0 Medicares Expenses Increased by 0 4 Really And Its All Because of the Affordable Care Act

If youre the head of Google and you want to teach about the internet, North Korea is a swell place to visit.  If your goal is air travel safety, the 787 Dreamliner is the plane for you.  If you would like to get the puck from an opposing professional hockey player, saying "please" helps.  And if Medicare costs dip, the Affordable Care Act (ACA) obviously deserves the credit.

Writing on an HHS website, Richard Kronick and Rosa Po announce that 2012 Medicare expenditures per beneficiary grew only by 0.4% over the 2011 baseline.  They credit the ACAs value-based payment (VBP) system, attacks on fraud and abuse, reduced payments to Medicare Advantage plans, cutting hospitals payments and "innovation."

The Disease Management Care Blog isnt too sure about that.

1. This Kaiser Health News article notes the VPB program withholds 1% of hospital payments and uses that fund to award bonuses in what is really a zero sum game.  And this Health Affairs article suggests the overall financial impact of VPB on hospitals is quite minimal anyway. 

2. While there have certainly been some big fraud and abuse busts, theres plenty of reason to still be skeptical about the ability of Medicares ossified bureaucracy to catch up with the sophisticated criminal enterprises that are routinely fleecing billions from the U.S. taxpayer.

3. As for the one-time payment cuts to providers and insurers, the DMCB is confident that theyll figure out ways to get their money back.  They always do.

4. The innovations are in demonstration phase.  Its too early to tell.

In addition, the DMCB is surprised that Medicares 2012 insurance claims were ready to be rolled up and quantitated in early 2013. Check out this telling quote from the website:

"2010 and 2011 statistics are calculated on a calendar year incurred-basis. 2012 statistics are calculated on a fiscal year cash-basis, because calendar year incurred-basis data are not yet available." (bolding from the DMCB).

Last but not least, the DMCB believes the lackluster economy has probably had the biggest impact on consumers willingness to use their Medicare benefit.  While Kronick and Ro state" Medigap" insurance benefits have protected the beneficiaries from the financial pain of Medicares out-of-pocket expenses, the expense of using a hospital or seeing a doctor is more than the sum of all those medical bills.

Is the DMCB being too skeptical?  Perhaps, but this particular HHS spin is built on assumptions that are backed by associations that are biased by partisan loyalty.  Taxpayers deserve better.

Image from Wikipedia

0 Medicare Accountable Care Organizations Medical Homes Experimental Potential or Essential

Time to measure some
new Medicare office drapes?

One major and longstanding criticism of CMS numerous innovation and demonstration projects is that they seldom lead to any meaningful orm of the core Medicare program.  In response, the Affordable Care Act created an "Innovation Center."  Despite legions of lobbyists, a third rail dread afflicting our political class and a powerful Medicare voting bloc, the intrepid folks in the Center promise to deliver insights that will advance quality, lower costs, increase access and spare all sacred cows.

Naturally, the thousands of health care experts who regularly read the Disease Management Care Blog have their doubts.  As a result, theyre unlikely to be moved by Karen Davis and colleagues "Medicare Essential" proposal appearing in the May issue of Health Affairs.

Assuming that the most wildly optimistic Accountable Care Organization (ACO) and medical home pilot programs projections are fulfilled, Dr. Davis et al propose the creation of a new "Medicare Essential" program that would co-exist with standard Medicare and Medicare Advantage.

"Essentials" essential purpose would be to finance ACOs and medical homes.  Given the authors enthusiasm, the DMCB is surprised that their Health Affairs paper isnt also recommending measuring drapes for the programs new offices.
 
In "Medicare Essential," Parts A (hospital), B (providers) and D (drugs) would be combined. There would be a single overall deductible, followed by low co-pays for primary care and higher co-pays for specialty and emergency room care Preventive care would have first dollar coverage. Pharmaceuticals would be governed by a single national formulary with low co-pays for generics as well as for perred brands and condition-specific/value-based drugs. Persons in the "Essential" program who are receiving care in ACOs or medical homes (financed with capitation, bonuses, gain sharing and monthly fees) would naturally have even lower co-pays.
 
Using "modeling by the Actuarial Research Corporation" and, as the DMCB understands it, transferring all savings back to the beneficiary, monthly out-of-pocket costs for the average Medicare enrollee could be reduced from the currently level of $427 to $354.  As an added bonus, if the patient used an ACO/Medical Home, the out of pocket would be further reduced to $254.

Case closed, right?

The DMCB isnt too sure.

Dont Measure Those "Essential" Medicare Program Office Drapes Quite Yet: While Davis et al should be commended for sending the savings back to the patient instead of Uncle Sam, their optimistic actuarial "research" projections cant be based on any consistent, statistically significant and real-world published proof.  Thats because there is no consistent, statistically significant and real-world published proof that ACOs and medical homes save money.  Come back, says the DMCB, when you have an analysis based on some real numbers.

Behavioral Economics: Furthermore, we dont know if monthly beneficiary savings of $73 to $173 are enough to move market share away from Medicare and Medicare Advantage to "Essential."  Thats doubly true if ACOs and medical homes, despite their quality, are viewed by patients as another way to impose a restricted network.

Disease Management Playbook: Advocates for the earliest versions of disease management likewise used official sounding projections to confidently project huge benefits for the Medicare program. When reality rudely intruded, the industrys fall was spectacular and almost fatal.  With friends like Dr. Davis similarly doubling down with huge ACO and medical home promises, who needs enemies?

