Health Policy Insights from the Medical Home Summit: Wellness, ACOs

The Opening Ceremony of
The Medical Home Summit

The Population Health Blog is back home after attending the intellectually rewarding Population Health Colloquium and Medical Home Summit.  It was great to reconnect with old colleagues and make new friends.

In no particular order, here are some PHB take-aways:

One representative from household-name health insurer spoke in a lofty plenary session on the merits of keeping patients healthy. While the PHB was inspired by the videos of device-wearing joggers, it all seemed eerily reminiscent of the wacky pharmaceutical company value-propositions from years ago. That's when these companies said that they weren't selling "pills" but "cures."  It remains to be seen if Humana's transition from pooling risk to promoting fitness will lead to a similarly unprofitable ending.

More than one smart policymaker expressed skepticism on-stage about the ability of Accountable Care Organizations to reduce costs or increase quality. Wow. The PHB suspects more ACO shoes are getting ready to drop inside the beltway. If that's correct, it seems the expert-class is not only reducing their exposure to the coming stinkbombs, but is retooling to get in on The Next Big Idea gravy train.

One compelling speaker suggested that truly "patient-centric" primary care medical homes should offer timely access, the ability to talk to the doctor by phone at any time and attentiveness to the social dimensions of their patients' needs while richly rewarding docs to provide high-value care to fewer patients.  When the PHB mused out loud that may be what precisely what Concierge/Direct Primary Care practices are doing, the reaction of the audience prompted momentary concern that it might get lynched. 

The looming repeal of the SGR was mentioned only in passing, suggesting that few believe that this latest legislative fix portends a renewed commitment to health care reform.  As the PHB understands it, the current proposal commits Medicare to a .5% increase in physician fees per year over the next five years. This reminds the PHB of a compromise it made when the Spouse countered that a loaded SUV was a better option than a loaded sedan.  We got the loaded SUV.

And the EHR wasn't mentioned at all, which kept the PHB from offering its novel twist on Ms. Clinton's Emailgate tempest. It's clear that the Secretary reasonably concluded that her State Department's email system was unable to meet her personal workflow electronic communication and documentation needs. Our nation's EHR-using physicians feel her pain and salute her for her approach to finding a workable solution. After the American Medical Association gives her a suitable award, they should ask her if they can expect that same commitment to innovative health information technology solutions when she wins the White House.

Image from Wikipedia
         

A Generic Keyword "Pitch" to Better Sell the Medical Home

Applause!

While the just concluded 2014 Medical Home Summit was a wonderful learning and networking confab, it did have it's moments of jargon-laced salesmanship.

Think mixing two parts suspect data with one part dubious claims and a helping of preordained conclusions, bake with PowerPoint and serve to a fawning audience with a garnish of sweeping generalizations. And the dessert?  Applause.

Naturally, some of the Population Health Blog's evidence-based colleagues fussed over the occasional spills of snake oil. The PHB isn't at all concerned, because it was taught years ago by the old disease management industry that even the most pristine research in the most elite journals gets spun.

And let's face it: we collectively crossed that Rubicon when the Mr. Obama sold us a health insurance reform program that promised we could keep our doctors.

Since we all gotta make a living, the PHB is pleased to offer a free service to its more honest, non-for-profit and spin-challenged colleagues. It has combined its trove of disease management nostrums with a list of medical home keywords (underlined) that appeared in many of the Summit's presentations and huckstered over cheese and wine during the Exhibit Hall receptions:

Our (insert name of your medical home program) is a transformative and population-based initiative that shifts health care delivery from volume to value that proves that that JAMA article (link here) was wrong. Our transparency is only matched by our EHR registry and teaming of physicians, nurse practitioners, social workers, office staff, clerks, temps and janitorial service workers and we (pick one: have been, will be or should be) the subject of a (pick one: grant or report) by (pick one or more: PCPCC, the Commonwealth Fund, AHRQ, Medical Home News) that further shows why JAMA was woefully mistaken.

By proactively focusing on impactful care coordination and reducing care gaps, engagement of both patients and primary care providers drives triple-aim outcomes that include (insert percent numbers here without p values), which further demonstrates the JAMA article is a despicable outlier.

Our savings, enhanced clinical outcomes, decreases in readmissions, improved patient care experience and betterment of the community show that (name of medical home program) is foundational to the success of accountable care, which is why JAMA sucks.

As a result, we conclude that (pick one or more: politicians, employers) (pick one: wisely have or definitely should) require commercial and government insurers to pay (pick one or more: millions, specialists less, or through the nose) to save primary care despite what JAMA says.

Noise to Signal Ratio in the Assessment of the Medical Home

From time to time, the Population Health Blog's consulting business generates supplemental income.  When that happens, it gets dropped into the PHB's cash flow and life goes on.

Months later, is the PHB household better off?  On one hand, every little bit helps.  On the other, total income is the result of many jobs and total well-being is only partially a function of the PHB's bank account.  In other words, it's difficult to gauge the one time contribution of a consulting gig to the "outcome" of total income.

It's a classic "noise" (total income) to "signal" (the gig) conundrum.

That's how the PHB addressed the problem of this disappointing JAMA article in its conversations with colleagues at today's Medical Home Summit meeting.  As readers will recall, this JAMA research showed no statistically significant impact on claims expense for all patients who were attributed to a medical home clinic compared to a parallel population of patients attributed to non-medical home clinics.
 
To the PHB, "total claims expense" is akin to total income, while the impact on a smaller subpopulation segment of patients with chronic conditions who were at special risk is the "gig."  Because of the overwhelming "noise" of insurance claims involving tens of thousands of patients, it's practically impossible to discern the benefit of the medical home for the smaller number of vulnerable patients.

The lesson?  While all patients assigned to a medical home clinic won't benefit, some could.  Until we understand that, we won't really know the return on investment of this approach to care. 

A Reprise of the Infamous CBO Report on Disease Management and the De-linking of Health Insurance and Wellness

Two things "heard on the street" at today's Medical Home Summit:

1) The recent JAMA article on the failure of the medical home to reduce health costs is provoking the same defensiveness as the infamous 2004 CBO report on "disease management."  PCMH advocates are using the same arguments that were used by the old DM vendors to defend their business model back in 2004.

Two of the more common ones heard by the Population Health Blog are that 1) today's model is far improved over the Ver. 1.0 reported in the JAMA article and 2) the improved health status of populations is not correlated with reduced insurance claims expense.
 
2) The bad news is that employers have given up on health insurance and many are prepared to push their workforce into the health insurance exchanges.  The good news is that they are continuing to invest in wellness and health promotion programs for their employees - not because they believe it saves money, but because it increases productivity.

In other words, commercial health insurance and wellness are being de-linked.