MANAGED CARE December 2011. ©MediMedia USA

Clinicians can consider this radiotherapy a viable treatment option

Thomas Morrow, MD

There are about 25 million people in the United States who have asthma, whose hallmarks are hyper-responsive airway constriction of the smooth muscle, increased mucus production, and inflammation of the airways. This results in shortness of breath and significantly diminished quality of life.

Despite nationally accepted guidelines and a host of medications, this disease costs the United States about $19 billion per year in total costs and nearly 15 million lost workdays.

All of the therapies require continuous use of medications — often many doses per day — except one, a procedure called bronchial thermoplasty (BT).

Radio frequency

BT, discussed here in January 2010 before approval by the FDA, is a bronchoscopic procedure performed over several months. Using radio frequencies to “cook” the smooth muscle in airways that measure 3–10 mm in diameter, it reduces the amount of smooth muscle available to constrict the airways.

Leaving the gym on an unseasonably warm night, I struck up a conversation in the parking lot with a vascular surgeon acquaintance. He recounted a technically demanding procedure that he had done the day before with a reported 10 percent risk of stroke and a 3 percent mortality risk.

The two-stage procedure was optimally done in one trip to the OR with two surgeons involved in the several-hour two-stage surgeries. My acquaintance commented that his reimbursement and that of his colleague came to about $70 an hour — and that does not include the 90 days of post-op care associated with the reimbursement for the surgery.

In the reimbursement of medical services, complexity abounds: new technologies or the application of existing technology in new ways; the supplanting of one modality for another; efforts to tie reimbursement to performance, outcomes, and/or quality.

This surgeon mentioned that he could have done the two-staged procedure as two separate surgeries and been reimbursed considerably more. I am heartened to know that he did what he perceived to be best for the patient versus his kids’ college fund. He also commented on witnessing interventional internists and surgeons who elected to separate procedures, for example, diagnostic cardiac catheterization followed by PCI, versus completing both in one trip to the cath lab.

Despite the enthusiasm that many of us share for the medical home and other forms of value-based reimbursement, there is still plenty of work to be done to rationalize the blocking and tackling in the still-dominant fee-for-service payment model.

Steven R. Peskin, MD, MBA, FACP is executive vice president and chief medical officer of MediMedia USA, which publishes Managed Care. He is Associate Clinical Professor of Medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School

MANAGED CARE December 2011. ©MediMedia USA

We look at a few programs designed to address adherence-related behavioral problems

Carol Milano

“Adherence is a behavioral issue,” says Bob Nease, chief science officer at Express Scripts. And inadequate adherence is so widespread that the World Health Organization estimates that half of all patients do not take their medications properly. Yet few efforts to improve compliance are specifically designed to help people overcome internal barriers.

The obstacles vary so widely that no single approach can be effective. Stephen Wegener, PhD, a psychologist and associate professor in physical medicine and rehabilitation at Johns Hopkins University School of Medicine, studies noncompliance. He has described four categories of underlying impediments to adherence:

Access. Taking a medication presumes the patient saw a doctor, received a diagnosis, and was able to fill a prescription. “But some people may have trouble getting to a pharmacy and live in an area without delivery options,” Wegener says. Others hesitate to fill a prescription if their insurance does not cover the medication.

Knowledge. A patient may not understand all the instructions for how to take this particular drug, or may not fully grasp exactly what the medication is for, which limits the motivation to take it.

Cognition. Sometimes a patient with faulty memory simply doesn’t remember to take the medication on time or exactly as directed.

Behavior. “Any number of comorbidities can influence medication-taking,” Wegener says. Depression might lead to feeling, “Why bother? Who cares?” Anxiety about side effects can interfere. “It could make me gain weight” is a common deterrent, as are warnings about other unpleasant possibilities, like constipation. “Some people take too little medication because they are afraid of addiction. The fewer the side effects, the higher the adherence,” he reports.

Now, several ambitious projects are tackling adherence-related behavioral problems.

