Health for life

ACOs at work.

According to this Bloomberg news release, some of Medicares Accountable Care Organizations (ACOs) are already achieving cost savings. Mt. Sinai and Coastal Carolina are reducing emergency room visits while Hackensack is reducing costs.

All three institutions are using two key ingredients:

1) information technology-based risk stratification to identify the persons at greatest risk and

 2) dedicated full-time nurses who perform telephonic and in-person outreach, coordinate care and provide patient coaching that, in turn, is tailored to that risk.

To the DMCB, the good news is that ACOs are using the two approaches that define modern-day disease and population health management. That industrys success will be Mt Sinais, Coastal Carolinas and Hackensacks success.

The bad news is that the news release only addresses half the question: did any savings exceed the institutions cost of the risk stratification and the nurse-FTEs? If the early answer is no, then avoided ER visits and reduced costs could turn out to be much like Governor Christies lap band: so far so good but its still risky and could ultimately be all for naught.

And on an unrelated note, this just-published New England Journal article makes note of "not made in America" health care innovations from overseas that could hold important lessons for the United States. In particular, the authors point out that Germanys DRG hospital payment system includes 30-days of post-discharge care and includes the physician payment. Readmissions within that 30 day window are, with a few exceptions, not covered and physician payment is possible because docs are often employees of the hospitals.

"Interesting!" says the DMCB, but is reminded that Germany is hardly a model for reducing inflationary cost trends.   It also specifically recalls hearing Germanys Minister of Health, Daniel Bahr, express impatience with his countrys DRG system just last week. He criticized it for not advancing enough quality in his keynote address at the HauptKongress in Berlin.

Change in Weight More Important Than Where You Start

Some overweight older adults don’t need to lose weight to extend their lives, but they could risk an earlier death if they pack on more pounds.

In fact, the nationwide study found that people who were slightly overweight in their 50s but kept their weight relatively stable were the most likely to survive over the next 16 years.

They had better survival rates than even normal-weight individuals whose weight increased slightly, but stayed within the normal range.

On the other hand, those who started out as very obese in their 50s and whose weight continued to increase were the most likely to die during that period.

Overall, the results suggest that about 7.2 percent of deaths after the age of 51 are due to weight gain among obese people, at least among the generation in this study, said Hui Zheng, lead author of the study and assistant professor of sociology at The Ohio State University.

“You can learn more about older people’s mortality risk by looking at how their weight is changing than you can by just looking at how much they weigh at any one time,” Zheng said.

While some extra weight seemed protective in this study, Zheng cautioned that these results applied only to people over 50. His previous research, published in Social Science & Medicine, suggests that being overweight may not be helpful for younger people.

“Our other research suggests that the negative effect of obesity on health is greater for young people than it is for older people, so young people especially shouldn’t think that being overweight is harmless,” he said.

This new study was published online this month in the American Journal of Epidemiology. Co-authors are Dmitry Tumin, doctoral student, and Zhenchao Qian, professor, both in sociology at Ohio State.

The researchers used data from the Health and Retirement Study, a nationally representative survey of Americans born between 1931 and 1941. This study analyzed 9,538 respondents who were aged 51 to 61 when the survey began in 1992. They were re-interviewed every two years until 2008, and the researchers had information on how their body mass index (BMI) changed at each interview and whether they died at any point before December 2009.

Body mass index measures weight relative to height and is often used to evaluate obesity.

Zheng and his colleagues classified respondents into six groups, depending on their BMI at the beginning of the study and how it changed over the 16-year period they were surveyed.

While slightly overweight people (BMI of 25 to 29.9) whose weight was steady had the highest survival rate, those who moved from overweight to obese (BMI 30 to 34.9) were close behind.

“This suggests that among overweight people at age 51, small weight gains do not significantly lower the probability of survival,” Zheng said.

The third highest survival rate among the six groups was normal weight individuals (BMI of 18.5 to 24.9) whose weight increased slightly, but stayed within normal range.

Next came the Class I obese (BMI of 30 to 34.9) whose weight was moving upward.

“You can learn more about older people’s mortality risk by looking at how their weight is changing than you can by just looking at how much they weigh at any one time.”

Next to last were normal weight individuals who lost weight. Although the study attempted to control for illnesses among those studied, it may be that many of these individuals dropped weight because of illness.

The most obese individuals (BMI of 35 and over) who continued to add weight had the lowest survival rate of the six groups.

There weren’t enough people who started out as overweight and obese and lost weight to include in this analysis, Zheng said.

“We can’t really evaluate the effectiveness of planned weight loss on mortality. Even in the normal-weight people in this study, there was no way to tell whether weight loss was planned,” he said.

