The Patient Centered Medical Home and Diabetes: A Timely Review of the Evidence

Where's that evidence?

After last week's Disease Management Care ACO-Blog-Fest (which catapulted the DMCB onto a highly coveted 'first page' Google "search" status for "Accountable Care Organization"), the DMCB turns its attention back to the Patient Centered Medical Home (PCMH), thanks to this timely hot-off-the-presses review by Trajko Bojadzievski and Robert Gabbay of the Penn State College of Medicine. 

Anyone pondering the many promises of the PCMH is likely to eventually focus on diabetes mellitus.  The condition is not only highly prevalent and costly, but its quite measurable.  Patients with diabetes are readily identified in most healthcare databases and it's relatively easy to measure the frequency of recommended tests and treatments over time.  It could also be argued that diabetes is a "bell weather" for overall quality for providers and insurers.  Solve diabetes and you solve the health care conundrum.

With that as background, Drs. Bojadzievski and Gabbay asked a simple question: what is the evidence that the PCMH reduces costs or increases quality for patients with diabetes?

The authors assembled peer-reviewed published papers as well as all the web-based reports on the PCMH and its impact on diabetes. They identified 41 programs and pilots; three were excluded because of their small size and focus on converting from usual care to a medical home practice, leaving 38. 

Unsurprisingly, the authors found that common ingredients for the PCMH include payment reform (with additional money to pay for new infrastructure, patient coordination and quality bonuses), care management, patient registries, electronic records and expert consultation support. They provide succinct summaries (including a well organized table) of the what the DMCB is coming to refer to as the "Top Eight" PCMH pilots: Community Care of North Carolina, Geisinger Health System, the Pennsylvania Chronic Care Initiative, Group Health, the Rhode Island Initiative, Health Partners, the Colorado PCMH pilot, and the PCMH National Demonstration Pilot.

While their review showed the PCMH was associated with impressive quality gains, the authors' answer to the question poised above was telling:

"Although randomized trials have yet to be performed, the eight Medical Home initiatives reported provide encouraging “before and after” results to support the PCMH as a viable mechanism to improve the quality and costs of diabetes." 

"Before and after?" Once again, the DMCB is left wondering if the enthusiasm for the PCMH will ever be matched by its evidence base.  Recall the following quote from a past 2007 article from the American Journal of Managed Care that critically examined "disease management":

"However, the vendor-run assessments typically do not meet the requirements of peer-reviewed research in terms of the comparison strategy, and adequate control for selection bias and regression to the mean."

Fortunately for the DM industry, they responded by adopting approaches that meet many of the rigor and plausibility requirements of peer reviewed research. The good news for the PCMH is that they can do that also as better data from the pilots are released the coming months.  That being said, the DMCB is also coming to believe that the uptake of the medical home may ultimately hinge less on the pilots than on how well it supports the success of ACOs.  Unfortunately for advocates of the PCMH, that ACO evidence base - and it prospects for profitability - remains an even bigger question mark.

One last important point from the authors was that expert "practice transformation coaches" and "learning collaboratives (meetings to explore and exchange ideas) are a common feature of the PCMH.  If that is one of the factors leading to "before and after" success described above, ACOs that are building medical homes in their networks may be well advised to tap into that kind of expertise.

Crossing Over From Medical Home Land: Lessons For The Patient Centered Medical Home (PCMH)

Think Chinese culture is inscrutable? That the laws in Saudi Arabia are alien? That Lutheran Norwegians at a dinner table are weird? That, once you leave the familiar safety of home, life unpredictably becomes more opaque, dizzying and unfamiliar?

Such appears to be the reaction of some of the Disease Management Care Blog's colleagues once they venture outside the borders of "Medical Home Land." Case in point is this essay by Bob Doherty and this heartfelt "I second that emotion" by Dr. Bob at the aptly named Medical Rants Blog.

Inside Medical Home Land, transformed primary care always increases health care quality, reduces cost, increases patient access, attracts medical students, increases patient satisfaction and increases wellness. Inside that protective bubble, the medical home has admiration of PhDs, unquestioning acceptance by fawning medical journal editors and keynote status from pricey conference promoters. It is a nice place to be.

Unfortunately, Medical Home Land is missing one absolutely necessary natural resource. No, it's not statistical significance for measures of claims expense reduction (for example, p=.08 at Group Health, p=.21 at Geisinger and not even mentioned at HealthPartners). Rather, what's missing is money. To get their hands on that, Medical Home Land denizens have to step outside its borders and deal with insurance market skepticism, physician "transformation" inertia and patient-voter apathy.

As the DMCB has previously described, the likelihood that anyone is going to just hand over fistfuls of money to something that is a good idea is nil. Saying the Medical Home is the right thing to do is not enough. But be of good cheer, says the DMCB. While stepping outside of self-reinforcing closed information loops can be traumatic, dealing with reality has its benefits. The Medical Home is still a work in progress. Learning to joust with hard nosed actuaries, insurance execs and CFOs will ultimately help it be a leaner and more effective approach to patient care.

To help the Medical Homeites successfully adapt to being strangers in a strange land, the DMCB offers up some lessons learned by others that have also had to deal with the trauma of crossing over:

1. Once the disease management industry was confronted by data that it wasn't really saving money, it changed. It used its experience in wellness to contract with self insured employers to develop worksite-based prevention programs. It also honed its protocols to target the patients most likely to benefit. The point is that that industry figured out what the naysayers wanted and jettisoned the rest.

2. The electronic health record vendors worked for decades in the shadows of the health system before they finally achieved enough of a critical mass to catch the attention of a U.S. President. Yes, the EHR vendors continue to spout unrealistic bromides, but they were very patient. So should supporters of the medical home.

3. The DMCB learned the hard way that simply publishing positive results seldom achieves stakeholder buy-in or generates change from front-line providers. Recall how slowly physicians adopt any evidence-based medicine? Quoting it may be necessary but that alone will get medical home advocates about as far as quoting a Berwick paper to a Republican US Senator.

4. The pharmaceutical industry figured out how to trump branding for its me-too products. It's not that pill, its being able to ride motorcycles with your chums, blow rose petals at your daughter's wedding and lounge in twin bathtubs with the spouse. The ex-medical director DMCB has had to deal with countless enrollees demanding coverage of me-too lipid lowering agents at $80 a month. It's time for Medical Home Land to figured out how to harness that energy and the cash that goes with it. Which would patients rather have: a "patient centered medical home" or a "concierge?" Figure that out and commercial insurers and Medicare will follow.

5. Think being invited to the White House means anything? Not only does that environment also suffer from its own brand of health care unreality, you'll be asked to take a seat between the Thoracic Surgeons and the the National Association of School Nurses. Good luck with that.

The DMCB says be of good cheer, medical home supporters. Listen to the naysayers and adapt, hang in there for the long haul, figure out how to create patient demand and put publications and the support of fickle politicians into perspective. Good ideas always win out in the end.

