Vacation

I'll be out of town until the beginning of November, so I won't be responding to comments or e-mails for a while. I'm going to set up a post or two to publish while I'm gone.

As an administrative note, I get a number of e-mails from blog readers each day. I apologize that I can't respond to all of them, as it would require more time than I currently have to spare. The more concise your message, the more likely I'll read it and respond. Thanks for your understanding.

Quick Impressions From the Forum10 Care Continuum Alliance Meeting

The Disease Management Care Blog's web traffic is noticeably down and it knows why: many readers are preoccupied with the goings-on at the Forum10 annual meeting of the Care Continuum Alliance (formerly known as the DMAA). So, by the way, is the DMCB, which arrived today and has been catching up with old colleagues and making new acquaintances.

Three quick impressions:

Compared to previous years, the disease management vendor exhibit booths seem larger and more garish. This suggests that the industry is feeling more confident about their future. What's more, there seems to be a wider array of exhibitors with wares in informatics, wellness, prevention and pharmacy, with a special emphasis on interacting with consumers through their cell phones. More on this in a future post.

The DMCB also got the impression that the core disease management companies are being sought out by other entities that are seeking a variety of relationships, partnerships and alliances. Two examples were in the area of Accountable Care Organizations (ACOs) and telecommunications (see above).

Last but not least, this is a crowd with a high level of enthusiasm. Thanks to a combination of cash from the Federal health reform legislation and a reemergence of disease management, a.k.a care management a.k.a population health management as a key ingredient in increasing quality and lowering costs, everyone seems enthused.

The Forum10 continues for another two days and the DMCB will be keeping notes for future postings. If you recognize the DMCB, please say hello. The first person to do so will be rewarded with an increasingly rare "DMAA" lapel pin.

What Can Baseball Teach Us About the Return on Investment (ROI) of Disease Management? Nothing, Actually.

Growing up in New York City and then living outside of Philadelphia, you’d think that the Disease Management Care Blog would have a better appreciation for major league baseball. It likes the stadium spectacle (and food), but league standings, box scores, individual player statistics and television game play is as soporific to the DMCB as looking at the aortic valve “Mercedes Benz” sign on an echocardiogram. Try as it might DMCB cannot understand what gets baseball fans and cardiologists so atwitter.

Maybe it's because the DMCB thinks because baseball is so linear. The entire game consists of a series of singular events involving individual players surrounding one ball occurring over the time dimension of nine innings. Sure, there are other moving parts, enormous talent and high drama and but the game has a compelling degree of compact simplicity.

To each their own, says the DMCB, which is one reason why it tried to compact the moving parts, talent and financial drama of disease management (DM) into a (curvi)linear display. This is an admittedly very simplistic and not-drawn-to-scale graph of what financially happens to the return on investment in an ideally executed one-year DM contract:

The black line represents the typical accumulated savings of a well run disease management program over time. Thanks to the use of health risk assessments and predictive modeling, the patients that initially get recruited in the program are those that are a) most vulnerable and b) most amenable to care management coaching and outreach. They’re “rescued” from unnecessarily visiting emergency rooms and being unnecessarily admitted to the hospital. Note that savings grow rapidly. With time, additional patients at lower risk are recruited, but since they’re at less risk, the savings curve begins to flatten out. As more patients get recruited, it’s possible that savings can erode, because the low risk/low utilizing patients can ironically be prompted to seek out additional care services.

The red line represents the cost of the disease management program over time. Initially, there are steep and fixed start-up costs which then slow down over time but never flatten. As additional patients get recruited, more personnel and infrastructure are required for coaching and follow-up. If the program pursues each and every additional patient with multiple attempts at outreach, costs can accelerate.

The small yellow area displays when the savings exceed the cost. That means the "return on investment" (ROI) is positive. That doesn’t happen early in the program and it doesn’t happen late: it's in the middle. Early and late in the program, there are losses. Also note that the ROI is a moving target that changes that as more patients get recruited. This also explains why a positive ROI can be achieved when far less than 100% of patients are engaged in DM.

Of course, this is very rudimentary and doesn't take into account the moving parts of the baseline utilization patterns, the enormous talent of the nurse-coaches and the high drama of how costs and savings are actually calculated.

Every baseball game is arguably unique, but DM is far more complicated. It's sort of like baseball, but all the players have bats, there are 100 balls, pucks and Frisbees in play and the bases move as the game goes on. That's one of the reasons it's so much fun.

Sleep Post Correction

An astute commenter pointed out that I misread the numbers in the paper on sleep and fat loss. I wrote that out of the total 3.0 kg lost, the high-sleep group lost 2.4 kg as fat, and the low-sleep group lost 1.4 kg of fat out of 2.9 kg total.

In fact, the high-sleep group lost 1.4 out of 2.9 kg as fat, and the low-sleep group lost 0.6 out of 3.0 kg as fat. So I got the numbers all mixed up. Sorry for the mistake. The main point of the post still stands though: sleep deprivation negatively influences body composition.

The correct numbers are even more interesting than the ones I made up. Even in the high-sleep group, nearly half the body weight lost by simple calorie restriction was lean mass. That doesn't make calorie restriction look very good!

In the sleep-deprived group, 80% of the weight lost by calorie restriction came out of lean mass. Ouch!

That illustrates one of the reasons why I'm skeptical of simple calorie restriction as a means of fat loss. When the body "wants" to be fat, it will sacrifice lean mass to preserve fat tissue. For example, the genetically obese Zucker rat cannot be starved thin. If you try to put it on a severe calorie-restricted diet, it will literally die fat because it will cannibalize its own lean mass (muscle, heart, brain, etc.) to spare the fat. That's an extreme example, but it illustrates the point.

The key is not only to balance energy intake with expenditure (which the brain does automatically when it's working correctly), but to allocate energy appropriately to lean and fat mass.

The Playbook Used by the Food & Beverage Industry to Avoid All Blame for the Obesity Epidemic, and What Disease Management Can Do

The Disease Management Care Blog thinks that the disease, care and population health management providers deserve a lot of credit for leading the way in our national battle against obesity. This industry "gets it." It's more than just "consumer education" and go-see-your-PCP about starting a diet. While those elements are certainly necessary, disease management also knows about consumerism, engagement, overcoming barriers, behavioral theory, relationships, life-style management, being realistic and follow-through. These vendors are getting far more savvy about studying outcomes and using those data to continuously improve. They are participating in coalitions, joining public health initiatives, off-loading overburdened physicians, establishing partnerships, leveraging community resources, and formulating a compelling business case. They can do all that and still end the day with a tidy profit.

The DMCB also figures the disease management (DM) industry is also well aware of the cynical speciousness of the food and beverage industry's public posture about obesity. At the same time it's intentionally packing calories and salt into servings are both unhealthy and excessive, the food and beverage manufacturers have somehow escaped being lumped with tobacco and pharma. Something is terribly wrong with this picture.

That's the topic of an October 6 JAMA paper by Jeffrey Koplan and Kelly Brownell aptly titled "Response of the Food and Beverage Industry to the Obesity Threat." It's worthwhile reading for those combating the obesity epidemic. It gives special insight on how that industry combats greater scrutiny and regulation as well as why overweight patients desiring to lose weight can be so misinformed. This is important to know about so that patients can be better educated, know what they're up against, overcome barriers and better manage life-style choices.

Drs. Koplan and Brownell's report on the food industry's strategy is summarized below for DMCB readers that may not have full access or lots of time:

Associate with a widely respected health organizations: this gives the casual observer that the industry's wares are good for you.

As the DM industry's role in the crusade against obesity grows, it should probably resist any affiliation with the businesses that profit from making people fat.

Associate with a widely respected connotation: this generates the impression of wholesomeness. The authors mention featuring svelte exercisers on the packaging and in TV commercials, but the DMCB thinks claims of being "green" are also part of the mix.