Reinventing A 3rd Wheel? Many Advantage plans have similar co-pay arrangements and are already investing in ACO-like and medical home programs in their networks. They are likewise more than able to leverage out-of-pocket expenses to incent beneficiary behavior.

Suppose You Gave An ACO Party and Nobody Came? The last time the DMCB looked, many parts of the country lacked fully functional ACOs and medical homes. Dr. Davis says beneficiaries will respond by demanding local access to the Essential program and theore turbocharge additional health orm. The DMCB is unaware of any published data that supports that notion and, furthermore, wonders if the local lack of these programs will translate into even more variation in the U.S. health care system.

0 The Dilemma of Medicare Coverage of Reasonable and Necessary Care and Why Its Important

If you get sick, health insurance should cover all the "stuff" necessary to make you better, right?

While that sounds good in principle, Uncle Sam has made it a lot more complicated than that.  As we continue to struggle with health orm, this New England Journal article on "Medicares Enduring Struggle to Define Reasonable and Necessary Care" is very timely.

According to Drs. Neumann and Chambers, Medicare has always covered medical services that are "reasonable and necessary." As new approaches, drugs and medical technologies have been released, youd think coverage would be based on an objective analysis of outcomes and cost effectiveness.

Youd be wrong.

Years of differing interpretations, patient advocacy, Congressional meddling, regulatory carve-outs and case law have generated a miasma of bureaucratic complexity that will guarantee the incomes of thousands of lawyers for years to come.

Not that CMS hasnt tried to be reasonable about "reasonable and necessary." According to the article, in 1989 CMS specifically proposed that the words "cost effective" could be used to assess new technology. That proved too controversial. It later tried "least costly alternative language" for coverage of durable medical equipment and Part B medications.  This too was dismantled by the courts when plaintiffs argued that the term "reasonable and necessary" could only be applied to medical services, not to the costs of those services.

How ironic. Even though CMS is making "value-based purchasing" judgements for hospital payments and costs can be factored in the coverage of preventive services, that still doesnt apply to new technologies and drugs.

The latest dysfunction is CMS pretzel logic of "coverage with evidence  development" approach to medical devices, essentially agreeing to coverage that is conditional on CMS evaluation of additional outcomes data.  Unfortunately, CMS ability to collect and interpret these kinds of data in the current political environment remains an open question.

Outside of Medicares cost travails, why is all of this important?

1) Medicares price tag was $509 billion in 2010, taking 12% of the federal budget. While there are other drivers of cost, such as aging, coverage arrangements, income, pricing, administrative costs and defensive medicine, technology could account from 38% to more than 65% of the current growth (inflation) in spending.  Medicares historic inability to control this does not bode well for future cost projections.

2) This is not a partisan issue and there are no partisan solutions.

3) Commercial insurers generally use Medicares coverage criteria to define their own benefit structure.  Medicares problems are everyone elses.

4) This is another reason why Medicare is banking on ACOs.  By delegating management and the associated risk of all these thorny coverage issues, theyre hoping ACOs can do within three years what CMS couldnt do in three decades. Well see.

0 Of Intellectual Enclaves and Self Reinforcing Media Crossing The Health Care Reform Divide

Watch for and report any
contrary opinions!

Theres an interesting Saturday Essay in The Wall Street Journal that describes the self-perpetuating socioeconomic-neighborhood enclaves that separate Americas "haves" and "have nots."  Its turning out that zip code is not only associated with health, its becoming associated with destiny.

Not only fascinating, says the Disease Management Care Blog, but the essay reminds it of the pernicious twin intellectual enclaves in the health care debate.  While the progressive-liberals and the market-oriented conservatives in D.C. remain stuck in their closed information loops, the political process has been boiled down to the Supreme Courts nine lawyers and vague threats to unilaterally "repeal Obamacare."   Yikes, says the DMCB, the Dark Knights Joker had it right: we deserve a better class of politician criminal.

And if you think Newt is being wacky over the media bearing some responsibility, check out this NPR interview with the author of the book The Information Diet.  Unrepentant lefty Clay Johnson points out that the news outlets are becoming less of a solution and more of a problem.  By serving pre-digested and ined reports that cater to our pre-existing biases, organizations like CNN, Fox, The New York Times and The Wall Street Journal are creating an epidemic of intellectually obese brains that are hooked on the sugar and fat of what wed like to know, not what we should know.

Which is why the DMCB steeled itself, stepped outside its right-of-center comfort zone and sat through this C-SPAN broadcast of pro-Obamacare Jonathan Gruber being lobbed softballs by the fawning attendees at a Seattle Town Hall.  It makes for a spirited retread of the merits of enlightened central government, the villainy of the health insurers and the intrusion of politics, even as Dr. Gruber characterizes opponents as either 1) uneducated or 2) mistaken.  Thats why hes written this comic book designed to help both classes of simpletons.

The DMCB suspects its readers wont need to order a copy.

+++++++

As an aside, the Penn State graduate DMCB sadly notes the passing of Joe Paterno, the recently fired Penn State football coach. Despite his legendary stature, even "JoePa" was no match for the toxic Sandusky scandal.  It wasnt too long afterwards that Coach Paterno was diagnosed with what was eumphemistically characterized as a "treatable" form of lung cancer.  Occasional news reports since then described an increasingly frail 85 year old man struggling with the side effects of his cancer treatment.