MANAGED CARE December 2011. ©MediMedia USA

Now that we know there is so much unwarranted deviation in care, payers are promoting comparative effectiveness research and other efforts to help providers embrace the evidence

Joseph Burns

Contributing Editor

Barry Patel, PharmD, is on a mission to improve the delivery of health care, one physician at a time. His company, Total Therapeutic Management, hires physicians, pharmacists, nurses, and nurse practitioners to meet other clinicians, one on one, to discuss best practices identified in the medical literature.

The company has been conducting this type of work since 1995 and is now working under a $12 million contract with the federal Agency for Healthcare Research and Quality (AHRQ) to disseminate the results of comparative effectiveness research (CER) to primary care physicians nationwide, says Patel, TTM’s president and cofounder.

Discussing all therapeutic options for treatment goes a long way with doctors, says Barry Patel, PharmD, of Total Therapeutic Management.

For the Department of Health and Human Services, CER is designed to identify the best practices from the medical literature and from other sources and to spread the word to clinicians. TTM is on the cutting edge of a movement to help eliminate variation in how care is delivered and to get physicians, regardless of training or where they practice, to understand and use the best methods of treating patients with specified conditions.

MANAGED CARE December 2011. ©MediMedia USA

Costly protease inhibitors work well in many patients, but call for careful monitoring

Thomas Reinke

Contributing Editor

In less than a year, two new protease inhibitors — telaprevir (Incivek) and boceprevir (Victrelis) — have changed the standard of care for hepatitis C by introducing a new mechanism of action, but their significance goes beyond that.

They are the first new medications for the disease in 10 years and they have brought dramatic improvements in outcomes by knocking out this infection in many more patients, including previous poor responders. They have also complicated care by adding a third agent to the previous standard regimen of two agents.

“We took a step back ... to make sure we could capitalize on the value of these medications,” says David Lassen, PharmD, chief clinical officer at Prime Therapeutics.

The new agents are examples of how therapy management for new and costly medications is moving from traditional utilization and outcomes management to more sophisticated strategies. The focus on adherence and medication possession rates is giving way to patient selection criteria and close monitoring of clinical results.

MANAGED CARE December 2011. ©MediMedia USA

Clinical executives who oversee physicians often wrestle with what hospital-physician consolidation brings to the table. Insurers have responded to this consolidation by trying to manage care more effectively, through such techniques as bundled payments. (See our July cover story, “What Can Be Done to Counteract Growing Power of Providers?”) Which physicians are most interested in becoming hospital employees? Pricewaterhouse-Coopers asks that in a report, “Four Key Findings From Health Reform.”

“[Cardiologists] want hospital paychecks,” the report says. “Two thirds of [cardiologists] surveyed said they’re interested in being employed by hospitals. The cardiology specialty — which is among the most lucrative of all physician specialties — has experienced deep cuts in Medicare payments.”

Cardiologists aren’t the only physicians looking for greener pastures, as psychiatrists, surgeons, and pediatricians give thought to becoming hospital employees. “Overall, 56 percent of physicians surveyed … want to more closely align with a hospital in order to increase their income. Another 40 percent want to align to ensure a more consistent income stream.”

The data were collected through 28 interviews with influential people and executives representing health care providers, payers, and professional associations.

PwC also conducted an online survey of more than 1,000 physicians “balanced by age, gender, practice type, and specialty.”

Source: PricewaterhouseCoopers.

David KibbeHealth and Human Services (HHS) just released data on 2010 health expenditures, reporting that we, as a nation, have now reached the $2.6 trillion mark, consuming 17.9% of our GDP. Reaching that new mark required 3.9% annual growth vs. 3.8% in 2009. On the surface, the rate of growth seems less alarming than the insurance premium trends of 7%, 8%, and more that have been common year after year over the past decade. Yet the reality is that the changes are really like comparing apples and oranges, as the aggregate figures provided by HHS include a number of factors that mitigate the apparent modest rate of increase.

