assurance.  The latter may be enough for business-minded health insurers.

3. The conclusion is based on published research.  Unpublished "in house" data have convinced many insurers to include the medical home in their covered benefit.  They know something AHRQ doesnt.

4. While medical homes alone may be insufficient to save money, that doesnt mean that medical homes that are part of a package of interventions (value-based purchasing, P4P, vendor-based population health management or an ACO) are unnecessary.

5. While there is no evidence of savings, there is also no consistent evidence of increased cost. That means the quality associated with the medical home represents high value.

That being said, the U.S. Agency for Healthcare Research and Quality (AHRQ) Evidence Report Technology Assessment on the Patient Centered Medical Home says:

"Based on a combination of good- and fair-quality studies, there is a low strength of evidence that PCMH implementation may lead to lower utilization (inpatient and emergency department) for some subgroups of patients, but this effect was not uniform. Moreover, total costs were not lowered in the reviewed studies.

However, three observational studies specifically designed to test PCMH do report lower inpatient and emergency department utilization among patients in the PCMH program. However, total costs were not statistically different for PCMH and non-PCMH patients in the three studies. None of the clinical trials of functional PCMH interventions had statistically significant differences between intervention and control arms for inpatient or emergency department utilization.

No studies reported statistically significant cost savings among PCMH patients. In fact, when taking into account program costs, two studies, one good-quality trial and one fair-quality observational study, reported greater total costs among intervention patients."

 Image from Wikipedia

How would Ms. Antoinette ponder health orm with her advisors?

While commonly attributed to Marie Antoinette, the phrase may actually be testimony to Jean Jacque Rousseaus genius in using four words to capture an elites inability to grasp the plight of a struggling underclass.  For a more modern depiction of a lifestyle bubble, think of the 1% not getting just how difficult it can be to make a living wage.

And its not just the 1%. African Americans, with some justification, note that whites have yet to grasp "the set of experiences and a history" that perpetuates racial inequality. Its not just the "facts" but how facts are sorted, prioritized and interpreted by a brain wired by decades of being surrounded by like-minded people caught up in their information loops.

But it cuts both ways. When confronted by the hostility of tens of millions of Americans to the Affordable Care Act, liberal-progressives likewise respond with similar puzzlement. Who can blame them for rationalizing things with attempts to provide more "education" or blaming it all on obstinate Tea Bagger and "Birther" wackiness?

Its not that simple.  As pointed out in this The Atlantic article, conservative skepticism about the size, regulatory reach and spending of government was well underway long before Mr. Obama set foot in the White House.  Focus groups have little trouble finding deeply held opposition to expanding government entitlements, middle class dependency, pro-business globalization, wealth transfers and scary levels of deficit spending. Given the big picture,  Obamacare is less of a problem than a symptom. 

As result, even if the White House and its Democratic allies prevail on the shutdown showdown, successfully raise the October 17 debt ceiling, cancel the January 1 2014 sequester and take back the House in November 2014, the opposition to the health care law isnt going to simply fade away.

But, say my liberal friends.....

1. Much of the Affordable Care Act is based on Republican ideas, including the mandate and Romneycare.

The mandate and Romneycare were never intended to be imposed nationally, but adapted by each of the states. 

2.  It will save money.

Health care consumption declined before the passage of the Affordable Care Act. Experts legitimately disagree on the impact on future health care costs but it stands to reason that more people with insurance will lead to increased demand and higher spending..

3.  The health care system is broken

Actually, the part of the system that was broken was the individual insurance market.  This objective OECD Report summary points out that, compared to many other developed countries, U.S. quality has been quite good and our cost trends are lower.  And while its too early to tell, the health insurance exchanges travails combined with multiple other self-inflicted wounds suggest that the cure may end up being worse than the disease.

The point here isnt whos wrong or whos right.  Rather, its clear that skepticism over Obamacares ability to deliver on all its promises is not crazy.  Its critics not only deserve their time in the public square but to have their perences lected in policy and legislation..

Whats more, the Obamacare dust-up is part of a bigger concern over the expanding role of government that tens of millions of Americans find potentially intrusive and unaffordable.  The inability of the DMCBs liberal progressive colleagues to comprehend that may be a less a function of their superior intellect or the stupidity of the opposition than an Antoinette-esque inability to step outside their familiar biases and ponder a different point of view. 

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.

According to this 2011 article in The Atlantic, the middle class is in trouble.  The Disease Management Care Blog agrees and wonders if they are ultimately doomed. Either way, there are important implications for health care in general and the care management industry in particular.

The amateur DMCB explains.

