Latest Health Wonk Review Is Up!

Louise of the Colorado Health Insurance Insider has a marvelous summary of this week's Health Wonk Review, accompanied by telling Simpsons graphics. Highly readable, well edited and linked up nicely, everything you'd want to know about many of the latest developments in health care policy is just a click away. Check it out.

Three Years Of Medical Home Demonstration Preparation Down the Drain?

By Vince Kuraitis & Jaan Sidorov

You'd think if anyone were disappointed at the shelving of the Medicare Medical Home Demonstration (MMHD) in favor of the Multi-Payer Advanced Primary Care Initiative (MAPCI), it would be the primary care physicians.

However, we pick up on no signs of discontent.

After 3 long years of anticipation, secrecy and considerable work by multiple stakeholders on the MMHD, including all of the major primary care physician organizations, you’d think doctors should be having an Animal House Bluto Butarski-like reaction to this sudden shift in Medicare policy.

In fact, based on some informal conversations with many of the organized physician groups’ leaders, we are finding that most doctors are actually pleased with the recent developments.

What's going on here? What does this tell us about what we’ve we learned about the patient centered medical home (PCMH) and Medicare's new direction?

• Challenges of the PCMH’s Business Model Come to Light. Most of all, we believe that over time, the challenges of basing the PCMH business model on reduced costs became increasingly well understood. Based on preliminary information coming out of the PCPCC pilots and early peer review publications along with greater scrutiny of many of the past studies that were being taken for granted, we suspect that there was a growing realization that a MMHD would turn out like the star-crossed disease management Medicare Health Support Demo. This alone would have jeopardized the long-term prospects of implementing PCMH in Medicare.

• Many PCMH Details Yet to Be Worked Out. While the PCMH "concept" has been widely accepted and embraced since 2006, many operational "devil’s in the details" have yet to be developed. Incorporating these into a full-fledged multi-State Demo was probably turning out to be far more complicated than originally anticipated.

• Small/Medium Physician Groups Could Struggle With Infrastructure Required by MMHD. It’s unrealistic to expect a high percentage of small independent physician-owned groups which, by the way, deliver 75% of patient visits in U.S. today, to implement the PCMH. The MMHD required individual physician groups to develop an extensive disease/care management infrastructure and anticipated physicians would hire and supervise nurse care managers to manage their sickest patients. Because this part of the market is so highly fragmented, we think it was becoming increasingly apparently that it was not scalable across large geographies.

• Questionable Physician Interest. We also think that while there were many physicians that were very interested in developing a PCMH, many were also disinterested.

• Medicare Demonstrations As “Change Agents.” We also wonder if there was growing realization that a prospective randomized control trial was an unwieldy challenge for CMS. Data management for multiple primary care sites spread over eight States would be daunting for any research group, including one with CMS’ resources.

• Need/Opportunity for Physicians to Sync With ACOs. Last but not least, the Obama Administration seems more interested in making the Accountable Care Organization (ACO) the lead dog in health care reform. ACOs can incorporate and support many of the care management activities of the PCMHs and, with some tweaking, we believe these models of care are highly synergistic. In fact, evolving ACOs seem extremely provider friendly and offer primary care physicians the opportunity to have an important voice in regional delivery system development.

All things considered, we suggest that CMS and the primary care physicians are considering that it makes more sense to conceptualize all care management activities as a "public utility" – resources that can be shared across multiple physician groups. Perhaps there is growing realization that the PCMH is still in evolution and that much work remains. Accordingly, showing a more flexible approach in ‘piloting’ medical homes, working with other payors and allowing ACOs to support the PCMH is a more viable approach.

The major stumbling block that we can see at this time is whether the small, independent physician practices will readily ally themselves with ACOs and accept a partnership with them over the creation of PCMH’s. That depends on the details of health reform legislation, the local culture in the ACOs and the impact of physician leadership. While the details of MAPCI have yet to be worked out, we believe these questions are best answered in numerous pilots, where Medicare and the physicians can strive to find out what works and what doesn’t work.

So, from the physicians’ standpoint, what’s there not to like?

Another Reminder that Integrated Delivery Systems Are Not All That

The Disease Management Care Bog is not in the habit of handicapping health care legislation, but it did check in with one of the information markets. The prospect of passage seems to be less than the prevailing spin would suggest.

If one rationale of health care reform is to disseminate the superior performance of integrated delivery systems (IDS), readers may want to check out this largely underreported study in the latest issue of the American Journal of Managed Care. While the 'definition' of a delay in radiation treatment following surgery for breast cancer remains hazy, two months not only 'seems' like a long time but there are data that suggests it can affect survival. According to Taffet Gold et al, IDS' overall rate of a 14% delay of two months or more is no better or worse than what has been reported in other settings.