Like many friends and colleagues, the DMCB wondered if the "stress" of his ignominous departure was the real cause of his death.  According to this Psychosomatics case series of 43 lung cancer patients based on used of the Hospital Anxiety and Depression Scale, baseline depression was associated with a poorer 6 month survival, but not overall survival. 

In other words, they die sooner.
 
Image from Wikipedia

0 What Is The Difference Between Pay for Performance and Accountable Care Organizations

Wheres that evidence?

The Disease Management Care Blog has occasionally wondered about the difference between pay for performance (P4P) and accountable care organizations (ACOs).  While the latter involves a more explicit transfer of risk, it thinks the underlying logic for both is ultimately the same: better quality performance should translate into less sickness, fewer specialist physician visits and reduced hospitalizations which, in turn, should save money that can be shared with the providers.  Assuming thats true, the possibility of getting that kind of money should prompt physicians to prevent, coordinate, counsel, immunize and screen instead of treat, er, ignore, not immunize and hustle out the door.

Unfortunately, a recently published Cochrane Review says otherwise. 

The DMCB likes CRs because they are state-of-the-art and highly disciplined reviews of the worlds scientific medical literature.  In this instance, after an exhaustive examination of every published paper on the topic of P4P, the authors conclude....

"....there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."

The DMCB will be the first to argue that academic, rigorously conducted, randomized and controlled clinical trials are not the final answer when it comes to managing the subtle complexities of physician behavior change.  The DMCB has run into some very smart and passionate physician leaders who have few doubts about the real world links between P4P, increased quality and reduced cost.

That being said, given the commonalities between P4P and ACOs, no one should assume that ACOs are going to succeed based on any notions of "evidence" that the promise of savings will translate into a changed physician workforce.   Cochrane says it just aint there.

0 The 12 Population Health and Care Coordination Colloquium

Mark your calendars for Philadelphia Feb 27-29, 2012! 

This premier educational event is a must for anyone interested in population health and care management.  More information on attending virtually or in person can be found here.

0 The Heartbreak of Not Regularly Reading the Disease Management Care Blog

Upon the death of Dear Leader Kim, North Koreans discover that state censorship under his regime had prevented them from regularly reading the Disease Management Care Blog......

0 Hewlett Packard and the Disease Management Care Blog Part Company

Most DMCB friends, colleagues and enemies are aware that it had a half-time job at HP as a Medical Director of Analytics.  Two days ago, as part of reduction in force involving over a 100 individuals, its position was eliminated.

First and foremost, the DMCB is very grateful for having gotten to know so many smart and dedicated information technology professionals. They are a credit to HP and are the very definition of high worth human capital.  They also taught the DMCB about the value of relationships underlying countless emails and conference calls that form the living fabric of a world class IT company. 

Some of the very smart ones even read this blog.  The DMCB hopes they stay in touch.

Working for HP was also a DMCB eye-opening educational experience.  Among the more important lessons learned:

The Cultural Crosswalk: While many of the DMCB physician colleagues work in small business settings, our health care culture - despite its imperfections - is imbued with a commitment to social mission and patient service. That contrasts with HPs culture of maximizing shareholder value and the customer always being right.  That mix of non and for profit incentives accounts for much of what is both very good and not so good about the U.S. health care system.  That being said, some health care providers could learn a lot from from HPs approach to "customer facing" interactions.

The Gold Rush: The DMCB has come to believe that, just like dot.com and mortgages, there is a health care bubble underway. While thats been obscured by a moribund economy, a perfect storm of boomer demographics, consumer demand and government largess continue to fuel increasing employment and capital investment in the health care sector. When that kind of gold rush builds, success has less to do with "prospecting" and more to do with selling shovels.  While ACOs are taking considerable risk and medical home advocates think $3 per patient per month is a good deal, companies like HP are selling network architecture and servers at a very tidy profit.

Sales: There is no underestimating the days of strategizing, worry and planning that go into a seemingly innocuous customer sales meeting.  In the past, when the DMCB was on the "buy-side," it thought of vendor meetings as a one hour pitch.  It has since learned that the "sell-side" is an expertly crafted event designed to define the problems, present the solutions, forge relationships and land a maximally profitable contract. The DMCB will never underestimate a sales representative again.

The Social Contract? While the DMCB grew up in an era of employment being a lifelong commitment to a company that ended in a gold watch and a retirement party, those days are long gone. Employment is now a mutual agreement to exchange a work product for compensation. The DMCB witnessed the transaction being unilaterlly cancelled by co-workers as well as by the company many times. While the DMCB was on the receiving end this time, it knows that its exit from HP is just business.


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0 Big Data and the Coming New Value Proposition for Disease Care and Wellness Management Providers

Disease Management Care Blog readers know that the its latest interest is "Big Data." While the researcher-DMCB has played in the sandbox of some insurance claims data sets, the idea of combining and combing through multiple terrabytes of clinical and public data remains a topic of endless fascination. It knows its not alone.

So, it was only a matter of time until one of the major clinical journals published an article on the topic. JAMA has stepped forward, and not a moment too soon.

Its "must reading" for the disease and care management provider community.

Drs. Murdoch and Detsky point out that Big Data offers four value propositions:

1. Observational correlations may generate insights that cannot be found using standard research approaches. Scanning text for key words in electronic record systems involving hundreds of thousands of patients may find associations or trigger early warnings faster, quicker and cheaper than any formal scientific protocol or clinical trial.