With the advent of the Gilded Age in the 1870s, the industrial revolution ushered in more than a century of heavy industry, railroads, mining, commercial farming and manufacturing that were powered by millions of skilled and unskilled workers. Wealth and power remained concentrated in an elite 1% plutocracy that had prevailed throughout most of human history, but a newly emergent "middle class" benefited from high wages and became an accepted part of the American political and cultural landscape.  Thanks to their labor, the quality of goods and services increased while simultaneously becoming cheaper.

While the middle class was in retreat at the turn of the millennium, The Great Recession suggests that their century-long party may be truly over. Global competition with the free movement of labor and capital combined with automation have made the costs of industry even cheaper. The plutocracy that has always been there can shrug off the effects of a recession, but the intrinsic value of traditional labor has popped, bubble fashion. 

In the last decade, persons in the nominal middle class with less than $90,000 a year in income have had flat wages and have been unable to increase their spending. Since 2000, American manufacturing - which has not only lost ground to China but become more mechanized - has lost about a third of its jobs. This has played itself out in geographic terms, where the elite hubs around Washington DC, San Francisco and Boston have high wage job listings, while cities like Detroit and Miami have been in the dumpster. In other words, much of the middle class is being hollowed out and being forced to downjob into personal services, retail and food preparation - while leading lives that are at risk for financial stress, partner conflicts, single parenting and troubled children.

In the meantime, the DMCB suspects that the "fat cat" billionaires so reviled by progressives are not any more numerous or fantastically wealthy.  The DMCB thinks that theyre only more visible.  It remains to be seen if government will be successful in moving wealth from that top 1% to the struggling 99%.  History suggests otherwise.

Long term implications for the health and care management industry:

Health care will sort into 1) high end, high touch, personalized care for a small elite that can not only afford it, but will be responsible for profitable top line revenue and 2) a strained publicly underfunded system with thin margins for the rest.  Care management providers will likewise sort into these two camps.  The first involves high margin value, the second involves low margin volume.  Given the disparate business models, its unlikely that single companies will be able to do both.

While universal access to affordable health insurance remains a bipartisan goal, high out-of-pocket costs combined with limited provider access for persons outside of the 1% will increase the popularity of cheap "DIY" care involving eHealth. This is a natural fit for the care management industry.

Lacking factory work, more workers than anticipated may be available as the U.S. population ages and the demand for personal health care attendants increases.

Classic health care "knowledge workers" may not be immune, since information tech and automation may enable machines to generate a differential diagnosis and read an x-ray, while cheap and highly trained remote labor may be able to deply robotics to perform routine surgeries.  For the care management industry, an on-line script that prompts a nominally-trained health educator may be able to replace nurse care managers.

Image from Wikipedia

Months ago, the caffeine-addled Disease Management Care Blog reviewed with the spouse how to pre-set the kitchen coffee brewer for a pot of fresh coffee for the next morning. After listening politely to its earnest instructions, the DMCB spouse rarely set up the brewer.

Which is why the DMCB wasnt surprised by an Iowa Chronic Care Consortium (ICCC) study of how its newly minted medical home coach trainees were being deployed in the real world. The ICCC is a not-for profit organization that was founded in 2002 and offers a training program that prepares health professionals to be members of a medical home team.
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The Consortium surveyed 318 graduates from their program. Of that number, there were 164 responses, yielding a 54% response rate. 83% of the respondents were nurses, while the remainder were medical or office assistants, diabetes educators, dietitians, social workers, physicians, pharmacists or administrators.
 
The good news is that care-management caffeine was available. The majority of respondents reported that they were using their skills to coach patients for self management, care coordination, planning visits and supporting registry use.  The majority also found their work professionally rewarding.

The bad news is that these professionals were not being supported for maximum effect:

55% were still "building support for the position."

48% reported that "office work" was given a "higher priority," often due to physician and administrator resistance.

73% reported that their coaching duties were part time and was in addition to their more traditional roles.

Only 8% were involved in office "change management."

Only 11% enjoyed a pay differential that rewarded their coaching skills.

The Consortiums paper concludes - paralleling the DMCBs coffee-making travails - that a good idea accompanied by well-meaning training is not enough to overcome established clinic routines, business roles and local culture.  The authors recommend that provider payments "change," coaching functions be "operationalized," training programs be "advanced," outcomes be "demonstrated" and that roles be "clarified."

While the DMCB ponders coffee change, operations, advances, demonstrations and clarifications, the DMCB has a far more more fundamental concern for the medical home:

With friends like this, the fledgling medical home movement doesnt need any enemies.

If the clinics that took the time and the money to train these individuals are unable to leverage their skills, disappointing outcomes could end up snatching usual care from the jaws of primary care clinic transformation.

