Health for life

The regulators go to work....

Fed up by pharmceutical, biotech and medical device manufacturers vulgar use of "honoraria," "consulting fees" cozy "investment" relationships and other financial sweeteners to buy physician loyalty, Congress included the "Physician Payment Sunshine Act" as part of the Affordable Care Act.

The initial proposed set of regulations appeared in the Federal Register on December 19, 2011.  Comments were invited and CMS reponse i.e., the"Final Rule," has just been released.  It can be found here.  This sample of the mainsteam news media reporting indicates generally positive reviews.

Case closed? 

Not quite.  Thats why you read the Disease Management Care Blog.

As the DMCB understands it, the idea is to notify patients and the public about potential physician conflicts of interest, especially if they are recommending one treatment versus another. The financial relationship data from August through December of this year has to be reported to CMS by March 31, 2014. CMS will, in turn, post the information on the web in September of 2014.

While the DMCB agrees with the intent, it also took the time to scroll through the Final Rule and found some interesting information on page 226. 

CMS estimates the manufacturers will each need to hire a compliance officer and bookkeeping personnel.  Based on prevailing hourly salary rates (page 228) for approximately 1,150 companies, the total cost in year 1 of the Sunshine Program will be $193,037,104.  After some systems automation kicks in and start-up costs are eliminated, the cost will decrease to $144,777,828 "annually thereafter" (p. 229).  There will also be "infrastructure costs" to the tune of just over $12 million in year one and just over $1 million for each subsequent year.

The DMCB thinks thats worthy of some sticker shock, especially when were all agreeing that the health care system is already too expensive. Ultimately, it remains to be seen if patients will use the internet as advocate-consumers and blunt their physicians conflicts of interest.  Based on data like these (the impact on consumer behavior) and these (on hospitals) we dont know if patients will vote with their feet or if physicians bad behavior will lessen. 

It could work, but once again, finding out is going to cost American health care consumers hundreds of millions of dollars.

Stay tuned!

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

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

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

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

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

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

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

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

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

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

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

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

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

The DMCB has three recommendations:

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

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

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bushs gut instincts over Iraqs weapons of mass destruction versus Barack Obamas disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isnt too sure how TEDTalks Dr. Iyengars suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldnt have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.

Its no secret that the Disease Management Care Blog is an enthusiastic believer in nurse care managers.  In its humble opinion, it makes no difference what "bricks" are used to build a Patient Centered Medical Home, an Accountable Care Organization, a Population Health Management Program or an employer-based care support/wellness initiative, the nurses are the mortar.

Readers can read more on how this specifically works in a DMCB co-authored article titled "The Focus of Case Management Grows" in this on-line version of The Case Management Society of Americas (CMSA) Case In Point magazine.

While the manuscript focuses on the PCMH, its lessons can be applied to any corner of primary care:

1. Some patients have higher health care needs, more care gaps and greater risk.  Surveys and analyzing insurance claims and electronic health record data can find them.

2. There are cheap medical  interventions that increase quality and lower costs.  Nurses know about them and, when theyre supported by physicians, can champion their use among patients with the most to gain.

3. Most patients want to meaningfully participate in their own care.  This goes to the core of patient centeredness and these nurses know how to harness that energy.

As systems confront the limitations of pay-for-performance, the disappointments of the EHR Kool-Aid, the inertia of Washington-run health care and dwindling budgets, the DMCB is confident that these nurses will finally get the recognition they deserve. Whats more, patients will be better off for it.

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.

Read this lead American Journal of Managed Care article on Geisingers approach to the patient centered medical home (PCMH), and you may agree that the major findings are:

1) the longer patients with chronic conditions are exposed to care coordination, the greater the impact on claims expense, and

2) while insurance claims went down, the savings werent enough to generate a return on investment, i.e., the program itself cost too much.

The DMCB also agreed but mined the article to find out more.