The Rocket Science Double Standard, Medical Home Induced "Change Fatigue" & If Universal Coverage Doesn't Reduce Bankruptcies, We Need "More" Of It

In a quick "walkabout" of the web, the Disease Management Care Blog came across some interesting items:

Introducing the latest issue of Health Affairs on Innovation In Health Care Delivery, Editor-in-Chief Susan Dentzer writes that the March issue's descriptive profiles of fifteen organizations that have a) focused on the sickest people, b) keep chronically ill people as healthy as possible and c) rely on a team approach patients’ varied needs, amply demonstrate that innovation doesn't require "rocket science." Yet, that was precisely the level of rigor demanded by policy makers of the investor-owned for profit disease management industry years ago, when it was doing the same thing. But the DMCB is not bitter.

Neither, apparently, are the physicians who participated in American Academy of Family Practice's nationwide demonstration of the Patient Centered Medical Home. Rather, these physicians are tired. Very tired. Writing about lessons learned in the same Health Affairs "Innovation" issue mentioned above, Paul Nutting and colleagues describe how - despite the extensive support of a team of facilitators and experts - transforming motivated physician practices into medical homes takes more than two years, is often incomplete, intrudes into cherished notions about the doctor-patient relationship, is stymied by the EHR's shortcomings and often exhausts "adaptive reserve" which leads, in turn, to "change fatigue." The authors suggest a balm made up of "medical neighborhoods," which are supported by even less evidence than the medical home.

Speaking of a lack of "evidence," that isn't going to stop the Physicians for a National Health Program either. Co-founders David Himmelstein and Steffie Woolhandler have apparently (the on-line March issue of the Green Journal is not available yet) found (according to this press release) that Massachusetts's universal coverage law has not been associated with a statistically significant drop in "medical bankruptcies." This has apparently led the authors to counterintuitively conclude that even more health insurance coverage is necessary. The DMCB suggests that they address the concerns in this post instead. Just because there is an association (two things seem to happen at the same time) doesn't mean there is any causality (that one causes the other) or that we know directionality (or which causes which).

So Many News Events, So Little Blog

Why Not Fast Track the ACA to the Supreme Court?

The Disease Management Care Blog asked the same question as Senator Nelson in this quixotic post weeks ago. The real news is that as a lawyer, the Senator has shown there is an exception to every algorithm.

Career Management 101

The DMCB understands the best time to exit any position is while your reputation is high and before things start going bad. That may be the intentional or unintentional thinking behind Dr. Blumenthal's decision to exit, but that doesn't make it any less true. As studies begin to show that the EHR stampede is not leading to higher quality or lower costs, explaining that sorry news will become the duty of a third HIT Czar.

A Vice President for Patient Centered Medical Homes

All well and good, says the DMCB, but the PCMH will not have truly achieved the pinnacle of corporate medical-industrial success that it so richly deserves until a major health system identifies a Chief PCMH Officer, or CPCMHO for short.

This Is How We Make a Health Law Better?

There's the cost of the ACA and then there is the revenue necessary to fund it. Repealing the 1099 provision addresses only half of the problem. The DMCB fears having Congress oversee the fiscal integrity of the ACA is like having Charlie Sheen emcee a spring break party.

1000 Posts!

Last week, the DMCB broke the 1000 post barrier. Really.

Disease Management, ie Population Health Management Organizations (PHMOs): Plan B to Support the Creation of the Patient Centered Medical Home (PCMH)

As the Disease Management Care Blog has previously pointed out, there is is a lot that the disease management industry has to offer the Patient Centered Medical Home (PCMH). That's why it agrees with this webinar summary that appeared in the latest issue of Population Health Management.

In it, Darren Schulte MD of Alere points out that expectations for the PCMH are very high. Its value proposition includes reversing the decay of primary care, meeting the consumerist needs of an aging population, increasing quality and securing additional practice income. A growing body of evidence suggests that the more successful PMCHs have 1) a dedicated non-physician patient coordinator, 2) expanded in-person and virtual patient access, 3) health information technology that includes a functioning registry and point-of-care decision support and 4) increased practice income. Without these key ingredients, PCMHs have an uphill battle managing a population of patients, building a team-based culture and marshaling resources to change patient behavior.

Enter disease management vendors, although Dr. Schulte prefers to use the politically correct term "population health management organizations" (PHMOs) They have decades of experience in patient education, monitoring, self management, treatment adherence and care coordination. Despite physician skepticism and a cultural bias that favors "build" over "buy," he argues that PCMHs may find PHMOs attractive not only because they're speaking the same language, but because their services are "plug n' play" and highly adaptable across a wide variety of small to large settings. All that needs to be worked is out how PHMO support will be paid for so that the PCMH succeeds.

Enter Dr. Greg Sharp of Ideal Family Healthcare in Woodland Park, CO. He notes that health insurers have a key role to play because they're not only providing the additional monthly payments for the PCMH, but they're being called on to support health information technology solutions and provide work-flow consultation services. Since insurers are very involved anyway, he implies that it's not a great leap form them to also facilitate the sponsorship of PHMOs in the PCMH network. Once that happens, he sees few barriers standing in the way of PCMH team members virtually working with remote or in-person PHMO health coaches, accessing the PHMO's registries and relying on PHMO decision support tools.

The acronym addled DCMB likes this description of how insurer sponsored PHMOs can help PCMHs. For a fiduciary and risk-bearing health insurer, the DMCB agrees that the road to patient behavior change, prevention and savings in medical homes may run through disease management. The DMCB suspects many primary care practices won't necessarily want to create (training the non-physicians in behavior change and coaching?) or be able to afford (buying the hardware and programming expertise to create a fully functioning registry?) all the features of a fully transformed PCMH. Calling it "PHMO" instead of using the scorned term "disease management" will also increase its acceptability.

Smart health insurers will recognize that there will be primary care sites that want to go their own way in establishing PCMHs. That's fine. For those primary care sites that may not have the resources or the inclination to build a fully functioning PCMH, bringing in a "population health management organization" vendor is a good Plan B. That disease management Plan B is a rose that by any other name still smells as sweet in the science of increasing quality and optimizing costs.

Insights from the Care Continuum Alliance Meeting: Federal Planning, Small Low-Overhead Practices, Full Risk Contracting and Social Networking

A number of insights from attending today's Forum10 in Washington DC:

It seems that once D.C. policymakers get armed with Federal health legislation, they like nothing better than to talk-circuit with bubbled, arrowed, jargon-filled and notion-addled PowerPoints. The Disease Management Care Blog witnessed this first hand today, when it learned from a plenary session speaker that our government is developing a national health agenda that will drive measurement and change quality for the better. All well and good, says the DMCB, but the fact is that it's locally developed programs that have always been the source of real innovation, and that they only use the Feds' resources only when they add real value. The conceit was astonishing.

If physician income is no object, it's possible to set up a small, low-overhead, limited panel clinical practice and still take good care of patients. It may mean that the docs escort the patients back to the single examining room themselves, draw up and administer their own immunizations, carry a cell-phone 24-7 and create their own primitive records on desktop PC's. That was not surprising to the DMCB - what was interesting was the physician-speaker's assertion that doing all that gives that clinic a head start on getting NCQA recognition as a medical home. Will "concierge practices" add claims of also being a medical home to their other supposed virtues?

