Health for life

1. Using traditional research to detect a "statistically significant" decrease in insurance claims expense is notoriously difficult.

2. Theres scientific statistical proof and then there is a reasonable business assurance.  The latter may be enough for business-minded health insurers.

3. The conclusion is based on published research.  Unpublished "in house" data have convinced many insurers to include the medical home in their covered benefit.  They know something AHRQ doesnt.

4. While medical homes alone may be insufficient to save money, that doesnt mean that medical homes that are part of a package of interventions (value-based purchasing, P4P, vendor-based population health management or an ACO) are unnecessary.

5. While there is no evidence of savings, there is also no consistent evidence of increased cost. That means the quality associated with the medical home represents high value.

That being said, the U.S. Agency for Healthcare Research and Quality (AHRQ) Evidence Report Technology Assessment on the Patient Centered Medical Home says:

"Based on a combination of good- and fair-quality studies, there is a low strength of evidence that PCMH implementation may lead to lower utilization (inpatient and emergency department) for some subgroups of patients, but this effect was not uniform. Moreover, total costs were not lowered in the reviewed studies.

However, three observational studies specifically designed to test PCMH do report lower inpatient and emergency department utilization among patients in the PCMH program. However, total costs were not statistically different for PCMH and non-PCMH patients in the three studies. None of the clinical trials of functional PCMH interventions had statistically significant differences between intervention and control arms for inpatient or emergency department utilization.

No studies reported statistically significant cost savings among PCMH patients. In fact, when taking into account program costs, two studies, one good-quality trial and one fair-quality observational study, reported greater total costs among intervention patients."

 Image from Wikipedia

Its no secret that the Disease Management Care Blog is an enthusiastic believer in nurse care managers.  In its humble opinion, it makes no difference what "bricks" are used to build a Patient Centered Medical Home, an Accountable Care Organization, a Population Health Management Program or an employer-based care support/wellness initiative, the nurses are the mortar.

Readers can read more on how this specifically works in a DMCB co-authored article titled "The Focus of Case Management Grows" in this on-line version of The Case Management Society of Americas (CMSA) Case In Point magazine.

While the manuscript focuses on the PCMH, its lessons can be applied to any corner of primary care:

1. Some patients have higher health care needs, more care gaps and greater risk.  Surveys and analyzing insurance claims and electronic health record data can find them.

2. There are cheap medical  interventions that increase quality and lower costs.  Nurses know about them and, when theyre supported by physicians, can champion their use among patients with the most to gain.

3. Most patients want to meaningfully participate in their own care.  This goes to the core of patient centeredness and these nurses know how to harness that energy.

As systems confront the limitations of pay-for-performance, the disappointments of the EHR Kool-Aid, the inertia of Washington-run health care and dwindling budgets, the DMCB is confident that these nurses will finally get the recognition they deserve. Whats more, patients will be better off for it.

Read this lead American Journal of Managed Care article on Geisingers approach to the patient centered medical home (PCMH), and you may agree that the major findings are:

1) the longer patients with chronic conditions are exposed to care coordination, the greater the impact on claims expense, and

2) while insurance claims went down, the savings werent enough to generate a return on investment, i.e., the program itself cost too much.

The DMCB also agreed but mined the article to find out more.

Geisinger has a ""Proven Health Navigator" system of primary care sites with "embedded" nurse case managers who serve medically complex patients. As more primary care sites were recruited into the system and as more Medicare Advantage patients were enrolled by the nurses, it became possible to contrast the duration of exposure to Navigator with the amount of savings. Based on over one million member-months in 43 primary care sites over four years, the authors found that from one to twelve months of exposure, patients claims expenses were not statistically significantly less than expected. However, once more than twelve months elapsed, the percent savings ranged from 4.3% to 6.7%. Yet, while the savings per member per month ranged from approximately $70 to $120, that was still not enough to exceed "the actual dollar amount invested in implementing" Navigator.

What else can the DMCB conclude?

1) When it comes to reducing claims expense, itll take more than 12 months to see a reduction in claims expense, i.e., "to bend the curve."  According to these data, itll take 2 years or more.  That means starting a care coordination program is a two to three year commitment.