2. Those insights, especially since they can be tailored to fit the circumstances of an otherwise unique patient, can be used to guide diagnosis or treatment. Physician judgement cannot be replaced, but if Big Data points out that there were other patients with a similar pattern of illness who responded best to one treatment versus another, patient outcomes could improve.

3. A Big Data approach to genomics can correlate genetic information with outcomes and further guide therapy. While the DMCB still wonders if "genomics," outside some narrow anecdotes, will always remain the science of the future, Big Data may turn out to be the key to finally unlocking its potential.

4. Since Big Data, by its very nature, can combine clinical information to other personal data (the foods youve bought or your driving history), Big Data will necessarily tilt toward the patient-consumer and away from the health care system. Not only does permission for access lie with the patient, but the insights will be less about sickness and more about wellness.

The authors do a good job of pointing out that there are plenty of challenges. Most doctors dont get it, privacy laws could be over-interpreted or enforced, it remains to be seen who will pay for it and Big Data is still in its infancy.  The DMCB also points out that while Medicare has just discovered that alternative research innovations are possible, Big Data promises to eclipse those approaches (like traditional time series analysis, propensity matching), again making CMS a day late and another dollar over budget.

The implications for the care management and population health community are considerable. The industry has amassed years of intellectual capital in the science of predictive modeling and Big Data is its next step. Many care management vendors have multiple clinical partners and already have access to terrabytes of data involving millions of persons. Not only is the math and the informatics well within reach, they also "get" the tilt toward wellness and consumer empowerment. Last but not least, if anyone can monetize a value proposition like this and turn insights into revenue (or "shared savings"), these nimble vendors can.

A DMCB prediction: while academics will write about Big Data in scientific journals, the care management industry will be doing it.  In fact, they probably already are.

Two particularly good quotes to use to impress your CEO and stymie your competitors:

"Data has gone from use to riches."

and

Economic theory describes the quantitative conversion of 3 kinds of inputs (capital, labor, and raw materials) into outputs (goods and services)...The current revolution in data management makes it clear that a fourth kind of input, information, will become just as important as these other inputs in the future of many industries.

0 Health Care Tithing

As Mr. Romney continues his uninspiring march toward the Republican Presidential nod in Tampa, voters will have a chance to familiarize themselves with the practice of religious "tithing."  

If giving up 10% seems like a lot, the Disease Management Care Blog says think again. The concept may not be all that foreign after all, because Americans practically (if unknowingly) already "tithe" to health care.

The amateur economist Disease Management Care Blog cannot resist and naively explores the implications of tithing, beginning with a "thought experiment."

Imagine two neighboring towns. One is populated with persons who earn $50,000 a year. The other has richer persons who earn $100,000 a year.  Assume that, for both towns, voluntarily buying comprehensive health insurance costs $10,000 a year (according to the White House, an average premium is $12,680 a year).

Smart DMCB readers know that $50,000 isnt necessarily a lot of money. Persons in that lower income town wont have much left over after they pay for clothing, food, housing, transportation and energy (and in the case of the DMCB spawn, internet access, gaming consoles, tatoos, cable TV and consumer electronics).

Persons in the higher income $100,000 town can afford the basic necessities and more.  That means once income passes a certain threshold, the top margin is comparatively more disposable. That makes makes the option of buying expensive health insurance bearable.

In other words, the richer town can effectively "tithe" by devoting a big percent off the top to health insurance and health care.  While the cost of clothing, food and housing are elastic, those necessities come first.  Health insurance has to wait its turn.

With that in mind, check out the following infamous, public domain and very downloadable graph.  No PowerPoint on health care costs is complete without it.  While this one is from 2002, the 2006 data can also be easily accessed and arent much different. While the U.S. is wealthier on a per individual ("capita") GDP ("gross domestic product") basis than the rest of the developed world, it spends far more per individual than would be expected:

Most economists explain that big the gap between the U.S and the other countries represents "waste" from the economic drag of evil insurer-driven administrative costs, unnecessary care in an economically  misaligned non-system, an overindulgence in specialists, our love for the latest technology, a widespread belief in taking drugs for every ailment and time wasted reading the DMCB.

All that (except for the DMCB reading) may be true, but the DMCB also wonders if the graph above is a display of a world filled with $50,000 towns and one $100,000 town. The DMCB thinks its only natural to for a uniquely wealthy country to be willing to spend much of its excess "top" income on health insurance and health care. When that happens, spending will mathematically jump and the U.S. will appear to be a "nonlinear" outlier.

Functionally, thats tithing.  The DMCB doesnt think thats unexpected.

Of course, the economics of wealth and health care is more complicated.  Wealth not only results in "parallel" increases in spending (allowing the purchase of dried cranberries for tonights salad or outfitting that man-cave with miniature gargoyle statuary) but "serial" increases that also lead to the purchase of new goods and services like health care. It may not mathematically equate to 10%, but it is still a fraction that is taken off the top. 

The U.S. can afford to commit the top margins of its excess income toward health insurance and health care. Its also "all or none," which may also explain some of the non-linear and disproportionate non-linear compared to other countries.

Contrarian economists have been arguing this for years, but the DMCB never heard it described as "tithing."  While health insurance has "stolen" income from U.S. employees paychecks and employers profits, whats also happened is that that economic damage is partially limited to top "excess" levels (or brackets) of our nations business and personal income.

