Health for life

Its such a no-brainer, right?  If persons at risk for diabetes would only eat right and exercise more, theyd avoid the disease.  And for those who develop diabetes, diet and exercise will reduce death rates and complications.

Yes and no, say Elizabeth Sumamo Schellenberg and colleagues at the University of Alberta.  Their review of the mixed published scientific evidence on the topic appears in the October 15 issue of the Annals of Internal Medicine.  The purpose of their study was to ascertain the impact of diet and exercise on the prevention of "Type 2 diabetes," as well as lowering complications among persons with who had established Type 2 diabetes. 

To be included, studies had to be prospective and compare the outcomes from an intervention versus a randomly selected control group. The study could only be included if it examined the impact of exercise plus diet and "one other component," such as "counseling, smoking cessation and behavior modification."  The outcomes had to include the development of Type 2 diabetes (in the prevention trials) or complications (in the treatment trials).

1289 candidate studies were found but only 20 made the grade. Nine were prevention trials and 11 were treatment trials.

For the prevention trials:

The interventions lasted from 6 to 72 months, with follow-up going for 3 to 20 years for between 39 to 3234 participants.  The counseling varied and included group and/or individual with or without tobacco cessation, telephony, goal setting, cooking classes or pills involving a range of physician and non-physician professionals.

Results?

Seven of the nine studies showed that diabetes can be delayed. When the results were pooled, compared to the control patients, the risk of developing diabetes over 10 years was only a third and the difference was statistically significant.

But, there was no detectable impact on cardiovascular disease events or on eye, kidney or nerve damage. That may have been due to not all the studies including these outcomes as well as the time it takes for these complications to occur once diabetes develops.  With more patients or more time, a difference could have become apparent.
 
For the treatment trials:

The interventions lasted from 6 to 48 months with follow-up for 6 to 93 months. The counseling was as varied as the prevention trials but included glucose and blood pressure monitoring as well as stress management and, in one instance, a three day residential retreat. There was likewise the range of professionals who provided the interventions.

Results? 

Compared to the control patients, there was no statistically significant difference in all-cause mortality.  Some individual studies had beneficial outcomes involving cardiovascular events or diabetes complications, but they included the aggressive use of medications.  There were no sustained impacts on weight or dietary intake.  And if pills were not included, there was also no real improvement in measures of blood glucose control.

The Disease Management Care Blogs take?

The good news is that there is good evidence that exercise and diet can prevent diabetes.  The bad news is that it takes years for that "return on investment" to declare itself and typically involves interventions that fall outside the traditional health care delivery system.  Its unlikely, thinks the DMCB, that current iterations of payment orm (value based purchasing, bundled payments or upside risk) can be marshaled to make this a reality.  That being said, population health management (PHM) companies like Omada Health are making their evidence-based services available to, for example, employers who have a longer term commitment to the well being of their "human capital" outside of the traditional insurance market.

The bad news is that once diabetes declares itself, diet and exercise dont result in life extension, and control of complications as well as overall blood sugar levels is more a function of pills than lifestyle. Accordingly, expectations need to be realisitically shared with patients and PHM should emphasize taking the pills as prescribed.

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

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

Image from Wikipedia

Say hello to the CMS Administrator

Bowing to the implacably oppositional Republicans, President Obamas first selection for Administrator of CMS tendered his resignation and made way for second-in-command Marilyn Tavenner.  Whats more, instead of using a recess appointment, the White House has submitted her nomination to the U.S. Senate.

So who, asks the Disease Management Care Blog, is she?

According to this biosketch (scroll down, youll find her), Ms. Tavenner has a 25 year hospital administrator pedigree that includes being CEO at two Virginia Hospital Corporation of America hospitals (Chippenham and Johston Willis).  That part of her career culminated in her being the companys "President of Outpatient Services."  As the DMCB understands it, she entered the major leagues of public service in 2006 when Democratic Governor Tim Kaine tapped her as Virginias Secretary of Health and Human Resources.  Thanks in part to her links with Mr. Kaine, she later jumped to CMS, where she became the "Principal Deputy Administrator and Chief Operating Officer."  Unsurprisingly, her duties have included loyally defending the Affordable Care Act (ACA).  You can see her in action here on C-SPAN.

By the way, did the DMCB mention that Ms. Tavenner is a registered nurse?

She has an Virginia Commonwealth University BSN undergraduate degree and apparently climbed the HCA ranks one patient care unit at a time.  Somewhere along the line she also nabbed a Masters in Health Administration.

