Monday, September 8, 2008

Disease Management - Patient Centered Medical Home Collaboration

The Disease Management Care Blog listened in on the DMAA web cast by Paul Grundy MD of the Patient Centered Primary Care Collaborative and Bruce Bagley of the American Academy of Family Physicians.

It liked what it heard.

Dr. Grundy went first and angrily declared U.S. health care purchasers are buying ‘garbage.’ He asserted the U.S. has been dead last in quality and expense in the world thanks, in part, to the 'immoral' disintermediation of the primary care physician-patient bond. Primary care needs to be resurrected. To make that happen, buyer-primary care physician 'covenant' needs to be reestablished. The docs themselves will also need to get some religion about value-based systems of care. That will require a host of blended payment reform interventions that lead to primary care site teaming, electronic data systems and decision support. In other words, it will take the patient centered medical home or PCMH. So far so good.

Dr. Bagley was less evangelical. If primary care is going to be continuous, comprehensive and personal, says he, it will need to adopt:

1) teaming with shared responsibility with awareness of mutual strengths that results in human resources greater than the sum of the FTEs,

2) registries (clinical data bases that monitor essential care elements and facilitates active management)

3) care coordination ‘microsystems’ that foster the right care at the right time,

4) ‘built in’ quality measures and reporting,

5) leverage of community resources including support services, family, disease management organizations and home health

6) self management support, which is NOT education but enabling patients to achieve informed medical decision making free of provider bias.

So far so good, but once Dr. Bagley got past all that jargon, things became really interesting.

He noted that there are physician practices that are immature mom and pop shops with non-professional approaches to finance, human resources and quality. They talk and act like victims, rely on top down command and control, have no clue about process mapping, try harder instead of smarter and have unapproachable physicians. Many other clinics may share some of these features but have a much better prognosis.

That’s where disease management organizations come in. According to Dr. Bagley, DMOs need to move from helping patients become engaged to helping the struggling clinics become expert. In his opinion, this can occur in a number of ways including training office staff in registry and care coordination functions, providing patient self management support, helping with community services and providing 24/7 telephonic support.

During the question and answer period, there was a ‘who’s going to pay’ inquiry about the disease management support. Dr. Bagley didn’t quite answer the question, but this is what the DMCB thinks:

1) if DMOs are ultimately going to paid to deliver outcomes, it stands to reason that physicians are an important ingredient. Why not devote resources their way if it means better outcomes?

2) it seems it’s more than just a question of physician engagement. It’s achieving physician buy in. Outcomes are the 'tangible asset'; physician buy in can be thought of as 'good will.' Maybe it should be monetized. Next.

3) managed care organizations are also struggling with physician engagement and know how tough it is. The DMCB thinks they’d be sympathetic to the idea of partnering on helping primary care physicians, especially if they’re getting impatient over enrollee reach rates or other outcomes.

While the DMCB can continue to ponder just how and why the DM-PCMH divide can be bridged, the key take away here was that these two PCMH physician leaders welcome the prospect of collaboration DMOs and have some interesting ideas on how that can be pursued.

The DMCB says let that dialog continue.

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