Michigan physicians are more focused on medical homes and accountable care organizations and more optimistic about careers in medicine. Coincidence?

A recent article in Crains Detroit Business reported the results of a national physician survey conducted by The Doctors’ Company, a large malpractice insurer. According to the survey, 10% of physicians nationally report plans to convert their practice to a “medical home” model. But, that number was 27% for Michigan. Nationally, only 14% of physicians are interested in joining an accountable care organization (ACOs). But, in Michigan this number was 25%.

Why are Michigan doctors twice as interested in medical homes and accountable care?

Steven Newman, M.D., president of the Michigan State Medical Society, attributed it to the fact that Michigan physician organizations have been working on this for a long time. I was proud to see that he called out Blue Cross Blue Shield of Michigan as being one of the drivers. BCBSM’s Patient Centered Medical Home designation program has been going on for 4 years.  Its Physician Group Incentive Program (PGIP) has been going on for 8 years.   Its Collaborative Quality Intiatives (CQIs) have been going on for more than a decade.

Unfortunately, these things take time.  Fortunately, in Michigan, we started a long time ago.

My former boss, Tom Simmer, MD, CMO of BCBSM, has consistently emphasized the importance of using time as a lever of change.  And, he insisted on staying positive and respectful, focusing on building energy that can “catalyze” change by physicians and other health care professionals.  It seems to have paid off in terms of physician interest in medical home and accountable care transformation.  Although it is difficult to measure “energy,” a physician’s willingness to recommend a career in health care is as good a metric as any.  According to the physician survey, only 11% of physicians nationally would recommend a career in health care.  In Michigan, that number is 53%.  That’s huge.

We still have a lot more work to do before we can say that this long slog has resulted in substantial, measurable improvements in the overall quality of care, and overall reductions in per capita health care spending.  But, at least we have solid indicators that hearts and minds are optimistic and energized among those who will drive those improvements.

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The free market is at the heart of diverse debates in health care

Wil Rutt, MD, the founder of the Center for Clinical Effectiveness and my boss during the 1990’s at Henry Ford Health System, is retired.  But, he still has an interest in the improvement of our health care system, and he still sends interesting articles to provoke thought and constructive dialog.  This week, Dr. Rutt sent two New York Times articles, asking for a response.   I found it interesting that both articles, seemingly unrelated on the surface, have in common a failure to appreciate the value of free, competitive markets in health care.

Supreme Court Decision on Health Care Reform

In the first article, Adam Liptak discusses the upcoming Supreme Court decision regarding the health care reform law, describing it as a career-defining decision for Chief Justice Roberts.  Conservative political leaders are against the law.  Many such leaders have argued against the constitutionality of the law on the grounds that the mandate that people purchase health care insurance extends the power of the federal government to regulate interstate commerce beyond the intentions of the framers of the constitution.  This debate is interesting in that it cuts across different facets of conservative thought: the libertarians, the free-marketers and the “haves.”  The libertarian-leaning side of conservative thought focuses on maximizing personal liberty by minimizing government power.  The argument against the health care reform law’s expansion of federal commerce powers is completely consistent with this aspect of conservatism.  This argument is also aligned with the interests of the “haves” (recently re-labeled the “1%” by those at the opposite end of the political spectrum).  Except perhaps for Warren Buffet, who argued in a NY Times Op Ed that tax rates should be increased for anyone with annual income over $1 million, wealthy Americans are usually not eager to foot the bill for social benefits for others, particularly not for expensive and rapidly escalating health care benefits.

