The Patient Centered Medical Home PCMH Gets On Base with Increased Quality in the Real World

Getting to first base

Advocates for the Patient Centered Medical Home will probably like what they see in the lead research article in the June 3 Annals of Internal Medicine.

The Population Health Blog likes it too.  But first, let's look at the study itself.

The Taconic Independent Practice Association participated in a multi-commercial insurer medical home program.  For each patient enrolled in an NCQA Level 3 primary care home, the IPA was offered $2 to $10 per patient per month. 

Since not all of the 675 IPA practices created medical homes in the 2008-2010 time frame, researchers were able to compare the quality of care for the approximately 27,000 patients attributed to the medical homes versus the approximately 64,000 patients attributed to usual care settings.  While they were at it, they also evaluated the quality impact of having an electronic health record (all medical home practices had one, but not all users of electronic health records were medical homes) vs. having a paper record. Quality was determined by examining a subset of NCQA-based measures of recommended routine screening tests and care of persons with diabetes, asthma and (for children) pharyngitis.

While the impact of being in a medical home was not a home run, it definitely got on base.

Over the three years of the study, the medical home practices' measures diverged from the other two groups by an average of a 7% vs. paper and 6% vs. EHR.  While none of the practices hit 100%, and not all of the differences were statistically significant, if an EHR-based clinic was able to hit (for example) a "72%" quality measure, the medical home was"79%" (mammogram screening). 

As one more gauge of its impact, as time went on, the spread of the data grew over time as medical homes outpaced the usual care practices.

The authors correctly point out that the study was observational and that there could be hidden factors other than the presence or absence of a medical home that could be biasing the data.  While the authors did everything they could to statistically "neutralize" the impact of unequally distributed patient or practice factors, the study process is not perfect.

This was also in a commercial insurance setting.  We don't know if Medicare patients would gain the same benefit.

The PHB will also point out that the NCQA's one-size-fits-all measures are intermediate in nature and are imperfectly tied to long term outcomes.  They also fail to account for patient preferences.

On the other hand, the PHB likes this because it was a huge "real world" study involving hundreds of clinical practices taking care of tens of thousands of patients over three years. It helps the PHB put things in perspective by showing that the team-based care management of the medical home can have a discernible impact on quality.

Unfortunately, there is nothing on the cost of care. The PCMH is still struggling to prove that it "saves" money; the PHB says health care consumers will get what they pay for and - aside from a selected high-risk subpopulation - the medical home offers high value at a reasonable additional cost.  The commercial insurers got their money's worth from the Taconic IPA.

While the authors don't specifically call it out, there doesn't appear to have been a large impact by the EHR on the quality of care in the real world.  Compared to practices with paper records, the impact of the EHR seemed to be scant.

Smart MedPAC Wonks Think Out Loud About the Medical Home

If you spend a lot of time building, administering, expanding, marketing, promoting or networking "medical homes," it might be a good idea for you to read this MedPAC meeting transcript.

As Population Health Blog readers know, the Medicare Payment Advisory Commission advises Congress on how to best run Medicare, which includes the thorny issue of how to pay physicians who care for Medicare beneficiaries. During their March 6 meeting, the Commissioners discussed how to replace the primary care bonus program that is set to expire at the end of 2015.

By the way: The 10% bonus in 2012 amounted to $664 million for approximately 200,000 providers caring for 21 million beneficiaries.  That means, thanks to Uncle Sam, average participating docs got another $3400 in yearly income.  For PHB readers who are familiar with the per-member-per-month metric, that amounts to $2.60 PMPM.  As of 2014, there is still no hard information on whether the bonus resulted in any improvement in access, quality or outcomes.  In fact, despite the bonus, there is preliminary data that 28% of Medicare beneficiaries have had trouble finding a primary care provider.

As the PHB understands it, the bonus program was funded with additional fee-for-service money for primary care services.  Since that's going away at the end of next year, the Commission considered whether to continue it as is, or to reengineer it as a medical home payment system.

The transcript on whether to pay for medical homes reflects a wandering discussion with no final consensus. That being said, there were some interesting takeaways from a group of policy wonks who've spent a lot of time thinking about this approach to care:

Budget Neutral Bad News: While you may argue that the medical home "saves money" in excess of the fees used to pay for it, no one at MedPAC believes the additional funding will continue.  That means the $664 million after 2015 will likely have to come from budget-neutral reductions in payments for other medical services.  In zero-sum terms, that means someone (specialists?) has to lose in order for the medical home to win.