You heard the concept of health care tithing here first.  That being said, the DMCB can think of some wrinkles:

1. The Fat Lady teaches that humbly religious tithing takes the first 10%, even if there are other necessities. The political version of that in the U.S. is "entitlements."

2. The other "$50,000"countries devote a percent of their budget to health care, but the DMCB thinks that theyre buying "perence insensitive" care at the lowest level of service.  Thanks to our wealth, the U.S. can technically afford to indulge in perence sensitive care services - and the variation that comes with it.

3. Many persons in the U.S. are very low income and cant afford any care.  Thats true, but thanks to our GDP, they get the worst of both worlds: they have the appearance of a higher than average income compared to the world without the ability to pay the tithe.

4. Just because were willing to "tithe" doesnt mean were getting our moneys worth and that there isnt diminishing marginal utility.  We arent and there is.

5. If inflation and stagnant wages are eating away our ability to pay for the more basic necessities, its easier to stop tithing and jettison health insurance altogether. That means were less able to cut health care by 10% to make up for a 10% increase in the cost of other goods and services. This may partially explain ....

1) why persons are willing to completely "drop" their health insurance and use 100% of the top marginal money for lifes more basic necessities;

2) why employers would be willing to drop health insurance altogether as a benefit.  We may be underestimating the likelihood of a flood of persons being pushed into the individual market when the ACA kicks in.

6. Tithing is an expensive proposition.  No wonder Professor Fuchs is proposing a simple solution: pay for it all with a VAT.

7.  Think the cavernous edifices, expansive lobbies and pricy stonework of premier health care institutions sometimes make them resemble cathedrals? Now you know why.

0 Why Population Based Care and Disease Management Can Increase Access to Primary Care

If the population health management (PHM) service industry needed just one evidence-based medical journal article to justify its existence, it couldnt do better than this. Writing in the New England Journal of Medicine, Amireh Ghorob and Thomas Bodenheimer advocate for Sharing the Care to Improve Access to Primary Care.

The authors argue there can be only one solution to the twin challenges of dwindling primary care physician (PCP) numbers and the increasing burden of chronic illness : reallocating clinical responsibilities away from PCPs to empowered non-physician team members. These responsibilities include, but are not limited to a) prescription drug monitoring, titration and renewals, b) scheduling and processing of routine blood testing (like cholesterol) and imaging studies (like mammography), and c) counseling patients about lifestyle changes, medication adherence and their perences, priorities and goals for their chronic conditions.

In order for all this to happen, Mr. Ghorob and Dr. Bodenheimer suggest two ingredients will be necessary: 1) payment orms that make teaming profitable and 2) physician compromise over their long-cherished notions of control.

Thats precisely the approach that has been used by the PHM vendors for decades.

They have nurses, they rely on the teaming, they can manage routine prescriptions, testing and counseling and they can do it for a relatively small monthly fee. Theyve also learned their lesson: the vendors are doing a much better job of navigating through the doctor-patient relationship and discerning the important differences between clinical responsibility and busy-work control.

A far less important issue is the location or level of service provided by the non-physicians. 

The Disease Management Care Blog argues that sorting that out is a local decision based on physician perences, pre-existing clinical infrastructure, history and organizational culture. Highly integrated systems may per to achieve teaming by transforming their primary care sites into medical homes. Less integrated networks may per a shared services model that in or outsources the teams. 

The point is that there is no one-size-fits-all approach to relying on teaming to increase access to primary care. Dr. Bodenheimer has confirmed which are the basic ingredients.  Now its time for the rest of the system to figure out the details.

0 Should Patients in Population Health Management Programs Have Access to Lay Care Coaches

Based on prior posts like this, the Disease Management Care Blog thinks the answer is yes. 

That being said, this hot-off-the-presses research paper shows just much we need to learn about this emerging approach to the care of persons with chronic conditions like diabetes, high blood pressure and chronic heart failure.

Lay Persons Educating Persons With Chronic Conditions in Primary Care Clinics

The paper was just published in the Annals of Internal Medicine. It was a one year randomized study involving the patients at six Allina Health primary care clinics. 

Twelve lay "care guides" had at least 2 years of college education and "strong interpersonal skills." They received two weeks of education that included setting goals, identifying and overcoming care barriers, behavior change techniques, the limits of scope of practice and how to use the electronic records to message physicians.  It was up to the care guides and the patients to decide on how often they needed to meet in face or by telephone. The guides were supervised by two RNs.

Active (i.e. seen in the clinics within 6 months) patients who agreed to be in the study with high blood pressure, diabetes or heart failure were allocated in a 2:1 ratio to either a "care guide" or usual care. Goals were proscribed and were the usual HEDIS-style outcomes, such as achieving blood pressure control, reaching an A1c level, getting an echocardiogram, being on beta-blocker medications or getting a pneumovax immunization.
 
The study was not "blinded," in that they and their providers were aware of the assignment. Recruitment began in July of 2010 and the study was completed in April of 2012. 6168 patients were screened, 2135 patients agreed to participate and 1423 and 702 completed the study from the care guide and usual care study arms.

Results?

One year later, 82.6% of the care guide patients achieved their selected care goals vs. 79.1% of the usual care patients. That 3.5% increase was statistically significant.

Most of that improvement was accounted by a higher rates of tobacco cessation, pneumovax immunization, getting persons with diabetes to get an eye exam as well as urine protein testing, and getting persons with heart failure to go through an echocardiogram.  There were no statistically significant impacts on blood pressure control, diabetes control, cholesterol control or medication prescribing.

