Health for life

While the population health management service industry has a successful track record when it comes to chronic heart failure, diabetes and asthma, the Disease Management Care Blog thinks, after a quick scan of the literature, that there are fewer studies of its impact on hypertension.

 A recent Morbidity and Mortality Weekly Report (MMWR) reminds us that thats a problem.

The National Health and Nutrition Examination Survey(NHANES) performs interviews and physical examinations of a representative sample of U.S. households.  This particular report on the prevalence and treatment of high blood pressure was based on a sample of 20,811 individuals from four 2-year survey cycles that were performed from 2003 to 2010.

Extrapolating from the sample, 66.9 million persons or 30.4% of the U.S. populationn have high blood pressure. Of this population, just over half (54% or 35.8 million) have uncontrolled hypertension.  Of these persons, 31 million (or 88%) had been seen by a health care provider in the preceding year. The prevalence of uncontrolled hypertension among those hypertensives with Medicare was 52%. Not having health insurance or having seen a health care provider in the past year increased the risk of untreated and uncontrolled high blood pressure.

Whats more, the DMCB discovered control of hypertension doesnt appear to be getting better over time.

The good news is that the treatment of high blood pressure is not all that complicated and that team-based non-physicians can play an important role.  Patients should be engaged on weight control, a DASH diet, restricting salt, exercise and moderating alcohol intake. Medication therapy can be individualized and tailored to meet mutually agreed-upon goals and to minimize any barriers.  Check out this MMWR table and youll see erences to "lifestyle counseling," "self monitoring," "self-management education."

Given the looming shortage of primary care care settings and the coming influx of newly insured persons, the DMCB believes population health management will need to be part of the solution.  In addition to the established science, the industry 1) understands the importance of risk stratification, 2) can be bolted onto accountable care arrangements and 3) understands that optimal outcomes are somewhere between 46% and 100% control.

Hopefully, given the relative dearth of high quality studies, this opportunity will be accompanied by ongoing studies of outcomes.

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.

Getting ready for another announcement

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

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

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

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

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

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

Measuring ROI

In yesterdays posting on Al Lewis book Why No One Believes the Numbers, the Disease Management Care Blog pointed out that the measurement of population health management (PHM) outcomes remains an inexact and still evolving science. While that can be a source of endless fascination for the DMCB, the inability of the industry to rustle up credible "return on investment" numbers has prompted some observers to condemn PHM as a waste of money.

The search for simple answers explains much of the appeal of this book.

According to author, one important solution is the "dummy year analysis" (DYA). This relies on repeated year-over-year measurements of utilization that use multiple comparison pairings of all patients with the condition of interest. When thats combined with a "plausibility" check list, Mr. Lewis says purchasers of the Patient Centered Medical Home (PCMH), disease management or wellness programs should be able to get a better fix on whether they saved any money. You can a sense of that perspective here.

The DMCB isnt too sure about that because a) other factors that have nothing to do with population health management can also impact utilization during and after the dummy years, making it difficult to assign an attributable ROI and b) entire health plan populations can likewise regress toward a regional or national mean.

The DMCB also sees three additional reasons why there may be less to this books methodology than meets the eye:

1. When employers, health plans, accountable care organizations or other buyers have a list of names that have been through a care program, they typically want to understand the outcomes for the individuals on that list. If thats the case, the challenge is to find an adequate comparator that portrays what would have happened in the absence of the care program. Multiple options for identifying a parallel comparator have been used in published science for decades. Thats difficult, imperfect, but not broken.  It remains an option.

2. While the book is replete with examples of "actuaries behaving badly," it is impossible to underestimate the influence of actuarial science and trending on premium rate setting, statutory accounting, and the regulation of insurance. As a result, if the actuaries say money is - or is not - being saved, health system leaders ignore their insights at their peril.

3. Isolating the impact of PCMH, disease management or wellness program out of all the other "noise" of a changing economy, evolving consumerism, benefit changes, electronic health record databases, medical advances, inflation and the news media is a function of an increasingly sophisticated and changing statistical sciences and computational technology. Its ironic, but one outcome has been a better description and measurement of the uncertainty surrounding a result.
 
To the authors credit, Why No One Believes the Numbers is not being promoted as the single best methodology that will lead PCMH, disease management and wellness programs to outcomes certainty. Rather, it is one option among many in asking whether a program had any financial impact.

Ultimately, theore, thats why the DMCB advises that measuring outcomes in PHM - absent an ironclad methodology - comes down to using multiple approaches to triangulate on the truth. After reading Why No One Believes the Numbers, some readers may choose it as one of those approaches.

Changing opinion from right to left

Has marriage made the Disease Management Care Blog a better person?