Definition: While there was admiration for the National Committee on Quality Assurance recognition program for medical homes, Commission members wondered whether that recognition translates into value. Would a "leaner" model be more cost effective?  And, if Medicare favored a non-NCQA leaner medical home structure, how would it be implemented?  It providers had to apply for it, should they subject to an audit?

Attribution: Figuring out which doc among several should be paid for medical home services isn't easy.  There was little appetite for having beneficiaries sign an attestation, while a claims analysis would have to be done using a "look-back" based on Medicare billing patterns.  That would result in a one year payment delay.

Whither Primary Care: There was doubt that an additional income stream of $2.60 PMPM would be enough to incent medical students to shun higher paying specialty careers.

Generalizability: There was some doubt on whether the medical home works outside of integrated delivery settings. 

More Bad News On The Way?: One Commissioner also works as an editor at a top tier medical journal, and he hinted that more negative manuscripts on the medical home are being submitted for publication.

What Wasn't Said: The Population Health Blog was surprised that MedPAC did not address:

1) the concept that the medical home should be directed at a subpopulation of patients most likely to benefit (raised in this "one size does not fit all" editorial), or

2) that getting the Medicare bureaucracy to introduce a new complex payment mechanism may be far more easier said than done (and that's according to White House insider Dr. Emanuel)

More on the Failure of a Huge Medical Home Initiative to Reduce Health Care Costs

Getting the medical home back on the road

In this JAMA editorial, Thomas Schwenk agrees with the Disease Management/ Population Health Blog that the recent negative report on the medical home may have been the result of the lack of any risk stratification.

Recall that this negative report, Association Between Participation in a Multipayer Medical Home intervention and changes in Quality, Utilization and Costs of Care, compared three years' worth of clinical and economic outcomes for 32 community-based medical home clinics vs. those from 29 similar non-medical home clinics.  Claims expense, ER visit frequency, hospitalization rates and 10 out of 11 HEDIS measures were no different between the two groups.

He points out that this study....

.... has done a great service for the advocates of the Patient Centered Medical Home by effectively ending promotion of this care model as a generic, low-level, unselective approach to health care delivery for all.  The next critical phase of PCMH development should focus on its strategic deployment for the care of high-utilization patients...."

The DMCB couldn't have said it better.  The medical home should be "aimed" at patients who are most likely to benefit.

Upon further reflection, it would add two other comments:

1. Another under-recognized feature of successful population health systems is the central administration (and employment) of the non-physician care managers who are peripherally distributed throughout the primary care network.  Here's one example as well as another that suggests the central model has a better track record.

In other words, this study showed multiple independently functioning "stand-alone" medical homes is equal to the sum of its parts.

2. The study also, by the way, calls into question the return on investment of achieving NCQA Medical Home recognition.  While it's possible that it's ultimately necessary, it would appear that just having it doesn't mean a health system will save money or improve quality.

Image from Wikipedia

Electronic Health Record Portals: So What Is the Evidence That Supports Their Use?

Talk about a compelling story that went ignored.

In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch. 

In particular, any impact on diabetes care was short-lived or nonexistent, patients with heart failure had no meaningful improvement, blood pressure control did not improve and adherence to prevention recommendations were marginal.  One observational study found persons with heart failure were more likely to use the emergency room.  The only study that found any benefit involved a single randomized control trial that examined the impact of portals in the co-management of depression.

After looking at this review, depressed advocates of EHR portals may have to personally use their own portals to communicate with their docs health care medical neighborhood.

The only good news is that there were some data that suggested that a substantial number of consumers liked using the portals.  But the DMCB likes channel surfing too, but that doesn't mean that the spouse agrees that its television-watching quality has improved or that the cost of all those premium channels is moderating.

The authors pointed out that it was difficult to isolate the impact of a portal vs. a portal plus care management.  To the DMCB, that means that portals are at best a means-to-an-end of enabling care managers to better communicate with their enrollees. 

To the thousands of DMCB readers, that is not a surprise.

In the meantime, the Feds and the NCQA have one more reason to re-examine their many cherished assumptions about health information technology and the stand-alone electronic record. The last time the DMCB looked, the federal government continues to extoll portal's stand-alone virtues. The National Committee on Quality Assurance (NCQA) still includes two way communication for appointments, referrals and prescription referrals as a standard for the medical home.  Finally, the Fed's promotion of the electronic health record (EHR) approves of portals as an option in meeting meaningful use criteria.

Image from Wikipedia

Where's the Gas When You Need It?

The Disease Management Care Blog confesses that it wasn’t easy learning the differences between an EMR (electronic medical record), an EHR (electronic health record) and a PHR (personal health record). While medicine is certainly riddled with its own complexities and acronyms, health information technology (HIT) seems to have taken it to a whole new level.

