Wednesday, March 6, 2013

In Defense of the Patient Centered Medical Home and Consumer Directed Health Plans (CDHPs)

Writing in the Health Affairs Blog, health policy savant Michael Millenson has been infected with an unusual case of naysayerosis. Since the Disease Management Care Blog has likewise suffered from the syndrome's twin symptoms of clever rhetoric and consumer faddism, it takes one to know one.

Basically, Millenson argues consumer directed health plans (CDHP) and patient centered medical homes (PCMH) are the beer in the chardonnay world of true patient-empowerment. He favors the fruity consumerism of open access EHRs and the oaked ability of hospitalized patients to trigger "911" from hospital beds 24-7.

And what's not to like about CDHPs and PCMHs?

When insurers give consumers the CDHP money that was theirs all along, they (gasp) reduce health care utilization and become "better shoppers!" And in contrast to any health reform ever implemented by the central planners in Washington DC, the impact of CDHPs on medical expenditures was "modest" - as in real. Despite that comparative success, that's enough, according to Millenson, to toss the concept on the ash heap of other bad ideas, like those 401(k)s that were invented by the nefarious insurance executives.

PCMHs?  Patients "do not seem happy," could overwhelm practices with "streams of data" and become ensnared in an unfriendly "payment model."  Millenson rejects the notion that, like disease management, the best days of the PCMH lay ahead.  Never mind that there are some anti-Utopian business realities like customer service, workflows and contracts that are necessary to turn good policy into workable reality. Rather than dealing with all those operational details, Millenson seems to say that it's better to throw it all out.

And what would he substitute them with?

Open Notes, where patients can annotate their physicians' EHR entries. In this "quasi-experimental" (definition here) study - reminiscent of the earliest pre-post disease management research studies that were riddled with selection bias - patient and provider surveys showed participants in Open Notes liked their on-line medical record keeping. There is no mention of any objectively measured clinical or economic outcomes.

And how about patients being able to trigger 911 from hospital beds? While the DMCB finds the notion compelling and AHRQ finds the data "suggestive," it fears that for every real ("true positive") call for help, the number of false alarms ("false positives") will overload the hospital on-call system. It's a great topic for research, but it's not quite ready for real time, despite the imprimatur of Health Affairs bloggery.

The DMCB finds Open Notes and 911 tantalizing concepts but it thinks it needs additional information to make an informed judgment.  That's not the case for CDHP or the PCMH.  Ultimately, it suspects a more virtuous world of patient-empowered and provider-driven health care will include a version of Open Notes, inpatient 911 and the PCMH and CDHPs.

That yessayerosis.

Image from Wikipedia

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