Thursday, September 18, 2008

The New England Journal Writes Lots About the Patient Centered Medical Home

Like the latest issue Health Affairs, today’s New England Journal of Medicine (NEJM) has been glommed onto by irresitible Patient Centered Medical Home topic. Despite the newsworthy heart pounding excitement of (gasp!) Heathways’ URAC accreditation and (zounds!) McKesson’s New Hampshire Medicaid contract renewal, the siren call of the PCMH is just so irresistible, isn’t it?

After all, CMS is getting ready to launch its three-year eight-state dirigible, the USS Medical Home Demo, while dozens of commercial insurers are in the midst of their own PCMH pilots, trials, studies, collaboratives, programs, research, tests and assessments. This issue of NEJM has not one, not two but three articles looking past all the smoke for the fire, beyond the froth for the caffeine.

Don’t get the NEJM, don't want to take advantage of the free access (thanks NEJM!) or don’t have the time? No problem, you’re a short read away from getting what you need to know.

Before we briefly look at what John Iglehart, Meredith Rosenthal and Elliott Fisher and have to say, the DMCB discovered that CMS updated its Medicare Medical Home Demonstration web site on Sept 11 with a new fact sheet.
  • There is much involvement of the organized primary care medicine groups. While transparency is an issue, kudos for getting the docs involved.

  • Subspecialty practices (endocrinologists, for example) will be allowed to participate.

  • The NCQA PCC-PCMH Recognition Program template will be used to define what constitutes a “medical home”, but two, not three tiers will be used. That tiering (and the payment that goes with it) will be based on a specially modified version of PCC-PCMH. One key feature that distinguishes the two tiers is the presence or absence of an electronic record.

  • One chronic condition is all that’s needed for a patient become ‘high need’ and be eligible for recruitment into the demo. That’s a very low threshold.

  • Primary care site recruitment begins in the Spring of 2009. The DMCB suspects the organized physician groups will play an important role here.

Enter John Iglehart in the NEJM with more information. He writes the RVU-based monthly payments to physicians will probably range from $30-$50 per patient per month, which contrasts nicely with the $3-$10 fee prevalent in the private sector. He also notes there will be an upside gain share. The good news is that it will be up to 80% of any savings above a 2% savings. The bad news is that the case management monthly payment fees will be subtracted first.

P4P Guru Meredith Rosenthal’s interpretation? This sure looks like going back to the future with capitation, albeit a ‘soft’ version. Instead of incenting physicians to withhold referrals, physicians are being incented for ‘quality and efficiency.’ Do not despair, however, because we are making progress toward 1) paying for value, 2) distinguishing random variation from case mix from avoidable complications and 3) getting to the point where payment ‘form’ equals ‘function.’

The dour Elliott Fisher agrees the medical home has considerable face validity but counsels against unrealistic expectations like saving lots of money or getting medical students to abandon careers in botox administration. He argues two key success factors will be 1) full access by medical homes to all patient information across all hospitals and care providers and 2) physicians’ buy-in over collaborative decision making. He also wonders if consumer support is guaranteed and if funding in a zero sum environment is realistic. Finally, there is a disturbing lack of information over the impact of the medical home on health care spending versus the cost of implementing it versus the well known ability of the system to neutralize savings with increases in volume and service intensity. His common sense suggestions include creating supporting practice networks that share data for the medical homes, increasing medical home ‘connectivity,’ using fully transparent evaluation methodologies and relying on credible payment updates, P4P and gainsharing.

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