Health for life

While the national mainstream media focuses on Obamacares dimming prospects, internecine Republican conflicts over the merits of a government shutdown, pugnacious Democratic debates over government price controls and who should take credit for the drop in health care cost inflation, check out this local city paper article on the One Simple Idea (that) Could Revolutionize Health Care. As the reporter pointed out, there was no press release, no touting and no awards.  Simply results.

The DMCB agrees.

Barbara Schneider and her team work with Philadelphia health insurer Keystone Firsts community outreach and care coordination programs to intervene on the "sickest of the sickest" diabetics.  These are 35 patients who are admitted on average more than twice a month.  Patients who are on a first-name basis with all the local emergency rooms nurses on all the shifts. Patients who live in run-down boarding houses on a good day.  Patients who are lucky if their blood sugar is only 600 mg%.  Were talking hundreds of thousands of dollars in health care costs.

Dr. Schneiders lay community health workers (more info on the science here) are seeing these individuals in parking lots, McDonalds, row homes and halfway houses  to cajole, coach, text, call, shuttle and haggle with patients, families, social workers, pharmacists and insurers to dismantle barriers one patient at a time.  If a patient isnt ready to stop abusing drugs, that doesnt mean he cant be taught to use a glucose meter.  While living circumstances may be chaotic, that doesnt mean she cant use a cell phone instead of just going to the emergency room.

As Dr. Gawande noted in his The New Yorker article about the super-utilizers, those kinds of interventions can add-up significant savings.

While Keystone has yet to release an analysis on the impact on claims expense for these patients, a cursory review of the data shows emergency room visits have been cut by a third, while inpatient stays declined by more than half.  Even with the DMCBs limited background in analytics, it suspects that when the return on investment is finalized, Keystone will conclude that the program was an unqualified success.

To the DMCB, this is what its all about.  Washington DC can continue its partisan scorched earth battles while, in the meantime, small regional community minded health insurers like Keystone First are figuring out how to do right by patients using novel programs like this. 

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"Maybe you should go back to the hospital!"

Ask most wonks - especially ones who never took care of a patient - about "readmissions," and, after quoting this article, these health policy Urkels will tell you that returning to a hospital is the poster-child of all that ails U.S. medical care. Providers who cant get it right the first time, they say, are not only giving slipshod care, but are double dipping because their mistakes generate even more fat fees the second time around.

"Balderdash!" says the Disease Management Care Blog. Many Medicare inpatients are so sick that its a miracle that they get to go home in the first place.  Keeping patients in the hospital can be more life-threatening than the home environment and, when things dont get well after a discharge, its often more a function of social support than medical skill. 

That doesnt mean that CMS is going to listen to docs and back off of its Hospital Readmissions Reduction Program (HRRP). Using risk-adjusted actuarial projections, every U.S. hospital will be prone to a possible payment reduction if their observed rate of readmissions for heart attack, heart failure, and pneumonia exceeds the expected rate. Based on those projections, approximately two thirds of hospitals could be penalized.

Writing in the New England Journal of Medicine, Karen Joynt and Ashish Jha point out that hospitals are concerned because 1) readmissions fall outside of their control and 2) the actuarial projections are imperfect.  As a result, hospitals that care for the most fragile and socioeconomically disadvantaged are at risk for paying more than their fair share of CMSs $280 million claw-back penalty. 

The NEJM authors recommend three modifications to CMS HRRP:

1. Include patients socioeconomic status in any risk adjustment modeling. One easy-to-obtain modifier, for example, could be whether the patient is on Supplemental Security Income.  Patients on SSI are less able to cope, which is why they quality for the program in the first place.

2. Include hospitals mortality rates in any risk adjustment modeling.  Hospitals with special expertise are less likely to have borderline patients die on their inpatient services, which means theyll have their more than their fair share of fragile survivors.

3. Limit the penalty to readmissions that occur within hours or days of a discharge, instead of the current problematic policy of counting any readmission that occurs within 30 days.  It makes sense to believe that a premature discharge or slipshod discharge planning is at fault if the patient returns within 3 days instead of three weeks.

Since its unlikely that HRRP program is going away, the DMCB agrees with the three recommendations.  In the meantime, it also suggests:

1. CMS should be held accountable by Congress to execute well on the program,

2) Claims analytics - possibly using a "Big Data" approach - should be applied to Medicare claims to examine whether hospitals are turning to two potential options to undermine the program:

a) gaming the system by altering how they "code" the billing for their readmission patients, or

b) accepting the penalty because of favorable income from readmissions.

