Health for life

The Disease Management Care Blog was shocked, shocked when it learned that Representative Pelosis political opponents have conspired to fund federal student loan subsidies by "tak[ing] it from their favorite target: womens health" (italics DMCB). The White House has chimed in about this political evildoing, noting defunding womens health could result in "hundreds of thousands of women" losing access to cancer screenings.

Alarmed by this unfair disenfranchisement of half of the U.S. population, the DMCB spouse and a number of future Secret Service agents, the DMCB decided to investigate.

As the DMCB understands it, the House Republicans propose to pay for the loan subsidies by defunding all or some the Sec 4002 of Affordable Care Acts Prevention and Public Health Fund (PPHF). 

Heres the key wording from the ACA:

SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND ....to be administered through HHS, to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs. FUNDING.—There are hereby authorized to be appropriated, and appropriated, to the Fund, out of any monies in the Treasury not otherwise appropriated—
(1) for fiscal year 2010, $500,000,000;
(2) for fiscal year 2011, $750,000,000;
(3) for fiscal year 2012, $1,000,000,000;
(4) for fiscal year 2013, $1,250,000,000;
(5) for fiscal year 2014, $1,500,000,000; and
(6) for fiscal year 2015, and each fiscal year thereafter, $2,000,000,000.
(c) USE OF FUND....for prevention, wellness, and public health activities including prevention research and health screenings, such as the Community Transformation grant program, the Education and Outreach Campaign for Preventive Benefits, and immunization programs.

Unable to find the words "womens health" in Sec. 4002 of the ACA, the DMCB next looked up the Community Transformation grant program and the Education and Outreach Campaign.  There is practically no mention of "womens health" there either.

With further research, the DMCB did find this insight on the mechanics of federal health grant funding in the unbiased and ereed policy journal Health Affairs.  According to Boston academic authors Mariana Arcaya and Xavier Briggs, the institutional complexity of overlapping committee and agency jurisdictions and budgets make it extremely difficult - absent innovation, reorganization and new support mechanisms - to coordinate grant programs like the PPHF and give the taxpayers their moneys worth.

The DMCBs conclusions?

1. Given the size of the U.S. governments deficit, its Congress job to make tough choices. Cancelling one program to fund another is one of them. The DMCB wishes that happened more often.

2. Trading a costly and questionably effective PPHF for a national investment in college education doesnt sound like a bad idea to the DMCB.

3. This is only the beginning. Those of us in the health care industry can look forward to the threat of funding cuts in other federally supported programs.

4. Even in this time of political discontent, Speaker Boehner has a point. Shame on Ms. Pelosi and her allies for their bombast and for the mainstream news media for failing to recognize it.

Image from Wikipedia

Nature often plays a delicate balance, like these two bugs holding on against the wind, behind these delicate, white blooms.  Its a rainy, cold, and wet  day, in Iowa.  Fall is just around the corner. (September 11, 2008)

One of the biggest challenges, when helping newly diagnosed persons with diabetes, is finding balance in the information provided. Helping create a positive environment, which encourages a person to learn the scope of the disease and its complications, but still keeping their heads above water. No matter the diabetes community -- this is a struggle that I have found almost everywhere. Even in my own diabetes groups.

Whenever I share any information, my hope is for you, the patient, to be able to make your OWN decisions -- and not make MY decisions as yours. I have this crazy idea that, when empowered with basic information, people will tailor their diabetes regimes to their own circumstances, and find balance. That I dont need to tell anyone what to do, and that since this is diabetes were talking about, what has worked for me... will definitely, and not necessarily, work for you.

The problem is that diabetes is a dick. Diabetes doesnt play fair, and it doesnt give two shits about our feelings. It doesnt. It doesnt care that the news of the things it can do, can scare us, nor does it politely pass us over when we decide to close our eyes against it. So... sometimes, this harsh bit of reality might lead people to behave in one of two ways: either by becoming inflexible with their ideas of control, or by becoming completely lax in their control. Neither of these two ideas is good, even if one of them has much, much better numbers.

Inflexible Control

Laxed Control

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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