What patient-centeredness looks like
Depending on who you believe, Donald Berwick, MD, the Harvard professor, Institute for Healthcare Improvement president, and pediatrician appointed by President Obama to head the Centers for Medicare & Medicaid Services (CMS), is a radical bent on transforming the U.S. health care system in the image of Great Britian’s or a genius capable of reinventing health care and saving the U.S. economy in the process. (Just search for “Donald Berwick” on Google to see what I mean.) Of course the truth lies somewhere in between, and time will reveal the extent to which he can effect real change in his latest role.
Back in May, Berwick was a proud father delivering the commencement address at his daughter’s Yale Medical School graduation, the prepared text of which is making the rounds via e-mail. In describing the first history and physical he performed as a medical student and also in telling the story of a woman who was prohibited from seeing her ailing husband in the intensive care unit during most of the last hours of his life, he touches on themes that should be familiar to any family physician – the biopsychosocial model, patient-centered care and family:
“Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul.”
Download the entire speech from the Institute for Healthcare Improvement web site.
Donald Berwick, MD, faces his biggest challenge yet
President Obama’s impending nomination of Donald Berwick, MD, MPP, to head the Centers for Medicare & Medicaid Services (CMS) is welcome news. Berwick, a pediatrician and professor at Harvard Medical School and Harvard School of Public Health, is president and CEO of the Institute for Health Care Improvement (IHI), a think tank whose impressive and ambitious work we at FPM have been following since it launched the Idealized Design of Clinical Office Practices (IDCOP) initiative in 1998 (read more about IDCOP in FPM). Our only beef with Berwick is that, following IDCOP, IHI hasn’t devoted more focused attention to office-based practice.
Washington Post blogger Ezra Klein calls Berwick "the most important health-care reformer you’ve (probably) never heard of” and Maggie Mahar’s two-part profile of Berwick introduces him (don’t miss the video clip that, near the end, features Berwick’s thoughts on primary care payment). Having heard several of Berwick’s rousing keynote addresses at IHI’s Annual National Forums, it’s hard to imagine him not making the most of the new tools and authority of the CMS position to improve health care for patients and providers. If only we will let him. Let’s hope his confirmation isn’t a casualty of the resentment bred by the passage of health care reform legislation. May it be quick and painless. This man has work to do.
A detour on the way to the medical home
Last week the Centers for Medicare & Medicaid Services (CMS) published an update on the long-delayed Medicare Medical Home Demonstration. The September announcement from the Department of Health and Human Services of a Multi-Payer Advanced Primary Care Practice Demonstraton initiated by the Obama administration had raised more questions about the future of the medical home project. The explanation from CMS was brief and to the point: “At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot.”
CMS describes the similar pilot as “an independent practitioner-based medical home pilot.” The pending legislation that describes it is the House of Representatives health care reform bill (HR 3200). The two pilots do appear similar in many respects, but one needs to read no further than subsection (a)(4) of Section 1302 “Medical Home Pilot Program” to discover a significant difference between the proposed pilot and its would-be predecessor. Under “Participation of Nurse Practitioners and Physician Assistants,” the bill stipulates that nurse practitioners and physician assistants may lead patient-centered medical homes as long they are acting consistently with state law and other requirements are met.
Family physicians concerned about turf issues may see this as a setback. The good news is that primary care and medical homes are still the focus of discussion and legislation in Washington, even though the first Medicare medical home demonstration, which many believed would help breathe new life into family medicine, is apparently at death’s door.
Medicare's medical home demonstration project: Old news?
A recent press release from the Department of Health and Human Services (HHS) announcing plans for a demonstration project designed around "Advanced Primary Care models" left us, and perhaps many of you, with two big questions: What is the status of the much-anticipated and long-delayed Medicare medical home demonstration project? What is an Advanced Primary Care model? We now have at least partial answers to these questions.
The Medicare medical home demonstration project is at least briefly mentioned in a fact sheet that describes the newer initiative: "CMS will move forward with a separate Medical Home Demonstration required under the Medicare Improvements for Patients and Providers Act (MIPPA) and the Tax Relief & Health Care Act of 2006 (TRHCA)." But the time frame for the project remains unclear. The original schedule called for the Centers for Medicare & Medicaid Services (CMS) to announce in December 2008 the states where the demonstration would be conducted. The application and qualification processes were to have played out this year, and payments to participating practices were to have begun in January 2010. James Coan, a CMS project officer, said in the spring that the eight states have been selected, but CMS is still awaiting approval from the White House Office of Management and Budget to move forward with the project. That approval was first expected nearly a year ago.
The HHS fact sheet says the Advanced Primary Care model that the new project is designed to test is "also known
as the patient-centered medical home." The reason for the new term will
have to be the subject of a future blog post, but here's what we do know: The project will build on a model being tested in Vermont, where private insurers and the state's Medicaid program are collaborating to develop standards and compensation incentives for primary care physicians. The demonstration project will create opportunities for Medicare to join in similar efforts. Application materials will be developed this fall with the expectation that the demonstration projects will begin in 2010, according to the release. Nancy-Ann DeParle, director of the White House Office of Health Reform, called the project "a jump start on health insurance reform." Given the uncertainty surrounding the Medicare medical home demonstration, you have to wonder whether government health programs are capable of such a thing.