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According to South Dakota researchers, the predator status of Tyrannosaurus rex can no longer be questioned. After finding one of its teeth embedded in the healed spine of a Hadrosaurus, paleontologists now believe T rex was a fearsome hunter, not an carrion munching opportunist. 

But, asks the Disease Management Care Blog, how do we really know that that Hadrosaurus wasnt  pretending to be dead when the T rex took its bite?  Alternatively, the Hadrosaurus could have been sleeping and only looked dead to a slow-witted and lazy T rex. 

Dino doubts, says the DMCB, remain.

Such is the level of skepticism that the DMCB is bringing to its reading of the recent CMS press release describing the initial results of the Pioneer ACO program.  CMS says "positive" and "promising." The DMCB says "problematic" wonders if, like the T rex dilemma, there isnt an alternative interpretation.

The DMCB explains.

Recall that the Pioneer ACO program is designed to test whether large integrated organizations can be successfully rewarded for reducing health care costs through a program of "shared savings."  Under the program, if the savings exceed a minimum threshold, CMS will remit a portion of the upside savings back to the participating organizations.

According to the press release, the health care costs for the 669,000 Medicare beneficiaries cared for by the 32 Pioneer ACO program providers grew only .3% versus .8% for a parallel group of "similar beneficiaries." 13 organizations exceeded the savings threshold, which will lead to Uncle Sam writing checks for $76 million in shared savings.

This front page article in The Wall Street Journal has more detail. It says 18 of the 32 reduced health care costs, which leads the DMCB to conclude that five otherwise "successful" participants did not cross the required savings threshold. Two participants lost money. That, in turn, suggests the remainder, or twelve, broke even.

Details on how each individual institution fared are not readily available.  According to WSJ, Bostons Partners Healthcare reduced Medicare claims expense by $14 million.  They will be rewarded with a shared savings check of $7 million. Wisconsins Bellin-ThedaCare will get "several million."

Good "win-win" news for the Pioneer organizations, CMS, Uncle Sam and U.S. taxpayers, right? A critical mass (40%) achieved millions in shared savings, which means proof of concept met and that a key part of Obamacare is successful, right?

"Not exactly," says the DMCB.

It figures 100% of the participating organizations had to each invest millions for personnel and other infrastructure to pursue the Medicare savings in the first place.  In other words, they were in the red before Pioneer even began.  That means that, in addition to the two participating organizations that lost money, the 12 that "broke even" as well as the 5 that did not make threshold also lost millions. 

Thats 19 losers or almost 60% of the participating organizations.

In addition, its possible that for some of the 13 "winners" that the shared savings awards wont  match their up-front multi-million dollar investment either.  Assuming thats true, its possible that as many as two thirds of the Pioneer organizations lost money. No wonder 9 of the participants have signaled a desire to exit the program.

The DMCBs dinosaur analogy may be apt.  Given a two out of three likelihood of losing millions in the first year of operations, ACOs may just be too big and complicated to survive in the current health care environment.  Nonetheless, the Pioneer program will continue and the DMCB will stay tuned for the Year 2 results.

In the meantime, the DMCB wishes CMS good luck in using these "positive" and "promising" results to expand the program anytime in the near - or distant - future.  

If youre one of those disease management skeptics, you might enjoy the lingering anti-vendor schadenfreude of this bottom-up re-analysis of the MHS program that was just published in the New England Journal.  However, if you are a fan of the Feds programs for the Patient Centered Medical Home or Accountable Care Organizations, youll also want to pay close attention to a timely reminder about the perils of contracting with CMS.

The Disease Management Care Blog explains.

Recall MHS was a CMS program designed to test old fashioned disease management in fee-for-service Medicare.  A total of eight vendors launched their programs in separate geographic areas across the U.S. in the latter half of 2005.  Each area had about 30,000 beneficiaries with diabetes and heart failure who were randomized to disease management or usual care in a 2:1 ratio.  Participants were ill with an average of more than one recent hospitalization in the previous 12 months and more than $15,000 in baseline costs.  The programs consisted of remote call centers staffed by nurse-coaches who counselled patients on a regular basis.  Each of the vendors negotiated a monthly "at risk" administrative fee from CMS.  To retain the fee, the companies had to reduce costs in excess of the fee and simultaneously achieve a variety of quality and satisfaction targets vs. the usual care patients.  If they failed to save enough money, CMS clawed the money back.

The Journals reanalysis, involving more than 240,000 beneficiary-participants, didnt shed any new light on the original depressing report to Congress.  Among the eight vendors, the change in the per beneficiary per month (PBPM) cost ranged from $22 in savings to $38 in additional costs; most of the PBPM changes were in the single digits.  In contrast, the fees ranged between $74 to $159 per beneficiary per month.  Only three of the eight vendors had lower costs, none achieved statistical significance and none had savings that exceeded their fees. There were some improvements in quality, but they were spotty and quite modest.

