Three Population Health Management Principles for Reconciling Quality Based Pay for Performance and the Doctor Patient Relationship

Writing in the New England Journal, Robert Berenson and Deborah Kay of the Urban Institute say a linchpin of Washington DCs pursuit of quality is a "policy overreach [that] could undermine the quest for higher-value health care."

Yikes.  The Disease Management Care Blog turns to population health management to ponder their unhappiness.

The authors concern is over Medicares "Physician Quality Reporting System" or "PQRS."  As the DMCB understands it, PQRS rewards (and penalizes) physicians for outcomes that are calculated from a set of quality "modifiers" that are submitted as part of the Medicare billing statement (an example can be found here).  The amount of money at stake is in the range of 1%-2% of the Medicare reimbursements.

Berensen and Kay point out that while the system has been ramping up over 6 years, 70% of Medicare participating physicians do not submit any modifiers.  In their opinion, thats because:

1) the loss of 1% of any payment is practically meaningless,

2) physicians distrust the metrics and

3) there is a fundamental disconnect between the modifiers and the complex world of clinical practice. 

As examples, radiologists are being dinged for total x-ray exposure while surgeons are being held accountable for pre-op antibiotic administration. While these and other quality measures are important, they fall far short of recognizing what keeps docs up at night, like reading the x-ray correctly and getting a patient through surgery and out of the hospital.

"Hear hear!" says the Disease Management Care Blog.  In the course of a normal day, it is job of doctors to do "doctor stuff" involving one patient at a time. 

But, you ask, isnt that contrary to being accountable to the health of populations? 

The DMCB doesnt think so, because state-of-the-art population health management (PHM) agrees that:

A. Physicians need to be immunized from disruptions their "customer facing" (i.e., the patient) activities.  Otherwise known as the doctor-patient relationship, thats the part of the health care system that relies on the seven or more years of undergraduate and graduate training that turns smart people into exquisitely trained physicians.  Let the doctors be doctors, says the DMCB, and let them worry about their patients.

B. High performing systems - as much as possible - need to be configured around those customer-facing activities, further enabling the doc to focus on the patient who is right here and right now. 

From time to time, PHM might have to intrude.  When it does, the DMCB suggests policymakers recognize that they should proceed:

1) only when its really important

2) only infrequently and

3) whenever possible, when it reduces physician work by outsourcing (an example in primary care can be found here) those things that dont require the personal involvement of a doc.

It would seem that Medicares PQRS failed to recognize the fundamentals.

Image fromWikipedia

Do Employer Based Wellness Programs Work

Reuters tackles worksite wellness outcomes

Mrs. Smith (name changed) was overweight.  She knew it and her physician, the Disease Management Care Blog, knew that she knew it.  Since the DMCB was one of the two persons on the planet who knew her true weight, she could talk to it behind closed doors about diet, exercise, fads, over the counter meds, prescription appetite suppressants and even bariatric surgery. 

What the DMCB quickly discovered was that Mrs. Smiths weight-loss goals were not only unrealistic but, like many women struggling with weight, driven more by the prospect of how shed look in a bathing suit than any real health benefit.

Mrs. Smith wasnt alone. This seminal study demonstrated just how unrealistic womens weight loss goals (in the range of 50 lbs.) can be.  Think of the popularity of The Biggest Loser and its easy to see why persons think thinness is just a matter of a few months of dieting and exercise, and that being skinny leads to health and happiness, 

Easy, right?

DMCB readers know otherwise. Thats why theyre not going to be impressed by the tone of this May 24 Reuters article on worksite wellness.  RAND, in a not-quite released report to Congress, examined the impact of several employee based programs and found, in the words of the Reuters reporter, only a "modest effect."  Average weight loss was "only" three lbs., tobacco cessation rates were significant but "short term," average cholesterol levels were unchanged and reductions in health insurance claims expense failed to achieve statistical significance.

Researchers have known for years that conservative dietary and lifestyle therapy typically results in weight loss in the range described above. In addition, cholesterol reduction as a primary prevention intervention is low yield when it comes to health. On the other hand, even short term tobacco cessation is a good thing. When it comes to the ability of wellness to reduce health care costs, weight reduction is unlikely to drive claims expense for a health insurer within two to three years, the impact of obesity on overall mortality rates is not as large as youd think and "prevention" rarely saves money.

Whats more, these programs were able to achieve their "modest" outcomes without increasing claims expense.  Participants lost weight and stopped smoking at no additional cost to the system.  Now that is something.

Mrs. Smith and Reuters are very similar.  Both are struggling with nrealistic expectations thanks to dubious fashion trends, media misinformation and scientific ignorance.  Fortunately, Mrs. Smith had access to a resource that could help her better manage her weight.  The DMCB can only hope that Reuters has access to a resource that can help it manage its lack of background knowledge.

The benefits of fruit based on color

White-colored fruit

Color knows, garlic fruit color, the color of low-fat cheese, yogurt color, the color of soy milk and fruit color of milk are examples of foods that are white, contain many flavonoids that may help the cell membrane. Low-fat milk can also be helping with the work of the heart while calcium to build fat and lose weight. So it is great for the body.

Red-colored fruits

The color of vegetables and fruits that contain lots of red pigment which is useful for fighting disease and lycopene, a substance that acts to maintain cell health and can reduce the risk of cancer. Such as: tomatoes, strawberries, watermelon, apples, cranberries, cherry, red grape, beet, and red peppers. While most high-containing oxidants are strawberries, cranberries, cherry, red grape, beet, and red peppers.

Yellow-colored fruit

Yellow color in vegetables and fruits contain vitamin C indicates that quite a lot. Where in the body of vitamin C is necessary to protect the body cells, contain potassium which is good for lowering high blood pressure, reduce plaque formation in arteries, and serves as a natural laxative.

Green colored fruit

Fruits and green vegetables contain sulfarophane, isothiocyanates and indoles. Serves to stimulate the level of component makers that can break down cancer-causing chemicals. The darker the green color in vegetables, the more chlorophyll it contains and the greater the need for antioxidant protection. Such as: broccoli, lettuce, spinach, and green tea. According to the study of tea can provide a boost in your metabolism because tea contains polyphenols and caffeine, which unite to open up the fat burning process in the different control values.

Orange colored fruit

The color of sweet potatoes, squash orange color, the color of carrots, and cantaloupe color of pumpkin, peach, mango color, color apricot and papaya are some of the examples of fruits and vegetables are colored orange. Each serving of fruits & vegetables that give a lot of beta carotene alpha-carotene, beta-carotene which can nourish the body and alpha carotene can be effective against cancer. Half a bowl of fruit & vegetables are colored orange are to meet the requirement of vitamin C in the body.

Chocolate-colored fruit

The habit of consuming food or brown, it can help remove toxins in the body that cause disease. Such as: breads, grains, cereals, granola, and nuts. Seeds contain lots of vitamin B that can increase the bodys ability to convert calories into energy.

Blue and purple colored Fruit

Examples of vegetables and fruits that are blue purple eggplant are a fruit, raisins and grape fruit. The content of magnesium in grapes and raisins fruit is necessary for the movement of stool is good. Grape skins are also a laxative (laxative) is good. Water containing high enough, so it can add the necessary body fluids. While the eggplant may lower cholesterol and bile acids in the gut and drove him out of the body. In addition, the fruit of eggplant also contains cholesterol-lowering pectin in considerable numbers.