Often, to really see where we are, we need to see where we were. In 1978, as I started my graduate studies in health care economics and finance, health care expenditures were approximately $250 billion in the U.S. I still remember my mother, a hospital nursing administrator, showing me the financial records of a hospital that could fit on one large table in approximately five large filing containers. There was already growth and complexity in health care compared even to the prior decade, but compared to today, it was a simpler, less expensive world, to be sure. So, now today, 34 years later, we have a health care economy that is 10 times that size.

Well, getting from that point to today has involved an agenda of power, politics, money, greed, and sex (well, I don't know about that, but it seems to go along with the others). As supposedly rational people, we often assert very good reasons for the growth in health care: population growth, aging, technology, medical advances, defensive medicine, and other factors. With a good actuary and economist, we even break down the factors driving the growth and ascribe percentages or weights to each one to explain how together, they comprise the whole. As we do that, many of us question whether the expenditures are all justified. What is "essential care"? What is discretionary? What is supply-driven? So analysis does not lead to acceptance of the expenditures but it does make us think in rational, economic terms.

There is validity to that rational economic analysis but this should be a time to explore the role that power, politics, money, and psychology have played in the development of modern medicine and the "health care system" that we have today. We would be naive to think that they have not had an enormous impact on health care today.

Much more significantly, we will fail to create "Escape Fires," as Dr. Don Berwick stated years ago at an annual IHI symposium, if we don't understand and appreciate the real human elements of health care and our industry today. The role of leaders is to define reality, as awkward and uncomfortable as that reality often is. The reality here is much more than the HHS notification of 2010 health expenditures. The reality is that we live and work in a complex, very human, self-serving system that has relatively few checks and balances, compared to other industries. So the question is, what does that reality then mean, relative to shaping a different system, a system that actually functions well, a la Peter Senge's systems thinking? That is not something answered in a few paragraphs but it deserves answers and that will shape forthcoming thoughts.

David Kibbe is CEO of New West Health Services https://www.newwesthealth.com/

Editor's note: The article that the author refers to appears below this one.

There have been unsavory rumors flying around the internet that disease management as practiced today may not be all that effective. I’m not going to reveal who started these rumors but her name rhymes with Archelle Georgiou. This person says disease management is “dead.” Since there are still many disease management departments operating around the country apparently oblivious to their demise (and disease management departments are people too, you know), I suspect this commentator was using the word "dead" figuratively, as in: “The second he forgot the third cabinet department, Rick Perry was dead." (Another example of presumably figurative speech in the death category would be: "After he denounced gays while wearing the Brokeback Mountain jacket, you could stick a fork in him.")

And if the rhymes-with-Archelle commentator intends “dead” as a synonym for “not in very good shape,” she certainly has a point. Not only does she have a point, but I would add more items to her list of reasons for the field's current troubles:

(1) The interval between diagnosis (the point where readiness to change is usually greatest) and successful patient contact can exceed three months;

(2) Predictive modeling “risk scores” that tell you only how sick someone was, dressed up as a “risk score,” not how sick they will be, even though they aren’t already high utilizers;

(3) Some interventions are so expensive that they exceed the cost of the disease;

(4) The physicians are still not involved;

(5) Rather than using actual mathematically sound methodologies to calculate results, many vendors and consultants damage the credibility of the entire endeavor by believing in the Outcomes Fairy.

Fortunately, there are improvements afoot to address all of these issues:

(1) Electronic medical records presage faster claims adjudication, and ICD-10s will mean much more detailed patient information than is possible today. And disease management departments are already coordinating with UM/precertification/discharge planning better than even two years ago. Together, these innovations will match people with programs much faster;

(2) Predictive modeling is increasingly including the lab scores. “Increasingly” meaning that instead of 1% of models having lab data, maybe 3% do. Still, it’s a start. Lab values allow actual prediction, instead of simply drawing a line connecting last year’s high claims to this year’s high risk scores;

(3) The cost of interventions is declining quite rapidly, largely with the advent of mHealth (use of mobile communications devices in health care), which is hugely overrated by venture capitalists as a vehicle for getting rich from, but quite appropriately rated as a way to facilitate contact with members if indeed privacy regulations get rewritten to assume that the only person who answers a cellphone is the owner of that phone, and hence no “opt-in” app is needed;

(4) Some physicians are getting involved because their contractual arrangements and accreditation, such as patient-centered medical homes, are requiring it;

(5) And finally, my own forthcoming book, Why Nobody Believes the Numbers: Separating Fact from Fiction in Population Health Management, will take care of the last item. Imagine the Outcomes Fairy-meets-The Hurt Locker. Credibility will be restored for those vendors whose outcomes are modest but valid. The introduction may be downloaded gratis from www.dismgmt.com .

