By JACOB REIDER, MD

Two and a half years ago, John Halmaka posted an entry with this title – and I recall that it was a good summary of the state of the industry.  While I didn’t agree with all of his suggestions, I enjoyed the review and it offered a good set of guiding principles.  Since I was Acting National Coordinator for about the same duration as Vindell will serve, (Fall of 2013 – after Farzad Mostashari departed, and before Karen DeSalvo arrived) I’ll offer some thoughts from one who has been in his position.

1. Certification.  The health IT certification program is the core of ONC’s responsibility to the nation.  While some have called for the eradication or reduction of the certification program, I would argue that this would be akin to scaling back Dodd-Frank.  Yeh – crazy.  As a product of ONC’s certification program, we now have health IT systems that do what their developers claim they do.  Before this program existed, creative health IT salespeople would assure customers that systems had functionality that simply didn’t exist, or was nonfunctional.  The program, like certification programs in other industries (telecommunications, transportation, etc.) is in place to assure the purchasers of products that these products do what developers claim.   Is the certification program perfect?  No.  Of course not.  The program needs to iterate with the evolution of the industry and the standards that are evolving.  Revisions to the certification program must therefore continue, so that the certification requirements don’t point to obsolete standards.  A focused “2015R2” certification regulation would therefore be an appropriate component of ONC’s fall work – so that something can be “shovel ready” for a new administration for ~ February release – with final rule in ~ April/May of 2017.

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By KIP SULLIVAN

In the first article in this three-part series I reviewed the findings in CMS’s latest report on one of its “medical home” experiments – the second-year evaluation  of the Multi-Payer Advanced Primary Care (MAPCP) Demonstration.We saw that the “patient-centered medical homes” (PCMHs) in that demo have failed to cut costs or improve quality during the first two years of the demo. We also saw that the sloppy definition of “medical home” put the author of the report, RTI International, in a bind: They did not identify a single feature of PCMHs to treat as an independent variable, and were forced to offer an impressionistic, on-the-one-hand-on-the-other-hand account of what the PCMHs are doing.

In the second article of this series I examined the report’s explanation for why the PCMHs have so far been unable to outperform non-PCMHs despite receiving substantial subsidies from CMS and other sources that non-PCMHs don’t get. The report seems to say that insufficient subsidies explains the PCMHs’ failure. I noted, however, that the report contains no evidence indicating how much more money PCMHs might need.

At the end of my second article I characterized the problem presented by the report as a conundrum. On the one hand, PCMH staff and many other observers feel PCMHs are severely underfunded, but on the other hand no one can say by how much or which PCMH services need more money.

So what do we do? Do we just pick a number out of thin air and say that’s how much more money PCMHs need, and pour that money down the PCMH black hole along with the other subsidies PCMHs receive now? That appears to be CMS’s position judging from its endorsement of yet another “medical home” program (CPC+ as an “alternative payment model” in its proposed MACRA rule despite the fact that all three of CMS’s “home” demos are failing.

Salvaging what we can

Throwing more money down the PCMH black hole is not a good idea. I recommend that CMS allow PCMHs to focus, and that CMS do so by radically sharpening and cutting down the definition of “PCMH” so that the concept refers to a uniform set of medical and social services provided to a subset of the chronically ill. [1]

Once CMS has clearly defined what services it wants “homes” to provide, it can then determine what the extra services cost and make adequate payment for them. It would help if, in addition to paying adequately for the extra services, CMS would let doctors and patients decide when the extra services should be provided rather than stick its nose into the doctor-patient relationship with pay-for-box-clicking schemes. Paying adequately for additional services and eliminating pay-for-clicks schemes would increase the physician “flexibility” that CMS claims it seeks to promote with PCMHs. Eliminating pay-for-clicks schemes would also lower physician overhead and reduce physician burn-out.

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By JEREMY WALLMAN

Customer centricity has been a mantra of managed care organizations for well over a decade. If you listen closely, you can hear plaintive cries of our care providers, lamenting the labyrinthine, almost Kafka-esque system of prior authorization, reimbursement, meaningful use, and near-real-time obsolescence of medical technology. The crushing weight of reform, the perverted incentives created by volume-based reimbursement, and the soaring costs of doing business have created a situation, much like in public education, where our system is fueled primarily by the power of a dedicated and passionate community whose members are motivated by their desire to care for other human beings.

“How can we possibly think about self-service websites when we are holding back an imploding healthcare delivery system”. Maybe we need to ask a more basic question…..is the U.S. healthcare system viable in the long-term? That question might simply be too hard to answer. So instead, we try to convince ourselves that, like educating our citizens, delivering medical care should be treated as a business. Innovation and value are fueled by financial incentives and healthcare is no different.

But it is different. It is very different.

In some particularly competitive/ wealthy markets, Providers are offering differentiated services….delivery rooms with hotel-style amenities, upgraded menus, concierge services, etc., usually available for an extra charge. But these services are not adding to anyone’s bottom line…they are just attracting those few patients who have the luxury of choice. Where is the value here?

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By HANS DUVEFELT, MD

Part of a series on primary care challenges and their solutions.

Medication reconciliation is something we do every day, in the clinic and in the hospital. It shouldn’t be as hard as it is.

A patient with multiple medical problems returns for a fifteen minute quarterly visit. He saw his cardiologist three weeks ago and was told to double his metoprolol.

There are two ways to catch this change: when the cardiologist’s office note comes in, or as we check the patient in for his visit.

The cardiologist’s office note, generated by one of the leading EMRs, runs seven pages and contains entries about immunizations, fall risk and other quality measures of little relevance in specialty care. On one of the last pages, tucked away in a nondescript paragraph, at the very bottom, waiting for me to find it, is the notation that my patient’s metoprolol dose was doubled.

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By NIRAN AL-AGBA, MD

Quality measures began as tools to quantify the healthcare process, using outcomes, patient perceptions, and organizational structures associated with the provision of high-quality health care. Overall, the goals should focus on delivery of care that is effective, safe, efficient, and equitable.  Did you notice a particular word missing?  Yes, I missed the word physician too, because they have been left out of the conversation entirely.

Measuring quality healthcare by a patient lab result is like recording a patient’s temperature by waving the thermometer near their face.  One has little to do with the other except for the slight appearance of connection.  Quality must be measured by physician outcomes and not those of patients.  For instance, our county does not have fluorinated water.  Measuring the percentage of children that have cavities is a patient outcome and not an accurate reflection of medical care provided.  A physician outcome would be calculating the percentage of children who received a prescription for supplemental fluoride during their office visit.

If the intended goal is to reduce unnecessary ER visits, then we must determine the root cause.  Patients with private insurance rarely go to the ER for non-emergencies because they pay a large out-of-pocket cost.

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