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Archive for December, 2008

Telephonic Disease Management for Severe Mental Illness

by jsidorov

We can telephonically engage/coach/monitor and help persons with diabetes, asthma, heart failure, COPD, coronary artery disease – but how about serious persistent mental illness? Check out this interesting paper published in the latest issue of the American Journal of Managed Care by Paul F. Cook, Suzie Emiliozzi, Corey Waters and Dana El Hajj of the University of Colorado, ScriptAssist and Centene Corporation (the latter two entities paid for the study).

This was a study involving outpatient Medicaid beneficiaries who were taking anti-psychotic medications for more than 30 days. 210 candidates were identified for nurse-based telephony, but only 59 (28%) could be reached on the phone. Of these, 8 declined to participate, leaving 51 intervention patients. The remaining 151 formed a comparison group. The results that caught my eye were that intervention patients visited ERs an average of about 1 time per year, versus 5 in the comparison group. While the comparison group initially had higher pharmacy compliance rates in the first month, by 6 months is was clear that the intervention group was doing much better at taking their anti-psychotic medications at 48% vs. 26%.

This was far from a perfect study. The intervention and control groups are probably not comparable, since patients who can be reached by telephone and agree to participate are probably more compliant in general and are more likely to avoid ERs and take their medicines as prescribed. That’s called selection bias. There was also insufficient detail about the protocols used by the nurses to help the patients.

Think of this as a pilot study. That being said:

Among a population of severely mentally ill outpatients who are notorious for not taking their antipsychotic medications, we’ve learned that it’s possible to reach a quarter of them by telephone and engage them in regular follow-up. This may reduce ER use and it may increase medication compliance. This is worth more study.

There were other lessons learned from this paper. The authors pointed out that there was a delay between the time patients got their qualifying medications and the telephony was initiated. Another was the use of a masked “unknown” caller ID when patients were called (to protect confidentiality), which in turn prompted patients to not pick-up.

Despite all the limitations, I like this study because it’s disease management outside the usual big 5 of asthma, diabetes, heart failure, COPD and coronary artery disease. It uses a well known approach to a population that is very difficult to manage with high levels of avoidable utilization and complications. It was performed in a community setting with high generalizability and had the wherewithal to not only implement a program but simultaneously study the impact at the same time.

It is common in research settings to conclude manuscripts like this with the adage that more research is necessary. The authors of this little gem did that also. However, I’d go one step further and suggest (unless there are better ideas out there) that telephonic follow-up/coaching of persons with mental illness who are on antipsychotics be expanded and that more research be performed to better assess what works and what doesn’t.

More blogging from WHITC . . .

by World Health Care Blog

The below post, wrapping up Day 3 of the 4th Annual World Healthcare Innovation and Technology Congress, is from Tim Edwards, manager of physician relations at University of Texas MD Anderson Cancer Center. His blog is “Misunderestimation”

World Healthcare Innovation and Technology Congress Day 3 Wrap-up and Summary
The final day of the World Healthcare Innovation and Technology Congress began with a bag, Scott McNealy from Sun discussing how Open Source works for healthcare. McNealy’s presentation was incredibly entertaining; equal parts insightful information and stand-up comedy. Here is a sampling of quotes from McNealy:

We must go digital. Just look doctors handwriting and you’ll see, we must go digital.
Open Source is a very old concept that we’ve been doing since 1982. If I can go a little Al Gore here, we invented Open Source.
Public key encryption schemes are the best option. If you have a secret in your code, it will be discovered and breached. Humans cannot keep a secret. What if the Trojan horse was made of glass? Would they have let it in?
When I hear “enterprise license agreement,” I think, “The first hit of heroin is free.”
Technology has the shelf life of a banana; it will be outdated before you can roll it out.
McNealy’s message centered around the very real impact Open Source is having on the market and how that success can be brought to healthcare. Sun has spent $26 Billion on research and development and is currently involved in the creation of the Nationwide Health Information Network (NHIN).

Open Source has tremendous advantages including avoiding “format rot” in archiving information. What happens 20 years from now when someone needs to open a document created in a proprietary tool like MS Word? Or better yet, how does one render a document created in the Wang system? With Open Source you can bundle the files with the rendering agent.

In a nutshell, McNealy says there are 7 reasons to be open

Lower barriers to entry
Increased security
Faster procurement
Lower cost
Better quality code
Open standards last longer
Lower barriers to exit
As a recovering developer, his comments on better code peaked my curiosity. Basically, developers are very protective of their reputations and releasing code into an open environment for the scrutiny of other codes ensures the code is top-notch. Open Source code tends to be written cleaner and documented thoroughly; coders are opening their robes and exposing themselves to the world. They want to look good.