Four initial thoughts from the DMCB:

1. The new CMS nominee is another example of the emergence of nurses as go-to health leaders.  Not only does the public trust them, theyre able to bring a real-world understanding of hands-on patient care to the high falutin mix of operations, policy, politics and finance.  The good ones know how to deal with grumpy doctors and neutralize clueless administrators.  That being said, the physician DMCB cant help it and still wishes there was a doc at CMS helm. 

2. In its long career, DMCB has witnessed the Dark Side Transformation of many well-meaning physician or nurse administrators to a type that places profits over patients. Whats more, few have become hospital CEOs without making some enemies along the way.  Will any past foes come forward with unpleasant anecdotes from an otherwise forgotten past?  Stay tuned.

3. Despite lots of searching, the DMCB couldnt find much of a track record outside some speaking gigs and serving on some boards.  As far as it can tell, she has no peer-reviewed publications and her public statements have been pretty vanilla.  While that may impair Mr. Obamas foes ability to attack Ms. Tavenners record, the DMCB wants to know more about someone who is going to be leading the worlds largest health insurer.

4.  The absence of a track record doesnt mean that the nomination process isnt an opportunity for politically motivated mischief.  It remains to be seen how well Ms. Tavenner testimony holds up to the Republicans intense "gotcha" scrutiny and whether her nomination ultimately becomes a toxic partisan (re)hearing on the merits of the ACA.

EHR portals at work?

The Disease Management Care Blog had this thoughtful reply logged onto its "Follow-Up" post on the topic of EHR patient portals. Logged by Rebecca M Coelius MD, Medical Officer for Innovation at HHS/ONC, the DMCB recognized that this was important enough to warrant its own separate page.

While we wish that the results were more conclusive and positive, the Office of the National Coordinator for Health Information Technology (ONC) applauds the meta-analysis and the recent upswing in articles on patient portals and other patient-facing technologies. The number of patients and caregivers who desire greater participation and transparency in their healthcare makes continued research in this area vital. Yet, in a close read of the full Annals of Internal Medicine meta-analysis article and in many of the studies it cites, there were unquestionably statistically significant positive clinical outcomes, as well as positive patient experiences, associated with certain patient portal functions.

The ONC does not believe that Health IT alone is a panacea, or that meeting the form of Meaningful Use, while not embracing the new functions the technologies it enables, is likely to result in measurable improvements. The study authors caution that it was case management that tipped the utility of portals from unclear or small to more substantial, but it is important to note that the case management activities happened via the portal itself. This is a perfect example of Health IT as an enabler of new ways of reaching and caring for patients; we would not separate the two concepts.

To the study’s described limitations, we offer two significant additions. First, the definition of a patient portal remains loosely specified, so it is difficult to make conclusive statements about the entire category. The meta-analysis did attempt to list which functions were present for each study, but half of the studies that looked at patient outcomes gave only a partial description of portal features, and a deeper assessment of the quality of functions and their relevance to the outcomes measured was not present for any study.

A more illustrative future approach would be to evaluate individual functions of portals for impact on patient participation in their care and specific health outcomes, and then ask what design principles and organizational contexts were necessary to make that function successful. For example, the impressive OpenNotes project demonstrated that patients with access to provider notes had a better understanding of their health and condition, improved recall of their care plan, and increased likelihood of taking medications as prescribed. In a New England Journal of Medicine study on weight loss interventions, over twice the number of patients in the remote support intervention groups (telephone, website access, and e-mail support) lost more than 5% of their weight versus the control group. Secure messaging and the ability to view personal health information are two cornerstones of portal functionality within Meaningful Use.

Second, more than 10% of these studies are ten years old, and over a third were published five or more years ago. We understand the necessity of adequate numbers for meta-analyses, but statistical significance does not necessarily confer relevant insights. Technology, and patient perences and capabilities for using technology have fundamentally changed over the study time periods included, not to mention the maturation among health-care organizations themselves and the expectations of patients.

The very premise of the patient portal is a rapidly ageing one. As the ONC articulated in a 2013 Health Affairs article, there are shifting attitudes related to the traditional roles of patients and providers, and exploding demand and penetration of smartphones, health and wellness apps, and connected devices. We are moving the conversation from engaging people with our existing healthcare system through “portals”, to using technology to move outside our system to reach them every day where health truly happens. What we need to measure and incentivize in the future is not the value of portals, but the value of delivering the right information and intervention to the right person, at the right time, through the right interface based on an individual user’s context.

Approximately one-third of Americans take a daily multivitamin, but little is known about a multivitamins long-term affect on chronic diseases. Now, new research from Brigham and Womens Hospital (BWH) finds that daily multivitamin use does not reduce the risk of cardiovascular disease in men. A similar BWH study, announced last month, found daily multivitamin use can reduce a mans risk of cancer by 8 percent. The cardiovascular disease findings will be presented Nov. 5 at the American Heart Associations Scientific Sessions 2012 and published simultaneously in the Journal of the American Medical Association.

