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.

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How To Provide Care for the Medicare Medicare Duals The Population Health Management Playbook

The Care Continuum Alliance (CCA) has come out with an important report on how to improve the care of the 9 million persons who are "dual eligible."  These individuals are among the most economically vulnerable and sickest Americans.  They simultaneously qualify for both Medicare and Medicaid and their health care costs are staggering.

The CCA recommendations for the care of duals on a regional or state basis should not be unfamiliar to regular readers of the Disease Management Care Blog: collect the necessary data, risk-stratify the individuals, maximize coordinated care for those at greatest risk, work with the docs, measure outcomes, lather, rinse repeat.

No knowledge base on disease and population health management and dual eligibles is complete without this download.  Check it out and youll learn that....

Data on this population should be centralized, comprehensive and interconnected: This means pooling insurance claims, electronic records, labs and pharmacy and making the data available in health information exchanges.  How else will program planners understand the duals needs, plan programs, foster communication among providers and evaluate outcomes?

The population should be risk stratified.  Health risk assessments are a good option because these persons may drift in and out of dual eligibility.  Incentives should be offered to increase the likelihood that the HRA surveys will be completed.

Professional care planning should be used to to best "position" patients in a coordinated, patient centered and streamlined manner.  This coordination should include providers, pharmacy, behavioral health and long term care to maximize mental health support, rehab, end-of-life care, additional counseling needs and erral to community-based programs.

Provider incentives should use all possible options including capitation, shared savings and bonus payments.  Training and tools should be made available.

Goals for the dual population should be defined and there should be measurement of progress toward those goals.

The Underestimated Power of Online Relationships and the Implications for Population Health Management

Health care in a box?

Macis very upset.  Dopey Kyle, who otherwise seems like a nice guy, has been hot-chatting it up with online girlfriends.  Good thing pop psychologist Dr. Drew can come to the emotional rescue on MTVs "Teen Mom."

The Disease Management Care Blogs response?  Mute and quickly change the channel before the DMCB spouse has one more reason to doubt the intelligence of the male species.

Yet, only the perspicacious DMCB can use this sordid tale to extract an important lesson for the population health management (PHM) community.

Thats because it listened caully to TedMeds Jay Walker, who spoke at the closing plenary session at the Care Continuum Alliances Forum12.  Mr. Walker observed that handheld devices with texting are blurring the lines that separate in-person and virtual relationships.  While 3-D, face-to-face "analog" interactions still count, people are also going online to achieve an astonishing level of digital familiarity and even intimacy with each other.

While regular readers already know that persons turn to trusted in-person as well as virtual "friends" and "communities" for health care advice (past DMCB posts on the topic are here and here), the DMCB may have underestimated the full implications of just how real and behavior-changing an on-line relationship can be. 

No, the DMCB is not suggesting that PHM vendors start hot chatting with clients. 

But it is saying that vendors as well as buyers who discount "remote" web-enabled and text coaching versus in-person services may need to take another look at their future business plans and underlying value propositions. Maci and Kyles dysfunction are teaching us that remote texting has far more "connectedness" potential than generally appreciated. If a social-media-based relationships downsides can capture Maci and Kyles attention, why cant the upsides also be harnessed to change behavior?

We have a lot more to learn about the determinants of on-line relationship building.  Companies that figure it out will win.

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Another Randomized Controlled Clinical Trial Proves Outsourced Population Health Care Management Works Hypertension

Heres another high quality randomized controlled clinical that confirms the benefits of outsourced care management.

Margolis and colleagues accessed Minnesotas HealthPartners electronic records to identify all patients who had had two sequential primary care clinic blood pressure readings that were more than 140 systolic or 90 diastolic.  These patients with hypertension were asked by letter and then phone calls to participate in the research trial.  Those who agreed were rechecked by research assistants who re-measured the blood pressures to confirm the hypertension.

16 clinics participated. 8 were assigned to the intervention group. 8 served as comparison (control) "usual care" clinics that relied on usual physician care.

In the intervention clinics, a pharmacist interviewed each patient and sought agreement to lower the blood pressure by 5 points. The patients received a home BP monitor that transmitted data to AMCHealth six times a week. The pharmacist and patient met by telephone every 2 weeks. Based on the BP monitoring and the telephone interviews, the pharmacist used a standardized medication algorithm to adjust medications until control was achieved for 6 weeks.  Telephone calls were then reduced in frequency to monthly.

The research assistants reassessed the participants blood pressures at 6, 12 and 18 months.

Over 14,000 patients were identified and 2020 agreed to be screened. 450 met criteria for persistently elevated blood pressures. 228 were cared for in the intervention clinic and 220 were cared for in the usual care. The mean age was 61 years, 45% were women, 82% were white and 48% had a college degree. The average blood pressure was 148/85.

Both groups had a similar frequency of follow-up visits. 380 patients had completed both 6 and 12 month follow-up visits with the research assistants. 

The proportion of patients with controlled BPs at both visits in the intervention clinics was 57.2% vs. 30% in the control clinics. If those patients lost to follow-up were counted as blood pressure "failures," the success rate was 48.5% vs. 25.1%. Both sets of measures were statistically significant.  The relative proportions held up at 18 months.

Unsurprisingly, intervention patients were taking more medications over the duration of the study and at 6 months were statistically more significantly more likely to report that they were taking them. 

