Just when you thought it was safe to go back to the water, the CBO is out with the bad news that in its analysis of over 30 disease management programs, and none of the independently run ones saved Medicare any money. Even the ones that succeeded, which put the medical groups at risk and generally lodged the DM nurses with them (rather than have them call in on the phone), didn’t save enough to justify the costs of the program.

Now the first group isn’t a surprise to those of us who followed the fate of Medicare Health Support. The second group includes a series of demonstrations paying physician groups to save money. They did better, but not well enough to save once the extra costs of the program are included. (Details here). We can only hope that using more lightweight technologies with better understanding of patient behavior does in fact end up saving money–as has been shown in some commercial medical home settings. But we must also be prepared to admit that we don’t yet know how to save money in the care of the chronically ill under Medicare. Which means that the only obvious way to do it is to cut payments to providers!

By Matthew Holt

ONC Director Farzad Mostashari is out with his review of 2011 on a month by month basis. Good to see that Farzad & colleagues took December 2011 off (just kidding!). He calls it a year of “momentous” progress. I’m doubly biased because I’m a proponent of newer and better health technology for clinicians AND citizens. Also, (FD) Health 2.0 is the main subcontractor on the i2 Investing in Innovation challenges which were–as noted by Farzad–launched in June, have had several close already, and will continue to roll off the production line for another 18 months. But as a general and occasionally cynical observer I’m very impressed with what ONC has done.

There are complications, many of them written into the law–for example the MU dollars are also going to organizations that already spent the money (e.g. Kaiser Permanente) but that’s a complication of the way the law had to be written to assure that it went to technology that was actually used properly. And it’s still unclear if the NHIN requires expensive local public HIEs or if that a simpler form only (e.g. Direct plus more innovation) will do. But given that the USA was at least a decade behind most other developed nations in its use of primary and ambulatory care, the numbers from CDC are really encouraging. And on a personal note, in my 3 person family, now at least the PCP and the Pediatrician are using EMRs (the OBGYN still is not). One day I hope to be given access to what’s in them! Finally, ONC and Farzad & Lygeia in particular are to be applauded on making sure that patients are valued in their health IT strategy. After all, few others in the health care establishment seem to pay much more than lip service about integrating consumers/citizens/patients into health care.

For a long time now patients have been meeting in online (and offline) communities, sharing experience, advice and more recently data and measurements. And the health care system–which knows that communities improve health–has done virtually nothing–other than some doctors having doctors answer questions on MedHelp. That is just starting to change. Last year Geisinger did a small trial with dLife that showed improvement in diabetics outcomes. More recently Aetna inked partnerships with MindBloom and OneRecovery, two communities focused on spirituality and addiction, and today Diabetic Connect (part of Alliance Health) announced a deeper integration with the Joslin Diabetes Center. It’s been a while, but the heart of Health 2.0 (communities) are starting to move towards the mainstream.

By Matthew Holt

It’s been a while since THCB discussed usual customary and reasonable charges, and it’s been longer since health plans did much about them–other than cover them at a low rate and let providers charge what they like. That’s mostly because Ingenix (now Optum Insight) got itself and United beaten up about the topic a while back. But I noticed today (via a company selling expensive webinars about the topic) that Aetna is starting to go after providers that are gilding the Lilly on out of network charges again. In this case a couple of surgeons who were self-referring to a surgery center they owned, not charging the patients their official share, and meanwhile somehow managed to charge nearly $100K for ear wax removal. Aetna, don’t forget, was the “nice” insurer that started the trend of settling with doctors and being nice to them over pricing back in Jack Rowe’s time as CEO. If Aetna’s now starting to get aggressive about out of network charges to its members, then perhaps we really are entering a new era of health insurer activity.

