Thursday, November 13, 2008

The Baucus Blueprint for a Call to Action for Healthcare Reform, Part 2

How about chronic illness? Even if the Senator Baucus' Call to Action never sees the light of day, this document gives some useful insight on a prevailing attitude in Congress. In this post, the Disease Management Care Blog pays special attention to the Baucus Blueprint (BB) chronic illness recommendations. No reproduced quotes here about the growing prevalence of disease, stubbornly poor quality and unsustainable costs. DMCB readers already know that stuff and want the bottom lines:

Hanging by a thread but there’s hope: This is rather important, so the DMCB pulled this quote verbatim (italics added): ‘Vendor-based disease management programs, which typically involve phone-based care planning and follow-up by nurses, have found some success in the private market but have not fared as well in recent Medicare demonstrations. While these approaches should not be jettisoned without consideration of new evidence from state and private payer programs, it remains an open question whether Medicare should make direct payments to vendors outside of a comprehensive care management model, such as the medical home.'

To the DMCB this means that under the BB, 1) all insurers except Medicare are free to include disease management (DM) in the benefit if that's what they prefer, 2) there is still time to pursue new evidence about what works and what doesn't, and 3) there is less support for traditional 'stand-alone DM' versus an integrated approach that uses DM as part of a broader care management care system.

Medical Homes remain the darling, but ‘require ongoing evaluation: The BB describes the medical home is described as a 'work in progress' and expansion will require 'ongoing evaluation.' An interesting twist is that the measures have to be meaningful to consumers, not academics, editors, the NCQA, economists, policy makers, partisans, advocacy groups, physicians or politicians. Can the Medical Home consistently bend the trend and reduce claims expense? Until it succeeds where DM has not, the BB urges that coverage not be automatic.

Bundled payments! That's right, the BB mentions 'episode groupers.' In fact, it states Medicare should develop its own 'open-source technology platform' that includes information on both episodes of care and per-capita resource use. This will presumably help ensure that episodes of care are both necessary and efficient. What isn’t mentioned is how this is a first step on the inevitable road to bundled payment. By the way, the DMCB adds, this will also pave the way for no-pay for inpatient readmissions, because they’ll be rolled into the global payment.

And bundle the providers too: The BB praises the assembly of providers into 'Accountable Care Organizations' such as hospitals that employ their own physician staff, academic medical centers and their affiliated faculty practices, multispecialty group practices, physician hospital networks or independent practice associations, and primary care physician groups able to identify the other providers from whom their beneficiaries receive their care. It suggests there should be an ACO pilot in communities and regions where meaningful integration does not yet exist — such as in rural areas and small group practices.

If you don’t measure it, it doesn’t happen: The Blueprint would give the Independent Health Coverage Council described in the prior Part 1 post the ability to set standards for chronic care management and quality reporting. Insurers would be responsible for collecting and reporting the performance of providers in their networks. Presumably, patients would make better decisions about their own care.

Value-based insurance benefit: Out of pocket expenses for recommended preventive services will be dropped.

‘Studies’ and ‘Demos’ remain a fav: The BB asks for a ‘study’ to identify the various federal programs that can help prevent the development of chronic disease and suggests options to more effectively coordinate efforts going forward. There are lots of the standard goodies such as “demonstrations’ for obesity, and grants to nudge local governments, employers, schools, health care systems, communities and individuals to work together and support healthy lifestyles.

And the DMCB offers closing thought about the physicians. As Governor Rendell is discovering in Pennsylvania, if you're going to change the system, it sure helps to have the physicians on your side. The BB has two features going for it: 1) the support of primary care physicians who believe anything is better than the status quo, especially if they get paid for the medical home, and 2) a promise of permanently repairing the Sustainable Growth Rate formula used to threaten all physicians with deep fee schedule cuts.

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