Who was involved
Here in St. Louis, only one hospital was involved–St. John’s Mercy. St. John’s was busy building the first heart-only hospital in the state, at the same time that it was awarded one of the 7 MHS positions. Why would a hospital work hard to keep patients out of its new subspecialty profit center?

How they behaved
Sandy Foote, the Director of MHS, was present with Sean Tunis, the former Medical Director of CMS, when I told them how to save 90% of their dialysis and transplantation budget in October, 2004 (1). At the time, this represented some $22 billion. The amount is several billion dollars more now. Neither one had any interest whatsoever in eliminating the dialysis program.

None of the participants in MHS had any interest in reversing kidney failure, when I contacted each of them individually.

My conclusions:

1. MHS was designed to fail. If DM can be shown not to work, then we’ll all just have to be satisfied with our expensive hospital-based system, secure in the knowledge that there’s nothing better we can do.

2. Bureaucrats cannot be trusted to lower healthcare costs and improve outcomes. Neither can First Generation DM companies.

3. Eventually, thanks to the Internet, word will get out that dialysis could have been prevented back in 2002. Those involved in keeping the secret might have a little explaining to do.

Gordon has a great point on the double standard applied to conventional medical care vs. care coordination services.

The issue I have with the current assessment on MHS pilot is…the attention has not been paid enough on what exactly each patient is getting from this pilot and what outcome (clinical, quality of life) that delivered or did not deliver to the patient. As Gordon mentioned, the secret must be hidden in the rich clinical and patient satisfaction data, and I hope we examine it thoroughly before we jump onto the next untested paradigm.

Secondly, even the very preliminary results from the initial RTI report highlight that the original premise of testing “Does DM have ROI?” was overly simplistic, if not fatally flawed from the outset. Just as the questions, “Does surgery have ROI?” or “Does medication have ROI?” seem ridiculous on their face, the important questions we should be addressing now are more complex – e.g., “What outcomes (clinical, financial, mortality, quality of life, functional) are impacted, for which patient subpopulations, over what time frame, by which care management interventions, delivered in what fashion, with what roles for each component in the healthcare value chain, etc.?” Care and disease management are complex processes, with many data gathering and intervention components and integration across multiple sites and among multiple parties. Attempting to evaluating effectiveness at such a high level of abstraction may be misleading, at best, or worse, lead us to throw out the baby with the bathwater.

It is interesting to note that in deciding on approving new medical services for Medicare coverage, CMS is not permitted any consideration of cost-effectiveness; also, the FDA approves new drugs on the basis of safety and clinical effectiveness, not on cost-effectiveness. Yet in the case of care management interventions, it would appear that the primary outcomes of greatest interest to Medicare are the cost-savings. Even MedPAC has noted this constitutes something of a double standard applied to conventional medical care vs. care coordination services. MHS pilots are gathering rich clinical and participant satisfaction data that are critical for assessing the value provided by these programs.

Yes, as Vince/Tom state, “high risk, chronic, comorbid patients are a challenging population”; if they were not, the current system of care would be doing an adequate job with this task and we would not have such a desperate need to find new solutions and alternative approaches, such as those represented by these MHS pilots. There is already widespread belief in the value of DM services for senior populations in the Medicare Advantage realm, where these programs are prevalent and in many cases, long-standing, based on measured outcomes outside of experimental settings. It should be the job of CMS, its contractors, and others to ferret out the valuable insights from the rich dataset provided by MHS for learning purposes, regardless of what other judgment uses it will provide for contractual reconciliation of these pilot projects. After all, isn’t that the usual purpose for which pilot projects are undertaken? To discover unanticipated issues, learn of early successes, adapt and refine and then iteratively retest new approaches based on the pilot learnings?

MHS outcomes analysis is still in its infancy, there are many questions yet to be answered, and premature summary judgments based on overly simplistic premises may preclude us from thoroughly extracting the rich learnings that should inform the healthcare and care management communities. The bathwater may be murky at this point, to be sure, but let’s not throw it out before we even know whether one or more babies are lurking beneath the surface. The potential to use learnings from Phase I of MHS to refine the approaches used for a broader Phase II implementation is not just the icing on the cake – it is the cake!

Thanks to Vince and Tom for pointing out these important points. While their Apollo 13 analogy may be apropos in some regards, the MHS situation could also evolve to one more suggestive of Apollo 11, where taking the “one small step” of devoting as much attention to the learning potential of MHS as for judgment purposes could result in “one giant leap for mankind” as represented by FFS Medicare beneficiaries and the global healthcare community who urgently need to find better ways of providing care coordination and disease management. “Houston” may be able to lead the way, but not with the mindset that got them this far along the MHS journey.

I also wonder if the study cohorts were relatively medically underserved. I’m not familiar with the average Medicare PBPM, but if true, MHS may have prompted increased utilization compared to baseline. This contrasts with typical commercially insured populations, which are prone to relative ‘over” utilization. This has implications for the generalizability of MHS to all sectors of the DM industry.

I could not agree more with the even broader dimension of generalizability raised in “5) Implications/Discussion” above: MHS may be already testing an outmoded version of DM. As you note, the industry is destined to change, and many of the adjustments you identify are already happening. Many of these changes will be on display at the upcoming DMAA DMLF meeting this month in Las Vegas.

Can one achieve measureable improvement in a population that has taken six+ decades to get where they are? Does Disease Management in Medicare
populations change (and improve) outcomes, or are we simply delaying
the inevitable based on what the patient did in the preceding decades?

Are the incentives in these programs aligned properly? I’m not convinced the Advanced Medical Home project will do any better, as physicians are not trained / do not have the patience to
act as care managers.

Perhaps others can comment on the value of these federally-funded chronic care projects. As a taxpayer, I’d like to know my money is being spent wisely.