Wishful Ideology About Integrated Delivery Systems

Kaiser Health News has posted a telling interview with former White House health adviser Ezekiel Emanuel MD. In it, Dr. Emanuel repeats a bold prediction about the end of health insurance companies:

Question: You also predict the end of insurance companies as we know them. Rather than continuing to function as the middleman between employers and health care providers, you say insurers may themselves contract with networks of doctors and hospitals, morphing into integrated health care delivery systems. But a one-stop shop isn’t always good for consumers. Networks are restrictive, and at least now, if your insurer turns you down for treatment, your doctor may go to bat for you.

Answer: I don't agree with you. In general, integrated systems do a pretty good job compared to lots of other ways care could be delivered. We like the adversarial system. We believe that’s the best. On the other hand, with integrated networks you can have better coordination of care. And people are mildly sticky. Once you pick an insurance network, you tend to stick with it. That's also good for the insurer. If someone selected you, year in and year out you'll be with them. That changes the dynamic. And to the extent people are long-term keepers, that’s going to be a better arrangement.

"Better arrangement?" The Population Health Blog isn't so sure:

1. As pointed out at the start of the interview, health insurance has been around for more than 200 years. Its staying power is testimony to the enduring value proposition of pooling and monetizing risk. We discard that our peril.

2. Assuming "integrated systems" will competently manage that risk is a stretch.

3. Part of competently managing that risk - even for provider groups - is utilization review.  While the interviewer unflatteringly portrays that as "your insurer turns you down for treatment," the truth is far more complicated mix of advantages and disadvantages that have been heavily regulated (an example here) for decades.

4. Can enlightened "coordination of care" make utilization review unnecessary?  The luxury of Dr. Emanuel's anti-health insurer ideology makes it easy for him to say yes.  So far, inconvenient facts about the ACO pilot program suggest a different story.

5. Plus, can restrictive networks also make utilization review unnecessary?  It remains to be seen whether consumers will appreciate the irony that this invention of managed care is now being embraced by Dr. Emanuel and other progressives, or agree that significant limits on provider choice will be a "better arrangement."

6. Last but not least, doctors like the PHB have been trained and acculturated to put the individual patient's interests before any other consideration, including the success of an integrated delivery system. Unable to say no, our loyalty will translate to the usual specialist referrals, sophisticated testing, the latest technology and the priciest drugs.  Culture trumps everything.

Like it says, the PHB isn't too sure.  Maybe with the right combination of patient incentives, decision support, shared decision making, risk stratification and tailored population health, integrated systems will ultimately prevail.  Time will tell.

Give credit, however, to Dr. Emanuel for being consistent over the last two years.

The same is true for the PHB.  Based on the emerging facts on the ground, the PHB still thinks the odds remain against Dr. Emanuel.

And the offer of a $1000 bet still stands.

The Latest Cavalcade of Risk Is Up!

Rebecca Shafer hosts the Cavalcade's round-up of risk-related posts. A wide variety of topics, including Wounded Warriors, venture capitalists, Aristotle, enterprise risk management and risk adjustment await your reading pleasure.

Enjoy!

Bikini Contest Prep: 10 Weeks Out

Just popping in to share a progress picture I snapped today- 10 weeks out from my bikini contest.  I am seeing good progress, but I also am standing tall and "sucking in"! ;)  I hope that in the next few weeks, I won't have to try so hard! 

I'm happy to be back home so that I can stick to my eating and training routine.  Last week I was off my game with the trip to Dallas and then the Gala on Saturday night.  But, being home, I can eat my food and on schedule.  It's a lot of food to eat, but I'm hungry every few hours, so it's perfect right now.   

Also, while I was gone, we didn't get much sleep, staying up with late-night pillow chats that I wouldn't miss, but paid for when I got home.  I'm back on my sleep schedule now (which is CRUCIAL for the workouts I'm doing.  I notice a huge difference in the difficulty level of my workouts when I haven't gotten enough sleep.  Like, I want to quit and go home, but my trainer keeps me going.   I tend to be a night owl, but I find myself being ready for bed by 10:00 p.m. now.

I have to do posing practice for the show too.  I went to one session and it was terrible.  My coach said I was stiff and couldn't twist enough- she said I needed to get massages to loosen up . . .   My next posing practice is Friday, and I hope it goes better!  It feels ridiculous, but I don't want to embarrass myself on stage.

My trainer measured my body fat last Thursday, and it was down to 21% (from 25% when he first measured it).  I also lost 3 pounds.  I'm not sure how accurate the measurement it, and I really want to go to a facility to get it tested with the Bod Pod y'all recommended, but I haven't made time for it yet.  

