Tuesday, March 3, 2009

Presentation at the Medical Home Summit: Medical Home Has Shortcomings & Disease Management Can Help

The Disease Management Care Blog was a speaker today at the National Medical Home Summit in Philadelphia. Not only was it an honor to be speaking among the likes of Ed Wagner, Vince Kuraitis and Chad Boult, it had the pleasure of sharing the presentation spotlight with Doug Berkson of Health Dialog.

Our presentation examined ways in which disease management organizations (DMOs) and the Patient Centered Medical Home (PCMH) can collaborate. The DMCB had the easy part and spoke at a theoretical level for about 10 minutes. It then sat down and stayed quiet. Doug then did an absolutely outstanding job of describing his company's approach to integrating its program offerings with the provider-based PCMH. (Afterwards, the DMCB approached the rest of the Health Dialog folks [DMO sales people tend to cluster] and suggested that the company get someone to write about their interesting methods and submit it to a peer review journal. They didn't disagree).

One part of today's DMCB presentation dealt with the widely recognized and oft-published shortcomings of the PCMH, and how disease management can help:

Lack of an operational definition. Close examination of the peer-reviewed literature on medical homes reveals that when you've seen one PCMH, you've seen one PCMH. Disease management organizations (DMOs) can help fill in what's missing, from remote registries to extra nurses.

Not a cure for the 'tyranny of the urgent.' There's no shortage of patients in crisis at 4:45 in the afternoon. DMOs can free up patient slots by handling patients that don't need a face-to-face appointment to meet a more simple healthcare need.

Implementing a PCMH is a struggle for small practices. Indeed, it's a complete redesign that is likely to distract busy physicians for weeks if not months. The American Academy of Family Physicians recommends that DMOs could help train office staff in registry maintenance and care coordination functions. The DMCB agrees that would be a big help.

PCMH is not a cure for the physician shortage. It is unlikely that a fully implemented PCMH will enable an increase in the size the average physician's panel from the typical count of 2000-2500 patients. DMOs can offload physician work loads by taking on simple tasks, such as follow-up and patient education. With a fully implemented DMO on board, can physicians increase their panel to 3000? The DMCB says maybe.

Is the PCMH for all patients or just those with chronic illness? Either way, DMOs are one resource among many that can be triggered by a primary care physician as part of a plan of care for persons with conditions like diabetes and heart failure.

The PCMH has many local management challenges. While the larger clinics can dedicate FTEs to change management, not so for the smaller 1-5 person physician-owned primary care sites. The DMCB predicts that the smarter DMOs - in addition to TransforMed - will devote personnel to helping clinics. Why not? This will help build local relationships that further their ability to manage the insurance risk of populations.

What is the role of non-PCP specialists? The DMCB suspects that of all the stakeholders in this controversy, DMOs will be the most agnostic to the merits of an endocrinologist-run PCMH. They can go either way.

Should patients be locked-in to their primary care site? Under the Medical Home Demo, patient-participants will need to explicitly agree to rely on the PCMH to coordinate their care. It remains to be seen how well patients will respect this requirement. In the meantime, however, DMOs are more than capaple of calling 'on behalf' of the primary care physician (by name) to promote the idea that their primary care provider really is in charge.

The PCMH is becoming all things to all people. Given the excitment over the medical home, you'd think it was going to fix global warming and rescue Madam President from the safe room in the latest episode of 24. By bringing DM into the picture, the chances for success or failure would be spread over a greater number of supportive stakeholders.

Where's nurse-based telephony in the PCMH? Devoting a nurse to full or even part-time telephonic coaching for all patients that need it in a clinic is an expensive proposition. DMOs can do it far cheaper AND follow the doc's directions.

PCMHs have suspect network scalability. The DMCB thinks that if this takes off, many primary care providers will develop partially implemented medical homes. In the meantime, managed care organizations have a duty to provide a uniform level of care across their networks. DMOs may be able to fill in the gaps.

If you build it, will primary care physicians come? Maybe not. The DMCB also thinks many primary care providers will chose to NOT develop medical homes at all. DMOs may be able to fill in the gaps.

If you build it, will medical students come? Maybe not. There are surveys of medical students that suggest that their preference for dermatology has less to do with the money. They don't like to care for patients with chronic illness. Deans of the U.S. medical schools have been notoriously resistant to engineering their admissions process. The DMCB thinks we're in for a long dry spell of PCPs. DMOs are needed once again to fill the gaps.

Do remote population-based resources count? Suppose the primary care site uses a DMO-maintained electronic registry? Suppose there are nurses under the employ of a DMO on-site, doing care management? The DMCB thinks both meets the letter and intent of the NCQA recognition process for PCMHs. It's also a heckuva lot cheaper than letting PCMHs hire everyone.

What does the science say about the impact of the PCMH on variation? While there is evidence that the medical home promotes greater adherence to guideline based care, the DMCB wonders if that will be enough to have a noticeable impact on regions of the U.S. with high levels of unwarranted utilization for preference-senstive care. The DMCB thinks more - much more - will be needed. Among the many resources that can also be deployed: DMOs.

And finally, that Holy Grail: saving money. There is no evidence that the PCMH consistently reduces claims expense, especially outside of integrated delivery systems or Medicaid. The DMCB suggests that when it comes to saving money, the more that is done to coach patients into being better utilizers of health care services the better. DMO plus PMCH is better than either alone.

It may have been the DMCB's imagination, but many in the audience were nodding in agreement.

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