The care guides interacted with their patients on average 7 times (2 face-to-face and 5 by telephone).  They messaged physicians an average of 4 times.  There was no difference between the two groups in primary care office visits. Estimated cost was $286 per patient per year.

The Disease Management Care Blogs take:

There is increasing interest in incorporating lay-persons in the outpatient care of persons with chronic conditions.  That makes sense, because much of the educational "payload" may be deliverable using far cheaper and more engaging "peer" members of the community who - literally - speak the patients language.  This is a nicely done randomized clinical trial done in a real world setting that adds to our understanding of this care option. The bottom line is that this study showed that the care guides had a real impact.

When the DMCB looks at the actual numbers, it is also clear that the study had an uphill climb.  Many of the baseline measures of blood pressure, diabetes and heart failure quality relatively high to begin with. The impact of the care guides may have been much greater in a population with a lower baseline (such as in this study) with more "room" to move.

Problems to think about for the next study.....

Not all outcomes are created equally: Unfortunately, this study was something of a disappointment because the improvements were spotty, relatively small and limited to lightweight "testing" outcomes vs. more -hard-to-achieve disease control outcomes.  It may one thing for a peer patient to talk a patient into a urine test or a heart scan, its another getting a patient to take more pills.  That may take a professional educator, a pharmacist or nurse.

What do the patients want: In addition, the goals were based on a one-size-fits-all HEDIS approach.  They were not adaptable, negotiable or subject to shared decision-making.  If that had been in the mix, patient engagement may have been an additional ingredient that could have pushed other outcome measures toward statistical significance.

What do the docs think: The DMCB notes that provider office visits did not go down among the care guide patients compared to the usual care patients. This makes the DMCB wonder if there wasnt enough physician buy-in: if there had been higher trust in the care guides ability to manage these patients, it would have been reflected in less need to see the patients for a separate appointment.

Predictive modeling to the rescue: Finally, there is the problem of treating all chronic illness patients the same. Not all patients with high blood pressure, diabetes or heart failure are as susceptible to behavior change, and not all patients who engage in behavior change achieve better outcomes.  The trick is to use risk stratification to find the patients with the greatest chance at benefit.  This study may have benefited from a more focused approach.

0 BackBone Care Keep your body position

BackBone Care - Spinal pain is often ignored. In fact, once the main supporting bone of the body was disturbed, pain attacks and impaired productivity. Not surprising considering the spine is a dynamic object that holds the load of each of our activity.

Later, Andi often disturbed pain in his left. The result of the scan at the hospital turned out to have bearing prominent in the neck so that pinch nerves. "The pain disappeared arise," he said.

The doctor suggested that the defective part is replaced with implants. However, he was worried because many people who say the high risk in a series of spine surgery. Hesitate to risk the operation, pain was forced to hold-resistant.

As two-legged creature that stands upright, the human spine is an extremely vital organ as it works to sustain weight loss. Spine bone covering the neck (cervical), the middle back (thoracic), and lower back (lumbar/waist).

The series of spine divided into segments and between segments of the joints and bearings are composed of layers of structure. Serves to protect the bearings so that in between the bones do not clash.

The muscles that support the spine helpful.

Spine surgeons from the Spine Center Hospital Ramsay Premier Bintaro, Lutfi Gatam, say, the load on the spine while sitting, working, and carrying enormous loads. Lightest load spine only when we sleep.

Complaints most disorders of the spine is generally in the form of pain on the bottom (low back pain).

"Complaints are dominant because most of our body weight fall at the bottom so easily injured," Lutfi said, while giving exposure in the Kompas daily of "Spinal Problems", last week.

Causes of spinal disorders include muscle disorders, broken bones, bearing a damaged (broken/torn), interference with the joint or a mixture of several factors for tumors, cancer, and infections.

In people with normal spinal structures, spinal problems often caused by the activity of motion and posture.

Risk factors that, for example, repetitive heavy lifting, bending, and excessive movement. Static posture, such as sitting too long, is also a risk factor. Overworked muscle contraction and occurs continuously so there is a complaint.

From: KOmpas.com

0 Anti Aging Diet And Skin Care

Depending on how much exercise and sleep youre getting, and how much
water you are consuming, you can see results from a diet rich in
antioxidants in as little as three days. You can feel the difference
right away energy-wise.

ANTIOXIDANT ALTERNATIVES:
* Citrus fruits like oranges and lemons contain vitamin C.
* Liver, fish oil, and eggs contain vitamin A
* Nuts and avocados contain vitamin E.
* Fish, red meats, chicken, grains, and eggs contain selenium.

INGREDIENTS WITH BEAUTY BENEFITS:
* Cherries, bananas, tomatoes, and ginger fight inflammation.
* Nuts, eggs, peanut, butter, oats, and liver strengthen nails and hair.
* Grapes, blueberries, and red wine prevent sun damage.
* Kiwi fruit, citrus fruits, wheat germ oil, nuts, and leafy greens repair
damaged skin.

DID YOU KNOW: Eating foods with high water content, like cucumbers,
can help reduce surface dryness.