Participation rates among eligible beneficiaries averaged 85%.  Mean telephone contacts per patient was .7 per month and ranged from .4 to 1 per month.  Patients were telephoned on average every 2.7 months; over a 30 month period, 59% were contacted at least 10 times and 23% were contacted fewer than 5 times. 

And what are the lessons?

The authors had five, all of which also apply to the medical home and ACOs.  The DMCB has two more.

1) Show me the money:  In retrospect, the research that led to MHS that suggested that disease management "worked" was imperfect.  By the way, the same can be said of the largely observational and underpowered research supporting medical homes and the total lack of any meaningful experience with ACOs.  Will these innovative care approaches share the same fate as MHS?  Based on what we know at this time, it cant be ruled out.

2) Needy patients:  Medicare beneficiaries with diabetes and heart failure are sick. The nurse-coaches were unprepared to meet all of their patients needs.  Medical homes and ACOs may end up being surprised also.

3) Analytics:  In the CMS "data dumps" to the vendors, it was difficult to find the patients who were the most vulnerable.  This good news is that modern predictive modeling analytics - despite its limitations - may enable medical homes and ACOs to target their care management at those patients with the greatest need and at the highest risk for increased costs.

4) Timely access to data: CMS data transfers to the vendors could be tardy, resulting in telephonic outreach to patients long after it could have done any good.  ACOs will need to worry about this in their dealings with CMS. 

5) The doctors: despite the vendors assurances, the disease management programs were not aligned with the beneficiaries doctors.  This is less likely to be a problem in medical homes and ACOs, but doesnt mean that they wont have to worry that their docs arent fully buying into the notion of teaming with non-physicians.

The DMCB offers two other lessons:

In retrospect, calling sick Medicare patients infrequently may have been one factor in MHS undoing.  The telephone will probably have a role to play for medical homes and ACOs, but the best mix of telephonic and face-to-face visits remains an open question.  At any rate, it seems that contacting patients at least every 30 days would be a good benchmark.

The DMCB remembers the confident "this is guaranteed to work!" hubris of yesterdays MHS architects and finds it eerily similar to the enthusiasm surrounding todays medical homes and ACOs. If the Medicare medical home and ACO programs dont work out, itll set these innovations back ten years or more.

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Hi,

I remembered that before I started the last program that my doctor gave me, I had told myself that if that program did not work, I thought that the Carbohydrate Addicts Lifespan Program should work. After all, this program was designed by people like me who found the solution. Doctors Richard and Rachael Heller are the authors and they have both been overweight in the same way that I have been -- and the evidence points to that they are still normal weight after all these years. I hope that is accurate. Prediabetes aside, they write about controlling insulin. Ah hah! Just what I need.

Since it has occurred to me, I want to point out that during this latest experiment with the juice fasting I cut out all dairy, all protein, all nuts and seeds, all grains, and all starchy vegetables. I did the program for eight days and only twice had really hard hard temptations that I shared about. The one that broke the camels back being last night when I simply walked to the fridge and got out some eggs and cooked them for me. I weighed myself this morning and I put on .5 of a pound. The highs of my blood sugar levels were about where they normally are but the lows were lower. I want to test my blood sugars on the new program to see if the highs are lower because of the addition of protein and I hope to keep the lows lower still.

Now I want to try something more balanced. I got out my CALP book which I have had on the shelf since 1998. I have always believed in that book -- but never completely was obedient to the program rules. I never ate the required salad. I often ate more carbs than recommended at the reward meal and simply did things "MY WAY" -- as per usual. But after having done the juicing, Ive learned that things can be done differently-- meaning I do have the strength to do things as they should be done -- especially if I rely on Gods help to do what is right.

I have been reading the section on how to actually do the program and have been a little surprised because the actual rules are more precise than I think I had understood before -- or was willing to do. I remember hating all the myriad of details and wanted to boil it down to its most simple terms -- but in doing that I missed some important details. This time, I am not going to do that. I have already made a copy of the two lists, one for high carbohydrate foods that can be eaten only at the reward meal, and the other list is of Craving Reducing Foods.