I found the first picture I posted when I started working out again after the New Year.  It was taken on February 6, 2014.   The second picture is the one I took today, April 29, 2014- so just about 3 months apart.  And I only started with my trainer 5 weeks ago.  I'm wearing the same sports bra in both pictures.  Seeing it this way makes me realize how far I've come.  I'm proud of my efforts!

Okay, off to bed!  Gotta get that sleep!  Thank you for following in this journey with me!

Handling HHS Secretary Nomination Questions

The Population Health Blog notes that HHS nominee Burwell has been scheduled to appear before the U.S. Senate Health, Education, Labor and Pensions Committee on May 8.  In all likelihood, the hearing will alternate between yawnfest softball and hyperparisan gotcha questions on the budget, ACA repeal, agencies and contraception.

The PHB plans on watching C-SPAN, hoping that some of the questions deal with its favorite blogging topics.

In the unlikely event that they do come up, the public-service minded PHB is pleased to prep Ms. Burwell with some "canned" and ready-to-go responses. The turnkey options below have been crafted to upend foes and friends alike.

When asked any question about "population health," respond by:

1. pointing out that you rely on the Population Health Blog's definition and, based on its author's many insights, believe that it is a promising feature of health reform, or....

2. affirming that "if you like your population health, you can keep it," or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of population health as an important option to derive high value care for Medicare beneficiaries!

When asked about the part of the Obamacare law that includes "shared decision making," respond by:

1. noting years of research on the topic have demonstrated that it is among the few interventions that can simultaneously reduce health care costs and increase beneficiary satisfaction, or...

2. reiterating that Congressional Republicans are not going to share in any decision making when it comes to any health care reform, or....

3. saying that HHS remains strongly committed to evaluating and further developing the future role of shared decision making as an important option to derive high value care for Medicare beneficiaries!

When asked about the Patient Centered Medical Home, respond by:

1. quoting extensively from the PCPCC web site, or...

2. announcing cautious support for the medical home, but confirm HHS' intention to name it something else, create alternate criteria, assess different outcomes and insist on budget neutrality, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of the Patient Centered Medical Home as an important option to derive high value care for Medicare beneficiaries!

When asked about care management, respond by:

1. pointing out that, for the right patients, studies like this show teaming between physicians and non-physicians can result in outcomes that are the result of more than the sum of its primary care parts, or...

2. announcing your intent to regulate the carbon footprint of all Medicare-participating acute-care hospitals, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of care management as an important option to derive high value care for Medicare beneficiaries!

When asked about primary care, respond by:

1. not saying that the 10% fee increase has resulted negligible changes in primary care physician satisfaction, or...

2. promising you're going to fix low primary care fee schedule rates faster than a Florida ophthalmologist submitting a $10,000 Medicare billing code, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of primary care as an important option to derive high value care for Medicare beneficiaries!

When asked about the sustainable growth rate, respond by:

1. Denying any White House responsibility, or....

2. Denying any White House responsibility, or...

3. Denying any White House responsibility

Image from Wikipedia

Fat vs. Carbohydrate Overeating: Which Causes More Fat Gain?

Two human studies, published in 1995 and 2000, tested the effect of carbohydrate vs. fat overfeeding on body fat gain in humans.  What did they find, and why is it important?

We know that daily calorie intake has increased the US, in parallel with the dramatic increase in body fatness.  These excess calories appear to have come from fat, carbohydrate, and protein all at the same time (although carbohydrate increased the most).  Since the increase in calories, carbohydrate, fat, and protein all happened at the same time, how do we know that the obesity epidemic was due to increased calorie intake and not just increased carbohydrate or fat intake?  If our calorie intake had increased solely by the addition of carbohydrate or fat, would we be in the midst of an obesity epidemic?

The best way to answer this question is to examine the controlled studies that have compared carbohydrate and fat overfeeding in humans.

Horton et al.

Read more »

Commitment Devices, Behavior Change and Population Health

A new addition to the
behavior change tool box

Whenever the Population Health Blog encountered a tobacco user in its clinic, it would gauge the patient's readiness to quit. For those patients who were ready, it then established a future "quit date" (to facilitate planning), a "contract" (a jointly signed prescription for display on the home fridge) and advice to use any money savings (tobacco is expensive) for a nice reward once seven days of success (for example, a restaurant dinner) was achieved.

The PHB didn't know it at the time, but that seven-day reward was a variation of a "commitment device."  That's what it learned after reading this just-published JAMA manuscript by Todd Rogers and colleagues.

