Tuesday, June 2, 2009

“Faith” in the Patient-Centered Medical Home

Outer%20BanksJaan Sidorov, over at the Disease Management Care Blog, has two excellent posts on the Patient-Centered Medical Home (PCMH).

In the first post, Dr. Sidorov notes that while at the National Medicaid Congress currently underway in DC, Al Lewis (Disease Management Purchasing Consortium), dissected North Carolina’s Community Care (CCNC) Model. The CCNC has been highlighted at MFP (here and here), by other blogs (here), the media (here), and the Commonwealth Fund (slide below).


Mr. Lewis believes these types of systemic interventions should be more thoroughly tested (drugs require numerous studies, why not changes to the health care system) and after kicking the tires, he states that he does not believe the CCNC saves money after accounting for administration costs. This is in stark contrast to the state’s analysis by Mercer but is consistent with other major recent findings for systemic interventions (see Medicare’s evaluation of its Health Support Program).

Truth is, who knows? Even though state budgets are driven by hard data, the interplay between various budget line-items and policies are so complex (drug discounts, waivers, categories of aid, recipient churn, CHIP, uninsured funds, DSH, UPL, etc), that evaluating Medicaid policy changes is often a best-guess scenario. Also, remember that CCNC is a “weak” PCMH model in that it pays $3 PMPM to local physician for management services and $3 PMPM to local organization for additional case management services and these amounts are much less than what most experts believe is necessary to achieve real PCMH transformation.

In the second post, Dr. Sidorov highlights a recent paper from the Annals of Family Medicine that should be required reading for anyone interested in “medical homes.” The authors’ initial "lessons learned" were that:

  • Becoming a PCMH requires transformation (no small thing)
  • Technology needed for PCMH is not plug-and-play (especially with current systems)
  • Transformation to the PCMH requires personal
    transformation of physicians
    (again, no small thing)
  • Change fatigue Is a serious concern even within capable and highly motivated practices
  • Transformation to a PCMH is a developmental process (it takes time)
  • Transformation is local

And some of their “hopeful warnings” were that:

Part of the PCMH’s strong appeal, and also what creates confusion, is that it potentially unites 4 compelling areas of health care reform activity. These areas include research on primary care’s value, improved approaches to chronic care, consumerism, and new health care–related information and communication technology. There is mounting evidence showing
primary medical care’s value in assuring a health care system of higher quality at lower cost and with more equity.

The primary care and practice characteristics associated with this evidence are first-contact care with easy access, comprehensive care (degree to which primary care clinician provides a broad range of services), sustained partnerships or longitudinal care, coordinated care, and personal or patient-focused care with family and community orientation.

In addition, there is growing support for the use of the chronic care model in health systems and primary care practices. These core primary care features and the chronic care model constitute core elements of the medical home concept…

The PCMH represents a pivotal turning point for the restoration of a healthy primary care foundation and better health for our nation. Everyone should have a PCMH, and it should be developed primarily to improve health care; payment reform should remain an important secondary goal. In the spirit of seizing this historical moment, we close with some reminders
and hopeful warnings.

The PCMH will need adequate capital funding from a combination of federal, state, local, insurance industry, and health systems’ participation. Having practices front the cost of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed. We will need more transparency and negotiation of the many hidden agendas, especially among insurers and physicians.

We should be wary of industrial-like schemes and excessive use of the language of productivity and efficiency. Primary care, like healthy food, works best at a local and personal level. What is waste on an assembly line is not necessarily waste in a healing relationship; allow for appropriate variability. Stewarding patients toward healthier lives is a deliberate process—stewarding practices toward health and toward becoming a PCMH is also.

economist_slow_downWhat does all this mean? Well, one of the big dynamics in national health reform is to what extent the reform will rely on “faith” or “science”. By faith, I mean doing what we believe to be good (like PCMH) and by science, I mean what is “scorable” by the Congressional Budget Office. Let’s hope that whatever comes out of the mosh-pit of legislation will have strong doses of both.

The important thing is that we are getting our bearings straight by refocusing on primary care. But as the articles (and the graphic) accurately point out, even though we are pointed in the right direction, it will take some time to get where we want to go. ~BAA


Quinroxanne said...

Great post. Lots of information. Thanks a lot for sharing this.