While it and the spouse heartily agree on the ultimate answer, using hard numbers to prove it to a skeptical mother-in-law is a different matter. To definitively answer the question, the affable DMCB came up with some proposed measurement approaches, such as:

1. Pre vs. Post: comparing past beer guzzling to present-day chardonnay sipping;

2. Actuarial: actual vs. projected appreciation for the leather-clad vampire vixens of Underworld;

3. Comparison to a Control: the DMCBs willingness to take direction on shrubbery trimming, versus that of more docile hubbies;

4. Randomized and Prospective: (the DMCB has wisely opted to not go there).

While the DMCB continues to work on the complex methodology of marital outcomes, it is reminded of a key paradox: while we live in an "Information Age," other pressing questions - such as the extent of the Eurozones influence on GDP, the merits of vouchers in public education and the link between the Presidents approval rating and his governing by remote memo - likewise defy conclusive measurement.

Whats more, frustrated by our worlds complexity, we ironically want fewer answers. The DMCB suggests this search for simplicity partially explains the luster of a balanced budget amendment, laws on minimum medical loss ratios, Newts bombast, Obamas rhetoric, blanket coverage of birth control and, last but not least, single approaches to assessment of population-based programs.

Which brings the DMCB to Al Lewis $10,000 challenge, in which he dares anyone to come up with a more accurate approach to measuring disease management return on investment. 

Al is a luminary in the disease management firmament who leads the Disease Management Purchasing Consortium. He was there at the founding of the Disease Management Association of America, led the attack on the vendors past lazy outcomes reporting and has been instrumental in questioning the conclusions about North Carolinas Medical Home Program. He now claims to offer the only approach to accurately measuring the financial impact of disease and population health management.

Maybe, but the DMCB would like to humbly offer up an alternate perspective.

Check out this DMCB paper that simultaneously deployed three uncomplicated methodologies to assess the claims expense impact of a chronic heart failure disease management program. While all three gave different answers, they all pointed in the same direction.

That was enough for the DMCB boss to continue the programs funding.

This same overlapping and multi-layed approach also underlies the Care Continuum Alliances Outcomes Guidelines Reports, which recommend a suite of measurement approaches that pivot on important determinants such as population characteristics, the influence of confounders as well as bias and the resources available to answer the question.

None of this should be any surprise to seasoned and prudent health administrators, physician leaders, clinical program architects or DMCB readers. They know that good actuaries use complimentary and overlapping approaches to come up with the right premium. They understand that good medical researchers demand caution, skepticism and multiple research studies before reaching any conclusions.

In other words, there is no one-time and one-size fits all approach in outcomes assessment.

All this adds up to the fact that optimum outcomes measurement triangulates on the truth. The measurement approaches advocated by the DMCB, Care Continuum Alliance members and health system leaders have been around for years, are within the reach of standard statistical software, are familiar to researchers and are highly adaptable to the circumstances of 99.99% of disease management programs, not to mention the medical home and accountable care organizations.

The DMCB says that when multiple, competing, overlapping, repeated and adaptable measurement methodologies point in the same direction, thats when regulators, consumers, purchasers, buyers, providers and patients and mothers-in-law can be really confident that they have the answer they need.

Image from Wikipedia

But wheres the money?

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

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

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

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

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

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.
.
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.

Now that scientists have taught robots the complexities of dancing upright, the next step is outfitting them with some phone headsets and a list of patients to call.....

Are you helping your e-patients?

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

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

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

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

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

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

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

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

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

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

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

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

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

Some other DMCB take aways:

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

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

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

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

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

You are already an ePatient.

Image from an HHS web site

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

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

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

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

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

Image from Wikipedia

A physician welcoming the patient back to the hospital

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

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

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

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

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

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

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

Drs. Joynt and Jha have two good recommendations:

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

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

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

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

Lets fix it!

While noisy media leprechauns dispense blame and declare winners in the government shutdown imbroglio, the Disease Management Care Blog remains focused on the next steps for meaningful health orm. So are JAMA authors Jack Lewin, Lawrence Atkins and Larry McNeely who, other than one lapse in their editorial, get it mostly right.

Their important insight is that the Bipartisan Policy Center, Brookings Institution, Commonwealth Fund, Kaiser Family Foundation, the National Coalition on Health Care, Partnership for Sustainable Health Care and Urban Institute all have a remarkable degree of overlap in their recommendations for the next phases of health orm. 

Most of these expert organizations agree on the merits of value-based payment as well as insurance orm (pay for quality), information technology, competition, tort orm, evidence-based benefit design (paying when theres evidence that it works), workforce changes (greater efficiency), orming Medicare, changing tax policy (the exemption for health insurance) and instituting regional or local caps (stick to a budget or theres consequences).

The DMCB wholeheartedly agrees and hopes that the bipartisan consensus evident among these think-tank institutions leads Congress (if not this one, the next) and the President (if not this one....) to use these ingredients to build on the successes and correct the many deficiencies of the Affordable Care Act.

And the lapse? 

Jack Lewin et al were missing one thing. The DMCB looked in each of these organizations web sites and found that there was also considerable support for population health management.