Commitment devices are a way that "present" persons can commit their "future selves" to a sufficient level of needed behavior change.  The threat of a penalty, such as the loss of a night out on the town, imposes a limit on future choices and makes success more likely. 

Other examples of commitment devices described by the authors include applying cash to a success contract (for example, employers could link a bonus to participation in a exercise program that would otherwise be lost), "temptation" bundling that limits access to a gratifying experience in exchange for "consistent" behaviors (used with repeated success by the crafty PHB spouse), limiting bad choices to small packages (smaller portion sizes) and partnering (to avoid disappointing a buddy who shares the commitment).

In retrospect, "commitment devices" have been used in population health for decades.  As Rogers et al point out, however, despite some good research on how effective this approach is, they're generally underused by providers and patients.  One potential way to overcome that is to offer them routinely on an "opt-out" basis, 401k savings-plan style.  The authors also point out that a series of commitment devices on a longitudinal basis could be used to blunt drop outs and maintain long-term behavior change. Last but not least, leveraging social networks with or without handheld "apps" remains an area ripe for future research.

As medical homes spread and shared-risk payment reforms gain traction, the art and science of commitment devices will likely grow. Not only is it a cool piece of insider jargon ("Hey, Mary, I like this care management proposal, but have you any plans to develop commitment devices?"), but any addition to the behavior-change tool box can only help.

Image from Wikipedia

Eating Healthy When Traveling

With 10 weeks until my fitness bikini competition, I'm getting a little freaked out.  The meal plan I'm on is really tough, mainly because it's boring to eat the same thing over and over and over.  I have not been perfect, but I'm doing pretty well.  I flew to Dallas for two days on Thursday and in preparation for the trip, I brought food so I could stay on my meal plan.  My flight was only an hour, so I packed my small skillet (perfect size for my protein pancake), Pam coconut oil spray, ground oats (for the pancake), brown rice, and protein powder in my checked luggage.  My local friend Cassie brought me frozen chicken, veggies, and egg whites. 

We lucked out and landed in the penthouse suit of the hotel that was equipped with a stove and microwave, so I was able to prepare some meals.  But, nothing is easy.  The room was so high-tech that we couldn't get the stove working and the engineer had to come 3 times to get it to work.   My protein pancake had to be cooked in a special skillet designed for the stove and pretty much fell apart, but I ate it anyway.  (My pancake is just 1/2 cup of ground oats, 3/4 cup egg whites, 1/4 cup water and cinnamon).  I have been "cheating" and eating it with a trace amount of natural peanut butter spread on top. 

My chicken, rice, and veggies were easy to microwave and I had that several times during the trip.

But, I wasn't perfect.  I ate pita chips and hummus, small part of a chocolate bar, and a glass of champagne at the pool.  

Thursday night at dinner I ordered a buffalo burger with no bun and a side salad without dressing. We  ate dinner at a Mexican restaurant on Friday night, and although I ordered iced tea (when everyone had margaritas) and skipped the chips and queso, I ordered grilled chicken with onions, rice and beans and devoured it.  

Saturday morning before my flight, I didn't have time to eat breakfast before heading to the airport (besides an apple and peanut butter) so  before my plane took off I grabbed a turkey sandwich and just ate the turkey out of it since the bread was soggy.  And I had my Starbuck's iced tall 2-pump mocha on Saturday and Sunday.  Yikes.

At our school Gala on Saturday night, I had two glasses of champagne and on Sunday I had a piece of pizza!

I know that strictly sticking to the meal plan is key, so I'm going to be on it this week.  Tomorrow is a new day!  Last Friday I got my body fat tested again by my trainer and it went down from 25% to 21% in just a couple weeks, which is good progress.  I've found the best way to get through sticking to the meal plan is to just put it on auto-pilot.  Don't think about it, just do it.  The good results I'm seeing keep me motivated to continue.

I'll post a progress pic soon!

LOVE THE HATERS

Yes I do.  I love my haters and I will share that typically those who are “hating” or critical of others really do desire to be loved.  There is something down deep inside of each of us that longs to be accepted and  feel good enough, and when hate comes to the surface it usually defines deep insecurities or unresolved issues within a person.  The ability to be motivated or happy by or for another is replaced with bitterness, jealousy, and to the point of “hating” a person for their accomplishments.  Because I realize that there are underlying factors involved with “hating”, I can look past comments and know that it is not about me when my haters come to calling.  Lately, I have received lots of negative comments, and especially when I share motivational posters that feature me in fitness wear or bathing suits.  If I allowed the negative posts I receive to negatively impair me as a person, I really do not have any business being an internet personality.  I have been in this industry for thirty years, and have read and heard my share of negative as well as the positive.