Geisinger has a ""Proven Health Navigator" system of primary care sites with "embedded" nurse case managers who serve medically complex patients. As more primary care sites were recruited into the system and as more Medicare Advantage patients were enrolled by the nurses, it became possible to contrast the duration of exposure to Navigator with the amount of savings. Based on over one million member-months in 43 primary care sites over four years, the authors found that from one to twelve months of exposure, patients claims expenses were not statistically significantly less than expected. However, once more than twelve months elapsed, the percent savings ranged from 4.3% to 6.7%. Yet, while the savings per member per month ranged from approximately $70 to $120, that was still not enough to exceed "the actual dollar amount invested in implementing" Navigator.

What else can the DMCB conclude?

1) When it comes to reducing claims expense, itll take more than 12 months to see a reduction in claims expense, i.e., "to bend the curve."  According to these data, itll take 2 years or more.  That means starting a care coordination program is a two to three year commitment.

2) The authors point out that with more time or more patients, they may have been able to achieve enough observations to achieve a statistically significant return on investment. Unfortunately, close reading shows there is little information in the manuscript on the program costs which led to the authors conclusions.

You probably know some of the leading risk factors for osteoporosis -- being female and past menopause, smoking, or having a small frame. But did you know that some fairly common medical conditions are also among the causes of osteoporosis bone loss?

If you have one of these conditions, either because of the disease itself or because of the medications you have to take to manage it, you face an increased risk of developing osteoporosis:
1. Diabetes Mellitus and Osteoporosis

For reasons scientists still dont fully understand, people with type 1 diabetes tend to have lower bone density.

Studies show that people with type 1 diabetes may have low bone turnover and lower than normal bone formation.

"It seems that high blood sugar may shut down bone formation, just as with steroids," says Beatrice Edwards, MD, MPH, associate professor of medicine and director of the Bone Health and Osteoporosis Center at Northwestern University Feinberg School of Medicine. Since type 1 diabetes usually develops in childhood, when the body is still building bone, someone with type 1 diabetes may never have the opportunity to reach their peak bone density.

Even if their bone mass isnt that much lower than normal, people with both type 1 and type 2 diabetes have a much higher risk of fractures than other people, adds Edwards. 
2. Lupus and Rheumatoid Arthritis

Nearly 3 million adults in the U.S. have either lupus or rheumatoid arthritis. Both of these diseases are autoimmune conditions, in which the body attacks its own healthy cells and tissues, causing inflammation.

Any chronic inflammatory disease can put you at greater risk of osteoporosis, says Edwards, because it appears to increase the rate of bone turnover, in which old bone is replaced with healthy new bone. People with both lupus and RA usually take corticosteroids for an extended period of time to manage their symptoms. Long-term use of steroids such as prednisone is also a leading cause of osteoporosis, possibly because they slow the activity of bone-building cells.

Lupus is a particular problem because it is common in women between the ages of 15 and 45 -- often during the peak bone-building years up to age 30. "Anything that impedes the growth of bone during these years puts you at greater risk for osteoporosis," says Edwards.
3. Hyperthyroidism

Hyperthyroidism occurs when the thyroid gland -- a small, butterfly-shaped gland at the base of the neck -- becomes overactive and produces too much thyroid hormone.

"Hyperthyroidism increases the number of bone-remodeling cycles you go through," explains Edwards. "And after age 30, every bone-remodeling cycle is inefficient. You lose bone mass rather than building it. So the more cycles you go through, the more bone mass you lose."

Hyperparathyroidism, a similar condition involving related, but different glands, also ups the risk of osteoporosis.

4. Celiac Disease

A number of digestive disorders, such as Crohns disease, can be causes of osteoporosis. Perhaps the most common such cause, says Edwards, is celiac disease, an allergy to a protein called gluten that is often found in wheat products.

Left untreated, celiac disease can damage the lining of the digestive system and interfere with the digestion of nutrients -- including the calcium and vitamin D that are so important to bone health. So even if youre getting the recommended daily amounts of calcium and vitamin D in your diet, if you have celiac disease, you probably dont have enough of those nutrients in your system, and you likely have low bone density.
5. Asthma

Asthma itself does not increase your risk of developing osteoporosis, but the medications used to treat it do. Approximately 20 million people in the U.S. have asthma, including some 9 million children under the age of 18.

