Tag: Jaan Sidorov

How About Team-Based Care AND Experts

Jaan Sidorov

Posted 5/2/12 on the Disease Management Care Blog

Disease Management Care Blog readers may recall this snarky “It’s Team Based Care, Not More Experts” speechifying that challenged aJohn A Hartford Foundation report on the growing need for expert geriatric care.  The Foundation’s Program Director Christopher Langston responded and, rather than let it languish as a bottom-of-the-page-comment, the DMCB thought it warranted its own separate posting. Dr. Langston makes some good points:

The John A. Hartford Foundation has long recognized (here’s an example) that there are only 24 hours in the day and that teams are critical to delivering quality care in a cost-effective way.

So when we reported the results of our recent poll showing that despite the existence of the new Medicare Annual Wellness Visit benefit, older adults still aren’t getting important assessments (like fall risk, mood screening, or medication review) at adequate rates, we weren’t trying to doctor bash or even suggest that MDs should work harder. They just need to be sure that the work gets done by someone.

Continue reading “How About Team-Based Care AND Experts” →

Should Health Insurers Cover Lung Cancer Screening with Low Dose CAT Scans?

Jaan Sidorov

Posted 4/9/12 on the Disease Management Care Blog

Remember this article on screening for lung cancer?

More than 54,000 former and current tobacco users who looked like they were free of cancer were randomly assigned to a yearly cheapo chest x-ray vs. a yearly pricey low-radiation-dose CAT scan. Over 5 to 7 years of follow-up, the CAT scan was better at picking up early lung cancer (119 cases) which translated into a small but statistically significant survival advantage of 62 lives saved per 100,000 patient years.

Does this mean that Medicare, Medicaid and all commercial insurers should “cover” a baseline and yearly follow-up screening CAT scan for tobacco smokers at risk for lung cancer?  According to actuary Bruce Pyenson and colleagues writing in the latest issue of Health Affairs, the answer may be yes.

The Disease Management Care Blog thinks the answer may still be no.

Is it being a heartless curmudgeon?  Read on and decide for yourself…….

Continue reading “Should Health Insurers Cover Lung Cancer Screening with Low Dose CAT Scans?” →

Of Zombies, Emperor’s New Clothes, Documentation Inertia: LIngering Untrue Diagnoses That Persist in the Electronic Health Record

Jaan Sidorov

Posted 4/04/12 on The Disease Management Care Blog

Every practicing physician using an electronic health record (EHR) has seen them.  Past diagnosis zombies that stumble endlessly through every encounter record.  “Coronary heart disease” that the patient never really had, “diabetes” that was only one possibility among many and a “fracture” that never appeared on any x-ray.

These undead conditions clutter the technology-enabled health system basically because of two EHR value propositions:

Continue reading “Of Zombies, Emperor’s New Clothes, Documentation Inertia: LIngering Untrue Diagnoses That Persist in the Electronic Health Record” →

A Thousand Dollars Says Dr. Ezekiel Emanuel Is Wrong About ACO’s Long Term Prospects

Jaan Sidorov

Posted 2/1/12 on the Disease Management Care Blog

Approximately 15 years ago, the Disease Management Care Blog was a speaker at a conference with an audience mostly made up of managed care leaders. It boldly argued the nation’s disease management vendors were going to help put the nation’s health insurers out of business by simultaneously assuming risk and lowering costs.

Hows that for chutzpah. The DMCB was never invited back, but not because it isn’t an outstanding conference speaker who deserves fat fees.

It was because it was utterly wrong.

And so is this online commentary on accountable care organizations (ACOs) courtesy of the The New York Times. In it, Dr. Ezekiel Emanuel boldly predicts that by 2020, ACOs will drive health insurance companies out of business. They’ll do that by assuming full risk, dropping patient barriers to care, coordinating services, fostering communication, promoting health, banning fee-for-service, increasing efficiency, relying on evidence-based care, being locally responsive and competing against other ACOs on cost and quality

Dr Emanuel is being astonishingly overconfident for four reasons.

Continue reading “A Thousand Dollars Says Dr. Ezekiel Emanuel Is Wrong About ACO’s Long Term Prospects” →

More on the Death of Disease Management

Jaan Sidorov

Posted 1/30/12 on The Disease Management Blog

At the email prodding of several colleagues, the Disease Management Care Blog next turns its attention to a blog posting by Archell Georgiou MD provocatively titled “The Death Of Disease Management (Finally!).  The Archelle on Health Blog contrasts the industry’s early promises of evidence-based medicine plus patient self-care with the bitter fruits of non-existent savings, the disappointing Medicare Health Support (MHS) demo and a just-published anti-disease management New England Journal article.