But, the free-marketers seem to be taking a back seat on this issue.  Free marketers are skeptical that a monopoly provider of health care insurance services will be efficient and maximize value.  For this reason, free marketers loathe the notion of a federal government-run single payer system.  They prefer a market with multiple competing private health insurance providers, with just enough government regulation to ensure that competition is real and that consumers are properly informed and protected.   Such a competitive private market has worked well for property and casualty insurance, where the risk of loss can be assessed by the insurer almost as well as by the insured.  But, in health insurance, the insured have superior knowledge of their own health status.  Therefore, it is a widely held belief by health economists that if insurers are to be forced to offer insurance to everyone, it is necessary to have a mandate for people to purchase insurance to make a private health insurance system work.  Without such a mandate, health economists fear that too many people will wait until they know they are sick to buy insurance, forcing insurers to raise rates.  This dynamic is described as “adverse selection” and is thought to eventually lead to a death spiral where private insurers fail. According to this view, if you don’t mandate the purchase of private health insurance, you are implicitly sabotaging a free, competitive market for health insurance that can support near-universal coverage.  The only alternatives are a government monopoly, paid for with mandatory taxes, or a continuation of a broken system that fails to insure tens of millions of Americans.

It seems to me that a coalition of the libertarians and “haves” within the conservative community have overpowered the free-marketers.  Republican presidential candidates are being forced to reject the mandate as a condition of being worthy of being a “true conservative” (despite the fact that both Gingrich and Romney have supported such mandates in the past!).

Milton Friedman

Remember Milton Friedman, the Nobel laureate economist from the University of Chicago?  He used to be considered a conservative.  He was a free market conservative.  He advocated for universal tax-funded high deductible health insurance, administered by the government or through vouchers that could be used to purchase such insurance from private insurance companies.  He advocated for the elimination of Medicare and Medicaid, the elimination of tax exemption for employer-provided health insurance benefits, and for the adoption of medical savings accounts.  All of these proposals were aimed at having consumers bear the costs of non-catastrophic medical care so that free market mechanisms apply, as they already do for other necessities of life such as food and shelter.  If Dr. Friedman were alive today, he would probably not pass the current test of being a “true conservative.”   I call for the free-marketers to speak up.

America Stealing Doctors from Third World

In another New York Times article served up by Dr. Rutt, Matt McAllester describes the “brain drain” of physicians from third world countries who seek training in the U.S. and then stay in the US.  Such physicians stay because they will have access to the latest technology and they can make ten times the salary they would earn in their native countries.  The article portrays this as unethical behavior by the US that harms the third world countries.  The article does not advocate for any particular remedy.

In my opinion, it is necessary to take a broader view.  This medical brain drain problem is an undesirable side effect of a larger trend that has greatly benefited the third world.  As described in a compelling and entertaining way by Hans Rosling, the last century has been characterized by dissemination of scientific and economic innovations throughout the world which has lifted up third world countries in terms of health and economic advancement.   The free flow of capital, goods, labor and ideas across the world has been the driver of this broad advancement.  This amazing global success (with some tragic exceptions such as with the AIDS epidemic holding down Sub-Saharan Africa), has been underappreciated by those who fight against “globalization.”

In this context, should we try to protect third world countries from brain drain by constraining the existing freedom of the world market for physician services and therefore constrain opportunities for physicians from those countries?  I don’t think so.

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People are recognizing that medical informatics is about people, not just installing software. But, unfortunately everyone is trying to find such people at the same time.

I have long criticized the “informatics,” “analytics” and “business intelligence” industries for over-emphasizing the value of installing analytic software or producing a pile of routine reports.  As described in a previous blog post, I have found such tools to add value only in the hands of talented, trained people with the ability to tell interesting, truthful, actionable stories, backed up by data.

This is an inconvenient truth for technology vendors and their investors, who prefer the exponential growth that can be achieved by developing some technology and licensing it quickly to a broad customer base, rather than the linear growth associated with finding and developing good people.  It is also worrisome for some IT professionals in health care institutions, who are often more comfortable with acquiring and maintaining a portfolio of software applications than dealing with the ambiguities of analytic talent and insight.

Since the development of an informatics talent base is a long slog, I always advise my clients to get started with it as quickly as possible.  However long it takes only gets longer if you haven’t started.