Zheng noted that the study took into account a wide variety of demographic and socioeconomic factors that may play a role in both weight and mortality among Americans. The researchers also controlled for whether the respondents smoked, whether they had a variety of chronic illnesses and even how they rated their own health. The results stood even after all of these factors were taken into account.

Why is being slightly overweight protective for older people?

“It is probably because the older population is more likely to get illnesses and disease, especially cancer, that cause dangerous weight loss,” he said. “In that case, a small amount of extra weight may provide protection against nutritional and energy deficiencies, metabolic stresses, the development of wasting and frailty, and loss of muscle and bone density caused by chronic diseases.”

Younger people are less likely to get many of the diseases that afflict older adults, which is one reason extra weight is not good for them, he said.

But Zheng said the main message for everyone, including older adults, is that packing on the pounds, especially if you’re obese, can be hazardous to your health.

“Continuing to put on weight can lower your life expectancy,” he said.

When pundits claim that health care spending is out of control, what do they mean?

Does it mean that Massachusetts outlawing of hospitals excessive price increases is a good thing? That rolling back the Affordable Care Act will automatically usher in a new round of price gouging? That when the DMCB generates another medical co-pay, the DMCB spouse is right to wave a copy of the bill around and demand that the DMCB do something now to orm the U.S. health care system?

As the Disease Management Care Blog understands it, what the pundits, Massachusetts legislators, patient advocates and the DMCB spouse mean is that more and more of our nations gross domestic product (GDP) is being spent on health care services.

That assumes wed all be better off if the U.S. were spending its national treasure on stuff like manufacturing, technology, education and innovation. So, instead of committing just under 18% of our output on hospital care, physician services, nursing homes, medical devices and drugs, wed all be better off if we spent it on the production of solar panels, Facebook, public school vouchers and iPhone apps.

That way we wouldnt be struggling with the prospect of another 1% gain on GDP (to 19%) and the looming possibility that well soon be spending a whopping fifth of our economy on health care.

But is the spending on health care really that bad?  As noted here, the DMCB pointed out that non-government-insured health care costs have been moderating for years.  Whats more, recent year-to-year increases in health care spending in the U.S. are actually lower than much of the developed world.

And now theres one more reason to doubt the prevailing wisdom about rising health care costs. Charles Roehrig, Ani Turner, Paul Hughes-Cromwick and George Miller of the curiously name Altarum Institute point out that the normally rising and falling GDP associated with routine economic cycles can make steady health care costs look relatively worse or better than they appear.

To dampen the impact of a cyclic economy on the assessment of health care spending, the authors compared health spending to U.S. "potential GDP." Apparently, this obscure economic metric has been used by economists to portray what GDP would be if the economy were operating at full employment of the current population and without any idle production capacity.  This metric has the advantage of "smoothing out" many of the peaks and valleys of the normally measured GDP.

Using potential GDP as the comparative baseline, the authors found that health care spending growth gained less than 1% of the economy starting in July of 2005, well before the onset of the Great Recession of 2008. In other words, during that time, the health care industry grew pretty much at the same rate as the "potential" GDP. 

Whats more, in June of 2009, health care cost growth gained an additional 1% of potential GDP, only to fall back below 1% again in May of 2011.  Most of the increases seemed to be accounted for by Medicare Part D spending; if that particular cost is backed out, excess growth would have been 1% or less throughout the measurement period.

The authors can only hypothesize on why health care costs didnt outstrip the U.S. economy. While it could be partially accounted for by the rising numbers of uninsured (who would have avoided going to hospitals or seeing doctors), the authors point out that other trends could have played a role: changing physician practice standards, increasing numbers of salaried physicians, market pressures pushing down on fee schedules, increases in patients out-of-pocket expenses making them less likely to access the care system, new care models (including disease management?), the increasing use of generics, previously expensive drugs going off patent and the drop-off in the number of "blockbuster" pharmaceuticals.

This means when the economy bounces back and/or Obamacare results in more insured Americans, there is no guarantee that underlying health care inflation will return.

The right definition was there all along!

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over "population health."

The Disease Management Care Blog says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing "population health" for an entire geography. 

Between the here of "improving chronic care" and the there of "population health," Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term "population health" in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

In short, they dont believe ACOs, as currently configured, are up to the new task.  Thats because ACOs would need to collaborate with social service organizations, be responsible for a geographically defined service area and improve long term public health outcomes.  According to the authors subtitle, the answer to the question "should they try" is "no."