There may be one less acronym, however, to worry about. If (and that is a big if) this post from the Health Care Renewal Blog has any basis, there may allegedly be little reason to distinguish HIMSS (a membership organization) from CCHIT (involved in certification of electronic records). Is the DMCB’s buddy Scott Silverman an HIT voice crying in the wilderness? Time will tell but the DMCB will be harkening.

The disease management community, in contrast, seems to have had its act together from the very beginning. The DMCB was there in the early days when several disease management companies earnestly set out to define what set them apart. That’s when they came up with this. Realizing that a distinct brand was emerging, they sought a process that would accredit reputable full-service disease management companies – similar to the track record of hospitals and managed care organizations. They correctly reasoned that the more distant they were from owning the accreditation process, the more credible it would become. Not to mention that their lawyers pointed out that anything less could result in the improper appearance of collusion. It was good business sense and it was also the right thing to do.

It paid off. The highly regarded National Committee for Quality Assurance (NCQA) and URAC have both developed independent programs that are distinctly free of any allegations or even the appearance of conflicts of interest.

++++++++++++++++++++++++++++++++++

And a now for a non-sequitur: It’s bad enough having to see a dentist, but having him remind you of the striking difference between medicine and dentistry makes the drilling seem comparatively blissful. Grinning through his mask and goggle-glasses, he asked his physician-patient today what he thought of the newly inked ‘stimulus bill.’ By this time the DCMB was immobilized thanks to having to simultaneously guess where half of its face was while French-kissing a latex dome with a mouthful of gruesome metal objects. Not caring to translate my gurgling, he went on, ‘Looks like the government wants to tell you guys how to practice.’ After a pause, he added, ‘And they’re going to get away with it.’

Where’s the gas when you need it?

Observations on the Leveling Off and Narrowing Confidence Intervals in the NCQA State of Health Care Quality Report

The NCQA has released its annual ‘State of Healthcare Quality’ report that examines the quality performance of the nation’s participating health insurers. While the NCQA says the big news is that the NCQA is relevant, variation persists, the NCQA is relevant, that many measures are incrementally if slowly getting better, the NCQA is relevant and that Federal programs need to get aboard comparative quality bus, the Disease Management Care Blog was much more interested in the actual numbers and their trends.

Speaking to the currently limits of medicine and biology, less than two thirds of persons with high blood pressure achieve control of their condition, just more than half of persons who have had a heart attack attain low cholesterol levels and about 80% of kids get adequately immunized.

But more importantly, the pace of improvement in many measures – while still showing gratifying increases – is leveling off. For example, check out these trends snipped from the NCQA report on A1c testing among persons with diabetes:

and blood pressure control among persons with hypertension:

Also note that the confidence intervals are narrowing, meaning the spread between competing health insurers is narrowing. This may be a function of increasing numbers of participating insurers or less variation. Either way, the DMCB predicts that with time those point scores are going to cluster even more tightly.

The good news is that if these trends continue, variation will diminish. The bad news is that the insurers will become indistinguishable from each other and have to locally compete on tenths of a percent of improvement. Will this force them to look for ‘breakthrough’ strategies for improvement or will they settle with the conclusion that usual care is reaching the limits of improvement that can be attained in usual settings relying on usual ways of payment?

Comment on the Proposed NCQA Measures for Disease Management Programs

Readers of the Disease Management Care Blog (and anyone else for that matter) have been invited to click on over to NCQA and comment on its proposed measurement specifications for disease management programs. Do that and you will be able to revel in a host of diagnosis & procedure codes, numerators, denominators, continuous enrollment windows and pharmacy claims.

The DMCB understands the adage that a) quality cannot advance without measurement and that b) the NCQA methodology has resulted in untold jumps in quality and lives saved. Kudos to the NCQA for taking this assessment hammer to a new set of nails.

Yet, the DMCB has three concerns about the proposal:

Well executed disease management raises all boats: While DM programs can always do a better job of documenting and reporting their clinical outcomes, the DMCB believes effective population-based coaching programs that successfully engage patients in self care will spin off increases (for example) in A1c testing in diabetes, appropriate prescriptions for asthma and flu shots when chronic heart failure is present. The opposite is not true: prompting patients to get process-based lab testing, prescriptions or flu shots will not necessarily promote optimum self care. After these specifications are finalized and approved, the DMCB hopes disease management organizations will resist the temptation to issue (for example) a directive to its nurses to stop educating and start directing, to coach less and document more.