Using that last Journal article as the final word, Dr. Georgiou provides her readers with a graveside eulogy of what went wrong:

Continue reading “More on the Death of Disease Management” →

The Digitization of Health Information: Why Primary Care Is At A Moneyball Moment

Jaan Sidorov

Posted 1/17/11 on Disease Management Care Blog

In a yesterday’s post, the Disease Management Care Blog used Edie Weiner’s video presentation on digitization and commoditization to launch into its own version of health care futurism.  While it struggled with notions of “opportunity costs,” it concluded that a) highly evolved patient data bases, b) biometric monitoring systems, c) artifical intelligence-based decision support and d) growing consumer acceptance of informatics will make the need for many traditional outpatient visits obsolete.

Thanks to inspiration from the movie Moneyball, the DMCB explains why.  The movie chronicles the decision of the Oakland A’s General Manager (or “GM” played by Brad Pitt) to apply a more scientific approach to recruiting players. Eschewing the largely subjective evaluation process used by his veteran scouts, the GM decides to focus on a few key player statistics.  As a result, he recruits players with high “on base” metrics and comparatively low salary demands. Success follows, and not only does he build a championship team, but he is offered a job with the legendary Red Sox. There is a telling scene filmed at Fenway Park in which the Sox owner salutes the new revolutionary approach to baseball by giving a small soliloquy on the merits of adapting or dying. Building a winning team is no longer a highly tailored and subjective approach to individual players, but data, information and insights.

Lesson learned.

Continue reading “The Digitization of Health Information: Why Primary Care Is At A Moneyball Moment” →

Why Medicare Access Is In Jeopardy In Both Salaried and Physician Owned Settings

Jaan Sidorov

Posted 12/21/11 on The Disease Management Care Blog

Don’t underestimate the physician dismay over the looming “Doc Fix” debacle. Unless some budget compromise gets hammered out, Medicare is about to stick it to a lot of docs.

Ever since the passage of the Balanced Budget Act of 1997, Congress has been repeatedly delaying a yearly mandated cut in Medicare’s physician fees. That statutory reduction has been slowly accumulating through no fault of the physician community and is now estimated to be more than 27%.  Assuming most physicians’ practices are made up by a majority of Medicare beneficiaries, that represents a huge hit to their cash flow. KHN has a good summary of the partisan mutual assured destruction that has led us to this crisis here.

Continue reading “Why Medicare Access Is In Jeopardy In Both Salaried and Physician Owned Settings” →

Warfarin, Insulin, Anti-platelet Agents, and Hypoglyemic Medications in the Elderly May Warrant a Population Health Management Program to Reduce Avoidable Hospitalizations

Jaan Sidorov

Posted 11/28/11 on The Disease Management Care Blog

100,000.

That’s how many persons aged 65 years or more are seen in U.S. emergency rooms and then hospitalized every year because of an adverse drug event.

Writing in the New England Journal, Daniel Budnitz and colleagues report data from the “National Electronic Injury Surveillance System – Cooperative Adverse Drug Event Surveillance” (NEISS-CADES) project.  The Disease Management Care Blog never heard of it either, but it’s a consortium of 58 typical U.S. hospitals that are participating in an ongoing observational research project.  Whenever a physician blames a drug for an emergency room (ER) visit, trained chart reviewers go through the medical record.  From 2007 through 2009, there were 12,666 drug-related ER visits in the NEISS-CADES hospitals, which extrapolates to over 265,000 in the U.S.  More than a third required hospitalization, which rounds to approximately 100,000.

Continue reading “Warfarin, Insulin, Anti-platelet Agents, and Hypoglyemic Medications in the Elderly May Warrant a Population Health Management Program to Reduce Avoidable Hospitalizations” →

A Population-Based Care Management Lesson: What Telephonic Disease Management Lacks In Individual Effectiveness Is Made Up By Its Greater Reach

Jaan Sidorov

Posted 11/17/11 on the Disease Management Care Blog

In yesterday’s post on the role of telephonic disease management for obesity, the Disease Management Care Blog pointed out that POWER was a landmark study that demonstrated that remote lifestyle counseling performed as well as traditional face-to-face counseling.

A New England Journal of Medicine editorial accompanying thePOWER article points out that there may have been an additional factor that explained the results: patient attendance at the in-person counseling sessions dropped off precipitously as the trial progressed (an average of only 2 out of 24 scheduled visits after the seventh month), while the telephonic approach achieved 16 out of 18 scheduled contacts.

The DMCB agrees and suggests this is an additional virtue of remote telephonic disease management.  While in-person counseling may have more of an individual impact, it does little good if  patients no-show.  In contrast, “high volume” telephonic counseling may have more of a population-based effect, because a lower intensity intervention has greater absolute impact if it’s delivered to morepersons.

NIH scientist Susan Yanovski’s editorial falls short on capitalizing on that insight.  While it grudgingly points out that POWER shows “PCPs can deliver safe and effective weight-loss interventions in primary care settings,” it neglects to mention the two important implications of POWER:

1) non-physician team members acting in collaboration with PCPs are an important resource in the national battle against obesity and

2) offering a variety of communication channels increases reach and gives more patients new and effective options to access anti-obesity programs.

