By Jaan Sidorov, MD

We’re all aware of the past criticisms of “disease management.” According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of “outcomes” were based on flawed research that was never intended to be science; it was really intended to market their wares.

But suppose this correspondent alerted you to:

1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.

If you think that sounds like typical vendor-driven telephonic disease management, you’d be right.  You’d also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses.  When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.

Continue reading “Why Disease Management Won’t Be Going Away Any Time Soon”

By Dan Diamond

In November 2008, the New England Journal of Medicine convened a small roundtable to discuss “Redesigning Primary Care.”

U.S. primary care is in crisis, the roundtable’s description reads. As a result … [the] ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields.

Nearly five years out — and dozens of reforms and pilots later — the primary care system’s condition may still be acute. But policymakers, health care leaders and other innovators are more determined than ever: After decades where primary care’s problems were largely ignored, they’re not letting this crisis go to waste.

Ongoing Shortage Forcing Decisions

The NEJM roundtable summarized the primary care problem thusly: Too few primary care doctors are trying to care for too many patients, who have a rising number of chronic conditions, and receive relatively little compensation for their efforts.

Continue reading “The Radical Rethinking of Primary Care Starts Now”

By Michael L.  Millenson

It is as natural for doctors, hospitals, health plans and others to aggressively affirm their “patient-centeredness” as it is for politicians to loudly proclaim their fealty to the hard-working American middle class. Like the politicians, the health care professionals no doubt believe every word they say.
The most accurate measure of “patient-centered” care, however, lies not in intentions but implementation. Ask one simple question ­– what effect does this policy have on patients’ ability to control their own lives? ­­­– and you start to separate the revolutionary from the repackaged. “A reform is a correction of abuses,” the 19th-century British Parliament member Edward Bulwer-Lytton noted. “A revolution is a transfer of power.”

With that in mind, which purportedly patient-centric policy proposals portend a true power shift, and which are flying a false flag?

Falling Short Of Shifting Power

The two most prominent examples of initiatives whose names suggest power sharing but whose reality is quite different are so-called “consumer-driven health plans” (CDHP) and the “patient-centered medical home” (PCMH). Both may be worthy policies on their merits, but their names are public relations spin designed to put a more attractive public face on “defined contribution health insurance” and “increased primary-care reimbursement.

Continue reading “The Patient-Centered Practice, Revisited”

By Al Lewis

It’s not quite time to publish the obituary for by far the most extensive patient-centered medical home (PCMH) network in the country, Community Care of North Carolina (CCNC) but it’s certainly time to spellcheck it. The HMO-friendly GOP controls the statehouse, a blistering audit on Medicaid management has just been released (with plans for a CCNC-specific audit in the works), and the state’s most influential media outlet has ”vindicated” those who were excoriated for daring to question it, such as me, to name one random person who has frankly obsessed with it.  (This might explain why I never get invited to parties.)

By way of background, the state’s Medicaid agency initiated what might loosely have been termed an enhanced-access model almost 15 years ago, and have subsequently expanded their experiment into a full-fledged patient-centered medical home, which currently covers many disabled members, the large majority of the non-disabled adults, and most of the children.

This wasn’t just any old medical home – it was the “poster child” for the PCMH movement, even making it onto NPR. Here is the influential and literate Disease Management Care Blog on the subject:

It’s impossible it seems to read anything about the Patient Centered Medical Home (PCMH) and not run into Community Care of North Carolina (CCNC) as the ‘The PCMH Saves Money’ poster child. No power point presentation on the topic is complete without its mention, no Meeting Agenda is full if it’s not there, if you’re going to testify on the PCMH’s benefits before Congress, you should bring it up , the Commonwealth Fund is working hard to replicate it and it’s even embedded in Medical Home Wikipedia.

Further, North Carolina and states that wanted to adopt this model were given an unprecedented 9-to-1 federal match, reflecting the Obama Administration’s admiration for its success.

Continue reading “Community Care of North Carolina’s Last Chance: To Fool the Legislature Rather than Answer the Questions”

By Al LEWIS

The ongoing saga of savings estimates for the Community Care of North Carolina (CCNC) patient-centered medical home (PCMH) is finally over.  The verdict: no savings. Because the scale and visibility of the CCNC experiment are unparalleled in the Medicaid sector today, it is important that the right policy and delivery system lessons be learned from this dispositive conclusion.

Lesson 1:  Enhancements in access do not necessarily create cost reductions, at least in Medicaid.

