A Watershed Year: What 2013 Holds for the Patient Centered Medical Home (PCMH)

The savvy Jeff Levin-Scherz, who blogs over at Managing Healthcare Costs has responded to the Disease Management Care Blog's snarky "Prattling Pinheads of Pessimism" post on the topic of the Patient Centered Medical Home (PCMH). 

He's not a nattering nabob of negativity or a prattling pessimistic pinhead, says he.  He'd like to be thought of as a skeptic seeking substantiation.   The DMCB wholeheartedly approves of the agreeable alliterative appellation.

2013 may well turn out to be the watershed decision year for the PCMH:

If there's no published peer-reviewed proof that it reduces health care costs, nabobs, pinheads, skeptics and policymakers will need to decide if no evidence of an impact on costs is the same as evidence of no impact on costs.

If the answer is no, THEN we'll then have to decide if the traditional "X causes Y" mathematical approaches to derive proof (such as a comparison of averages using standard power calculations and/or impact on expected or observeed trend) are equal to the task in a very "statistically noisy" environment involving complicated human beings.

If that answer is no, THEN we'll have to decide if reasonable and informed assessments of potential cost reductions, used by countless other businesses every day in other sectors of the economy, are good enough,

If that answer is no, THEN we'll have to decide if there is face value to the PCMH. This involves a contrast of any patient benefit versus its incremental cost.  If the benefit is worth the cost.....

THEN we may have to decide if consumers are willing to pay for it, or if health care costs will need to be cut elsewhere to pay for it.

Stay tuned!

Additional Ingredients for ACO Success: Communication Training, Support Tools and Culture

Pity the hospital CEOs, EVPs and Chairs and their "Accountable Care Organizations" (ACOs). They've lined up the doctors, invested in an electronic record, hired some care management nurses and signed the risk contracts.

And then Matthew Press and colleagues come along with this AJMC article on Care Coordination in Accountable Care Organizations: Moving Beyond Structure and Incentives.

Their message? You may have what's necessary, but it's not sufficient. Organization and incentives are not enough.

What's also needed are:

1. Training: physicians need education on coordination, collaboration communication and teamwork.  The education should be an organizational priority and typically involve course work, observation and feedback with continuous evaluation.  This cannot be accomplished in a one day workshop.  An example of what it might take can be found here.

2. Support tools: since efficient information transfer must to be built into ACOs' workflows, informal "situation" or "personality" dependent communication between docs and nurses need to be transformed.  An example of the kind of framework that Kaiser instituted can be found here.  While you're at it, think about HIPAA-compliant texting, wiki-enabled EHR records and patient activity streams.

3. Culture: if front line staff are going to support the delivery of high quality and optimum cost care, the organization will need to protect time for care coordination activities, multi-disciplinary meetings, forums to share best practices and incentives that recognize collaborative behaviors.

Looks like the work has only just begun.

Holiday Preparations at the Disease Management Care Blog

How, you ask, does the Disease Management Care Blog spouse approach the days ahead?

The Latest Health Wonk Review Is Up!

How can you reconcile all this seasonal merriment with your need to achieve one or two more days of productive learning?

Easy, says the Disease Management Care Blog.  Head on over to the Workers' Comp Insider's "Holiday Edition" of the Health Wonk Review.  Health insurers aren't following the ACA script, pharma's bad behavior shows no sign of abating, expert mandarins continue to plot transformizations, Medicaid continues to vex and stymie and Santa's workshop is in serious need of insurance.

And that's only a sample.  Much more can be found here.

Enjoy!

Going Long on the Patient Centered Medical Home (PCMH) Despite the Prattling Pinheads of Pessimism

Is the Disease Management Care Blog worried about the prognosis of the Patient Centered Medical Home (PCMH)?

Not in the least.

It's simply marching from its "Peak of Inflated Expectations" through the "Trough of Disillusionment." Before you decide to short the PCMH, check out this very enlightening Bloomberg editorial, Lure More Doctors Into Primary Care With 'Medical Homes.'

