The Affordable Health Care For America Act and the Patient Centered Medical Home: the Disease Management Care Blog Takes a Look

The Disease Management Care Blog finally got around to opening the online version of House Resolution 3962, otherwise known as the House of Representative’s Affordable Health Care for America Act, pejoratively named PelosiCare by detractors, a Defining Moment by Nobel Prize Laureates or just AHCAA for acronymically inclined.

Good thing Adobe has a word search function available for this 1990 page behemoth. The DMCB used it to hunt for our U.S. House of Representatives’ leadership plans for the ‘medical home.’ It figures many DMCB readers may appreciate a one-pager CliffsNotes summary.

There was plenty. It mostly begins on page 672:

Assuming this passes the House and makes it past even more changes thanks to the Conference Committee, the Secretary of HHS will charged with establishing a ‘medical home pilot program’ that evaluates the ‘feasibility and advisability’ of paying for qualified patient centered medical home (PCMH) services. The DMCB suspects that the staffers that wrote this bill did their homework, because the Act’s definition of the PCMH borrows heavily from the 2007 Joint Principles including:

1) accepting responsibility for providing first contact, continuous and comprehensive care

2) coordinating the teaming, arranging care with specialists, maintaining continuous access to care,

3) providing support for patient self management, information management and guidelines

4) offering a principal care provider that provides the majority of personal health care needs

There is considerable leeway for the Secretary, who is free to determine how practices become eligible as PCMHs. It’s also up to the Secretary to decide how to exactly pay PMCHs in the pilot but the Act supports, ‘prospective payment,’ higher payment rates for patients with’ high risk scores,’ and additional differential payments based on the provision of additional services such as ‘population disease management .’ Beneficiaries also have to agree to be a participant before the PCMH can be paid for providing medical home services.

The Act stipulates that the Secretary has to test the pilot in ‘various settings’ including practice sites that have ten or less full time physicians. Specialist physicians (presumably such as endocrinologists) that act as a ‘principal’ provider as well as nurse practitioners are also allowed to act as PCMHs. The Act also supports funding the PCMH pilot in not-for profit community health centers.

It’s also up to the Secretary to decide how well the PCMH addresses health care quality, health care disparities, preventable hospitalizations, readmissions, emergency room visits, beneficiaries’ functional status and satisfaction, health care efficiency and health care expenditures. The latter issue is not entirely up to the Secretary, however, because the DMCB found additional language that bars the Secretary from expanding the pilot to as ‘large a geographic scale as practical’ unless:

‘the Chief Actuary of the Centers for Medicare& Medicaid Services certifies that the expansion of the components of the pilot program … would result in estimated spending under this title that would be no more than the level of spending that the Secretary estimates would otherwise be spent under this title in the absence of such expansion.’

Last but not least, this particular bill, if the DMCB is reading things right, does NOT repeal the 2006 Medical Home Demo.

The DMCB didn't find much difference between this and what was originally included in HR 3200, including the relative latitude given to the Secretary and the requirement from the Chief Actuary that the medical homes be cost neutral.

The DMCB also finds it interesting that there appears to be language that supports additional funding for disease management services being folded into the PCMH. There may be some collaborative opportunities between the disease management organizations and the PCMH here.

Stay tuned!