I am known in the disease management and wellness fields as a naysayer, critic, curmudgeon, and/or traitor…and those are only the nouns that are allowed to be blogged across state lines. This is because I am driven not by wishful thinking but rather by data. The data usually goes the wrong way, and all I do is write down what happened. Then the vendors blame me for being negative — sort of like blaming the thermometer because the room is too hot — because they can’t execute a program.
However, the nonprofit Iowa Chronic Care Consortium (ICCC) apparently can execute a program. They reduced total diabetes events by 6% in the rural counties they targeted. This success supports a hypothesis that in rural (presumably underserved) areas, disease management fulfills a critical clinical gap: it provides enough basic support that otherwise would not be provided even to those who actively seek it to reduce near-term complications and exacerbations.
This result will likely produce its own unanticipated consequence: because many people now believe (thanks, ironically, to some of my own past work) that disease management doesn’t produce savings, there will be widespread skepticism about the validity of this study. Quite the opposite: this “natural experiment” is as close to pristine as one could hope for in population health, for five reasons:
- There was no participation/self-selection bias because outcomes were measured on all Iowa Medicaid members.
- The program was offered in some Iowa counties but not others, so there was no eligibility or benefits design bias, Medicaid being a statewide program.
- The program encompassed only one chronic condition (diabetes) rather than all five common chronic conditions normally managed together (asthma, CAD, CHF, and COPD being the other four). Since all five conditions were tracked concurrently, whatever confounders affected the event rate in one of those conditions should have affected all of them. And event rates in the four other conditions did indeed move together in both the control and study counties. Just not diabetes.
- The data was collected exactly the same manner by the same (unaffiliated) analysts using exactly the same database so there is no inter-rater reliability issue.
- Both groups contained hundreds of thousands of person-years and thousands of events.
As one who has reviewed another high-profile “natural experiment,” North Carolina Medicaid, and found that the financial outcomes were the reverse of what the state’s consultants originally claimed (incorrectly, as they later acknowledged by changing their answer), I can also say that natural experiments in population health don’t harbor some as-yet-unidentified confounder that causes the study population to outperform the control population.
Continue reading “Stop the Presses: A Disease Management Program Worked”
Filed Under: THCB
Tagged: Al Lewis, Disease Management, Iowa Chronic Care Consortium, Medicaid, Population Health, prevention, Wellness
Jul 30, 2013
Use of an at-home telemonitoring blood pressure device significantly reduced out-of-control high blood pressure, according to a recent study in the Journal of the American Medical Association. It’s another data point showing the potential of telemedicine to have a profound effect on American medicine, by positively modifying health behaviors, providing real-time data to clinicians through “automated hovering,” and helping Americans get and stay healthy – all of which holds the promise of bending the cost curve.
Led by Karen Margolis, MD, MPH, a Senior Investigator at Health Partners Institute for Education and Research, the cluster-randomized study investigated whether using a cloud-connected, at-home blood pressure monitor paired with pharmacist and case manager support would lead to controlled blood pressure more than typical care, which involved check-ups with a physician.
Those using the telemonitoring device were 90% more likely to have controlled blood pressure at both the six and twelve-month checkups than the control group (57.2% and 30%, respectively), and had, on average, statistically significant lower systolic and diastolic readings.
Continue reading “Blood Pressure Monitoring, Telemedicine, and Automated Hovering: A Future Model for Disease Management?”
Filed Under: The Business of Health Care
Tagged: automated hovering, Costs, Disease Management, Hypertension, Mike Miesen, Telemonitoring, The Affordable Care Act
Jul 19, 2013
Every now and then the title of a book influences your thinking even before you read the first page.
That was the case for me with Thomas Moore’s “Care of the Soul” and with “Shadow Syndromes” by Ratley and Johnson. The titles of those two books jolted my mind into thinking about the human condition in ways I hadn’t done before and the contents of the books only echoed the thoughts the titles had provoked the instant I saw them.
This time, it wasn’t the title, “Cultivating Chi”, but the subtitle, “A Samurai Physician’s Teachings on the Way of Health“. The book was written by Kaibara Ekiken (1630-1714) in the last year of his life, and is a new translation and review by William Scott Wilson. The original version of the book was called the Yojokun.
The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.
The translator, in his foreword, points out the ancient sources of Ekiken’s inspiration during his long life as a physician. Perhaps the most notable of them was “The Yellow Emperor’s Classic on Medicine”, from around 2500 B.C., which Ekiken himself lamented people weren’t reading in the original Chinese in the early 1700′s, but in Japanese translation. One of his favorite quotes was:
“Listen, treating a disease that has already developed, or trying to bring order to disruptions that have already begun, is like digging a well after you’ve become thirsty, or making weapons after the battle is over. Wouldn’t it already be too late?”
Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:
“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.
Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference toarchetypal or somatic medicine.)
The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.
If you restrain the inner desires, they will diminish.
If you are aware of the negative external influences and their effects, you can keep them at bay.
Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”
On the topic of Restraint, the Yellow Emperor text states:
In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.
