Sunday, May 2, 2010

Patient Centered Medical Home "vs." Disease Management for Hypertension: More Similarities than Differences

Long ago, the Disease Management Care Blog was a co-investigator in a multi-center high blood pressure (hypertension) research program. Everyone was treated with a precisely defined script and, compared to it's regular patients, the blood pressure of all the DMCB's research participants dropped. The DMCB concluded that that was thanks to two features of the research trial: 1) free drugs, and 2) a nurse devoted to making sure people took their free drugs.

That nurse helped convince the physician-DMCB that disease management could work.

"Could work," with the emphasis on could, is also the context of this report by the expert health insurance actuaries over at Milliman, who examine the same potential of the patient centered medical home (PCMH) in the management of hypertension. In this handy and thoroughly researched review (63 references), authors Kathryn Fitch, Kosuke Iwasaki and Bruce Pyenson discuss how the PCMH could improve the treatment of hypertension thanks to its a) ongoing patient monitoring and treatment plans, b) use of telephonic and email outreach, c) concurrent co-morbidity management, d) efficient medication adjustments, e) liberal use of non-physicians for low-risk patients, f) increased patient-provider communication, g) coordination of specialist access and g) an ability to measure population-based outcomes.

All well and good, says the DMCB, but the reason why policymakers and other stakeholders may want to download the report is because it contains some key caveats:

1. While the Milliman report doesn't come right out and say so, there's a lack of studies that have consistently concluded that the PCMH results in better blood pressure control and/or reduction in complications or cost over usual care. The PCMH and hypertension is more a matter of potential and possibilities than promise and proof.

2. That being said, if health insurers believe its impact on hypertension is one reason to support the PCMH, the "hard" additional costs of new physician fees, service codes, higher payment rates or incentives will need to be reconciled against 'soft' cost offsets, such as the expectation that this will result in reduced hospitalizations.

3. Outcomes reporting for the PCMH and its impact on the combined financial and clinical outcomes for hypertension will be needed, 'much like those used by the disease management industry' that avoid regression to the mean, minimize selection bias, use HEDIS®, study 'ambulatory care sensitive conditions' and assess medication possession ratios (MPR).

4. Smaller physician groups may find it a struggle to create medical homes. What's more, there's a mismatch between the rising number of patients with chronic illnesses such as hypertension, so insurers will need to think about the role of a) physician extenders and b) specialist physicians in the PCMH.

The Milliman also report pooh-poohs classic disease management for hypertension because of the spate of negative reviews and, more importantly, the stubborn persistence of uncontrolled high blood pressure in the U.S. today. The DMCB isn't too sure about either argument because:

1. There aren't any good studies examining the impact of disease management for hypertension. The lack of proof isn't the same as proof that disease management doesn't work. What's more, the same could be said of the PCMH when it comes to hypertension.

2. While suboptimally treated hypertension remains a persistent problem in the U.S., check out this NCQA report and go to pages 47 and 48. The DMCB did and found out that in commercial and Medicaid managed care, there has been a gratifying increase in hypertension control. The DMCB suspects these payors rely heavily on disease management programs to achieve many of the same outcomes described in the Milliman report.

Ultimately, however, it makes little difference if it's old fashioned DM or newly annointed PCMH. Both approaches' similarities outweigh their differences: non-physicians - like nurses - helping patients to choose to do the right thing.

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