Conduct one big study of a disease management/telephonic care management program that shows a big return on investment. Check. Get it past peer review to make sure that what you think you've found is correct. Check. Conduct a bunch of similar in-house studies involving other clients that show the same thing. Check. Then, and only then, can you be confident enough to go to market with that program with a guaranteed, full-risk contract option. To do otherwise would be foolish.

Did you know there are 105 million Twitter users? 400 million on Facebook? That there have been 6.5 billion views on YouTube? Yet, while the telecommunications, computer, specialty retailers and the food industry have all tapped into this "social networking" phenomenon to great effect, the health care industry is still looking at it as an answer that's in search of a question. While there are some health care examples of social networking like hospitals (that use it to market and get patient feedback), patient communities (an example is PatientsLikeMe) and the Centers for Disease Control and Prevention (podcasts and videos are out there extolling the virtues of influenza immunization), this has yet to truly fill it's potential. Consumers are worrying about privacy and they'll only use social networking if it yields better information than a simple Google search. As you ponder this for your company, think about issues involving 1) identity (how much personal information must users share?), 2) authenticity (is this really good from the users' points of view?), 3) accessibility (you cannot afford to have your site go down), 4) reputation (users may not trust managed care-run networking, no matter how well-meaning) and 5) reciprocity (this is two way). These and other insights are courtesy of Deloitte. You can read more here.

Of Actuaries, Consumerism, Care Management and the Patient Centered Medical Home

"But we're saving money!" said the Disease Management Care Blog.

"I don't really care" said the company actuary.

That pretty much summed things up years ago when the DMCB was arguing the merits of expanding the care management programs. The good news is that the DMCB stopped talking, listened and got educated.

It learned that actuaries assess past patterns of health care utilization to project future patterns, much like looking in a rear view mirror to drive a car forward. Knowing that the previous years' rate of hospitalizations is "X%," that physician offices visit rates are "Y%" and that other rates for other forms of utilization are "Z%" etc., actuaries, knowing the cost for each unit of service, can then project the cost of future services. Since care management is an additional cost, that "hard" number is simply added into next year's budget. It's all added up and voila! the cost of providing insurance was known. Our customers never liked it because rates kept going up. Our State Department of Insurance - and their actuaries - required it because they knew rates had to go up.

Even though the DMCB could demonstrate that a $70,000 per year case manager could save (depending on the condition) $100 to $700 PMPM, the actuary only saw spiraling cost inflation with higher rates of utilization. Just because a segment of the overall book of business may have cost less, it was calculated that the costs for all persons with diabetes and heart failure would continue to rise and that the nurses were an additional cost center of $70K per FTE.

Case closed.

That was the logic then and is still believed by naysayers today. So, how has care née disease management survived years of actuarial skepticism?

One answer may lie in this J.D. Power press release. Human Resource directors, managers and owners that have responsibility for buying commercial health insurance are unhappy with the industry's ability to service accounts, design new products, resolve coverage problems and manage costs. However, the most important determining factor in overall satisfaction is "employee plan experience."

In reading the press release, the the DMCB can't tell what makes up "employee plan experience," but it has a pretty good idea that a large part includes wellness, prevention and care management. So, in addition to "patient engagement," and "self care" and "risk reduction" and "behavior change," care management's secret sauce consists of personalized outreach and creating special relationships with patients. It's called talking to your customers.

Which offers two lessons and a warning:

1. Service Recovery: This is one of the reasons why disease management, now called care management, wellness and prevention, has done so well in the self and fully insured commercial insurance settings. If JD Powers' press release is to be believed, insurers are relying on their care management programs to partially make up for their perennial inability to execute well on other parts of the business. That doesn't mean there isn't growing evidence that the actuaries can be wrong and that care management also saves money. This is cake and eating it too.

2. Medical Loss Ratio: Given the actuaries' biases and an in-house perception that disease management was a customer service function, it's no surprise that disease and care management programs were placed in the administrative cost column and not the MLR. The care management industry always thought it was a clinical function, but with the widespread perception that health insurer administrative costs are too high (and that the MLR is too low), the industry is working hard at getting their costs reassigned.

And the warning?

While my colleagues who are promoting the Patient Centered Medical Home (PCMH) are fixated on its ability to increase quality, reduce costs, rescue primary care, minimize variation, reverse the Federal deficit and banish all hunger in America, it may turn out that a key success factor will be none of those things. Rather, the long term staying power of the PCMH may hinge on its ability to enhance the health care experience for patients. GroupHealth understands that (here at the 30 sec mark) and so does Blue Cross Blue Shield of Michigan (here). If the actuaries get skeptical and consumers don't notice a palpable change, the PCMH may go the way of dermatologists who remember which end of the stethoscope goes in the ears, the dodo bird and good taste in a Lady GaGa music video.

Image from Wikipedia

A Potporri of News About Marketing & Social Media, Savings from Telephonic Disease Management and Methodologic Problems in the PCMH Pilot Evaluations

Today brings a grab bag of worthy news to the Disease Management Care Blog readers. Topics include social media, old fashioned telephonic disease management and the Patient Centered Medical Home.

First off, did you know the population health/disease management company Healthways has a Facebook page devoted to its elder wellness program SilverSneakers? The Disease Management Care Blog did also, but what it didn't know is that, according to this press release, uptake lagged until a professional marketing firm began to promote it.

The DMCB insight: while social media is supposed to be a "viral," bottom-up democratic phenomenon, the professionals have moved in.

Secondly, there are two research findings on the topic of old fashioned "telephonic" disease management. Does it or doesn't improve quality? Does it save money?

In this early release publication in the prestigious Journal of General Internal Medicine (known to publish papers with high methodologic rigor), Daren Anderson et al were unable to demonstrate in a prospective randomized clinical trial that a telephonic disease management program versus usual care resulted in better blood glucose control. However, this was a single site study involving a community health center serving disadvantaged patients. Patients were enrolled in the study without regard to baseline diabetes control, the intervention group had a lower A1c at the start of the study and there was a significant prevalence of depression in both groups. In addition, it's possible the intervention may have changed provider behavior for the control patients.

The second study JL Rosenzweig and MS Taitel was only released in abstract form (its P3-715) from this year's Endocrine Society's meeting. This research involved enrollees from a Medicare Advantage plan that focused its telephone diabetes disease management program on high risk patients. This was also a randomized prospective study that showed the intervention patients....

"....decreased ... all-cause total medical costs by $984,870 per thousand members per year (PTMPY), compared to a $4,547,065 PTMPY increase in the Control Group (p≤.05). All clinical quality measures significantly improved from baseline (p≤.05) including A1C, LDL ,and microalbumin testing, retinal exams, foot exams ACE or ARB use,and aspirin use.

