Thursday, April 10, 2008

The Medical Home and a Preference Sensitive Read of the 2008 Dartmouth Atlas on Tracking the Care of Patients with Severe Chronic Illness

The Disease Management Care Blog likes to troll other sister sites to see what there is to see and came across some commentary here and here and here on the 2008 ‘Tracking the Care of Patients with Severe Chronic Illness’ from the folks at the Dartmouth Atlas. Wennberg and colleagues used the same methodology deployed in prior reports by relying on Medicare claims data from the end of life, but this time applied it to persons with ‘chronic illness,’ defined as congestive heart failure, chronic lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes, chronic liver disease, and dementia. There have been news releases, print media reports and even a 'told you so' commentary from the CBO.

Some of the blog sites linked above make obeisance to Wennberg’s discussion of the “Medical Home.” Interested in knowing whether this was a ‘preference sensitive’ read of the document, the DMCB downloaded all 174 pages. On page 104, there is indeed a 3 paragraph section titled “How physicians may respond.’ It notes patients with chronic illness would ‘presumably’ benefit most from the kind of care coordination under the ‘medical home,’ but (and this is a big but) a) the primary care physicians would need to assemble into networks and b) they’d need to be willing to profile hospitals and use the data to steer patients and c) Medicare would need to execute on shared savings arrangements. The term ‘medical home’ appears 3 times.

How about disease management? While the press releases, print media and sister blogs fail to bring it up, the DMCB fired up the “Search” function in the Adobe reader and found 7 references (mathematically that comes to over twice as many vs. medical home) on the topic. They are pasted below for your reading pleasure. They address a spectrum of care settings and are hardly any less supportive:

  • 'Because seriously ill patients are highly loyal to the hospital where they receive their care—as has been shown elsewhere—hospital-specific utilization rates reflect the approach to chronic disease management of the physicians who practice in association with that hospital.'
  • 'In the ambulatory setting, for instance, patients with chronic heart failure are routinely hospitalized during acute episodes of the underlying disease that often could have been controlled with better disease management and coordination between physicians.'
  • 'More to the point, do patients who receive more supply-sensitive care have better outcomes? Do they live longer? Do they have better quality of life? Such questions have received virtually no attention from academic medicine or from federal agencies, such as the National Institutes of Health, that are responsible for the scientific basis of medicine. With the exception of a few studies of chronic disease management, clinical research that might shed light on the question simply has not been done.'
  • 'Care transitions (i.e., “hand-offs”) in particular—between primary care and specialist physicians; between nursing homes and hospitals; between home health care and primary care; and between acute care and hospice and palliative care—are often plagued with miscommunications about the patient’s medical needs and care preferences, leaving patients in the wrong facility or receiving the wrong care. In the ambulatory setting, for instance, patients with chronic heart failure are routinely hospitalized during acute episodes of the underlying disease that often could have been controlled with better disease management and coordination between physicians.'
  • 'Over the last 50 years, the nation has invested heavily in such medical resources as specialists, acute care hospitals, intensive care beds, and expensive imaging equipment, much of which is allocated to the management of patients with chronic illnesses. Underlying this investment is the assumption that more intensive management of the chronically ill results in better health outcomes and greater patient satisfaction. That assumption is being challenged by the hospice and palliative care movement, by the growing chronic disease management industry, and by population-based chronic care models that emphasize continuous and coordinated management of patients over time and among sectors of care.'
  • 'The cost-sharing provision would create revenue for the provider partner to manage the financial consequences of downsizing its acute care component in the process of creating an organized system. These costs might include the amortization of debts to bond holders and employee buyouts. Savings would also be allocated to pay for the infrastructure required to build organized care, such as the IT systems required, and services for caring for the chronically ill that are not funded under traditional Medicare Part A and B, such as nurse coaches and other key personnel required for active disease management.'
  • 'Beginning first with its own physician staff and referring physicians, how would the various components of chronic care management be integrated? A plan would include the specification of new roles for providers in managing chronic illness, perhaps worked out with the support of disease management companies that could help provide some of the missing infrastructure. Special focus would be on filling gaps in care management that result in unnecessary (preventable) exacerbation of underlying disease.'

My read is that Wennberg et al recognize the established positive role of disease management in the care of chronic illness. At the same time, they point out that the medical home also offers distinct advantages, even if the barriers are formidable. They also appear to have independently come to the same conclusion as the DMCB: a combined approach warrants consideration.

The DMCB agrees the Dartmouth Atlas is a critically important document that should better inform the policy debate over the direction of healthcare in the U.S. Let’s hope the politicians, regulators, policy makers and industry leaders closely read the entire document.

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