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. Michael Rich 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:
- 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.
- 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.
- 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:
- 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.
- 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.
- 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.
- 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.
- 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
Having just finished reading Walter Isaacson’s brilliant rendition of Steve Jobs’s life and career, I’ve considered whether there are health care marketplace lessons to be garnered from his central casting in the extraordinary tech wars for primacy over the past 25 years. I’d commend this biography to anyone who loves great writing and insightful analysis of the human condition, along with the foibles of growing a business. But first, here are a few reasons for and against reading Steve Jobs’s biography if you’re hesitant to take on a lengthy tome. If you’re drawn to business books that profile great leadership and exemplary business practices, Isaacson’s research will leave you cold and spent.
Jobs was a textbook narcissist and his vaunted “reality distortion field” will leave you puzzling over why anyone tolerated his oddities and crudeness. But if you are interested in how creative genius, serendipitous convergence of industrious minds, and shrewd, albeit fanatical, business decisions can shape the direction of an industry (and, yes, change the world), this is the tale not to miss. As for Isaacson’s clever writing, let me know if you laughed as hard as I did when you reach the part about Jobs’s vendor partner proudly printing T-shirts with an acronym not to be described in this more civilized blog post.
Now on to whether Jobs would appreciate the merits of regulations advancing Accountable Care Organizations (ACOs). I think not. Jobs had individual market instincts and would likely scoff at the idea that innovation can be promulgated by thousands of pages of what “the ACO shall provide.” Still, if the strongest case for ACOs rests with the idea that this time we intend to execute on a shared vision of inexorably integrated primary care, I think Jobs would want to learn more. Jobs had a career-long vision and constancy of purpose grounded in his belief that the best user experience comes from a closed system, and his conviction that controlling the quality of both hardware and software was vital to offering consumers what they needed. What’s more, he felt it was the only way for him to invent what consumers didn’t even know they wanted. Such was his tireless battle against Bill Gates, Google, and all other comers who believed open architecture would drive greater choice, better prices, and, in the end, more innovation for the consumer.
So far, ACOs are closed systems. To wit, the majority of the “pioneers” are simply those that already own the integrated medical records, call centers, and IT-abetted care coordination infrastructure needed to pursue the economic potential of an ACO delivery model. But I can just hear Jobs’s reaction: “It’s not the shared savings, stupid.” Actually, he’d have used much more colorful adjectives. Jobs defied business maxims assuming innovation and profit are a virtuous upward spiral. Indeed, he routinely eschewed profits and blew apart operational efforts to lower development costs in deference to his puritanical devotion to sweating every detail related to quality. If you told Jobs about VA Health Care as an example of how health information technology can reduce errors, improve quality, and reduce costs, he’d be fascinated. But if you then told him that most of health care is provided by small groups of medical providers and that very few of them believe they are equipped to accommodate ACO requirements, I think he’d react with conversation-ending expletives. Remember the famous Macintosh commercial proclaiming “1984 won’t be like 1984”? Ironically, as much as Jobs would likely favor the cottage industry innovators over the “big brother” version of an integrated platform, he and his wife, in effect, built their own ACO. That one of the richest men in the world was experiencing such uncoordinated care that his family decided to step in to assemble and coordinate their caregivers shows just how far we need to go before the integration tenets of the ACO movement can be realized.
Paul E. Terry, PhD, is CEO of StayWell Health Management
What do these characteristics bring to mind?
- Flexible appointment scheduling
- Advanced electronic communication
- Care coordination
- Counseling and education
- Electronic prescribing
- Electronic health record with patient portal
If you thought Level 3 Medical Home, you were correct. If you thought retainer (concierge) practice, you would also be correct.
To me, it seems eminently rational for people who have sufficient discretionary income to choose to use it to obtain more rapid access to a personal physician of her/ his choosing through a retainer (concierge) practice. The advantages might be more time spent in conversation (in the office, over the phone, via e-mail or text messaging, in video conferences), more in-depth condition or prevention education, coaching, counseling, and/or less waiting time.
Some in the medical profession have raised the question of the ethics of retainer practices. An excerpt from an Annals of Internal Medicine editorial:
"I am less charitable, however, toward concierge physicians and am surprised by the neutrality with which the medical community has addressed their work. First, each of us has vowed to treat without exception all who seek [our] ministrations,and limiting one's practice to several hundred wealthy patients undermines this tenet of our profession. Even though economic realities and schedule limitations dictate that some physicians maintain a certain payer mix or eventually close their panels to new patients, I am certain that the legendary physicians of our profession would be embarrassed by the criteria some of our colleagues have used in selecting which patients they will and will not see." Ann Intern Med. 2010;152:391392.
