Patient-centered medical homes and outcomes
Health care reform returned to the national spotlight this week with the unveiling of President Obama’s new federal budget and renewed debate about how best to reduce escalating health care costs and fund expanded coverage for the growing numbers of uninsured Americans. Outside the beltway, the chorus of voices calling for primary care payment reform grew a little louder with the publication of a new report from national health care coalition the Network for Regional Healthcare Improvement (NRHI) titled “Pay for Innovation or Pay for Standardization: How to Best Support the Patient-Centered Medical Home.” The NRHI recommendations sound similar to other primary-care-oriented reform proposals, but with a few different notes that may be music to the ears of those who question the conventional wisdom about how to define, recognize and pay for patient-centered medical homes.
For one, the report recommends that higher payments to primary care practices be based primarily on whether they improve outcomes for their patients rather than whether they meet detailed accreditation standards, such as those established by the National Committee for Quality Assurance patient-centered medical home (PCMH) recognition program. The report emphasizes that additional evaluation is needed to determine which processes and structures produce better outcomes. “While standards such as those developed by NCQA could serve as helpful guidelines to providers in improving their care processes, it is impossible to say that a provider that meets the standards will deliver higher-value care than one that does not,” the report says. It urges that primary care physicians should be able to participate in payment systems designed to support improved care without having to meet “detailed and potentially expensive requirements” without more evidence of their impact on quality and cost-effectiveness.
In a recent post for his FPM blog "Making It," Doug Iliff, MD, calls for PCMH initiatives, including the AAFP's TransforMed national demonstration project, to focus "like a laser beam on Outcomes, both medical and financial," while being "as flexible as silly putty on Inputs," or the methods and practices that produce the outcomes. The NRHI report explains it this way:
“For example, the NCQA standards and many payers have proposed rewarding practices that have electronic health record (EHR) systems. While EHR systems can be very helpful to physician practices in providing quality health care, merely having an EHR does not guarantee quality care. Additionally, many physician practices that do not have EHRs provide high-quality care. If a payment system requires that a physician practice have an EHR in order to participate, it will potentially exclude some practices that provide high-quality care but do not, at least yet, have an EHR. Moreover, it may force physician practices to devote disproportionate time and resources to installing EHRs rather than implementing other types of care improvements that could provide a bigger impact on quality and costs in the short run.”
The report also acknowledges that it might be more difficult for small primary care practices to offer PCMH services than for larger practices. Michael W. Painter, MD, JD, a senior program officer at the Robert Wood Johnson Foundation, which provided funding support for the report, says, “We should encourage and assist small physician practices to participate in medical home initiatives, since that is where the majority of primary care physicians in the nation practice.”
The other key recommendation in the NRHI report advocates replacing fee-for-service payment with a single, severity-adjusted, comprehensive payment that covers all of a person’s outpatient primary care, with a portion of the payment based on outcomes and costs. (Capitation, anyone?) “Payers should phase in changes to payment systems to support the changes in primary care needed to improve quality and cost outcomes, beginning with enhanced fees and moving toward more comprehensive payments,” the report says.
recommendations were developed by more than 100 health care leaders
from across the country who participated in NRHI’s 2008 National Summit
on Healthcare Payment Reform. The full set of recommendations from the
summit is included in NRHI’s previously released report, “From Volume
to Value: Transforming Health Care Payment and Delivery Systems to
Improve Quality and Reduce Costs.” NRHI plans to hold another national
summit this year and to encourage implementation of its recommendations
across the country.
Saving primary care
One recent event that gave me a little hope for the future was the launch of a new Web site called SavingPrimaryCare.org. The site, an effort of the Ideal Medical Practices Project, is intended to help build support for a redesigned health care system in which primary care can take its rightful place. The site identifies its supporters as "a bunch of physicians, nurse practitioners, nurse midwives, physician assistants, nurses, office managers, secretaries and just plain folks who want to see the U.S. develop a high performing health system." While the effectiveness of the new site remains to be demonstrated, I find its approach encouraging. It reminds me a little of the Better Health Initiative of the Trust for Healthcare Excellence: idealistic, hopeful, representative of our better natures and, if it doesn't get chewed up in the machinery of the system, full of promise.
It was just about exactly five years ago that the Future of Family Medicine Project gave family medicine 10 to 20 years to live if the specialty and the health care system didn't change their ways. While it hardly seems necessary to call in hospice yet, it does seem that we have been changing our ways rather slowly. The leaders of the specialty are betting that the patient-centered medical home (PCMH) is the fitness program that both the specialty and the system as a whole needs – a model for better practice that also involves a model for better payment. (Of course, it could be argued that the PCMH requires practices to transform themselves into the practices of tomorrow in order to have some chance of getting paid what they should have been paid yesterday, but that's another story.) In any case, if we are to accept the gloomy prognosis, it's clear that a lot will have to change very quickly now for the specialty to survive.
But it isn't just family medicine that's in trouble. Family physicians aren't the only ones underpaid, overworked and underappreciated. They're not the only ones practicing in a swamp of regulations, insurance hassles, 40-patient days, perverse incentives and rapacious payers. They're not the only ones operating in practices short of funds, short of management expertise, unable to measure their own effectiveness, and troubled by staffing problems. The system is hostile to all primary care, and it's all of primary care that's at risk.
That makes me wonder if one problem is that we don't have a strong enough primary-care-wide response to the problem. True, the primary care specialty societies have worked together on various issues over the years, and they're certainly together in the Patient-Centered Primary Care Collaborative – although there we find ourselves in with payers and other organizations that may have conflicting aims. Despite such examples of coordinated work, there's a sense in which the disconnection of the primary care specialties from one another, not to mention the disconnects between physician groups and organizations for nurses and midlevel providers, may weaken our response. With all the talk of team-based care these days, you'd think we'd have a team-based response to the challenges of the moment rather than the response of a loose alliance. It would be nice to think that efforts such as SavingPrimaryCare.org could steer health care in a better direction.
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