The DMCB has three recommendations:

History Repeats: Years ago, established "disease management" companies had to go on record and oppose start-ups that were offering "faux" telephonic patient counseling programs. The medical home and population health management community, including the PCPCC, likewise cant afford to have clinics going to market with diluted medical home programs that deliver empty process instead of hard outcomes.  All health care is local, and much of the buy-in for the medical home will ultimately be won or lost at that level.  Speak up!
 
Buyer Beware: Payers and insurers need to be wise to the possibility that having a trained health coach on staff with credentials is not the same as having a health coach on line with the patients. On site credentialing may be in necessary that includes review of policies, job descriptions, pay scales and staff interviews.

Build or buy: Primary care clinics need to know that when they buy patient counseling services from a population health management vendor, you get full time on a plug and play basis. That may be a better option for a clinic that is not prepared to both train and fully use an on-site health coach.

In yesterday’s posting on care management nurse-staffing ratios and their associated costs, Peter McMenamin pointed out that a per member per month cost (PMPM) that ranged from $8 to $17 was a reasonable estimation.  Whats more, it compared favorably to the monthly management fee in the Comprehensive Primary Care Initiative. 

This is also important for Accountable Care Organizations that are grappling with the amounts that they’ll need to invest in care coordination to achieve the shared savings.  Assuming an ACO becomes accountable for 5,000 beneficiaries, that calculates out to between $480,000 and $1,020,000 per year.

But, asked the Disease Management Care Blog, should there be any differences in care management ratios and costs for Medicare, Medicaid and commercial insurance?  If it’s a commercial ACO, should it estimate $500K, while a Medicare ACO should plan lower ratios and invest $1M?

Peter McMenamin’s thoughts:

A parity between Medicare, commercial, and Medicaid is possible but not exactly plausible.  Thanks to many co-morbidities, Medicare patients have more different docs, more visits, and more drugs.  Unless they are particularly compliant with respect to medications, you’d expect Medicare patients to be more demanding.  Unless they return to a physician so frequently that care coordination is incidental or are hospitalized so much that their care is taken care of, they need considerable care management. If Medicare patients take more time for follow-up, etc. that might explain the difference between $20 PMPM and the somewhat lower PMPM estimates from my calculations.

Good point, of course.  Yet the DMCB is not so sure that there is a correlation between savings and the intensity of care management beyond a certain threshold for any patient of any age.  In addition, while persons with Medicare have greater illness burden, that doesn’t mean the day-to-day management, care plans and shared decision making for conditions like diabetes or heart failure making varies depending on a patient’s age.

Dr. McMenamin and the DMCB will keep their eye out for answers.  More to follow.

Remember that Affordable Care Act (ACA) "essential health benefit (EHB)?" 

While Disease Management Care Blog doesnt want to be reminded about it either, the topic bubbled into the health policy news cycle thanks to this sleeper bulletin recently released by HHS. Recall, despite the ACA requiring an approach based on a "typical" insurance plan covering ten categories of services, that the law set the stage for a requirement that every U.S. health insurer would have to potentially cover an expansive, complicated, expensive and controversial suite of services in each and every health insurance policy.  Any insurance plan not meeting the EHB would be excluded from the exchanges.

While the DMCB feared the unable-to-say-no amateurs in HHS would stumble their way into an unaffordable and one-size-fits-all package, it appears theyve blinked.  Thats because theyve discovered that the ACA misread things: while insurance policies typically cover a core set of services, they vary in coverage of other services.  That includes dental care, acupuncture, bariatirc surgery, hearing aids, tobacco cessation, in-vitro fertilization, certain autism services, a variety of mental health and substance use disorders and habilitative (yes, that was a new one for the DMCB too) services.

How does HHS intend to reconcile this?

"We intend to propose that EHB be defined by a benchmark plan selected by each State."  

Whoa.

In other words, there would be 50 EHBs.  As the DMCB understands it, each would be calculated using an intra-state combination of the largest small group plan, any of the largest thee state employee plans, any of the large three national FEHBP plans and the largest commercial plan.  If a state doesnt calculate the benefit, the Feds intend to use the one used by the largest small group insurance plan.  If the calculation doesnt include sufficient coverage in all the ten categories, the ultimate default is using whatever is in the states largest FEHBP plan.

Business groups and state leadership will probably find the local state-based approach a more palatable alternative, while some professional (for example) and patient advocacy (for example) may be disappointed.

You sure about that?