Of course, this is just one study and there is considerable literature in support of IDS. Ultimately, however, we still don't know if the importation of IDS into areas of the U.S. that are struggling with high cost or low quality or high variation would be the panacea some would like. The American Journal of Managed Care article above reminds us of that inconvenient truth.

Image from Wikipedia Commons

The Disease Management Care Blog Learns A New Term: 'Decremental Cost Effectiveness'

Dennis Hopper, a Disease Management Care Blog fav thanks to his roles as a 60's addled motorcyclist in Easy Rider, a manipulative scheming huckster in Boiling Point and a sociopathic bomber in Speed, is battling prostate cancer.

The DMCB wishes him all the best and not just because Mr. Hopper was an inspiration for an early DMCB post.

And thanks to another Dennis Hopper quote:

Pop quiz, hotshot. There's a bomb on a bus. Once the bus goes 50 miles an hour, the bomb is armed. If it drops below 50, it blows up. What do you do? What do you do?

....the DMCB gets to think about 'decremental cost effectiveness.'

This is a concept raised in a November 3 Annals of Internal Medicine article by Aaron Nelson and colleagues titled 'Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation.' The authors reviewed over 2000 peer review articles on new innovative therapies that included cost and benefit in their analyses. While the majority of the innovations increased cost and benefit, there were nine articles that saved a significant amount of money in exchange for a small decrease in quality. Examples included doing percutaneous coronary interventions vs. more expensive and better open heart surgery, using watchful waiting for inguinal hernias instead of routinely operating on them and using drugs to treat reflux disease with symptomatic heartburn instead of laparascopic surgery. These treatments were almost as good, but were a heluva lot cheaper.

The point of the article is that the medical literature on medical innovation is characterized by a 'race to the top' and little attention is being paid to the economic trade-offs that routinely occur in other parts of our economy. Given our growing national interest in finding health care bargains, giving consumers the option of spending far less money is exchange for giving up a slightly greater benefit may not be so outlandish. This has implications for how comparative effectiveness research (CER) should be conducted in the short term, and what we'll need to do to bend the cost curve over the long term.

So pop quiz, hot shot. There's a health care cost inflation bomb on the body politic's bus. Once we find 2009 health reform doesn't work, that bomb is armed. If the cost curve doesn't drop, it blows up. What do you do? What do you do?

Not Impressed

True, while it does take a lot to impress the Disease Management Care Blog, the House's passage of health reform legislation is not landmark, revolutionary or courageous. Rather, it is:

Just one step on the road to a Conference Committee, a closed door affair from which will emerge an entirely new bill.

A gateway to November 2010 'Midterm-istan,' where little of Mr. Obama's 2008 magic and a lot of voter concerns await our increasingly nervous politicians.

Testimony to the gap that exists between the old guard liberal Committee Chairs and the more moderate Representatives.

While complicated at 1,990 pages, it is no where close to matching - or taming - the complexity of U.S healthcare (non)system, and

A chance for readers to look at how their own Representatives stand on health reform (you can look up the name here).

Getting In Line For the Swine Flu Shot: A Physician's Story

The Disease Management Care Blog has a primary care physician buddy that has offered up his insights from time to time, and he's done it again. When he and another physician were unable to secure any of the H1N1 swine flu vaccine for themselves or their clinics, they decided to personally access the local public health system. For those of us with decent health insurance and an established relationship with a physician, the scenario below is surreal - and eye opening.

The photo is from the clinic and even with the alterations to anonymize things, the expressions speak volumes.

Draw your own lessons: this can either be an anecdote describing just how broken the system is or what happens when the government has full control. Either way, we can all agree this is something that should happen to as few people as possible.

When we arrived 10 minutes early, the first thing that struck us was how we had to enter the clinic building through a side door. The door was guarded by a burly security guard who told us that the waiting room was packed and that we would be given numbers as soon as people started exiting. As we waited in line, there were numerous sarcastic comments about nationalized health care. After almost an hour, the line we were in stretched about half a city block. The guard wondered aloud whether we’d ‘storm the castle.’

Finally, we were in the first group of twenty that were allowed in and I was given my prized laminated numbered card. Once inside, I was led up a flight of steps into the clinic waiting room that was teeming with lines leading to many doors and a longer line stretching along the near wall of a large room. We asked a clinic worker with a name tag and walkie-talkie where we should go. We were directed to the ‘reception hall’ and asked to wait until the line for registration got shorter. We waded through the lines and went to the hall with about 3 others out of the 20. The remaining 17 got in the registration line. Sometime later, a clinic worker told us to get in the registration line.

