Beauty Health for Life

Playing whacamole

"Immunizations cause autism." 

"Health care blogging will never lead any serious beer money."

"Disease management coaching focuses exclusively on just one disease."

These are three falsehoods that bubble up in the unlikeliest of places, including cable news outlets, replying to the DMCB spouses asking "and what did you do today?" and webinars, webcasts and other educational meetings about population health and disease management.

While the Disease Management Care Blog finds all three vexing, the most irksome is the canard that the commercial health coaching service providers purposely limit their programs to just one chronic condition, like diabetes, weight loss or readmission prevention.

While that may have been the case in the earliest versions of disease management, that narrow approach was dropped years ago. Thats because patients typically seek advice for a wide range of overlapping concerns and the good nurses hired by the vendors will respond to them.  The vendors also understand that their shared risk and performance guarantees depend on claims expense that is driven by the synergies of multiple co-morbidities. 

While a purchaser, insurer or accountable provider organization may start out with a focus on a population defined by a single condition - such as diabetes mellitus - that doesnt mean their protocols and care plans wont span the continuum of care and include hypertension, tobacco abuse, depression, housing, chatting about the grandkid and responding to concerns whether this will be finally be NBA superstar LeBron James year.

And the published literature supports the DMCBs contention that modern population health management is multifaceted.  Examples include this seven-condition program for dually eligible Medicaid beneficiaries in Georgia, this Midwest employer-sponsored program that enrolled persons with multiple care needs and this physician-focused program that used pay-for-performance to improve measures across multiple conditions.  Check out some vendor web sites and youll see erences to "whole person health," the "interrelated aspects of social, emotional, and physical health" and "a holistic view of member health across internal and external care management initiatives."

That being said, the DMCB knows that perception and reality can be two different things. Given the whac-a-mole persistence of the "single disease" myth, the DMCB says the population health management community may benefit clarifying the broadness as well as the depth of their offerings as they continue to build their brand.

Image from Wikipedia

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.

The opening Supreme Court Affordable Care Act (ACA) deliberations focused on the obscure 1867 Anti-Injunction Act and whether the mandate is a "tax." Its not until the day two of arguments that The Nine Lawyers will take on the "individual mandate."

That day of reckoning yet awaits.

Obliging more health persons into the insurance "risk" pools is fundamentally an exercise in spreading the same risk and health care costs over a larger population. While individuals may see their health insurance premium decline thanks to more persons paying into the system, the total consumption of health care services has no reason to slow down. A mandate by itself will not reduce costs.*

Speaking of saving money, the omnivorous DMCB, spent some of its teenage years living on a country farm. The family did its own butchering and, never leaving anything to waste, did everything it could to use every scrap of meat. As far as the DMCB is concerned, "pink slime" a.k.a. "boneless meat trimmings" is a virtuous confluence of that same thrift on an industrial scale combined with centrifuges and ammonia. Talk about a slaughter.

Last but not least, the DMCB got one more population health management insight from Charles Duhiggs book The Power of Habit. In it, Mr. Duhigg describes how Targets brainiacs discovered an association between the emergence of new buying habits in young women and early pregnancy. While that classic exercise in predictive modeling is not new, what happened next was insightful: creeped out Target customers pushed back when they unexpectedly started getting maternity and baby product coupons. In response, Target learned to camouflage its recruitment efforts by disseminating its coupons with random and unrelated product offers. The DMCB wonders if the same surreptitious approach could somehow be adapted to recruit high risk patients into population health management.  $5 toward text messaging if we can ask you some questions about your wellness.... and diabetes.

*Assume for a moment that 90 persons have health insurance which costs $500 a year.  That "pools" 90 x $500 or $45,000 in resources that are available pay for persons that need to be in a hospital.

Then assume 4 persons get sick - one gets appendicitis, one is involved in a car accident, one gets gets an infected paper cut  and the last one neglects to follow a DMCB spouse preventive health recommendation and gets what he deserves.  If the average cost per hospitalization is $10,000, the total cost is $40,000.  That leaves $5000 left over.

Cost of the insurance for each of the 90 persons: $500.
Cost of the illness for each of the 90 persons : $444.
Total amount of money going to the insurance company: $45,000.
Total cost of the illness: $40,000.
Amount that goes to the insurance companys bottom line: $5000

One year later, the 90 persons realize that there are ten persons living in their community who are not buying insurance.  Assume these freeloaders are healthy.  The 90 persons have a majority and pass an ACA with a mandate.  Over the next year, four other persons get sick again.

Cost of the insurance for each of the 100 persons: $500.
Cost of the illness for each of the 100 persons : $400.
Total amount of money going to the insurance company: $50,000.
Total cost of the illness: $40,000
Amount that goes to the insurance companys bottom line: $10,000

Of course, its more complicated than that.  Of the ten forced to buy insurance, some have preexisting conditions and the cost of a hospitalization rises year after year, but that doesnt change the basic math underlying a mandate: total health care costs are the same, but theyre spread over a larger base population.