2) The authors point out that with more time or more patients, they may have been able to achieve enough observations to achieve a statistically significant return on investment. Unfortunately, close reading shows there is little information in the manuscript on the program costs which led to the authors conclusions.

There are several reasons to attend the Oct 21 Patient Centered Primary Care Collaboratives 5th Annual Summit.

Youll see the good work that the PCPCC is doing as the leading national organization advocating on behalf of the Patient Centered Medical Home (PCMH).

Along with an auditorium-full of like-minded learners, youll benefit from an agenda that is packed with clinicians from the real world of medical practice who have developed successful medical homes. 

Youll get to meet others who share your interest in an innovative and rapidly evolving approach to primary care.   

Youll be in Washington DC at the height of beautiful fall weather. 

And, last but not least, youll get your own copy of the PCPCC Report, Care value, community connections: Care coordination in the medical home.  According to this newswire press release, the report "includes the insights of thought leaders" on the theories and tactics behind the definition, role and function of care coordination.

The immodest Disease Management Care Blog couldnt have put it better itself, especially because its the author of the first second chapter.

...and you can take that to the bank?

It seems no discussion on the Patient Centered Medical Home is complete without a erence to Medicaids Community Care of North Carolina. The states consultants reports on CCNC have been accepted as gospel by the academic community (for example) and have contributed to a widespread consensus that the PCMH saves money. As in billions.

Or does it? For a readable discussion of why CCNC may or may not have saved money, check out this four pager by Joseph Burns appearing in March 2012 issue of Managed Care Magazine. Skeptics point out numerous inconsistencies, including North Carolinas lingering high costs and little change in inpatient utilization. MCM asked analytics impresario Ariel Linden to take a look at CCNC and, after using a time series analysis, he was unable to find evidence of savings.

Nothing new, says the Disease Management Care Blog, which has long been unable to make much sense of the consultants reports either. What is new are the responses of CCNCs Paul Mahoney, founding physician Charles Wilson and advocate Adam Searing. It seems North Carolinas fee schedule is complicated, physician buy-in is high, something must be working because the Medicaid program has avoided making fee schedule cuts and, last but not least, the States legislature never intended the consultants evaluations to meet the exacting standards of the DMCB readership.

The DMCB doubts the controversy will go away.  What we can learn from the CCNC imbroglio is how important it is to think about the analysis early in the planning process. In the meantime, PCMH advocates will probably have to look elsewhere if they want to er to studies that are understandable, transparent and convincing.

Coda: By the way, whatever its imperfections, the CCNC is a good example of a "shared resources" approach to nurse care management. As the DMCB understands it, in CCNC, the primary care sites do not hire their own nurses.  Rather, the costs of the nurses are regionally supported and the nurses are, in effect, loaned out to the clinics. 

The DMCB argues that there is little difference between this and hiring a disease management/population health service provider. To paraphrase Comrade Deng again, the color of the cat may be different, but it still catches mice.

If you lead a horse to water, will it drink?  If it drinks, does that cause it to be a horse?  Who says being a horse is good? Do horses cure thirst?

Those were the silly Disease Management Care Blog questions prompted by a paper trail of articles and letters about the Patient Centered Medical Home (PCMH) that recently appeared in the Archives of Internal Medicine.  That being said, the series was a telling example of the assumptions underlying PCMH research and the lack of of buy-in from community-based physicians

To wit:

Primary Care Is Good: The first article was this October 2011 published research that retrospectively mined the Surveillance, Epidemiology and End-Result (SEER)-Medicare-linked database.  The authors found that for Medicare fee-for-service beneficiaries aged 67 to 85 years, more colorectal cancer screening, earlier cancer diagnosis and lower cancer mortality were all associated with an increased number of past primary care visits. While the study could not rule out the possibility that other factors were involved in the association between primary care and cancer screening (Katy Courics campaign, for example, could have prompted patients to see their PCPs), this study indicated that that access to primary care is a good thing.