But, the process of building informatics talent is being made even more difficult by the fact that many health care organizations are trying to find such talent all at once.  Health care market changes and accumulating disappointment with the lack of value of canned reporting tools are making more and more organizations realize that they need to establish medical informatics as a core competency.


At the recent HIMSS ’12 meeting in Las Vegas, Price Waterhouse Coopers described the results of their survey of 600 organizations in the health care field, covered in an API article.  According to the survey, 70% of health insurers, 48% of hospitals, and 39% of pharmaceutical/life-sciences companies are planning to hire more medical informatics staff in the next two years.  Forty percent of respondents noted that lack of skilled informatics staff is a barrier to their efforts to develop a comprehensive informatics program.

Furthermore, it is important that new informatics staff be knowledgeable not only in technology and analytic methods, but also in health care.  For informatics to be incorporated into the care delivery process, medical informaticists must be able to effectively communicate and collaborate with physicians.  In fact, according to the PwC report, 50% of hospitals and physician respondents reported that misalignment of clinical and technology teams is a barrier to incorporating sophisticated analytics into clinicians’ everyday work.

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Dr. Ward to present at World Congress 3rd Annual Data Analytics Summit for Health Plans

For more information: www.worldcongress.com/claimsanalysis

Phone: 800-767-9499

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To resolve conflicts, re-frame polar positions as optimization between undesirable extremes. But, sometimes there is no way to win.

In politics and professional life, achieving success requires the ability to resolve conflicts.  I’ve noticed that conflicts often become entrenched because the opposing parties both simplify the conflict in black and white terms. They conceptualize their own interest as moving in one direction. And, they conceptualize their opponent as wanting to move in the opposite, wrong direction. As a result, the argument between the parties generates no light, only heat.  Each side only acknowledges the advantages of their direction and the disadvantages of the opposing direction. Neither side seeks to really understand and learn from the arguments offered by the other side.

When I’ve had the opportunity to mediate such conflicts, I almost always used the same strategies.

  • Step One.  I try to move both parties to some common ground, moving back to some basic statement that seemingly nobody could disagree with.  This generates a tiny bit of agreement momentum.
  • Step Two. Apply the momentum generated in step one to getting the parties to agree that, if you took each party’s position to an extreme, the result would be undesirable. The parties are inherently agreeing to re-conceptualize the disagreement from being a choice between polar opposite positions to an optimization problem. The idea is to choose an agreeable value on some spectrum between undesirable extremes.  If the parties make this leap, we are half way to sustainable agreement.
  • Step Three.  Get the parties to agree to avoid talking about the answer, and focus on reaching consensus on the factors and assumptions that influence the selection of the optimal answer.  Sometimes, this can be done subjectively, simply listing the factors.  Other times, it is worthwhile to get quantitative, working together on assumptions and calculations to estimate the magnitude and uncertainty of the outcomes at various points along the spectrum of alternative answers.  This quantitative approach has been described as the “explicit method,” and an example of applying it to resolve fierce disagreements about mammography guidelines is described in an earlier post.
  • Step Four.  Finally, ask the parties to apply their values to propose and explain an optimum answer, from their point of view.  In this step, the important point is to insist that the parties acknowledge that they are no longer arguing about facts or assumptions, since consensus has already been achieved on those.  If not, then go back to step three. The objective is to untangle and separate factual, logical, scientific debates from the discussion of differences in values.  If those remain tangled up, the parties inevitably resort to talking at each other, rather than engaging in productive dialog.
  • Step Five.  Try to achieve a compromise answer.  In my experience, if you’ve really completed steps 1-3, this ends up being fairly easy.
  • Step Six.  Work to sustain the compromise.  Celebrating the agreement, praising the participants for the difficult work of compromise, documenting the process and assumptions, and appealing to people to not disown their participation in the process are all part of this ongoing work.   Passive aggressiveness is the standard operating model in many settings, part of the culture of many organizations.  And, it is a very difficult habit to break.