The Disease Management humbly disagrees.  Thats because Drs Noble and Casalino, the editors of JAMA and the manuscripts peer reviewers seem to be ignorant of the the correct definition of population health. Its right there on the Care Continuum Alliances web site, in this longstanding page that describes the "population health model of care."  When the DMCB did a simple Google search on "population health definition," it had little difficulty finding the link.

The CCA helpfully describes population health as:

a delivery model characterized as a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.

Was that so hard?

And how is that accomplished?  According to the CCA, the ingredients to that make for population health include:

• Population identification strategies and processes;

• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;

• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;

• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;

• Self-management interventions aimed at influencing the targeted population to make behavioral changes;

• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;

• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health

Accordingly, if an CMS-contracted ACO can identify its assigned Medicare population, perform needs assessments, promote awareness of health risks, offer education as well as support, increase self management, use data feedback and evaluate outcomes, its offering "population health."  By using that playbook, an ACO will capitalizing on the experience of a community of population health service providers that have been doing precisely this for over a decade.

This vision is far more compact than the overreaching, misinformed and muddled definition of "population health" offered in JAMA.  It is also, if ACOs invest in the right resources and partnerships, well within reach.

The DMCBs answer to the question "Should they try?" is "yes."

One of the Disease Management Care Blogs local hospitals has jumped into a lawsuit against Medicare. 

According to this article, the dreaded 2003 Medicare Modernization Acts RAC audits have gummed up Part B as well as Part A payments.  Thats important because Part B includes physician services, which outside of hospital-physician alliances like Accountable Care Organizations, is typically completely separate. Hitting A as well as B not only represents a potential double hit to hospitals bottom lines.

Could that give hospitals a reason to think again about hiring physicians?

Even if the DMCB is wrong about the scope of the lawsuit, the articles paragraph on this hospitals costs in dealing with the RAC audits are eye opening: 6 staff members and additional hundreds of thousands of dollars to cover medical record requests, consultants and appeals.  If other hospitals are being forced to follow suit, the cost to the health care system is considerable.

And those are Medicare administrative costs. These are borne not by the feds, but by hospitals, which must comply with thousands of pages of complex rules and regulations.  While its mathematically true that Medicare has "low administrative costs," thats because the Agencys principal means of enforcement are cudgels like RAC audits with clawbacks with interest, penalties and other sanctions. 

While there is no shortage of hospital bad behavior, DMCB suspects most hospitals are honest and, despite that, have had no choice: add additional administrative expenses that are ultimately passed through to the patient and the nations fisc.

Hugging a health insurer

Its an old conservative joke, but what is the one key difference between health insurers and terrorists? 

Answer: liberals only occasionally attack terrorists.

For the latest example of the continuing disdain for health insurers, check out this rather typical July 5 Washington Post article "Is this the end of health insurers?" After extolling one enlightened companys decision to self-insure its workers*, writer Sarah Kliff points out that hospitals can cut out the insurer middle man and offer the same service. The result, says the article, will be the wiser use of the premium dollars, lower costs and fewer coverage denials.

While the physician Disease Management Care Blog agrees that the health insurers have only themselves to blame for their bad reputation, it doesnt think that these companies are going to go away anytime soon.  Its not because, under Obamacare, U.S. citizens are now required to buy their product at any price.  Its not because they control hundreds of billions of dollars.  And its not because theyve had the ear of the political class for years.

The contrarian DMCB thinks theyll continue to stick around because they perform a two useful public services:

1. Keeping Providers From Going Belly Up: There have been too many examples of hospitals and physician organizations being unable to collect todays premium dollars and hold them as a promise to pay for tomorrows sickness.  Whether its not charging enough or being unable to say no, providers are vulnerable to running out of cash and being unable to cover their insureds health care bills.  The DMCB says its better to insulate hospitals and doctors from the perils of the underwriting cycle.  Insurers do that.

2. Keeping Providers From Going to the Dark Side: Assuming a hospital or physician organization can hold the dollars, pay for all that health care and end the year in the black, theres a good chance that theyll do it by ultimately employing the same tactics used by many mainstream insurers: denials of services based on determinations of "medical necessity."

*As an aside, self-insured companies dont always act in the their employees best interest.  Look at this infamous example and note that Cigna only "administered" the insurance plan on behalf of a self insured organization.

One outcome of the Disease Management Care Blogs authorship of this manuscript that questioned the merits of the electronic health record (EHR) was an enduring belief that these systems didnt save money. The DMCB doubted that it would increase provider efficiency, decrease avoidable complications, reduce duplicative testing or increase quality. Its best educated guess was that the impact on overall health care costs was neutral.