Noting that many commercial insurers remain committed to the medical home model of care, Bloomberg's business-savvy editorial board also points out that the PCMH has the added quality of attracting physicians to careers in primary care. The Josia Macy Jr. Foundation has some preliminary data suggesting that experience in medical home settings increases medical students' enthusiasm for primary care.

It's a timely article.  While prattling pinheads of pessimism (examples here and here) glom onto imperfect research methodologies and findings that are unequal to the task at hand, top notch organizations like Sutter, University of Pittsburgh Medical Center and Horizon Blue Cross Blue Shield are going long on the PCMH.

These guys know something that the academics are missing.

Too bad there isn't a PCMH futures market; the DMCB could make some serious money.

Image from Wikipedia

The Relationship Between Discharging Patients From the Hospital Too Early and the Likelihood of a 30 Day Readmission: Treat, Street and Repeat.

I'm baaaaack!

When persons are admitted to a hospital, insurers' payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blog's physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  That's why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But that's all theoretical.  What's the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine. 

The authors used the U.S. Veterans Administration (VA) Hospital's "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  That's the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  That's the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears there's an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."

The Medical Home News Question: The DMCB Answers "Other."

The Disease Management Care Blog is happy to serve on the National Advisory Board of Medical Home News.  MHN has important insights and updates on the implementation of Patient Centered Medical Home (PCMH).  It also regularly poises a "Thought Leader's Corner"question and prints answers from the PCMH community.

The December '12 issue question was:

What is the single most important issue to overcome in terms of widespread implementation of the medical home model?
A growing shortage of PCPs?
Lack of payer commitment to reimburse care coordination?
Lack of incentives to adopt/implement EHRs?
Lack of sufficient team culture being taught?
Other?

The Disease Management Care Blog naturally answered "other...."

"While I used to think the most important issue was finding generalizable approach to care (template) and an accompanying business model that has consistently been shown to reduce health care costs in a clinically and statistically significant manner, I’m changing my mind. 

The most important issue is the emerging link between accountable care organizations and the medical home to the exclusion of all other approaches to care.  The medical home has had its victories, but much of the published high quality research is from highly integrated settings and even then, it’s unclear if the avoided claims expense is greater than all the indirect and direct costs. We still don’t know if the medical home can succeed in the other kinds of networks being established by ACOs. 

As a result, if ACOs stumble and prove to be an unsuccessful reprise of the 1990s style physician-hospital initiatives, the medical home could be taken down before we know if it can work in non-academic, non-Medicaid community settings. 

This promising baby could be thrown out with the bathwater."

If, despite the DMCB's participation, you're interested in subscribing to MHN, getting your boss to pay for it or giving a year's worth of issues as a fitting holiday present, more information can be found here.

The Horrific Newtown Shooting and the Inconvenient Facts About Gun Control, Mental Illness and How the Physician Community Should Respond

Like millions of other Americans, the Disease Management Care Blog was transfixed by Mr. Obama's comments at last night's Newtown vigil.  The President passionately spoke for and to the nation in a time of heartbreaking grief.  Well done, sir.

Then reality set in. 

Unfortunately, there are a number of inconvenient truths that are more than a match for President's considerable intelligence and persuasive rhetoric. 

To wit:

1) First some perspective: Schools are extraordinarily safe with a suicide/homicide rate of one death per 2.5 million (see page 6). All in all, a child is still far more likely to be injured on the way to school or in their home pool than on our nation's school grounds.

2) Been there, done that: according to this classic MMWR report, the evidence that restricting access firearms improves community-based outcomes is inconsistent.

3) Soft target: And then there is the disturbing possibility that armed killers, with little to fear from metal detectors or sign-in policies, purposely choose gun-free zones like schools. 

In the meantime, the DMB's physician colleagues are renewing calls for firearm ownership screening and education at the point of care.  To their credit there is good evidence that it helps....

But:

1) While there are two sides to every story, law abiding and constitutionally protected gun-owning parents may feel they are being unfairly bullied by a well-meaning physician.

2) When pediatricians are confronted by adults who are unwilling to consent to their child's immunization recommendations, the "difference in philosophy" may lead to a termination of the doctor-patient relationship. The same happened to this patient because of her weight. Are gun owners next?  And after them?