0 Homemade Skin Care Recepies

HsayaEMADE SKIN CARE RECIPES:
* Avocado is a natural skin firmer. It works particularly well on the neck area.
* Baby wipes are perfect for removing makeup or just for cleansing

the facial area.
* Baking soda naturally exfoliates the skin, while softening it as well.
* Coffee grounds can help you rub away that unsightly cellulite.
* Egg whites deliver an instant facelift. Just apply the whites
directly to wrinkles and remain perfectly still until they
dry.
* Eye drops with anti-reddening properties can be applied to
pimples during the day to help disguise them.
* Olive oil is a rich moisturizer that doesn’t irritate the
skin.
* Toothpaste will work in a pinch when pimples pop out.
* Yeast improves blood flow and circulation and is very
rich in B complex vitamins.

HOW TO REMOVE SKIN TAGS NATURALLY !
* Clear nail polish can also be used to remove warts.
* Tea tree oil is a strong antiseptic and alleged to work well for removing

skin tags.
* Oregano oil is known as a strong agent that can help

fight infections, inflammations,viruses, and bacteria.
* To stop itchy and burning skin use walnut or almond oil and apply.

This will leave the skin soft and itch free for 3 to 7 days.

0 Steps To Reduce Frizz In Your Daily Hair Care Routine

Frizzy hair can ruin your hairstyle or even cause you to have a bad hair day. Now a days there are even more ways than ever to keep frizz at an arms length, whether you wear your hair straight or curly, or go outside or stay indoors. Frizz occurs when moisture enters the hair cuticle causing it to swell. Take steps to reduce your frizz throughout your hair care routine. To prevent frizz you must start at the very beginning, in the shower, then continue with drying, and styling. The right products, treatments and techniques will seal the hair cuticle to protect your hair from frizzing.

In the Shower

Start your frizz free hair care routine in the shower. What you use in the shower, how you wash your hair and how often you wash your hair all contribute to whether your hair will be frizzy. Use a gentle sulfate free shampoo to clean your hair. Many shampoos contain the lathering agent sulfate, which can dry out hair, by stripping it of moisture. Dry hair is at greater risk for frizz. Next time you are shopping for shampoo check the label for sulfate free ingredients.

After conditioning, rinse your hair with cold water. This is an essential step in avoiding frizzy hair. Warm water opens up the cuticle allowing you to clean the hair shaft, but if you use warm water to rinse your hair the cuticle will stay open allowing moisture in and the hair shaft to swell. Cold water seals the cuticle closed reducing your risk for frizz.

When you are done in the shower gently squeeze out excess water from hair. Instead of rubbing your hair with a rough towel, which can rough up the cuticle, press and squeeze hair with a soft towel or paper towel. You can also wrap hair with a towel to allow it time to dry itself.

While hair is still damp apply a leave in conditioner to seal in needed moisture and lock out excess moisture. A weekly deep conditioning treatment is pivotal to fight frizz. A light weight mask or gloss applied one time a week will replenish the hairs lipid barrier to prevent breakage and repel moisture. A conditioning mask can be applied in the shower and left on for five minutes. Apply a gloss as a protective outer coat to infuse shine and smooth hair.

Do not wash your hair everyday. Over washing can dry out your hair, leading to damage and frizz.

Drying Hair

When blow drying hair use the concentrated nozzle to make the air come out in a flat plane instead of in a circular flow. Aim the air downward to avoid ruffling the cuticle. This flattens the cuticle to the hair shaft. By using a round brush, separate out sections and pull the hair taut. Avoid whipping your hair back and forth, which can disrupt the cuticles exposing them to moisture, and ultimately frizz. Finish off with a blast of cold air to secure a smooth cuticle.

When wearing your hair curly the best defense against frizz is to dampen hair. When coming straight out of the shower apply a cream, serum or oil to wet hair. Apply product evenly through wet hair from root to tip with your fingers. Twist hair into long loose curls and allow hair to air fry. If using a blow dryer, make sure to use one with a diffuser to speed up the frying process. Keep the blow dryer nozzle pointed down. In between shampooing use a curl-refreshing product to eliminate frizz.

When you wear your hair straight start by applying an anti-frizz product to protect hair from the environment such as humidity and rain. Then blow-dry with hot air concentrating the air downward and finishing off with a blast of cold air. In between shampoos use a dry shampoo to extend the time between washings and the use of heat styling tools.

Once hair has dried avoid playing with it. Touching and flipping your hair can aggravate frizz. Its a hard habit to break especially when you leave your hair down.

Plan for the Weather

Be prepared for a rainy day. The humidity that comes with rain can cause your hair to frizz up in an instant. Before you go out add a few drops of frizz serum to your dry hair.

If its a hot, humid day, forget about washing your hair. The natural oils that the body produces act as a barrier against moisture. Its best to use a flat iron or curling iron on steamy days. The combination of heat and pressure will seal the cuticle to the hair shaft very tightly. This way moisture cant penetrate the cuticle and cause frizz.

Authors Resource Box

Sarah Labdar graduated with a BA in exercise science and has worked in the medical field since. Her focus is alternative medicine and how it interacts and works in conjunction with traditional medicine. Better Health-Live your Life to the fullest! - http://www.universalhealthinfo.com/Steps_to_Reduce_Frizz.html

Article Source : Steps To Reduce Frizz In Your Daily Hair Care Routine
Author : Sarah

0 Skin Care Tips

The following skin care tips:

• Clean your face with a cleanser and toners that matches your skin type every morning and evening

• Apply a moisturizer. For women who are elderly may be followed by the use of serum and eye cream so that the skin does not look wrinkled. Moisturizer should be used not only in the morning, but also at night, for example, with night cream.

