Thursday, October 22, 2009

Observations About Today's Patient Centered Primary Care Collaborative Annual Summit. Most Important: The Value of Magic Nurse Stuff.

The Disease Management Care Blog spent an extremely rewarding day at the Washington DC Primary Care Patient Centered Collaborative's Annual Summit on the Patient Centered Medical Home. It caught up with colleagues, got some valuable scientific updates and got to share in the growing enthusiasm for a very compelling approach to care. It also grabbed a copy of this report that was released today, 'Proof In Practice,' that will be the topic of a future DMCB post.

Random observations from today's meeting in no particular order:

This time the PCPCC Meeting was held in a very large room in the Washington DC Convention Center. There were over 400 attendees and the crowd was very supportive. The Patient Centered Medical Home appears to have gained considerable momentum - and that's putting it mildly.

Several Congressional staffers were there along with a House Representative who gave the keynote. Based on their comments, it's pretty clear that some version of the PCMH will be in the final health reform bill. The DMCB suspects that 'pilots' will be used in lieu of 'demonstrations' in FFS Medicare. In D.C.-speak, pilots have a better open-ended political prognosis than 'demonstrations.'

One key Congressional staffer pointed out that there seem to be many iterations of the PCMH ('means different things to different people') with variable outcomes ('for example, it doesn't consistently reduce repeat hospitalizations'). While some prefer to 'lump,' Congress is leaning toward 'split' by recognizing two models of the medical home: 1) 'high intensity' and 2) 'low intensity.' Each warrant different levels of funding support. Watch for this in the final health reform bill.

One physician audience member pointed out that his Medicare Advantage (MA) Plan has been offering a version of the PCMH for years. He pointed out that if MA funding is cut, this could mean its demise. The panel responded by noting that most MA Plans have not used their allegedly high fees to support versions of the PCMH. In response, MA funding cuts are politically inevitable, but there is a chance that bonuses will be offered to MA Plans that offer care coordination. Look for this in the final health reform bill also.

Why aren't commerical insurers and self-insured employers stampeding toward the PCMH? Three reasons were offered: 1) the PCMH is very much a function of managing 'locations' in a network that depends on local physician adoption; it's easier to just manage the benefit design, 2) it's still all about a short term focus on costs, not a long term emphasis on 'value,' and 3) irrefutable and solid 'proof of concept' is still lacking.

That's not stopping the Veteran's Administration. All 820 of their primary care sites are going to be transformed to PCMHs over the next two years thanks to a combination of experiential learning collaboratives, learning colleges, consultation teams, demonstration labs and an abundance of communication. The VA's challenges are 1) promoting 'top of license' care among members of the PCMH team, 2) limited phone based care experience, 3) the usual challenges in retooling for chronic care activities, 4) limited experience in managing transitions between the hospital and the outpatient setting, 5) while the VA's EHR is robust, its decision support capabilities are minimal.

Last but not least, much of what appeared in the many panel discussions and on screen in the PowerPoints was filled with nursing concepts and terminology. To the DMCB, it's pretty clear that the core of any PCMH is high-end primary care nursing. Sure, we need physician leadership, information technology, teaming, payment reform etc, but let's face it: when it comes to assembling and managing the resources necessary to care for patients with chronic illness, physicians can best lead by getting out of the way. To us docs, it's magic nursey stuff. The good news is that it seems to work not matter what you call it and that the nursing profession is finally going to get the recognition that it deserves.

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