"The findings from our large clinical trial do not support the use of a common daily multivitamin supplement for the sole purpose of preventing cardiovascular disease in men," said Howard D. Sesso, ScD, lead author and an associate epidemiologist in the Division of Preventive Medicine at BWH. "The decision to take a daily multivitamin should be made in consultation with ones doctor and consideration given to an individuals nutritional status and other potential effects of multivitamins, including the previously reported modest reduction in cancer risk."

Researchers enrolled nearly 15,000 men over the age of 50 in the study and followed them for more than 10 years. The men were randomly assigned to take either a multivitamin or a placebo every day which ensured that both treatment groups were identical with respect to risk factors for cardiovascular disease. The men self-reported episodes of heart attacks, strokes and cardiovascular disease, and a panel of physicians reviewed and confirmed their events with medical records. Researchers then compared the group that took the multivitamin with the group that took the placebo and found no significant impact on risk of heart attack, stroke, or cardiovascular mortality. Additionally, the effect of a daily multivitamin on major cardiovascular events did not differ on participants with a baseline history of cardiovascular disease and those who were initially free of cardiovascular disease.

J. Michael Gaziano, MD, chief of the Division of Aging at BWH, investigator at VA Boston and senior author of the study, said, "Since so many Americans take daily multivitamins, studies like this are key to providing us with valuable information about what specific benefits multivitamins do or do not provide in terms of their long-term impact on chronic diseases. For cardiovascular disease, we must continue to emphasize a heart-healthy diet, physical activity, smoking cessation and regular screening for cardiovascular risk factors."

Which naturally worries the contrarian DMCB.

In Bob Woodwards tell-all book The Price of Politics, Mr. Obama reportedly  reassured a skeptical Speaker Boehner by saying  "John, Ive got great confidence in my ability to sway the American people." 

That was certainly evident today.  He really thinks speeches can win hearts and minds.

Contrast Mr. Obamas oratory self-assurance with his predecessor, Ronald Reagan.  In the book, Reagan, A Life In Letters, it seems our 40th President used the written word to not only hone his communication skills but to internally develop and ine his thinking on the great issues of the day. Armed with that kind of self-clarity, Mr. Reagan speeches were secondary to his far more important skill of compromising without giving up on his principles.

Über academic Pat Thomson says it best: "Binge writing" allows authors to become immersed in a topic "to make sense of it."  Fifty Shades of Gray author, E.L. James, may have expressed it best: “Write for yourself,” she said. "That’s it. And write every day."

The modest DMCB agrees. Its bloggery (just over 1500 posts and counting) helps it better fashion real-world business plans that involve inevitable trade-offs between what the scientific evidence says what should be with what clients have already decided what will be.

The DMCB will never give a speech on the Washington Mall, thank goodness, and its not like Presidents will ever seek its counsel.  But it knows that philosophic certitude is better tasked to navigating inevitable compromises in the real world, not convincing skeptical listeners to give in.

Let the games continue!

A study recently published in Social Indicators Research (Blanchflower, Oswald and Stewart-Brown 2012) investigated the relationship between fruit and vegetable consumption and mental health. The study drew upon three robust, representative, cross-sectional studies of random samples of adults in three UK countries; England, Scotland, and Wales. Each of these surveys gathered self-reported intake data, measured in portions of fruit and vegetables of up to eight or more a day. Most surveys stop at the recommended five or more. The study also gathered data on seven different measures of mental health, from mental wellbeing (WEMWBS) through mental illness (GHQ-12), life satisfaction, happiness, nervousness and downheartedness.

Together these surveys captured information from more than 80,000 people, taking account of a wide range of other potential explanatory factors such as age, sex, ethnic group, socioeconomic and educational circumstances; and other lifestyle factors, such as smoking. They show a remarkably monotonic dose-response relationship between mental health and the number of portions of fruit and vegetables consumed. That is, the more fruit and vegetables consumed, the greater the mental wellbeing. In models based on indicators of positive mental health (WEMWBS, Life Satisfaction and Happiness) the corresponding coefficients continued to increase by up to seven or more portions of fruit and vegetables. In models based on mental health problems (GHQ-12, nervousness, feeling downhearted) they increased by up to five or more.


A strong and consistent dose-response relationship, as shown in these studies, acts as evidence that fruit and vegetable consumption is influencing mental health. Yet, the possibility remains that we could just be documenting a simple correlation; people with better mental health tend to look after themselves – by eating more fruit and vegetables – than those with worse mental health.