Ironically, a disease management care plan with overemphasis on exercise as a cure for obesity is playing right into the food and beverage industry's hands. That has a role to play, but the key thing remains smart food choices and long term calorie restriction.

Reframe the issues: instead of addressing the merits of caloric excess, the idea here is to move the focus onto caloric neutrality (a serving of broccoli can be equal to a side order of fries), "in versus out" caloric balance (hence the intrusion of exercise as a fix for being fat; think about that the next time you watch Biggest Loser), keeping collateral societal costs out of the discussion ("even though half of all obesity related costs are paid for with public funds") and trumping free markets (we have a constitutional right to be fooled into making bad decisions).

At the individual patient level, part of the strategy of coaching is to help patients keep their eye on the caloric ball. Thanks to its growing visibility at various policy-making levels, the DM industry should continue to step up and shine a light on those collateral costs and take a greater leadership role in figuring out ways to help people make right decisions. Kudos, by the way, to the Care Continuum Alliance for doing its part.

Deceptive advocacy: this is setting up faux grass roots groups that are allegedly against regulation and taxation.

Hey, it's free speech. The DM industry needs to fight fire with fire.

Deceptive science: consisting of sponsoring biased studies and creating hollow self-regulating standards based on those biased studies.

The DM's industry's long tradition of tapping into vetted guidelines has been an important counterweight in its care for millions of Americans. It needs to stick to that tradition and educate policymakers and politicians about what works - and what doesn't.

Product formulation: it may still be the same air-filled puffs of fructose and fat, but add some vitamins or fiber and "voila!" the overwhelming impression is that it's now good for you.

In its day to day interactions, this and other attempts at caloric camouflage need to be countered one patient at a time. It may be that no patient coaching is complete without addressing that particular falsehood.

Go on the attack: it's not enough to deny any harm. Rather, get a stable of loyal talking-head scientists, lobby heavily, fight every unfriendly public health measure and label opponents as enemies.

The DMCB is looking forward to the day when a member of the DM industry is attacked by the food and beverage industry or one of its lackeys. They we'll know we're getting somewhere.

Health Care Rationing and the Role of Physicians In Its Design

Writing in the October 6 issue of JAMA, RAND physician-scientist Robert Brook ponders how physicians will react to the certainty that current efforts at bending the cost curve will fail and "sooner or later, health care will need to be explicitly rationed." Examples of more local explicit rationing include Oregon Medicaid’s experiment with selective coverage and the use of tiered economic incentives by pharmacy benefit plans.

According to Dr. Brooke, all that remains is a decision on whether the national plan to ration will be led or not be led by physicians. After all, they’re not only generally knowledgeable about health care, but they're trusted by a majority of the U.S. public. Unfortunately, he notes, there is little research on just how U.S. physicians would install "explicit" rationing. Rather, docs seem to prefer using “implicit” and "microsystem" approaches, such as queues (“we can give you an appointment next Tuesday”), subjective priority setting (“that rash sounds worse than the headache”) and networked relationships (“Fred’s referring another patient and I gotta keep him happy").

Dr. Brooke also cautions that the current mix of single specialty organizations, practicing physicians' distrust of ivory tower policy making, physician vs. physician jockeying over the SGR and the one-at-a-time Hippocratic devotion to the "here and now" of each patient make it unlikely that the docs will be collectively able to drive change. The only thing that is buying them time – for now - is that the chances of Washington doing anything about this in the near future is about as likely as witnessing a dermatologist successfully figure out which end of a stethoscope goes on the patient.

While this isn't a pretty picture, the DMCB points out that Dr. Brooks' original premise - that there aren't "systemic" changes that could bend the curve - isn't necessarily correct. As a society, we’ve only just begun to appreciate the interlocking synergies of ACOs plus medical homes plus disease management plus shared decision making plus bundled payment plus value-based insurance designs plus wellness/prevention plus smartly regulated market-based competition. If the premise is that it’ll be up to the vast Washington DC blob-collective to show how it can’t execute on these policy-options, the DMCB agrees that diktat-style rationing will be inevitable.

Plus, there’s another premise of Dr. Brooke’s that isn’t quite correct. Check out this 2006 JAMA article by Dr. Gruen and colleagues that shows that physicians are paying lots of attention, but their focus is on the local community and public health issues such as obesity, poor nutrition, immunizations, substance abuse, and seat belts. What’s more, recall that physicians not only helped lead the way in defanging health maintenance organizations (HMOs) but the AMA’s umbrella organizations were a positive force in the successful passage of the Affordable Care Act.

Last but not least, physicians’ participation in Medicare is not mandatory. Call that BATNA, leverage or a "nuclear option," the fact is that once physicians become actively engaged, they are quite capable of wielding considerable leadership and influence. They may not have a single public service union president, a trade association president or a sympathetic cable news channel that Dr. Brook can point to, but the DMCB suspects that rationing, at this point, is only a possibility. What's more, thanks to their track record, the DMCB is confident that any Central Committee-style planning will be dead in the water unless the docs have a major hand in its configuration.

Affordable Care Act. No Time For Amateurs. Shenanigans Inevitable.

The Obama Administration is dealing with the many unintended consequences of the Affordable Care Act's (ACA) medical loss ratio (MLR) limits. As readers may recall, setting the MLR at least 80% to 85% was intended to assure that 80% to 85% of the insurance premium was dedicated to paying for medical services. That limited commercial insurers' administrative expenses to 15% to 20%.

Things are not going quite as intended, reports Reed Abelson in an informative article published in The New York Times. A surprising number of health insurers have asked to have that MLR requirement waived by HHS and there may be more on the way. The good news is that the Administration is applying the "special circumstances" granted to it under the ACA to permit waivers if there could be significant market disruptions. While the White House clearly hopes that much of the market turmoil is a function of transitioning between now and 2014, there is the specter that some insurers will be unable to continue in certain markets, period.

All well and fine says the DMCB. The ACA is the law of the land and the Administration is doing what it needs to do on a case-by-case basis. It has only two concerns:

1) The DMCB heard from an NAIC official that the persons in the Obama Administration with all that authority over the waivers are still on a steep health insurance learning curve. In particular, there was a scary anecdote that when news of insurer exits from the "child only" market hit, officials couldn't quite grasp what a death spiral was all about. This is no time for amateurs.

2) It will be very difficult for well-connected lobbyists, insurers and politicians to resist seeking waivers, less on the merits of "insurance" and more on the basis of connections, pull and relationships. The ACA apparently grants huge "special circumstances" power to HHS and the likelihood of shenanigans, given the government's track record, is high. It may even be inevitable.

The DMCB hopes the two concerns are overblown. If not, you read it here first.

Millennial Generation Physicians and Disease Management

Oh, those "Millennials." Also called "Generation Y," this is the American demographic group born during and after the '70s, that was vicariously raised by "learning is fun" Sesame Street and became accustomed to getting awarded for any effort. They don't know about bomb shelters, walking to school, tape decks or having to get up to change a TV channel. Well, they're now entering the workplace and their informality, disregard for rank, fun-addled lifestyle and astonishing career expectations are making management rather interesting for their Boomer bosses. They're also the medical students, residents and young physicians who are shaking the health care culture up by a novel expectation about working to live, not vice versa.

The Millennial non-attitude about status or rank has implications for the hierarchical command and control that, up until now, has has been overseeing health system. No longer will a VP for Medical Affairs be able to assume young physicians will readily agree to taking "call" in evening outpatient clinics to off-load unnecessary emergency room visits. If a Grand Rounds speaker lacks sufficient eye-candied edutainment in PowerPoint, all the more reason for those young docs to skip out, grab some tofu and surf some YouTube. White coats will be optional and these docs will default to a first-name relationship with their patients.