The DMCB insight: as publications expand in number, the science matures and other settings/patients are explored, both positive and negative studies are not unusual. However, if that Medicare Advantage study is correct, that's some serious money being saved. Looks like the the taxpayers were getting their money's worth after all in this particular Medicare Advantage plan. The DMCB is looking forward to seeing more details in a peer review publication soon.

Thirdly, in this study, the authors surveyed the larger PCMH pilots and provide a useful national-level summary overview. For example, per member per month (PMPM) payments for eligible patients range from $0.50 to $9 plus pay for performance (P4P) bonuses along with other payments to fund practice transformation or other care strategies, such as embedded nurse care managers or quality improvement programs.

But particularly worrisome was this finding:

"...the evaluation plan for nearly 60% of demonstrations had not yet been devised in detail at the time of the interviews. Even among those with more developed plans, the specification of which variables would be measured, along with surveys to be used, was uncommon."

What's more....

The heterogeneity in program design suggests an urgent need to incorporate evaluation in all programs’ designs. Less than half of the programs had well specified evaluation plans that were designed in conjunction with the pilot. In most cases, although evaluation is considered important, the evaluation designs had not been pre-specified, thus necessitating a reliance on existing data, and funding had not been secured to support a robust evaluation. Furthermore, many of the pilots do not identify adequate control groups against which to compare the intervention practices.

The DMCB insight here is that if the PCMH pilots are not careful, they could end up being condemned in a CBO report saying there's no good evidence that their intervention works. Based on the two disease management studies described above, it's safe to say that the disease management industry has learned its lesson: valid comparator groups are being used to accurately assess their impact. The industry has even developed a state-of-the-art evaluation guide that addresses many of the methodologic issues (that's for free, by the way) in program evaluation. PCMH pilot managers should take note.

More on the Success of Blue Cross Blue Shield of Michigan's Success With the Patient Centered Medical Home (PCMH)

The Disease Management Care Blog heard back from the folks at Blue Cross Blue Shield of Michigan (BCBSM) about their positive experience with Patient Centered Medical Homes (PCMHs). As outlined in this prior DMCB post, it may be that this Blues plan has finally found the PCMH Holy Grail: genuine savings in a commercial real world, i.e., non-academic, non-integrated delivery and non-government insurance setting.

Questions that the DMCB asked and the gently edited BCBSM responses are below. The DMCB, because it cannot help itself, has some additional comments in italics.

Question: It isn’t clear how the medical homes were certified by BCBSM: did you do onsite visits, use NCQA criteria, or simply rely on attestation?

"BCBSM works with more than 100 physician organizations across the state on the PCMH program. Physician organizations nominate practices from within their organizations for designation. Physician organizations work with their practices to self-report data on PCMH capabilities into BCBSM. BCBSM also reviews quality data on key metrics, such as generic dispensing rate, ED visits for non-emergent conditions, evidence based care, and imaging use. BCBSM then conducts a site visit at a sampling of nominated practices to validate the data and to see the PCMH capabilities in place.

Designation decisions are made according to how much progress the practice has made in implementing the PCMH capabilities, and on quality and use data. Practices are analyzed and scored using a weighted measurement model."

This tells the DMCB that cooperation between a regional insurer and physician groups can be an important asset in promoting the PCMH. Imagine that: real partnerships between and insurer and physicians. What's more, the PCMH is not operating in a vacuum: there's a link with pay for performance and managing the pharmacy benefit.

Question: The PCMH certification you use itself seems pretty generic. What was the secret sauce(s)?

"Designations are conducted annually, and each designation lasts for one year. Designation is based on 50% progress on adopting PCMH capabilities (124 capabilities organized around 12 domains of function) and 50% quality and utilization performance.

Our “secret sauce” is the voluntary engagement of the physicians themselves. We developed the PCMH model together with the physicians. We are not dictating that primary care physicians become PCMH-designated. There are 5,800 physicians in Michigan who are eagerly and voluntarily choosing to transform their practices to earn designation."

This tells the DMCB that BCBSM didn't assume that all of the State's primary care sites would automatically want to become PCMHs. Rather, the model was jointly developed and remains voluntary. Some physicians are apparently not turning their clinics into PCMHs and BCBSM is not only fine with that, it has enough of a critical mass to work around it.

Question: Do the savings in your press release match your administrative costs as well as any P4P/gainshare or other economic incentives to the PCP? In other words, did you bend the total cost curve?

"The data that we shared on savings should be considered “early findings.” A complete cost analysis will be completed in the fall. However, our early findings indicate that the PCMH model is helping to avoid costs, such as ER visits, hospital admissions and radiology usage. BCBSM’s “spend” on the extra 10% payment to PCMH doctors in 2009 was approximately $8 million. These are dollars that were reallocated from other areas of the annual fee schedule. In other words, no extra or additional dollars were expended. PCMH doctors earned a higher fee, while some specialists earned slightly less.

BCBSM worked in partnership with its physician organizations to help provide administrative support to physician practices. As part of our Physician Group Incentive Program, BCBSM allocated approximately $30 million in 2009 from that reward pool to go toward PCMH capabilities and performance. Those reward dollars go to the physician organizations. The physician organizations determine how they wish to use those dollars. Many have used the funds to help pay for care management nurses, disease registries, electronic medical records, and physician training."

Let's be realists: unlike the Feds, regional insurers like BCBSM cannot print money and it has to come out of somewhere. It appears to the DMCB that money that would have been used to pay for year-to-year trend was used to support the PCMH. They apparently did not assume that "savings" this year would pay for next year.

Question: The numbers in your press release are percents. Any preliminary dollar numbers you can share?

We do plan to share dollar numbers later in the year, after the cost analysis is complete. BCBSM actually began developing the PCMH program with our partner physician organizations in 2004, and in 2009 we left the “pilot” phase and launched the full program. One of the first initiatives we launched with our physician organization partners was the generic dispensing effort – we estimate that since this program began in 2001, generic use has saved more than $700 million.

We are working with researchers from the University of Michigan School of Public Health on a comprehensive evaluation of the PGIP program, which includes the PCMH program. Funding for the evaluation has been received from Robert Wood Johnson Foundation, Commonwealth Fund and Agency for Healthcare Research and Quality (AHRQ). We have some articles in development for submission to health care publications and industry journals.

The DMCB agrees that if you are in the health care industry, you have an obligation to advance the science by sharing your knowledge in a transparent fashion that allows peers to review your results. That may involve traditional publications but can also involve other venues. However it is done, other workers in the PCMH field need to learn what works and why.

The DMCB hopes we learn more soon.

Disproportionate Share Clinics Are More Likely to Have Features of the Medical Home

The Disease Management Care Blog would have guessed that primary care sites serving socioeconomically disadvantaged populations would be more likely to be shut out of coming medical home payment bonanza. Given the assumption that their practice income is lower than average, it follows that they'd probably be unable to afford the added costs of a practice redesign to qualify for the additional payments.