CCNC is by all accounts an excellent program from the patient’s perspective.  Indeed, if I were a Medicaid recipient, I would want to live in North Carolina.  The leadership of CCNC is passionate about the program and constantly strives to improve it.  However, as was amply observed by J.D. Kleinke on this very blog last week, Medicaid recipients have many lifestyle and economic issues that even the best-intentioned and best-incentivized doctors will never be able to systematically address.

Lesson 2:  Perhaps it is time to create an ER co-pay for Medicaid recipients that has more than one digit to the left of the decimal point.

Even as ER co-pays for commercial insurers have soared in the last decade, Medicaid ER co-pays remain virtually non-existent.  CCNC created excellent reasons to use primary care but was not permitted to re-price the ER to economically encourage use of primary care.  Many Medicaid recipients overuse the ER in part because it is basically free.  For the CCNC experiment to truly have a chance to reduce ER visits now that they have created a worthy substitute with their PCMH, it’s only fair to them (and to taxpayers) to reconfigure the financial incentives so that people use their worthy substitute … and then re-measure savings.

Continue reading “North Carolina Medicaid’s Patient-Centered Medical Home: Lessons Learned”

By David C. Kibbe, MD  & Vince Kuraitis

Everywhere we turn these days it seems “Big Data” is being touted as a solution for physicians and physician groups who want to participate in Accountable Care Organizations, (ACOs) and/or accountable care-like contracts with payers.

We disagree, and think the accumulated experience about what works and what doesn’t work for care management suggests that a “Small Data” approach might be good enough for many medical groups, while being more immediately implementable and a lot less costly. We’re not convinced, in other words, that the problem for ACOs is a scarcity of data or second rate analytics. Rather, the problem is that we are not taking advantage of, and using more intelligently, the data and analytics already in place, or nearly in place.

For those of you who are interested in the concept of Big Data, Steve Lohr recently wrote a good overview in his column in the New York Times, in which he said:

“Big Data is a shorthand label that typically means applying the tools of artificial intelligence, like machine learning, to vast new troves of data beyond that captured in standard databases. The new data sources include Web-browsing data trails, social network communications, sensor data and surveillance data.”

Applied to health care and ACOs, the proponents of Big Data suggest that some version of IBM’s now-famous Watson, teamed up with arrays of sensors and a very large clinical data repository containing virtually every known fact about all of the patients seen by the medical group, is a needed investment. Of course, many of these data are not currently available in structured, that is computable, format. So one of the costly requirements that Big Data may impose on us results from the need to convert large amounts of unstructured or poorly structured data to structured data. But when that is accomplished, so advocates tell us, Big Data is not only good for quality care, but is “absolutely essential” for attaining the cost efficiency needed by doctors and nurses to have a positive and money-making experience with accountable care shared-savings, gain-share, or risk contracts.

Continue reading “The Power of Small”

By Andrew Morris-Singer, MD

Annie Lowrey’s July 28 article “Doctor shortage likely to worsen with health law” in the New York Times noted the growing shortage of primary care doctors particularly in economically disadvantaged communities, both in rural and inner-city America. This problem will likely get worse before it gets better as more Americans gain coverage and seek a regular source of care. As the article suggests, training more doctors and incentivizing them to pursue careers in primary care will be a key part of the solution. And it will require a multipronged campaign, using both some of the traditional strategies for workforce renewal and a few unique tactics not typically deployed in efforts to fix health care.

The primary care workforce pipeline had dried up before the Affordable Care Act was passed. Currently, one out of every five Americans lacks access to primary care. As a result, up to 75% of the care delivered in emergency departments these days is primary care . This overcrowds and overburdens EDs, raises costs, and limits EDs’ ability to do what they were designed to do: provide acute, emergency care that makes the difference between life and death. So the primary care shortage threatens our access not only to primary care but also to emergency care.

How did we get here? Many are quick to point to primary care doctors’ low salaries compared to those of their sub-specialist colleagues. Indeed, choosing a career in primary care rather than a sub-specialty means walking away from 3.5 million dollars of additional lifetime earnings.That’s tough to do when you’re looking at $150-200,000 of debt, which is the average debt of an American medical student at graduation.But the crisis in our primary care pipeline goes far beyond the money.

Continue reading “Reviving the Pipeline: A Call to Action For All”

By Paul Grundy, MD

In the next 10 years, data and the ability to analyze the data will do for the doctor’s mind what x-ray and medical imaging have done for their vision. How? By turning data into actionable information.