The woman in front of us was admonished for not being in a high risk group until she told the receptionist that she was here to register her child. We were luckier: our medical licenses served to verify our high risk status. We were then asked to fill out a form, which had all of the appropriate questions on them. We were then told to pick an immunization line. There were 6 rooms with frosted glass windowed doors that had long lines in front of them. We picked one and slowly made our way through the door. Two paramedics were there to greet me. One very patiently and slowly drew up the shot into a 3cc syringe with a large headspace. This is important because 1cc syringe with low headspaces are known to maximize vaccine yield, especially in times of shortage. The second paramedic patiently put on a new pair of nitrile gloves and administered the vaccine, and the first paramedic then proffered a band aid. While they reviewed my paperwork, no one verbally confirmed whether we had any allergies.

We then left.

At no time were we asked to verify our identities or addresses, nor were we asked for any insurance information. I am still wondering what the laminated number 23 was for, and had no idea where to return it to. If anyone is in need of one, please notify the DMCB blog and shipment for first class postage will be arranged.

The total experience lasted about 70 minutes from arrival to departure. It was certainly run differently than physician-based clinics. We agreed that it was nice to not have to show photo ID, insurance cards, or make a payment. The illusion of free care and no insurance hassle was kind of nice, but this was hardly the promise of Washington DC’s health care reform. We also agreed that our clinics were faster, had less staff, had more redundant system checks for allergies, conserved more vaccine and were more organized.

New Cavalcade of Risk Is Up!

How assured can you be that you know everything you need to know about insurance? Find out at Debbie Dragon's WiseBread Blog - where folks learn about about living large on a small budget. Debbie has assembled the best of the bloggery on risk and finance, with some good links about health reform.

The Obama Administration's 'Top Ten' Answers to the Swine Flu Vaccine Shortage

With apologies to the David Letterman Show's Top Ten List........

10. Those long lines are only being shown on Fox News.

9. Um, hellooo... joblessness, global warming, health care reform, Afghanistan, Republican resurgence, Olympic city competition, Noble Prize winning. We'll get to it.

8. It's not a shortage. It's a temporarily prolonged lag time in vaccine availability compounding a public health emergency.

7. We said 'Yes We Can,' not 'Yes We Will.'

6. Maybe, but this also means that persons in my Administration have a personal excuse to avoid getting vaccinated.

5. There is obviously not enough Federal regulation, oversight and supervision. We intend to fix that.

4. It's not called 'Swine Flu.' It's called H1N1 and 24.8 million doses are available.

3. It's President Bush's fault!

2. It's the health insurers' and big pharma's fault!

and the number one answer......

1. We unfortunately didn't read the Disease Management Care Blog's past postings on the topic.

Image above available via Creative Commons

Health Care's Actual Costs Versus Their Reasonable Costs: Insights From the New England Journal

You can't fight City Hall, the State Capital or Washington. Not when it's not 'reasonable.'

Right after an embarrassingly self-promoting and one-sided political treatise by Senator Max Baucus (the link is undeserved, that's how awful this is), there is a far more telling November 5 New England Journal of Medicine article by Wendy Parmet titled 'Litigation Amidst Reform - The Boston Medical Center Case.' It reviews how BMC elected to go to court even as Massachusetts' ballyhooed health reforms were being implemented.

BMC, unlike its more profitable neighbor hospitals, has a mission of treating the poor, the uninsured and, by extension, those with Medicaid. When the State altered the safety net hospitals' payment methodology as part of its reform, BMC decided to sue. It used several arguments: 1) safety net funds that had been previously authorized were still owed, 2) demanding services without just compensation is akin to the taking of property and 3) there is legal precedent that requires that the State meet the hospitals' financial requirements.

Not so says Massachusetts. Its filings in response to the suit indicate that the funds that have been authorized have been paid in full. What's more, they argue that BMC has long agreed to accept Medicaid payment rates - period. What really caught the Disease Management Care Blog's eye, however was another novel arugment from the State: the law only requires that hospitals be paid their reasonable costs, not their actual costs.

Ms. Parmet suggests BMC has an uphill fight on its hands. State courts have been generally deferential to their health agencies in these matters. Many scholars have pointed out that the Constitutional prohibition against the unreasonable seizure of property does not extend to 'services.' Finally, while there was a part of Federal law that required 'reasonable and adequate' payment rates under the 'Boren Admendment,' that inconvenience was repealed years ago.