Of course, in the routine work of mediating conflicts, I don’t really explicitly go through these six steps. This conflict resolution approach is in the back of my mind. They are really more like habits than steps.

Sometimes this approach works. Sometimes, it does not.  It can break at any step.

Notice that break downs in most of the steps are basically people issues. People won’t change their conceptualization. They are unwilling to make their assumptions explicit. They are unwilling to acknowledge differences in values. They are unwilling to compromise.

But, sometimes, the process breaks because of the nature of the issue being debated. Sometimes, conceptualizing the debate as an optimization problem between two undesirable extremes fails because there are really not good choices along the spectrum.

For example, when debating the design of a program or policy, I have often encountered a no-win trade-off between keeping it simple vs. addressing each party’s unique circumstances.  If I keep it too simple, people complain that it as a “hammer,” failing to deal with their circumstances.  If I add complexity to deal with all the circumstances, people complain that it is a maze or a contraption.  If I select some middle level of complexity, the complaints are even worse because the pain of complexity kicks in before the value of complexity is achieved.

I’ve seen this no-way-to-win scenario in my own work, in the design of information systems, wellness and care management protocols, practice guidelines and protocols, analytic models, organizational structures, governance processes, contractual terms, and provider incentive programs.  And, I’ve seen this scenario in many public policy debates, such as debates about tax policy, tariffs, banking regulations, immigration, education, and health care reform.  In cases when the extremes are more desirable than the middle ground, the only approach I can think of is to bundle multiple issues together so that one party wins some and the other party wins others, to facilitate compromise.

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CBO: Bundled payments for bypass surgery saved 10%, but pay-for-performance and gain-sharing was not effective in 3 Medicare demonstrations

Lyle Nelson from the Congressional Budget Office (CBO) has been busy.

Two weeks ago, I commented on the results of Nelson’s review of 6 Medicare Care Management demonstration projects over the last decade. At the same time that report was released, Nelson also released a companion report on the 4 “Value-based Payment” CMS demonstrations over the same period. The following is my adaptation of the main results table in this new CBO report.

The most influential of these demonstrations was the Physician Group Practice Demonstration (PGP).  The ten PGP participants included 2 faculty group practices within academic medical centers, 5 non-academic integrated delivery systems, one freestanding group practice, and one network consisting of 60 small practices.  All had experience with care management programs before the demonstration, and all implemented care management programs in the Medicare population for the demonstration.    These care management programs mostly consisted of nurses serving as care managers, focusing primarily on patient education and monitoring for patients with CHF or diabetes or meeting other “high risk” criteria.  Most implemented chronic disease registries for use by the care managers, in addition to using electronic medical records systems that were already in place or in the process of being implemented before the start of the demonstration.

Two of the ten PGP participants received bonuses in the first year, since the Medicare expenditures were more than 2% below the expected expense.  Four participants received bonuses in the second year, five in the third and fourth years, and four in the fifth year.  A formal evaluation of the program conducted after the first two years concluded that the overall effectiveness of the PGP across the ten participants was about 1% gross savings in year two, and even lower in year one.  Net savings, after counting the cost of the bonuses paid to some of the participants, was only 0.1% in year two.

The CBO report points out that even this meager 0.1% net savings might be an over-estimate, because PGP participants changed their diagnostic coding practices, making their populations appear to be sicker, and therefore making the risk-adjusted cost targets artificially high.  Such revenue maximization efforts have been job one in Medicare Advantage plans for years.  The PGP participants succeeded in lifting their risk scores by 8%, which was 3 percentage points higher than the increase in the comparison population.  And, the savings might have been further overestimated because all four of the PGP participants that achieved reward payments in year two already had slower than normal growth in Medicare expenditures before the PGP demonstration began.  All the other PGP participants that did not earn year 2 bonuses had pre-demonstration Medicare growth that was no different than the comparison population.