There are only three guidelines to the basic program:

1. Eat a Balanced Reward Meal Every Day -- and they describe what that is

2. Complete Your Reward Meal Within One Hour -- and they tell you why this is important

3. Eat Only Craving-Reducing Foods at All Other Meals and Snacks -- the choice is yours whether you want to do 50/50 protein and craving reducing vegetables; or less protein and more vegetables -- recommended portions are average size -- but you can eat as many portions as you need to and the portions can be whatever size you choose to make them as long as you eat them together. Also: if you are not hungry, you dont have to eat. Yes!!

The idea is to achieve balance and control your insulin by using the right kinds of foods to achieve this. I really like this quote:

"If youre eating too much or too often, dont blame yourself -- you are simply exhibiting a powerful sign that your body is out of balance. A balanced body eats just enough, feels satisfied, then stops eating -- naturally." -- Drs. Richard and Rachael Heller.

Amen to that.

It is not about a cup of this and a half-cup of that to lose weight. It is about eating the right foods to control your insulin which is the "appetite hormone." If you can control the insulin, you can control the cravings and begin to eat naturally. When insulin is controlled and your body is in balance, they say, the cravings disappear and you begin to lose weight. And they tell you to weigh yourself every day and then at the end of the week take an average of them all. Even in their example the weight fluctuates up and down every day -- just like it did for me, only it seems my fluctuations were more radical than in their example -- perhaps because I was not eating any animal-type protein.

I really like the idea of having a list of craving reducing foods and am surprised at which vegetables are on which list (either craving reducing, or carbohydrate-rich foods). There are vegetables on the carbohydrate-rich list (meaning they raise the blood sugar, which raises the insulin, which packs on more pounds) that I have been juicing this past week. Carrots for one -- but I began to notice they were raising my blood sugar and on Wednesday night I donated them to some friends who own rabbits. Also on the carbo-rich list are beets, squash, zucchini, corn, peas, potatoes (all kinds) and you can only have 1/4 of a tomato (which mirrors another diabetes doctor that I know). No fruit. Not even limes or lemons, which I sort of knew.

The Craving reducing vegetables are a list from bamboo shoots to wax beans that are low in starch and high in micro-nutrients. All Greens are on it. Cabbage and cruciferous vegetables are on it, but they made a note next to the broccoli which surprised me. They mention that for some people who are particularly sensitive to carbohydrates broccoli can cause rebound cravings or reduced weight loss. They recommend that if you are concerned you can either eliminate them, or save them for Reward Meals only.

I have made copies for myself of the two lists and will do my shopping today based on these lists. They allow no fruit juice nor vegetable juice... but they only list carrot juice and V-8 juice. I guess if I am going to follow this program I will have to put the juicer away. I was hoping to juice a couple of times a day for the good nutrients, but the things that make the juice palatable (the fruits) are simply not allowed on the program. There are no nuts and seeds on the program, either. It kind of boils down to protein and vegetables with a few extras (a combination which I have always secretly believed I should be eating).

There is some dairy, which I need to be careful of -- but I can have eggs, cream cheese, and all varieties of cheese except low-fat ricotta. Cottage cheese falls under the same category as broccoli which can cause what they call rebound cravings... I am not sure what that is, but I know that I can easily binge on cottage cheese, so I am better off leaving it alone. Of course, all the sweet things like ice cream and yogurt are on the carbo-rich list and should only be eaten at a reward meal.

So. Here I go again. This time, the program, as I read it, seems to fit what I particularly need and I want to try it. One thing... they have the basic program and then they add some options that you can choose to incorporate or not, but they say they will make things works better. I have read through them and am already doing almost all of them already, so all I need to do now is sort out the veggies, add back in the protein that keeps my blood sugars lower and head out on the basic plan path to, I hope, finally, controlling the insulin and inflammation, and losing weight.

There is one list from the options that I am making a copy of because I believe I am up for it. According to the basic plan, a one-third portion of the reward meal is any high carbohydrate item that you choose. Once a day, you get to eat a high carb item, but the list I am referring to, which is one of the options that can be added later, suggests that instead of cake you choose bagels or bread. Instead of candy you choose beans. Instead of yogurt you choose nuts or seeds. I like the idea. I am already off of most of those things anyway, so it should not be a problem to make better choices in that area, too.

I also want to say the Juice Fast/Feast/Feat has been a big help to me. I am not, at this time, in a place where I can do what Joe and Phil did, which is to go on for 60 days, but I now understand why Joe calls it a "Reboot." I feel like Ive been "rebooted" and have a clean slate to work on. I know I have the strength to make right choices and that if I make right choices I am on the path to insulin control and weight loss.

I, again, have high hopes. I am really glad that I am starting the new program right away. No time wasted. I shall be praying for the Lords help. Please pray for me as the Spirit leads you.

Be back soon,

Marcia