"Five Recommendations for ONC Head Who Understands Health IT Innovation"

The team of David Kibbe and Brian Klepper are at it again with some advice on who best understands the health IT challenge in America:Five Recommendations for ONC Head Who Understands Health IT Innovationby DAVID KIBBE and BRIAN KLEPPERNow that the legislative language of the HITECH Act -- the $20 billion health IT allocation within the economic stimulus package -- has been set, it's time to

Presentation at the Medical Home Summit: Medical Home Has Shortcomings & Disease Management Can Help

The Disease Management Care Blog was a speaker today at the National Medical Home Summit in Philadelphia. Not only was it an honor to be speaking among the likes of Ed Wagner, Vince Kuraitis and Chad Boult, it had the pleasure of sharing the presentation spotlight with Doug Berkson of Health Dialog.

Our presentation examined ways in which disease management organizations (DMOs) and the Patient Centered Medical Home (PCMH) can collaborate. The DMCB had the easy part and spoke at a theoretical level for about 10 minutes. It then sat down and stayed quiet. Doug then did an absolutely outstanding job of describing his company's approach to integrating its program offerings with the provider-based PCMH. (Afterwards, the DMCB approached the rest of the Health Dialog folks [DMO sales people tend to cluster] and suggested that the company get someone to write about their interesting methods and submit it to a peer review journal. They didn't disagree).

One part of today's DMCB presentation dealt with the widely recognized and oft-published shortcomings of the PCMH, and how disease management can help:

Lack of an operational definition. Close examination of the peer-reviewed literature on medical homes reveals that when you've seen one PCMH, you've seen one PCMH. Disease management organizations (DMOs) can help fill in what's missing, from remote registries to extra nurses.

Not a cure for the 'tyranny of the urgent.' There's no shortage of patients in crisis at 4:45 in the afternoon. DMOs can free up patient slots by handling patients that don't need a face-to-face appointment to meet a more simple healthcare need.

Implementing a PCMH is a struggle for small practices. Indeed, it's a complete redesign that is likely to distract busy physicians for weeks if not months. The American Academy of Family Physicians recommends that DMOs could help train office staff in registry maintenance and care coordination functions. The DMCB agrees that would be a big help.

PCMH is not a cure for the physician shortage. It is unlikely that a fully implemented PCMH will enable an increase in the size the average physician's panel from the typical count of 2000-2500 patients. DMOs can offload physician work loads by taking on simple tasks, such as follow-up and patient education. With a fully implemented DMO on board, can physicians increase their panel to 3000? The DMCB says maybe.

Is the PCMH for all patients or just those with chronic illness? Either way, DMOs are one resource among many that can be triggered by a primary care physician as part of a plan of care for persons with conditions like diabetes and heart failure.

The PCMH has many local management challenges. While the larger clinics can dedicate FTEs to change management, not so for the smaller 1-5 person physician-owned primary care sites. The DMCB predicts that the smarter DMOs - in addition to TransforMed - will devote personnel to helping clinics. Why not? This will help build local relationships that further their ability to manage the insurance risk of populations.

What is the role of non-PCP specialists? The DMCB suspects that of all the stakeholders in this controversy, DMOs will be the most agnostic to the merits of an endocrinologist-run PCMH. They can go either way.

Should patients be locked-in to their primary care site? Under the Medical Home Demo, patient-participants will need to explicitly agree to rely on the PCMH to coordinate their care. It remains to be seen how well patients will respect this requirement. In the meantime, however, DMOs are more than capaple of calling 'on behalf' of the primary care physician (by name) to promote the idea that their primary care provider really is in charge.

The PCMH is becoming all things to all people. Given the excitment over the medical home, you'd think it was going to fix global warming and rescue Madam President from the safe room in the latest episode of 24. By bringing DM into the picture, the chances for success or failure would be spread over a greater number of supportive stakeholders.

Where's nurse-based telephony in the PCMH? Devoting a nurse to full or even part-time telephonic coaching for all patients that need it in a clinic is an expensive proposition. DMOs can do it far cheaper AND follow the doc's directions.

PCMHs have suspect network scalability. The DMCB thinks that if this takes off, many primary care providers will develop partially implemented medical homes. In the meantime, managed care organizations have a duty to provide a uniform level of care across their networks. DMOs may be able to fill in the gaps.