Six patients in the intervention group vs one in the control group had "events" related to low blood pressure, dizziness and loss of consciousness.

The cost, based on pharmacist time, was $1350 per patient.

The Disease Management Care Blogs take:

This adds to a growing body of evidence that non-physicians working under clinical protocol side-by side with busy primary care physicians can achieve control of a chronic condition - in this instance, hypertension.  This is a core attribute of population health.

Another piece of good news is the emergence of the electronic health record as a means to identify patients who are program candidates.  Now thats "meaningful."

The bad news:

The cost was $1350.  It is unlikely that those direct costs were mitigated by hypertension-related "savings" within the same fiscal year.  On the other hands, thinks the DMCB, the use of other types of non-physicians with or without IT-based decision support and higher throughput could lessen that cost.  The DMCB is sure that the population health service providers are already on it.

Even with state of the art population health, the rate of hypertension control was ultimately 50%.

A small excess of participants experienced an excess of treatment side effects.  While this may be the inevitable consequence of more aggressive treatment, it could expose the program to liability.

This was Minnesota: we dont know if this would work in, say, Los Angeles.  This needs to be tested elsewhere.

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An Update On Population Health Management Its Working!

CMS, MA Plans & Disease Management?

Its a good day when Health Affairs has nice things to say about population health management (PHM).  After all, Health Affairs is one of the bedside reading options for inside-the-beltway health care elites. So, when hostility to Ver. 1.0 disease management turns into a reasoned summary of Ver. 2 PHM, thats not only evidence of PHMs success but waning anti-vendor ideology. While the ultimate success of PHM is a function of market demand, this kind of endorsement cant hurt.

Using the Care Continuum Alliances definition of PHM, researchers from Americas Health Insurance Plans (AHIP) and Brandeis University conducted a written and then telephonic survey of 42 out of 72 larger Medicare Advantage (MA) Plans. While the results were interesting, what caught the Disease Management Care Blogs eye was that.....

Disease and case management are "routinely used." These programs are made up of nurse hotlines, telephone visits, increasing access to social services, meeting patients psychosocial and providing care coordination. An accompanying infographic says "100%" offer "teaching chronic disease self-management."

Health risk assessments are also used "universally" and target self-identified individuals with outreach designed to educate and/or enroll in programs that reduce risk factors.

Care managers for the frail elderly are available in "100%" of plans. A second infographic points out that home safety, in-home visits and community services errals are among the top used interventions. And, as testimony to a lingering sense of skepticism over remote home monitoring, the infographic says that was only used in 56% of plans.

Unlike Medicare fee-for-service (FFS), hospital readmissions have been a top concern of the MA Plans for years. They know there is no single "silver bullet" and have long relied on a combination of nursing, social services, home-health visits, medication reconciliations, follow-up care coordination programs and home visits. Survey respondents were convinced their programs were "effective."

In other examples of MA Plans being light-years ahead of Medicare FFS, if providers need data, MA Plans will make it available. If payment orm is necessary, MA Plans will make deals involving global risk arrangements, bundled payments and shared savings.

Evidence? Regretfully, say the authors, there is a lack of "systematic evidence" supporting PHMs effectiveness.  They also believe that there is conflicting evidence on whether MA Plans achieve better outcomes versus Medicare FFS.

The Disease Management Care Blogs take:

While skeptics continue to believe that Medicare Health Support "proved" that "disease management" doesnt work, the MA Plans correctly surmised that MHS only proved that early versions of disease management in Medicare FFS settings doesnt work.  The MA Plans have figured out how to improve on disease management.

While published data may be lacking, the people who run MA Plans are not dunces.  They have internal data showing that it works, or they wouldnt be using it.

While the Medicare Advantage program is controversial, the Health Affairs post suggests the MA Plans are useful laboratories for seeing what can be of benefit in the care of Medicare-eligible seniors.  If ACOs flop, perhaps CMS will go back to the future with their MA Program for ideas on what can work.

On the Invisibility of Selection Bias and Regression to the Mean in Population Health Management

A DMCB Vacation....

While the Disease Management Care Blog is neglectfully vacationing at the New Jersey shore, the spouse is slathering it and the spawn with SPF 100³.  Thats why the DMCB cant help but recall the recent advice of a media dermatologist: fear the sun.  Every melanoma patient he had ever cared for "recalled at least one severe sunburn!"

The population health management providers would be well advised to remember that skin doctors silliness.  While every patient we recall "got better" also ask yourself the simple question that should have been posed by the radio-show host:

"What about the patients you didnt take care of?"

Talk to any telephonic-coach nurse or any medical home care manager, and he or she will likely be able to rattle off dozens of HIPAA-protected encounters that started with an expensive clueless patient and ended with a less-expensive empowered patient. They and their manager-supervisor-vice-presidents are sure they had an impact. They see little reason to believe otherwise and see no need for "proof."

Theyre wrong.

Unfortunately, for both dermatology and PHM, it cuts both ways.  Plenty of patients have had severe sunburns and never had to see a dermatologist.  And there are plenty of patients who go from high to low intensity without the benefit of care management.

Of course, dont credit the DMCB for this example of selection bias with regression to the mean.  Skeptic Francis Bacon commented on the invisibility of drowned worshippers centuries ago.

The DMCB wont mention that problem to the spouse when it enters the surf.

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