Many people with asthma use corticosteroids -- such as asthma "inhalers" -- to help control their disease. During asthma attacks it is not uncommon to start drugs like prednisone for small periods of time. These are very effective in relieving the shortness of breath and wheezing that are common with asthma or emphysema, but they may also contribute to bone loss and osteoporosis.

"In addition to this, many young people with asthma may have more difficulty participating in some activities, which means they might not get as much weight-bearing exercise as they need to help build bone," says Andrew Bunta, MD, associate professor and vice chair of orthopaedics at Northwestern University Feinberg School of Medicine.
6. Multiple Sclerosis

Asthma and multiple sclerosis are two very different conditions, but there are very similar reasons why they both increase the risk of osteoporosis. Like people with asthma, people with multiple sclerosis take steroid-based medications to help manage their symptoms, and steroids are associated with bone loss. Since multiple sclerosis also affects balance and movement for many people, someone with MS may find it more difficult to get as much weight-bearing exercise as they need to in order to build and maintain bone.

"Anything that impedes your ability to walk accelerates bone loss," says Edwards.

If you have one of these conditions, how can you help protect yourself from osteoporosis? First, dont assume that your doctor will take care of it for you.

"When you are troubleshooting a primary condition like MS, asthma, or lupus, youre not thinking about the side effects. Osteoporosis can take a back seat," says Felicia Cosman, MD, medical director of the Clinical Research Center at Helen Hayes Hospital in Haverstraw, N.Y., and an editor of Osteoporosis: An Evidence-Based Guide to Prevention and Management. "Thats understandable -- but you dont want osteoporosis to add more disability to an already disabling condition."

So if the doctor treating your celiac disease or rheumatoid arthritis hasnt already brought up osteoporosis with you, ask to discuss it. Depending on your age and your specific condition, you may have several options to help prevent osteoporosis symptoms:

    * Get an early bone density test. Doctors dont usually recommend bone density tests for postmenopausal women, but if you have one of these conditions, you may need to be monitored more closely, and treated for bone loss more aggressively.
    * Push for more vitamin D and calcium in your diet, and supplement. Edwards recommends that people with conditions that accelerate bone loss get at least 1,000 to 1,500 milligrams of calcium and 400 to 600 international units (IU) of vitamin D from food and supplements. Look for low-fat dairy and fortified foods.
    * Consider getting the vitamin D levels in your blood measured. "Thats not a specific recommendation from the National Osteoporosis Foundation, but it makes so much clinical sense," says Cos man. "Because vitamin D levels vary so much between individuals, its hard to know how much supplementation is needed to reach sufficient levels."

"Stand up, bend over and let me see that itchy rash!"

In another lesson on how its clinical world is changing, the Disease Management Care Blog recently witnessed a "virtual" computer-based video patient-physician office visit. The patient seemed to like the convenience, while the physician reminded the skeptical DMCB that most of any medical diagnosis is based on the patient history, not the physician examination. 

It worked pretty well.  Whats more, the literature suggests that this is not all that new,  there are studies that suggest high levels of patient satisfaction and a surprising willingness to pay for the service out of pocket.  Time will tell on whether this leads to comparable clinical outcomes at an acceptable cost.

But what has struck the DMCB most of all was a business model "dichotomy."  Talk to most policymakers about virtual office visits and youll discover that it is being hailed as another advance in increasing consumer-patient access to cost-effective care.  In other words, persons living in Faraway Montana will be able to discuss their rash with the expert Dr. Windowchat anywhere in the world.  The DMCB thinks of this as the "enlightened" side of "telemedicine."