If Primary Care Is Good, So Is The Patient Centered Medical Home: The second article was this "Decisive Moment" editorial appearing in the same issue of the Archives, authored by Boston academics Asaf Bitton and Joseph Frolkis.  They reviewed the SEER article, which never even mentioned the PCMH.  That didnt stop the editorialists from bringing it up in an opening paragraph as an "innovative model of care delivery." The article then went on to describe the virtues of generic primary care and the need to increase PCPs in the physician workforce. It then saluted the PCMH as "offer[ing] promising early results [with] a pathway to weld some of the best incremental practice change initiatives onto a chassis of sustainable, term based care."

Who Says the PCMH Is So Good? The third was this Editors Correspondence letter that appeared six months later in the March 26 2012 issue of the Archives. Arguing that many PCPs already provide medical home-like services, private practitioner Edward Volpintesta of Connecticut didnt share Drs. Bitton and Frolkis "optimism" over the PCMH  He observed that 100% of any additional fees generated by the PCMH would have to go toward funding its excess costs and never go toward rewarding the physician.

We Say Its Good: Drs Bitton and Frolkis disagreed in a Editors Correspondence reply. Depending on your definition of a medical home, they argued that most PCPs do not offer that kind of care and that their research shows that the added income from the PCMH can be considerable. 

While the article-editorial-correspondence virtual paper trail is a classic exercise in academic repartee filled with the usual medical jargon, tangential policy nostrums, assumptions and quoting the literature out of context, the real lesson here is that there is some real skepticism about the PCMH among otherwise seasoned primary care physicians. While the mainstream peer-reviewed medical journals have articles that are extrapolating the virtues of primary care onto the PCMH, docs like Dr. Volpintesta arent necessarily buying it.

To the DMCB, this spells significant challenges for the dissemination of the medical home outside the academic community and their early adopter allies. 

Some mainstream doctors remain unconvinced.

The Battle of Thermopylae or an image of modern patient care?

What can the Battle of Thermopylae and The Simpsons teach us about patient centered medicine?

The Disease Management Care Blog says read on.

At one testosterone-laden point in the six-pack riddled fantasy movie "300," the Spartan narrator admires how some non-Spartan warriors made a "wondrous mess of things" at the Battle of Thermopylae.  It was professional warriors accommodating the pitchfork wielding non-professional farmers in the drive to victory.

And so it is with "patient centered medicine." When it read the New England Journal Perspective by Charles Bardes titled Defining "Patient Centered Medicine," the DMCB was reminded of a coming mess in health care.  That includes the doctor-patient relationship, payment and quality measurement, all of which promise to be scrambled by a decidedly non-professional, imprecise and radical notion: consumers are going to have a big role in what drives value in health care.

While DMCB readers are already familiar with the rhetoric of consumerism, empowerment and shared decision making, Dr. Bardes reminds us that full adoption of PCM will go far deeper. PCM is based in a "biopsychosocial model" that trumps illness over disease and caring over curing. Its rooted in 1960s style psychotherapy that involves a highly tailored, shared and special therapist-client relationship where the journey was no less important than the destination. Graft that onto modern notions of consumerism and medical "value" goes from being scientific, precise, quantitative and measurable to being subjective, shifting, qualitative and immeasurable.

This is important because it redefines the one-sided "special knowledge" that defines the doctor-patient relationship,threatens the business-as-usual payment methods and calls into question the use of measures like HEDIS and Medicares HospitalCompare.

This may be silly, but think about donut munching Homer Simpson and what this could mean for primary care.  While one would expect Homer to get a prescription to control his diabetes, generate a monthly management fee for his patient centered medical home and have an A1c (that would probably undermine his PCPs quality scores), that goes all away in PCM. What we have instead is empowered Homer ultimately deciding if he really wants to take any pills, payment that is based on his subjective satisfaction and quality measures that record whether Homer was allowed to make informed choice among several treatment options. Whether Marge gets a mammogram is not important; its whether Marge actively choses to get a mammogram or choses not to.