According to the White House, the Affordable Care Act (ACA) is obviously responsible for the significant decrease in health care cost inflation over the last three years.
The respected health economist Victor Fuchs, writing in the New England Journal, disagrees.  He points out:

1) there is a strong relationship between growth in the U.S. gross domestic product (GDP) and growth in health care spending: for the last 60 years, when one goes up, the other follows suit.  While the prevalence of illness drives the consumption of health care, it turns out that the prevalence of illness plus a rising income is a stronger driver of health care consumption*.

Its far more likely that the lackluster economy has been responsible for the low rate of inflation.

2) Two to three years is not enough time to guage the impact of any single intervention on health care spending. In his NEJM article, Dr. Fuchs presents a graph showing the relationship between a two year period of spending and what follows over the next twenty years.  It turns out its a very poor predictor.

So, even if the ACA could have an impact, its far too early to tell.

In the meantime, skeptics like Bob Laszewski, are pointing to richer mandated insurance benefits and are confidently predicting that health care costs are destined to increase.  Former CBO Director Douglas Holtz-Eakin worries young healthy adults wont sign up, which could further fuel health insurance premium increases.

Who to believe?  A partisan White House?  Skeptics who want a return to market-based insurance?  The DMCBs solution is to believe Dr. Fuchs and confidently state it doesnt know which way things are going to go.

*The only exception to the association between GDP and health care costs was during the mid-1990s when managed care had its stranglehold on the delivery system

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When pundits claim that health care spending is out of control, what do they mean?

Does it mean that Massachusetts outlawing of hospitals excessive price increases is a good thing? That rolling back the Affordable Care Act will automatically usher in a new round of price gouging? That when the DMCB generates another medical co-pay, the DMCB spouse is right to wave a copy of the bill around and demand that the DMCB do something now to orm the U.S. health care system?

As the Disease Management Care Blog understands it, what the pundits, Massachusetts legislators, patient advocates and the DMCB spouse mean is that more and more of our nations gross domestic product (GDP) is being spent on health care services.

That assumes wed all be better off if the U.S. were spending its national treasure on stuff like manufacturing, technology, education and innovation. So, instead of committing just under 18% of our output on hospital care, physician services, nursing homes, medical devices and drugs, wed all be better off if we spent it on the production of solar panels, Facebook, public school vouchers and iPhone apps.

That way we wouldnt be struggling with the prospect of another 1% gain on GDP (to 19%) and the looming possibility that well soon be spending a whopping fifth of our economy on health care.

But is the spending on health care really that bad?  As noted here, the DMCB pointed out that non-government-insured health care costs have been moderating for years.  Whats more, recent year-to-year increases in health care spending in the U.S. are actually lower than much of the developed world.

And now theres one more reason to doubt the prevailing wisdom about rising health care costs. Charles Roehrig, Ani Turner, Paul Hughes-Cromwick and George Miller of the curiously name Altarum Institute point out that the normally rising and falling GDP associated with routine economic cycles can make steady health care costs look relatively worse or better than they appear.

To dampen the impact of a cyclic economy on the assessment of health care spending, the authors compared health spending to U.S. "potential GDP." Apparently, this obscure economic metric has been used by economists to portray what GDP would be if the economy were operating at full employment of the current population and without any idle production capacity.  This metric has the advantage of "smoothing out" many of the peaks and valleys of the normally measured GDP.

Using potential GDP as the comparative baseline, the authors found that health care spending growth gained less than 1% of the economy starting in July of 2005, well before the onset of the Great Recession of 2008. In other words, during that time, the health care industry grew pretty much at the same rate as the "potential" GDP. 

Whats more, in June of 2009, health care cost growth gained an additional 1% of potential GDP, only to fall back below 1% again in May of 2011.  Most of the increases seemed to be accounted for by Medicare Part D spending; if that particular cost is backed out, excess growth would have been 1% or less throughout the measurement period.

The authors can only hypothesize on why health care costs didnt outstrip the U.S. economy. While it could be partially accounted for by the rising numbers of uninsured (who would have avoided going to hospitals or seeing doctors), the authors point out that other trends could have played a role: changing physician practice standards, increasing numbers of salaried physicians, market pressures pushing down on fee schedules, increases in patients out-of-pocket expenses making them less likely to access the care system, new care models (including disease management?), the increasing use of generics, previously expensive drugs going off patent and the drop-off in the number of "blockbuster" pharmaceuticals.

This means when the economy bounces back and/or Obamacare results in more insured Americans, there is no guarantee that underlying health care inflation will return.

The Disease Management Care Blog spent the day navigating the halls of Congress.  The DMCB discerned a perence for black-toned suits and dresses among many of the staffers, making it think in was either in a "Men In Black" movie or that the depths of D.C.s doldrums worse than even it imagined.

