Tuesday, April 8, 2008

The Emergence of the Middle Ground: the Convergence of Disease Management, the Medical Home and the Re-Emergence of a New Version of Primary Care

What was most newsworthy message from the Chicago ABQUARP conference? For the Disease Management Care Blog, it didn’t come from the speakers but from the audience of physician leaders, many of whom had backgrounds in primary care. Despite all the exciting developments in advancing the quality agenda, they are concerned, angry, dismayed, demoralized and paranoid. The good news is that they still very much give a damn. The DMCB doesn’t know how much longer that will last.

What ails the physicians? The corporatization/industrialization of medicine, failure to leverage their waning influence over their patients’ access to specialists, commoditization of primary care, lack of any political traction and declining reimbursement.

In the opinion of the DMCB, one illustration of the forces at play is the rise of the 'Minute Clinic.' That’s where patients choose not to see a regular physician and instead buy an aliquot of standardized, convenient and perfectly adequate care at a competitive price. The economics are very threatening to docs: while these kinds of encounters in usual primary care settings are not individually remunerative, they have a more favorable “margin” per visit and yield more visits per hour than the time-consuming “complex” office visits. Sore throats and sprains subsidize adjusting insulin and addressing hypertension medicine side effects.

Such may the implacable nature of medical markets (however imperfect they may be) in response to regrettable but permanent shifts in customer preferences. Between the allure of specialists for more complex medical diagnoses “above” and the convenience of non-physicians for self-limited problems “below,” primary care physicians are being left with a “middle ground” of complex co-morbid condition patients that are not easy to treat and are not easy to make a decent living on.

So what should be done? One solution is to let Adam’s Smith’s invisible hand perform its magic. While the Dartmouth Atlas reminds us that the workings of the U.S. medical market leaves much to be desired, the outpatient corner occupied by primary care may ultimately be righted by the simple laws of supply and demand: fewer and fewer clinicians with the requisite skills for the middle ground needs of the aging boomers will ultimately be able to command a premium.

Alternatively, for those readers of the DMCB who are inclined toward activist policy and planning, we might consider the insight of Sir Muir Gray, who was quoted in Pat Salber’s excellent TDWI blog: more money and more science is not the answer. It’s a matter of executing on the knowledge that we already have. That knowledge includes (but is not limited to) the behavioral science behind turning patients into participants, making the movement of HIPAA protected health information less proprietary and less “viscous” (a term coined by my colleague Vince Kuraitis), capitalizing on true clinical effectiveness and aligning incentives with the money that we already have. As for the executing part, I leave it to the DMCB readers to decide if Washington DC’s track record passes muster.

What about the activist alignment of those incentives? While there is fee-for-service, reimbursement for high-value middle ground care in outpatient settings would seem better suited to FFS plus some sort of global per-patient payment. That’s because, in the opinion of the DMCB, that work is variably spread over channels outside of the typical doctor visit using many types of interconnected providers relying on myriad systems. Global payment to whatever entity is providing that package of services could be risk-adjusted or, alternatively, flexible and tied to financial (upside gain sharing or risk corridors for example) or clinical targets (pay for performance) or both. If it sounds like an enlightened form of capitation, you’re right.

What should be done with those capitation dollars? Hopefully, physicians in the middle ground will industrialize their practice of chronic illness care, reassert control of referrals, create value, become leaders in chronic illness care and make a good living.

What about the spat between the devotees of the medical home and the acolytes of disease management? The DMCB predicts Ver. 1.0 predictive modeling/remote behavior change of disease management will combine with Ver. 2.0 hands-on medical home/case management. We will witness the creation of a yet to be developed Ver. 3.0 population chronic illness care program that combines the best of both. Whether that’s accomplished by a primary care physician-led entity that outsources to disease management vendors or vice versa isn’t important. From the end-user’s perspective it should make no difference. The DMCB doesn’t think that will big a deal for my colleagues in primary care either.

Continue to give a damn, my friends. Hang in there, but you need to start planning now.

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