A Marriage Made in Heaven? Accountable Care Organizations, Patient Centered Medical Homes and the New England Journal. The DMCB Says Not So

There they go again. It's one thing for the Editors to allow authors to use the 'Perspectives' section of the New England Journal of Medicine as a soapbox, it's another thing to let it happen absent any recognition of the inconvenient reality that awaits outside of the academic dreamscape.

This latest gaffe is also happens to be the lead article in the December 10 2009 issue (not online at the time of this posting). Written by Diane Rittenhouse of UCSF, Stephen Shortell of Berkley and Elliott Fisher of Dartmouth, it simultaneously extolls the virtuous synergies of the Patient Centered Medical Home (PCMH) and the Accountable Care Organization (ACO) as the linchpins of health reform. The basis of this essay was a Commonwealth Fund supported confab involving 'other leaders' that led to a 'consensus.' These leaders number a grand total of nine and hail from such representative organizations such as Tufts, Hopkins, the American College of Physicians, the American Academy of Family Physicians, UCSF, the Commonwealth Fund, the Urban Institute and U Mass. You get the picture.

So what did this beau monde bull session yield up? In the opinion of the Disease Management Care Blog, some very good points. It's what was lacking that has the DMCB vexed, but more on that later.

These Brahmins point out that the PCMH is advantaged by its strong primary care foundation that 'builds on substantial evidence' that it leads to increased quality and lower cost. However, two issues block its adoption: 1) there are no incentives for non-primary care (i.e. specialist) providers to work collaboratively with the PCMH and 2) financial arrangements that allow the primary care physicians to share in savings from reduced utilization are lacking.

In the opinion of these learned ones, both shortcomings can be fixed by ACOs. Recall these provider-led regional hospital-physician organizations are responsible for the cost and quality in the full continuum of care for their defined populations. The business model is predicated on sharing in the cost savings achieved relative to a risk-adjusted projected spending target (or capitation), tempered by quality performance measures. To succeed in this, it's clear that ACOs will need a strong primary care base. They'll be organized to make their specialists play nice and will have to channel their savings toward their formerly victimized PCP's PCMH's.

So, ACOs need the PCMH and the PCMH needs ACOs. Here's how to make it happen:

1) Organizations like the NCQA need to not only have a recognition program for medical homes but for ACOs and a key criterion needs to be the strength of their primary care base.

2) A common set of quality performance measures for both ACOs and PCMHs need to be developed

3) Payment reform needs to be implemented so that ACOs and PCMHs can thrive

4) CMS' and AHRQ's ability to implement, support and measure 'these promising delivery system reforms' needs to be expanded.

So just what is the DMCB's beef?

First off, both the PCMH and ACO remain ultimately unproven in their ability to create savings. While the former is butressed by some promising literature, the PCMH is not without its problems (see Medicare's travails here, some bad news about Group Health's non-savings here, the controversy about North Carolina's Community Care here and then there's this piece). The ACO remains a tantalizing concept that has yet to be implemented anywhere. While late in the article the authors advocate for Medicare and other demonstration projects on the PCMH and ACO, the DMCB thinks the NEJM editors allowed Rittenhouse et al to finesse the issue and portray the PCMH-ACO as an economic slam dunk.

Not so. Add a number 5 to the list of make-it-happens above: Conduct rigorous research that determines if the PCMH-ACO results in reduced claims expense that can meaningfully contribute to 'bending the curve.'

Secondly, there was no mention of how little is known about independently practicing primary care physician attitudes about the considerable work-effort and risks associated with converting to a medical home, or about their probable skepticism about the merits of affiliating closely with hospitals. This NEJM piece assumes that if you build it, they will come.

Not so. Add a number 6 to the list of make-it-happens above: Survey primary care physicians (especially ones that don't regularly read, let alone believe everything written in, the NEJM) to assess what it will take to generate participation in PCMH-ACOs.

Note that this article brought up the "C" word, i.e., capitation. This comes perilously close to assuming insurance risk and going back to the future of health maintenance organizations (HMOs). Have we really forgotten the bad behavior that can occur from putting profits (from 'savings') before patients? While 'quality' is an ingredient designed to put the brakes on 'lowering costs,' do we really believe ACO budgets will yield to measures of A1c, tobacco cessation metrics or the number of persons reporting they exercise regularly?

Not so. Add a number 7 to the list of make-it-happens above: In the PCMH-ACO pilots, the development of payment systems that assure quality measures will temper the pursuit of savings will need to be high priority.