While that topic may be worth a post in the future, the Disease Management Care Blog thinks there is a far more important trend afoot: the Millennials' "paradigm" is good news for disease and population-based care management.

Witness the Institute of Medicine's report on The Future of Nursing (summary here), which points out that "scope of practice" laws are not necessarily aligned with the profession's skill set, that nurses can be partnered with physicians for mutual benefit and that they can help meet the United States' burgeoning demand for health care. While physicians have been traditionally dyspeptic over the "hot button" issue of independent practice and the intrusion of nurses into the doctor-patient relationship, the DMCB has a prediction about a far more mundane issue: when it comes to non-physicians and disease management, the coming generation of docs will be far less worried about issues of rank, credentialing or licensure and far more flexible over relationships, skill sets and outcomes.

It simply won't concern them. They won't even think the IOM Report is all that noteworthy and they won't mind if a care management nurse is semi-autonomously involved in the care of their patients, just so long as it works.

What's more, they're far more likely to be comfortable with the idea of "virtual" patient interactions involving calls, e-mails and social media. The Millennials have never lived without e or voice-mail and they're the ones that powered texting, Twitter and Facebook.

Last but not least, if a nurse care manager can help them get done by 4:30 PM so they can go to little Johnny's soccer game, even better.

The arrivals of the Millennial physicians are another reason to be bullish on disease management.

The Latest Cavalcade of Risk Is Up!

The Disease Management Care Blog has a special place in its heart for the Wenchypoo Mental Wastebasket. Always a curious and compelling mix of libertarianism, street-wise economics, vegetable gardening and good old common sense, Wenchypoo is one of the best examples of why bloggery is emerging as a critically important window into the good and the bad of current public policy. This particular Cavalcade host is also one of the cheeky few to ever reject a past DMCB submission. This time the DMCB made the cut, along with a host of other bloggers that - combined with Wp's unique narrative - makes for a worthwhile read.

Check it out!

Ten Inconvenient Possible Downsides to Accountable Care Organizations: Details, details

Talk to any of the Disease Management Care Blog's doctor or administrator colleagues about the Affordable Care Act (ACA) and, faster than a specialist physician can tell a needy time-consuming patient to go away and "see your PCP," two panaceas will quickly come up: patient centered medical homes (PCMHs) and accountable care organizations (ACOs). The problem is that neither have been been conclusively shown to work in usual practice settings and, what's more, the ACO is still only a concept that even hasn't been even been tried.... anywhere.

Recall that ACOs can be defined as "provider collaborations that integrate groups of physicians, hospitals, and other providers around the ability to receive shared-savings bonuses by achieving measured quality targets and demonstrating real reductions in overall spending growth for a defined population of patients." As the DMCB has previously discussed, its luster is ultimately based on a bet that the efficiencies of integrated delivery systems can be exported to other settings. That's why the concept was written into the ACA for Medicare A and B (go to page 277 to read all about it).

While we all await the regulations that will detail exactly how ACOs will be approved by the Secretary of HHS, academicians, policymakers and wonks are continuing to ponder just how an ACO would - or would not - work. For an even-handed discussion of some of the problems that could undermine an ACO, check out Harold Luft's October 7 New England Journal article titled "Becoming Accountable - Opportunities and Obstacles for ACOs" (here). If you're an administrator, Dean, VP for Medical Affairs, member of a target="_blank"hospital Board, physician staff member, group manager or any of the medical types that believe an ACO puts patients in one end while money comes out the other, you may want to think about the following inconvenient truths:

1. The regulations haven't even been written yet.

2. The ACO business model is largely based on benefiting from the "upside" of risk contracting, which protects against higher than expected "risk-bearing" utilization. This sounds like a no-brainer, until you consider that ACOs will "bear the up-front costs of organizational and cultural change." In other words, that upside will only materialize if quality and costs meet muster, but the far more important profit will only occur if that upside is greater than those up-front costs.

3. Ever hear of the "attribution rule?" ACO wannabes may want to study just how Medicare will assign patients to you when those regulations come out, because you won't be able to pick and choose. Once those patients are assigned, you'll want to know everything you can about their baseline utilization and quality measures, because that'll be what you need to beat to get that upside mentioned in #2 above.

4. And ACOs will also need to bet that Medicare will do a good job of "efficiently and rapidly" providing ongoing data on the attributed patients so that the system can react to unfavorable trends. Medicare's track record in the ill-fated Medicare Health Support pilot should make you pause.

5. And by the way, ACOs will need Medicare D data too, even though controlling pharmacy costs are not part of the deal. If you look around the room and realize that your ACO co-planners don't understand why pharmacy data are important, you may need to rethink the suitability of doing this in the first place.

6. Not all physicians - including primary care - are likely to be invited to participate in ACOs. That spells all kinds of trouble. Some docs may not want to participate, creating even more headaches.

7. Further complicating the relationship with the physicians is the overlap between their fee-for-service payments and the compensable activities - like complex visits, post-discharge care or hospice - that manage the upside risk. Should the docs be paid twice if there are cost savings?

8. Federal anti-trust concerns may prompt the decision to require multiple ACOs in one region, further complicating things. The DMCB wonders if adverse selection could occur.

9. "Outliers" may also become a term ACOs would like to familiarize themselves with. A few patients with unlucky and catastrophic health care costs can shift those average "attributable" Medicare charges, torpedoing that upside risk mentioned in #2 above. What's more, they may not be under your control if the Medicare beneficiary happens to be traveling out of region. Think what would happen to your business plan if a tour bus loaded with your "attributed" patients has an accident while visiting Branson....

10 (while not brought up by Dr. Luft...) One key to increasing quality and lower costs will be active care management, typically controlled by non-physician health professionals, usually nurses. Creating a phalanx of care managers to coordinate outpatient care is typically outside the competence of the types that run clinics and hospitals. It remains to be seen if they'll be wise enough to outsource it, even if it does add to those initial up front costs.

Shared Decision Making to Aid in the Purchase of Health Insurance? Why Not?

The Disease Management Care Blog thought some more about the healthcare.gov site and yesterday's post. It looks forward to eventually reading a news release not unlike the one below in the not too distant future.....

HHS.gov
FOR IMMEDIATE RELEASE
Tuesday, Oct 4, 2014

HHS Announces Unique Three-Way Public-Private Partnership To Better Serve Purchasers of Health Insurance

The U.S Department of Health and Human Services (HHS) today announced that it has contracted with the National Committee for Quality Assurance (NCQA) and Amazon (AMZN) to help individuals and businesses make truly informed decisions about buying health insurance.

Thanks to relying on the NCQA's highly respected approach to the measurement of health insurer performance and using Amazon's track record of giving consumers tailored personalized purchasing choices, HHS has revamped its healthcare.gov site to aid consumers with shared decision making (SDM) when they are assessing their health insurance options.

"When the U.S. Congress demanded that HHS be subject to the same rigorous standards of health care outcomes measurement as doctors and hospitals, we quickly determined that the original http://www.healthcare.gov/ website was not exceeding the American people's expectations," said CMS Director Carolyn Clancy, formerly of AHRQ. "Consumers are interested in a host of complex features that include network physicians, keeping hassles to a minimum, time to answer a phone with a knowledgeable person, programs that promote wellness and prevention, web site usability and consumer satisfaction rates, among others. We decided it was time to let the experts discover what those interests are and get out of the way."

"I'm proud of CMS' efforts to meet the original intent of the Affordable Care Act of 2010" added HHS Secretary Donald Berwick. "Thanks to the leadership of President Meghan McCain, we are making important strides in combining the best features of federal and state oversight while simultaneously letting consumers reward the better insurers with their business in a fully transparent marketplace."

Shared decision making (SDM) is a process that relies on state-of-the-art and consumer-friendly media formats to provide unbiased information that allows consumers to rely on their own values and needs to make complex health care choices. Research funded by the newly named Agency for Healthcare Consumerist Research and Quality (AHCRQ) determined that if patients can use this to make informed choices about cancer treatment options, they could also use it in purchasing insurance.