The distinction between reasonable and actual has been enough to give the DMCB a head cramp. If a course of treatment for cancer 'costs' $100,000, should the reasonable cost or the actual cost be covered? While commerical insurers and their slim 3.3% profit margins may pay a negotiated payment for $100,000 services (which essentially boils down to an actual cost), should a government with sovereign immunity be allowed to define reasonable payment levels? If the government deems a hospital bill as 'unreasonable,' should commerical insurers have the same option? What precisely is the definition of 'reasonable' anyway? Cost of capital and labor plus a small profit margin (like 3.3%)? Or, anything that results in an extension of life at a price equal to or less than consensus opinion? If many insurer-provider contracts are based on a percent of prevailing Medicare rates, what happens if the AMA Relative Value Scale Update Committee turns from being 'fair and accurate' to being 'reasonable?' While the current legislation before Congress has the proposed Public Plan negotiating rates with providers, is there any chance that elements of that will be repealed like the Boren Amendment?

While the DMCB was struggling with this, it turned again to the DMCB spouse for her always unique insights. Pointing out that the DMCB has needs, it asked if its actual or reasonable needs should be met.

Her unhelpful response: there is an important difference between 'needs' and 'wants' and both are only sometimes reasonable.

The Affordable Health Care For America Act and the Patient Centered Medical Home: the Disease Management Care Blog Takes a Look

The Disease Management Care Blog finally got around to opening the online version of House Resolution 3962, otherwise known as the House of Representative’s Affordable Health Care for America Act, pejoratively named PelosiCare by detractors, a Defining Moment by Nobel Prize Laureates or just AHCAA for acronymically inclined.

Good thing Adobe has a word search function available for this 1990 page behemoth. The DMCB used it to hunt for our U.S. House of Representatives’ leadership plans for the ‘medical home.’ It figures many DMCB readers may appreciate a one-pager CliffsNotes summary.

There was plenty. It mostly begins on page 672:

Assuming this passes the House and makes it past even more changes thanks to the Conference Committee, the Secretary of HHS will charged with establishing a ‘medical home pilot program’ that evaluates the ‘feasibility and advisability’ of paying for qualified patient centered medical home (PCMH) services. The DMCB suspects that the staffers that wrote this bill did their homework, because the Act’s definition of the PCMH borrows heavily from the 2007 Joint Principles including:

1) accepting responsibility for providing first contact, continuous and comprehensive care

2) coordinating the teaming, arranging care with specialists, maintaining continuous access to care,

3) providing support for patient self management, information management and guidelines

4) offering a principal care provider that provides the majority of personal health care needs

There is considerable leeway for the Secretary, who is free to determine how practices become eligible as PCMHs. It’s also up to the Secretary to decide how to exactly pay PMCHs in the pilot but the Act supports, ‘prospective payment,’ higher payment rates for patients with’ high risk scores,’ and additional differential payments based on the provision of additional services such as ‘population disease management .’ Beneficiaries also have to agree to be a participant before the PCMH can be paid for providing medical home services.

The Act stipulates that the Secretary has to test the pilot in ‘various settings’ including practice sites that have ten or less full time physicians. Specialist physicians (presumably such as endocrinologists) that act as a ‘principal’ provider as well as nurse practitioners are also allowed to act as PCMHs. The Act also supports funding the PCMH pilot in not-for profit community health centers.

It’s also up to the Secretary to decide how well the PCMH addresses health care quality, health care disparities, preventable hospitalizations, readmissions, emergency room visits, beneficiaries’ functional status and satisfaction, health care efficiency and health care expenditures. The latter issue is not entirely up to the Secretary, however, because the DMCB found additional language that bars the Secretary from expanding the pilot to as ‘large a geographic scale as practical’ unless:

‘the Chief Actuary of the Centers for Medicare& Medicaid Services certifies that the expansion of the components of the pilot program … would result in estimated spending under this title that would be no more than the level of spending that the Secretary estimates would otherwise be spent under this title in the absence of such expansion.’

Last but not least, this particular bill, if the DMCB is reading things right, does NOT repeal the 2006 Medical Home Demo.

The DMCB didn't find much difference between this and what was originally included in HR 3200, including the relative latitude given to the Secretary and the requirement from the Chief Actuary that the medical homes be cost neutral.

The DMCB also finds it interesting that there appears to be language that supports additional funding for disease management services being folded into the PCMH. There may be some collaborative opportunities between the disease management organizations and the PCMH here.

Stay tuned!

