The Integration of Disease Management & the Patient Centered Medical Home

The Disease Management Care Blog has made no secret of its prediction (or maybe it's a preference, but, hey, it's my blog) that the 'patient centered medical home' and 'disease management/population health' will become integrated.

While the PCMH is many things to many people, in the opinion of the DMCB, its best features are a) the new version primary care physician and b) a team of hands-on providers. By 'new version,' it means a PCP with a commitment to chronic illness and population-based clinical and economic outcomes. By 'team of hands-on providers,' it means nurses (usually) who can help particularly ill patients navigate an increasingly complex and unending episode of care.

While disease management is the Anti-Christ to many people, in the opinion of the DMCB, it brings a remarkably sophisticated high-volume low-cost outreach/communications/coaching ability that simply cannot be matched by most primary care networks in most geographies. This seems well suited to patients with a chronic condition who need to be engaged in self care, but who do not need much hands-on care.

In order for integration to occur, three things will need to happen:

1) the PCMH pilots will go through the same cycle as DM of inconsistent findings about savings versus usual care. Think MCCD, which was more about the Medical Home. This will diminish some of the hubris and prompt recognition that a wider population reach is necessary.

2) a formula about who is "in charge" will emerge. It will reconcile the PCMH's central clinical role and DM's insurance-risk mitigation role.

3) a successful pilot/demo/clinical trial that passes muster.

The DMCB doesn't think it needs to happen in that order either.

And what does the DMCB do at times like this when it's pondering this stuff?

Why, it breaks into song! Click on the YouTube window and test drive the lyrics below. With apologies to Canned Heat.

Together we'll stand
Divided we'll fall
we need more data
the… cash flows will stall
let’s work together
Come on, come on
let’s work together
Now now people….
Because together we will stand
Every doc, all the vendors and Plans!

D M, your fees - they suck
and the.... costs still rise
n’ your …results are luck
a …roll of the dice
You can do better
You know, you know
You should do better
Ohhhh…
So says CBO and RAND,
Every blog, doc, buyer and Plan!

Ohhh, M H, you’ve got your share
there’s too much doubt
and no one cares, what
about… the docs
they want the money
they think, they think
it’s just the money
Now now people….
and the pilots may tank
you’ll be the topic of RAND!

Ahhh, come on now...
(RIFF time, dance in front of your computer)
Ahhh, come on, let's work together! (Woo hoo!)

Now…, don’t wait too long
Until it’s too late….
Let’s mix together and just integrate
It’s more efficient
the trend, the trend
the Fund’s deficient
Now now people…
Because we can’t afford
The usual for the elders of the land!

Oh well now come on you doctors
Do a group hug
With all those vendors, they are beggin for love
To work together
C’mon c’mon
please work together
Now now doctors
Because together we can share
Every fee that’ll be for Medi--care
Ahhh, yes!

(RIFF #2 time, time to dance in front of your computer again)

Because together we can care
For all those elders yes, woman and man!