The only thing in this life I can control is me, and I let go of all the rest.  What I share with you comes with pure intention to motivate you to live a healthy life, and if that is not well received that is the chance I take, and the positive will always outweigh the negative in my opinion.  The recent “hating” on my body and boobs with a post focus/motivation  to live a healthy lifestyle, exercise, eat healthy,  or be happy with self is a clear demonstration of people that are not happy with “self” and feel the need to project and vent their frustrations.  The sad part about hating on the internet is the people acting out the behavior do not know the circumstances or life journey of the person they are criticizing.  Let’s use breast augmentation as an example in general and the possibility that the woman making this choice is doing so for cancer reconstructive purposes, or has been involved in an auto accident which has disfigured her breast, or to feel better about herself by gaining a more proportionate figure, or to regain fuller breasts post pregnancy of one or more births and breast feeding her blessings in life, and the list of reasons can go on and on.  I had a girlfriend who was out for a jog and an unleashed dog attacked her, leaped at her breast and pulled it off her chest, which took months of reconstructive repair.  We all need to realize, accept, and appreciate that personal choices belong to each person and that it does not make that person fake or a “bad” example.  In fact, it could be this person’s life story that can reach out and help others in similar situations.  It really comes down to if you do not have anything nice to say, do not say anything at all. 

Wouldn’t life be grand if all of us were pro-positive of each other, supportive, motivating and complimentary?  The sad truth is that life is not that way, and within this imperfect world we are imperfect people trying the best we can to deal with unfair issues in this life.  That is the point of it all to be happy, and become a better person each day through our journey.  That is not accomplished riding in the “hate” wagon of life.  So whether it is a new house, car, clothes, body, face or your life in general, haters will hate because you possess something they don’t.  Their inability to figure out how to obtain happiness within their own self and life can create a very upset and angry person who copes with frustration through “hating”.  They deal with personal feelings of inadequacy after comparing themselves with others by turning themselves on what they think is making them feel upset…Me, You, Us.

Understanding the psychology of people has helped me a great deal in my journey of life, and has enabled me to develop a “turtle shell” skin that shields me from the negative drama in life.  Also, knowing that there is a lot to be said and appreciated with that old saying “sticks and stones may break my bones, but words will never hurt me”.  I think it also comes down to maturity and realizing that life is too short and precious to not be surrounded by positive and to choose to be positive in life.  Loving my haters is a decision to persevere through adversity, and a choice to continue motivating no matter what the cost.  Also, I do wish for their health and happiness deep down and regardless of the negative, I get people talking and learning through the process.  That is a great thing! 

Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list.  If you are inspired, LIKE my entry, leave a comment and I look forward to responding!

StayHealthy!

Darla

The Latest Health Wonk Review Is Up

Louise Norris hosts a wide ranging Health Wonk Review at her smartly-written Colorado Health Insurance Insider. Like prior HWRs, Louise summarizes and links the best health policy bloggers on topics like the high price of Hepatitis C treatment (follow the money), Medicaid (does it really save lives), how the competition in Mexico is taking a bite out dentists' fees... and so much more.

Enjoy!

Questions That Should Be Asked in the Upcoming HHS Secretary Nomination Process

As a public service, the Population Health Blog is pleased to offer up some questions that may or should arise in the course of Senate confirmation process for HHS nominee Ms. Burwell. 

If she can address the inquiries in these key categories, the PHB suggests she'll be more than prepared for the job:

The Clinton years: Supporters of the Affordable Care Act say "it is now the law of the land."  Based on your extensive experience in the Clinton White House, how would you define "is?"

Signing up young people: Do you credit the last-minute surge in sign-ups on the individual exchanges to Mr. Obama, Mr. Galifianakis or to the Two Ferns?  How will you use that insight to increase individual enrollments in 2015?

Use of social media: Since the Population Health Blog began on-line publication more than 5 years ago, health care cost inflation has moderated significantly. Please explain how Medicare's actuaries will factor this into their future projections.

Doing your part for the 2014 mid-term elections: Will you advocate that the "essential health benefit" be broadened to include coverage for global warming?

To test your awareness of the employer mandate: If Peter Baelish hires 47 part-time seasonal service employees in KIng's Landing for more than 120 continuous days in the first quarter of 2014 without a profit sharing provision, what is the number of FTEs and what would the "4980H penalty" be if it were calculated in Gold Dragons?