3) What happens if firearm-screening bubbles up into a 6th vital sign (the 5th one didn't work out so well) or physician pay-for-performance (with gaming could alienate the very patients it's designed to help?).

4) No corner of health care delivery is immune from the mischief of electronic health records (EHRs) and gun control is no exception.  Should gun owners be concerned that a) millions of unintended data breaches or b) government "background checks" of health information exchanges could increase their vulnerability?

And then there is the thorny issue of mental illness.

1. The majority of patients are still concerned about the release of any of their medical information.  Behavioral medicine providers are too.

2. We can not only use computer based algorithms to assess the quality of life for persons with mental illness, but predict a likelihood of community violence. Should either be made available to law enforcement?

3. Last but not least, us docs can issue and reissue impotent position statements all we like. but the mental health system is failing: we are all Adam Lanza's mother.

DMCB take-aways:

The DMCB has seen the President confidently direct his considerable rhetorical skills at topics like global warming and war in the Middle East.  While Mr. Obama is well-meaning, guns may similarly be beyond his political skills, especially because he's a 2nd termer with limited political capital. 

While Newtown has shocked the conscience of a nation, the DMCB is not holding its breath.

That doesn't mean America's docs can't be of assistance.  In addition to dusting off, recycling and renewing their current policies, physicians need to keep things in perspective and

a) lead the discussion on the use of predictive modeling to identify potentially violent patients. How do we reconcile the privacy rights of persons with mental illness with a constitutionally broad right to bear firearms?  If we remain silent on this, the lawyers will decide and it won't be pretty.

b) confront the possibility that the EHR is a threat to gunowners.  If not, explain why it wouldn't be cross-referenced with firearm licensing, pharmacy records or used to perform background checks?

c) advocate for fixing the mental health system so that parents who are struggling with a deeply disturbed child can get the help they need.

Image from Wikipedia

The Latest Cavalcade of Risk Is Up!

As part of its continuing efforts to stay up to date on business risks and insurance, the Disease Management Care Blog participates in the Cavalcade of Risk.  The latest edition is hosted over at the Reduce Your Workers Comp Blog.  Topics include social media, the evolution of the San Francisco health market into the haves and have nots and the business lessons from Israel's "Iron Dome."

Enjoy!

Of "Antifragile" and Accountable Care Organizations (ACOs)

Emboldened by yesterday's economics post on the U.S. "headwinds" that are marginalizing the "fiscal cliff" negotiations, the Disease Management Care Blog now turns it's attention to a magnificent new word:

"Antifragile."

That's the term invented by Nassim Taleb in his latest book. In it, he counterintuitively suggests that political, business and economic systems can benefit from recurring and unexpected mishaps. The sucess of antifragile systems is based on their fragile constituents that rise and fall on their own merits. One "antifragile" example is the local restaurant industry in many large cities. It may be beset by recurring single unit bankruptcies but it ultimately provides the marketplace with a dependable set of gustatory options every Saturday night. 

The converse are "fragile" systems that are ironically made up of highly stable individual units. An example is the highly regulated U.S. banking industry, which amply demonstrated its collective vulnerabilities in the 2008 crash.

The terms "antifragile" and "fragile" speak to the threat of unknown and potentially catastrophic "Black Swan" risks, such as torrential superstorms and toxic mortgage assets.  Many New York restaurants rebounded (by candlelight), while the banking industry almost took down the entire U.S. economy.

The erudite Dr. Taleb often turns to mythology, molecular biology, physics, history and more to make his points, but the DMCB is naturally thinking cinema.

In The Godfather, after the Corleone family goes to the mattresses, Clemenza explains periodic war between the New York families is a good thing because it gets rid of a lot of "bad blood" (the Mafia is antifragile).

In the silly Underworld vampire movies, chief bloodsucker Viktor condemns the successful liaison between his race and the werewolf "Lycans" as an "abomination" that upsets centuries of rigidly enforced stability (vamps are fragile).