According to the widely read and oft-quoted Disease Management Care Blog, once the NCQA announced the methodologies to isolate, measure and audit the key consumerist attributes of quality health insurance, it was a "no-brainer" to turn to Amazon's expertise in efficiently guiding consumers to find options to match their particular preferences. "Hit" rates from web-enabled cells phones on the HealthCare.gov site skyrocketed and taxpayers finally knew they were getting their money's worth.

For more information, visit our Facebook page at Facebook.com/HealthCare.gov, or the @HealthCareGov Twitter account.

To download a www.HealthCare.gov Insurance Finder widget – so that visitors to your website can easily start searching for health coverage options – visit www.HealthCare.gov/stay_connected.html.

The DMCB made several calls to the office of former HHS Secretary Kathleen Sebelius for comment at the headquarters of the National Coalition to Establish the Swedish Republic of Vermont. They went unanswered.

The Big Sleep

This blog usually focuses on diet, because that's my specialty. But if you want Whole Health, you need the whole package: a diet and lifestyle that is broadly consistent with our evolutionary heritage. I think we all know that on some level, but a recent paper has reminded me of it.

I somehow managed to get on the press list of the Annals of Internal Medicine. That means they send me embargoed papers before they're released to the general public. That journal publishes a lot of high-impact diet studies, so it's a great privilege for me. I get to write about the studies, and publish my analysis at the time of general release, which is the same time the news outlets publish their stories.

One of the papers they sent me recently is a fat loss trial with an interesting twist (1; see below). All participants were told to eat 10% fewer calories that usual for two weeks, however half of them were instructed to sleep for 8 and a half hours per night, and the other half were instructed to sleep for 5 and a half hours*. The actual recorded sleep times were 7:25 and 5:14, respectively.

Weight loss by calorie restriction causes a reduction of both fat and lean mass, which is what the investigators observed. Both groups lost the same amount of weight. However, 80% of the weight was lost as fat in the high-sleep group (2.4/3.0 kg lost as fat), while only 48% of it was lost as fat in the low-sleep group (1.4/2.9 kg lost as fat). Basically, the sleep-deprived group lost as much lean mass as they did fat mass, which is not good!

There are many observational studies showing associations between insufficient sleep, obesity and diabetes. However, I think studies like that are particularly vulnerable to confounding variables, so I've never known quite what to make of them. Furthermore, they often show that long sleep duration associates with poor health as well, which I find highly unlikely to reflect cause and effect. I discussed one of those studies in a post a couple of years ago (2). That's why I appreciate this controlled trial so much.

Another sleep restriction trial published in the Lancet in 1999 showed that restricting healthy young men to four hours of sleep per night caused them to temporarily develop glucose intolerance, or pre-diabetes (3).

Furthermore, their daily rhythm of the hormone cortisol became abnormal. Rather than the normal pattern of a peak in the morning and a dip in the evening, sleep deprivation blunted their morning cortisol level and enhanced it in the evening. Cortisol is a stress hormone, among other things, and its fluctuations may contribute to our ability to feel awake in the morning and ready for bed at night.

The term "adrenal fatigue", which refers to the aforementioned disturbance in cortisol rhythm, is characterized by general fatigue, difficulty waking up in the morning, and difficulty going to sleep at night. It's a term that's commonly used by alternative medical practitioners but not generally accepted by mainstream medicine, possibly because it's difficult to demonstrate and the symptoms are fairly general. Robb Wolf talks about it in his book The Paleo Solution.

The investigators concluded:

Sleep debt has a harmful impact on carbohydrate metabolism and endocrine function. The effects are similar to those seen in normal ageing and, therefore, sleep debt may increase the severity of age-related chronic disorders.

So there you have it. Besides making us miserable, lack of sleep appears to predispose to obesity and diabetes, and probably sets us up for the Big Sleep down the line. I can't say I'm surprised, given how awful I feel after even one night of six hour sleep. I feel best after 9 hours, and I probably average about 8.5. Does it cut into my free time? Sure. But it's worth it to me, because it allows me to enjoy my day much more.

Keep your room as dark as possible during sleep. It also helps to avoid bright light, particularly in the blue spectrum, before bed (4). "Soft white" bulbs are preferable to full spectrum in the evening. If you need to use your computer, dim the monitor and adjust it to favor warm over cool colors. For people who sleep poorly due to anxiety, meditation before bed can be highly effective. I posted a tutorial here.

1. Nedeltcheva, AV et al. "Insufficient Sleep Undermines Dietary Efforts to Reduce Adiposity." Annals of Internal Medicine. 2010. Advanced publication.


* The study was a randomized crossover design with a 3 month washout period, which I consider a rigorous design. I think the study overall was very clever. The investigators used calorie restriction to cause rapid changes in body composition so that they could see differences on a reasonable timescale, rather than trying to deprive people of sleep for months and look for more gradual body fat changes without dietary changes. The latter experiment would have been more interesting, but potentially impractical and unethical.

HealthCare.gov Compares Insurers With Little Evidence That It Works

As further testimony to the current Administration's commitment to force those dastardly commercial health insurers out from under their rocks into the cleansing light of righteous Obamacare, the "health care dot gov" web site has posted all the nation's commercial insurers' pricing and application rejection rates. Input your state of residence, marital status (single, married, children), whether you've been rejected for coverage, age, overall health status, employment situation, and zip code and [poof!] the site will generate (when the Disease Management Care Blog took it for a test drive) several pages of options with varying deductibles, co-pays and premiums.

All well and good, says the DMCB, until it thinks about the evidence that this will work as intended. For consumers who are lucky enough to fall on the more affluent side of the digital divide and have a choice of media, only a minority actually use the internet to shop for health insurance. The DMCB could find no published research on the topic of it changing purchasing behavior, which is ironic, given our federal infatuation with comparative effectiveness research.

Research on internet-based ratings of hospitals has shown internet-based comparisons are not the slam dunk that many assume they are. The ratings are subject to variable methodologies (an issue for healthcare.gov that was already raised by AHIP) that can "confuse, rather than inform consumers," or may not tell the whole story, or simply get it wrong. The surfing public may not reward "better" entrants with increased market share and one reason may be because users don't find the information helpful. Even CMS's own web site that compares hospital quality isn't really all that.

While the insurer compare site may have given the Obama Administration some positive news media attention, (aided by AHIP's needless push back) the DMCB doubts it will ultimately have much of a material impact - based on the current evidence - on the purchasing behavior of consumers of health insurance. To go about this right, HHS should measure "hit" rates and conduct user-surveys to see how it's going. If the data are disappointing, hopefully they'll have the courage to take down the site and announce its demise with the same fanfare that accompanied its start.

Somehow, the DMCB thinks that is unlikely.

Potatoes and Human Health, Part III

Potato-eating Cultures: the Quechua

The potato is thought to have originated in what is now Peru, on the shores of lake Titicaca. Native Peruvians such as the Quechua have been highly dependent on the potato for thousands of years. A 1964 study of the Quechua inhabitants of Nuñoa showed that they obtained 74% of their calories from potatoes (fresh and chuños), 10% from grains, 10% from Chenopodia (quinoa and cañihua), and 4% from animal foods. Total energy intake was 3,170 calories per day (1).

In 2001, a medical study of rural Quechua men reported an average body fat percentage of 16.4% (2). The mean age of the volunteers was 38. Body fat did increase slowly with age in this population, and by age 65 it was predicted to be about 20% on average. That's below the threshold of overweight, so I conclude that most men in this population are fairly lean, although there were a few overweight individuals.