As further evidence of the dysfunction, the DMCB was told that the "clean-up" bills that typically follow every major piece of legislation are unlikely to get anywhere anytime soon.  The inevitable additions, deletions and clarifications that are usually necessary to align any newly minted U.S. law with its original legislative intent are typically tackled over the following years, but not for the Affordable Care Act.  Cleaning up the ACA is being stymied by the Republicans, whose only solution to any problem in the law is to repeal it, as well as the Democrats, who are reluctant to introduce any bill that could open a Pandoras Box of crippling orms.  That no-go approach has also spilled onto other unrelated health care legislation.

And speaking of no-go, it also took the DMCB twice as long to get out of downtown DC thanks to traffic that was stuck somewhere between paralyzed and gridlock. 

Funeral garb. Legislative brainlock.  Automotive immobility. Merely a coincidence?  You be the judge.

Image from Wikipedia

The Disease Management Care Blog is proud of its native ability to resist the highly tailored "microtargeting" of advertisers. It can confidently say this because it uses its own independently formed perences to take advantage of on-line sales, movie placements, Twitter prompts, cable TV commercials and internet radio ads. Its not its fault that it attracts certain targeting and rejects the DMCB spouses assertion that theres no discernible difference between Chopin and Smirnoff.

Smart DMCB readers undoubtedly feel just as secure about their native immunity to outside influencers. But that doesnt mean they wont be impressed by just how industrialized microtargeting has become when they look at this Feb 27 C-SPAN Washington Journal on Targeted Political Ads. The same decades-old science that matches a particular product to a certain profile for automobiles, accessories and aspirin is now being used as never before in the 2012 political campaigns.

The DMCB thinks there may be a silver lining here.  As this gets better every day, microtargeting is undoubtedly destined to be adopted by the disease and population health management industry. Over and beyond its ability to use details from insurance claims and electronic health records, microtargeting can also vacuum up and digest data on the magazines we subscribe to, the cable shows we watch, the credit charges we amass, the computer "cookies" we accumulate or the social media we embrace to triangulate on consumers health profiles.

For example.... the analytics modeling could fit a known behavior (like having a lot of flat screens in the home tuned to reruns of the gluttonous Man vs. Food ) with certain conditions (like undiagnosed diabetes). It could also be used to link key health consumer attitudes (like wanting to sign up for your PCPs newly minted patient centered medical home) with a certain behaviors (such as being unable to resist viewing online images of cute puppies). Or what about leveraging the most obvious association: possessing high native intelligence and reading this blog.

Silliness aside, to the DMCBs knowledge, tapping into our public, demographic and on-line footprints for "health care microtargeting" hasnt been really commercialized - yet. It searched the published medical literature and didnt find much that was useful (though given its academic pedigree, that shouldnt be surprising), but, thanks to Google, it did find this blog post (as if wed expect otherwise) by "Sirensong. She points out that geeks are on it, so the DMCB suspects its just a matter of time.

If any readers are aware of anything more to this, please share.

Image from Wikipedia

Your doctor will see you now!

If only the U.S. health care system had the democracy of the French, the efficiency of the Germans, the primary care of the Brits and the common sense of the Swiss. Then wed be able to see our beret-wearing PCPs ad lib, receive care in 9 minute aliquots, mutter "bullocks!" when were told were too old for dialysis and then die old and quietly at home.

Victor Fuchs, writing in the Jan 2 edition of JAMA, has a slightly different perspective.  He notes that American history is dominated by waves of immigrants who came here to escape oppression. We are far more distrustful of government.  We are also less likely to support redistributive public policies. That may be partly due to a more heterogeneous population that is less sympathetic to the less fortunate when they fall outside the right social or demographic class. Last but not least, our system of government is quite inefficient compared, say, to a parliamentary system.

Thats why:

1. Government spending on health care is comparatively lower: 46% in the U.S. vs. 75% in Organization for Economic Co-operation and Development (OECD) countries.  As a result, a) administrative costs are fragmented, and b) there is less ability to negotiate prices with providers and suppliers

2. There is a different mix of services: in the U.S., less top-down control means more high tech, specialists and amenities with relatively less reliance on physicians and hospitals to render health care services.

What is the way forward?  Dr. Fuchs recommends that future health orm efforts not be modeled on Europe.  Instead, Americans should scale back their expectations and focus on what is necessary, not desireable.

If government is to assume a greater share of health care costs beyond the current 46% level, it should probably worry about funding basic care, not all care.  In addition, Americans are less likely to support total equality; they want to preserve the option of "buying up" when they can afford it.  Last but not least, future orm is going to have to find a middle ground between all the advocacy groups, stakeholders and special interests that dominate the mix of services.

Image from Wikipedia