In one of the Star Trek movies, engineer Montgomery Scott deftly disables a new star ship after pointing out "that the more they overthink the plumbing, the easier it is to stop up the drain" (warp drive-enabled space ships are fragile). 

And finally, Pandora's ecosystem in the movie Avatar may be teeming with all manner of scary survival of the fittest, but its antfragility is what ultimately prevails against the despicably avaricious humans.

Which makes the DMCB naturally worry about fragility of accountable care organizations, which are arguably comprised of highly stable hospitals and clinics in an intensely regulated environment.    While you may be tempted to tut-tut the DMCB's antifragile infatuations, recall AHERF's spectacular failure and the Medicare Health Support Demonstration disaster.  When they started out, both were the darlings of health policy makers and both were torpedoed by large and unexpected catastrophes that were only identified in retrospect.

What Black Swans could take some ACOs down?

Many savvy DMCB readers may disagree about ACOs, but you have to admit, "antifragile" will be a great word guaranteed to impress colleagues, co-workers and bosses.  For example

"Broadening our provider network to those three new counties may be risky, but it'll make our managed care organization more antifragile!"

"Buying a single source electronic record will reduce our health system's antifragile competitive advantage!"

"By limiting my access to modern electronic gadgetry, the DMCB spouse is risking a system-wide entertainment failure of epic antifragile proportions!"

And so it goes......



 

Will A Negotiated Agreement on the Fiscal Cliff Fix Things?

While the dysfunction of the "fiscal cliff" negotiation crawls along like a slow-motion Titanic movie dubbed in some obscure foreign language, vaguely interested readers may want to check out this PIMCO analysis. PIMCO is a leading global bond trading firm and when its sages talk, people listen.

Bill Gross, PIMCO's CIO, offers a remarkably readable Beatle-esque analysis of the macroeconomic "headwinds" that are bedeviling the U.S. economy. While Mr. Gross' observations have important implications for the DMCB readers living on Main Street, they are particularly scary for the insurers on Wall Street (as well as their cousins on Not-For-Profit street).  That's because insurers rely on investments to supplement income. Sputtering bond returns in the insurers' portfolios could ultimately translate into even higher premium costs for their beneficiaries.

According to Mr. Gross:

1. Developed countries like the U.S are reducing their considerable debt and, like it or not, austerity will be part of the solution. In the meantime, there are compelling data that show that when a country's debt exceeds 90% of gross domestic product, it slows economic growth. The U.S. is now at 100%, which means the likelihood of using tax revenues to fix the debt will be blunted by years of a lackluster economy. Even if President Obama gets his way with the House Republicans, fixing the debt problem will take many years.

2. The fall of the Iron Curtain and the entry of China to the global economy added billions of consumers to the world market.  That impact is now waning.

3. "Technological unemployment" means machines, robotics and software are cheaper than full-time-equivalents (FTEs) on an assembly line. It's possible that that will lead to a "new normal" unemployment equilibrium of 7%

4. It's the 20 to 55 year age group that grows families, buys houses and grows companies. The U.S. population is aging, which means there will be greater savings and less consumption leading to lower economic growth.

The good news is that hydrocarbon energy will be getting cheaper, housing may finally be turning the corner and who knows when the "Next Big Thing" (think handhelds) will hit.

Depressing stuff, eh? The DMCB isn't the only one that's dismayed at all the doom and gloom.  Rather than turn to the Beatles for inspiration, the DMCB wonders if the current situation is being best summed up by the still-rockin' Rolling Stones. 




(By the way, the DMCB declines to link the actual music video. It's a horrid, misogynistic and antifeminist display of modern vulgarity that unnecessarily detracts from 1) a nifty chord progression and 2) the miracle that Keith Richards is still alive. Look no further for another window into the war on women.)

Some Medicare Stars Program Updates and the Overlap with Population-Based Care and Disease Management

The Disease Management Care Blog is back from grandly named "Healthcare Education Associates' and the Risk Adjustment Initiative And Society for Education's (RISE)" CMS Star Ratings Master Class conference. The day-long Miami meeting was all about succeeding in the CMS quality-based bonus program called "Stars."

