Beauty Health for Life

Care management planning

Hot off the heels of this cinematic debut on how NOT to conduct care management comes this handy Alliance of Community Health Plans 29 page handbook review on how to do it right.  Some of the experienced members of the Alliance shared insights on successful population health approaches, data on the "return on investment" and how to deal with the physicians.

But, say the Hardball-inspired Disease Management Care Blog readers, "tell us something we dont already know." 

The DMCB found three useful nuggets of information:

1. There is no firm rule on the operational balance between central administration and peripheral distribution.  Some of the Plans hire and oversee the care management nurses while others pay their network primary care sites to hire their own nurses.  If the practices employ the nurses, they are free to let the managers see patients on an all-payer basis.

2. Care management caseloads vary from 35 to 150 persons and the enrollee to nurse ratio ranges from one full time nurse to 5000 to 14,000 commercial members. If less than 5000 Plan members are assigned to a primary care site, care managers split their time among multiple sites.  As Plan members are further diluted or distributed through a network, there is greater reliance on remote telephonic communication and coaching. 

3. Reduced costs?  Group Health, Fallon and Security Health plan say they saved over $2.5 million, $2.3 million, and $1 million, respectively. Tufts Health Plan says they saved $1.90 for every dollar spent.

Other points known but worth repeating:

Features of successful care management include appropriate patient selection, person-to-person outreach, credentialed professionals, teaming, coaching on self-management, family involvement and access to community-based programs.

Embedding care managers in the primary care sites is worthwhile not only because face-to-face patient care has more of an impact, but because the physicians will benefit from the consultations, participation in "huddles" and discussion of the treatment plans. That also leads to a greater level of trust between the docs and the nurses.

Theres better buy-in if the care managers are viewed by enrollees as an extension of the physicians, not the sponsoring insurers. 

Technology is important: effective care managers are made more effective by electronic records, telemonitoring, decision support, work-flow aids and video/mobile communication.

 The backbone of care management is made up of generalist nurses who are simultaneously comfortable with multiple conditions such as, for example COPD, mental illness and diabetes.  That being said, there is a role for focused nurse support for patients with special needs, such as hospice, transplant or bariatric surgery.

An abundance of data support is only the beginning because the reports will need to be tailored to the physicians clinical needs  and communication perences.  They also have to be paired with regular meetings that promote best practices and solicit feedback.

When care management is first rolled out, physicians will first suspect this is another managed care ruse, assume its a fast track to prior authorization or try to "downjob" clinical duties to the nurses that are outside of their scope of practice.  It will take many months and much collaboration to sort out turf issues, control, office space, and offering care management to some but not all patients.

"This message will self-destruct...."

The international arm of the Disease Management Care Blog is working on a presentation for the upcoming Hauptstadtkongreß in Berlin Germany.  Its "Mission Impossible" is to explain the U.S. health care system to a group of German hospital executives in a half hour.

This, in a Nußschale, is what the DMCB intends to say, using approximately eighteen PowerPoint slides:

1. While rising health care costs, as a percentage of U.S. GDP, has always been a problem, rising health care costs as a percentage of U.S. debt is widely viewed as a highly significant threat. We mean it this time.

2. The conservative vs. liberal debate over how to reduce health care costs for the U.S. government is ultimately about transferring its insurance risk.  The conservatives want to transfer risk to patients in the form of vouchers, while the liberals want to transfer risk to providers in the form of bundled payments and gain-sharing.  The liberals, so far, are handily winning the debate.

3. Risk is only half the health orm story.  The other half is quality. There is bipartisan consensus that a) U.S. health care quality could be better, and b) greater quality will mitigate insurance risk, resulting in fewer medical complications, emergency room visits and readmissions.
   
4. There is additional bipartisan consensus that a) insurance risk can be managed and b) quality can be increased when care is provided in large vertically integrated and regional provider systems.