My favorite comments dealt with the privacy question and how it works the same in the Open Source world. First, “Somebody a long time ago someone said you don’t have privacy, get over it. Oh wait, that was me.” And the second quote, dealt with what is perceived now as a secure delivery system, the US Post Office. “You take an 8 x 11 piece of paper, stuff it in a folded paper envelope, seal it with spit, write unblinded information in the outside in the to and from areas, give it to the Federal Government for a couple of days, stick it into a tin box, all with the hopes that it will get there.” Yet somehow we worry about the level of encryption used on networks or go so far as to print everything and take them out of the secure networks to set them on a desk.

In closing, McNealy had one more comment on healthcare that resonated around the room, “There is only one industry more screwed-up than computers and that’s healthcare. You kill everyone eventually, I know you are working on it.”

I found more in that 30 minutes of Scott McNealy then I’ve found in entire conferences. I’m very appreciative of him and his taking the time to speak with us.

Next up, was a presentation on Direct Practice Medicine by Scott Shreeve and Jordan Schlain, two physicians who are delivering healthcare differently. Their belief is it’s not always about the throughput, it’s not always about speed, it’s about relationships. The business model involves seeing considerably less patients to avoid the “hamster wheel” syndrome of running faster and faster but not getting anywhere. Their patients subscribe to their clinic and have 24/7 access to physicians who actually know them and spend time getting to really know them. To pay for the services, subscribers increase decidable in their health insurance and use the money saved to pay the monthly access fee.

What I found intriguing was the level of detail in the understanding of the patient and access to care provided with their model. I’m not a physician, but I suspect most physicians enter practice to get to know and improve the lives of their patients. Somewhere along the line we have deviated into short episodes of disparate care that may be causing more harm then good. Having said that, I wonder what happens to patients who need care beyond what is being delivered in this manner, but I do like the concept. I’m going to watch the continued expansion of this model in the future and you can go to currenthealth.md to learn more.

Unfortunately, after this session, I had to be off to the airport and a return to the real world. However, on the way back, I take a couple of learning with me from the congress

Healthcare is in the midst of a fundamental transformation that is being driven by customers, globalization, economic factors, and an unprecedented influx of technology
Social networking on online communication have a central place in healthcare, both in the delivery of care and the support of the care process not to mention uniting the growing army of reformers who are finding support and ideas in the community.
We still have a long way to go.
I want to thank the organizers of the congress for their hard work in putting together an event that was both informative and entertaining. One suggestion, in the future, you audience members are very tech savvy. Give them tables and outlets so they can document and report on the event, look-up resources being discussed, and possibly participate in events online. Beyond that suggestion, I look forward to next year’s conference.

Health Alert | Memories

by John Goodman

Dr. John Goodman is the president of the National Center for Policy Analysis

At the National Journal Health Blog, Marilyn Serafini asked, “How much does health reform really cost, what elements are worth it, and what are the best and worst options for paying for it?” She invites bloggers to compare the current situation with the passage of Medicare and Medicaid in 1965. [link] Here is part of my response:

Here are five lessons from the Medicare and Medicaid experience:

The cost of Medicare and Medicaid was way beyond what anyone predicted. The reason: failure to realize that when any good or service becomes free, people will consume more of it.
Once started, these programs are extremely hard to curtail. If we ended Medicare today - collecting no more taxes and allowing no more accrual of benefits - we would still owe $33 trillion in benefits already earned! (Results of new NCPA study.)
Looking indefinitely into the future, the Trustees have calculated there is an unfunded liability (promises made over and above expected premiums and dedicated taxes) of $85 trillion - almost six times the size of the entire economy.
According to Amy Finkelstein, although Medicare was financially important to the elderly, it created no discernable health benefits in terms of reduced mortality. [link]
Despite no measurable health benefits, the explosion of spending on these two programs forced up prices for everyone else. In fact, HHS’ own internal estimates suggest that every $1 of additional spending buys 57¢ of higher prices.

“Memories Are Made of This”

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Bloggers report from WHIT

by World Health Care Blog

Tim Edwards, manager of physician relations at University of Texas MD Anderson Cancer Center, has posted a couple of nice entrires on his blog: “Misunderestimation: Life in the 21st Century” on WHIT. Read here for the Day 1 summary and here for Day 2.