While that may have merit, when the DMCB googles "virtual office visits," it finds a decidedly contrary business model: busy and computer-savvy suburbanites with the kind of disposable income who can pay out-of-pocket for the convenience of not having to sit in a waiting room.  From a health insurance perspective, this is quite compelling, since it substitutes a lower level of service for a population that is prone to overutilization.  The DMCB knows the doctors like it better when the insurers arent involved in a high cash-flow yes-Ill-take-VISA transactional business.  This is the "real" side of telemedicine.

The DMCB suspects this is one of those innovations that offers something for everyone: increased access for those with not enough of it and "disruptive" technology for a health care industry still locked into expensive and labor intensive one-on-one doctor-patient visits.  From all points of view, this form of telemedicines future is very bright.

...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.

If you lead a horse to water, will it drink?  If it drinks, does that cause it to be a horse?  Who says being a horse is good? Do horses cure thirst?

Those were the silly Disease Management Care Blog questions prompted by a paper trail of articles and letters about the Patient Centered Medical Home (PCMH) that recently appeared in the Archives of Internal Medicine.  That being said, the series was a telling example of the assumptions underlying PCMH research and the lack of of buy-in from community-based physicians

To wit:

Primary Care Is Good: The first article was this October 2011 published research that retrospectively mined the Surveillance, Epidemiology and End-Result (SEER)-Medicare-linked database.  The authors found that for Medicare fee-for-service beneficiaries aged 67 to 85 years, more colorectal cancer screening, earlier cancer diagnosis and lower cancer mortality were all associated with an increased number of past primary care visits. While the study could not rule out the possibility that other factors were involved in the association between primary care and cancer screening (Katy Courics campaign, for example, could have prompted patients to see their PCPs), this study indicated that that access to primary care is a good thing.

If Primary Care Is Good, So Is The Patient Centered Medical Home: The second article was this "Decisive Moment" editorial appearing in the same issue of the Archives, authored by Boston academics Asaf Bitton and Joseph Frolkis.  They reviewed the SEER article, which never even mentioned the PCMH.  That didnt stop the editorialists from bringing it up in an opening paragraph as an "innovative model of care delivery." The article then went on to describe the virtues of generic primary care and the need to increase PCPs in the physician workforce. It then saluted the PCMH as "offer[ing] promising early results [with] a pathway to weld some of the best incremental practice change initiatives onto a chassis of sustainable, term based care."

Who Says the PCMH Is So Good? The third was this Editors Correspondence letter that appeared six months later in the March 26 2012 issue of the Archives. Arguing that many PCPs already provide medical home-like services, private practitioner Edward Volpintesta of Connecticut didnt share Drs. Bitton and Frolkis "optimism" over the PCMH  He observed that 100% of any additional fees generated by the PCMH would have to go toward funding its excess costs and never go toward rewarding the physician.

We Say Its Good: Drs Bitton and Frolkis disagreed in a Editors Correspondence reply. Depending on your definition of a medical home, they argued that most PCPs do not offer that kind of care and that their research shows that the added income from the PCMH can be considerable. 

While the article-editorial-correspondence virtual paper trail is a classic exercise in academic repartee filled with the usual medical jargon, tangential policy nostrums, assumptions and quoting the literature out of context, the real lesson here is that there is some real skepticism about the PCMH among otherwise seasoned primary care physicians. While the mainstream peer-reviewed medical journals have articles that are extrapolating the virtues of primary care onto the PCMH, docs like Dr. Volpintesta arent necessarily buying it.

To the DMCB, this spells significant challenges for the dissemination of the medical home outside the academic community and their early adopter allies. 

Some mainstream doctors remain unconvinced.

Some medical devices

The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

During the political maelstrom of the October government shutdown that enraged Americans and enraptured Tea Party alike, a curious proposal emerged as a possible eleventh-hour savior: a repeal of the medical device tax. 

The medical device tax, a substantial revenue source for ACA funding, was seen as a compelling political bargaining chip. Although not achieving a full “repeal” of the ACA, the vitiation of the tax would have given Republicans a symbolic victory (political cover) and the medical device industry a reprieve. Although the tax remained in force, it still serves as a potent symbol of how health care orm will need to align long-term financing mechanisms that also promote a more efficient health care system. 

