Tuesday, December 8, 2009

A Marriage Made in Heaven? Accountable Care Organizations, Patient Centered Medical Homes and the New England Journal. The DMCB Says Not So

There they go again. It's one thing for the Editors to allow authors to use the 'Perspectives' section of the New England Journal of Medicine as a soapbox, it's another thing to let it happen absent any recognition of the inconvenient reality that awaits outside of the academic dreamscape.

This latest gaffe is also happens to be the lead article in the December 10 2009 issue (not online at the time of this posting). Written by Diane Rittenhouse of UCSF, Stephen Shortell of Berkley and Elliott Fisher of Dartmouth, it simultaneously extolls the virtuous synergies of the Patient Centered Medical Home (PCMH) and the Accountable Care Organization (ACO) as the linchpins of health reform. The basis of this essay was a Commonwealth Fund supported confab involving 'other leaders' that led to a 'consensus.' These leaders number a grand total of nine and hail from such representative organizations such as Tufts, Hopkins, the American College of Physicians, the American Academy of Family Physicians, UCSF, the Commonwealth Fund, the Urban Institute and U Mass. You get the picture.

So what did this beau monde bull session yield up? In the opinion of the Disease Management Care Blog, some very good points. It's what was lacking that has the DMCB vexed, but more on that later.

These Brahmins point out that the PCMH is advantaged by its strong primary care foundation that 'builds on substantial evidence' that it leads to increased quality and lower cost. However, two issues block its adoption: 1) there are no incentives for non-primary care (i.e. specialist) providers to work collaboratively with the PCMH and 2) financial arrangements that allow the primary care physicians to share in savings from reduced utilization are lacking.

In the opinion of these learned ones, both shortcomings can be fixed by ACOs. Recall these provider-led regional hospital-physician organizations are responsible for the cost and quality in the full continuum of care for their defined populations. The business model is predicated on sharing in the cost savings achieved relative to a risk-adjusted projected spending target (or capitation), tempered by quality performance measures. To succeed in this, it's clear that ACOs will need a strong primary care base. They'll be organized to make their specialists play nice and will have to channel their savings toward their formerly victimized PCP's PCMH's.

So, ACOs need the PCMH and the PCMH needs ACOs. Here's how to make it happen:

1) Organizations like the NCQA need to not only have a recognition program for medical homes but for ACOs and a key criterion needs to be the strength of their primary care base.

2) A common set of quality performance measures for both ACOs and PCMHs need to be developed

3) Payment reform needs to be implemented so that ACOs and PCMHs can thrive

4) CMS' and AHRQ's ability to implement, support and measure 'these promising delivery system reforms' needs to be expanded.

So just what is the DMCB's beef?

First off, both the PCMH and ACO remain ultimately unproven in their ability to create savings. While the former is butressed by some promising literature, the PCMH is not without its problems (see Medicare's travails here, some bad news about Group Health's non-savings here, the controversy about North Carolina's Community Care here and then there's this piece). The ACO remains a tantalizing concept that has yet to be implemented anywhere. While late in the article the authors advocate for Medicare and other demonstration projects on the PCMH and ACO, the DMCB thinks the NEJM editors allowed Rittenhouse et al to finesse the issue and portray the PCMH-ACO as an economic slam dunk.

Not so. Add a number 5 to the list of make-it-happens above: Conduct rigorous research that determines if the PCMH-ACO results in reduced claims expense that can meaningfully contribute to 'bending the curve.'

Secondly, there was no mention of how little is known about independently practicing primary care physician attitudes about the considerable work-effort and risks associated with converting to a medical home, or about their probable skepticism about the merits of affiliating closely with hospitals. This NEJM piece assumes that if you build it, they will come.

Not so. Add a number 6 to the list of make-it-happens above: Survey primary care physicians (especially ones that don't regularly read, let alone believe everything written in, the NEJM) to assess what it will take to generate participation in PCMH-ACOs.

Note that this article brought up the "C" word, i.e., capitation. This comes perilously close to assuming insurance risk and going back to the future of health maintenance organizations (HMOs). Have we really forgotten the bad behavior that can occur from putting profits (from 'savings') before patients? While 'quality' is an ingredient designed to put the brakes on 'lowering costs,' do we really believe ACO budgets will yield to measures of A1c, tobacco cessation metrics or the number of persons reporting they exercise regularly?

Not so. Add a number 7 to the list of make-it-happens above: In the PCMH-ACO pilots, the development of payment systems that assure quality measures will temper the pursuit of savings will need to be high priority.

Last but not least, the DMCB has repeatedly pointed out that it's not necessarily the PCMH that is the secret sauce, care management is the secret sauce. At its core, that means non-physician professionals (yes NURSES) that bring their special skills to bear in engaging patients to meaningfully participate in self-care. That ingredient is in the PCMH (which is probably why much of the literature is promising), but it's also present in old fashioned disease management.

Yes, that's so. Add a number 8 to the list of make-it happens above: In the PCMH-ACO pilots, pursue models of care that offer a spectrum of alternative forms of care management.

Coda: The DMCB is tempted to add another make-it-happen: regularly read this blog. Relying on just the NEJM isn't good enough anymore.

Here's the reference:

Rittenhouse DR, Shortell SM, Fisher ES: Primary care and accountable care - two essential elements of delivery-system reform. New Engl J Med 2009;361:2301-2303

(There's lots more on Accountable Care Organizations here)


Jeremy Engdahl-Johnson said...

Many seem to agree on the need to find a better approach than fee-for-service reimbursement. If accountable care organizations can adopt the risk-management know-how of health plans and integrate patient care using technology and best clinical practice, they may be part of the solution. See http://www.healthcaretownhall.com/?p=1732

Jaan Sidorov said...

The link leads to a pretty good summary. Thanks

Robert said...

What's in a name?

I would suggest that ACOs have, in fact, been tried and have a less than stellar track record. What I'm referring to of course is the experiements in totally capitated physician care and integrated delivery systems during the first half of the 1990's. Almost without exception, these efforts resulted in bankruptcies leaving insurance companies holding the bag.

Renaming may be an effective marketing strategy for a failed product, but in the end it is unlikely to make the product a winner. Why would we want to go down this road again?

Jaan Sidorov said...

Robert makes a good point. There is literature that indicates that when physician groups are capitated, they resort to managing utilization (and defending their budget) with the same ol' tricks: preauthorizations, concurrent reviews and denials.