"Treat without exception all who seek [our] ministrations" is from the Hippocratic Oath, a poignant ethical pledge believed to have been written in the late 5th century BCE. Our modern reality is that there are many constraints on how clinicians practice, the scope of that practice, where they practice, the patients that they treat, and the machinations of how that care is reimbursed.
As a volunteer faculty physician in a Federally Qualified Health Center, I find this challenge of ensuring adequate access to care to be abundantly evident. My own view: Health care practitioners should dedicate some time to service in situations with wider access, often pro bono, whether the field be medicine, nursing, pharmacy, or allied health professions. This may be difficult or impossible in a retainer medical practice, but that does not preclude service elsewhere.
Retainer practices have their place, but they will only be viable if the clinicians engaged in that model meet or exceed the expectations of their patients by providing a comfortable medical home for them.
It's that rational.
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
The drumbeat of EBM — Evidence Based Medicine — seems less vigorous in the wake of enthusiasm for new models of care — Medical Homes and Accountable Care Organizations — and reimbursement based on performance, outcomes, or episodes of care. A good definition of EBM from Sackett, et. al:
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. http://www.bmj.com/content/312/7023/71.full
In my view, evidence based medicine and evidence based practice will be central to the success of these delivery, risk sharing or risk shifting reimbursement models. A useful construct for implementation of EBM or EBP:
- Translation of uncertainty to an answerable question
- Systematic retrieval of best evidence available
- Critical appraisal of evidence for validity, clinical relevance, and applicability
- Application of evidence in practice; and
- Evaluation of performance
Managed Care Organizations can and should play a key role in numbers 1–3 and number 5 above. Payers and their provider networks will need to effect collaboration, share knowledge and learning, and orchestrate some degree of administrative and clinical data integration to put meaning into meaningful use and to achieve meaningful improvement in outcomes and affordability.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
So what is the connection to managed care? After two decades of struggle, innovation, and change — some that proved valuable and some that proved detrimental — payers, purchasers, and providers became relatively complacent. During the past decade, we have witnessed an erosion in trust ("The Trust Crisis in Healthcare: Causes, Consequences, and Cures"), costs that are once again significantly outpacing the CPI, and an acceleration in the decline in interest among medical students and internal medicine residents in pursuing careers in primary care.
We were jolted out of our complacency by the Affordable Care Act. Some positive signs: more adequate and more reasonable reimbursement for primary care clinicians through the patient-centered medical home model; private and public sector pilots/demonstration projects, including episode-of-care reimbursement, payment tied to outcomes and quality versus volume; or simply trying to rein in costs by reducing fees. A recent example is BCBS of Massachusetts's Alternative Quality Contract, as discussed in the New England Journal of Medicine: Health Care Spending and Quality in Year 1 of the Alternative Quality Contract
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
Steven R. Peskin, MD, MBA, FACP
is executive vice president and chief medical officer
of MediMedia USA, which publishes Managed Care
Mark Herzlich, Boston College All American linebacker and now New York Giants rookie, believes that positive thinking played an important part in his successful battle "to beat bone cancer" and return to football. World-renowned cyclist and cancer advocate Lance Armstrong credits not only topnotch medical care but also positive thinking in his overcoming testicular cancer. Armstrong stated on CBS Sunday Morning, "You can't deny the fact that a person with a positive and optimistic attitude does a lot better."
Like the vast majority of individuals polled on whether or not the positive thinking can influence cancer outcomes, I believed/wanted to believe that positive thinking would be correlated with better survival data. But the weight of evidence does not support the thesis that optimistic attitude trumps the Big C, or even influences oncology outcomes. Rigorous research done by James Coyne, PhD, professor of psychology at the University Pennsylvania, shows no correlation between positive thinking/optimism and cancer survival. In the article "Positive Psychology in Cancer Care: Bad Science, Exaggerated Claims and Unproven Medicine" in Annals of Behavioral Medicine, Coyne and Tennen examined: 1) role of positive factors such as a “fighting spirit” in extending the life of persons with cancer; (2) effects of interventions cultivating positive psychological states on immune functioning and cancer progression and mortality; and evidence concerning (3) benefit finding and (4) post-traumatic growth following serious illness such as cancer and other highly threatening experiences.
Coyne and Tennen found no scientifically rigorous evidence to support claims that positive thinking and optimism result in improved outcomes in cancer treatment. They challenge positive psychologists "to rededicate themselves to a positive psychology based on scientific evidence rather than wishful thinking."