Is disease management dead? No. It is going through a transition period in which older models are being replaced via “creative destruction” and plain old innovation with newer models. This isn’t too much fun now but ultimately this trial-and-error process should create health-improving interventions that are truly effective in preventing, forestalling and addressing some small but significant portion of the 75% of cost attributable to people with chronic disease.

So I think perhaps these two seemingly conflicting posts are in broad agreement, the only difference being that what I believe is well-founded, evidence-based optimism that the industry can innovate its way out of the current stagnation. On this point, only time will tell. In a few years we should know, to quote the immortal words of that aforementioned great philosopher Rick Perry, whether or not who is right.

Al Lewis is Executive Director of the Disease Management Purchasing Consortium

In 1995, Dr. Steven Rosenberg published an article in the New England Journal of Medicine (NEJM) that fueled the start of an industry. In a randomized, controlled trial, he showed that an investing in proactive disease management (DM) activities could decrease the cost and improve the quality of life for patients with congestive heart failure.

The premise of disease management seemed intuitive:

• Systematically assure that evidence-based medicine is applied.
• Educate and empower patients to practice self-care.
• Intensely manage the sickest 5—10% of the patients driving 80% of the costs.

Healthplans, employers and other payers (and I) jumped on the bandwagon hoping that these programs would be a consumer-friendly silver bullet to escalating health care costs.

Cardiac Solutions, Matria, LifeMasters and American Healthways, among others, became household names. In addition, business opportunities abounded:

• Disease Management Association of America was founded in 1999.
• NCQA developed an DM accreditation program in 2002.
• Data analytics companies developed predictive modeling tools to better identify the highest risk patients.
• Employee benefits consultants promoted the “new new thing” for cost control.

But, behind the scenes, there was a lot of hand-wringing. On the eve of a major Disease Management conference, circa 2004, I remember sitting in the bar of an Orlando hotel having cocktails with DM gurus who who’d nabbed the coveted keynote speaker spots at this major forum. The Medicare Modernization Act of 2003 had just passed, and CMS had a mandate to test the disease management model in Medicare fee-for-service beneficiaries. I was shocked when my industry colleagues admitted that this $20 billion industry would only last as long as it would take for the pilots programs to be completed and CMS to analyze the results.

In the meantime…double-digit healthcare cost inflation fueled employers' demand for a wide array of condition-specific programs as a cost reduction strategy. According to Mercer Consulting, in 2010, 73% of employers offered disease management programs even though consistent, reproducible evidence of a positive ROI is still lacking.

It’s been seven long years since that Orlando meeting…and the time has come when disease management may finally—finally—fizzle and die.

The CMS demonstration programs started between August 2005 and January 2006 and preliminary results reported in 2008 concluded that "Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization." The individual programs, all using nurse-based call centers, ended between December 2006 and August 2008, and the definitive results were published in NEJM in November 2011. In summary:

• Only 2 of 15 programs resulted in reduced hospital admissions. None generated net savings.
• There were only 14 significant improvements in process-of-care measures out of 40 comparisons.
• These modest improvements came at substantial cost to the Medicare program in fees paid to the disease management companies ($400 million), with “no demonstrable savings in Medicare expenditures.”

So, why did this intuitive approach to managing disease fail?

