Tuesday, March 22, 2011

Crossing Over From Medical Home Land: Lessons For The Patient Centered Medical Home (PCMH)

Think Chinese culture is inscrutable? That the laws in Saudi Arabia are alien? That Lutheran Norwegians at a dinner table are weird? That, once you leave the familiar safety of home, life unpredictably becomes more opaque, dizzying and unfamiliar?

Such appears to be the reaction of some of the Disease Management Care Blog's colleagues once they venture outside the borders of "Medical Home Land." Case in point is this essay by Bob Doherty and this heartfelt "I second that emotion" by Dr. Bob at the aptly named Medical Rants Blog.

Inside Medical Home Land, transformed primary care always increases health care quality, reduces cost, increases patient access, attracts medical students, increases patient satisfaction and increases wellness. Inside that protective bubble, the medical home has admiration of PhDs, unquestioning acceptance by fawning medical journal editors and keynote status from pricey conference promoters. It is a nice place to be.

Unfortunately, Medical Home Land is missing one absolutely necessary natural resource. No, it's not statistical significance for measures of claims expense reduction (for example, p=.08 at Group Health, p=.21 at Geisinger and not even mentioned at HealthPartners). Rather, what's missing is money. To get their hands on that, Medical Home Land denizens have to step outside its borders and deal with insurance market skepticism, physician "transformation" inertia and patient-voter apathy.

As the DMCB has previously described, the likelihood that anyone is going to just hand over fistfuls of money to something that is a good idea is nil. Saying the Medical Home is the right thing to do is not enough. But be of good cheer, says the DMCB. While stepping outside of self-reinforcing closed information loops can be traumatic, dealing with reality has its benefits. The Medical Home is still a work in progress. Learning to joust with hard nosed actuaries, insurance execs and CFOs will ultimately help it be a leaner and more effective approach to patient care.

To help the Medical Homeites successfully adapt to being strangers in a strange land, the DMCB offers up some lessons learned by others that have also had to deal with the trauma of crossing over:

1. Once the disease management industry was confronted by data that it wasn't really saving money, it changed. It used its experience in wellness to contract with self insured employers to develop worksite-based prevention programs. It also honed its protocols to target the patients most likely to benefit. The point is that that industry figured out what the naysayers wanted and jettisoned the rest.

2. The electronic health record vendors worked for decades in the shadows of the health system before they finally achieved enough of a critical mass to catch the attention of a U.S. President. Yes, the EHR vendors continue to spout unrealistic bromides, but they were very patient. So should supporters of the medical home.

3. The DMCB learned the hard way that simply publishing positive results seldom achieves stakeholder buy-in or generates change from front-line providers. Recall how slowly physicians adopt any evidence-based medicine? Quoting it may be necessary but that alone will get medical home advocates about as far as quoting a Berwick paper to a Republican US Senator.

4. The pharmaceutical industry figured out how to trump branding for its me-too products. It's not that pill, its being able to ride motorcycles with your chums, blow rose petals at your daughter's wedding and lounge in twin bathtubs with the spouse. The ex-medical director DMCB has had to deal with countless enrollees demanding coverage of me-too lipid lowering agents at $80 a month. It's time for Medical Home Land to figured out how to harness that energy and the cash that goes with it. Which would patients rather have: a "patient centered medical home" or a "concierge?" Figure that out and commercial insurers and Medicare will follow.

5. Think being invited to the White House means anything? Not only does that environment also suffer from its own brand of health care unreality, you'll be asked to take a seat between the Thoracic Surgeons and the the National Association of School Nurses. Good luck with that.

The DMCB says be of good cheer, medical home supporters. Listen to the naysayers and adapt, hang in there for the long haul, figure out how to create patient demand and put publications and the support of fickle politicians into perspective. Good ideas always win out in the end.

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