If you build it, will primary care physicians come? Maybe not. The DMCB also thinks many primary care providers will chose to NOT develop medical homes at all. DMOs may be able to fill in the gaps.

If you build it, will medical students come? Maybe not. There are surveys of medical students that suggest that their preference for dermatology has less to do with the money. They don't like to care for patients with chronic illness. Deans of the U.S. medical schools have been notoriously resistant to engineering their admissions process. The DMCB thinks we're in for a long dry spell of PCPs. DMOs are needed once again to fill the gaps.

Do remote population-based resources count? Suppose the primary care site uses a DMO-maintained electronic registry? Suppose there are nurses under the employ of a DMO on-site, doing care management? The DMCB thinks both meets the letter and intent of the NCQA recognition process for PCMHs. It's also a heckuva lot cheaper than letting PCMHs hire everyone.

What does the science say about the impact of the PCMH on variation? While there is evidence that the medical home promotes greater adherence to guideline based care, the DMCB wonders if that will be enough to have a noticeable impact on regions of the U.S. with high levels of unwarranted utilization for preference-senstive care. The DMCB thinks more - much more - will be needed. Among the many resources that can also be deployed: DMOs.

And finally, that Holy Grail: saving money. There is no evidence that the PCMH consistently reduces claims expense, especially outside of integrated delivery systems or Medicaid. The DMCB suggests that when it comes to saving money, the more that is done to coach patients into being better utilizers of health care services the better. DMO plus PMCH is better than either alone.

It may have been the DMCB's imagination, but many in the audience were nodding in agreement.

A Detailed Analysis of the Obama Health Care Reform Budget

Speaking about the imperative to bring America’s entitlement spending under control last December, Barack Obama said, "What we have done is kicked this can down the road. We are now at the end of the road and are not in a position to kick it any further. We have to signal seriousness in this by making sure some of the hard decisions are made under my watch, not someone else's.”Right-on!But in his

Learning Snippets from the National Medical Home Summit

The Disease Management Care Blog spent the afternoon in Philadelphia basking at the National Medical Home Summit. It may have been a Nor'easter blustery winter wonderland outside but inside, the learning warmed the heart of the DMCB and lit up all kinds of lightbulbs.

Here's some highlights from some of the luminary speakers:

Nancy Johnson, former Congresswoman: Don't expect healthcare reform including the words 'Medical Home' this year. That's not a bad thing, because we're on a learning curve and policy rushed into law can be overly prescriptive and punitive. Next biggest opportunity for the Medical Home: addressing end-of-life care. Interesting quote: if we don't get this right, we'll end up with a single payer system that is just like Medicaid.

Paul Keckley, of Deloitte: The term 'Medical Home' has bad connotations for health care consumers because it sounds so....institutional. 'Primary Care 2.0' sounds better, especially because it - along with Retail Clinics, Disease Management in Retail Pharmacies and Home-Based Connected Care - has to potential to be a cheaper and better disruptive technology that promises to upend care as we know it. Interesting quote: primary care physicians not only deserve $275,000 a year in income, pretending otherwise makes policy makers suspect there is some sort of hidden agenda.

Meredith Rosenthal, of Harvard: Expect the Medical Home to eventually be reimbursed with some combination of fee-for-service, capitation, pay for performance and upside risk sharing, possibly tied to incentives to invest in the primary care site's infrastructure. Unfortunately, we're not there yet with the payment models that work best: we need more time. Interesting quote: the greatest opportunities for the Medical Home may be in reducing duplicative tests and promoting referrals to efficient specialists.

Phyllis Torda, of the NCQA: Having NCQA recognition as a Medical Home correlates with clinical performance in diabetes care and cardiovascular disease. Expect the standards to be updated in 2010 (DMCB comment: they're not going to be easier, so if a primary care site is thinking about this, now is the time). Interesting quote: we need to engage the specialist physicians in a 'neighborhood' around the Medical Home.

Linda Magno of CMS: The Medical Home Demo is ready to go, and no, she's not going to spill any details until the Office of Management & Budget says it's OK to spill the details and no, she's not telling when that is going to happen. Interesting quote: Just because Medicare has two Medical Home levels and the NCQA has three doesn't mean that future Medicare iterations won't reflect the NCQA approach.