Finally, a Good EHR Anecdote

Jaan Sidorov

Posted 11/2/11 on the Disease Management Care Blog

The Disease Management Care Blog remembers when it was first introduced to an electronic health record (EHR).  After many days of learning how to document, link, retrieve, order, manage, view, bill, sign-off and close patient encounters, it asked about retrieving summary statistics on its patient population.  It wanted to know how many if its patients with high blood pressure were under control and how many of its patients with heart disease had low cholesterol levels. The practice administrator looked at the DMCB like it was crazy.

Continue reading “Finally, a Good EHR Anecdote” →

An Unbalanced and Harmful Approach to Quality Measurement: Is Life Expectancy Enough?

Jaan Sidorov

Posted 10/12/11 on Disease Management Care Blog

Sei Lee and Louise Walter, in this Commentary published in the Oct 5 issue of JAMA, argue that the current  approach to measuring health care quality often leads to unintended harm for many older adults.  That’s because the guidelines-driven and evidence-based measures are “unbalanced.”

The Disease Management Care Blog agrees that the state-of-the-art is unbalanced, but it’s even worse than Drs. Lee and Walter describe.

First, the Commentary…..

Right now, standard methods for assessing the degree of blood pressure control (typically defined as being less than 140/90) doesn’t account for some elders being prone to getting low blood pressure and dizzy when they’re upright. Blood sugar control is a good idea among most persons with diabetes, but for many reasons, older persons are more prone to having dangerously low dips in their glucose levels.  Last but not least, there’s also the questionable wisdom of screening for cancer when the likelihood of death from other causes is far greater.
Continue reading “An Unbalanced and Harmful Approach to Quality Measurement: Is Life Expectancy Enough?” →

The IOM and the Inconvenient Truth of the Affordable Care Act’s Real Affordability

Jaan Sidorov

Posted 10/10/11 on the Disease Management Care Blog

Enshrining a term only an actuary could love, the Affordable Care Act sets health insurance coverage on the basis of “actuarial value” (AV).  A good summary can be found in this Consumers Union Health Policy Brief.  As the Disease Management Care Blog understands it, AV is the percent of typical medical expenses that a health insurance policy will cover for a typical population.  In other words, some individuals will have no out of pocket expenses (deductibles, coinsurance and limits) while other individuals will have end up paying for most of their services.  When those expenses are rolled up over thousands of persons and compared to total health care costs, the percent left over is the “AV.”

Once the Disease Management Care Blog wrapped its head around the AV, it next tackled the ACA concept of the “essential health benefit” (EHB).  This is the minimum package of covered services (outpatient, emergency room, maternity, hospitalization, medications, rehabilitation and the like) that a health insurer must include in its coverage plan.  This will ultimately be defined in yet-to-be-determined federal regulations.

Continue reading “The IOM and the Inconvenient Truth of the Affordable Care Act’s Real Affordability” →

Predictive Modeling: The Second Most Important Ingredient for Provider Accountability

Jaan Sidorov

First posted 10/04/11 on The Disease Management Care Blog

“Accountability.”  Everyone wants it, right?

While it’s one thing for health care providers to be “accountable” for costs, it’s another for them to actually make money at it.  The Disease Management Care Blog is continuously amazed at how many physicians and administrators believe that dollops of “primary care,” “prevention” and “wellness” will empty hospital beds and cause insurance money to appear like the morning dew on a windshield of a physician specialist’s BMW.

Believe that and the DMCB has an ORD-SFO United Airlines upgrade “departure management card” it would like to sell you.

Continue reading “Predictive Modeling: The Second Most Important Ingredient for Provider Accountability” →

Practical Approaches to Obesity Care and Chronic Illness In Busy Clinical Settings: Three Key Ingredients

Jaan Sidorov

First posted 9/27/11 on the Disease Management Care Blog

If anything is true about the population health management service providers, they are constantly looking for better ways to fit their programs into busy clinical settings.

That’s why this article on New and Emerging Weight Management Strategies for Busy Ambulatory Settings, courtesy of the American Heart Association, should be “must” reading for the vendor industry.  It’s chock full of practical advice on how to “engineer” the PHM-physician partnership. While the focus of the article is on a practical approach to obesity, its approach can be applied to other conditions, such as diabetes or tobacco abuse.

Continue reading “Practical Approaches to Obesity Care and Chronic Illness In Busy Clinical Settings: Three Key Ingredients” →

Nurse Care Managers: The Mortar Holding the Bricks of Medical Homes

Jaan Sidorov

First posted 9/22/11 on the Disease Management Care Blog

It’s no secret that the Disease Management Care Blog is an enthusiastic believer in nurse care managers. In its humble opinion, it makes no difference what “bricks” are used to build a Patient Centered Medical Home, an Accountable Care Organization, a Population Health Management Program or an employer-based care support/wellness initiative, the nurses are the mortar.

Continue reading “Nurse Care Managers: The Mortar Holding the Bricks of Medical Homes” →