And finally, tort reform:  Suppose Iva Pannus buys taxpayer subsidized insurance but also participates in a workplace weight reduction program. If Iva's girth paradoxically increases and she develops sore knees, should she sue in state court to recover her out-of-pocket "bronze" plan expenses and should HHS assert a lien if there is a jury award?

Image from Wikipedia

Discovering What We Don't' Know About Risk-Adjustment for Hospital Readmission Rates in Medicare

Something like this?

When the Population Health Blog agreed with the spouse that it was time to replace the living-room gas fireplace insert with something more sleek and modern, it then turned its attention to changing the surrounding mantle. The PHB favored something heraldic, featuring partially-garbed warrior babes, sporting shields and sandals. Cherubs too.  Preferably oak.

After some counseling from the PHB spouse, it came to realize that its wayward tastes in interior design may be a function of going sans helmet during its childhood bicycle riding, its deepening appreciation of bourbon's mysteries and pausing too frequently on Fox News' The Kelly Files. 

Naturally, the PHB wants to know the relative influence of each. Increasing exposure will help it propose some ideas for the unfinished basement.

Hospital administrators are dealing with a similar problem when it comes to readmissions.

Approximately 20% of discharged Medicare beneficiaries come back within 30 days. In response, CMS financially penalizes hospitals with high readmission rates for heart attack, heart failure and pneumonia. To reduce that penalty, hospitals have asked about the quality of their care, discharge planning and follow-up outpatient care. 

But, what is the relative impact of each? Where should administrators focus their corrective actions? 

Or, like the PHB and interior design, are readmissions ominously outside of anyone's control?

According to some interesting research, it turns out that more than half of the variation in readmissions may be outside of hospitals' control.  What's worse, CMS doesn't account for that in its calculation of the penalty that uses patient factors, such as age, gender and illness burden.

That's the conclusion of this recent article appearing in HSR Health Services Research.

Herrin and colleagues correlated CMS's Hospital Compare readmission data with each hospital county's socioeconomic data (rural vs. urban, persons living alone, employment status and educational level), access to care (the per capita density of primary care and specialist physicians as well as hospital beds) and nursing home number and quality (the number beds and the number of high-risk, long-term patients with bed sores).

Based on risk-adjusted rates from 4,079 hospitals in 2,254 counties, the authors found that more half of the variation in hospital readmissions was statistically explained by the counties' data.  That included persons living alone, low educational attainment, urban setting, a higher number of Medicare beneficiaries, fewer primary care physicians, fewer nursing home beds, higher numbers of nursing home patients with bed sores.  More beds and more specialist physicians were also independently associated with higher readmission rates.

The Population Health Blog's take?

As it noted previously, much of the vituperation around the unexplained variation in health care has been less a function of an inefficient health care system and more a function of our inability to identify the underlying drivers of utilization.

And now we're getting better. The HSR article shows that when it comes to readmissions, much of that variation is a reflection of the poverty in our neighbors' homes as well as the strength of the primary care network and the ability of nursing homes to act as a cushion.

Hopefully the mandarins at CMS will take these findings into account as they continue to financially sanction hospitals for readmissions. A more sophisticated approach to risk adjustment could help lessen the budgetary impact of county-level factors that are outside the hospital administrators' control. 

And since hospitals' bottom lines typically reflect the populations they serve, better risk adjustment could also lessen the disparate impact on the nation's poorest hospitals.

Image from Wikipedia

I'm From CMS and I'm Here to Help

Writing in JAMA "online first," CMS Administrator Tavenner and colleagues offer a payment reform "framework" that includes "multipayer collaboration."  The article is wonky, so the Population Health Blog dons its universal adminispeak translator so us normal humans can better understand what CMS is up to.

According to the writers, CMS has a history of innovatively implementing reforms that were later adapted by other insurers. The most famous example is the hospital "DRG" system that, starting in 1983, paid for a diagnosis in lieu of a daily room rate.  Suddenly, hospitals had an incentive to shorten hospital stays, which is precisely what happened in the years that followed.

Buoyed by this success, the authors describe the merits of championing Medicare's transition from "category 1" fee-for-service without any link to quality to "category 4" population-based payments that are linked to quality. And, as CMS embarks on this excellent payment journey toward accountable care, they'll get other commercial insurers to mirror their efforts by:

"Being conveners" as in "working with" other insurers in a region or a state to implement large payment reforms.  Working with may include grants;

"Incentivizing," as in requiring the participation of other payers prior to funding any large pilot programs.

"Working with states" to implement additional reforms, when the state has sufficient influence over the health insurance or delivery system.