• Apply powder to face after using moisturizer. Use compact powder foundation and only at certain times, for example to makeup to invitations or other formal events. Avoid using makeup foundation for day-to-day so that skin pores remain untreated.

• Perform maintenance on a face mask at least once a week and scrub the face at least once a month. It is important to remove dead skin cells and keep the skin moisture and treating pores.

• Always clean your face before bed, either with a facial wash or cleansing milk. This is to prevent the occurrence of acne on the face.

• Use a body lotion or body cream to the entire body after bathing so that any moisture is maintained. For a frequent activity in the sun, do not forget to wear a moisturizer with SPF and UV filters.

• Take a bath at least 2 times a day, or any time after the activities that drain sweat. Use soap that matches the type kulitBerolahraga taking care of oneself.

0 Beauty Care with Fruit Seaberry

Besides Acay berry and goji berry, fruit Seaberry is a good source of antioxidants for the skin. Seaberry fruit which has a yellowish red color has been widely used for beauty products because of its antioxidant benefits.

Aware of the side effects of chemical products, many people have turned to natural products for beauty products. And one fruit choice is seaberry are believed to have antioxidant benefits for beauty and health.

Seaberry contains Vitamin A, B1, B2, E and 10 times more Vitamin C than oranges, and all content is beneficial for anti aging. Seaberry also rich in omega 3, 6, 9, including a very rare omega 7 useful produce collagen and maintain youthful skin moist.

0 Choosing a facial skin care product

Talking about sore care, �facial abrasion care' seems to top the architecture. There are loads of facial skin care products available in the market. The surpassingly common facial skin care products are the ones that are used as part of daily routine. These take things delight in cleansers and moisturizers. Toners and exfoliation ones are well close too but not bounteous people use them as such.

The general classification of facial gall care products is based on the following:

* Gender (so crackerjack are facial canker burden products over men and able are facial skin care products for women)
* Skin type (facial sore products because oily skin, facial skin care products for wilderness skin, facial skin care products for normal graze and facial scratch charge goods for allergic skin)
* Age (facial skin care products for lapsed and facial canker care products for young)
* Skin infection (i.e. facial skin care products for treatment of various skin orders like eczema, acne etc)

So that is your starting point thanks to choosing a facial scratch care product that suits you. A convenient coming to start is by decisive your skin type first. and note that the skin singularity changes shroud age, ergo the facial skin product that suits you today, might not action you gigantic and hence you need to constantly evaluate the effectiveness of your facial canker anxiety product.

The facial skin care products are available in various forms i.e. creams, lotions, gels, masks etc, and a lot of people try to pit one against the other direction their discussion on which form is principal. However, one can't really standard one perform as better than innumerable shape. What suits you (and whatever you are comfortable with) is the boss form of facial skin care product for you, really.

However, it's important to note that these products happening differently for altered people. So the best thing is to try the facial skin care essay on a meagre patch of gall (e.g. grasp lobes) before actually going ahead and using it.

Another important consideration is the state of your sore. If you are suffering from a skin disorder of any kind, it is best to travel the advice of a dermatologist before you altogether make your selection and start using a facial skin hardship product.

Once you opine selected the facial skin care pull for yourself, you also libido to ensure that you use the facial skin care product in the right road i.e. follow applicable procedures for application, use the opportune quantity and make the facial product a part of your skin care routine.

0 Exactly How To Take Care Pregnancy

Health for human | All men want to have offspring. this can be done by way of engaging in sex. after the fertilization process successful it would result in the pregnancy. Pregnancy is an amazing event. From the beginning of fertilization (conception) to the growth of the fetus in the uterus, showing the hopelessness in the face of the divine beings, how great is His love, and how extensive his knowledge.


In the helplessness that, in the shade of his rahman and uterus, and the limitations of our science as a human being before him of the vast, he elicits an obligation to us to keep praying and endeavors in an effort to reach the condition of mother and baby are healthy. In this case, that we must understand, prayer and effort is a unified entity.

Often times we say, "We have endeavored, now living prayer." With say so, without realizing we have subordinated the prayer. In fact, if we reflect, we must make fundamental base of all things-even more problems with pregnancy, is the omnipotence of the Creator. Therefore, prayer should be fused with the endeavor.

Many things that we must understand in prayer and effort it. Starting from the problem of intention to technical implementation. These include the scale of priorities that must be made and adhered to, because not infrequently we prioritize less important things and left some very important things. For example, we prefer to spend the money on hand for the event Monthly Seven-a more directed at traditional rituals or traditions, rather than using it for a scheduled prenatal care.

We often overlook things that we think are trivial, such as good diet and the need to prepare before delivery. However, also keep in mind is the need that is not the same as desire. Setting up the diapers and baby clothes is a necessity, but set the thing by buying an expensive product, it is the desire or passion alone.

As fully described in the book Smart Guide to Pregnancy Muslimah (QultumMedia, 2009) that there are various steps that must be done by pregnant women. Starting from the welcome pregnancy, the first phase until the third trimester of pregnancy, up to delivery.

The author, Yazid Subakti, S.Si. and Derrick Anggarani Rizki, S.Gz. provide appropriate measures so that the mother and the baby safe and sound. What is also at the same time incorporate between prayer and effort.

These measures will reduce the risk of pregnant women and simultaneously push the quality level that is expected births by everyone. Baby healthy, strong, and smart, and safe motherhood.