Thursday, October 29, 2009

More Implications on the Suspended Animation of the Medicare Medical Home Demonstration

While most media and bloggery continue to glom incessantly over the iterations and implications of the ‘public option,’ the Disease Management Care Blog finds the suspended animation of the Medicare Medical Home Demo far more interesting.

As the astute Vince Kuraitis pointed out in this post, CMS' intentions are quite cryptic, the legal authority is opaque, plodding government demos can be outrun by the market and there’s a difference between demos (‘should we do this?’) and pilots (‘how can we do this?’). In prior posts (here and here), the DMCB also pointed out that a multi-payor collaboration offers up an important opportunity in experiential learning and could represent an important tipping point for the Medical Home.

What are other implications?

Medicare As A Continuous Learning Organization: Rigorously run demonstrations that compare one care approach versus usual care are ill-suited to finding out works in an environment of constant change and overlapping mutually supportive interventions in multiple geographies. This is CMS’ chance to realize an insight known to the population-based care community for years: when it comes to multi-dimensional care management, looking is not that same as seeing, listening is more important than hearing and knowledge pales in comparison to insight. The DMCB would like to be among the first to welcome CMS in from the oxygen-deprived academosphere.

First Among Equals: Not only are pilots broader in scope, the Vermont announcement suggests that future Medicare-owned medical home pilots will accommodate other insurers. These are typically fashioned as multi-payer ‘collaboratives’ (for example, here and here) that pool resources, share data, seek consensus and continuously adapt. How well Medicare can execute on this will depend on staffers who can be flexible and understand the difference between effectiveness and efficacy.

Government Silos: The DMCB has spoken to more than one Medicaid Medical Director who cajoled their States’ commercial insurers into participating in multi-payer medical home collaboratives. When it comes to government programs working with other payers, Medicaid’s clearly had a head start. Can Medicare and Medicaid just get along? We’ll see.

Boost to Accountable Care Organizations: Compared to Medical Homes, ACOs are far less defined, but the DMCB suspects they’ll be part of the coming health reform legislation. ACO’s will likely adopt Medical Homes along with all the other policy golden boys like electronic records, value-based purchasing arrangements and bundled payments. Look for CMS to use medical home collaboratives to ‘motivate’ multiple payers to support the embryonic ACOs until they’re able to prove their worth.

Start Building The Business Plans Now: Assuming a) multi-stakeholder pilots are flexible, b) can build on Medicaid’s as well as the commercial insurers’ positive experiences with disease management, c) care management resources can be shared among multiple primary care sites and d) many primary care sites will not want to reengineer what few nurses they have left, the future is very bright for organizations that know how to deploy trained, motivated and savvy nurses across a network. Here’s an example. More are undoubtedly on the way.


Addendum: e-CareManagement has another post on the topic that is well worth the read. Check it out.

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