To Spartas credit and Hollywood fiction aside, the historical record shows Spartan King Leonides et al welcomed the help of their amateur Greek brethren in stopping the Persian invasion. So, heres a question for the the DMCBs professionals colleagues running the health care system: are we prepared to accept the participation of Homer and Marge in reshaping a dysfunctional health care system?  If the answer is yes, where in the battle can we use them and how much "mess" are we willing to put up with?

As a public service, the Disease Management Care Blog is happy to build on what we know about the positions of the Republican Presidential candidates on health orm and speculate on the likely debate answers that the front runners would give if they were asked about the Patient Centered Medical Home.  By facilitating this political narrative, the DMCB hopes our candidates are now free to address the issues that really matter, like whether exposed mens toes are ever appropriate in the workplace, why airport skybridge personnel vanish when flights arrive after 11 PM and whether dermatologists working in ACOs could ever relearn which part of a stethoscope goes in the ears.

Rick Perry:  "Im opposed to P-C-M-H because they are one, patient centered, two medical and three.... um, I forgot what that third H is for.....ooops."

Mitt Romney: "While I supported it in Massachusetts, I oppose it now because the federal government supports it in other states, where it is both supported and opposed.  We also dont know if this approach to care will reduce elevated costs going down."

Newt Gingrich: "This is a constitutionally catastrophic and unprecedented intrusion of enormous federal power of stunning proportions.  Truman wouldnt have stood for this and Lincoln would be shocked, which is why you should buy my book."

Herman Cain:" I am opposed to the patient centered medical home because primary care should rely on teaming and electronic records so that they can take better care of patients."

Michelle Bachman: "A woman told me that her baby is brain damaged because of care received at a medical home!"

Ron Paul: "I dont see the words "patient centered" in the U.S. Constitution and whats more, when we switch to the gold standard, we wont be able to afford it."

Alt for Norge!

The Disease Management Care Blog is decamping to Norway for a meet-the-family and see-the-sights vacation.  The good news is that Europe is 8 hours ahead, which means the DMCB will know about the Supremes Thursday decision 8 hours before anyone else.  The bad news is that in the coming days, its posts will become infrequent at best.

In the meantime, check out this just-published JAMA article on the PCMH. 669 primary care centers participated in a Harris survey commissioned by the Commonwealth Fund.  While the "Safety Net Medical Home Scale" was not based on the NCQA, it inquired about the familiar care domains.  The 0 to 100 scale was correlated with financial data from the Uniform Data System reports that reflected the clinics operating costs.

Unsurprisingly, the authors found that as the medical home score increased, so did the operating costs. Moving from 60 points to 70 points increased the cost per patient per month by $2.26.  While the authors calculated that translated into more than half a million dollars of additional expense for the average clinic, the DMCB notes that kind of expense for an average physician panel of 1500 patients means more than $40,000 per year.

Readers familiar with the cost of disease and population health management will find that $2.26 PMPM statistic very significant because thats in the range of what is charged by many vendors.  Whats more, the vendors charges include a profit margin which was not necessarily included in the clinics study data.

Conclusions?

The PCMH is not necessarily "cheaper" than outsourced care management.

While the PCMH may (statistically significant proof remains elusive) "save money," it appears they have the same challenge faced by the disease management industry in the early days: savings net of fees doesnt necessarily equal profit or a financial gain for the health insurer or consumer.

Dr. Smith* was well known among the hospitals medical directors. Thanks to his superb training and busy clinical practice, this busy physician was convinced, thank you very much, that he had all the knowledge necessary to manage his patient population.

Summary quality reports, feedback and best practice advice he did not need.  He also loved pointing out that he wasnt being adequately reimbursed to deal with administrative hassles, many national Clinical Guidelines were based on faulty research, his patients were not "average," and his duty to his patients was to "first do no harm."  He believed in patient education but resented administrators meddling.

The medical directors werent about to use a "stick" and "de"credential Dr. Smith and kick him out of the network. The "carrot" financial P4P incentives they offered for quality measures were modest and comprised a only a small percentage of the physicians income.  They. Were. Stuck.