A 2.3% excise tax on all medical devices was included in the ACA as a main financing stream for health care orm. Indeed, according to CBO estimates, the tax is estimated to bring in $29.1 billion in revenue from 2012-2022.  A repeal of the medical device tax would not cripple the ACA’s implementation; however, it would make it difficult to move forward, and perhaps more importantly, reopen the bill to legislative scrutiny (Note: President Obama’s announced  administrative fix for health insurance in the individual market assiduously avoided legislative action for similar reasons). 

Some supporters of the tax argue for the concept of “shared responsibility.” Building on the fiscal architecture of Massachusetts’ 2006 health orm legislation, proponents posited that stakeholders who potentially benefitted from health care orm should lend fiscal support.  The ACA followed a similar funding model: hospitals, insurers, and pharmaceutical companies all decided to participate; the medical device industry, although more obstinate, was ultimately written in the legislation.

More sophisticated repackaging of this argument has also emerged. Topher Spiro argued that the medical device tax served as a bulwark against the industry’s egregious pricing and anticompetitive practices. Although, to his credit, Spiro lays out more commonsense policies to increase transparency and address monopolistic concerns besides taxation, he ultimately adopts an odd “the ends justify the means” policy prescription.

Opponents of the medical device tax adopt a well-known line of reasoning: taxation on medical devices will hurt domestic innovation, eliminate jobs in research and development, and have a negative economic impact. This is textbook economic analysis. While some of these points are apposite, much like pharmaceutical companies, medical device companies could arguably make up lost revenue through discriminatory pricing abroad, although this may be (increasingly) difficult in areas such as “austere” Europe. 

Overall, one may be agnostic regarding the substantive points of both supporters and detractors and still be dismayed at the misalignment between the medical device tax and its intended purpose. Granted, medical device providers are leveraging the opportunity to lobby and maximize the industry’s interests in the ACA tumult. However, the tax is not ultimately intended to discourage purchase of medical devices, many of which have substantially improved quality of life for patients. Rather, it functions as a defacto “windfall” tax clawing back excess profits from an industry seen as anticompetitive and opaque with oligopolistic pricing power. 

This narrative works only so far: Medicare, a publicly funded entity, is one of the largest purchasers of medical devices.  However, Medicare is not able (or is politically prevented) from exercising greater pressure on medical device providers through conducting cost-effectiveness analysis or lowering payments on devices that have a suboptimal cost-quality profile. It is true that Medicare is developing bundled payments that will subsume the cost of the device as part of the total procedure; this move away from fee-for-service charges may reduce the “economic rents” (profits) of medical device firms over the long-term. Until then, however, the misalignment between financing mechanisms and policy incentives will likely continue, along with the distortions of second and third-best policies in an already bloated system. 

Medical image from Wikipedia

As a public service, the Disease Management Care Blog is happy to build on what we know about the positions of the Republican Presidential candidates on health orm and speculate on the likely debate answers that the front runners would give if they were asked about the Patient Centered Medical Home.  By facilitating this political narrative, the DMCB hopes our candidates are now free to address the issues that really matter, like whether exposed mens toes are ever appropriate in the workplace, why airport skybridge personnel vanish when flights arrive after 11 PM and whether dermatologists working in ACOs could ever relearn which part of a stethoscope goes in the ears.

Rick Perry:  "Im opposed to P-C-M-H because they are one, patient centered, two medical and three.... um, I forgot what that third H is for.....ooops."

Mitt Romney: "While I supported it in Massachusetts, I oppose it now because the federal government supports it in other states, where it is both supported and opposed.  We also dont know if this approach to care will reduce elevated costs going down."

Newt Gingrich: "This is a constitutionally catastrophic and unprecedented intrusion of enormous federal power of stunning proportions.  Truman wouldnt have stood for this and Lincoln would be shocked, which is why you should buy my book."

Herman Cain:" I am opposed to the patient centered medical home because primary care should rely on teaming and electronic records so that they can take better care of patients."