In 2004, a study in rural Quechua women reported a body fat percentage of 31.2% in volunteers with a mean age of 35 (3). Body fat percentage was higher in a group of Quechua immigrants to the Peruvian capital of Lima. Among rural women, average fasting insulin was 6.8 uIU/mL, and fasting glucose was 68.4 mg/dL, which together suggest fairly good insulin sensitivity and glucose control (4). Insulin and glucose were considerably lower in the rural group than the urban group. Blood pressure was low in both groups. Overall, this suggests that Quechua women are not overweight and are in reasonably good metabolic health.

Rural Quechua are characteristically short, with the average man standing no more than 5' 2" (2). One might be tempted to speculate that this reflects stunting due to a deficient diet. However, given the fact that nearly all non-industrial populations, including contemporary hunter-gatherers, are short by modern standards, I'm not convinced the Quechua are abnormal. A more likely explanation is that industrial foods cause excessive tissue growth in modern populations, perhaps by promoting overeating and excessive insulin and IGF-1 production, which are growth factors. I first encountered this hypothesis in Dr. Staffan Lindeberg's book Food and Western Disease.

I don't consider the Quechua diet to be optimal, but it does seem to support a reasonable level of metabolic health. It shows that a lifetime high-carbohydrate, high glycemic index, high glycemic load diet doesn't lead to insulin resistance and obesity in the context of a traditional diet and lifestyle. Unfortunately, I don't have more detailed data on other aspects of their health, such as digestion.

Potato-eating Cultures: the Aymara

The Aymara are another potato-dependent people of the Andes, who span Peru, Bolivia and Chile. The first paper I'll discuss is titled "Low Prevalence of Type II Diabetes Despite a High Body Mass Index in the Aymara Natives From Chile", by Dr. Jose Luis Santos and colleagues (5). In the paper, they show that the prevalence of diabetes in this population was 1.5%, and the prevalence of pre-diabetes was 3.6%. The prevalence of both remained low even in the elderly. Here's a comparison of those numbers with figures from the modern United States (6):

That's quite a difference! The prevalence of diabetes in this population is low, but not as low as in some cultures such as the Kitavans (7, 8).

Now to discuss the "high body mass index" referenced in the title of the paper. The body mass index (BMI) is the relation between height and weight, and typically reflects fatness. The average BMI of this population was 24.9, which is very close to the cutoff between normal and overweight (25).

Investigators were surprised to find such a low prevalence of diabetes in this population, despite their apparent high prevalence of overweight. Yet if you've seen pictures of rural native South Americans, you may have noticed they're built short and thick, with wide hips and big barrel chests. Could this be confounding the relationship between BMI and body fatness? To answer that question, I found another paper that estimated body fat using skinfold measurements (9). That study found a body fat percentage of 15.4%, which is lean by any standard. Based on this paper and others, it appears that investigators shouldn't extrapolate BMI standards from modern Caucasian populations to traditional native American groups.

Back to the first paper. In this Aymara group, blood pressure was on the high side. Serum cholesterol was also a bit high for a traditionally-living population, but still lower than most modern groups (~188 mg/dL). I find it very interesting that the cholesterol level in this population that eats virtually no fat was the same as on Tokelau, where nearly half of calories come from highly saturated coconut fat (10, 11). Fasting insulin is also on the high side in the Aymara, which is also interesting given their good glucose tolerance and low prevalence of diabetes.

Potato-eating Cultures: the Irish

Potatoes were introduced to Ireland in the 17th century. They were well suited to the cool, temperate climate, and more productive than any other local crop. By the early 18th century, potatoes were the main source of calories, particularly for the poor who ate practically nothing else. In 1839, the average Irish laborer obtained 87% of his calories from potatoes (12). In 1845, the potato blight Phytophthora infestans struck, decimating potato plantations nationwide and creating the Great Famine.

There isn't much reliable information on the health status of the Irish prior to the famine, besides reports of vitamin A deficiency symptoms (13). However, they had a very high fertility rate, and anecdotal reports described them as healthy and attractive (14):

As far as fecundity is concerned, the high nutritional value of the potato diet might have played a significant role, but little supportive evidence has been presented so far... What is known is that the Irish in general and Irish women in particular were widely described as healthy and good-looking. Adam Smith's famous remark that potatoes were "peculiarly suitable to the health of the human constitution" can be complemented with numerous observations from other contemporary observers to the same effect.

Controlled Feeding Studies

Starting nearly a century ago, a few eccentrics decided to feed volunteers a potato-only diet to see if it could be done. The first such experiment was carried out by a Dr. M. Hindhede and published in 1913 (described in 15). Hindhede's goal was to explore the lower limit of the human protein requirement and the biological quality of potato protein. He fed three healthy adult men almost nothing but potatoes and margarine for 309 days (margarine was not made from hydrogenated seed oils at the time), all while making them do progressively more demanding physical labor. They apparently remained in good physical condition. Here's a description of one of his volunteers, a Mr. Madsen, from another book (described in 16; thanks to Matt Metzgar):

In order to test whether it was possible to perform heavy work on a strict potato diet, Mr. Madsen took a place as a farm laborer... His physical condition was excellent. In his book, Dr. Hindhede shows a photograph of Mr. Madsen taken on December 21st, 1912, after he had lived for almost a year entirely on potatoes. This photograph shows a strong, solid, athletic-looking figure, all of whose muscles are well-developed, and without excess fat. ...Hindhede had him examined by five physicians, including a diagnostician, a specialist in gastric and intestinal diseases, an X-ray specialist, and a blood specialist. They all pronounced him to be in a state of perfect health.

Dr. Hindhede discovered that potato protein is high quality, providing all essential amino acids and high digestibility. Potato protein alone is sufficient to sustain an athletic man (although that doesn't make it optimal). A subsequent potato feeding study published in 1927 confirmed this finding (17). Two volunteers, a man and a woman, ate almost nothing but potatoes, lard and butter for 5.5 months. The man was an athlete but the woman was sedentary. Body weight and nitrogen balance (reflecting protein gain/loss from the body) remained constant throughout the experiment, indicating that their muscles were not atrophying at any appreciable rate, and they were probably not putting on fat. The investigators remarked:

The digestion was excellent throughout the experiment and both subjects felt very well. They did not tire of the uniform potato diet and there was no craving for change.

In one of his Paleo Diet newsletters titled "Consumption of Nightshade Plants (Part 1)", Dr. Loren Cordain referenced two feeding studies showing that potatoes increase the serum level of the inflammatory cytokine interleukin-6 (22, 23). However, one study was not designed to determine the specific role of potato in the change (two dietary factors were altered simultaneously), and the other used potato chips as the source of potato. So you'll have to pardon my skepticism that the findings are relevant to the question at hand.

Just yesterday, Mr. Chris Voigt of the Washington State Potato Commission embarked on his own n=1 potato feeding experiment as a way to promote Washington state potatoes. He'll be eating nothing but potatoes and fat for two months, and getting a full physical at the end. Check out his website for more information and updates (18). Mr. Voigt has graciously agreed to a written interview with Whole Health Source at the end of his experiment. He pointed out to me that the Russet Burbank potato, the most popular variety in the United States, is over 135 years old. Stay tuned for more interesting facts from Mr. Voigt in early December.

Observational Studies

With the recent interest in the health effects of the glycemic index, a few studies have examined the association between potatoes and health in various populations. The results are all over the place, with some showing positive associations with health, and others showing negative associations (19, 20, 21). As a whole, I find these studies difficult to interpret and not very helpful.

Anecdotes

Some people feel good when they eat potatoes. Others find that potatoes and other members of the nightshade family give them digestive problems, exacerbate their arthritis, or cause fat gain. I haven't seen any solid data to substantiate claims that nightshades aggravate arthritis or other inflammatory conditions. However, that doesn't mean there aren't individuals who are sensitive. If potatoes don't agree with you, by all means avoid them.

The Bottom Line

You made it to the end! Give yourself a pat on the back. You deserve it.