The DMCB listened closely to one speaker.  First are its notes, which are followed by three take-aways.

The notes:

CMS had tried posting Medicare Advantage (MA) Plans' quality measures online, but they were generally ignored by consumers.  That's when CMS decided to change course and use its Demonstration authority to launch the current Stars program. It incents the MA as well as other contracting plans with bonus payments based on a complex weighted formula that includes satisfaction, quality of life and clinical outcomes.  The latter measures are dominated by chronic conditions.

While the measures' minimum payment thresholds are constantly changing, In 2012, 11 MA plans achieved the coveted "5 Star" our of 5 rating, while 127 achieved a respectable rating of 4 or better our of 5. Success appears to be associated with:

1. HMO-type physician network structure,
2. Not for profit status,
3. An enrollment of more than 90,000,
4. An established marketplace presence,
5. A track record of pursuing quality,
6. A track record of physician integration and
7. Advanced informatics including a data dashboard (tracking outcomes), physician level tracking and providing care gap information at the point of care

While the calculation and translation of a particular Stars rating to a particular bonus amount surpasseth the DMCB's understanding, the big picture is impressive.  In 2012, health plans with government contracts spent over $1 billion on their quality programs, while CMS is projected to award $3.1 billion in bonus payments.  This works out to a payment of $281 per beneficiary, or approximately $23 per member per month (PMPM).

The DMCB take-ways:

1. You call it "Stars" but the DMCB calls it population health management: CMS is basically paying its contracted health plans $23 PMPM to develop or outsource programs targeting chronic illness, quality of life and satisfaction, much of which is old fashioned PHM. The DMCB confidently assumes a lot of that $23 PMPM is paying salary and benefits for non-physicians (such as nurses), who are engaging members and doctors using risk stratification and outreach that includes the old fashioned telephone.

2. How generous: Compared to many population health management vendor fees, $23 PMPM seems high. What's more, an industry-wide return on investment of approximately 3:1 ($3.1 billion in payments vs. a cost of $1 billion) is lavish, especially because the DMCB suspects most MA plans were already willing to spend a billion to reduce their claims expense by even more.

3. We've changed our minds: An emerging Medicare "whisper" "fiscal cliff" savings target is $250 billion, which may be partially attained by cutting back on the Stars bonus payments.  While it could be argued that the MA plans have been amply rewarded by the program, the Fed's fickleness remains a considerable business risk, especially for the smaller not-for-profit MA plans 

The Latest Health Wonk Review Is Up!

A Festival of Lights and Insights awaits you at the latest Health Wonk Review.

This edition is hosted by the unsinkable Hank Stern over at the InsureBlog. You can learn about latke, the IOM, dreidls, cuts to graduate medical education, chanukiahs, premium taxes, sufganyot, deductibles, fried chickpeas and whether "Oy Vey!" is a good toast if you're drinking Aquavit.

Enjoy!

Some Follow-Up

Remember the Atul Gawande and McAllen Texas fracas?  That New Yorker article captured the national spotlight and put a harsh glare on areas of the United States that had unexplained high rates of health care utilization.  Dr. Gawande blamed the local culture of fee-for-service private practice, while the Disease Management Care Blog wondered if it was a statistical fluke and/or the burdens of a chronically ill population. 

It turns out that there might be another factor at play.

The DMCB recently received this rather stunning (and lightly edited) email:

Here is a little story I thought I would share.  As you know, Atul Gawande wrote about McAllen TX over 3 years ago. You would think having the spotlight on them would make people scramble to clean up their act. On a recent flight, I sat next to a medical sales representative. His company has a number sales personnel covering the state of Texas, but none of them are assigned to the McAllen territory. That's because it is known that you have to “pay to play.”  In one example, a physician asked the company to send a check to his charity…so they did some research and found the address for the charity was located at a corn field.  Reportedly there are dozens of medical companies that service Texas but only 3 or 4 bother to sell in that market. Sounds like old habits die hard!  

