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QUALITY/POLICY: Chronic care DM fails in a FFS world

This is no news to THCB readers, but let me remind you. Chronic care is hard work. Disease management programs are only partially effective because — even if you get it right — it goes against the incentives of doctors and hospitals (to do more, more expensive procedures now) and health insurers (to get sick people off their rolls ASAP). In a long look at diabetes care, the NY Times comes up with the conclusion that In the Treatment of Diabetes, Success Often Does Not Pay.

It‘s a long article but well worth a skim for those of you wondering what’s wrong with our health care system. How can we fix it? With FFS medicine, such as Medicare and copied by most insurers, you just can’t. The only hope is an extension of Kaiser-like pre-payment, or a chronic care system mandated from the top. Pay-for-performance has some potential, but it will require structural change, particularly in terms of the types of doctors and health professionals we train and the resources we allocate to preventative rather than sick care. And of course a system that excludes the poor and the sick by making it impossible for them to get insurance is never going to get close to doing that.

And just to depress you further, one health plan that has a better record than most in promoting DM programs, Pacificare, has just canceled a demonstration project in heart failure for Medicare FFS beneficiaries because it somehow couldn’t get people involved—even thought it will mean sending money back to the Federal government!

 

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Martin FeketespikeMelanie Matthewsjdinnycelliottg Recent comment authors
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Martin Fekete
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Martin Fekete

Everyone, Some very interesting posts and great comments regarding preventative health and various insurance and health care systems. However, one of the most important issues in the prevention of illness is simple the patient taking responsibility for their own health. With that said, the nation and world is facing a new epidemic, cardiovascular disease. In June of this year, the World Health Organization (WHO) released the “Top 10 Causes of Death” for the world. According to the report, an estimated 57 million people died. The number one cause of death throughout the world was cardiovascular disease, with 7.3 million dying… Read more »

spike
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spike

Eligibility companies are companies that are on-site at hospitals which screen self-pay patients to see if they qualify for Medicaid. If the patients do qualify, these companies help them wind their way through the bureaucracy get signed up for Medicaid coverage. Then, when the claims on services rendered are paid, the Eligibility company takes 10-15% of the Medicaid Payment as a service fee. I would go into more detail, particularly where I came up with the 20% number, but I don’t want to get in trouble at work. And I did work for a billing company that took about 25%… Read more »

Tom Leith
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Tom Leith

spike says: > Billing companies charging 25% of receipts to > get claims paid, Eligibility companies charging > 15-20% of Medicaid payments to help people become > eligible for Medicaid. It is sometimes estimated that the TOTAL cost of our reimbursement system comes to about 25% of total spending, but that includes everything from charge-capture in the hospital or doctors’ office, to the marketing activities of insurance companies. Moving to a single-payer sort of system would probably save between half and two-thirds of this amount. No billing company gets anything like 25% of “receipts”. I am not quite sure what… Read more »

spike
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spike

What I’m really saying is that there are lots of ways to encourage people to be more active participants in their healthcare, but HSAs are not the way. We probably agree on more than we disagree, but HSAs are the exact wrong way to get people more involved in their healthcare. Both because of policy reasons that have been discussed ad nauseum on this site (having to do with the pareto effect in healthcare and there being no money left over to treat the 20% of the population that is actually sic), and also because the incentives they set up… Read more »

Eric Novack
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Spike- what if the ‘policy makers’, in the ‘best interests’ of all, decide to not allow hip and knee replacements for anyone with a BMI greater than 30? This was policy just put into place in a health district in England. I am not making it up. Over half of all US adults would suddenly become ineligible for hip and knee replacements, arguably one of the best medical advances in terms of quality and extension of life of the last 40 years. What if the ‘policy makers’ decide that anyone over a certain age is no longer eligible for dialysis?… Read more »

spike
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spike

Keep in mind also that I’m doing everything I can to avoid discussion specifically of HSAs, though I feel they are very relevant to this discussion. I can’t bear another battle with Ron.

spike
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spike

Eric, I don’t think you can isolate it like that and say “My goal is better health” or “my goal is more cost efficiency”. I think all of those things go hand in hand. Better health, more standardization, and better management of chronic conditions would likely be reflected on the bottom line. My main point in this discussion is that when over 35% of your population is making the same bad choice, the answer isn’t to blame each of them individually for their bad choice, it’s to look at the system and understand why it’s so hard to make the… Read more »

Abby
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Abby

Eric,
We could also go to the docotr’s office twice as much and pay them half as much. Hmmm….

Matthew Holt
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Matthew Holt

Official word re Pacificare/QMed is that CMS has asked the parties involved not to comment further pending notification of the people in the program starting this coming Monday. So anything else would be speculation.

Eric Novack
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Spike- no evidence for small group or solo practices that the costs of conversion would ever be recouped for IT investment, but that’s not the point.
Let me pose my question/ issue to you in another way: what ‘change’ are you trying to achieve in healthcare? better health? reduced cost? more standardization? perhaps I could better respond if I knew what you are trying to achieve.

spike
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spike

When you talk about how the consumer is where it should all start it reminds me of how Healthcare IT firms always blame the medical professionals for not adopting their products. The consumer isn’t going to start it. While in a perfect world, that is what would happen, in our world, it isn’t. So saying “It has to start with the consumer” is throwing up a smokescreen to stand in the way of change. If it were easy for consumers to know everything they need to know to be a truly meaningful participant in their healthcare, you wouldn’t have had… Read more »

Matthew Holt
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Matthew Holt

Hmm…I’ll see what I can dig up about Pacificare’s problems

Melanie Matthews
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In a report available on our site, “Modifying Patients’ Behaviors to Optimize Disease Management Outcomes,” we talk about patient engagement strategies — getting patients into disease management programs and keeping them in once enrolled. We also explore the advantages of using an engagement model over an enrollment model. In a blog post today on our site, at http://blog.hin.com, we summarize the key findings of using an engagement model over an enrollment model. I am curious to learn more about the inside details on the Pacificare program. What strategies did they use to enroll members in the program? Was the failure… Read more »

eric Novack
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thank you all so much for the feedback… a little weird finding myself on Ron’s side of an issue. Let me try to address a couple of raised concerns: Abby- so many of THCB discussions are raised from a general policy point of view. An underlying theme of many of the blog participants is not necessarily that the US spends too much on healthcare (though many feel that way), but rather that the way it is spent is out of control, and that it continues to increase at rates that are unsustainable over the long term. Diabetes and heart disease… Read more »

jdinnyc
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jdinnyc

Eric, name one nation that got its healthcare costs under control by increasing its level of cost-sharing. What I don’t think you realize is that other developed nations use a modest amount of cost sharing, but also need to do other things in order to insure everyone and keep costs under control without sacrificing quality, measured by outcomes. I would like to submit that the discussion so far hasn’t been very clear. It isn’t that FFS medicine all by itself forces an inefficient, bloated healthcare system. Rather, our problem has three parts: FFS medicine + an insurance system that insulates… Read more »