Comments on: One More Dark Cloud in the Stormy Skies of Medicare DM http://e-CareManagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/ Chronic Disease Management • Technology • Strategy • Issues and Trends Tue, 27 Jul 2010 09:53:43 -0600 http://wordpress.org/?v=2.9.2 hourly 1 By: Warren Todd http://e-CareManagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/comment-page-1/#comment-48 Warren Todd Thu, 12 Apr 2007 19:57:36 +0000 http://e-caremanagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/#comment-48 Many thanks to Vince for summarizing and "translating" the 230 page report [ugh]..and making sure that we do not mix up all the demonstration projects. While the US market has been dominated by the original call-center centric model of DM, we do have some information on other models, not a lot,and it is somewhat mixed. Including early reports on the recent Medicare Health Support pilots. I must admit I am begining to be concerned that we have no clear cut solution in hand as a tsunami of elderly threatens to overwhelm our healthcare systems. A colleague and I recently wrote a brief commentary on the interesting prospect of more physician-centric models of DM and projected that we will likely hear more about them as the physician community starts to get there arms around going "back to the future" in terms of their role in care coordination. See [http://healthleadersmedia.com/viewfeature/88615.html] for the article. I also agree with Randy Williams;s comment about the promise of other more technology driven DM programs. As posted earlier, during this phase of DM we need to work harder at exploring different models of DM. Again, it is a bit discouraging that a host of Medicare demonstration projects are not turning up the silver bullet. Commenting of Dr. Wilson's posting, my only concern back in the early days of the pilots was whether Mathematica knew enough about disease management to be evaluating the pilots. This is out of my league but I am glad that more knowledgeable people like Tom have their eyes on the details of the outcomes analysis and I hope that Mathematica will tap into these industry resources. Many thanks to Vince for summarizing and “translating” the 230 page report [ugh]..and making sure that we do not mix up all the demonstration projects.
While the US market has been dominated by the original call-center centric model of DM, we do have some information on other models, not a lot,and it is somewhat mixed. Including early reports on the recent Medicare Health Support pilots. I must admit I am begining to be concerned that we have no clear cut solution in hand as a tsunami of elderly threatens to overwhelm our healthcare systems. A colleague and I recently wrote a brief commentary on the interesting prospect of more physician-centric models of DM and projected that we will likely hear more about them as the physician community starts to get there arms around going “back to the future” in terms of their role in care coordination. See [http://healthleadersmedia.com/viewfeature/88615.html] for the article. I also agree with Randy Williams;s comment about the promise of other more technology driven DM programs. As posted earlier, during this phase of DM we need to work harder at exploring different models of DM. Again, it is a bit discouraging that a host of Medicare demonstration projects are not turning up the silver bullet.

Commenting of Dr. Wilson’s posting, my only concern back in the early days of the pilots was whether Mathematica knew enough about disease management to be evaluating the pilots. This is out of my league but I am glad that more knowledgeable people like Tom have their eyes on the details of the outcomes analysis and I hope that Mathematica will tap into these industry resources.

]]> By: Randy Williams http://e-CareManagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/comment-page-1/#comment-46 Randy Williams Tue, 10 Apr 2007 12:39:08 +0000 http://e-caremanagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/#comment-46 While I agree with the concern that of the 15 different models and designs of care coordination, only one showed statistically significant improvements in hospitalization rates vs. control, I alsoo have first hand knowledge of the one program that DID reduce hospitalizations. By way of disclosure, that program, Mercy of Iowa, is a client of Pharos, and utilized a daily remote monitoring technology we vend called Tel-Assurance. While the Mercy program is relatively labor intensive and involves a number of other care coordination elements, we are currently undertaking an evaluation of the treatment effect seen, to determine what role our intervention played. This is not the only CMS demonstration looking at our model and technology intervention. Early results from 2 of the 10 Physician Group Practice demonstrations are showing similar positive results on averting hospitalizations. While still preliminary, perhaps there is an important difference between models and technologies which will deserve further understanding. While I agree with the concern that of the 15 different models and designs of care coordination, only one showed statistically significant improvements in hospitalization rates vs. control, I alsoo have first hand knowledge of the one program that DID reduce hospitalizations. By way of disclosure, that program, Mercy of Iowa, is a client of Pharos, and utilized a daily remote monitoring technology we vend called Tel-Assurance. While the Mercy program is relatively labor intensive and involves a number of other care coordination elements, we are currently undertaking an evaluation of the treatment effect seen, to determine what role our intervention played. This is not the only CMS demonstration looking at our model and technology intervention. Early results from 2 of the 10 Physician Group Practice demonstrations are showing similar positive results on averting hospitalizations. While still preliminary, perhaps there is an important difference between models and technologies which will deserve further understanding.