Complete article

D.C. deals with health insurers

As Disease Management Care Blog readers are aware (for example, here and here), Obamacare forces health insurers to spend at least 80% (small group) to 85% (large group) of their premium income on health care, leaving only 15% for "other," including administrative overhead and profits. If that 80%-85% "medical loss ratio" (MLR) threshold is not met, insurers have to rebate the difference to their customers.

 While the White House has been happy to extoll the millions of dollars that were repaid to consumers (even though the individual checks were hardly eye-popping and then there is the risk that theyre taxable), the DMCB is interested in what actually happened to the commercial insurers.  Did they game the system and garner even higher profits?  Or, have they gotten their comeuppance, are now losing money and have to pursue other lines of business, like covering zombie attacks?

This article in the latest Health Affairs looked at that impact of the law when it went into effect on January 1, 2011.  The authors used NAIC data to examine the impact on the individual (N=1,219), small group (N=804) and large group market (N=750) insurers.

Individual, small group and large group numbers are broken out below. If there is a *, the change is statistically significant.

In the individual market, from 2010 to 2011:

Median medical expenses, as a percent of premium, increased      by 5.5%*.
Administrative expenses, as a percent of premium, decreased            by 2.6%*.
Profit (otherwise known as "operating margin" or the bottom line) decreased by 1.3%*. "For profit" insurers fared even worse, with a decline in operating margin of 2.2%* vs. their nonprofit competition with a decline in 0.8%.

2011 operating margins were overall negative:

Individual overall -0.1%.
Nonprofits:  -3.5%.
For profits:  0.4%.

In the small group market:

Median medical expenses increased by 0.7%.
Median administrative expenses declined by 1%*.
The bottom line increased by .5%. Nonprofits saw an increase of 1.2%* vs. the for profits having a small decline of .3%.

2011 operating margins were positive, ranging from 2.8% to 3.8%  across the non and for profits, respectively.

In the large group market:
Median medical expenses declined by 0.7%.
Median administrative expenses declined by 0.9%%*.
Profit increased by .7%*. Nonprofits saw an increase of 0.1%* vs. the for profits having a increase of 1.2%.

2011 operating margins were positive, ranging from .7% to 2.6%  across the non and for profits, respectively.

The DMCBs take:

Obamacare had a single digit impact on health insurers.  More was spent on health care and less was spent on administrative costs.  While the shifts were relatively small, those changes represent swings of hundreds of millions of dollars to the bottom line in an already thin margin business. If the purpose of Affordable Care Act was to beat up on the health insurers, it was more of a push than a shove.

Small and large group profitability increased and operating margins were positive, while the individual market struggled. As readers may recall, the inability of individuals to obtain coverage at any price was a big factor in the eventual passage of the Affordable care Act. While the future individual market may eventually benefit from an influx of healthy young "invincibles" armed with an accompanying bolus of insurance subsidies, Obamacare ironically hurt the individual market in 2011. If health care utilization didnt go down in 2011 as a result of the economy, it could have been a lot worse.

That tells the DMCB that, contrary to the insurers reports of doom and gloom, the 80%-85% MLR rule hasnt been a catastrophe.  On the other hand, it hasnt been good news for the individual market.  If the young invincibles dont 1) respond to the individual mandate, 2) use functioning insurance exchanges and 3) sign up, it could portend further stress on that sector of the health care economy.  No wonder the Obama Administration is pushing that so hard.

Listen to the common wisdom about the state of health care in the U.S. and its easy to conclude that were on the verge of catastrophe.  Academics say we have a "non-system," politicians bemoan the "lack of coordination" and the policymakers condemn "unsustainable" costs. When our health care is compared to that of the Burgundy-sipping French, the olive-oil loving Italians and the bicyle-riding Dutch, our commentariat are ashamed that we Americans havent joined the rest of the civilized world in offering high value care to its citizens.

Is it really that bad?

To find out, the Disease Management Care Blog looked at these data from the Organisation for Economic Co-operation and Development. Take the test below and decide for yourself if the experts really have it right.  Answers are at the bottom.

1. Which country, as of 2009, had the highest percentage of persons who reported that their health is good?

A. Switzerland
B. Iceland
C. United States
D. New Zealand

2. Name the country that has the highest rate of obesity and the 2nd highest rate of diabetes?

A. Mexico
B. United States
C. Canada
E. New Zealand

3. An excess of physicians can drive increased health care costs.  Which country has the highest number of physicians per capita?