Last but not least, the DMCB has repeatedly pointed out that it's not necessarily the PCMH that is the secret sauce, care management is the secret sauce. At its core, that means non-physician professionals (yes NURSES) that bring their special skills to bear in engaging patients to meaningfully participate in self-care. That ingredient is in the PCMH (which is probably why much of the literature is promising), but it's also present in old fashioned disease management.

Yes, that's so. Add a number 8 to the list of make-it happens above: In the PCMH-ACO pilots, pursue models of care that offer a spectrum of alternative forms of care management.

Coda: The DMCB is tempted to add another make-it-happen: regularly read this blog. Relying on just the NEJM isn't good enough anymore.

Here's the reference:

Rittenhouse DR, Shortell SM, Fisher ES: Primary care and accountable care - two essential elements of delivery-system reform. New Engl J Med 2009;361:2301-2303

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

Selling Insurance Across State Lines--Now the Dems Are Pushing the Idea--Why It Won't Work

A favorite Republican health care soundbite calls for making the health insurance system more efficient by letting health plans sell across state lines.Now Democrats are jumping on that idea. The latest public option idea would have the Office of Personnel Management (OPM) contract with national not-for-profit health plans and introduce those plans into local insurance exchanges--that would be

Liberal Demands Over Giving Up the Public Option Threaten Health Care Deals

I actually feel for Harry Reid this morning.He was on his way. He had mastered an incredibly fine balance in his health care bill.No it wasn’t real health care reform and it wasn’t going to bend any curves but the Dems long ago gave up on that looking for one big political “W” instead.The liberals were finally backing off on the public option there never were the votes for. But even the “neutered

2009 Health Reform Belongs To The Insiders

As a past wannabe Kremlinologist, the Disease Management Care Blog remembers how the CIA was repeatedly stymied in its attempts to penetrate the upper echelons of the Soviet Union's nomenklatura. As a result, America's intelligence analysts were reduced to scrutinizing pictures of the Rodina's super-elite as they gazed upon Moscow's May Day parades from their perches high above their common people. U.S. foreign policy depended in part on who was standing next to who and for how long with what smiles or frowns or body language.

And such is the state of an outsider trying to figure out what's going on with health reform in Washington D.C.. For example, news reports noted that President Obama paid a rare Sunday visit with the Senate's Democrats on their pending legislation. The Disease Management Care Blog puzzled whether this unusual weekend visit was a pre-victory pep-talk or the mark of an impending Waterloo? Was his failure to mention the public option an inadvertent oversight or the telltale treadmarks from being thrown under the bus? Exactly what compromises aren't being discussed and how long have they been off the table? Sorry, said the President's handlers, no questions? What did independent Sen. Joe Lieberman's grin portend? Should we put our medium range missles up for negotiation?

The naive DMCB can't tell what's going on. It's come down to being very much an guesser's game, where the coin of the realm is rumor, insider contacts and experience with connecting the power dots. The media is not only about feeding the 24/7 news machine, but also influencing the outcome.

So this is transparency, participation and collaboration? The darkly suspicious DMCB doesn't think so, and thinks the similarity to the Soviet Politoburo is not a credit to our democracy. In the meantime, we will have to await the outcome of the political swordsmanship from afar. The good news is that, unlike the Soviet Union, our political elite are not entirely immune to Main Street and the November 2010 elections.

The Latest Version of the Public Option—The Democrats Could Have Saved Us Lot of Time If This is What They Call a “Public Option”

If the latest version of the public option is something that will give its proponents reason to argue they still have a way to "make the health insurance market much more competitive," then a motor scooter is a Ferrari.The details are still fuzzy but the word is that senators are working toward a compromise over the controversial public option that would create something that:Would be run by the

Public Reporting of Hospital Quality With Media Attention Can Make a Difference: The EFFECT Study from JAMA

In addition to widespread agreement that financial penalties are a good way to batter hospitals over the head on quality of care issues, many policy makers, insurers and academicians also believe in public reporting. After all, nothing like the glare of publicity to shame the poor performers and make patients think again about going to St. Infectya's ER when Washdahands County Hospital has much better numbers. This threat could prompt hospitals to improve their care processes and bend the curve, right?

Well, finally we have some clever and well performed research that says ‘maybe.’

Check out this study by Dr. Tu and colleagues on the EFFECT Trial that was published in the December 2 2009 issue of JAMA. A mix of 86 Canadian Ontario province hospitals participated in a randomized trial to assess the impact of public reporting on how well they treated heart attacks and heart failure.