]]> By: Thomas Wilson, PhD, DrPH http://e-CareManagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/comment-page-1/#comment-44 Thomas Wilson, PhD, DrPH Tue, 10 Apr 2007 00:45:18 +0000 http://e-caremanagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/#comment-44 <p>So Mathematica can not reject the null hypothesis at this point. But in the future it is possible they may be able to do so. Or in the words of Blogger Vince: "It's possible that the person sitting next to you could spontaneously combust in the next ten seconds." But, does anyone really believe in spontaneous human combustion? For the record, I refuse to answer that question on the grounds of self-incineration.</p> <p>But Mathematica could have / should have done the DM world a great service by showing how the average Medicare expenditures and admission rates changed from pre-DM intervention to post-DM intervention in both the treatment and control groups. They could have / should have helped us answer the question: "Are the results of the commonly used pre-post design in DM consistent with the results of the RCT?"</p> <p>I did a "quick and dirty" comparison of Table VIII.7 data (pre-enrollment characteristics) to Table V1.2 date (cumulative through month 25). It appears that a majority of the sites both treatment and control do show a decline in costs and/or admission rates from pre to post (not all do show the drop, so this does not appear to be an immutable law or regression-to-the-mean). But the latter table was regression adjusted and the former was not. So, it was not apples-to-apples: How can we encourage Mathematica to do formal and rigorous review of this comparison? And when? ... I'm burnin' up.</p> So Mathematica can not reject the null hypothesis at this point. But in the future it is possible they may be able to do so. Or in the words of Blogger Vince: “It’s possible that the person sitting next to you could spontaneously combust in the next ten seconds.” But, does anyone really believe in spontaneous human combustion? For the record, I refuse to answer that question on the grounds of self-incineration.

But Mathematica could have / should have done the DM world a great service by showing how the average Medicare expenditures and admission rates changed from pre-DM intervention to post-DM intervention in both the treatment and control groups. They could have / should have helped us answer the question: “Are the results of the commonly used pre-post design in DM consistent with the results of the RCT?”

I did a “quick and dirty” comparison of Table VIII.7 data (pre-enrollment characteristics) to Table V1.2 date (cumulative through month 25). It appears that a majority of the sites both treatment and control do show a decline in costs and/or admission rates from pre to post (not all do show the drop, so this does not appear to be an immutable law or regression-to-the-mean). But the latter table was regression adjusted and the former was not. So, it was not apples-to-apples: How can we encourage Mathematica to do formal and rigorous review of this comparison? And when? … I’m burnin’ up.

]]> By: Ariel Linden, DrPH, MS http://e-CareManagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/comment-page-1/#comment-38 Ariel Linden, DrPH, MS Fri, 06 Apr 2007 20:55:17 +0000 http://e-caremanagement.com/one-more-dark-cloud-in-the-stormy-skies-of-medicare-dm/#comment-38 These results are not terribly surprising. Given that this a randomized controlled trial, we can't really argue about the research design. My main points are these: 1) The hospitalization rates were not better in the treatment groups than in the control groups - and thus costs... (2) There was no indication that treatment group participants had any behavioral change. If we expect to see reduced hospitalizations, we have to see the intervention change behaviors. (3) As for the dose/response, it could be that longer time will move the non-significant levels to significant, however without demonstrating a meaningful intervention, I doubt we'll see that... These results are not terribly surprising. Given that this a randomized controlled trial, we can’t really argue about the research design.

My main points are these:

1) The hospitalization rates were not better in the treatment groups
than in the control groups – and thus costs…

(2) There was no indication that treatment group participants had any
behavioral change. If we expect to see reduced hospitalizations, we
have to see the intervention change behaviors.

(3) As for the dose/response, it could be that longer time will move
the non-significant levels to significant, however without
demonstrating a meaningful intervention, I doubt we’ll see that…

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