Oi Vey Public Plan!

With apologies to the AC/DC and this classic piece of pioneering heavy metal. The Disease Management Care Blog can't understand lead singer Brian Johnson most of the time anyway, so it likes the lyrics below. On the other hand, guitarist Angus Young's language is universal.

Oi! Oi Oi Oi VEY!

See me ride out of Chicago
On your color TV screen
Out to win no matter how low
Under the bus yes that’s mean
Pundits to the left of me
And loonies to the right
Damn CBO
Budget’s a fright
Let Harry Reid do the fight!

Cause I’m Public Plan, I think it’s right
Public Plan, budget’s out of sight
Public Plan, we can’t afford
Public Plan, taxes will soarrr……

It’s simple, mean and I really don’t care
AHIP’s damaged goods
Opponents best beware!
It’s understood!
So lock up your wallet
Keep income low!
The Feds have huge debt
Don’t you know
Tax man is back in town!
So don't you mess around

Cause I’m Public Plan, folks think it right
Public Plan, budget’s out of sight
Public Plan, we can’t afford
Public Plan, deficits explode!

Public Plan. oi, oi, oi (vey!)
Public Plan. oi, oi, oi
Public Plan. oi, oi, oi
Public Plan. oi, oi, oi
Public Plan. oi
Yes we can! (oi, oi)
Public Plan. oi
Costs kick the can (oi, oi)
Public Plan. oi This is why I ran (oi, oi)
Public Plan
Budgets explode!

Latest Health Wonk Review is Up!

Yikes!

Tinker Ready of Boston Health News is at your door trick or treat with a well written, extensive and illustrated version of the latest Health Wonk Review. This one is all treat.

Check it out here.

More Implications on the Suspended Animation of the Medicare Medical Home Demonstration

While most media and bloggery continue to glom incessantly over the iterations and implications of the ‘public option,’ the Disease Management Care Blog finds the suspended animation of the Medicare Medical Home Demo far more interesting.

As the astute Vince Kuraitis pointed out in this post, CMS' intentions are quite cryptic, the legal authority is opaque, plodding government demos can be outrun by the market and there’s a difference between demos (‘should we do this?’) and pilots (‘how can we do this?’). In prior posts (here and here), the DMCB also pointed out that a multi-payor collaboration offers up an important opportunity in experiential learning and could represent an important tipping point for the Medical Home.

What are other implications?

Medicare As A Continuous Learning Organization: Rigorously run demonstrations that compare one care approach versus usual care are ill-suited to finding out works in an environment of constant change and overlapping mutually supportive interventions in multiple geographies. This is CMS’ chance to realize an insight known to the population-based care community for years: when it comes to multi-dimensional care management, looking is not that same as seeing, listening is more important than hearing and knowledge pales in comparison to insight. The DMCB would like to be among the first to welcome CMS in from the oxygen-deprived academosphere.

First Among Equals: Not only are pilots broader in scope, the Vermont announcement suggests that future Medicare-owned medical home pilots will accommodate other insurers. These are typically fashioned as multi-payer ‘collaboratives’ (for example, here and here) that pool resources, share data, seek consensus and continuously adapt. How well Medicare can execute on this will depend on staffers who can be flexible and understand the difference between effectiveness and efficacy.

Government Silos: The DMCB has spoken to more than one Medicaid Medical Director who cajoled their States’ commercial insurers into participating in multi-payer medical home collaboratives. When it comes to government programs working with other payers, Medicaid’s clearly had a head start. Can Medicare and Medicaid just get along? We’ll see.

Boost to Accountable Care Organizations: Compared to Medical Homes, ACOs are far less defined, but the DMCB suspects they’ll be part of the coming health reform legislation. ACO’s will likely adopt Medical Homes along with all the other policy golden boys like electronic records, value-based purchasing arrangements and bundled payments. Look for CMS to use medical home collaboratives to ‘motivate’ multiple payers to support the embryonic ACOs until they’re able to prove their worth.

Start Building The Business Plans Now: Assuming a) multi-stakeholder pilots are flexible, b) can build on Medicaid’s as well as the commercial insurers’ positive experiences with disease management, c) care management resources can be shared among multiple primary care sites and d) many primary care sites will not want to reengineer what few nurses they have left, the future is very bright for organizations that know how to deploy trained, motivated and savvy nurses across a network. Here’s an example. More are undoubtedly on the way.

++++++

Addendum: e-CareManagement has another post on the topic that is well worth the read. Check it out.