A. Netherlands
B. United States

4. Which country has the greatest number of MRI and CAT scanners per capita?

A. United States
B. Australia
C. Japan
D. Israel

5. Which country has the highest Cesarean section rates per 100 live births?

A. Italy
B. United States
C. Switzerland

6. Does the U.S or Canada have a higher percentage of women getting pap smears?

A. Canada
B. United States

7. Does the U.S or Belgium have a higher percentage of women age 50-69 getting  mammograms?

A. Belgium
B. United States

8. While the Slovak Republic leads the world in asthma admissions per 100K, which country is close behind in 2nd place?

A. Korea
B. United States
C. Poland

9. True or false: The United States rate of hospital admissions for uncontrolled diabetes is above the OECD average.

A. True
B. False.

10.  While the U.S. leads the OECD with a 20% rate of skipping a provider visit or going without a prescription, which country is in second place with a 17% rate?

A. Germany
B. Netherlands
C. France

11. While the U.S. spends more per capita for health care, health care costs are rising all the OECD countries:

True or False: from 2000 through 2009, the rate of increase in the U.S. health care costs was above the OECD average of 4.0%

12. While Americans make up the largest percentage of DMCB readers, which country in the last month came in second?

A. India
B. Canada
C. Great Britain

Answers:

1. C The U.S. So, while we spend more, it can be argued that we are getting our moneys worth

2. B The U.S. There may be lots wrong with the U.S. care system, but the U.S. also has a higher burden of disease. Toss in high trauma rates and other impacts from poverty and it can be argued that importing a new health system may not translate into greater health.

3. A The Netherlands.  In fact, both countries are below the OECD average.

4. C Japan, but the U.S. is second in the world in the per capita rate of scans.  We apparently use our scanners a lot more!

5. A Italy is higher. C-section rates are skyrocketing world wide.

6. B The U.S. is 78.7%, while Canada is 75.3%

7. B. The United States. In fact, Belgium is below the OECD average

8. B. This is one area where the U.S. should be doing better.

9. B. False.  Denmark and Sweden, by the way, are above average.

10. A Germany, which has universal insurance.

11. B. False  While absolute costs are a significant issue, the rate of cost increases also keep politicians and regulators awake at night. The U.S. rate was a relatively tame 3.3%, behind Belgium, the Netherlands and the United Kingdom, all of where were above average.

12. Everybody sing....."O Canada, our home and native land....."

A question, a question. All my kingdom (and sweet potatoes) for a question.

From Wiki user Lupin

Q: Do you give a whit about maintaining a healthy diet on Thanksgiving?

A: I do not. I tend to view Turkey Day like the Super Bowl, Christmas, and my birthday: 24 free hours to eat whatever I like, regardless of the consequences. I’ll go back to wholesomeness the day after.

Readers, what about you? Do you keep the healthy food faith on T-giving? Why or why not? Let’s debate.

Want to ask the interweb a question? Post one in the comment section, or write to Cheaphealthygood@gmail.com. Then, tune in next Tuesday for an answer/several answers from the good people of the World Wide Net.

Apparently not.

Thats the Disease Management Care Blogs main take-away after reading the Care Continuum Alliances "Population Health Management in Physician Practice: A Call to Action."

The CCA commissioned a survey that asked 105 primary care physician leaders about the implementation of population health-based care coordination in their clinics. The clinics were from all regions of the U.S. and ranged in size from 5 to 95 physicians (a total of 1,916 physicians with a mean of 18).  To be included in the survey, they had to be planning or had already implemented patient-centered care initiatives, many of which were modeled after the medical home. 93% already had an electronic record and10% reported being part of an Accountable Care Organization (ACO).
 
First the good news.

Over and beyond hiring non-physician providers (96% had at least one nurse practitioner and 70% had a physician assistant), 91% reported that they had hired a "care coordinator."  Whats more,  85% said that population health was conceptually important in their practices and the majority 55% rated this as either a "4" or "5" on 1 to 5 scale.

But the bad news is that less than half were familiar enough with the concept to fully implement it in clinical practice.  The number one challenge in this area was the difficulty in making sure that roles and responsibilities of the care coordinators were appropriately defined. 

It should be noted that the practices surveyed in this report were not typical of primary care,  where experience with care coordination is even lower.  This was a elite group of innovators on the cutting edge of primary care who had committed precious resources and already were hiring care coordinators. Yet even these select clinics risk being operationally stymied by not knowing how to effectively implement it in their practice settings. 

The CCA report appropriately concludes with a call for education, tools and support to help physicians fully implement this in their clinics.  The DMCB wholeheartedly agrees.  Based on this report, hiring care coordinators is certainly necessary but isnt sufficient to attain high quality population health.

We still have our work cut out for us.