To wit:

The Bipartisan Policy Center - while the emphasis of this report is on health information technology, the real dividends are pretty clear when it mentions "population health" 14 times:

This plan should address the development and adoption of policies and standards needed for the delivery of care, the empowerment of individuals, and improvements in population health based on national health and health care priorities.

The Commonwealth Fund:

 Effective population health management requires fundamental change in care delivery that must be supported by changes in payment.

National Coalition

Real orm means engaging consumers in their own health and health care choices. In both Medicare and too many private plans today, benefit design neither supports self-management of chronic disease nor distinguishes between care that is effective and care that is not.

Partnership for Sustainable Health Care - see page 22:

Federal nurse education funding should be ocused to equip registered nurses to assume the roles of case manager and population health coordinator.

The Urban Institute - see page 17 on the topic of Medicaid orm:

States can start in select geographic areas or specific population groups (adults and children or specific chronic conditions), and then incrementally expand them after learning from experience and making program improvements and adjustments. Broader efforts typically mean additional stakeholders, increased collaboration and communication.

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

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

The report discusses:

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

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

3) how to recruit and engage patients at greatest risk

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

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

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

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

An echocardiogram of the heart

The shortness of breath just wasnt going away.

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

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

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

The DMCB explains.

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

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

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

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

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

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

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

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

The DMCBs take:

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

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

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

Image from Wikipedia

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

Not getting your shots is crazy.

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

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

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

There are four approaches to achieving high vaccination rates:

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

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

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

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

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

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

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

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

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

Image from Wikipedia

While it is no Steven Spielberg, the Disease Management Care Blog humbly posts this short cinematic opus that portrays how easy it is for the wheels to come off of the care management train.

"Hello its so nice to interact with you today.  My name is Nurse Vera Zealus and Id like to help you get engaged today in the personalized  ongoing management of your diabetes in the context of your medical home.  Would you like to become engaged and  ongoing and managing at home while I get a care management fee on your behalf....?"

At one point he asks if shes a doctor.

Enjoy!


(Link to YouTube: http://youtu.be/VayIpAuSQAI)

The Disease Management Care Blog remembers when one of its patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirins benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then theres the Feb. 11 Wall Street Journal, where "Notable and Quotable" ers to the "BA Bubble." Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as "apprentices" and "journeymen" before becoming "craftsmen."

All of which makes the DMCB wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, "alternative" web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.
 
Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. The DMCBs traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

The DMCB also remains impressed by the ready availability of medical information in the public domain that is enabling some laypersons to become astonishingly expert.  In addition to the patient above, think about the self-taught parent of a child with a rare condition or the plucky cancer patient who guides the oncologist toward choosing the right life-saving therapy.  Imagine what happens when IBMs Watson is fully commercialized and available to anyone at anytime.

The physician DMCB understands all the perspectives above, but given the decline of the BA and the law degree, it worries that the medical traditionalists may ultimately end up being on the wrong side of history.

While regulators and the markets sort all this out, this may open another business proposition for care management. As patients with chronic conditions continue to seek ways to better share in their self care, theyll also be seeking providers that best suit their needs and expectations.  In other words, the population health vendors can not only help with shared decision making, but provider selection making. 

More on this in a future post.

Image from Wikipedia

Were all aware of the past criticisms of "disease management." According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of "outcomes" were based on flawed research that was never intended to be science; it was really intended to market their wares.  

But suppose the Disease Management Care Blog alerted you to:

1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.

If you think that sounds like typical vendor-driven telephonic disease management, youd be right.  Youd also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses.  When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.

Or how about.......

2. A major insurer that decided to use its claims data to identify its own "best practices" without waiting for any published evidence-based studies?  Since "strict experimental conditions cannot always be met," shortcuts like time-series analyses" and "propensity score approaches" will be used to "blur" the lines between feedback and evaluation, as well as the lines between provider and insurer?

If you think that sounds like an commercial insurer muscling into health care delivery while using quasi-experimental research shortcuts, youd be right.  Youd also be describing how Medicares Innovation Center is borrowing from the disease management industrys approach.  Its all here.

Lastly, theres......

3. A major insurer that decided to NOT to pay primary care sites enough fee-for-service or capitation, preventing them from hiring nurses who could provide coordinated care.  The insurer instead hired its own nurses and "embedded" them in the primary care sites while linking additional monthly payments of approximately $5 to pay-for-performance metrics.

If you think that sounds like a step away from the usual Patient Centered Medical Home, youd be wrong.  In this instance, having the embedded nurses did not get in the way of the sites achieving PPC-PCMH recognition. Whats more, compared to usual care in a prospective randomized study that was underwritten by the medical-home fans at the Commonwealth Fund, the embedded nurse approach resulted in better hypertension care, breast cancer screening and fewer emergency room visits.

Alas, disease management: to paraphrase The Bard, a rose still smells as sweet by any other name, especially if its used by Group Health, CMS and the Commonwealth Fund.