There’s a great post on the NY Time Economix blog from Uwe Reinhardt explaining the theoretical difference between premium support and voucher systems (and you thought they were the same thing!). Unfortunately it skirts the real problem that those of us playing along at home know too well. Either a well constructed premium support (Ryan done right), or a well constructed voucher/managed competition (Enthoven) system, a mixed public/private system (Germany, Starr, Reinhardt) or even a decent Medicare for all /Single payer system (PNHP, McCanne) needs to be designed holistically to have a chance of working–especially to ensure that all people are in plans that treat them all equally. Note that this very week HHS devolved the choice over plan benefits to the states–meaning that the very notion of Enthoven-like standard plan benefits required in a voucher system gets tossed out the window and even in the exchange plans will likely be able to alter their benefits to risk select. The sad facts of the matter are though–speaking as one who is a lefty but supports the concept of managed competition a la the Enthoven or Dutch model–that the 2009-10 debate shows that no holisitic system can emerge through our political process. And worse, no cost containment device will be left alone by a future Congress, as this weeks extension of the now more than a decade old SGR cuts demonstrates. So my non-Christmas cheery message is that the health care system will continue to promote over spending on the wrong types of people, and rational transformation of our 1950s designed insurance coverage and payment system will remain elusive for decades to come. What we get IF we keep the ACA will be the best we can hope for. Meanwhile, back over at NY Times it’s great to see Uwe Reinhardt reacting to his commenters (even those not paying Princeton tuition fees!).  Kudos from a health care blogger who doesn’t engage with his commenters enough.

CDC data just in, reported by Jonathan Cohn at THR, suggests that the impact of allowing young people to stay on their parent’s insurance (or as Michael Cannon would say, forcing employers to cover dependents up to the age of 26) is having a big impact. Up to 2.5 million adults under the age of 26 have moved into coverage. Frankly I’m not surprised. There’s always been a huge group of uninsured young adults moving between high school and college and the workforce. And if you hadn’t noticed, there’s a recession on and good jobs with insurance are hard to find. I know at least three young adults working in the semi-contingent labor force who are on their parents’ insurance. Of course they’d better hope they don’t turn 26 before 2014. But even this little gain is something the Democrats need to punch home about the Republicans: Those bastards want to take your kid’s insurance away! And they do.

Long time THCB readers will remember how several times I’ve called out AHIP president Karen Ignagni for being economical with the truth. Today in a letter to the NY Times she actually tells it how it is. Medicare Advantage plans provide more and better benefits than the FFS program. Ignagni also says that FFS program is outdated and that Medicare Advantage plans also emphasize prevention, wellness, care coordination and management of chronic conditions, do better than the FFS program in reducing hospitalizations and even are fostering the innovations needed to reduce health care cost growth. So given that there is so much waste and poor care in the FFS program (over 35% by most estimates) why do the so superbly managed Medicare Advantage plans require and spend more money per capita than the FFS program? Imagine my surprise when I was unsuccessful in my search to find the explanation for this in Ms Ignagni’s letter.

There ‘s an excellent article by physician Ken Murray at Zocalo Public Square suggesting that few (or no) doctors would put themselves through routinely practiced end of life care. Let’s face it. The system is on automatic for reasons that are lost in professional medical culture and propagated by the Jerome Groopman meme that we must keep practicing new stuff to find out what works, and if lots of people suffer on the way….well that’s the cost of progress. The result is a medical system that does massively excessive care of everyone–especially the nearly dead. As the old joke goes, they really do put nails in coffins to keep the oncologists out. Yes there are cases when intensive treatment does work, but I suggest everyone looks at the engagewithgrace.org site in order to start the conversation with their own families and providers. At least take the system off automatic for you and your loved ones.

Every VC loves and hates the hockey stick–that growth curve that potters along and then suddenly shoots up. But if you check out the new numbers from CDC the use of a basic EMR is on that hockey stick curve. Adoption of a “basic system” has gone from under 17% in 2008 to 33% this year, with another 40% of doctors saying they’re going for the Meaningful Use gold–which means essentially a more than “basic” system. So maybe this is a hockey stick curve that we can all love. (Well all other than the curmudgeons over at Health Care Renewal!). On a somewhat related personal note, I too was awaiting the hockey stick of EMR adoption. I abandoned my attempt to catch the start of the hockey curve in 2000 when I quit my EMR survey job at Harris Interactive. All I had to do was hang on for another eight years and I’d have been proved right!

Another data breach–this time impacting 4 million Sutter patients. My daughter is among the patients in this breach (most likely), But even if this data isn’t immediately wiped by the thief, I’m struggling to see what’s worse about this than a standard credit card theft–which happens everyday. To me the worse impact from “data” being known about anyone is the completely OPEN data that is forcibly shared about people in the individual market (you are forced to share it to apply for coverage). And the only slightly less forced sharing of health information to get a job with a self-insured employer (yes they know who you are and they can tell what you’re likely to cost before hiring you). And do we hear shit about that? No, but that has real not imagined consequences. I sincerely hope that by the time my daughter gets to school in 3 years, there is no legal discrimination on health data whether that data is forcibly extracted or stolen. Oh and BTW premiums for California small group are going up 20% again this year … and that may be Sutter’s fault.