Not so, says this paper* just published in the Archives of Internal Medicine. Titled "Medical Home Capabilities of Primary Care Practices That Serve Sociodemographically Vulnerable Neighborhoods," Bostonian authors Mark Friedberg, Kathryn Coltin, Dana Gelb Safran, Marguerite Dresser and Eric C. Schneider used their own survey to determine how much 'medical homedness' was already present in sample of Massachusetts primary care sites. They then used geomapping to assess the sociodemographic case mix of the sites' surrounding neighborhoods.

The authors' survey included asking if interpreters and multi-lingual physicians are available (features not specifically spelled out in this and this description of the optimum features of a medical home, but heck, it's their survey). It turned out those two features and - depending on the definition used of being a disadvantaged primary care clinic - electronic records, having staff for patient education and being aware of patient experience ratings were all more likely to be present in clinics located in socioeconomically vulnerable neighborhoods. None of the other medical home features that were assessed were less likely to be in these sites either.

While the study may be limited by the lack of generalizability (the sites surveyed were physician owned practices that were not public health clinics, plus this was Massachusetts) and by the vagaries of the survey that was used (as opposed to the more widely accepted NCQA assessment tool), the DMCB thinks this counterintuitive study may have important policy implications. Clinics that serve populations with care disparities may be helped by a payment stream promoting medical homes.

In retrospect, it makes sense to the DMCB that 'disproportionate share' clinics might have access to funding or other resources that enable them to have electronic records and rely on non-physicians for patient contact. If that is the case outside of Massachusetts, the DMCB suspects that NCQA accreditation would be within reach for these clinics if they decided to go through that process.

Hopefully this study will be replicated in other areas of the country to see if it holds up. If it does, it may make sense for disease management organizations to anticipate possibly not having to support disproportionate share clinics in their medical home activities and being able to count on them as resources in their ongoing care management.

As an added bonus, the DMCB notes that if you can get past the manuscript and into the online article itself (requires a subscription), the Archives has an on-line copy of the survey that was used to assess the clinics' medical home characteristics. This could be theoretically be used by a payer or purchaser in their own network.

*Hat tip to HealthHombre

CMS Steps Up With the Multi-Payer Advanced Primary Care Practice Demonstration on the Patient Centered Medical Home (PCMH) at $10 PMPM

Readers have questioned the Disease Management Care Blog about its Facebook and the other glow-pink eyed portraits in the right side of the page. It's been told that it conveys a buffoonishness that is inconsistent with the DMCB reputation of sober erudition and morose skepticism. What's more, it's been asked: just what are those lights?

Well, the pic is not long for this blog, but that doesn't mean it doesn't hold a special place in the DMCB Galaxy. Those are, by the way, pink flamingo tree lights, surreptitiously added to the cart by DMCB after being invited by the spouse to accompany her on a holiday shopping errand months ago. Despite the DMCB's merry participation, it was pointedly warned during check-out that this was the "last time" it would "ever" etc. etc. It seems it turned left in the aisles when it was supposed to go right, touched things it shouldn't have and said things that weren't helpful. While the lights were disappointingly never tasked to their original celebratory purpose, the DMCB has discovered - despite occasional attempts at spousal sabotage - that they are suitable for year-round display in the Executive Suite of DMCB World Headquarters.

And the States with Patient Centered Medical Home (PCMH) pilots may gain a special appreciation for the DMCB spouse's travails after they're done checking out just how CMS intends to merrily participate in their programs. The Feds have just released their "solicitation" for their "Multi-payer Advance Primary Care Practice Demonstration." This is **THE** three year demo designed to test the PCMH across multiple insurers, including Medicare fee-for-service (FFS).

Recall that one big problem encountered by the current bevy of pilots is that they're typically sponsored by just one or a few insurers. As a result, it's been difficult to ask primary care practices to reengineer their daily workflows to offer the "Cadillac" PCMH to patients with one type of insurance and "Chevy" usual care to patients with another type of insurance. Up until now, Medicare has relegated its patients to the Chevy.

Can the Cadillac PCMH pay off in Medicare FFS? To find out, CMS is inviting up to six States with ongoing multi-payer pilots to submit applications by August 3, 2010.

CMS' requirements are considerable. It wants (in "40 pages or less"):

1) a State agency to lead it,

2) enlistment of multiple group/individual private payers (that together enroll ">50% of State residents") as well as its Medicaid program,

3) the State to"demonstrate [the] commitment" of majority of its PCPs,

4) identification of and a way to certify PCMHs that also have links to State/community, public health, wellness and prevention resources,

5) to have the provider payment mechanisms in place,

6) CMS's uniform payments for the clinics/coordination/CMS' share of the administrative expenses (plus not to exceed $10 PMPM) all set up,

7) a way to figure out how to "attribute" a beneficiary to a PCMH (for example, by "designation"),

8) the State to line up any necessary waivers,

9) the creation of an adequate monitoring system,

10) State agreement to participate in an independent evaluation by an entity of CMS's choosing,

11) a reasonable assurance that the demo will be "revenue neutral" ("describe the anticipated effect of the State initiative on aggregate or global expenditures under the Medicare program for all covered services combined"), and

12) be ready to go by the end of 2010.

The DMCB's first reaction is that these requirements to the States and their physicians will be, er.... daunting. It is going through the other documents on the CMS web site and will be pondering them over the appropriate beverages this weekend. Look for lots more on the topic here.

Here's a Novel Thought: Leave the Success of the Medical Home Up To Patents

Is the Patient Centered Medical Home (PCMH) the panacea for all that ails health care? Have we exhausted all the allegories related to the term “home?” The answer to both questions apparently is no, thanks to this American Journal of Managed Care article by Timothy Hoff titled “The Shaky Foundation of the Patient Centered Medical Home.”

Dr. Hoff appropriately shelves PCMH policy and looks at the topic with a market-based perspective. From that vantage point, it all boils down to two customers: the primary care physicians and their patients.

Neither are slam dunks.

Primary care physicians: fewer medical school graduates are pursuing generalist careers and, in the meantime, the existing primary care workforce is getting older. Dr. Hoff quotes optimistic estimates of $30,000 to $40,000 per year in extra PCMH income per primary care physician and doubts those sums will be enough to dissuade the freshly minted doctors from pursuing more lucrative specialist careers. To add insult to injury, primary care is also saddled with 1) a relative absence among U.S. medical school faculty, 2) a lingering second-class “image problem,” 3) chaotic work schedules, 4) novel professional responsibilities (“team leader?”) and 5) the distinct possibility that transforming primary care clinics into PCMHs will require even greater effort and economic sacrifice over the short term. It’s enough to make even the DMCB want to apply to a dermatology residency right now.

The Patients: there is an abiding assumption among policy makers that health care consumers pine for the days when they had a personal physician to coordinate their health care needs, tut-tut don't-worry about that nagging backache and ask how Aunt Bee is doin'. Unfortunately, many of the Boomers, Generation X and the Millenials have grown up with a fragmented health care system and may not mind episodic care as much as has been assumed. No wonder the rise of Retail Care Clinics are such an irritant to many of the health policy mandarins, since their success among persons who treat health care like fast food seem to run counter to our cherished – and possibly mistaken – central-planning style notions of how patients should behave.

