Health for life

With atypically little fanfare, the Disease Management Care Blog gazes into the crystal ball and offers ten health care predictions for 2012:

1.  After Mitt Romney secures the Republican nomination for President, he and Mr. Obama will mutually try to find ways to avoid debating the issue of health care orm.  Both will calculate that there’s little advantage to reminding voters of the messes they’ve made.

2.  As a result of 1 above, the election will not hinge on health care orm, which, thanks to an improving economy, will otherwise be very close and not be a erendum on Obamacare.

3. Yet, the U.S. Supreme Court will stir things up with a ruling that the Affordable Care Act mandate is unconstitutional because, among other reasons, Congress should have used its power to tax, not impose a penalty.

4.  There will be no generalizable and published peer reviewed studies on the Patient Centered Medical Home or the electronic health record that conclusively demonstrate that either reduces health care costs.

5.  Even though CMS will have trouble providing timely claims data feeds to its newly established ACOs, we’ll hear little about it in the public domain.  ACOs have every incentive to not cross CMS.

6. Speaking of ACOs, the least recognized Achilles heel as they start up will be a pervasive physician culture that trumps patient perence over shared savings.

7.  We will learn that, thanks to their complexity, the deadlines for implementation of health information exchanges will need to be pushed back.

8.  Congress will "kick the can" of the Sustainable Growth Rate conundrum down the road and past the 2012 election with another temporary patch.

9.  More academic medical center faculty will find that it’s far more professionally rewarding to post on line than to publish in paper-based journals.  Department Chairs will reluctantly find ways to use web statistics in promotion and tenure.

10. Piqued by Mr. Obamas recent recess appointments, the Republicans will respond by holding the up the appointment of Ms. Tavenner as CMS Administrator.

The study showed that older women, non-white women, women who do not have insurance, and women who are not treated at a teaching facility where a plastic surgeon is more likely to be on hand are less likely to undergo reconstruction.

The study was presented at the annual meeting of the American Society of Breast Surgeons (ASBS) in Las Vegas.

About 40% of Early Breast Cancer Patients Undergo Mastectomy
Although studies have shown that women with early-stage breast cancer who undergo breast-conserving surgery and radiation live just as long as women who have a mastectomy, about 40% of women still choose mastectomy, says study leader Laura Kruper, MD, a breast cancer surgeon at City of Hope Medical Center in Duarte, Calif.

"Once they choose mastectomy, there are clear psychological benefits to reconstruction," she says.

So the researchers used California’s government-funded health care database for women treated for breast cancer in four counties from 2003 to 2007 to look into what factors influence their decisions to have implants.
Older Women, Non-Whites Less Likely to Have Breast Implants

Results showed that the number of mastectomies performed increased slightly between 2003 and 2007, and the reconstruction rate rose substantially, from 21% to 29%.

Further analysis showed:

• Women under age 40 had the highest rates of immediate reconstruction compared with any other age group. Compared with them, women 40 to 59 were 48% less likely, women 60 to 79 were 68% less likely, and women over age 80 were 93% less likely to have reconstruction.

• African-American women were less than half as likely as white women to undergo reconstruction, and Asian women had one-third the reconstruction rate of white women.

• Women with private insurance were nearly eight times more likely to have reconstruction than women with Medi-Cal insurance, California’s Medicaid program.

• Women treated at teaching hospitals were twice as likely to undergo reconstruction as women treated at other institutions.

Patient Perence Influences Breast Implants

ASBS spokeswoman Deanna J. Attai, MD, of the Center for Breast Care Inc., in Burbank, Calif., says that in some areas, particularly rural regions, it may be difficult to find plastic surgeons trained in reconstructive surgery.

But, she says, "sometimes its patient perence. I am continually surprised at the number of women, younger women, who feel it is just not important to them. It really is an individual issue," she tells WebMD.

John Corbitt Jr., MD, a private practitioner in Palm Beach County, Fla., was completely surprised at the studys findings.

"In my practice, closer to 90% or 95% of women opt for reconstruction," he says.

Nipple-Sparing Mastectomies Seem Safe

At the meeting, Corbitt presented a study of nipple-sparing mastectomies. The procedure is just what its name implies: intricate surgery to preserve the nipple and the areola after mastectomy.

"For years, the nipple was removed because there were worries the breast tissue it contained had breast cells with the potential to become cancerous," he says.

Once considered experimental, nipple-sparing mastectomy has become common enough that the ACSM is starting a registry to ensure women who have it fare as well as women who dont, Attai says.

In Corbitts small study, one of 228 procedures resulted in a recurrence of cancer in the nipple. "So we simply went in and removed it, and the patient had no cancer.

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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