In my opinion, there have been 3 critical missteps in the evolution of this industry:

1. NCQA Accreditation Standards: NCQA’s health plan accreditation standards require that DM programs be population-based—in other words, that ALL individuals with a condition be eligible for participation—not just those at highest risk who are most likely to benefit clinically and financially. Healthplans and vendors complied to achieve the marketing value of the NCQA gold seal of approval. Employers bought into this approach in the spirit of “prevention.” However, this peanut butter approach allocates time and money to individuals who are so low risk that there is little opportunity for clinically meaningful improvement that translates into financial savings.
2. Toys and Trinkets: From glossy brochures to felt puppets to refrigerator magnets, DM companies have differentiated themselves with collateral materials that have sales appeal but have little impact on improving care or decreasing utilization. At the same time, all these all of these items inflate program costs and erode ROI. At the end of the day, DM that does not achieve a net savings is not successful.
3. Over-reliance on Evidence-Based Medicine: Yes, EBM is the holy grail. However, the sole reliance on these standards in disease management interventions does not actually "manage disease” since avoidable costs are frequently due to subtle opportunities and gaps in care that exist as a result of multiple co-morbidities. For example: A patient in a diabetes DM program may also have rheumatoid arthritis. If the patient’s hand/joint pain is not well managed, it is unlikely that she will be able to comply with manually operating a glucometer to check her blood sugars. Unfortunately, the critical thinking required to truly coordinate care is difficult to systematically build into program design. Therefore, too often, it is absent.

So, if disease management doesn’t work, what does?

This month, hundreds of health care entities will be submitting proposals to CMS to get a piece of the $1 billion funding available through the Health Care Innovation Challenge. As CMS grants between $1 M and $30 M to various projects, let’s hope that they fund initiatives that reflect fresh, not "same old, same old," thinking for improving health and decreasing cost.

Technologies and platforms that are relatively low cost, scalable and seem the most promising are those that leverage:

1. Social networking: Condition-specific communities of patients continue to proliferate and the user-generated content from “people just like me” is having a positive impact on compliance, self-care, and quality of life.
2. Gaming: Health gaming is extending far beyond Wii Fit. Game developers are designing increasing numbers of consumer-oriented applications that address prevention, healthy lifestyles and disease self-management.
3. Remote monitoring: Biometric and ambient activity sensors offer clinicians and caregivers 24/7 insight to a person’s clinical status so that care can be delivered when it’s needed rather than when it’s scheduled.
4. Mobile/wireless health management applications: In addition to consumer-focused health management apps, mobile and wireless access to patient medical information accelerates how physicians make critical diagnostic decisions and can prevent delays in care.
5. Environmental solutions: Innovative companies are poised to transform health care with disruptive products and systems that rely on design thinking — solutions that make it easy to be healthy, passively and continuously support better health, and don't rely on individual behavior change.

Proposals are due January 27, 2012. Awards will be announced in March. Results won’t be in for 3 years.

In the meantime, employers looking for immediate health care cost savings can save $2-5 per member per month in fees by terminating their disease management programs.

Disease Management: RIP

Archelle Georgiou MD is Chief Clinical Officer of EmpowHER and Senior Adviser to Triple-Free in Minneapolis, Minn.

Reprinted by permission from Archelle on Health

MANAGED CARE December 2011. ©MediMedia USA

However, they’ll need to prove it. Powerful interest groups say insurers have little experience with these patients and worry that MCOs will shortchange members.

John Carroll

Back in January, Massachusetts officials laid out some thoughts on how they could better coordinate care for people with dual eligibility, the poor and often seriously disabled population that can qualify for both Medicaid and Medicare. Encouraged by federal authorities to think outside the system, state officials focused on a chance to improve the care that these people receive while lowering costs by contracting with insurers, provider networks, accountable care organizations, and others that could create “integrated care organizations” and earn money on a capitated fee.

In the view of state officials, Massachusetts’s 115,000 people ages 21 to 64 with dual eligibility could be assigned to a plan, but would have the right to opt out. In mid-November, the state signaled it was preparing to petition the federal government for the right to push ahead with the plan as another 14 cash-strapped states hatched their own proposals for people with dual eligibility. Allies and opponents are arraying themselves along the front lines in one of the most contentious issues in managed care. Read more »