The Population Health Blog's take:

"Category 4 population-based payments" are a form of capitation that are ultimately designed to transfer insurance risk from CMS to providers. The PHB hopes the bureaucrats at CMS are aware of the risk re-introducing some 1990s-style managed care abuses. 
 
What also goes unmentioned by the JAMA article are examples of CMS payment reform unintentionally gone awry, including RVUs, regional payment variation and the SGR with lingering fraud. While CMS has had its successes, it's also had more than its share of problems.  Time will tell which track record will apply to population-based payments.

Convening was an art developed by Medicaid programs.

Ms. Tavenner implies that population-based payments (a form of capitation) are intrinsically linked to quality.  Nothing could be further from the truth, since it's possible to reward quality while also relying on a FFS methodology. 

Accountable population-based care remains a large experiment.  Ms. Tavenner implies that there is an aura of inevitability.  The PHB learned long ago that the sign of a good plan is an exit strategy in case things go south.  The PHB didn't read that here.

HAPPINESS DOESN’T JUST HAPPEN

Wouldn’t it be nice to wave a magic wand, and all of life is just how we wanted it to be?  We are blessed with the gift of life but how we live it is up to us, and that takes effort and choices.  There are consequences, hard lessons learned and happiness along the way, but ultimately it is in our choices that create the life of happiness we all desire.  Sometimes we do not even know what we want or how to create this happiness, and wander around going through some sort of life motions that we learned from healthy or unhealthy example.  Choosing the right way to create a life of happiness is quite the goal, but like anything else that takes time and effort, it is worth the journey to get there. 

I have gone through the ups and downs of not being happy in this journey of life, and have held onto the hope that God has a greater plan than I can ever imagine. Life has not been what I thought it would be as I contemplate it, but I am thankful for the life lessons of each circumstance that created an opportunity for me to learn and grow in positive ways. It took a choice for me to go to counseling during tough emotional times, to go to physical therapy during horrific physical times, and to rough up my knees in prayer during doubtful spiritual times.  All the choices to become a better person were in search of a happiness that I wanted in my life and I have always been in pursuit of all methods of work to reach that goal.

The pursuit of happiness also includes being a healthy person.  I believe that the two go hand in hand.  When we feel our best physically, it is easier to handle the emotional rides of life.  Also, when our “mental game” is healthy and our responses to life’s circumstances are handled with maturity, clarity, and good intentions this enhances our state of being healthy and happy overall. Happiness is a goal just like being healthy is a goal, and both are lifetime achievements.  There is no end to being a happy and healthy person, and each day is our chance to make choices toward being both. 

Easter seemed like the perfect time to share how important it is to be happy and healthy, and to take this opportunity to let you know that it is possible and necessary in this life.  Happiness does not just happen, but will take a commitment of self-discovery, and not being afraid to peel the onion and take a look at what is keeping you from being happy or healthy. This took years of work in my life, and I am thankful for it.  I will share that it has not always been easy, and nothing worth anything is, right?  My wish for you this Easter is health and happiness and for you to know that each day is a gift that provides a step closer to reaching those goals.  

Have a very Happy Easter from My Family to Yours

Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list.  If you are inspired, LIKE my entry, leave a comment and I look forward to responding!

Stay Healthy!

Darla

The Dichotomy of Medicare’s Data Release Policy: Moral Suasion and the Limits of Mass Data Transparency

The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

Medicare has had an interesting few weeks: Not only did Congress manage to pass another one-year “fix”  to the (unsustainable) sustainable growth rate reimbursement scheme, but planned Medicare Advantage cuts magically turned into a marginal increase (at least for some insurers) after deftly applied political pressure. This behind-the-scene politicking set the stage for CMS’s second massive release of provider data last Wednesday. Although the data release may further codify extant evidence of some specialists being more richly compensated than their primary care colleagues, coupled with the potential pursuit of fraudulent claims, unfiltered transparency reveals Medicare’s weakness in providing useful transparency for beneficiaries. 

CMS formally released data detailing the 100 most common inpatient services, 30 most common outpatient services, and all physician and other supplier procedures and services performed on 11 more Medicare beneficiaries. The data included information on the doctor who performed the procedure, as well as the city and zip code where the procedure was performed. The biggest related take away seems to be a rather intuitive one: specialists, particularly cardiologists, ophthalmologists, and oncologists, are the biggest recipients of Medicare reimbursements: The three groups of specialists accounted for 7% or $5.6 billion of reimbursements in 2012.

Some in the medical community have responded to the perceived public scorched earth exercise circumspectly: hell hath no fury like scorned ophthalmologists. Valid questions, however, have emerged not only regarding the veracity of released data, but also the lack of context: some individual provider numbers may serve as a pass-through for entire practices, and a longitudinal release of data might allow for a more accurate picture of how service and drug utilization has changed as the country’s demographic profile has grown older. 