Despite these discouraging results, the PGP demonstration was nevertheless used as the main evidence base supporting the design of the Medicare Shared Savings Program, calling for the establishment of Accountable Care Organizations (ACOs).  It is also the main evidence base for the associated Pioneer ACO program, for which 32 participating provider organizations have recently been selected.

The Premier Hospital Quality Demonstration focused on 5 disease states and made bonus payments that amounted to only 0.25% of the total Medicare payments for those disease states.  That’s two orders of magnitude less than the size of incentive payments thought to substantially influence performance.  With such a tiny prize, it is not surprising that the quality improvements were assessed to have only a 1-5% incremental impact of process of care quality metrics during a period of time when such process of care metrics were improving nationally.  And, the CBO report concluded that the demonstration had no effect on Medicare expenditures for inpatient hospital care.  In fact, taking into consideration the reward payments, the demonstration led to an increase of costs by 0.3%.

The most successful of the demonstration projects was the Medicare Participating Heart Bypass Center Demonstration, which was used as a model for similar provisions in the health care reform law (PPACA).  In this program, the hospitals negotiated their bundled payments up front, ensuring that Medicare received savings compared to typical fee-for-service cases.  Overall, the program saved Medicare 10%.

So, where did the savings come from?

It’s possible that  they just came from good negotiating by CMS with hospitals that wanted to get out in front of what they saw was an inevitable trend toward bundled payment.  But, let’s assume that the hospitals really had a plan to reduce their costs in proportion to the negotiated decline in their revenue.

In interviews with leaders of the participating hospitals, the important changes in their approaches to patient management that were intended to reduce their costs included:

  1. Greater involvement by surgeons in postoperative care
  2. Earlier discharge of patients from the intensive care unit
  3. Greater standardization of surgical protocols and supplies
  4. Substitution of less expensive drugs for more costly ones, and
  5. Greater reliance on clinical nurse specialists for managing patients’ care in the hospital.

The participating hospitals substantially decreased their length of stay during the demonstration period, although length of stay for bypass surgery was dramatically decreasing nationally during that same time period.

However, probably more important than these process changes was the fact that all the participating hospitals created a physician reimbursement approach that established a fixed per case payment expected to cover all physician payments.  This amount was split in defined percentages among the four types of specialists involved in every bypass case — the thoracic surgeon, cardiologist, anesthesiologist, and radiologist.  Any payments to other specialists was essentially payed from this pool, reducing the payments to the four core specialties. Therefore, the hospitals created a strong incentive for the core specialties to limit referrals to other specialists.  This undoubtedly led to a reduction in utilization of those other specialists and the tests and procedures they generate.  Therefore, some of the savings probably came from reducing revenue to non-core specialists.

My conclusions

  1. Don’t bother with incentives unless they are large enough to change behavior.  A 0.1% reward can’t work.  Nor can a 1% reward.  Try 10-20%.
  2. Don’t create asymmetrical up-side only incentives.  They are far weaker in terms of motivating change.  And, they create a problem with paying out undeserved rewards for lucky good results.
  3. Negotiate the savings up front, rather than just creating a game from which savings might be achieved.
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Coconut oil as an Alzheimer’s treatment? Please don’t short-circuit science.

My father recently forwarded an e-mail he received from a friend with a link to a TV news story about a physician who treated her own husband’s worsening Alzheimer’s disease with coconut oil.  My father is interested in the topic, particularly since he knows someone who suffered and died from the disease.  He forwarded the e-mail to me, asking my opinion.

The physician, Mary Newport, MD, is a neonatologist.  She explains that Alzheimer’s is thought to be similar to diabetes in that it involves an impairment in the ability of brain cells to respond to insulin and take in the glucose needed to provide energy.  As a result, brain cells die and eventually brain function is reduced.  She reasoned that the brain cells may avoid death by relying on an alternative fuel, ketones.  She identified coconut oil as a good dietary source of ketones.  So, she introduced coconut oil into her husband’s diet and noted improvement in his brain function.  She documented this improvement with a “clock test,” showing how a hand drawing of the face of a clock done after initiation of coconut oil treatment was more coherent and detailed that a drawing done before the treatment. Excited by the promising results, she wrote a book, started a web-site, and started doing radio and TV interviews to disseminate information about her new treatment.