Continue reading “The Samurai Physician’s Teachings on the Way of Health”
Filed Under: Physicians, THCB
Tagged: Country Doctor, Disease Management, Personal responsibility, Physicians, practice of medicine, prevention, The Yellow Emperor's Classic on Medicine
Jul 17, 2013
[This post is the third and final part of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here and Part 2 here.]
It seems that Dr. Larry Weed is commonly referred to as the father of the SOAP note and of the problem list.
Having read his book, I’d say he should also be known as the father of orderly patient-centered care, and I’d encourage all those interested in patient empowerment and personalized care to learn more about his ideas. (Digital health enthusiasts, this means you too.)
Skeptical of this paternity claim? Consider this:
“The patient must have a copy of his own record. He must be involved with organizing and recording the variables so that the course of his own data on disease and treatment will slowly reveal to him what the best care for him should be.”
“Our job is to give the patient the tools and responsibility to organize the knowledge and slowly learn to integrate it. This can be done with modern guidance tools.”
These quotes of Dr. Weed’s were published in 1975, in a book titled “Your Health Care and How to Manage It.” The introduction to this older book is conveniently included as an appendix within “Medicine in Denial.” I highlighted it this section intensely, astounded at how forward-thinking and pragmatically patient-centered Dr. Weed’s ideas were back in 1975.
Thirty-eight years ago, Dr. Weed was encouraging patients to self-track and to participate in identifying the best course of medical management for themselves. Plus he thought they should have access to their records.
Continue reading “Medicine in Denial: What Larry Weed Can Teach Us About Patient Empowerment”
Filed Under: Physicians
Tagged: Diagnosis, Disease Management, e-patients, Evidence Based Medicine, Larry Weed, Lawrence Weed, Leslie Kernisan, Medicine in Denial, patient engagement, Physicians, SOAP
May 22, 2013
We’re all aware of the past criticisms of “disease management.” According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of “outcomes” were based on flawed research that was never intended to be science; it was really intended to market their wares.
But suppose this correspondent alerted you to:
1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.
If you think that sounds like typical vendor-driven telephonic disease management, you’d be right. You’d also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses. When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.
Continue reading “Why Disease Management Won’t Be Going Away Any Time Soon”
Filed Under: The Business of Health Care
Tagged: CMS, Commonwealth Fund, Disease Management, Group Health, Insurers, Jaan Sidorov, Outcomes, Patients, PCMH, prevention, vendor-driven disease management, Vendors
Apr 2, 2013
Politicians and pundits everywhere call for more disease prevention as a way to reduce healthcare costs. Certainly you cannot argue with the logic that “an ounce of prevention is worth a pound of cure.”
Or can you? It turns out that you can not only argue against that so-called logic, but – just as with cancer detection, which may have been done to excess in some protocols — you can mathematically prove that, at least for asthma, it takes a pound of prevention to avoid an ounce of cure.
The database of the Disease Management Purchasing Consortium Inc. (www.dismgmt.com) tracks both asthma drugs and visits to the emergency room (ER) and hospital stays associated with asthma. The average cost of an attack requiring an ER visit or inpatient stay is about $2000. The average cost to fill a prescription to prevent or recover from an asthma attack is about $100. It turns out that asthma attacks serious enough to send someone to the ER or hospital are rare indeed. In the commercially insured population, these attacks happen only about 3-4 times a year for every thousand people. (The rate is much greater for children insured by Medicaid; additional resources spent on prevention could very well be cost-effective for them.)
For a million-member health plan, that might be 3000 or 4000 attacks Yet that same million-member health plan is paying for hundreds of thousands of prescriptions designed to prevent or recover from asthma attacks. Depending on the health plan, the ratio of drugs prescribed to asthma events serious enough to generate an ER or hospital claim ranges from 60-to-1 to 133-to-1. Using those statistics of $2000 per event and $100 per prescription, a health plan would pay, on average, anywhere from $6000 to $13,300 to prescribe enough incremental drugs to enough incremental people to prevent a $2000 attack.
Averages lump together people at all risk levels. Surely some of those people really are at high enough risk of an attack that they are already inhaling their drugs regularly to prevent one, and have a “rescue inhaler” nearby. By definition their risk of attack is much greater than for low-risk people. Assume, very conservatively, that low-risk patients have a risk of attack which is half that of the average patient. This means that putting most low-risk patients on drugs costs $12,000 to $26,600 for every $2000 attack prevented.
Continue reading “Can Too Much Preventive Care Be Hazardous to Your Health?”
Filed Under: OP-ED, THCB, The Insider's Guide To Health Care
Tagged: Al Lewis, Asthma, Cancer Screening, Disease Management, Economics, ER visit, Medicaid, prevention
Dec 2, 2012
Just about everybody in the health policy blogosphere has noted with disappointment the failure of Medicare’s demonstration projects to reduce the costs of care. Recall that these are critical to President Obama’s challenge “To find out what works and then go do it.”