Michelle Bachman: "A woman told me that her baby is brain damaged because of care received at a medical home!"

Ron Paul: "I dont see the words "patient centered" in the U.S. Constitution and whats more, when we switch to the gold standard, we wont be able to afford it."

Disease Management Care Blog colleague Michael Millenson has written a book called Demanding Medical Excellence. Like many other insightful observers, he wrote that only a minority of care interventions are evidence-based and that it can take years for proven therapies to be mainstreamed in clinical practice. Practice variation is rampant, avoidable errors occur too often, patients are passive bystanders in their own care and the U.S. health care system is spending money like trial attorneys at an anti-tort reform political fundraiser.

What few realize is that Millenson was among the first to recognize these issues when he wrote his groundbreaking book over 15 years ago. 

And, you ask, how have things fared since then?

Millenson answers the question in this Health Affairs article with some good as well as some bad news.

The bad news is that the U.S. health care system pays little attention to the prescient insights of smart people like Michael Millenson. The DMCB shares his pain because many of the things it has blogged about have likewise been ignored by the health care system.  The DMCB spouse and most persons working inside the health care system are not surprised.
 
The good news is that, while it may have taken 15 years to address these issues, things, according to Mr. Millensen, are finally beginning to get better.

In his view, the long delay was due to the commercial insurers unwillingness to give up on their misaligned payment systems that continued to reward preventable complications, prolonged hospitalizations and readmissions. 

This was finally overcome by the twin forces of public insurer activism and patient consumerism. . 

The former imposed no-pay for "never events," required computerized physician order entry (CPOE), promoted accountable care, introduced bundled payments, made physician quality reporting a reality, and reduced payment for hospital acquired conditions. The latter is now represented by internet-enabled consumers who can use their lap tops and handhelds to compare symptoms with other patients, assess treatment options and compare provider outcomes.

The result? According to Millenson, were finally seeing a long-due "paradigm shift" that is leading to transparent measurement and meaningful rewarding of quality improvement, accountability, safety, quality and value. Providers who are unwilling or unable to participate are seeing their services commoditized.

The DMCB agrees and is reminded that, from time to time, government can be a force for good.
 
That being said, it was the managed care backlash of the 1990s that scuttled the commercial insurers ability to implement many of their ideas that were eventually adopted by Medicare and Medicaid. 

Whats more, federal policy doesnt necessarily automatically translate into win-win, higher quality, lower costs and no unintended consequences for never events (here), CPOE (here), accountable care (here), bundled payments (here) or physician quality reporting (here). 

It may take a few more years before we can know if Millenson can write a follow-on book titled Achieving Medical Excellence.

Image from Wikipedia

Disease Management Care Blog readers may recall this post on the benefits of exercise in combating depression among persons with chronic disease. Thanks to the GlassHospital, the DMCB became aware of this entertaining, informative, accurate and savvy video on the benefits of putting limits on sitting, eating and sleeping to 23 1/2 hours a day.

Its very interesting:



Contrast the video above (by the way, its Canadian) with this CDC website (and practically nothing from the Feds on YouTube) and ask yourself two questions:

1) which approach to health promotion more likely to have a greater impact, and

2) is Washington D.C. really giving the taxpayers their moneys worth when it comes to awareness of the benefits of prevention?

A medical spa is a great place to go if you are interested in getting hair laser removal or any type of treatment for your skin or body. These services are desired by both men and women, and there are many to choose from. You can be assured that all of the technicians that perform these procedures are highly trained and skilled. There are many great choices, and financing options may be available for your convenience. You may even be able to find some that offer 0% financing to those that qualify.


Laser hair removal is one of the most popular requests from people that visit a medical spa. People are interested in this option because of the positive reviews they hear about it. It is a permanent way to eliminate hair on almost any body part you can think of. While this is typically something that women are interested in, many men opt for the procedure as well. For example, a man might want to have the hair on his back removed. The condition might be very embarrassing for him or his wife may find it unappealing.