The impact of the mind and its pervasive power and influence in our health and well being is undeniable, yet we need to carefully weigh the evidence and continue to seek to research and demonstrate the nature of the mind/body connection and not to oversimplify.
Keep the faith!
Steven R. Peskin, MD, MBA, FACP
is executive vice president and chief medical officer
of MediMedia USA, which publishes Managed Care
Americans’ girth is growing at an alarming rate. Many are too sedentary, too stressed, suffering from insomnia, making bad food choices. The drumbeat of “We need a culture of health versus a sickness culture” is a refrain that we now often hear and that I have espoused. Yet we advance this form of health and wellness promotion in the same way that we attempt to drive, sell, and be authoritative — in an almost combative fashion that is the zeitgeist of 21st century America. We also throw in healthy — or perhaps not — doses of carrots and sticks in our zeal to fix the great unwashed.
In contrast, looking at a society that has better health statistics than the U.S.A. on most measures, and spends far less, I note that the Japanese display a “culture of contentment.” A Japanese man who drove me from a hotel to the airport in Minneapolis got me thinking about this culture difference with his genuine pleasantness and “comfort in his own skin.” On a much broader scale, I was struck by the incredible courage, resolve, and even serenity of the Japanese people in the face of the horrific consequences of the earthquake and tsunami that struck the nation in March.
Could “culture of contentment” be part of population health improvement?
Food for thought!
I was just looking at the website of Newtek Business Services (www.thesba.com/), which also goes by the name of The Small Business Authority. It sells financial and administrative services to small businesses. I found more evidence that the public doesn’t have a clue about what’s going on in health care. This is goofy stuff, folks, so I'll have some fun with it.
Newtek has been conducting an online poll for about a month. I know, it is unscientific — it isn’t even clear that the poll is limited to small business representatives (I was able to vote, and was told that my vote was recorded, yet a news release describes those polled as “business owners”) — but it is interesting, to say the least. And the most interesting part is that about 5/6 of the respondents think it is wrong to force people to buy health insurance — much more than legit polls show, while at the same time, 9% plan to buy health insurance from the government. They must have heard that America’s gone socialist. I, however, thought the public option had been ditched in the negotiations leading to adoption of the Accountable Care Act.
And as if that weren’t enough, about a fourth of respondents expect the cost of health care to decrease in the next two years.
On what planet?
This is all ridiculous, to be sure, but it underscores the public’s confusion about current developments. And people should be confused! There’s even massive disagreement among health policy wonks about what’s in store. But I think the wonks could agree on one thing: Costs ain’t goin' down anytime soon.
I’d call it a sure bet.
Steven R. Peskin, MD, MBA, FACP
Is Executive Vice President and Chief Medical Officer
of MediMedia, USA, which publishes Managed Care
"You Can't Outrun Your Past"........ The title of a slide in a grand rounds presentation by Dr. David Kountz, senior VP for medical and academic affairs at Jersey Shore Medical Center and professor of medicine, UMDNJ-Robert Wood Johnson Medical School. The subtext is that the impact of being black in our society confers incremental risk across a range of cardiovascular and cardiometabolic conditions irrespective of socioeconomic status.
A 1997 journal article by Thomas, et al. reported the results of a 23–25 year longitudinal surveillance study of a cohort of all black physicians who graduated from Meharry Medical College from 1958 to 1965 compared to an all-white cohort that graduated from Johns Hopkins from 1957 to 1964. The black physicians had much higher risk of cardiovascular disease (RR= 1.65), incidence rates of diabetes and hypertension twice that of whites, a rate of coronary artery disease 1.4 times as high, and much higher case fatality rates (52 percent versus 9 percent). Most surprising to me from this study: Black physicians in this cohort had incidence of cardiovascular disease comparable to low socioeconomic status (SES) blacks. Higher SES in this well-educated, health-literate cohort did not improve health CV health outcomes.
In the study of Women's Health Across the Nation (SWAN), everyday discrimination was positively related to subclinical carotid artery disease for black but not for white women, and chronic exposure to discrimination over five years was positively related to coronary artery disease in black women.
A final study without a health care endpoint but one that drives home the impact of discrimination:
Pairs of young, well-groomed, well-spoken college men with identical resumes apply for 350 entry-level jobs in Milwaukee. Two teams of applicants are white and two teams are black. In each team, one applicant says that he had served an 18-month prison sentence for cocaine possession. The study found that it was easier for a white male with a felony conviction to get a job than a black whose record was clean.
Genetics, diet, physical activity, other factors certainly contribute. Nonetheless, these are sobering studies that strongly point to the adverse health consequences of allostatic load on the health of black Americans in the United States.