Monday, March 28, 2011

Nurses: The Secret Sauce for Disease Management, the Patient Centered Medical Home (PCMH) and for Accountable Care Organizations (ACOs)

The Disease Management Care Blog has made no secret of its opinion that the secret sauce underlying the success of the many iterations of disease management and the patient centered medical home is nurses.  While various pundits and commentators may assert that it's some latest electronic record tweek or a novel form of provider payment, the DMCB knows better. Once you pull it all apart, there's usually a trusted nurse in there using that EHR or finally getting paid to keep patients out of the emergency room with a special nurse sauce of advice, education, expedited appointments and an unwillingness to take "no" for an answer.  Find a news report or a scientific publication claiming that "DM" or the "PCMH" increased quality or reduced costs and you'll find mention of nurses in there somewhere.  They're the mortar holding those bricks together.  

A recent case in point is this article appearing in today's Wall Street Journal that describes the multi-specialty group Atrius Health Care.  In addition to apparently having solved every known problem there is in U.S. health care, these guys purport to being the Known Universe's First Successful Accountable Care Organization (ACO).  Read through the article, though, and you'll see it - as predicted:

"Atrius Health also uses case managers, who help patients with chronic conditions coordinate care using multiple doctors and medicines"

Which brings the DMCB to three points.

1.  As far as the DMCB knows, there aren't any prospective, randomized and blinded trials that compare nurse-centered disease management or medical home with usual physician-encounter care.  As a result, it's difficult to figure out causation: are high functioning clinics, that are already destined to do well anyway, more likely to hire nurses, or are the nurses responsible for making these clinics high functioning?  The DMCB suspects its more of the latter but it's possible both are happening at the same time.

2.  Which begs the question:  is it possible that an unmeasured "nurse impact factor" is not only responsible for the early achievements of the medical home but that these professionals will turn out to be one of the key success factors  for Accountable Care Organizations?  If that is a strong possibility, should CMS carefully examine whether there is sufficient nurse-support when it finally starts reviewing ACO applications?

3.  While it's mentioned in passing in the WSJ article, the DMCB has learned from personal experience that these nurses are fundamentally unable to "flex" their commitment to patients based on the insurance benefit.  As a result, patients with insurance that doesn't "cover" diseasse managment (for example,Medicare fee-for-service) who are being cared for in clinics with a large commitment to nurse-led disease management typically end up seeing these nurses anyway.  So, while Medicare doesn't pay for disease management, the irony is that its beneficiaries in Atrius and in other health systems are still receiving disease management services in what is another example of cross subsidization of government health care by the commercial sector.  For clinics without broad multi-payer support for their nurse medical home/disease managers, the hidden cross-subsidization of other payers is the price of doing business and could hamper adoption of the patient centered medical home.

1 comment:

Bradley Dean Stephan said...

Great point(s), which you've consistently emphasized. The icing on the cake, of course, is that we nurses come cheap! This leads to, what should be, a fundamental guiding principle of health system redesign: "Any intervention that can safely and effectively be performed by a non-physician, should not be performed by a physician." This principle, of course, only makes financial sense to physicians who are in a risk-sharing or salaried environment. This leads to a second, fundamental guiding principle of health system redesign: "All physicians should be compensated on a salaried or risk-sharing basis." (PS – I don't believe in P4P for physicians – either do it right or don't do it at all. The financial reward for physicians who do it 'righter' than their peers should be increased marketshare, not increased FFS payments – except for the increased compensation arbitraged through a well-managed risk-sharing arrangement, bringing us back to the importance of nurse coaches.)