The Disease Management Care Blog Welcomes A New Health Care Trade Association

According to Wikipedia, a "trade association" is a collaborative organization made up of businesses that operate in a similar area of commerce that pool resources aimed at a) public relations (education, advertising and lobbying aimed at influencing public policy) and b) standardization (uniform engineering or technical specifications, criteria, methods, processes, or practices). If form follows function, the December 16 "Innovations Across the Nation in Health Care Delivery" conference was about as trade association as you can get.

The purpose of the day long confab hosted by the folks at Health Affairs was to showcase healthcare organizations "that have innovated at the patient care level, created more highly coordinated patient care systems and improved population health." The showcasing was prominently directed at the leader and staff of the newly established Center for Medicare and Medicaid Innovation (CMMI) who treated the conclave as another one of their many listening sessions.

The Disease Management Care Blog listened in too. Once it got past the enthusiasm, PowerPoints and data, it concluded that much (not all) of the day consisted of reports of strained credibility, generalizability and scalability. The DMCB counted nine presentations relying on unsophisticated "pre-post" methodologies to support their triple aim claims, while four others contrasted their cost savings vs. projected costs of unknown pedigree. Most of the practice settings had unique cultures, economics and leadership styles that would be challenging to export elsewhere. Many also involved a local commitment of financial or organizational resources that seemed out of reach of most provider settings, even with CMMI's $10 billion.

It wasn't until the DMCB made full weekend use of spiritually-based libations to commune with the health service research and policymaking gods that it divined that it was probably the last person in the room to recognize what was really going on. Hidden under the patina of evidence-driven policymaking was a five-fold vision: 1) large not-for-profit provider groups using 2) primary care medical homes in 3) regional care systems driven by 4) an academic government alliance using 5) insurance levers to ultimately control health care. Check out at the videos and the listening will reveal classic "trade associating": a) education really aimed at convincing an already favorably predisposed CMMI coupled with b) an emerging evaluation standard that doesn't include rigorous research methodologies. All that's lacking is name, set of bylaws, a red ribbon ceremony and directors. Perhaps this will make do in the meantime?

While DMCB has been skeptical about CMS' ability to actually "innovate," it likes the "systemizing" of medical practice as well as the reorganization of primary care. The DMCB also knows trade associations are important and that their support by medical journals or government is not unusual. So, it would like to be among the first to welcome the colleagues named in this Agenda to getting the recognition they deserve. May you and yours be blessed with regulatory favoritism and being mentioned in legislation. May the organizations that want to be like you get those 6 or 7 figure grants and thousands of frequent flyer miles earned to and from Dulles-IAD.

In a future post, the DMCB will examine the implications of this in greater detail. It will also cull out the few presentations that had some useful data and insightful lessons for it's colleagues in the population health management community.

Accountable Care Organizations: The Good, the Bad and the Better Thanks to Health Affairs

In a prior post, the Disease Management Care Blog not only explained, but got all mushy over the notion of ‘Accountable Care Organizations” (ACOs). The DMCB felt that ACOs could provide the endoskeleton over which a mix of carve-in and carve-out population-based systems of care - including commercial disease management - could be assembled.

ACOs may be a healthcare policy golden-boy, but the Health Affairs Blog has a posting authored by Jeff Goldsmith that argues the concept is simply not ready for prime time.

The Bad: Jeff Goldsmith notes the ACO concept was born when policy makers realized that many community physicians are loosely organized around hospitals anyway. So, the thinking went, it shouldn’t be too hard to devise risk-based incentive payment mechanisms to nudge these nascent ACOs into coordinating care. Dr. Goldsmith disagrees. He says we saw this bad movie before back in the 1990s when hospitals snapped up physician practices like brides grabbing gowns at Filene’s. Payers didn’t like their closed networks, their internal controls were atrocious, they couldn’t manage risk contracting and the administrators knew about as much about running ambulatory-based clinics as Barney Frank’s dining room table. What’s more, Dr. Goldsmith charges, once they failed, single-specialty physician groups had learned to integrate, leading to local monopolies that are still present in many U.S. cities. Even though things are different ten years later, physicians are still unlikely to play nice across specialties, the proceduralists have cherry-picked the remunerative patients for their own surgi-centers and the Generation X physicians are more likely to trump kayaking over the after-hours call it would take to make ACOs a success.

Aaron McKethan and the famous Mark McClellan have a different take in separate post.

The Good: They like ACOs and think they have a decent shot at success thanks to a wider range of more sophisticated payment options such as upside risk or quality-based payments. What’s more, since ACOs are just starting out, it should be possible to experiment and to see what works best. As for Dr. Goldsmith’s criticisms, ACOs may be just the ticket to bridge the physician-physician and physician-hospital divides, there are physician leaders that can make this work and today's information technology is much better compared to the 1990s. Indeed, they point out that there are some anecdotal reports of success emerging from the ‘ACO Learning Network,’ (hm... the DMCB Googled that one but found very little), various State-level reform efforts and, last but not least, the Medicare Demos. Last but not least, if the ACOs can also figure out how to motivate their patients toward better self-care, it won’t be a rerun, it could be a hit movie.