Enter the Affordable Care Acts Patient Centered Outcomes Research Institute (PCORI). Writing in the latest issue of Health Affairs, RAND researchers Justin Timble, Eric Schneider, Kristin Van Busum and Steven Fox reassure frustrated medical directors everywhere that PCORI will come to their rescue by ushering in a new dawn of clinical trial research.  The studies will be so good that Dr. Smith will change his passive-aggressive ways.

Dr. Timble et al point out that the reluctance of physicians like Dr. Smith to change their clinical practice is not surprising.  Payment mechanisms incent questionable treatments, much of the published medical science is riddled with ambiguities, even expert scientists succumb to a host of biases when they interpret study results and doctors are more interested in avoiding the risky downsides versus the upside benefit of new medical advances.  Last but not least, clinic-based electronic record decision support never fails to disappoint.

Fortunately, says these RAND authors, the PCORI is on it. Its sponsored research will transparently solicit stakeholder input and investigate all meaningful outcomes, including side effects.  When this high octane knowledge is combined with a dollop of rigorous guideline development, more gigabytes of information tech decision support and the luster of Obamacares payment reforms, uncooperative Dr. Smith will be transformed into compliant Dr. Smith.

Sounds good, but the DMCB doubts that sprinkling PCORI pixie dust on docs is the cure to what ails the health care system. In its estimation, the RAND authors and the editors of Health Affairs are only telling half the story.

The DMCB to the rescue.

Despite the authors enthusiasm, PCORIs well-meaning stakeholders will have to make real-world compromises on study scope, data collection and completeness. Their research methods and findings will never be completely immunized against healthy skepticism.  And while RAND scientists and the readers of Health Affairs are professionally invested in PCORI, how well it competes for the attention of practicing docs like Dr. Smith remains to be seen.

Financial carrots and sticks can be used to change physician behavior, but Dr. Smith will ultimately stay in the drivers seat thanks to a) a looming physician shortage and b) the prospect that total physician reimbursement will go down, leaving no room for incentives. While integrated delivery systems, accountable care organizations and physician-hospital alliances may (or maybe not) wring some dollars out of PCORI-based efficiency and quality studies, it remains to be seen how these big capital-intense organizations will share any precious leftover dollars with their docs.

The population health management (PHM) service community has a better answer.

While high quality research conducted under the supervision of an expert professional class has its place, they know its ultimately up to the informed patient to make decision.  A considerable body of research, much of which would pass PCORI muster, has shown that shared decision making using a personal physicians advice is remarkably adept at reconciling imperfect research with patient values and preferences.  This, in turn, increases quality and reduces unnecessary costs.

The DMCB has seen countless physicians like Dr. Smith welcome the help of team-based nurses who can help his patients. He may call it "education," but theyre engaging patients in science based decision-making and taking a lot of work off of Dr. Smiths hands. 

Diabetes control isnt their top concern

The Disease Management Care Blogs primary care colleagues are undoubtedly aware of how "social determinants" can undermine the best care planning. So, if youre going to rely on the Patient Centered Medical Home (PCMH) to increase health care quality and reduce costs, ignoring the impact of poverty or health literacy could lead to poor diabetes control, worsening high blood pressure or more hospital readmissions.

Arvin Garg, Brian Jack and Barry Zuckerman have written a JAMA "Viewpoint" that offers five lessons from pediatric medical homes that can mitigate harmful social determinants:

1) Include social determinants (for example, community factors, substance abuse, education, malnutrition or poverty) in the creation of national treatment guidelines.

2) Develop and implement screening programs to identify any social determinants that could impact medical treatment.

3) Colocate community resources that address social determinant in PCMHs.  Examples include housing programs, job training programs or food pantries.

4) Colocate "outside the box" social programs in PCMHs also.  This is an area ripe for piloting or researching innovative interventions

5) Integrate visiting nurse programs with the PCMH.  Think of the visiting nurses as an extension of the medical home.

As readers of the DMCB are aware, not all PCMHs can build the full suite of services that make up a medical home. Since health insurers and care management vendors are partnering with primary care physicians to build medical homes, this approach to incorporating social determinants in their programs is worth a closer look.