More on the Medicare Pilots: The Medical Home Purchasing Cartel That Includes Medicare

What percent of the revenue or the patients is enough to get a hospital's or a physician's attention? In it's prior life in not-for-profit managed care, the Disease Management Care Blog was stymied by only 'owning' a low percent of the patients in many of the provider settings. As a result, even if there were important quality initiatives backed-up by serious money or free assistance (usually in the form of care management nurses), the lack of critical mass compared to other payers hampered our ability to get anything done.

Which is why the Vermont CMS Demo i.e. pilot on involving a multi-payer collaborative in support of the medical home, is so important. By having the all the key purchasers of medical services form a medical home cartel i.e., monopsony, the providers will have to pay attention. The providers will also 'win' by having to operationally deal with single set of processes and payment mechanisms. Last but not least, Medicare (ironically) will be kept honest, because it will have to adapt some of its operations to mirror those of the other more experienced payors. Think tipping point leading to a virtuous cycle.

That's also called synergy, which is why a multi-stakeholder pilot - assuming CMS can collaborate - will be far more likely to show positive outcomes that a single Medicare demo.

Medicare Medical Home Demo Cancelled. Medicare Medical Home PILOTS Are On The Way

In a prior post, the Disease Management Care Blog broke the news that the Medicare Medical Home Demonstration had been placed on perma-hold by CMS. The announcement is now official, and you can read all about it and many of the implications at Vince Kuraitis' e-CareManagement Blog.

As pointed out in e-CareManagement, the purpose of a 'demo' is to ask 'if' a patient care intervention works, usually by comparing the outcomes of the patients in the intervention group to the outcomes of patients in a parallel control group. The Medicare Medical Home Demonstration is being effectively cancelled because the House Bill 3200 proposes a Medical Home 'Pilot' Program. The DMCB interprets the purpose of a pilot is to ask 'how' a patient intervention works. 'If' is first generation Ver. 1.0. 'How' is second generation Ver. 2.0

How could medical home 'pilots' be conducted by CMS? One big hint lies in the Green Mountain State, where the Secretary of HHS announced that Medicare will participate in a 'multi-payer' 'demo' evaluation. Don't let the word demo fool you. The bad news is that the multi-payer dimensions of this initiative will complicate any formal and traditional assessment of the impact of the medical home for fee-for-service Medicare beneficiaries. The good news is that this looks and feels like a pilot in which CMS will gain a treasure trove of experience on making the medical home 'work' in the real world.

The Guerrilla Approach to the Care Management that Underlies the Patient Centered Medical Home

At a recent webinar, the Disease Management Care Blog was asked how a regional health insurer implement a medical home if its provider network a) is dominated by small physician practices and b) there are no State-wide multi-payer-provider initiatives underway.

The DMCB at your service.

When it looks at what's been written about the core elements of the patient centered medical home, one recurring theme is the role of non-physician professionals - typically registered nurses - providing face-to-face (as well as remote telephonic) care management. The ingredients of that care management include patient engagement in the mangement of their own illness, coordinating that management with the primary care physician, acting as a primary point of contact for other members of the health care team as well as outside consultants, helping the patient to extract maximum value from the insurance benefit and maintaining and documenting an ongoing care plan.

Therefore, the guerrilla approach to creating care management to is for the insurer to establish that nursing resource for themselves.

Based on what it's heard on the non-Medicaid 'street,' the DMCB assumes that would involve a retail cost of anywhere from $20 to $50 per enrolled patient per month. Assuming that's true, it would dedicate most of that cost to the nurses' salary and benefits but take a fraction and give it to the physicians in exchange for letting the nurses into the practice. The DMCB is no business person, but a back of the envelope calculation suggests that each nurses would have to carry from 150 to more than 200 patients to cover their salary and benefits. There's some additional cost including the use of a car and laptops. The DMCB thinks the nurses would need to be distributed geographically and serve a hub of primary care sites, starting with the clinics that serve a large proportion of the insurer's patients.

Readers are probably thinking about the likelihood of getting this kind of sticker shock past the Chief Financial Officer. Yes, it IS pretty low, but you have several options: 1) argue that you'll only enroll patients that are likely to have $20-$50 in reduced claims expense thanks to the care management nurses' interventions, 2) sell the increased premium expense to customers that want a 'medical home' in their network (and that Medicare Advantage will use a bonus mechanism to cover that cost), 3) extract that cost by reducing payments for other services or 4) recognize this is a cost of doing business in an environment that demands the medical home all with or without the option of hiring a richly paid consultant (hint from the DMCB spouse).