12 Reasons Why Every Physician Should Have A Twitter Account

The Disease Management Care Blog really likes Twitter. Its scrolling 140-character tableau of news nuggets fit perfectly on the DMCB's hand held device, lap top and home personal computer.  It's easy to glance at between tasks and the advertising is blessedly minimal. The DMCB controls the content by following and unfollowing other Twitter accounts with a simple click or a touch.

But why, physician-skeptics may ask, is Twitter any better than traditional web browsing, email, list-servs and handheld apps?  Your DMCB thought about that and is pleased to offer its Top Twelve reasons why every doc should include Twitter in their informatics medical bag.

1. Lit Headlines: The major medical journals use Twitter to efficiently describe their latest content with links. For example.

2. Fame: Traditional print authors are publishing more and more about less and less. Getting peers to follow your original and insightful tweets is the new route to attaining status as an expert.  The DMCB has more than 500 daily followers vs. how many actually read the average peer-reviewed article?

3. News Junkies: Some of your like-minded peers are freely aggregating and retweeting relevant headlines with links for your perusing efficiency. They can be indefatigable.

4. Kool-Aid Immunity: Did you know your Chief, Chair, VP, lead administrator or Dean wants to control all your communication?  Twitter is an easy way to step out of the information bubble and monitor contrary news about that EHR, medical device, performance standards, your institution's business partners, the competition and more. For example.

5. Efficiency: Twitter trains you to be both brainy and brief. If you can't fit it into 140 characters or less, you're wasting your readers' time.

6. Messaging: The "@" allows you to interact with established and potential colleagues outside of your institution's email system. Thanks to this function, DMCB has met some wonderful colleagues.

7. Medical Conference Tweets: View formal and informal updates and insights about that conference you're attending from not only the meeting organizers but other attendees.

8. Community: Like-minded colleagues are not only clustering in listservs but in Twitter.

9. Room for Diversions: Efficiency makes it guilt-free to include non-medical content.

10. Speed: It's astonishing how quickly Twitter users spot and link just-released reports that take days to appear on the web and weeks to appear on print.

11. Searches: Yes, traditional literature searches and Google have their advantages, but the "#" function can find links to information resources that you might otherwise miss.

12. The Disease Management Care Blog is on Twitter.

Being Bullish on the Patient Centered Medical Home, Despite What the Annals of Internal Medicine Has To Say

The Disease Management Care Blog recently received a curious email from the Patient Centered Primary Care Collaborative.  As readers may recall, this is the Washington DC-based coalition that advocates on behalf of the Patient Centered Medical Home(PCMH). 

The content of that rather defensive communication can be found here.

What provoked this? The premier internal medicine specialty journal, the Annals of Internal Medicine, published a comprehensive review of the peer-reviewed literature on the PCMH, and its authors skeptically concluded:

The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes

Ouch. No "economic outcomes" means that there is no proof that the PCMH saves money.

Unlike the PCPCC membership, regular DMCB readers aren't surprised.  For example, the DMCB pointed out months ago that the U.S. government's Agency for Healthcare Research and Quality ("AHRQ") had concluded the same thing.  Countless other DMCB posts on the medical home have pointed out that there were problems with the published PCMH literature (for example, here and here).

Thanks to a past Congressional Budget Office report, the DMCB feels the PCPCC pain. It also knows that a) finding statistically significant cost savings in health insurance data bases are notoriously difficult, b) successful medical home initiatives that are outside the academisphere are the least likely to be reported it in the peer-reviewed literature, c) "savings" isn't the only measure of patient value and d) journals like the Annals of Internal Medicine are being sidelined by innovators who are more astute judges of what works for their patients.

What's changed for the medical home and the PCPCC after this unpleasant dust-up?  Ultimately nothing. Pairing nurses and physicians in team-based care, whether it's done remote telephonic "disease management" style or in the clinic "medical home" style is ultimately a good idea with obvious face validity. The Annals' problem is that we don't have pristine scientific methodologies that can identify, capture and measure the benefit.

The good news is that the science is getting better. Until it catches up, the population health and disease management service providers will remain in business and the medical home will continue to have a bright future.

Exercise Doesn't Have To Be Hard Work

With some creativity, it can be made downright fun.

C'est vrai, n'est pas?