According to six members of the United States Senate, the DMCB was wrong. They say the EHR may waste money and increase health care costs.

Thats among the conclusions of Senators Thune (R-S.D), Alexander (R-TN), Roberts (R-KAN), Burr (R-NC), Coburn (R-OK) and Enzi (R-WY) in their just-released report "Reboot: Re-examining the Strategies Needed to Successfully Adopt Health IT."

They point to the phenomenon of "code creep," which can result from using EHRs to document more extensive patient histories and physical examinations that, in turn, are used to justify an "upcoded" and theore richer bill with a higher payment.  In addition, the Senators point to research that suggests code creep can be linked to an increased ordering of clinical testing and services.  Last but not least, they point out that once an incorrect diagnosis enters the EHR, it is practically impossible to delete it, leading subsequent providers to mistakenly believe it is still active.

And to add insult to injury, Reboot describes the response of a "CMS official" who was asked about the above concerns.  The answer was that it would take years for the Agency to better understand the phenomenon.

The DMCBs take?

Closer examination of the Senators report shows that much of the cost concerns are based on lay media reporting instead of any peer reviewed studies.  That being said, there may be merit to the idea that EHRs can game billing systems.  It warrants further research.

Is partisanship playing a role?  The DMCB cant deny its a factor, but the same underlying motivation may be underlying CMSs unwillingness to do anything to diminish the Democrats health orm "branding."

Last but not least, the Agencys guess that it would take "years" to examine the concern is overly optimistic.  There are outside analytic/research outfits that can do a faster, better and cheaper job of coming up with an answer. 

The Senators and the U.S. taxpaying public deserve to know if this is true.

Disease Management Care Blog regulars are fully aware of the rich variety of care coordination approaches that exist outside of the patient centered medical home (PCMH).

They also know that the mainstream health policy dons have it wrong and that care coordination doesn’t come down to choosing between a Medicare PCMH and an ACO PCMH.  Other options are in or outsourcing a cohort of generalist, credentialed, dedicated and fulltime nurse-coaches on a shared service basis.  When done right, there is little physician disruption and a high degree of patient acceptance.

Prevailing common wisdom is wrong: primary care sites dont always need to individually hire, train and pay for a full-time nurse-coach when this human resource can be centrally managed by smart provider organizations, commercial insurers or self-insured employers using economies of scale.

In prior posts, the DMCB has repeatedly linked peer-reviewed literature describing successful "turnkey" approaches to care coordination and management.  Knowing, however, that published evidence is necessary but not sufficient for changing policy, the DMCB has also been keeping its eyes peeled for real world examples of outsourced care management.
  
It found one during the last Care Continuum Alliance webcast.

Webcast listeners got to hear from another company that has successfully commercialized outsourced care management.  MedAssurant does business with hundreds of provider organizations that ultimately touch 118 million persons. While MedAssurant is perfectly capable of providing modern remote telephonic disease management, it also offers a care management "solution" that relies on nurses who are embedded in physician offices and clinics.  Their value proposition is to complement the physicians care with additional face-to-face coaching that helps patients engage in greater levels of self-care. The nurses are backed up by predictive modeling that identifies the patients at greatest risk, a telephonic coaching program when appropriate and access to other community based services including social workers. 

While MedAssurants outcomes data havent been formally published anywhere, it has some compelling data in the graphic above as well as information here describing increases in HEDIS and CMS Stars Ratings as well as drops in condition-related inpatient and emergency room visits.  The DMCB also knows that the health insurers, employers and provider organizations that are buying or using MedAssurants offerings are skeptical, sophisticated and demanding. 

MedAssurant is doing something right.  

You’ve probably seen “a good source of omega 3′s” imprinted on various boxes and bags around the super market and wondered “what are omega 3′s and why should I give a damn?

Omega-3 fatty acids are considered essential fatty acids: Omega 3′s come from a family of unsaturated fatty acids.  Even the healthiest diets need a moderate amount of healthy fats, and omega 3′s are crucial to healthy, sustainable living.  They’re considered “essential” fats – Essential fats are so defined as they are vital for, but cannot be made by, the human body. Only plants can make the vital omega 3 and 6 parent fatty acids, human enzymes can then convert these to other fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) which are building blocks of the brain and nervous system. 

Omega 3 Source

 They are needed for the integrity of every cell membrane in the body so particulalry important for the health of vital organs such as the heart and brain.They are necessary for human health but the body can t make them -- you have to get them through food. Omega-3 fatty acids can be found in fish, such as salmon, tuna, and halibut, other seafood including algae and krill and there are plenty of vegan sources of Omega 3′s including spirulina (algae), nuts, flax, and vegetables. Vegan sources of omega-3s include canola oil, broccoli, cantaloupe, kidney beans, spinach, grape leaves, Chinese cabbage, cauliflower, spirulina, and walnuts.

