Tuesday, July 14, 2009

The Medical Home and the U.S. House of Reprentatives' "America's Affordable Health Choices Act of 2009"

A 1018 page behemoth of a health reform bill was released today in the U.S. House of Representatives. While it will take days for editorialists, columnists and bloggists to digest this, let alone try to reconcile it with what's going on in the U.S. Senate, you can get a good sense of the early liberal perspective by reading Ezra Klein's reaction here. The Disease Management Care Blog didn't find a conservative reaction yet, but it suspects it will mostly be something like this.

The DMCB donned its miners' helmet, broke out its hydraulic word search excavator and looked for 'disease management' (precious little), but hit a huge vein of Patient Centered Medical Home (PCMH) ore. It thinks, except for one detail, PCMH advocates should be well pleased.

A quick time out for one caveat. While the DMCB can get through the six point font "materials and methods' sections of dullest health research manuscripts, it's on thin ice when it's reading legislative stuff like '426 U.S.C. 1395b–1 note, as amended by section 133(a)(2) 7.' Accordingly, it will be very happy to accept any clarifications and corrections from readers.

Here's what the DMCB found:

In the 'Public Health Insurance Option' (a.k.a. the public plan), the benefit design 'may' include a version of the PCMH. The bills says the Secretary of Health and Human Services 'may utilize innovative payment mechanisms' for the medical home (and other 'care management 'payments' and accountable care organizations'). The DMCB thinks that will be welcomed by its primary care physician colleagues and may be enough to elicit their support for a public plan.

There's also language that supports payment to certain hospitals (the Disproportional Share Payment Hospitals) to cover the work of 'assigning' medical homes to vulnerable patients. 'Funding.... shall be used by targeted hospitals (that receive disproportional share payments) for transitional care activities designed to address the patient patient noncompliance issues that result in higher than normal readmission rates such as... assigning discharged individuals to a medical home.' This makes sense, since readmissions are frequently the result of fractured disjointed care immediately after discharge.

But it's Medicare that is the most significant. It has a five year $1.6 billion 'Medical Home Pilot Program' (MHPP).

Establishing and certifying the specific medical home criteria to be used in MHPP will be up to the Secretary, but the guiding legislative language pretty much reflects its now classic definition and will be aimed at the usual 'high need' beneficiaires. What's really different is that two types of Medical Homes are envisioned: 'Independent' (the usual physician or nurse-practitioner directed) and 'Community.' The latter consist of nonprofit community-based or State-based organizations that are under the 'supervision of' or 'collaborates with' a primary care physician and employs community health workers. Both are to be paid with monthly fees that are adjusted on the basis of a) the patient's risk and b) the scale of services and resources offered by the medical home. The pilot is supposed to specifically target small physician owned practices, is to start within six months (Independent) or two years (Community) of passage of the bill and last for five years. $6 million for each of the 5 years is dedicated to the design, implementation and evaluation of the pilot. $200 million/year for the Independent and $125 million/year for the Community are allocated to pay for patient care services. There is also a process for States to apply to create their own pilots within Medicaid that are also based on the above framework. Last but not least, the Medicare Medical Home Demo would specifically be repealed.

If the Medicare pilot results in improvements in quality, reductions in disparities, fewer hospitalizations, readmissions, emergency room visits, improvements in satisfaction, higher outcomes, fewer duplicative services 'and reductions in health care expenditures,' the program can be expanded 'on a permanent basis.'

Here's that one detail. Unless CMS' Chief Actuary certifies that expansion of the pilot 'would result in estimated spending .... that would be no more than the level of spending that.... would otherwise be spent in the absence of such [an] expansion,' the permanent program is no-go. In other words, it sounds like MHPP has to break even.

If this section of the bill survives, the DMCB thinks that the CMS certification of budget neutrality will be a significant hurdle. As noted in prior posts too numerous to mention as well as the published literature, there is a surprising lack of good evidence that the medical home consistently lowers health care costs, especially outside of community centers or in Medicaid programs. While robust primary care is certainly associated with lower health care costs, a) we don't know if the association is truly causal or just observational, b) if the medical home is truly better than the robust primary care that is associated with lower health care costs, and c) if expanding primary care services in areas with high baseline utilization will lower health care costs. Last but not least, the DMCB is skeptical that Medicare - even with $6 million a year - is optimally configured to conduct the kind of complicated study is needed to address the research question.

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