Health for life

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

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

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

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

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

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

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

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

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

2. The observed savings were never ascribed to avoided hospitalizations

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

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

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

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

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

Lesson learned.

So, does the medical home "save money?"  A recent publication in Population Health Management about Community Care of North Carolina (CCNC) says "yes." Thats important, because CCNC program has had more than its fair share of controversy. 

You can read more about CCNC here.  According to the Commonwealth Fund, Raleigh pays CCNCs 14 non-profit regional networks $3 per member per month (PMPM) for medical home services for over a million Medicaid and CHIP beneficiaries. In exchange, the 1300 clinics provide preventive care services, 24 hour coverage services, coordinating access to specialty services, care management and quality improvement. To do all that, CCNC uses a "medical home model" with "specialized chronic care programs" staffed by teams of docs, pharmacists and care managers.

The quasi-experimental evaluation published in PHM used "hierarchical modeling" to evaluate the impact of CCNC on two different samples of non-elderly (ages 0 to 64) disabled Medicaid patients who had no other insurance:

Model 1: compared the medical home patients claims expense within and outside the enrollment periods "after controlling for other covariate values"

Model 2 created matched cohorts of enrolled and non-enrolled patients to compare pre-post differences in insurance claims expense. Matching was based on pre-enrollment pharmacy use, race, age, enrollment duration, clinical risk and behavioral health burdens.  For every enrolled patient, ten non-enrolled comparison patients were selected. 

The study period was January 1 2007 through Sept. 30, 2011.  Any single months of disenrollment were "filled in" if there was enrollment 2 months per and 2 months post. 

Results?

Model 1: This used insurance claims data for over 169,000 patients with an average age of 35 years. 52% were male with a 24% rate of mental illness and an 8% rate of chemical dependency. Compared to the time of not being enrolled in a program, claims expense was statistically significantly $190 per member per month (PMPM) cheaper in the first year; that declined to $64 PMPM cheaper in the last ear of study.  Persons with a higher burden of illness had even greater savings.

Model 2: This studied claims from approximately 102,000 enrolled patients with pretty much the same baseline characteristics in Model 1. Savings achieved statistical significance in the 3rd, 4th and 5th years of study: $81, $73 and $121 PMPM, respectively.

The DMCBs take:

While it can get lost in the sublime minutiae of hierarchical modeling, the DMCB finds the methodology and the numbers to be credible.  It has used the same Model 2 style of matching in its own studies. Since a pristinely conducted prospective randomized control clinical study is functionally impossible in a state-wide Medicaid program, quasi-experimental study designs like this are a good window into figuring out what happened.

And what happened is that they saved a lot of money. Assuming CCNC was paid $3 PMPM or $36 million per year for a about a million beneficiaries, avoided claims expense appeared to be well north of that.

While CCNC has a lot of moving pieces, the DMCB believes the key success factor was based on identifying the most vulnerable patients and then using nurses to intervene on the them.

The average caseload per nurse ranges from 150 to 200 patients.  As the Commonwealth Fund summary describes.....

"Case managers... work with primary care providers (“medical homes”) to identify patients who will benefit most from targeted care management interventions, such as patients making repeated ER visits; patients diagnosed with asthma, diabetes, or heart failure; and patients who have two or more chronic conditions (including mental health conditions) with high service use or activity limitations indicating complex care needs. Care managers identify high-risk patients through the CMIS and from case-identification lists provided by the CCNC central office, notifications of admissions provided by hospitals, and physician errals."

CCNC is to be congratulated for moving from opaque actuarial studies to the harsh glare of peer-reviewed publications.  While some critics may pounce on some of the weaknesses inherent in any retrospective analysis of subpopulations, the observations from two "Model 1 and Model 2" vantage points  are sufficiently positive to believe that North Carolinas taxpayers got their moneys worth.

The DMCB would point out two caveats:

The disabled Medicaid beneficiary population is a notoriously high utilization group that is a classic example of the return on investment from "low hanging fruit." A little coordination goes a long way in a population with a baseline of high utilization.  The same approach may not work in other populations with different patterns of claims expense.

Unfortunately, this gives us little insight about the potential impact of a similar medical home model in commercially insured populations or among Medicare beneficiaries.  Thats doubly true for fee-for-service beneficiaries who are outside of any managed care networks.

...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.