QUALITY: Gordon Norman on DSM, Medicare and Oliver Stone & me

Last week there was remarkably little fuss in the health care press about the introduction of the new Medicare CCIP (DM-type) programs. I suggested that provider groups had been left out of the running when these programs were awarded. Gordon Norman, who runs DM at Pacificare and has contributed an excellent article on DSM to THCB in the recent past, and I agree that few provider organizations in the US would be able to run these big DSM demonstration projects, and that even fewer provider groups base their business on a preventative care and population-health coordination model (for the good of their own fiscal health). But I went further in suggesting that the ideological bias of this Administration and Congress was for private plans and organizations to solve the future issues facing Medicare, rather than the public program creating its own initiatives, or working with predominantly non-profit providers. No one would seriously disagree with that, but my connection of that fact with the non-appearance of providers or non-profits on the list of CCIP award winners has caused Gordon to disagree. He writes:

I have to call "Foul!" on your conspiracy theory…

It’s not evident from your blog entry today that you are aware of the latest DM Demo offered by CMS expressly targeted to providers and consortia where providers would take a lead role — the CMHCB Demo. (Here’s more detail on the CMHCB). Far from being the case that providers are "locked out" of the DM groundswell — if providers (remember, I am one of the guilty here) had manifested a sufficient collective will and effort to design a health care system that is primarily patient need-centric, then better integration of chronic care for patients, among providers, over time, across sites, among comorbidities, and embracing the biopsychosocial model might already exist and have obviated the need for a "DM industry" in the first place.

I can imagine my medical colleagues lamenting: "If only someone had accountability for that system’s performance (like oft-maligned executives in the managed care?), perhaps faster progress would be possible." As it stands now, it’s much easier for those who comprise our system to stand on the sidelines, as if helpless, and criticize others who are attempting to fill the care coordination vacuum of their own creation. At its best, DM is an "aftermarket fix" that can work surprisingly well under the right circumstances — that doesn’t mean it is superior to an "factory installed" integrated approach to better chronic care management by health care providers. "Systemness" is a fundamental property that is largely lacking in our health care system today, contributing to an inefficient, expensive, unfriendly, frustrating, and mediocre quality ecology for U.S. healthcare. When are providers going to become responsive to this obvious and growing need as an organized force? We’ll see how many line up for the CMHCB demos — I personally hope there are many and that they do well, since the DM need requires a very inclusive "DM tent" to address the gap between actual and ideal coordinated care. (And just wait for the Boomers…)

By the way, CMS made a commitment to those conducting the BIPA DM Demonstrations that it would not establish competing DM demos or pilots in their regions (e.g., CA, AZ, TX, parts of LA) which would jeopardize the results of this critically important DM study that will provider policy makers (CBO), advocates, and skeptics alike with rigorous RCT DM outcomes at least 1 if not 2 years in advance of the CCIP results. This was neither an arbitrary, capricious, or political decision, but rather a responsible approach to conducting a demonstration study without contamination that would confound the results.

Now I admit that my expertise on the finer points of CMS demonstration programs is limited, and I asked Gordon to confirm for me that the CMHCB awards are way smaller than CCIP and getting a much lower profile. Gordon stresses that CMS has reserved these for providers and that that’s the point!

Yes, the scale is different for CMHCB per award (though no specific limit on # of awards), somewhere between 800 – 3,000 depending on several factors — but that’s the point: it was designed specifically for providers. How many provider groups do you think could amass a patient population that would provide more than 3,000 Medicare FFS patients (HCC scores >2.0) willing to voluntarily participate in such a program with a 6 month recruitment window? Not many.

BIPA is 30,000 total enrolled maximum (+ another 12,000 controls which awardees also have to recruit, unlike CCIP or CMHCB design).

You and Mel Gibson and Oliver Stone should get together on the movie…

I told Gordon that if we were going down the Lethal Weapon path I’d rather make a movie with Danny Glover, and that anyway Michael Moore is already making this movie apparently. But slightly later I got a little more information from another of my DM sources, suggesting that there is trouble with the physician group practice demonstration. Apparently provider groups are dropping out from applying because OMB has changed the payment incentive formula. This is for one of the CMHCB demos that Gordon was talking about, and it looks like it’s in big trouble in advance of the award being announced. This is unconfirmed scuttlebutt and I personally don’t have the time to check it out, so please let me know if you can confirm or deny. But if true, it’s an interesting story, and adds a little fuel to the conspiracy theory fire about the Adminstration tilting the DM demonstrations towards the people it likes.

Paging Mr Stone…….

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