WHIT 4.0 Twitter Feed

by World Health Care Blog

We had a quite a few WHIT attendees posting their thoughts on Twitter these past three days. Click here to view the feed and type in #WHITC08.

WHIT 4.0 - Day 2 Begins!

by World Health Care Blog

The first day of the 4th Annual World Healthcare Innovation and Technology Congress is in the books. Yesterday’s packed presentations included a facsinating address by Newt Gingrich, founder of the Center for Health Transformation and former Speaker of the U.S. House of Representatives. Mr. Gingrich engaged the audience with his vision for a transformed health system that dramatically reduces fraud while engaging patients and providers. As a staunch conservative, the former House Speaker favors plans that minizmine government involvement and allow the best solutions to come from the best innovators in the market.

The World Horld Health Care Innovation and Technology Congress begins!

by World Health Care Blog

The 4th Annual World Healthcare Innovation and Technology Congress (WHIT 4.0) begins Monday, December 8 in Washington D.C. We will have an impressive line up of presenters this year. Scott McNealy, chairman of Sun Microsystems, Colin Angle, CEO of iRobot, Dr. Jeong Kim, president of Bell Labs and Newt Gingrich, founder of the Center for Health Transfromation are just a few. Please check back for posts from our speakers and attendees. The conference runs through Wednesday.


Health Alert | Limited Benefit Insurance: It’s Becoming Respectable

by John Goodman

Dr. John Goodman is president and founder of the National Center for Policy Analysis.

I have become increasingly intrigued by limited benefit insurance (covering primary care, but not hospitalization), even though it does the opposite of what most health policy wonks think insurance should do. See my previous posts here, here and here.

Blue Cross now offers a discount card to Florida residents. Its Web site lists likely savings on procedures. Blue Cross also has a limited benefit insurance plan, as does Aetna - which primarily markets it to employers with part-time and seasonal workers.

Pro Medical Plan, another insurer, charges $52 per month (individuals) and $130 (families). In return, people get “primary-care doctor visits for $10 and cheap basic lab tests at a variety of locations in Miami-Dade and Broward, plus a discount card for such things as specialists, pharmacy and vision.” [link]

What I like is that these products solve two big problems that are not solved, say, by Medicaid or SCHIP: (1) They offer access to primary care other than at public health clinics and emergency rooms and (2) they introduce price competition (and, therefore inevitably quality competition) into the primary care marketplace.

FYI | Doctors Online

by John Goodman

Dr. John Goodman is president and founder of the National Center for Policy Analysis.

It’s amazing what the free market can do:

Patients will no longer have to wait a month to see a doctor for an urgent sore throat, wait all day for a doctor to return their call or leave work midday and drive a long distance for a routine appointment. Instead, patients will log on to their computers and find themselves face-to-face with physicians over Webcam.

They also have electronic medical records and malpractice insurance. Medicare patients need not apply.

Full story here. NCPA summary here.

Health Alert | Daschle

by John Goodman

(John C. Goodman, Ph.D., Dr. John Goodman is president and founder of the National Center for Policy Analysis. Known as the “Father of Health Savings Accounts,” Dr. Goodman is the author of nine books; his book Patient Power is credited with setting a pro-free-market agenda for solving health care problems. He also has authored numerous editorials in The Wall Street Journal, USA Today, and many other newspapers and appears regularly on television, including Fox News, ABC, NBC, CBS, CNN, and CNBC. Dr. Goodman regularly briefs members of Congress on economic policy issues.)

With Tom Daschle slated to become the next HHS Secretary, there has been a mad rush to get a copy of his book, Critical: What We Can Do About the Health Care Crisis, which apparently no one had previously read. Since booksellers can’t possibly meet the demand, here is my brief attempt to satisfy your curiosity.

The main ideas: Medicaid expansion, Federal Employee Health Benefits Program (FEHBP) for everyone who wants to enroll, Medicare for the nonelderly as a FEHBP option, a play-or-pay mandate for individuals, income-based, refundable tax credit subsidies (both at work and away from work), a play-or-pay mandate for employers, electronic medical records, a national health board (”to establish a single standard of care for every other provider and payer”…covering every disease from cancer to diabetes and even depression), preventive care, dental health, mental health, long-term care, home care, community health centers and combating obesity.

Not on the list: Health Savings Accounts, although Daschle was once an advocate, and even cosponsored HSA legislation.

Not on the list: Single-payer health insurance, but only because it is not politically practical.

Not on the list: Any way to pay for any of this. (The issue is not, can we afford reform? The issue is, can we afford not to?) I’m not kidding.

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