In response, CMS and politicians have responded that the benefits of “transparency” would likely drive more cost-effective care with less waste. Putting aside concerns of what transparency actually means in this context, an economist might ask a more apposite question: while the literature shows that public excoriation (in limited doses) may be effective in reducing price variance in an established legislative framework on the supply side, where are equivalent measures to empower consumer (demand–side) decision making?

To perhaps put a finer point on it: while variance in the pricing of procedures by hospitals and providers is certainly a problem, an equal problem is the variance in treatment across patients using non-cost effective treatments and medical devices that add little or no value to outcomes.  On this critical point, CMS and their data are silent. While further data releases may address this critical lacuna in consumer information, it is not likely: statute prevents the agency from making drug and procedure approval decisions explicitly based on costs.  Thus, an odd dichotomy has emerged in Medicare’s transparency campaign: exposure of the downstream cost equation (doctors), while leaving the curtain back on the furtive upstream costs including the RUC committee and other important input prices that would help consumers to make more informed decisions. 

The conflation of releasing big data with transparency is not a fatal error. Numerous useful data products may ultimately be developed as a result of CMS’s efforts.   A bigger problem, however, may be the asymmetrical use of moral suasion to expose doctors to the glare of public scrutiny without giving consumers information on the cost and outcomes related to technology and drugs use. If transparency does not result in more informed decision making, some would argue it is not transparency at all.

Sculpted Ab Routine (Just 3 Exercises)

As I mentioned yesterday when I shared my meal plan, I'm currently 12 weeks out from my first bikini competition and this week, I start doing my ab exercise routine everyday.  I have definitely seen improvements in the last two weeks in the toning/tightening of my stomach. I'm sure it's a combination of my clean meals, workouts/cardio, ab exercises, and perhaps this cream I've been using.  The picture below was snapped on Monday morning (April 15, 2014).  

Now that I'm 12 weeks out, I'm doing my ab exercises every day.  I do 3 exercises in a row, and repeat them 4 times.  These exercises can be done in the comfort of your own home too.  

1.  Leg Raises- 20 reps

When I'm at the gym, I do leg raises on the roman chair.  

via

At home, you can do them lying on the floor.  

via

Watch the video HERE.

2.  Medicine Ball V-Ups- 15 reps 

These are really hard, but I'm getting better at them.

Watch the video HERE.

3.  Russian Twists- 20 reps

I don't use any weight, I just sit on the floor and touch my hands to the floor on either side. 

Watch the video HERE.

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Seven Things You Need to Know About The Overt Fun and Covert Benefit of Health Gamification

Channeling all this energy for
health and wellness?

The networked Population Health Blog got an alert about this just-published article on the "gamification" of health from the Games for Health Journal

The PHB was only vaguely aware of the growing medical literature that uses humans' love of gaming to promote healthy behaviors, increase prevention and mitigate chronic disease.  And it certainly wasn't aware that there was a entire journal dedicated to the topic.

In this particular article, author Brian Landwehr introduced the PHB to the term "gamification." Using "overt" fun to achieve "covert" benefit, gameplay is combined with virtual or real rewards to engage patients in behavior change. 

Examples include using:

~ videogaming, wireless mats, smartcards and monitors to increase and reward physical activity in children;

~ email/text to remind expectant mothers about appointments and healthy behaviors that are paired with incentives such as gift cards, baby toys and health and safety gear;

~ mobile health apps that track exercise and nutrition choices to earn discounts on merchandise.

What seven things did the PHB learn after reading the manuscript? 

The technology is

1) in its infancy, but it's already being launched in settings that involve thousands of people;

3) utterly scalable, since it can be offered today to entire school districts or fully-insured books of business;

3) very modular, using a surprising amount of "off the shelf" technology that are adapted and combined to build "prototype" products

4) creates products that can also quickly become obsolete thanks to the creation of better and cheaper replacement prototypes;

5) very entrepreneurial, which is one of the drivers behind gamification's surprising growth

6) substitutive when it replaces in-person education, or synergistic when paired with live health coaches

7)  cool because "gamification" is innovation jargon that the PHB cognoscenti can use in meetings and emails to impress their colleagues and stymie their opponents.

Image from Wikipedia

Garden Update: A Banner Year

Things are warming up here in Seattle and the flowers are blooming.  I just planted my first crops of the year-- potatoes and strawberries.

2013 was a banner year for my 500-square-foot urban vegetable garden, including my first experience growing and processing a grain.  I never got around to posting about it last year-- so here it is.