The definition of the 'medical record is changing: In true NCQA fashion, many ‘numerator’ criteria rely on traditional medical record documentation or insurance claims to fulfill criteria and obtain credit. Yet, the DMCB believes registry data collected by disease management organizations in the course of their outreach are also a resource. Patient self reports, documented by a DM nurse outside of claims or physician encounters, are a measureable and auditable source of measurement that are going untapped by much of the proposed NCQA methodology. While patient self reports are prone to error, so are insurance plans with pharmacy deductables. What’s more, what happens if the personal health record really takes off? Why not aggressively include patient self-reports in the numerators?

Patients may reasonably elect to not comply with NCQA criteria: Consider this scenario: a fully coached and empowered patient with chronic illness reviews the recommended menu of preventive services, understands the benefit of each, gauges at his or her needs, the doc’s recommendations, the out of pocket expenses and reasonably decides to forego recommendation “A” and adhere to recommendation “B.” This DMCB thinks that is not unreasonable not only because it happens in primary care clinics everyday, but because all medical interventions are not created equally. Why not include empowered patient refusals in the numerators?

The DMCB will be providing a link to this post over at the NCQA site. Readers can too, but the DMCB recommends you check the methodology out for yourself and comment. You have until Sept 3.

Physician-Focused HEDIS Is Not Enough

The curmudgeonly Disease Management Care Blog recently provided input on some proposed preventive care measures for HEDIS. While it thinks the proposed methodologies are sound, are helpful and should go forward, it remains unconvinced that physician-based promotion and prevention is really really up to the task. Brief counseling makes a difference, but doctors fall short of consistently providing necessary wellness and prevention counseling in areas such as adolescent tobacco use, alcohol abuse, HIV prevention, osteoporosis treatment, cardiovascular disease in diabetes and obesity. What are the docs trying to tell us?

Surveys have demonstrated that individual physicians prefer to independently review the science that undergirds many wellness and prevention guidelines for themselves and, many times, agree to disagree. They may a) not have enough information, b) conclude the recommendations are in error, c) doubt that they have the necessary skills to carry them out or d) believe carrying them out the will make no difference. For some HEDIS measures, that's not unreasonable. Being human, if they don’t practice what they preach, they’ll also not preach.

The fix is not necessarily ‘payment’ as in performance (P4P). Other surveys have shown physicians can be ambivalent about the role of economic incentives and that many don’t buy into the notion that they should benefit if the patients’ outcomes are improved. Physicians may also doubt that commonly used measures of performance capture what is truly important. This dissonance may be particularly acute when they care for elderly vulnerable patients with multiple co-morbidities. No wonder there’s data showing P4P may have a limited impact.

And then there is the problem of trying to figure out just which physician is responsible for what. As pointed out in this article, patients (in Medicare fee for service, and by extension, in commercial PPO insurance products that don’t require a referral) may be seeing multiple physicians, each with a hand in the management of an aspect of prevention or chronic illness. Many people also rarely see physicians. If HEDIS, which is based on insurance claims and chart audits, can’t identify a responsible physician, is it reasonable to make physicians accountable?

There is also the emerging perspective that patients need to be equal participants in medical decision making. A distinct percentage of health care consumers may therefore decide, based on their goals, values and resources, to not follow through on the prevention recommendations of their physicians. Why should their physicians be held responsible if patients make a decision that is counter to HEDIS recommendations? Shouldn’t physicians be given credit for a) informing their patients of the recommendations (via chart documentation or by use of a special code) and then b) honoring their wishes?

What is the fix for skeptical physician-scientists that are human, resistant to blunt economic incentives, are interacting with a complex web of other physicians and letting patients decide for themselves? The DMCB doubts there is a magic mix of resources, incentives and sticks based on HEDIS measures alone that can be aimed at docs and appreciably change their prevention and wellness care patterns. Rather, it's time to invite other stakeholders to the party.

The DMCB recommendation: it's time to determine and accept the upper range of what is typically possible in physician-based prevention and wellness activities in usual clinical settings. Once that is understood, the sometimes successful use of HEDIS can be integrated with the promotion and measure of wellness and prevention in other sectors of the economy such as school districts, employers, communities, disease management programs, wellness providers and personal health record vendors. In the meantime, promoting physician reliance on the Patient Centered Medical Home's approach to 'outsourcing' prevention and wellness to other local team members may help increase clinic-based HEDIS measures.

Based on what we know about traditional physician approaches to wellness and prevention, is this necessary? Yes. Difficult? Yes. Naive? Yup. Outside the typical mandate of HEDIS? Absolutely. Do consumers deserve new approaches that build on the successful track record of HEDIS? Yes.

When should policy makers start working on this? ASAP.