Dr. Hoff’s solutions include “socializing” medical students to primary care and recognizing that it may need to create a two track medical home and assembly line model of care.

The Disease Management Care Blog agrees with Dr. Hoff's analysis but is tempted to go one step further. Ultimately, it thinks, the success of the PCMH could end up being dependent on patient demand and patient dollars. If those two elements are there, the doctors will eventually follow. That may mean that the PCMH will have to adapt to the creative destruction of capitalism. Like it or not, it's an important force in healthcare, even with the government meddling. If the PCMH doesn't make it, maybe it'll be for the right reason: consumers want something else. If that happens, the DMCB is confident future leader-entrepreneurs in primary care can come up with the answer.



Image from Wikipedia

An Update On Pennsylvania's Collaboratives on the Patient Centered Medical Home (PCMH)

Go to the National Committee on Quality Assurance's (NCQA) or the Patient Centered Primary Care Colloaborative's (PCPCC) web sites on the Patient Centered Medical Home (PCMH) here and here, and you'll be treated to a set of criteria, principles, guidelines, certifications and other high falutin' stuff that are well suited to policymakers, academics and administrators. All that documentation is a necessary evil that helps certify and assess PCMHs. Unfortunately, for the healthcare providers that actually take care of patients, those concepts are of less use. They need something with more substance.

The Disease Management Care Blog to their rescue, thanks to its participation today in an update on the Pennsylvania Diabetes Action Partnership. Much of this initiative is directly focused on setting up regional multi-county "collaboratives." Within each are a limited number of primary care sites that receive logistical assistance in setting up PCMHs. Depending on the support of health insurers as well as the availability of grant support, financial aid is also available. As of this posting, a total of 152 clinics are participating and each clinic is submitting outcomes data into a central Statewide registry

Now that more than a year has elapsed, it's becoming possible to use the data to assess which clinics seem to be achieving more than their fair share of success. According to today's update, visit the higher performing clinics and you will find:

Ready/short hand identification of patients and records of persons with diabetes: This may mean a sticker on the cover of a paper chart or an onscreen prompt when there is an electronic record.

Regular review of registry data for "exception" patients: It's one thing to maintain a paper or electronic registry, it's another to actually use it so that the providers can spot the patients with care lapses such as missing appointments or absent lab testing. This review can occur weekly or monthly.

Contact them: This may take a lot of time, but someone has to telephone, leave voice-mail messages, telephone again, email, text etc over and over and over to track down the exception patients with care lapses.

And bring them in: This also burns a lot of time, but many of these individuals need to be corralled into coming into the clinic for face-to-face care. These patients don't necessarily need to see a physician, but they do frequently need to see a trained health care professional.

And, most of all, get them to take care of themselves: These clinics have set up multidimensional educational interventions (from brochures in the waiting room to one-on-one sessions with nurse-educators) aimed at getting the patient to set up their own care goals and avoid having to be a future "exception" patient.

Like other sectors of the service industry, this is a high touch game won by lots of individual consumer attention. It's also a set of characteristics that seem to be largely under-recognized by the accreditation process.

There was also some interesting information on three barriers to PCMH implementation that the DMCB had not previously read or heard about until today:

1. Staff turnover is not unusual among primary care clinics, but this is now resulting in the loss of trained teamed members and the need to invest in ongoing and costly staff education.

2. Simultaneous installs of electronic health records. This makes sense, but primary care sites are being asked to institute an electronic record and start of PCMH. The level of effort is reportedly extraordinary.

3. Large multi-clinic practices are frequently run as primary care site "confederations." Just because one physician group is enthusiastic about the PCMH doesn't mean that its sister sites will be willing to redesign their practices.

Finally, there is still no definitive word on reduced claims expense and whether the Pennsylvania version of the PCMH saves money. More to follow.

Group Health Medical Home "Savings" At Year Two Fails To Achieve Statistical Significance

When the Disease Management Care Blog saw the flurry of news reports (for example, not to mention a YouTube video) about the Patient Centered Medical Home (PCMH) "saving money," it couldn't wait for the full print version of Health Affairs to arrive at the DMCB World Headquarters. The DMCB had previously reviewed Group Health's negative "no statistically significant.... cost differences" one year study and was looking forward to seeing researchers Robert Reid et al's reportedly positive two year follow-up.

Here's what the DMCB found out when it lifted the abstract gown and examined the patient-manuscript itself:

The authors reported the outcomes of a single clinic with a "stable workforce, strong leadership and history of successful quality improvement" that cared for about 9200 patients and which was selected to pilot a "prototype" medical home. This clinic's results were compared to 19 other Group Health primary care clinics without a medical home approach to patient care. Investing in the medical home was not cheap, because the prototype clinic had to hire additional physicians, medical assistants, licensed practical nurses, physician assistants, nurse practitioners, registered nurses and pharmacists. It also appears that the clinic "downsized" its primary care patient panels to reduce physician workloads.

Using vigorous statistical methods to neutralize baseline differences, the authors compared over 200,000 usual care patients to the medical home's 7,000 continuously enrolled patients. The medical home was associated with fewer emergency room visits and inpatient admissions with greater numbers of specialty physician visits. When the costs were added up, this is what the authors found:

"When costs are totaled across all types of care and adjusted for case-mix and baseline costs, we estimate a total savings of approximately $10.30 per member per month, a result that approaches statistical significance, p=.08, meaning that the difference could still be due to chance." (bolding from DMCB)

In other words, the savings failed to meet the conventional threshold for statistical significance.

Despite the negative finding, the authors forged on and added up the cost of the program and compared it to the savings:

"...we can estimate return on investment associated with the prototype at 21 months at 1:51"

In addition to its failure to achieve statistical significance (let alone mention that in the abstract), there are several possible weaknesses with the study that went unmentioned in the "Lessons Learned" and Policy Implications" sections of Reid et al's Health Affairs publication: 1) the authors chose their strongest clinic (making its generalizability to other Group Health clinics suspect), 2) it's not clear which patients were dropped from the panel prior to institution of the PCMH, 3) despite statistical attempts to neutralize any known sources of bias, this was a non-randomized study and could have been influenced by unknown or unreported factors, and 4) what works at Group Health - an integrated delivery system in the Northwest - isn't necessarily going to work in any primary care clinic in Dade Country Florida, McAllen Texas or Mobile Alabama.

The DMCB wonders why its friends in policy circles and academia continue give the PCMH a pass. Based on these data, the PCMH is still not ready for prime time and should be confined to pilot testing. The DMCB is not the only curmudgeon that feels that way: check out this thorough review of the possible sources of bias and the testy response of the study's lead author.

Speaking of pilots, check out what Rhode Island Blue Cross Blue Shield is up to. The insurer is directly paying for the salaries of nurses that are being dropped into network primary care physicians' offices. While the Group Health article preaches about investing in primary care, clinical leadership, change management, electronic records, transformation, educational reform and the like, the folks in Ocean State have come up an approach that is a quadruple threat: it's 1) generalizable (could work in multiple settings), 2) adaptive (care management nurses are a supremely flexible species) 3) probably cheaper than "redesigning" primary care sites and 4) preserves the core value of non-physician coaches dedicated to engaging patients in their own care. That used to be called disease management, but it's really become a hybrid "2.0" version of the medical home that, if it works, may also deserve the attention of Health Affairs.