5. If the twin exigencies of risk and quality are not addressed in the next 3-5 years, disappointment could lead to the unraveling of Obamacare and the introduction of a public payer option.

Image from Wikipedia

Yesterday, Kris floored us with her Top 10 Kitchen Items list. So much good stuff—I use 6 of the 10 (pepper grinder, kitchen scale, food processor, bulk storage containers, tongs, and slow cooker) weekly, if not daily.

My choice of skillet, however, is cast iron all the way, and if I keep treating them properly, the two I have will be my nonstick pan of choice forever and ever, amen.

Growing up Southern, every kitchen I knew had a cast iron skillet for frying chicken and baking cornbread. It’s a versatile piece of cookware, which makes it great for tiny New York apartment. Once I started cooking again, after a long hiatus of take-out and junk food, the cast iron skillet was my first purchase.

Seasoning a Cast Iron Pan
If you’re starting out with a new cast iron pan, you’ll need to “season” it. Seasoning is essentially baking on a layer of oil to fill in any nicks or divots in the surface of the pan and create a protective layer that prevents rust. Season your new pan, even if it is “pre-seasoned.” If you’re salvaging an antique, seasoning will restore the beauty to its former glory.

The InterWeb is rich with tips for seasoning your cast iron pan. My tried and true method is a combo of Grandma/Dad/Mom’s and a trick I picked up on What’sCookingAmerica.com.

1) Clean the pan with a mild soap and hot water. Use a fine-grade steel wool, salt, baking soda, or this handy potato method from TheKitchn to remove rust. (See below.) Rinse and dry completely.

2) Pre-heat the oven to 350°. Line the bottom of the oven with a baking sheet or foil.

3) Coat the entire pan, inside and out (Thanks, WCA!), with vegetable shortening (or any neutral cooking oil). Wipe off the excess.

4) Turn the pan upside-down and place it in the oven. Bake for 45 minutes.

5) Remove the pan from the oven and wipe off the excess oil. Give the cooking surface (and sides) another coat of shortening, wiping off any excess. Return to oven for another 30–60 minutes.

6) Turn off the oven, open the door, and allow to cool a bit before removing the pan.

7) Again, wipe off the excess oil. Your cast iron pan is ready to use.


Seasoning can be repeated anytime your pan is getting a little sticky or funky. Acidic foods, like tomatoes, break down the coating. Also, water is the enemy. Case in point:

Last week, I left my 5” cast iron skillet on the counter next to the sink for a couple of days. In that time, I washed a couple of sink-loads of dishes and made several pots of tea, which I spilled repeatedly. (I’m a klutz.)

When I went to use my little pan for a quick egg breakfast, the entire underside was covered in rust. I cut a potato in half, sprinkled a little baking soda on the rusty area, and gave it a scrub. Seriously, I don’t know what it is about the potato, but combined with baking soda, it only took about three passes (slicing off the used bits of potato each time) and 10 minutes for all the rust to disappear—even from those little grooves. (Tip: If you’re in the market for a cast iron pan, don’t get one with little grooves on the bottom.)


Even though the cooking surface looked okay, I re-seasoned the pan anyway (coating the inside AND outside). Now it’s back in action, and the outside is way more rust-resistant.

Cleaning and Maintaining a Cast Iron Pan
There is much debate over whether or not to use soap on a cast iron pan. It all depends on your comfort. I am squarely in the no-soap camp, but do what feels right for you. You just may need to re-season more frequently.

1) Clean your cast iron pan immediately after cooking. Letting food sit, particularly acidic foods, will break down the coating you’ve worked so hard to build.

2) Rinse with hot water and remove any debris with a natural fiber or plastic scrub brush. Do not use metal on cast iron—scrubbers or utensils. You can prevent metal on metal crime.

3) Dry immediately and thoroughly. Lingering water = rust. I usually put the pan back on the stove for a minute to cook off any renegade droplets.