The Better: The DMCB points out that the consolidation of specialty physician groups could actually work in favor of ACOs; rather than deal with multiple small physician groups, getting buy-in from the big cardiology group would not only be administratively simpler, they’d be less likely to feel victimized by take-it-or-leave-it contracting. What’s more, if organized correctly, ACOs are more, not less likely, to help Gen X physicians stick to their precious 35 hour work week. The DMCB likes the point about role of physician leadership and thinks there are a whole new generation of MD-MBA-MHSAs that are up to the task.

Last but not least, when it comes to patient support services, savvy ACOs will be far less likely to insist on a 100% ‘own’ strategy if they can buy a better product at lower cost. That and the experimentation mentioned above will lead to exciting new models of care that incorporate the best of HIT, decision support, registries, disease management and the medical home.

The only downside? ACOs control of the local hospital(s) and physicians could tempt them to act like a regional monopoly. While the DMCB can be suspicious about government regulation, much work remains on crafting the kind of checks and balances that assure that ACOs translate their efficiencies into competitive and not predatory pricing.

(There's lots more on Accountable Care Organizations here)

Impressions from the Health Affairs Briefing on Overhauling Health Care Delivery

Impressions and quotes from the Washington DC Health Affairs ‘release party’ min-lecture series over the September/October issue on ‘Overhauling Health Care Delivery’:

Large, high ceilinged room at the InterContinental stuffed with academics, policy makers and note-taking congressional staffers. It ended at 11 AM with the hotel staff noisily wheeling in the next function's lunch tables at 11:01 AM. The DMCB regrets not having the chance to meet the hard working editors.

Paraphrased quote from Mark Smith of the California HealthCare Foundation: ‘The solution to health care access and cost will not be mathematical linear rearrangement. The solution will be structural.’ The DMCB wonders if it will involve dynamite.

Challenges to the Patient Centered Medical Home identified by Bob Berenson: 1) lack of an operational definition, 2) it won’t cure the ‘tyranny of the urgent,’ 3) it will be a struggle for small practices, 4) it won’t cure the PCP shortage, 5) it’s unclear if this is for all patients or patients with chronic illness, 6) there are many local management challenges, 7) non-PCP specialists (endocrinologists) may warrant inclusion, 8) it’s unclear if patients should be locked-in to their primary care site and 9) becoming all things to all people may mean that this becomes another failed silver bullet. The DMCB adds that it has yet to leverage remote and efficient industrial strength telephony and monitoring as one ingredient in its suite of services.

A large integrated delivery system CEO saluted its EHR, large mass and adaptable primary care practices as the key ingredients in its version of the medical home. The DMCB disagrees and thinks it was parachuting in nurses into its primary care sites that are paid for by the managed care organization (or disease management function). They are the secret sauce.

The jargon used most stridenty to describe what health care consumers want: ‘personalized medicine.’ The DMCB recommends that DMOs alert their DC lobbyists to resurrect this term.

An unnecessarily complicated health care engineering term from Richard Bohmer: It will be impossible for primary care to diversify enough to meet all that is being asked of it. The answer is a new ‘care platform’ designed from the bottom up. All retail clinics are one type of care platform. Not all care platforms are retail clinics. And the DMCB’s running shoes are a type of aerobic exertion platform.

The Patient Centered Medical Home for Chronic Illness: The DMCB Asks (and Answers) in Health Affairs: Is It Ready for Prime Time?

If you didn’t have enough reasons to subscribe to Health Affairs or regularly check their web site, here’s another: the Disease Management Care Blog has landed a publication in that staid prestigious journal. No longer encumbered by a news embargo, the DMCB sallies forth with the announcement about a “Perspective” piece entitled “The Patient Centered Medical Home for Chronic Illness: Is It Ready for Prime Time?” in the September/October 2008 issue. It’s a response to a very scholarly work by the Urban Institute's Bob Berenson and colleagues appearing in the same issue, who present some interview-backed insights on how physicians and Patient Centered Medical Home (PCMH) advocates agree and sometimes disagree on just what the PCMH will accomplish.

In its article, the DMCB notes the PCMH has great promise but has three challenges to address before the health care system should dive in and begin widespread implementation. They are:

1) Varying definitions of the PCMH across real world clinical settings. Close scrutiny of the underlying literature shows there is a surprising degree of variation in the implementation of the medical home and chronic care model in clinical settings. What’s more, there is little evidence that locating all or some of the elements of the PCMH in the primary care site results in better patient care than, say, letting it reside in managed care or disease management.

2) Limited scalability outside of Medicaid programs, publically funded clinics, pediatric or psychiatry setting or integrated delivery systems. In looking at the literature, experience in implementing the PCMH in smaller physician-owned practice settings is quite limited. The evidence that does exist suggests uptake can vary considerably from clinic to clinic.

3) Scant documentation of cost savings. There is peer-reviewed evidence that many of the individual components of the PCMH may reduce claims expense but there is scant evidence that the PCMH as currently conceived will routinely achieve meaningful savings in commercial insurance programs or in the Medicare program.

Until current and future pilots address these three challenges, the DMCB suggests the answer to the above question is ‘not yet.’

Health Affairs will hold a briefing on the issue on Sept 10, 2008 at 9 AM at the Willard InterContinental. The DMCB was invited to go and it cannot resist. More posts on the topic to follow.