Wednesday, November 11, 2009

Three Years Of Medical Home Demonstration Preparation Down the Drain?

By Vince Kuraitis & Jaan Sidorov

You'd think if anyone were disappointed at the shelving of the Medicare Medical Home Demonstration (MMHD) in favor of the Multi-Payer Advanced Primary Care Initiative (MAPCI), it would be the primary care physicians.

However, we pick up on no signs of discontent.

After 3 long years of anticipation, secrecy and considerable work by multiple stakeholders on the MMHD, including all of the major primary care physician organizations, you’d think doctors should be having an Animal House Bluto Blutarski-like reaction to this sudden shift in Medicare policy.

In fact, based on some informal conversations with many of the organized physician groups’ leaders, we are finding that most doctors are actually pleased with the recent developments.

What's going on here? What does this tell us about what we’ve we learned about the patient centered medical home (PCMH) and Medicare's new direction?

Challenges of the PCMH’s Business Model Come to Light. Most of all, we believe that over time, the challenges of basing the PCMH business model on reduced costs became increasingly well understood. Based on preliminary information coming out of the PCPCC pilots and early peer review publications along with greater scrutiny of many of the past studies that were being taken for granted, we suspect that there was a growing realization that a MMHD would turn out like the star-crossed disease management Medicare Health Support Demo. This alone would have jeopardized the long-term prospects of implementing PCMH in Medicare.

Many PCMH Details Yet to Be Worked Out. While the PCMH "concept" has been widely accepted and embraced since 2006, many operational "devil’s in the details" have yet to be developed. Incorporating these into a full-fledged multi-State Demo was probably turning out to be far more complicated than originally anticipated.

Small/Medium Physician Groups Could Struggle With Infrastructure Required by MMHD. It’s unrealistic to expect a high percentage of small independent physician-owned groups which, by the way, deliver 75% of patient visits in U.S. today, to implement the PCMH. The MMHD required individual physician groups to develop an extensive disease/care management infrastructure and anticipated physicians would hire and supervise nurse care managers to manage their sickest patients. Because this part of the market is so highly fragmented, we think it was becoming increasingly apparently that it was not scalable across large geographies.

Questionable Physician Interest. We also think that while there were many physicians that were very interested in developing a PCMH, many were also disinterested.

Medicare Demonstrations As “Change Agents.” We also wonder if there was growing realization that a prospective randomized control trial was an unwieldy challenge for CMS. Data management for multiple primary care sites spread over eight States would be daunting for any research group, including one with CMS’ resources.

Need/Opportunity for Physicians to Sync With ACOs. Last but not least, the Obama Administration seems more interested in making the Accountable Care Organization (ACO) the lead dog in health care reform. ACOs can incorporate and support many of the care management activities of the PCMHs and, with some tweaking, we believe these models of care are highly synergistic. In fact, evolving ACOs seem extremely provider friendly and offer primary care physicians the opportunity to have an important voice in regional delivery system development.

All things considered, we suggest that CMS and the primary care physicians are considering that it makes more sense to conceptualize all care management activities as a "public utility" – resources that can be shared across multiple physician groups. Perhaps there is growing realization that the PCMH is still in evolution and that much work remains. Accordingly, showing a more flexible approach in ‘piloting’ medical homes, working with other payors and allowing ACOs to support the PCMH is a more viable approach.

The major stumbling block that we can see at this time is whether the small, independent physician practices will readily ally themselves with ACOs and accept a partnership with them over the creation of PCMH’s. That depends on the details of health reform legislation, the local culture in the ACOs and the impact of physician leadership. While the details of MAPCI have yet to be worked out, we believe these questions are best answered in numerous pilots, where Medicare and the physicians can strive to find out what works and what doesn’t work.

So, from the physicians’ standpoint, what’s there not to like?

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