For instance, take Watson, IBM’s intelligent supercomputer. Watson can analyze the meaning and context of human language, and quickly process vast amounts of information. With this information, it can suggest options targeted to a patient’s circumstances. This is an example of technology that can help physicians and nurses identify the most effective courses of treatment for their patients. And fast: in less than 3 seconds Watson can sift through the equivalent of about 200 million pages, evaluate the information, and provide precise responses. With medical information doubling every 5 years, advanced health analytic systems technologies can help improve patient care through the delivery of up- to-date, evidence-based health care.

Continue reading “Now you have healthcare data. So where does it go?”

By MARGALIT GUR-ARIE

Care coordination is one of the four pillars of Meaningful Use, one of the six NCQA Patient Centered Medical Home (PCMH) standards and one of the main goals of Accountable Care Organizations (ACO). Care coordination, particularly for patients with multiple chronic conditions, is expected to reduce unnecessary repetition of laboratory testing or imaging and the number of avoidable admissions. Other than reducing overall costs, care coordination is also supposed to improve quality of care. According to experts like Joe Flower, “Lack of care coordination is at the core of the mess healthcare is in”, and nobody in their right mind would argue that it is best that medical care remains disorganized and uncoordinated, if it is indeed so. It seems that our fee-for-service, fragmented and fractured (lots of f-words here) health care system is not conducive to care coordination. When patients float around in a sea of hospitals, physicians, nursing homes and other facilities, each care provider gets paid, and is responsible for the piecework performed at their independent entity and nobody is minding the handoff of patients to the next provider of care, and nobody is assembling a comprehensive picture of the entire care process, let alone orchestrating, or coordinating, the progression of patients between stages of care and the overall needs of patients in transit. What would it take then, to see that the bits and pieces of health care we now have, become a safe and affordable continuum of care?

CMS is taking the lead, as it should, in an all-out effort to encourage health care coordination through various carrot-stick initiatives, aligned to ultimately base payment for medical care on value to the patient, as measured on a population level, instead of fee-for-service and no accountability for outcomes. These initiatives fall into three general categories:

1. Health Information Technology to assist with documentation, information exchange and measurements as required in any coordination effort.
2. Incentives and penalties for providers based on measures thought to be influenced by care coordination (e.g. preventable hospitalizations, readmission rates, etc.)
3. Financial and structural encouragement for vertical integration of the delivery system (e.g. ACOs, consolidation, employed physicians, etc.) Continue reading “Coordinating Care Coordination”

By MARGALIT GUR-ARIE

The term patient-centered has become a serious contender for the most flippantly used term in health care publications and conversations. Of course meaningful use is still #1 on the popularity charts, with ACO quickly moving up, but even meaningful use and ACO are almost always accompanied by patient-centered as a way to add legitimacy and desirability to the constructs.

Even Paul Ryan’s new recipe for fiscal Nirvana is touting patient-centered health care as one of a litany of fictional achievements made possible based on an array of wishful thinking assumptions. But perhaps the most common usage of patient-centered terminology is the Patient Centered Medical Home (PCMH), which is touted as the ultimate patient friendly solution to our health care difficulties. Since PCMH is heavily reliant on Health Information Technology (HIT) to achieve patient-centeredness, and since Meaningful Use of Electronic Health Records (EHR) is being increasingly aligned with this goal, it may behoove us to explore the features and functionality that would qualify an EHR to support a patient-centered approach to health care delivery.

But first, what exactly is patient-centered health care? From reading the NCQA medical home specifications, the Meaningful Use definitions, the HIT suggestions from PCAST and the brand new ACO regulations, all of which assert a patient-centered approach, one would conclude that patient-centered care is made possible by providing all patients with timely electronic access to the entirety of their medical records including lots of patient education, electronically coordinating a multitude of transfers of care, empowering non-physicians to provide most medical care, measuring a bewildering array of health care processes and constantly evaluating and reporting on population metrics, while somehow allowing patients and families to express their wishes regarding the nature of care within the boundaries specified by each proposal. I am excluding the Ryan budget proposal here, since other than having “patient-centered” typed in various spots, there is no reference to actual health care delivery, or what is left of it after most seniors, sick and disabled folks are reduced to begging for medical care. Computers and EHRs can, and to some extent already do, support many of the above activities, but is this truly patient-centered (singular) care, or should we add an “s” and refer to a plurality of patients-centered, or population-centered, care? Continue reading “The Patient-Centered EHR”