Thursday, February 11, 2010

A Report on the Electronic Record and a Report on the Patient Centered Medical Home: Good Reading

The bookish Disease Management Care Blog found two recent and interesting pieces from the medical literature for your consideration. One deals with the electronic record and the second deals with medical homes. Both are written with the physician incentives in mind and deserve to be considered by policy-makers and anyone with 'line' responsiblity for dealing with either of these two initiatives in a provider network.

The first is from David Kibbe MD, a senior advisor to the American Academy of Family Physicians. Writing in an online 'ahead of print' version of Family Practice Management, Dr. Kibbe offers up some words of caution over the latest plan (proposed rule making) by the Feds to promote the 'meaningful use' of the electronic health record (EHR). This should give pause to policy makers that think the EHR is a wonderful idea that only needs a nudge to make it become reality in every corner of every physician practice.

Basically, he says, the Feds' latest actions have raised even more uncertainty. As a result, physicians without an EHR may elect to sit tight and use paper for at least one more year or longer. According to Dr. K, here's why:

1. emerging 'meaningful use' requirements by the Feds will force EHR vendors to reconfigure their wares, which is leading to future price uncertainty. (Ditto for the docs that were brave enough to invest in EHRs, by the way).

2. health reform has been slowed, leading to additional uncertainty about future physician fee schedules, revenue and their ability to afford investment in an EHR in the first place.

3. 'modular' EHR-like components are around the corner, which will allow docs to assemble 'clinical groupware' into a functioning EHR, which raises additional uncertainties.

4. the Physician Reporting Quality Reporting Initiative (PQRI), another CMS program that promised to reimburse physicians outside of the normal fee schedule 'P4P style,' has not gone all that smoothly. Docs may doubt that the government can really deliver the goods, er, make that checks.

5. money aside, it's just a big hassle to deal with Uncle Sam

6. the meaningful use process will eventually require the on-line submission of quality outcomes data. Right now, it's not clear how CMS will handle what promises to be a huge data load, introducing even more doubt about the promise to pay physicians in a timely manner.

7. the Feds are threatening penalities down the road for physicians that don't comply with meaningful use EHRs. Many physicians may respond by planning on using paper until that date and then simply retire from practice altogether (when the economy eventually turns around and the 401k's get back)

The second article is available (subscription required beyond the abstract) at the Annals of Internal Medicine. Recall that advocates of the Patient Centered Medical Home (PCMH) suggest that physicians who offer it should be reimbursed with a monthly and risk-adjusted fee per PCMH enrollee in addition to the usual fee-for-service payments. If that sounds like 1990's style capitation, you're right. Written by Ann Mirabito and Leonard Perry of Baylor, the article presents three HMO mistakes that need to be avoided by capitated PCMHs:

1. resist the temptation to go along with any mandated patient enrollment in medical homes. If PCMH's work so well, they should have no problem attracting patients by acting as a 'trusted' guide to navigating referrals in a patient-centered and evidence-based manner.

2. early HMOs were regarded as patient friendly, but things quickly turned sour when there were too many patients and things turned impersonal. Physician practices without the capacity to truly be medical homes will need to resist the allure of signing up too many patients and grabbing all that capitation revenue.

3. simple risk-adjusted payment systems will simply reward physicians for signing patients up. Better to include meaningful dollar incentives that reward measurable quality.

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