Monday, August 11, 2008

America's Uninsured. A Reality-Based Six Point Counter Proposal

In a prior post, the Disease Management Care Blog reviewed an Annals of Internal Medicine report by Wilper and colleagues on the 25% prevalence of chronic illness among America’s uninsured. An accompanying editorial (subscription necessary, but don't bother - you'll see why soon) by Marshall Chin of the University of Chicago's Land of Make Believe dismisses the idea that extending health insurance to this group as necessary but insufficient.

Drawing on the science of quality improvement, reports from the Robert Wood Johnson Foundation and experience from the Health Disparities Collaboratives from community health centers, Dr. Chin recommends instead that every practice, every hospital and every health plan also 1) analyze quality performance data by race, language and socioeconomic and insurance status, 2) implement training programs in responding to diverse populations, 3) routinely measure reductions of inequities of care, 4) adopt clinic-based models of care that have been shown to improve care for vulnerable patients, 5) smartly align incentives that reward providers and organizations for providing care to vulnerable populations 6) allocate the resources by paying providers, especially those have a disproportionate share of uninsured persons, including ‘efforts to create and certify patient centered medical homes….’

The DMCB thinks the editorial itself is well intentioned yet insufficient. Here’s why:

While the devil is in the details underlying the content and delivery of any quality improvement activity, its impact on (for example) provider behavior, diabetes control or quality of care for the elderly is far from a sure thing. The DMCB also had little trouble finding references here and here suggesting the impact from 'collaboratives' outside of community health centers is less of a slam dunk that its advocates would have you believe. The other recommendations above are worn out nostrums of dubious evidence based on an antiquated focus on physician-centric care.

Disappointed yet undaunted by the inability of my academic colleagues to cross over from their parallel universe of contented salaried physicians, grants and tenure tracks, the DMCB would like to offer its own, if admittedly politically na├»ve, 6 point approach to meeting the goal of the Annals editorialist: improving care and outcomes of uninsured persons with chronic disease….'now’:

1) Develop a stripped down insurance benefit that covers that which is patently medically necessary. One could start by covering services recommended by the U.S. Preventive Health Services Task Force along with a representative standard benefit, probably with mental health parity. Assuming local or regional insurers take this on, the Feds or some other entity may need to help with reinsurance.

2) Pull out all the stops of utilization management including pre-authorization, concurrent review and denials of payment for services that require approval, specifically targeting the usual suspects: those notorious outpatient procedures, high dollar radiology and the biologicals.

3) Accept the high likelihood that extending insurance coverage to a group with a 25% prevalence of chronic illness is likely to result in costly health care utilization that will be borne by the taxpayer or add to deficit spending no matter what you do. While this is a stretch, Governor Rendell of Pennsylvania teaches us that taxpayers will accede if a) you’re up front with them and b) they believe they are getting their money’s worth.

4) Deploy disease management programs, especially ones with the years of experience in Medicaid, to temper the inevitable demand for health care services by coaching patients to use the most cost-effective care options, including self-care. And face the ugly truth: the patient centered medical home is just getting off the ground and doesn’t have the mass or scalability to carry this out. Helloooo, it's also being 'piloted' everywhere because it's unproven.

5) Start out by paying the primary care physicians, and we're not talking penurious RVUs either. Since primary care is in short supply in many areas of the United States, programs that offer alternate levels of care including non-physician practices and retail clinics will be necessary. Without it, emergency room use for persons with their new-found insurance will not only increase, it will go through the roof.

6) This is an area ripe for trying even more novel approaches to care such as upside gain sharing, combined disease management-patient centered medical home strategies, community-based lay educators, consumer incentives and private-public partnerships.

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