In my opinion, the scientific literature as a whole, including animal and human studies, suggests rather consistently that potatoes can be a healthy part of a varied diet for most people. Nevertheless, I wouldn't recommend eating nothing but potatoes for any length of time. If you do choose to eat potatoes, follow these simple guidelines:

• Don't eat potatoes that are green, sprouting, blemished or damaged
• Store them in a cool, dark place. They don't need to be refrigerated but it will extend their life
  
• Peel them before eating
  

Enjoy your potatoes!

The Latest Health Wonk Review Is Up!

Peggy Salvatore makes an excellent and entertaining debut hosting this weeks "Health Wonk Review." Its the Take Me To Your Leader – Egads!" edition at her Health Talent Transformation blog. Check it out and enjoy the best and brightest thinking from the blogmos.

The Obama Administration Gets Into the Pre-Approval Business: "Coming Between You and Your Doctor"

Unless you are a national T.V. reporter, vacuous socialite Paris Hilton or a leading official in the Obama Administration, you probably already know that health insurers do not deny coverage of medical services based on cost. Instead, payment (or non-payment) for healthcare services is based on an assessment of "medical necessity," which, in turn, is ultimately determined by published evidence, expert opinion, clinical guidelines and national standards of care (here's an example). Once what is covered is known, it's a matter of knowing the unit charge and expected utilization and rolling that up into the insurance benefit design and the price of the premium. From time to time, insurers may require knowing if the medical treatment fits the science. That can be complicated and can be a source of insurer mischief. Doctors and patients can get tangled up in differing interpretations of a policy. Ultimately, however, the often derided "insurers coming between you and your doctor" is typically a function of thought, not thievery.

Well, thanks to this summary, courtesy of the New England Journal of Medicine, we are now witnessing an intrusion of the Federal government into the decision-making between doctors and their patients. Aside from a problem with occasionally killing patients, Avandia remains an important option in the treatment of diabetes. It's possible for a doctor and a patient to weigh the benefits, risks and alternatives and correctly mutually decide to use it. Their problem now, however, is that they'll need to seek permission. According to the Journal, the Food and Drug Administration's "Risk Evaluation and Mitigation Strategy" (REMS) will require the following prior to obtaining approval to use the drug:

"Doctors will have to attest to and document their patients' eligibility; patients will have to review statements describing the cardiovascular safety concerns"

The Disease Management Care Blog points out that the FDA is doing this because of two reasons 1) it's science-based and 2) using that science to come between a doctor and a patient works. So, the DMCB says "welcome to the managed care club" to the FDA and the Obama Administration.

By the way, the better health insurers typically strive to streamline this kind of pre-approval process by making toll-free lines available 24-7 or using web portals with data entry fields that can be completed in minutes. The DMCB hopes the FDA sets up a similar process for Avandia. Doing this by paper promises to be a bureaucratic nightmare.

Is A Back Door Being Built For A Single Payer System?

That question is considered in the guest post that was provided below by a DMCB physician-colleague.......

From my perspective as a solo family doctor it looks that way to me.

I am seeing some disturbing changes in how physicians bill for their services, the rise of insurance mandates and increasing consolidation of the health insurance industry. Carried to their logical conclusion, the government will need to step in. Maybe that's the intent.

My daughter recently had an appointment with her pediatrician for a “well-child” visit. When I received a copy of the physician’s bill, I noticed that there was a fee for the well visit as well as for an intermediate acute visit (99213). This is important because my family insurance uses a high deductible policy. When I brought the possibility that there may be overbilling to the attention of physician’s office, they claimed it was well within coding guidelines.
I didn’t agree, so I asked for a copy of the physician’s office note. This was enough to have my inquiry referred to the physician’s coding and compliance officer. After reviewing my daughter’s chart, he agreed that it did not meet requirements for a 99213 intermediate visit and informed me that the account would be credited.

This is more important than now being able to enjoy a night out with my spouse. That pediatrician’s practice was recently acquired by a hospital that is positioning itself to become an “Accountable Care Organization” (ACO). Before the hospital owned the pediatrician's practice, it was unheard of it to bundle a well and acute visit. But now, the hospital has apparently launched an aggressive coding initiative that is designed to maximize revenue. I predict that future ACO’s will find this and other ways to maximize revenue in ways that would have never been considered by well-meaning physicians and policy makers. This will increase costs.

In the news, I hear that some are calling the individual insurance mandate unconstitutional. They are trying to strike this provision from “Obamacare”. If this is taken out without modifying the other provisions (i.e. dealing with preexisting conditions ), there is evidence that this will bankrupt insurance companies or cause skyrocketing premiums.

Government mandates for coverage without regard for actuarial consequences will also cause premiums to dramatically increase. In Pennsylvania we now have an autism mandate for enhanced coverage to care for autism patients. Any enhanced or generous coverage for any specific disease process has the ability to bend the cost curve in the wrong direction. This will also increase costs.

Lastly, insurance company mergers and acquisitions have been commonplace in the last decade. If oligopolies occur (and by many accounts they already have) prices will go up and the government may be inclined to enact anti-trust protections, further increasing the involvement of government in health care.

Taken together, these developments and others may ultimately open up a back door for the single payer system. The combination of aggressive clinical billing, expanded disease coverage without universal coverage and insurance oligopolies may set the stage for increased government intervention backed by a frustrated voting public.

The most worrisome aspect is that the government may be as dumb as a fox. It is well known that the Obama Administration is enamored with increased federal involvement of healthcare. Between navigating the health care system for myself and my patients, watching the news and following the political dramas, it sure looks as if the stage has been set for the eventual passage of a single payer system.

Ideology vs. Values in Health Reform: We Deserve Better

Following the collapse of the housing market back in 2008, former Federal Reserve Board Chair Alan Greenspan appeared before the U.S. House Oversight Committee for a rather painful post-mortem examination. Over the course of several hours, he endured biting criticism for relying on what was described as a flawed free market "ideology." Henry Waxman's metaphysical questioning of the humbled former Fed Chief was a masterful combination of partisan opportunism, photo-op politics and angry revenge.

It was also a demonstration of the political process run amok.

David Brooks, writing recently in the New York Times, has it right: the political classes' ideological anger is out of step with Main Street citizens' anger over values. While the two concepts overlap, the former deals with creed and belief systems, while the latter deals with interests and materiality. The former has led to intellectual/political gridlock that now presides over a bloated, metastasizing and unwieldy thicket of statutes, regulations, law suits, lawyers, unions and craven complex of private sector government contractors. Mr. Brooks argues this has ultimately short-circuited a key American value: being able to benefit or suffer from the upsides and downsides (including luck) of personal initiative. He's not sure that things will necessarily change after the midterm elections, but he does predict that to succeed, a future President may need to understand the difference.

And look no further for a poisonous example of recent ideological jousting than HHS Secretary Kathleen Sebelius' editorial in the September 28 Wall Street Journal. In it, Ms. Sebelius retreads an ultimately ideological perspective that the purpose of health insurance, apparently in the absence of a preferred single payer system, is to guarantee access to care by selling "reasonably" low-priced insurance policies that cover all the medical costs for anyone who wants to buy it anytime. And, as typical for ideologues, falsely contrived good vs. evil battle lines are drawn: in this instance she pits down-on-their-luck self-employed, hard-working persons against faceless and avaricious health insurers.

As testimony to the righteousness of Ms. Sebelius' side, her Exhibit A is a recent North Carolina Blue Cross Blue Shield premium rebate. It turns out that the story is a little bit more complicated. For that, see Carl Mecurio's excellent summary of what happened here. Basically, the introduction of exchanges in the near term meant that the insurer's reserves against long term costs were becoming redundant. Sending checks out for a few hundred dollars to the involved BCBS enrollees was based on an actuarial decision that had little to do with the HHS' saintliness.