From the simple explanation, it seems biologically plausible. And, I’m sure that Dr. Newport had nothing but the best intentions, motivated by love for her husband and a desire to help millions of people suffering from Alzheimer’s. And, it is possible that she is absolutely right. Coconut oil may be a simple, inexpensive, non-invasive, effective treatment for the disease.

But, obviously, we would not want to make decisions about treatments from a single data point, where the main outcomes measurement was a subjective assessment about how coherent a hand drawing of a clock was.

It would have been more appropriate for this physician to actually do the work of scientific research before disseminating results.  That would start with writing a study proposal, convincing peers in a study committee for a research granting agency that it was a plausible and promising idea. Then, she would conduct a randomized study, making objective measurements or collecting careful observations by impartial observers.  Then, she would analyze the results to see if there is a statistically significant difference in the outcomes between the treatment group and the control group.  The purpose of the statistical significance test is to assure that there is a low probability that any observed differences are just due to chance.  Finally, she would do the work of writing up a paper and submitting it to a peer reviewed journal to convince expert reviewers that there were no obvious flaws in the methodology.  Only then should she consider further dissemination of the information, such as by writing a book, starting her own web site, and doing TV and radio interviews.

The scientific approach to medical innovation has served us well as a society.  When this physician went straight from one observation to TV interviews, she short-cut the scientific approach.  She may be helping people with Alzheimer’s.  But, she may potentially be distracting Alzheimer’s patients from seeking proven treatments or diverting funding away from competing innovative treatment ideas that have gone through the scientific “front door.”  More generally, she may be harming our society’s commitment to a scientific approach.

The fact that the treatment is a type of food, rather than a patentable drug, admittedly changes the situation.  No drug company wants to fund research on coconut oil.  And, the coconut oil industry is not familiar with clinical research, even if they could benefit from increased demand for treatment of Alzheimer’s.  This is a good argument for why the National Institutes of Health and private research foundations should fund more research related to diet and natural remedies.   It should not be an argument for short-circuiting the scientific approach to health care innovation.

Fortunately, a research team from Oxford is pursuing a randomized clinical trial to test the use of dietary ketones as a treatment for Alzheimer’s.  The Oxford team is testing a specialized ketone ester that is thought to be ten times better than coconut oil in terms of delivering ketones to the interior of brain cells.  Results should be available later this year.  Hopefully, they will show meaningful improvement.

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Slides for Dr. Ward’s presentation at 3rd Annual Predictive Modeling Congress for Health Plans, Orlando, Florida, January 31, 2012


Click here for PDF copy of slides.

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Congressional Budget Office: Care management programs only work if care managers have face to face contact with patients and substantial interaction with physicians

This month, Lyle Nelson of the Congressional Budget Office (CBO) released a “working paper” summarizing the results of a decade of experience with 6 care management demonstration projects in the Medicare population.  These demonstrations included a total of 34 disease management or care coordination programs. Nelson briefly summarized the working paper in a recent blog post.

All of the 34 care management programs were designed to reduce Medicare costs primarily by maintaining or improving the health of the Medicare beneficiaries, and thereby reducing the need for expensive inpatient hospital stays.  As shown the graph below, different programs showed different effects on the rate of hospital admissions.  On average, the programs showed no effect.

Effects of 34 Disease Management and Care Coordination Programs on Hospital Admissions (Percentage Change in Hospital Admissions)


The CBO analyzed whether specific characteristics of programs led to better or worse results. They found that programs where the care management provider’s fees were at risk did not perform better or worse than those with fees not at risk.  However, they did find two things that worked.  They found that programs in which care managers had substantial direct interaction with physicians and those with significant in-person interaction with patients reduced hospital admissions by an average of 7%, while programs that did not have these features had no impact on hospital admissions.