Readers may recall that the Disease Management Care Blog has pointed out that formal randomized controlled clinical trials can be time consuming, cumbersome and expensive. This Ontario research is an example of a staggered roll out design in which everyone eventually receives an intervention. Since it can be administratively cumbersome to intervene on all hospitals at the same time, it can make sense to do a fraction of the group first and then follow-up with the rest later. During the period of time when the laggards are waiting their turn, they can act as a functional control/comparator group. That’s what happened here.

After 5 hospitals eventually withdrew from the study, 42 hospitals were assigned to and completed an ‘early’ and aggressive roll-out of public reporting that started in January of 2004. 39 hospitals were assigned a ‘late’ and more modest roll-out that started 21 months later. The study design can be found here.

Both groups of hospitals had baseline performance measures collected on the quality of care for all of their heart attack and heart failure patients that had been admitted over a two year period from 1999 through 2001. The ‘early’ hospitals had these baseline performance measures released in January of 2004 with considerable fanfare. It was reported in many TV, radio and print media outlets. In September of 2005, the delayed hospital’s data were released on the web only and without any media fanfare. It was left up to the individual hospitals to decide how to respond to the measures. After a period of time, the hospitals’ heart attack and heart failure measures were assessed again.

So what happened? Most of the twelve measures of quality in heart attack care, such as the use of standard admission orders, assessments of cardiac function, measuring blood cholesterol levels, use of clot busting medications and the use of aspirin, beta blockers, cholesterol medications and ACE inhibitors went up in both hospital groups. The degree of change was no different in the two groups except for one key measure. The aggressive and early use of 'clot busting' medications prior to transfer to a cardiac care unit turned out to be statistically significantly higher in the ‘early’ group. The ‘early’ group also had a 30 day mortality rate that was 2.5% lower compared to the ‘late’ release hospitals. This difference turned out to be statistically significant.

There were six measures of quality in heart failure care, including assessment of left ventricular function, getting daily weights, patient counseling, use of ACE inhibitors, beta blockers and warfarin. Once again, most measures went up in both sets of hospitals, but only the greater use of ACE inhibitors in the ‘early’ group achieved statistical significance. One year mortality rate for heart failure was also statistically significantly lower in the early intervention hospitals.

While the authors were critical of relatively blunted effect of high publicity quality reporting (‘only one of 12 heart attack process measures and only one of six heart failure measures showed any improvement,’ and ‘public release of data may not be particularly effective.’) the DMCB is favorably impressed. Interventions that reduce mortality rates in heart attack and heart failure are difficult to come by and this intervention seemed to make a difference.

What’s more, the DMCB also finds the data are intuitively credible. It's been known for a long time that giving clot busters early in the course of care instead of waiting until the patient is in the cardiac care unit saves lives among heart attack victims. In addition, increasing the use of ACE inhibitors is well known to reduce the mortality rate among persons with heart failure.

Take aways:

For the first time, we have good research showing that public reporting with media uptake can lead to real changes in processes of care that are linked to tangible reductions in death rates. While the reductions are not huge, they are meaningful and of a similar magnitude compared to those obtained from other modern interventions in cardiac care.

While public reporting and media attention didn't lead to across the board improvements in all corners of cardiac care, the DMCB wonders if ‘fine tuning’ the measures and the public reporting on interventions that are shown to meaningfully change mortality rates should be considered. For example, should future public reporting be limited to measures on the use of clot busters or ACE inhibitors?

This is also an excellent example of the difference between peer-review published articles that double as marketing materials versus those that are credible scientific reports. The former typically extol their modest findings as robust or ground-breaking advances, while the latter are hyper-critical and tend to understate the significance of their findings while letting the numbers speak for themselves. This particular article is definitely in the latter category.

Last but not least, this is also a good example of clever regional collaboration among care providers to answer important research questions. It seems to the DMCB that all the Ontario Hospitals had pretty much agreed to public reporting. They saw the roll-out as an opportunity to test various methods of carrying it out and came up with some important insights. Hopefully future U.S. comparative effectiveness research will see these opportunities for what they are and the Medicare Chronic Care Practice Research Network will also be willing to adopt these kinds of efficient models.

Image from Wikipedia

2009 a Year of Surprises and Change for the EHR Technology Market

2009 a Year of Surprises and Change for the EHR Technology Marketby DAVID C. KIBBE and BRIAN KLEPPER"Oft expectation fails, and most oft thereWhere most it promises; and oft it hitsWhere hope is coldest, and despair most fits." All's Well That Ends Well (II, i, 145-147)2009 began with a bang for legacy Electronic Health Record (EHR) vendors, promising strong sales and windfall profits