The DMCB suspects some physicians will simply refuse to let a nurse into their practice. Other physicians will demand to hire their own nurse in exchange for the option of collecting the entire fee of $20-$50 PMPM. Fine, says the DMCB, but it would want to see a care management job description connected to a live care manager and have the option of performing an audit of the care plans.

Last but not least, the DMCB understands there are other elements of a medical home such as decision support, an electronic record, creating policies, NCQA recognition and 'transforming' the primary care site. While those other elements bring additional value, the purpose of hiring the nurses is not to establish 'medical homes,' but to create the greatest value proposition of medical homes: nurse-led care management.

The secret sauce here is the background, skill set, attitude and personality of the nurses. They need to understand outpatient primary care, appreciate the importance of patient engagement, buy into the notion of bridging the primary care-insurer divide and be smiling and steely-nerved ambassadors.

By the way, yes, that's a picture of Flo Nightingale above after her return from the Crimean front. Take away the bullets, and the DMCB sees many similarities between her role then and the new role demanded of nurses in the battle against chronic illness.

H1N1 Vaccination: The Difference Between the Obama Administration Being At Fault and Being Responsible

The Disease Management Care Blog has pointed out twice (here and here) that the Obama Administration's health care chops will be tested by H1N1. The President can't blame a lack of any warning, the prior Republican administration, absent regulations or an unfunded infrastructure. While moving virus from eggs to humans is very complicated, this is a public health effort that risks falling short across the entire system bandwidth of health care - most visibly the part owned by the Federal government.

Of course, there is no underestimating the capacity of loonies on the left or the right and the middle to refute the same technology that conquered small pox and polio. The community-dwelling DMCB personally discovered this nuttiness is not confined to distant enclaves and AM radio. The astonished DMCB ran into one urbane and educated colleague who, over a glass of Toasted Head, serenely discounted the research on vaccines. No amount of explanation could get past his blinkered anti-science puritanism.

Whatever. Americans still have the right to make bad decisions.

What the DMCB worries about, however, is that those who correctly decide to get the vaccine won't be able to get it, those unable to get the vaccine will get ill, those who are ill won't be able to get to a physician, those unable to get to a physician will overwhelm emergency rooms, and those in the emergency rooms will overwelm the hospitals. It won't necessarily by the White House's fault, but given their leadership and visibility in this area, they will be held responsible.

Fairly or not, the risk is that opponents of health reform will use a failed vaccination campaign to impugn the Obama Administration's competence in managing the nation's health. The DMCB wonders if this could reduce the odds that legislation will be passed.

Observations About Today's Patient Centered Primary Care Collaborative Annual Summit. Most Important: The Value of Magic Nurse Stuff.

The Disease Management Care Blog spent an extremely rewarding day at the Washington DC Primary Care Patient Centered Collaborative's Annual Summit on the Patient Centered Medical Home. It caught up with colleagues, got some valuable scientific updates and got to share in the growing enthusiasm for a very compelling approach to care. It also grabbed a copy of this report that was released today, 'Proof In Practice,' that will be the topic of a future DMCB post.

Random observations from today's meeting in no particular order:

This time the PCPCC Meeting was held in a very large room in the Washington DC Convention Center. There were over 400 attendees and the crowd was very supportive. The Patient Centered Medical Home appears to have gained considerable momentum - and that's putting it mildly.

Several Congressional staffers were there along with a House Representative who gave the keynote. Based on their comments, it's pretty clear that some version of the PCMH will be in the final health reform bill. The DMCB suspects that 'pilots' will be used in lieu of 'demonstrations' in FFS Medicare. In D.C.-speak, pilots have a better open-ended political prognosis than 'demonstrations.'

One key Congressional staffer pointed out that there seem to be many iterations of the PCMH ('means different things to different people') with variable outcomes ('for example, it doesn't consistently reduce repeat hospitalizations'). While some prefer to 'lump,' Congress is leaning toward 'split' by recognizing two models of the medical home: 1) 'high intensity' and 2) 'low intensity.' Each warrant different levels of funding support. Watch for this in the final health reform bill.

One physician audience member pointed out that his Medicare Advantage (MA) Plan has been offering a version of the PCMH for years. He pointed out that if MA funding is cut, this could mean its demise. The panel responded by noting that most MA Plans have not used their allegedly high fees to support versions of the PCMH. In response, MA funding cuts are politically inevitable, but there is a chance that bonuses will be offered to MA Plans that offer care coordination. Look for this in the final health reform bill also.