Why Linking Quality & Process Is So Difficult: Do Primary Care Physicians Have a Point About Elements of the Patient Centered Medical Home?

Who can blame the primary care physicians for their discontent?

They are loved by their patients, but their patients with heart problems or cancer love their cardiologists or oncologists more. They work hard for their patients, but not as hard as emergency room docs and general surgeons. They command respect, but not as much as nurses. They make decent amounts of money, but not as much as their ex-college roommates. They take good care of their patients, but not as much as insurers, government, academics and policymakers say they should.

No wonder they’re cranky. Some policymakers believe this vexation could explain some of the PCPs' reluctance to adopt information technology (IT) or the patient centered medical home (PCMH). The Disease Management Care Blog disagrees: PCPs are unhappy but they're also hardened realists.

This paper in the latest issue of Health Affairs helps explain why. Eric Holmboe, Gerald Arnold, Weifeng Weng and Rebecca Lipner, all of the American Board of Internal Medicine (ABIM), did a deep dive into the practices of a representative sample of 202 primary care internists’ practices. Physicians completed a “Physician Practice Connections Readiness Survey” that assessed their use of Chronic Care Model (CCM), which in turn forms much of the basis of the PCMH. In addition, trained abstracters used the “Comprehensive Care Practice Improvement Module” to review a year’s worth of representative medical records.

The composite practice CCM survey score averaged 48 points on a scale of 0-100. Average clinical performance scores on chart review ranged from 45% to 59%. Like the DMCB, readers may be unfamiliar with the details of the survey and the module scoring. The DMCB isn’t surprised, however, that the ABIM would use a difficult set of measures resulting in less than 100% scores. But that’s not what’s important about this paper.

Since the authors didn’t use the “Lake Wobegon” approach, there was useful a “spread” of physician and patient measures. This allowed the authors to assess whether higher physician CCM-based survey scores should lead to better chart review outcomes, right?

That's not what was found.

The only characteristic that seemed to correlate with improved patient outcomes was the use of “reminders” that prompt doctors to use evidence-based care. For other CCM-based processes such as quality improvement, a registry, teaming, patient centeredness, enhanced access and clinical information systems, there was no correlation with patient outcomes.

The authors speculated that many of their CCM survey measures were too dependent on information technology that missed the impact of patient-physician relationships or local physician leadership. They also pointed out that their sample size may have been inadequate to detect small yet important changes, that they could have missed aggregate improvements at a practice or group level and that their results could have been biased by an overreliance on self-reported physician measures.

Keeping those weaknesses in mind, this is still another study that shows that processes of care may not be associated with better patient outcomes. But this paper is important at a more fundamental level: it reminds the DMCB that the ability to link process and outcomes at an individual physician level is very very difficult. While having registries, teaming, patient centeredness, enhanced patient access and clinical information systems may make a difference on a group, regional or national basis, the difference is difficult to detect in the average physician’s office.

This means that insurers, government, academics and policymakers may not be able to expect local process improvements to lead to observable local quality improvements. Thinking that practice by practice, physician by physician redesign will add up to population-based improvement may make sense, but it won’t be detectable at the individual clinic level.

The next time physicians say they don’t “get” the link between the push to redesign the delivery of primary care practice and what it means for their patients, maybe they’re not being obstructionist. They're being realists. They're not seeing it.

Medical Homes & CMS' Chief Actuary: The Mirrored Gazing Globe of Health Reform?

The Disease Management Care Blog believes a gazing ball would be a handsome addition to our yard. In its opinion, a mirrored globe would be a festive compliment to the property and introduce a distinct classiness that is absent around our neighborhood. Yet, the DMCB spouse's opaque logic has inexplicably vetoed the idea. What gives?

And the same cold water could end up being splashed on the equally good ideas behind the various pilots and demos in the recently passed Patient Protection and Affordable Care Act (APPAC). In Section 3021 (p. 271), the yet to be formed Center for Medicare and Medicad Innovation is charged with testing various models of care including medical homes. The HHS Secretary may, 'through rulemaking,' expand the models if:

"...the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce program spending under applicable titles."

Egads. Getting the CMS Chief Actuary to certify there is reduced program spending may be a tough hurdle. According to this news report, this is the same equally hardnosed Chief Actuary that recently calculated that the newly passed health reform bill will lead to "increased costs associated with the expansions of health insurance coverage" and that "the longer-term viability of the Medicare ... reductions is doubtful."

The policy response from the White House and its Favored Chosen, of course, is spin. Given the Chief Actuary's uncanny similarity to the DMCB spouse, however, the DMCB isn't sure that spin will meet "reduce program spending" muster.

In the meantime, the DMCB is moving on. Inspired by the release of the movie Avatar on DVD, its latest pilot ornament idea is to festoon our shrubbery with solar powered glo-in-the dark Pandora-like butterflies. The DMCB looks forward to the DMCB spouse's analysis and the expansion of this meritorious landscaping model.

Specialist Physicians and Patient Centered Medical Homes: Here's How To Make It Work

Should specialist physicians be allowed to hop on the Patient Centered Medical Home gravy train? That's the topic of an interesting New England Journal article by Larry Casalino (Cornell), Diane Rittenhouse (UCSF), Robin Gilles (Berkley) and Stephen Shortell (Berkley).

Several organized specialist physician groups as well as the AMA have supported the notion of specialist (for example, urologist) medical homes. Dr. Casalino et al explored this with a telephone survey of randomly selected cardiology, endocrinology and pulmonary specialty practices. Unsurprisingly, 81% of the respondents described themselves as providing primary care services for 10% or less of their patients. Endocrinologists averaged higher, with about 10% providing primary care to up to 50% of their patients.

In response, Dr. Casalino and colleagues posed four open ended questions for health care policymakers:

1. Is it called 'primary care' if specialist physicians refer patients to other physicians for primary care services?

2. Are some specialty physicians, compared to others, better able to provide 'primary care?'

3. Is the extensive practice transformation necessary to become a PCMH possible or even worthwhile for specialty physicians when primary care only occupies a fraction of their practice?

4. Assuming specialty physicians are an important societal resource, should we be even encouraging the notion of them providing primary care?

While the few policymakers that actually read the Journal may ponder those questions, regular readers of the DMCB can go one step further and note:

1) how little mention the self and commercial insured markets get in this article. If there is a business case or consumer demand for cardiology, pulmonary, endocrinology or even urology patient centered medical homes, the purpose of policy makers should be to figure out how to get themselves and government out of the way.

2) that the answer to specialist-run medical homes may be sorted out in the coming Accountable Care Organization programs that were part of the health reform PPAC Act. In fact, the DMCB suspects, depending on how the regulations are sorted out, that the infrastructure of well managed ACOs will provide virtual and transorganizational PCMH services, blurring the distinction between physician 'owned' versus "rented" elements that make up a medical home.....