Research shows that omega-3 fatty acids reduce inflammation and may help reduce the risk of chronic diseases such as heart disease, cancer and arthritis.The omega 3 parent fatty acid is called alpha linolenic acid (LNA or ALA) and comes from vegan seeds such as flax, hemp and pumpkin, from nuts such as walnuts, and to a lesser extent from soya and green vegetables. 

Through a series of enzyme-controlled reactions the human body converts this LNA into a number of vital fatty acids including EPA and DHA. Among their many roles EPA is needed for brain function, concentration, and vision, and is also converted into a powerful anti-inflammatory agent. DHA is needed as a building material , particularly for brain structure and so is especially important in pregnancy for the baby’s brain and nervous system development, infants who do not get enough omega-3 fatty acids from their mothers during pregnancy are at risk for developing vision problems and nerve damage.



Additionally, the benefits of omega-3s include reducing the risk of heart disease and stroke while helping to reduce symptoms of hypertension, depression, attention deficit hyperactivity disorder (ADHD), joint pain and other rheumatoid problems, as well as certain skin ailments. Some research has even shown that omega-3s can boost the immune system and help protect us from an array of illnesses including Alzheimer’s disease.

Fish contain unsaturated fatty acids, which, when substituted for saturated fatty acids such as those in meat, may lower your cholesterol. But the main beneficial nutrient appears to be omega-3 fatty acids in fatty fish. Omega-3 fatty acids are a type of unsaturated fatty acid thats thought to reduce inflammation throughout the body. Inflammation in the body can damage your blood vessels and lead to heart disease.

Omega-3 fatty acids may decrease triglycerides, lower blood pressure, reduce blood clotting, boost immunity and improve arthritis symptoms, and in children may improve learning ability. Eating one to two servings a week of fish, particularly fish thats rich in omega-3 fatty acids, appears to reduce the risk of heart disease, particularly sudden cardiac death.

Alzheimers
Polyunsaturated fatty acids found in many fish may prevent damage to brain cells. Eating fish can also reduce the risk of high blood pressure, which is linked with dementia. A French study of 2000 people showed that those who ate seafood at least once a week had a significantly lower risk of dementia over a seven-year period than those who didnt.

Dementia - elderly people who eat fish or seafood at least once a week may have a lower risk of developing dementia, including Alzheimers disease.

Cardiovascular disease - eating fish every week reduces the risk of heart disease and stroke by reducing blood clots and inflammation, improving blood vessel elasticity, lowering blood pressure, lowering blood fats and boosting good cholesterol.

Cancer - the omega 3 fatty acids in fish may reduce the risk of many types of cancers by 30 to 50 per cent, especially of the oral cavity, oesophagus, colon, breast, ovary and prostate.

Asthma - children who eat fish may be less likely to develop asthma.    

Just how do omega-3s perform so many health “miracles” in people? One way, experts say, is by encouraging the production of body chemicals that help control inflammation — in the joints, the bloodstream, and the tissues

But even as important is their ability to reduce the negative impact of yet another essential type of fatty acid known as omega-6s. Found in foods such as eggs, poultry, cereals, vegetable oils, baked goods, and margarine, omega-6s are also considered essential. They support skin health, lower cholesterol, and help make our blood “sticky” so it is able to clot. But when omega-6s aren’t balanced with sufficient amounts of omega-3s, problems can ensue.  In general, Americans eat too much Omega 6 and not enough Omega 3.
You can replace some omega-6s from cooking oils with a third fatty acid known as omega-9 (oleonic acid). This is a monounsaturated fat found primarily in olive oil.

If you think you can get all of your omega 3′s only through fish oil supplements?  Think again.  There are other healthy components of whole foods containing Omega 3′s that make it better for your body and soul – flax, for example, is heavy in fiber which helps lower cholesterol, regulate blood sugars, and improve digestion. 
.
If you have diabetes, including more omega-3s in your diabetic meal planner can reduce your risk of certain diabetic complications, as well as:

• Decrease insulin resistance
• Improve mood and lower rates of depression
• Improve symptoms of inflammatory diseases, like asthma and lupus
• Reduce apoproteins, cholesterol and triglyceride levels
• Reduce risk of heart attack
• Reduce risk of macular degeneration
• Reduce risk of some types of cancer
• Reduce risk of stroke.

So just add some Omega 3′s to your diet today!