Lisa Letourneau of Maine's Quality Counts: Maine has it's own multi-stakeholder Patient Centered Medical Home demo underway, but this one really has put the patient in the center, including having two lay persons participate in designing initiative and the ongoing evaluation of the outcomes. Interesting quote: none, but the DMCB wondered why there isn't a majority of laypersons in the evaluation process.

Gordon Norman of Alere: Success for the Medical Home may be less dependent on "savings" and more on demonstrating some cost mitigation and value. Interesting quote: if we're not careful, demos involving the PCMH will lose the foot race for the hearts and minds of primary care physicians. Even if value is shown, there may be no one to turn on the lights in the primary care clinics.

Paul Wallace of Kaiser: Medical Homes need data including utilization information, admission rates and specialist efficiencies. Interesting quote: If we don't do everything to help Medical Homes succeed, we'll kill off the last PCP.

home

I arrived home from Dallas in the wee hours of this morning. I am exhausted but so glad I went. The 9th Annual Conference for Young Women Affected By Breast Cancer exceeded my expectations in every way.

I expect to be writing a lot about this later this week but I am so very tired and have chemo early tomorrow.

Meanwhile, here are some shots of folks gathered around for the group photo. Very many of us were hanging around above taking photos and I think we diminished the numbers a bit. There were 8oo women in attendance. Three hundred of us were on scholarship. It was incredible.

A Commission on Entitlement Reform--A Good Idea

The Kaisernetwork reported the following today:On Sunday, White House Office of Management and Budget Director Peter Orszag during an appearance on ABC's "This Week" said that Obama might establish a commission on entitlement reform, or broader health care reform, to take some of the authority over the development of legislation from Congress. Under such a commission, the Obama administration and

A Video On Electronic Health Records Teaches Us About Its Many Shortcomings

The Disease Management Care Blog thinks that Wall Street Journal Health Blog unwittingly posted a highly instructive video that demonstrates much of what is good, bad and downright ugly about the electronic health record (EHR). The posting superficially describes a reporter’s cross country trek and he happened upon an “Ohio primary-care doc” using a record system envisioned by the Obama team. For your viewing pleasure, the video is posted below:



The DMCB deployed its forensic video watching CSI skills and checked for DNA, fingerprints and carpet fibers. Decide for yourself if its interpretation of the evidence will hold up in court:

The Good: the medications can be electronically transmitted to the pharmacy. The physician doesn’t need to write out the scripts and the patient doesn’t need to wait at the pharmacy window. In the opinion of the Disease Management Care Blog, the efficiency, accuracy and safety of EHR-based medication management are its greatest attractions. That being said, the DMCB isn’t sure its opinion would pass muster with the proposed FCCCER, since the evidence may be lacking. There is no shortage of recent studies saying we still have a way to go. So, let’s say it’s potentially good.

The Bad: Just because an EHR is present doesn’t mean there will be evidence-based practice. Case in point? The first patient in the video has shingles and the physician is prescribing valacyclovir (it fights the virus causing the condition) and ‘gabapentin’ to help with the pain. Unfortunately, the use of the latter drug, gabapentin, for the treatment of active shingles is questionable. The DMCB went to the AHRQ’s National Guideline Clearinghouse and found guidelines that suggest opioids – not gabapentin - be used as a first line agent. Not only is there little evidence that it offers all that much compared to the other treatment options, gabapentin is relatively expensive, the evidence that supports its use is troubled and it may be subject to quantity limits. None of that was shared with the patient.

The Ugly: And just where is the business model locally OR nationally? Is this physician any more efficient than the paper-chart-using doctor down the hallway? Is there better care or higher value packed into this office visit? While viewers may be comforted by the physician’s review of the past immunizations (‘flu shot’), the DMCB thinks that is a monumental waste of time. Ample evidence suggests nurses and pharmacists are more than able to use standing protocols to update any missing immunizations. What’s more, the video cleary demonstrates both patients already know about their immunizations and other preventive care needs. The DMCB ran this video several times and cannot find $20 billion worth of healthcare value or much hope of a return on investment as currently configured.