...which brings up a third wrinkle and possibly some answers to the questions poised by Casalino et al. Inside or outside of ACO's, the DMCB thinks - depending on market forces and the degree of Federal meddling - that the smarter commercial disease management organizations (DMOs) are already positioning themselves to provide many of the services that would fulfill the spirit and the letter of medical homes, including those run by specialists. DMOs can prompt patients to meet their primary care needs with shared decision making, level the playing fields between different types of specialists, reduce the need for a wholesale practice transformation and enable specialists to still function as specialists for an appropriate percentage of their practices.

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

First Impression Notes From the March 30 Patient Centered Primary Care Collaborative's Stakeholder's Meeting

It's been a long but rewarding day. The Disease Management Care Blog attended the Patient Centered Primary Care Collaborative's Stakeholders' Working Group meeting at Washington D.C.'s Ronald Reagan Building. You can download most of the presentations here. While the DMCB will be reflecting on some of the Conference's more interesting speakers' over the next few days, here are some immediate insights:

The PCPCC has come a long way with an energetic and impressive leadership that has ably harnessed the talents of a cast of thousands. There was a sense of real momentum in the room.

The "Patient Centered Medical Home" clearly continues to be hot, not only because of its inclusion in health reform, but because conferences on the topic can now attract U.S. Surgeon Generals and National Coordinators for Health Information Technology. Surgeon General Benjamin extolled her many past ties to organized medicine and demonstrated her understanding of clinical practice in small town poverty, making the DMCB wonder why she wasn't more visible during the Administration's recent legislative travails. As for Dr. Blumenthal, the irony of his "I'm from the government and I'm here to help" doctors adopt meaningfully useful electronic records speech at the Reagan Center was almost too much for the DMCB to bear. Lots of coffee helped maintain focus.

There is a telling absence of breaking news about cost savings, a.k.a. claims expense reductions, a.k.a., bending the curve, a.k.a, return on investment from the medical home pilots. The focus on payment reform, blended capitation/fee-for-service/P4P/shared savings models and an interesting discussion on an alternative approach to reimbursement for measurable outcomes that are 'delegated' to medical homes made the DMCB suspect that the pilots have begun to run into the same issues that plagued early versions of the disease management industry. Hang in there says the DMCB. Not only is the science of cost analytics evolving, so is the patient centered medical home itself, including combined approaches that leverage the best of health information technology, value based insurance and modern versions of disease management. More on that in a later post.

The not-for-profit community health plans, represented by ACHP, also have yet to demonstrate hard savings from their PCMH initiatives, but there are some promising "early indicators." The DMCB also does not blame ACHP or its members for being annoyed at being swept up in the anti-insurer bombast of Ms. Sebelius.

Last but not least, the language of "Patient Centered Medical Homes" may have shifted away from jargon about 'the medical home' to rhetoric about "patient centeredness." This sometimes drifted into a parallel universe of perfectly-practiced medicine, special PCP-patient intimacy, appointments whenever wanted, limitless access to caring specialists and virtuous declines in health care costs. It also included, and the DMCB is not making this up, being a role model for "student-centered schools." The DMCB endorses the concept and votes for commuter-centered DC Metro trains, working wireless-centered wirelessness at last night's cheapo hotel and, as always, DMCB-centered spousing.

This means that in workplace meetings, conferences and career laddering sword-play with colleagues, the thousands of regular DMCB readers once again have a critical advantage. You can once again demonstrate your complete mastery of this topic by minimizing use of 'medical home' in favor of the much preferred term 'patient centeredness':

Incorrect: "This initiative is designed to promote quality and consumer value by leveraging the principles of the medical home in our network!"

Correct: "This initiative will capitalize on consumerism, leading to heightened health care value by focusing on patient centeredness in our network!"

A Report on the Electronic Record and a Report on the Patient Centered Medical Home: Good Reading

The bookish Disease Management Care Blog found two recent and interesting pieces from the medical literature for your consideration. One deals with the electronic record and the second deals with medical homes. Both are written with the physician incentives in mind and deserve to be considered by policy-makers and anyone with 'line' responsiblity for dealing with either of these two initiatives in a provider network.

The first is from David Kibbe MD, a senior advisor to the American Academy of Family Physicians. Writing in an online 'ahead of print' version of Family Practice Management, Dr. Kibbe offers up some words of caution over the latest plan (proposed rule making) by the Feds to promote the 'meaningful use' of the electronic health record (EHR). This should give pause to policy makers that think the EHR is a wonderful idea that only needs a nudge to make it become reality in every corner of every physician practice.

Basically, he says, the Feds' latest actions have raised even more uncertainty. As a result, physicians without an EHR may elect to sit tight and use paper for at least one more year or longer. According to Dr. K, here's why:

1. emerging 'meaningful use' requirements by the Feds will force EHR vendors to reconfigure their wares, which is leading to future price uncertainty. (Ditto for the docs that were brave enough to invest in EHRs, by the way).

2. health reform has been slowed, leading to additional uncertainty about future physician fee schedules, revenue and their ability to afford investment in an EHR in the first place.

3. 'modular' EHR-like components are around the corner, which will allow docs to assemble 'clinical groupware' into a functioning EHR, which raises additional uncertainties.

4. the Physician Reporting Quality Reporting Initiative (PQRI), another CMS program that promised to reimburse physicians outside of the normal fee schedule 'P4P style,' has not gone all that smoothly. Docs may doubt that the government can really deliver the goods, er, make that checks.

5. money aside, it's just a big hassle to deal with Uncle Sam

6. the meaningful use process will eventually require the on-line submission of quality outcomes data. Right now, it's not clear how CMS will handle what promises to be a huge data load, introducing even more doubt about the promise to pay physicians in a timely manner.

7. the Feds are threatening penalities down the road for physicians that don't comply with meaningful use EHRs. Many physicians may respond by planning on using paper until that date and then simply retire from practice altogether (when the economy eventually turns around and the 401k's get back)

The second article is available (subscription required beyond the abstract) at the Annals of Internal Medicine. Recall that advocates of the Patient Centered Medical Home (PCMH) suggest that physicians who offer it should be reimbursed with a monthly and risk-adjusted fee per PCMH enrollee in addition to the usual fee-for-service payments. If that sounds like 1990's style capitation, you're right. Written by Ann Mirabito and Leonard Perry of Baylor, the article presents three HMO mistakes that need to be avoided by capitated PCMHs:

1. resist the temptation to go along with any mandated patient enrollment in medical homes. If PCMH's work so well, they should have no problem attracting patients by acting as a 'trusted' guide to navigating referrals in a patient-centered and evidence-based manner.

2. early HMOs were regarded as patient friendly, but things quickly turned sour when there were too many patients and things turned impersonal. Physician practices without the capacity to truly be medical homes will need to resist the allure of signing up too many patients and grabbing all that capitation revenue.

3. simple risk-adjusted payment systems will simply reward physicians for signing patients up. Better to include meaningful dollar incentives that reward measurable quality.