Tuesday, November 24, 2009

Primary Care Models That Are Outside the Mainstream: Will Health Reform Be Flexible Enough (and disease management see the opportunity?)

Thanks to a combination of colleagues' e-mails*, media outreach and alerts, the Disease Management Care Blog has become reacquainted with some interesting primary care models that aren't in the mainstream of healthcare reform.

They may be worth thinking about.

First off, the Philadelphia Inquirer has this report on an insurer owned and operated primary care clinic. The DMCB recalls that during the 1990's, some HMOs branded and operated their own outpatient networks. With the fall of capitation, the concept fell into disfavor.

Or how about the concept of 'Direct Primary Care,' where, for as little as $49 per month, patients can access primary, preventive and chronic care. If the DMCB understands this right, the DPC folks want to cut the insurer-middleman out entirely and effectively let each patient pay their own capitation. Could this arrangment make limited forms of health insurance a good option and a lot cheaper? This Wall Street Journal editorialist would probably say yes.

There's also the notion of the community based medical home, where a cluster of primary care physicians refer to and rely on a separate network of care management nurses. This is very nicely described in a recent editorial by Helene Levens Lipton appearing in the November 23 Archives of Internal Medicine. A good example of this can be found in Vermont and their shared 'Community Health Teams.'

Once again, the DMCB worries that whatever passes for health reform may not be able to accomodate the primary care work-in-progress. All of the ideas described above have their merits and, for some patients in some markets, may be a perfectly satisfactory option.

Last but not least. the 'community based' feature of a medical home could represent an important opportunity for the care/disease management vendors.

*you know who you are: thanks!


drdeb said...

While it might seem like Vermont is doing great things in the primary care arena I would urge you to look at the data which shows that over the past 6 years or so our costs have risen faster than the national average.http://www.bishca.state.vt.us/HcaDiv/Data_Reports/expenditure_analysis/healthcare_expenditure_analysis_index.htm We have always had high quality medical care and a strong primary care infrastructure. What is needed in Vermont and the rest of the nation is a system of cost control, and rational and equitable financing.

Jaan Sidorov said...

Deb: Thanks so much for a missing piece of information. When I review the site, it looks like the data only goes to 2007, so reformists might ? be able to argue their actions haven't kicked in yet. There's another document that predicts a 7.1% trend through 2011, suggesting the actuaries aren't putting a whole lot of stock in coordinated care.

I couldn't agree with you more on the need for cost control and intelligent financing, which is very much in short supply in all the reforms I've seen.

Any ideas?

Adam Kaufman said...

First let me say that I just found the DMCB blog and am glad I have. Jaan - thank you for continuing to find interesting stories that challenge us to think about health system design.

Adressing your question about how will reform impact these less conventional models (and the more conventional primary care models) -

I believe the incentive models for care delivery need to be adjusted to promote greater care coordinatino and a focus on outcomes. Ideally as these incentives are structured it will allow for creativity and innovation at the provider level. This is really the heart of how the market drives improved operating and allocative efficiency. The challenge with healthcare is balancing the productive efficiency with the selction bias.

What seems to be the current push is towards (1) both more integrated care favoring integrated health systems like Geisinger and simultaneously a (2) push towards consumer accountability.

This probably boads well for the return of HMO operated clinics and those systems where clinicians provide primary care and care coordination.

Interesting conversation...

Jaan Sidorov said...

Adam: Thanks for the nice comments. I couldn't agree more with you: by using incentives aimed at outcomes, we can trust the provider community to come up with the necessary details. That stands in contrast to the details that may end up being mandated in The Coming Health Reform.

A big stumbling block to insurer owned clinics is the perceived conflict of interest: patient-consumers may suspect that the providers are going to skimp on health care.

Interesting conversation. Interesting times.

drdeb said...

Their primary care models only reach our to some 20,000 or so people in Vermont. How could they possibly argue that this is going to control costs? There is not one shred of evidence that medical homes, or disease management saves money. That does not mean we shouldn't do it. We should but for reasons of improving quality. Disease management that is integrated into primary care would be welcome in the primary care world. I should know, I am a primary care doc.
The problem is, the folks promoting the medical home model and disease management are offering it a stalling tactic to real reform They say things like, "let's change the way we deliver care and then we will worry bout the financing". I should offer that as solace perhaps to my patients with $10,000 deductibles. Let's face it, we need to join the rest of the industrialized world and enact a publicly financed system for everyone. One with comprehensive benefits for all. Then we can manage the duplication of services that are really driving the costs.