If nothing works, the fallback weapon in Obama Care is to reduce fees paid to doctors and hospitals. Yet the Medicare actuaries tell us that squeezing the providers in this way will put one in seven hospitals out of business in the next eight years, as Medicare fees fall below Medicaid’s. Under this scenario, senior citizens may be forced to line up behind welfare mothers, seeking care at community health centers and in the emergency rooms of safety net hospitals.
I believe this is the only blog that has confidently predicted that health care costs will never be controlled by running pilot programs and trying to “copy what works.” (Note, however: the Congressional Budget Office has shared our viewpoint from the beginning; see their previous conclusions here and here.) I’ll explain why I predicted failure all along below. First let’s review the latest results.
Over the past two decades, Medicare’s administrators have conducted two types of demonstration projects.
Disease management and care coordination demonstrations consisted of 34 programs that used nurses as care managers to educate patients about their chronic illnesses, encouraged them to follow self-care regimens, monitored their health, and tracked whether they received recommended tests and treatments. The primary goal was to save money by reducing hospitalization. With respect to these efforts, the Congressional Budget Office (CBO) finds:
- On average, the 34 programs had little or no effect on hospital admissions.
- In nearly every program, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program.
Continue reading “Why the Pilot Programs Failed”
Filed Under: THCB
Tagged: Costs, Disease Management, Medicare
Feb 1, 2012
I’ve seen a number of responses to the news that the Medicare demonstration projects were not successful. Some have claimed that they were only demonstration projects, and the fact that some succeeded means we should look into those further. Others asserted that this once again proves that the government is incapable of making the health care system better.
As to the first point, it’s hard to get excited about this. By chance alone, a couple of programs were likely to save money. Four out of 34 reducing hospitalizations (when the best of them might have had inadequate data)? Hardly something to get excited about. Remember that two out of the 34 actually saw increased hospitalizations, too. I think it’s totally reasonable to think hard before just assuming there was something special about those four programs, and throwing more money at them.
But I think the latter point, made by Peter Suderman, is a bit of an over-reach as well. It’s important to remember that these were attempts by private hospitals and private physicians to change the way they care for patients. Granted, government was paying the insurance bills through Medicare, but this would have looked awfully similar if a private company had footed the bill. And, yes, private insurance companies have tried to use care coordination and disease management to reduce costs as well.
Continue reading “What Does Failure Mean?”
Filed Under: THCB
Tagged: Aaron Carroll, Care coordination, Disease Management, Health policy, Medicare, Pay for Performance
Jan 23, 2012
Perhaps Newt Gingrich’s book Saving Lives & Saving Money has been quietly redacted of a few lines since its original 2003 printing, because otherwise a simple read of the copies now in circulation would find a blueprint for Obamacare just like the first printing did. I dusted off my old, autographed, copy and re-read it, and am providing some highlights for THCB readers.
Much of the book does propose market-based solutions, such as the use of disease management programs to “dramatically improve outcomes.” However, the book also calls for bigger government, in the form of (1) drug coverage for seniors (since passed) and (2) a “tripling” of the National Science Foundation budget.
In addition to those two specific calls for increased government spending, the first printing contains language that might comfort Don Berwick more than Fox News, and not just because Dr. Berwick gets favorably mentioned twice.
P. 31: “The number of uninsured in America is a threat to our civilization.”
P. 54 “Don Berwick[has] pioneered the translation of the teachings of quality experts such as Edwards Deming and Joseph Juran to the healthcare profession.”
P 59 “It is justified to mandate the use of electronic systems to drag the medical system into the 21st century.”
Continue reading “Newt Gingrich Reveals His Inner Democrat”
Filed Under: OP-ED, THCB
Tagged: 2012 Election, ACOs, Al Lewis, Disease Management, Saving Lives & Saving Money
Jan 22, 2012
I will suggest that most of us believe the way to control health care costs, and at the same time maintain or improve quality, is to both use the managed care tools we have developed over the years, and perhaps more importantly, change the payment incentives so that both cost control and quality are upper most in the minds of providers and payers.
The Congressional Budget Office (CBO) has just released an important review of Medicare’s results in testing those ideas. The news is not good.
From the CBO’s blog post:
In the past two decades, Medicare’s administrators have conducted demonstrations to test two broad approaches to enhancing the quality of health care and improving the efficiency of health care delivery in Medicare’s fee-for-service program. Disease management and care coordination demonstrations have sought to improve the quality of care of beneficiaries with chronic illnesses and those whose health care is expected to be particularly costly. Value-based payment demonstrations have given health care providers financial incentives to improve the quality and efficiency of care rather than payments based strictly on the volume and intensity of services delivered.
In an issue brief released today, CBO reviewed the outcomes of 10 major demonstrations—6 in the first category and 4 in the second—that have been evaluated by independent researchers. CBO finds that most programs tested in those demonstrations have not reduced federal spending on Medicare.
Continue reading “(Almost) Nothing Works”
Filed Under: OP-ED, THCB
Tagged: ACOs, CBO, Costs, Disease Management, Medicare
Jan 21, 2012