The Disease Management Care Blog will be the first to admit that it and its fellow bloggers suffer from a sometimes overzealous dose of ideology, but heck, they're blogs. Their role is to use all the tools of rational thought to uncover points of view that deserve higher visibility. Public service and governance, on the other hand, calls for a far more subtle, balanced and difficult job of reining in ideology and reconciling the important notion of personal responsibility with our other cherished values of progressivism, justice and others. It's not easy, but the talent is out there.

The Wall Street Journal editorial only demonstrates how badly this Administration's lack of that talent is failing in that key attribute when it comes to health care reform.

"Treat to Target": Disease Management on Steroids

Writing in the latest issue of the American Journal of Managed Care, medical student David Margolius and academic scholar Thomas Bodenheimer describe an approach to hypertension management called "Treat to Target."

It has three ingredients:

1. Home blood pressure monitoring and recording

2. "... regular phone calls from a nonphysician team member who reinforces blood pressure goals and provides coaching on diet, exercise, and medication adherence. These team members—also referred to as health coaches—may be registered nurses, pharmacists, medical assistants, or other nonclinicians trained in behavior-change counseling."

3. Standing physician orders, which can be jointly used by the coaches and the patients to up doses are start new medications.

The authors quote several peer-reviewed studies that have shown it works. The secret sauce, they say, is making physician instructions understandable to patients, bringing them into the decision making, improving low medication compliance rates and overcoming clinical inertia.

The DMCB likes the idea because it takes the disease management coaching model (already in place in about 20% of all patients with a chronic condition nationwide) and gives it an additional punch. While physicians and policy makers may tut-tut about the potential to undercut the doctors' role, the fact is that "standing orders" are one of the great secrets of countless well-run clinics and, if done right, fall well within scope of practice laws in most States.

As typical of most academicians nowadays, Dr. Bodenheimer suggests all that is needed is insurer coverage of home monitoring and payment for the accompanying physician effort. The DMCB suggests these ingredients are necessary but not sufficient. Another resource is the disease management vendors. They've probably been thinking on how to systematize something like this across a network while simultaneously preserving the individual physician-patient dyad.

Finally, why stop at hypertension? This could also work in diabetes mellitus and hyperlipidemia.

Now that we have an scholarly article that links standing orders and disease management, the DMCB hopes its vendor-colleagues are printing out that article and approaching its buyer/purchaser/insurer customers with the next step up population care management. Hopefully, all of us will get to read about those outcomes in a future issue of AJMC.

a Summary of the Latest Population Health Management Journal

Like you, the Disease Management Care Blog has been busy. Yet, it finally managed to find some time to crack the latest issue of the Population Health Management Journal. What's more, the DMCB kept some notes for your quoting pleasure. Check it out and if any of the articles catch your interest, you can access the abstracts here.

Michael French, Jenny Homer, Shay Klevay, Edward Goldman, Steven Ullmann and Barbara Kahn: Is the United States Ready to Embrace Concierge Medicine?

This is a very detailed review of an emerging kind of primary care where, “in exchange for a retainer or membership fee, patients receive same day or next day appointments for non-urgent care, access 24 hours a day and preventive medical services not usually offered through health insurance.” Here are some facts that caught the DMCB eye: concierge medicine started in 1996, up to an estimated 5000 physicians are CM docs and the retainer fee is typically not covered by insurance. The practice has spawned its own not-for profit trade/advocacy association (http://www.aapp.org//). While you might think the phenomenon is limited to small physician-owned clinics, there are companies that employ physicians in concierge practices. The retainer fees range from $1500-$3600 per patient. Docs typically have just under 500 patients in their panel, allow about 10 visits per day and enjoy incomes as high as $800,000. The authors suggest this could crowd out regular primary care and further strain access. There is precious little research on quality or outcomes Last but not least, Medicare specifically prohibits billing beneficiaries for services that it already covers, which could lead to some physicians becoming ensnared in accusations of double billing. In light of all the attention concierge practices have received, the DMCB is surprised at the low numbers and the emergence of concierge "chains." It asks if and when there will be tipping point and wonders if the SGR will play a role.

Iftekhar Kalsekar, Samantha Record, Karly Nesnidal and Bruce Hancock: National Estimates of Enrollment in Disease Management programs in the United States: An Analysis of the National Ambulatory Medical Care Survey (NAMCS) Data.

The authors used data from the NAMCS to estimate the level of participation in disease management (DM) programs. Their bottom line estimate is that 21.3% of eligible patients are enrolled in DM. While the DMCB would have guessed that chronic heart failure is the chronic condition that the highest penetrance, the answer is that it's chronic renal failure at 40%. The other usual conditions range between 16 and 29%. In reading the methodology for this article, the DMCB couldn’t quite understand how the authors got at the DM enrollment information. Since it trusts PHM’s peer review process and the authors quote other studies that have similar figures, the DMCB finds the numbers credible. Assuming they are correct, they point to the considerable upside growth potential of the disease/care/population health management industry.

Richard Feifer, Laurie Greenberg, Sandra Rosenberg-Brandi Ellen Franzblau-Isaac: Pharmacist Counseling at the Start of Therapy: Patient Receptivity to Offers of In-Person and Subsequent Telephonic Clinical Support

100 consecutive patients who had just started a new medication for a chronic condition were contacted for disease management. Prior to the counseling, the authors used a short survey to ask these patients about their experience when they first picked up their prescription at their community pharmacy. 58% didn’t recall being offered counseling, 11% refused it and 12% couldn’t recall getting useful advice. While it’s difficult to generalize from such a small survey involving a small number of patients, it confirms the DMCB skepticism about the notion that retail pharmacy windows can be retrofitted to deliver disease management. The DMCB also better understands why its own personal chain pharmacy gets its sign-off on a mechanized offer of counseling - which it never gets and doesn't want.

Justin Schaneman, Amy Kagey, Stephen Soltesz, Julie Stone: The Role of Comprehensive Eye Exams in the Early Detection of Diabetes and Other Chronic Diseases in an Employed Population

The research database of Human Capital Management Services contains a vast amount of demographic, employment, compensation, medical claims, pharmacy claims, disability, workman’s comp and work absence information on millions of employees from across the United States – including, maybe, you. Do not, however, be paranoid, because the authors looked at persons with either specific check-box notification of, or, a claim consistent with a screening eye exam that was subsequently followed by the appearance of new claims for diabetes (N=620), hypertension (N=1558) or high cholesterol (2824). When that happened (eye exam, followed by insurance claims), the authors assumed that the eye examination discovered the condition, which then led to a referral for care. These persons were compared to 2,668 persons who also had new claims for diabetes (2668), high blood pressure (17,112) or high cholesterol (12,059) but without the preceding eye exam. . The authors found the eye exam group, compared to those without the exams, appeared to have a less costly course of care. What’s more, the eye exam was associated with less disability and lower workman’s comp claims and a lower likelihood of being terminated. It all added up to more than $4.5 million in possible savings. The authors correctly point out that there may be unidentified sources of bias that could account for the differences and that this may also be a classic example of lead-time bias. The DMCB also points out that association doesn’t mean causality.

Jeanne Clark, Hsien–Yen Chang, Shari Bolen, Andrew Shore, Suzanne Goodwin, and Jonathan Weiner: Development of a Claims-Based Risk Score to Identify Obese Individuals

These Johns Hopkins researchers had concurrent access to the self-reported height and weight data from health risk assessments (HRAs) as well as insurance demographic and claims data from seven Blues plans of over 71,000 individuals. Logistic regression was used to determine which kinds of insurance claims data could be used to predict the presence of obesity in the absence of an HRA. Armed with such an “obesity risk score” tool, commercial plans could presumably use this to recruit patients that appear to have obesity into disease management programs. While the sensitivity and specificity of the modeling was far from perfect (the area under the ROC curve ranged from .67 to .73), this study shows, once again, how health plans can infer important conclusions about their enrollees based on claims data. It should be no surprise that the regression equation it self with the weights were not reported, presumably because that will only be available if you pay for it.

