Wednesday, July 15, 2009

Chronic Disease Management and Building Medical Homes Without Having to Transform Primary Care Practice in the Senate HELP Committee Reform Bill

Hot on the heels of the unveiling of the health reform bill in the U.S. House of Representatives yesterday, the Senate's Health Education and Labor and Pensions (HELP) Committee passed the 'Affordable Health Choices Act.' Readers can look at the summary here, or if you’re so inclined, review the complete 615 page bill here.

If the Disease Management Care Blog is reading both bills right, the Senate's HELP bill - in contrast to what's in the House - is requiring health insurers to reimburse 'high quality care that improves health outcomes through activities that shall include... chronic disease management, medication and care compliance initiatives, including through the use of the medical home model' (bolding and italics mine).

While the DMCB is slightly confused by the language 'including through,' the specific mention of 'chronic disease management' in legislative language would appear to be good news for disease management organizations. Note that Sen. Chris Dodd (D-CT), the acting Chair of HELP, represents the home State for CIGNA and Aetna, both of which have invested heavily in population-based care and disease management programs. In addition, the ailing Senator Kennedy (D-MA) represents a State that is home to Health Dialog. Readers are free to draw their own conclusions.

In addition to this, the Senate bill importantly provides for 'grants' that will support 'health teams' that, in turn, can contractually support primary care physicians in the creation of medial homes.

The DMCB is discerning a significant pattern here. As readers may recall, the House bill has a provision that funds a 'pilot' designed to test 'Community' based not-for-profit entities that can associate with primary care providers in the creation of medical homes. It would appear the Senate bill is doing the same thing, but isn't insisting on a non-profit or State sponsored status. Both approaches recognize that not all primary care providers necessarily want to build their own medical homes, but may want to associate with entities external to their practice that enables them to do the same thing. Given the considerable expense and work of 'transforming' a medical practice into a medical home, providing this option makes sense not only to the DMCB, but also maybe to the Dr. Pectors and the rest of her colleagues that inhabit the real world.

On another note, the Senate HELP bill also trumps the U.S Preventative Health Services Task Force (USPHSTF). In addition to the disease management requirement above, the bill states insurers 'will not be allowed to impose more than minimal cost sharing for certain preventive services endorsed by the USPHSTF as clinically and cost effective...' It may surprise some readers to know what the USPHSTF does NOT endorse. If readers are interested, they can check the links to services that insurers presumably could impose significant cost sharing for:

Pap smears for healthy women over age 65 years - answer
Chest x-rays to screen for lung cancer - answer
Prostate cancer screening - answer
Routine stress tests - answer
Screening for ovarian cancer - answer
Testing for the presence of diabetes in adults - answer
Counseling to promote weight loss among the overweight - answer
Counseling to promote exercise - answer


Elizabeth A. Pector, M.D. said...

Insightful and hopeful article! If communities can get organized (and more importantly, get doctors on board), it will help to have valuable ancillary services (especially community-based dietician, coaching and counseling services) available to support physician efforts to manage disease and educate patients.

I do fear that early adopters with diverse EMR or disease management programs will be left behind if communities belatedly get organized. Organizing doctors has been likened to herding cats, and organizing cash-strapped hospitals and communities during an economic downturn may be next to impossible. Doctors who have endured two or more EMR implementations will probably not be happy, even if cost considerations are eliminated, to adopt the "latest & greatest Metropolis EMR with patient registry, patient portal, etc." if they already have such services in an existing program.

The USPSTF has required such rigorous evidence of efficacy that it lags behind protocols adopted by many physicians (and consensus standards). Urologists recently recommended PSA screening at 40, yet USPSTF does not side with them on any screening at all. It is best to practice rigorous evidence-based care, with long informed consent where evidence is unclear, but who has time to discuss all the options for a typical 50- or 65-year-old?

Thanks again for the glimmer of hope that small practices in cohesive communities can perhaps get some support if they band together regionally. This model would promote coordinated care while preserving physician independence--two major goals.

Elizabeth A. Pector, M.D.

Jaan Sidorov said...

Thanks Dr. Pector!

Plus you raise a good point. Execution matters in getting initiatives like this to work. Many details and involved and it remains to be seen how a Federal bureaucracy could pull this off, especially with all those moving pieces like EMRs and other programs in the cat herd.

As for urologists' opinions about anything....