Interbay mulch technique

The bed on the right has been mulched with leaves, spent coffee
grounds, and burlap sacks ($1/sack at the local hardware store).
The beds on the left were planted with a rye-clover-vetch-pea
cover crop.  Paths are mulched with wood chips.

In the fall of 2012, I tried a new technique for improving the soil called "Interbay mulching".  This is a variation on sheet mulching, which involves placing uncomposted organic matter directly onto the garden soil in fall and letting it compost until the next growing season.  To Interbay mulch, you simply cover your sheet mulch with burlap.  This keeps everything moist, protects earthworms from bird predation so they can munch freely, and suppresses weeds.  I used leaves (carbon) and spent coffee grounds from a local coffee shop (nitrogen) for my organic matter.

When I pulled back the burlap last spring, I was initially disappointed.  The coffee grounds had disappeared completely, but there was still a lot of leaf matter left on the soil, indicating that it had only partially composted.  However, I later decided that it had worked well, because the soil structure underneath was improved and it seemed to be enriched with significant organic matter as well as a large population of fat earthworms.  The mulch suppressed weeds remarkably well, and the beds remained mostly clean for the rest of the season.

Those observations, combined with huge yields from the mulched beds, convinced me that it was worthwhile.

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12 Weeks Out // My Bikini Contest Meal Plan

This week we're turning it up a notch in both the workouts and meal plan.  I still have fat to lose so, right now, there will be no fat in my diet, no sugar, no dairy.  I have to say that the meal plan is not very exciting, just a balance of lean protein, carbs, and veggies - 5 times a day.  

This is similar to how I've been eating, but there are things I'm cutting that I previously had been enjoying:  coffee with creamer (I can have coffee but don't like it without a lot of creamer, so I'm trading it for black unsweetened tea), peanut butter and syrup (on my protein pancake), peanut or sesame oil, egg yolk, low sodium soy, salt-free seasoning (in my stir fry), and milk (in my cheerios), nuts.  

Keep in mind that this meal plan was given to me for my specific goal of competing in a bikini contest in 12 weeks, and based on where I am in my fitness journey.  I'm sharing it with you partly to document my process and partly to just give you an idea of what these "fitness girls" eat like if you're curious. 

Here are some examples of lean proteins and carbs:

Protein:

• Tuna or most any fish.
• Cottage cheese.
• Eggs (especially the whites).
• Chicken breast (boneless skinless).
• Turkey breast (boneless skinless).
• Lean beef.
• Low fat or no fat cheese.
• Low fat pork.
• Milk protein isolate.
• Whey protein.
• Soy protein.
• Essentially most any other source of protein so long as it is low in saturated fat and carbohydrates.

Carbohydrates:

• Sweet potatoes.
• Oat meal, oat bran, oat bran cereal (i.e. cheerios).
• Bran cereal.
• Brown rice.
• Wheat bread (try to limit to 2 slices per day).
• Beans.
• Low fat popcorn (low fat butter spray makes this a delicacy).
• Fruits (limit to 2-3 servings per day).
• Malto dextrin (during workout).
• Dextrose (during workout)
• Vegetables.
• Stay away from refined grains and anything that says “enriched” or “high fructose corn syrup” on the label

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My breakfast (egg whites and oatmeal) will be made into a pancake and eaten dry (no PB or syrup)- boo. 

Meals 2 and 3 look something like below, on a smaller (9-inch) plate.  It is actually so much food.  This is 5 oz. boneless, skinless chicken breast, 6 oz. sweet potato, and 1 cup veggies. 

I'm still eating on the go a lot.  

Meal 4:  3/4 cup egg whites, 3/4 cup brown rice, and 1 cup mixed veggies cooked in a skillet with nonstick cooking spray, but no seasonings 

Meal 5:  Protein shake with one scoop of protein, 6-8 oz water, 2 ice cubes.  I make it like this because it doesn't make a huge drink. 

I'm now buying bags of frozen veggies and frozen chicken because it's so much food to keep preparing.   

And I bought a food scale that I really like so I can get the measurements exact. It's super easy to use and lightweight.  I poured through all the reviews and think this was a great choice- well worth the money.  

I think I will get one cheat meal a week and I'm already craving my iced tall 2-pump mocha from Starbucks.  But, I'm so excited to see the changes in my body.  I can't say I LIKE to eat this way, but I've never done it so cleanly or consistently and I have been wanting to cut sugar for a long time, so here we go.  Since the beginning of this journey I just keep thinking, "Do the work. Trust the process." 

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