Why aren't commerical insurers and self-insured employers stampeding toward the PCMH? Three reasons were offered: 1) the PCMH is very much a function of managing 'locations' in a network that depends on local physician adoption; it's easier to just manage the benefit design, 2) it's still all about a short term focus on costs, not a long term emphasis on 'value,' and 3) irrefutable and solid 'proof of concept' is still lacking.

That's not stopping the Veteran's Administration. All 820 of their primary care sites are going to be transformed to PCMHs over the next two years thanks to a combination of experiential learning collaboratives, learning colleges, consultation teams, demonstration labs and an abundance of communication. The VA's challenges are 1) promoting 'top of license' care among members of the PCMH team, 2) limited phone based care experience, 3) the usual challenges in retooling for chronic care activities, 4) limited experience in managing transitions between the hospital and the outpatient setting, 5) while the VA's EHR is robust, its decision support capabilities are minimal.

Last but not least, much of what appeared in the many panel discussions and on screen in the PowerPoints was filled with nursing concepts and terminology. To the DMCB, it's pretty clear that the core of any PCMH is high-end primary care nursing. Sure, we need physician leadership, information technology, teaming, payment reform etc, but let's face it: when it comes to assembling and managing the resources necessary to care for patients with chronic illness, physicians can best lead by getting out of the way. To us docs, it's magic nursey stuff. The good news is that it seems to work not matter what you call it and that the nursing profession is finally going to get the recognition that it deserves.

News About the Medical Home Demo

The Disease Management Care Blog understands that it has been decided that it would be impractical to clear the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot. You read it here first.

While a New England Journal of Medicine article on a poll showing high physician support for Massachusett's health insurance reforms* captured some of the news cycle, the Disease Management Care Blog was much more interested in catching up with this jewel from a week earlier on the logic underlying Medicaid's inclusion in healthcare reform.

This article by George Washington University academician Sara Rosenbaum is a very handy and well written summary. Recall that Medicaid covers a whopping 60 million Americans that generally meet three broad conditions: 1) age (children and the elderly), 2) a qualifying condition (pregnant, disabled or a caretaker of children) and 3) income (a percent of the Federal Poverty Level or FPL). The latter category threshold varies from State to State (from a low of 17% to a high of 275%). The first two conditions trump the latter. If you are a ‘nonelderly’ adult and don’t have a qualifying condition, you are out of luck when it comes to Medicaid no matter how low your income is. You probably can't afford commercial insurance either, which means you are uninsured.

That may change thanks to the bills before Congress. They bascially do two things: 1) eliminate the age/qualifying condition barriers, and 2) create a one size income standard as a percent of the FPL across all States.

Fans of the private market may wonder why health reform is turning to Medicaid. According to the article, it is more than just a matter of the Democrats’ policy preferences.

First of all Medicaid is the cheaper alternative. States are required to cover part of the Medicaid budget, Medicaid has a lower fee schedule and its administrative costs are partially carried by the government. Private insurers can't match this. Ms. Rosenbaum quotes research showing comparative policies for private insurance could cost approximately $6000 while Medicaid’s cost would be less than $2000. That’s over 4000 reasons in favor of Medicaid.

Secondly, absent highly vigilant and extensive regulation, the private market could easily tilt toward ‘cherry picking’ and actively enroll a younger and healthier population. Medicaid programs, in contrast, are configured to be a fiduciary for the poor and ill without any of the enrollment or benefit gamesmanship.

Last but not least, the professionals that administer Medicaid understand the special needs of persons living at the margins of society. They understand how community health centers, public hospitals and local agencies can be used to best serve underserved persons living in inner cities or rural settings. This kind of expertise is simply unavailable in the commercial insurance market.

The article closes with three 'show me the money' recommendations:

1) Show me (the States) the money. Without credible support from the Feds, the States may be simply unable to afford their share of an expanded Medicaid program.

2) Show me (the docs) the money. Without credible support from the Feds, the States may simply squeeze their payment rates down to unsustainable levels. Spotty physician refusal to accept Medicaid patients could uptick considerably.

3) Show me (the system) the money. Medicaid needs to become more a visible player in each of the States' efforts to rationalize health care, increase quality and drive greater value.

Readers may or may not agree with the rationales described above, but they make sense from an insurance reform perspective. Unfortunately, other than reducing benefits and lowering payment levels, the DMCB sees few other options for a new and improved Medicaid to hold down costs if health care inflation continues unabated.

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*The DMCB cannot resist. Of course physicians prefer it when their patients have an ability to pay for health care services. Check out this telling article on the Brit's introduction of the National Health Service in the 1940's and politician Nye Bevan's "bribe" to win the support of the physician consultants: "I stuffed their mouths with gold."