Women like to have this done on many different areas of the body including the bikini line, under arms and face. One of the great things that laser hair removal offers is that you will no longer have to worry about embarrassing body hair. You will also never have to shave again. However, it might require several sessions of the laser hair removal to permanently eliminate the hair. For most people, six sessions are needed, but after that the hair generally stays away for years. There might be a few stray hairs that reappear after a year or so, and this may mean that you should come back for one more treatment.

Juvederm is another thing that people get at a medical spa. Juvederm is something that is used for wrinkle elimination. It is safe and it is very effective. It is in the form of a gel, which is then applied to a persons face. It is usually placed around the nose and lips, and offers immediate results. The results are not permanent, however, but they do last for approximately one year. At that point, you could go back to a medical spa to have it done again. This is one great alternative to getting a face-lift or another type of invasive surgery. This is a procedure that will give you results immediately, but you will not have to recover from it. Whatever types of services you would like to do to your face may be available at a medical spa. These procedures can help you look younger, and they will all make you feel better about yourself.

Article by : Andrew Stratton

Article Source : A Medical Spa Specializes in Many Different Types of Treatments

Alt for Norge!

The Disease Management Care Blog is decamping to Norway for a meet-the-family and see-the-sights vacation.  The good news is that Europe is 8 hours ahead, which means the DMCB will know about the Supremes Thursday decision 8 hours before anyone else.  The bad news is that in the coming days, its posts will become infrequent at best.

In the meantime, check out this just-published JAMA article on the PCMH. 669 primary care centers participated in a Harris survey commissioned by the Commonwealth Fund.  While the "Safety Net Medical Home Scale" was not based on the NCQA, it inquired about the familiar care domains.  The 0 to 100 scale was correlated with financial data from the Uniform Data System reports that reflected the clinics operating costs.

Unsurprisingly, the authors found that as the medical home score increased, so did the operating costs. Moving from 60 points to 70 points increased the cost per patient per month by $2.26.  While the authors calculated that translated into more than half a million dollars of additional expense for the average clinic, the DMCB notes that kind of expense for an average physician panel of 1500 patients means more than $40,000 per year.

Readers familiar with the cost of disease and population health management will find that $2.26 PMPM statistic very significant because thats in the range of what is charged by many vendors.  Whats more, the vendors charges include a profit margin which was not necessarily included in the clinics study data.

Conclusions?

The PCMH is not necessarily "cheaper" than outsourced care management.

While the PCMH may (statistically significant proof remains elusive) "save money," it appears they have the same challenge faced by the disease management industry in the early days: savings net of fees doesnt necessarily equal profit or a financial gain for the health insurer or consumer.

Diabetes control isnt their top concern

The Disease Management Care Blogs primary care colleagues are undoubtedly aware of how "social determinants" can undermine the best care planning. So, if youre going to rely on the Patient Centered Medical Home (PCMH) to increase health care quality and reduce costs, ignoring the impact of poverty or health literacy could lead to poor diabetes control, worsening high blood pressure or more hospital readmissions.

Arvin Garg, Brian Jack and Barry Zuckerman have written a JAMA "Viewpoint" that offers five lessons from pediatric medical homes that can mitigate harmful social determinants:

1) Include social determinants (for example, community factors, substance abuse, education, malnutrition or poverty) in the creation of national treatment guidelines.

2) Develop and implement screening programs to identify any social determinants that could impact medical treatment.

3) Colocate community resources that address social determinant in PCMHs.  Examples include housing programs, job training programs or food pantries.

4) Colocate "outside the box" social programs in PCMHs also.  This is an area ripe for piloting or researching innovative interventions

5) Integrate visiting nurse programs with the PCMH.  Think of the visiting nurses as an extension of the medical home.

As readers of the DMCB are aware, not all PCMHs can build the full suite of services that make up a medical home. Since health insurers and care management vendors are partnering with primary care physicians to build medical homes, this approach to incorporating social determinants in their programs is worth a closer look.