4) Since it’s back on the stove, apply a thin, thin, thin layer of oil to the cooking surface. Heat for a few minutes; wipe off the excess; and store in a cool, dry place.

Cooking with Cast Iron
The more often you cook with your cast iron skillet, the more nonstick it will become. Eventually, you’ll only need a little bit of oil for even eggs to just slide right off the pan.

Plus, as I said before, cast iron cookware is versatile. It can go from the stovetop to the oven and handle both like a champ: sauté up a mess o’ greens and then bake a batch corn bread. You can pretty much do anything with a cast iron pan.

Cast iron cookware may seem like a lot of work, but the investment in time and care is worth the return you’ll get in durability, functionality, and longevity. This is cookware you can pass down through generations.

Can I get an Amen?

~~~

If you liked this ditty, you may like

• 10 Essential Kitchen Items for the Healthy Cook
• Desert Island Gadgets
• HOW Old Is That Oatmeal? When to Clean Out the Pantry

Since the Disease Management Care Blog not only wants to be informative but also helpful to its readers, it has developed a seven point generic physician employment inquiry response and recruitment letter.  It is available below. 

The DMCB is confident that those smaller physician-owned private practices that remain independent will find this form letter very helpful in the coming years.  The DMCB releases this to the public domain and its colleagues are welcome to copy, paste, distribute, share, alter, modify or adapt all or some of the document as it becomes necessary.

Dear [insert name of physician here]:

Thank you for your recent [select: tweet, email, Facebook posting or VM] inquiry about leaving your current salaried position and joining our practice.  Thanks to widespread patient dissatisfaction with the institutions that were spawned by "health orm," our small business has experienced tremendous growth. We are constantly on the lookout for new talent that complements our projected demand.  Maybe you can join our team!

As you are undoubtedly aware, many of our colleagues nationwide have been lured into full time employed positions involving large complicated corporate practice arrangements, many of which were set up to be ACOs. Savings havent materialized and many of these organizations have responded by demanding more patient "throughput" from their employed physicians and imposing cutbacks in vital support services.

In contrast to those organizations, our practice offers you:

1) a completely transparent compensation arrangement that equitably divides our net revenue income among the owner-physicians.   No more having to deal with an unwieldy administration that allocates salary amounts based on some opaque budget of anticipated revenues and upside savings minus overhead and capital allocations that you have no say in.

2) a team-based environment that not only relies on your expertise but knows whos boss.  Unlike those other complicated practice settings with layers of middle management, our office personnel report directly to you, period.

3) a patient population that is not only grateful for our high "same day" service standards and efficient and compassionate practice style, but who also recognize that unnecessarily calling at the end of the business day or repeatedly while were on night call is reason to be assisted in finding another physician.  We have caully cultivated a very loyal following of patients who genuinely partner with us.

4) a highly trained and motivated administrative support and care management staff that not only uses state-of-the-art approaches to deal with private managed care commercial insurers, but uses a "3A" approach of Anticipating, Automating and Appealing any service that requires prior authorization from you.  Youll only get involved in these matters when its necessary.

5) a stable practice environment. Speaking of managed care insurers, they comprise the bulk of our business. While they are far from perfect, Medicare and Medicaid they are not.  They dont threaten us with arbitrary fee schedule cuts, audits, and payment delays.  We firmly believe patients and taxpayers should get what they pay for.  Its not our fault if they havent paid for our level of clinical and consumer excellence. 

6) an EHR system is not only low cost and user-friendly, its modular and cloud-based.  Our vendor has agreed to performance guarantees, there are no one-sided "hold-harmless" clauses and its seamlessly compatible with any hand held device of your choice any time and any where.

7) a unique market niche that sits in that "sweet spot" between a local employer community that likes us, insurers that respect us, specialist physicians work with us and a multispecialty ACO close by that welcomes our errals.

