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.

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In the prestigious medical journal JAMA, Georgetown Universitys William Novelli, Kaiser CEO George Halvorson and Consumer Reports John Santa summarize the results of a patient survey and focus group results on the topic of shared decision making. The study was sponsored by the prestigious Institute of Medicine.

The results show that when it comes to treatment, patients want their doctors to present all relevant options, including the option of doing nothing.  Most also want to know each options risk.  Once they have good understanding, the majority are comfortable with letting their physician lead on chosing the "best" decision.  This approach is likewise associated with greater patient satisfaction.

Yet, despite their perence on how to best reconcile competing treatment options, few can recall it actually happening that way.

While this may be newsworthy to JAMA readers, the results should be of no surprise to anyone working in the population health management (PHM) field.  PHM service providers have been advocating for shared decision making for years. Theyve also developed business models that bridge the gap between JAMAs academic ideals and the real world inhabited by flesh and blood patients with busy doctors who need help now.

As testimony to the blurring between the theoretical and the possible, the Disease Management Care Blog has pasted 4 quotes below.  One is from a concluding paragraph of the JAMA paper, while the remainder are from the web sites associated some commercial care management vendors.

See if you can spot which is which:

physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health (link)

can ensure that in the trilogy of opinions, the patients opinion and perspective are core, helping fulfill the promise of better health at lower cost (link)

constantly make decisions that impact their health and provides them with the tools they need to make the decisions that are right for them (link)

based on each individuals readiness-to-change and what health issues they want to address, personalized interventions connect the widest range of health management solutions, devices and diagnostic tests (link)

Inspired by zoological bard Tony Hoagland, the ever romantic Disease Management Care Blog shares in the population-health inspired paean to commitment, support and caring.



  ....it is just our second telephonic encounter and I languidly sit with headset in a faceless building with the silent hum of desktops, not looking at you for eye contact is not necessary....

And if I were a medical home right now, I would securely message the physician, confident there is no time for her read it.... or act.... 

And if I were an ACO, I would lovingly attribute you, unless your baseline costs were already low so Id drop you fast and surpass the savings threshold.... 

And if you had moved beyond precontemplation, you would engage with my complex care plan and self-care your chronic condition and no longer bother me with your symptoms...and unhappiness.

And if I were an employer sponsored health plan, I would outsource the wellness program and demand fee clawbacks if target PMPMs were not achieved.

And if she were inside the risk corridor, we would avoid any clawbacks, earning me my bonus this year.....

which means we sit in silence and that your insurance wont cost less and ice cream cones wont be any more affordable for you for it is my ROI that we eat together.

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.

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