Manjiri Pawaskar, Steven Burch, Eric Seiber, Milap Nahata, Ala Iaconi and Rajesh Balkrishnan: Medicaid Payment Mechanisms: Impact on Medication Adherence and Health Care Service Utilization in Type 2 Diabetes Enrollees

According to the Kaiser Foundation, about 45% of Medicaid recipients nationwide are enrolled in “capitated” Medicaid plans. Are taxpayers getting their money’s worth and are these patients being care for properly? To find out, the authors looked at the claims data from between 1999 and 2005 of 8581 adults age 18 to 64 years with diabetes who were newly started on an oral anti-diabetic medication from 8 unnamed Medicaid managed care plans. 3763 patients were enrolled in “capitated” plans (where most medical services were paid for on a capitated basis) and 4818 were in fee-for-service plans. Logistic regression demonstrated that being in a capitated plan was statistically significantly associated with a greater likelihood of hospitalization and a lower frequency of outpatient visits and a lower likelihood of getting prescriptions filled. Hm, says the DMCB: maybe Medicaid plans should use disease management to make up for these shortfalls.

Nasiya N. Ahmed and Shannon Pearce: Acute Care for the Elderly: A Literature Review

Ever hear of Acute Care for the Elderly (ACE) Units? These are small 10-20 bed inpatient settings that are specially configured for the special needs of elderly persons with acute illness. It involves specialized geriatric care and interdisciplinary teaming all configured to maximize the likelihood of returning the patient to independent living. The authors summarized all the published literature on the topic and conclude that the clinical trials that do exist seem to show that ACEs, compared to usual care, generally lead to a shorter length of stay, have a lower likelihood of readmissions, end up with fewer transfers to a nursing home for longer term care, result in less functional decline, have a lower risk of delirium, reduce the chance of polypharmacy and experience lower cost. The authors caution the literature, while promising, is relatively limited and more research is necessary.

Potatoes and Human Health, Part II

Glycoalkaloids in Commonly Eaten Potatoes

Like many edible plants, potatoes contain substances designed to protect them from marauding creatures. The main two substances we're concerned with are alpha-solanine and alpha-chaconine, because they are the most toxic and abundant. Here is a graph of the combined concentration of these two glycoalkaloids in common potato varieties (1):

We can immediately determine three things from this graph:

• Different varieties contain different amounts of glycoalkaloids.
• Common commercial varieties such as russet and white potatoes are low in glycoalkaloids. This is no accident. The glycoalkaloid content of potatoes is monitored in the US.
  
• Most of the glycoalkaloid content is in the skin (within 1 mm of the surface). That way, predators have to eat through poison to get to the flesh. Fortunately, humans have peelers.

I'll jump the gun and tell you that the generally accepted safe level of potato glycoalkaloids is 200 mcg/g fresh weight (1). You can see that all but one variety are well below this level when peeled. Personally, I've never seen the Snowden variety in the store or at the farmer's market. It appears to be used mostly for potato chips.

Glycoalkaloid Toxicity in Animals

Potato glycoalkaloids are undoubtedly toxic at high doses. They have caused many harmful effects in animals and humans, including (1, 2):

• Death (humans and animals)
  
• Weight loss, diarrhea (humans and animals)
  
• Anemia (rabbits)
• Liver damage (rats)
  
• Lower birth weight (mice)
  
• Birth defects (in animals injected with glycoalkaloids)
  
• Increased intestinal permeability (mice)

However, it's important to remember the old saying "the dose makes the poison". The human body is designed to handle a certain amount of plant toxins with no ill effects. Virtually every plant food, and a few animal foods, contains some kind of toxic substance. We're constantly bombarded by gamma rays, ultra violet rays, bacterial toxins, free radicals, and many other potentially harmful substances. In excess, they can be deadly, but we are adapted to dealing with small amounts of them, and the right dose can even be beneficial in some cases.

All of the studies I mentioned above, except one, involved doses of glycoalkaloids that exceed what one could get from eating typical potatoes. They used green or blemished potatoes, isolated potato skins, potato sprouts or isolated glycoalkaloids (more on this later). The single exception is the last study, showing that normal doses of glycoalkaloids can aggravate inflammatory bowel disease in transgenic mice that are genetically predisposed to it (3)*.

What happens when you feed normal animals normal potatoes? Not much. Many studies have shown that they suffer no ill effects whatsoever, even at high intakes (1, 2). This has been shown in primates as well (4, 5, 6). In fact, potato-based diets appear to be generally superior to grain-based diets in animal feed. As early as 1938, Dr. Edward Mellanby showed that grains, but not potatoes, aggravate vitamin A deficiency in rats and dogs (7). This followed his research showing that whole grains, but not potatoes, aggravate vitamin D deficiency due to their high phytic acid content (Mellanby. Nutrition and Disease. 1934). Potatoes were also a prominent part of Mellanby's highly effective tooth decay reversal studies in humans, published in the British Medical Journal in 1932 (8, 9).

Potatoes partially protect rats against the harmful effects of excessive cholesterol feeding, when compared to wheat starch-based feed (10). Potato feeding leads to a better lipid profile and intestinal short-chain fatty acid production than wheat starch or sugar in rats (11). I wasn't able to find a single study showing any adverse effect of normal potato feeding in any normal animal. That's despite reading two long review articles on potato glycoalkaloids and specifically searching PubMed for studies showing a harmful effect. If you know of one, please post it in the comments section.

In the next post, I'll write about the effects of potatoes in the human diet, including data on the health of traditional potato-eating cultures... and a curious experiment by the Washington State Potato Commission that will begin on October 1.


*Interleukin-10 knockout mice. IL-10 is a cytokine involved in the resolution of inflammation and these mice develop inflammatory bowel disease (regardless of diet) due to a reduced capacity to resolve inflammation.

Snippets From A Conference on Health Care

The note-taking Disease Management Care Blog attended the World Congress Leadership Summit on Health Care Reform today. Thanks to a day of keynote presentations, panel discussions and audience questioning, the DMCB culled some of the more interesting pointers from the presenters:

State regulation of health insurance rates – to make sure they are reasonable – also means State responsibility for solvency. If a health insurer has to declare insolvency/bankruptcy, it’s up to the regulator to clean up the mess, which means helping to settle any outstanding claims. Up until now, that’s been a State budget issue. Members of the National Association of Insurance Commissioners (NAIC) fear Federal meddling in setting insurance premiums too low could eventually lead to some health insurers going out of business, leaving it up to the State taxpayers to have to step in.

Elements of health reform from 2012 to 2017 are vulnerable to two election cycles, one of them involving the Presidency. A lot can change between now and then.

Many employers are looking at the coming administrative hassles of providing health insurance and they don't like what they see. Dropping out and pushing employees into the State exchanges could lead to higher-than-expected number persons into the individual market, which may mean a need for higher-than-expected subsidies.

Health insurers in the individual market in Idaho and Maine are or will ask CMS for waiver of the 85% MLR rule.

Prior to passage of the Affordable Care Act (ACA), health insurers were required to convert to ICD-10-based claims systems. This considerable additional administrative expense is unfolding at the same time that the ACA is forcing insurers to maintain their medical loss ratios (MLRs) at 80% to 85%.

Thousands of self-insured employers, who pay claims every day, don’t buy the hard-ball demonization of the health insurance industry by the Obama Administration.

At the same time that the United States’ gross domestic product tanked, hospital prices increased.

Facing a death spiral in the face of looming guaranteed issue regulations, there are rumors that commercial health insurers are exiting the “child only” insurance market.

If the DMCB doesn't have it right, misheard or if anyone can clarify, please share.