Once again, thank you for contacting us.  Please send your CV to [insert P.O Box address here] where we will store it in strictest confidence along with dozens of your colleaques CVs.  We promise you that when we get to it in the coming months, we will contact you. 

Best regards,

How, you ask, does the Disease Management Care Blog spouse approach the days ahead?

Suspecting that the poorly controlled [insert name of chronic condition here] is the result of not taking the medication as prescribed, the doctor says: "Remember to take the [insert name of pharmaceutical here]!"

After silently concluding that the benefit of the medicine is less than the cost, hassles, side effects and long-term risks, the patient thinks "Like hell!"

That scenario has probably been played out thousands of times today in clinics across the United States.  According to Zachary Marcum and colleagues writing in the May 22 JAMA, thats costing $100 billion a year. 

Doctors like the Disease Management Care Blog have responded to "medication nonadherence" with entreaties to take the pills as prescribed. When docs take the time to address the issue with patients, research shows it can make a positive difference.

Marcum et al believe physicians can do better if they understand the six types of behaviors that lead to medicines going unused:

1. Insufficient understanding of the link to health and well-being

2. A decision that the benefit is exceeded by the costs.

3. Complexity of the medication management overwhelms the patient

4. Inattention (or what the authors describe as low vigilance)

5. Irrational or conflicting beliefs about medicine

6. Perceived lack of efficacy

What does the population health management service provider community need to know about this?

1. There are a variety of screening surveys that can be used to identify each of the patterns above; unfortunately for DMCB readers, however, there is no single survey that can do it all. 

2. There is also no single intervention that has been shown to consistently increase medication compliance.  Instead, multiple concurrent supports are needed, including education and behavioral support.  This paper by Ho et al echoes that assessment, pointing out that there is ample evidence that other valuable supports include reducing the number of pills, use of special containers, telemonitoring with interactive voice response, non-physician (nurse or pharmacist) one-on-one involvement and regular clinical follow-up with reminders.  Last but not least this paper in the Annals points out that reducing out of pocket patient costs can also make a difference.

Image from Wikipedia

Hot on the heals of the Disease Management Care Blogs bus tour of the problematic "dual eligibles"  comes this AHIP sponsored report from Emory health economist Kenneth Thorpe on how the Feds could save the taxpayers some serious money.   Recall that there are close to 9 million duals costing in excess of $230 billion per year and that the Presidents recent cost reduction proposal is curiously devoid of any mention of this group.

So what is Dr. Thorpes recommendation?  It can be summed up in two words:

"Care coordination."  The report can be found here.

 As the DMCB previously noted, the duals are being victimized by a perfect misalignment storm of Medicare and Medicaid.  Dr. Thorpe recommends that they be automatically enrolled (on an "opt-out" basis) in State-regulated managed care plans that would finance 24-7 centralized team-based care that, in turn, would be required to offer three key evidence-based services:

1. Transitional care or comprehensive planning and follow-up as patients move from the hospital to the community, which is led by dedicated full-time nurses.

2. Coaching and education using motivational interviewing and behavior change theory that is designed to prompt changes in life-style and greater self-care.

3. Medication management under the direction of a full-time pharmacists who make sure that the right medicines are being taken at the right time.

Based on a host of papers that have examined the impact of the interventions described above, Dr. Thorpe estimates, depending on the number of opt-outs, that the savings could exceed a whopping $125 billion over ten years.

The physician-DMCB endorses Dr. Thorpes recommendations:

While critics may charge that it gives too much power to the insurers, it thinks that the States and the Feds can ensure that there are consumer protections.  Witness the preliminary good work of the Special Needs Plans.

The report avoids drinking the "physician-centric" Kool-Aid that assumes some combination of electronic records and financial incentives will enable primary care docs to take this on.  They cant.

While the Patient Centered Medical Home (PCMH) is certainly an option, report capitalizes on the more important elements of the PCMH and discards the rest. 

Finally, its the health plan that has the accountability - and the downside financial risk - for making this work in a high cost and particularly needy population.