But, after subtracting the cost of the programs themselves, almost none of the programs achieved net savings.

The programs with the most compelling performance included:

  • Massachusetts General Hospital and its affiliated physician group reduced hospital admissions between 19-24% among patients selected as “high risk” using a program that was far more tightly integrated with the health care delivery system.  Physicians in the group were involved in the design of the intervention, and care managers were staff members in primary care physicians’ practices.  The patients received the vast majority of their care within the integrated delivery system, so almost all of their health information was available and up-to-date in an electronic medical records system.  Care managers were notified immediately when a patient was admitted to the emergency room or hospital.  They had an opportunity for face-to-face interaction with patients in the clinic.  And, they had access to a pharmacist to address medication issues.
  • Two multi-specialty group practices in the Northwest reduced hospital admissions by 12-26% among high risk patients using a program that involved telemonitoring with the “Health Buddy” device that transmitted symptoms and physiologic measurements to a care manager
  • Mercy Medical Center in rural Iowa reduced hospital admissions by 17% among patients hospitalized or treated in the ER in the prior year for CHF, COPD, liver disease, stroke, vascular disease, and renal failure using a program that involved care managers, many of which were located in physician offices and/or accompanied patients on their physician visits.

The methods used for these evaluations were far stronger than those used by the self-evaluations typically advertised by vendors of care management services.  In the CBO reports, 30 of the 34 programs were evaluated based on a comparison to a randomly selected comparison group.  The remaining 4 programs were evaluated using a concurrent comparison group selected using the same selection criteria.  In all cases, the programs were evaluated on an “intent to treat” basis, where study subjects were included in the evaluation regardless of whether they participated in the voluntary programs, thereby removing a source of bias that causes mischief in less rigorous evaluations.

To me, the take-away message is that provider-based care management is promising, but health-plan-style telephonic care management has not been successful, even in a senior population, where finding high risk targets is far easier and even when the care management services provider is highly motivated to succeed.

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I agree with the protesters that the proposed SOPA/PIPA anti-piracy legislation is more bad than good

Today, a number of web sites, including the amazingly useful Wikipedia.org site, have gone black to protest proposed anti-piracy legislation making its way through the U.S. Congress.

On the one hand, the entertainment industry does face a real problem as people are so easily able to steal their product and widely distribute it to people in the US using social network and other tools based outside of the US.  So, I can see why they are trying to get as much power as they can to shut that down through any of the U.S-based parties that are involved, such as search engines, web site hosts, and credit card clearinghouses.

From their perspective, all that talk about the importance of the internet as a vehicle for freedom and political change is a bit insincere coming from parties that are just trying to make a buck knowingly casting a blind eye to the fact that their customers are deriving a big part of the value of using their services by accessing stolen content.  The entertainment industry is basically just saying that if such parties are not putting in a reasonable amount of effort to block that, they should be considered accomplices to the theft.

But, on balance, I do side with the protesters.  The definition of reasonable amount of effort can very easily become a slippery slope to requiring tiny start-ups to buy unaffordable technology and putting in an unaffordable amount of manual labor into avoiding being accused of being an accomplish to someone else’s crime.  I agree with the protesters that this could easily stifle such start-ups, which would not displease the established big entertainment players.  The entire US-based entertainment industry is just not a very big part of the overall economy, and the internet has become an indispensable part of the entrepreneurship, innovation, political discourse, and social interaction that moves society forward.  The unintended consequences of the proposed SOPA/PIPA legislation, both directly in the US and on the precedent-setting impact on laws in other countries, could be huge and are not worth squeezing a few more dollars out of one small sector of our economy.

Therefore, we should reject the SOPA and PIPA legislation, and continue to pursue more incremental efforts to thwart internet piracy.

More information at http://en.wikipedia.org/wiki/Wikipedia:SOPA_initiative/Learn_more

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