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.

Posted at 01:58PM Nov 03, 2009 by Leigh Ann Backer  |  Comments[0]

Beyond PCMH: Is your practice an "accountable care organization"?

The patient-centered medical home model, which has been in the spotlight over the last few years, may soon have to share the stage with a new model: the "accountable care organization."

What's an accountable care organization? According to a recent report from Harold Miller, executive director of the Center for Health Care Quality and Payment Reform, an accountable care organization is "a health care provider or group of providers that accepts accountability for the total cost of care received by a population."

What does a practice need in order to act as an accountable care organization? Miller identifies eight elements:

1. Complete and timely information (including cost information) about your patients and the services they are receiving. Miller notes that most practices will need "significant assistance" from payers in order to obtain this information.
2. Technology and skills for population management and coordination of care, such as using clinical guidelines and monitoring compliance with them, analyzing data on resource use and utilizing a patient registry.
3. Adequate resources for patient education and self-management support.
4. A culture of teamwork among the staff of the practice.
5. Coordinated relationships with specialists and other providers.
6. The ability to measure and report on the quality of care.
7. Infrastructure and skills for management of financial risk.
8. A commitment by the organization’s leadership to improve value and create operational accountability.
   
   

How does an accountable care organization differ from a patient-centered medical home? According to Miller, "Most initiatives today to help primary care practices become Medical Homes do not require that the primary care practice accept any accountability for the total costs of care for their patients or for population-level quality outcomes. Even though many of the enhanced resources and tools being developed and used by Medical Homes, such as electronic health records, patient registries, patient education on chronic disease management, and more responsive scheduling, could help improve quality and reduce total costs, there is no guarantee that they will do so unless the primary care practice actually focuses on improving those outcomes as an explicit goal and uses the medical home tools to achieve the goal. Indeed, the Congressional Budget Office, in evaluating various health delivery reform options, estimated that paying for Medical Homes for chronically ill beneficiaries in Medicare would increase spending by $5.6 billion, rather than reduce costs."

Miller continues, "This implies that while becoming a Medical Home could help a primary care practice become an Accountable Care Organization, it is not sufficient. Conversely, in order to function effectively as an Accountable Care Organization, it may not be necessary for a primary care practice to meet all of the detailed standards that organizations such as the National Committee for Quality Assurance (NCQA) require of primary care practices in order to be formally designated as a 'Patient-Centered Medical Home.' Indeed, detailed accreditation standards are being used in medical home programs partly because payers are concerned about whether making higher payments to primary care practices to enable them to serve as medical homes will actually result in improved outcomes for patients and lower costs for payers. Since there is not strong evidence that all of the structural and process standards established for medical homes are necessary for improved patient outcomes and some may be difficult or expensive for practices to achieve, and because some practices that would not meet these standards have been successful in proactively managing and coordinating their patients’ care, a primary care practice should not be precluded from serving as an Accountable Care Organization simply because it has not met accreditation standards as a Medical Home."

Posted at 12:37PM Oct 16, 2009 by Brandi White  |  Comments[0]

Is your practice a medical home?

From NPR.org:

"Insurers will also pay [practices participating in a medical home pilot project] bonuses for keeping patients healthy. So, behind the scenes, the office is keeping track of patients, especially if they have a condition such as diabetes or asthma. Dr. Paul Grundy, the founder of a group that's promoting medical homes, says some doctors tell him they already do all that. 'One of the first questions I ask them is, Do you know every single woman in your practice [who is] over 50 and the status of her breast exams? And do you know every man who is over 55 and the status of his colonoscopy exams? If you don't, you don't have a medical home ...'"

Click here to read about the AAFP's definition of a patient-centered medical home.

Posted at 11:20AM Oct 08, 2009 by Brandi White  |  Comments[1]

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.

Posted at 02:24PM Oct 02, 2009 by Leigh Ann Backer  |  Comments[0]

"You're likely to hear a lot more about this idea"

Proponents of the patient-centered medical home gained a high-profile advocate this week – New York Times health columnist Jane Brody. Highlighting care provided by family physician Gloria Trujillo, MD, at Duke University Family Medicine Center, Brody's Monday column, "A Personal, Coordinated Approach to Care," highlights the medical home's potential to heal the U.S. health care system, both for patients and physicians: "As President Obama and Congress try to create a national system that provides better care for more people at lower cost, you are likely to hear a lot more about this idea."

Posted at 11:05AM Jun 25, 2009 by Lynn Hofeldt  |  Comments[0]

Barbara Starfield on Family Medicine and the PCMH

The work of Barbara Starfield, MD, MPH, has been enormously effective in establishing the value of primary care in general and family medicine in particular. One testimony to this is the AAFP’s list of 100 articles demonstrating the value of family medicine; she wrote or coauthored 18 of the 100 articles.

Given her strong support of primary care, it’s reasonable to want to know her thoughts on the Patient-Centered Medical Home (PCMH), a concept that seems likely to shape the future of the specialty. In an opinion piece written for the July/August issue of Family Practice Management, she sounds somewhat dubious of the direction the PCMH is taking: “Proposals for the PCMH are not very patient-centered. They are justified on the basis of evidence regarding the benefits of primary care, but the criteria for assessment of PCMHs, such as those promulgated by the National Committee for Quality Assurance, concern organizational features such as electronic health records, computerized guidelines and amorphous 'teams,' none of which have been demonstrated to be pursuant to good primary care.”

To read more, see the prepublication version of her essay.

Posted at 11:59AM Jun 01, 2009 by Bob Edsall  |  Comments[1]

What we now know about the patient-centered medical home

Three years and some $8 million ago, the AAFP boldly launched TransforMed, whose primary mission was to carry out a national demonstration project (NDP) to test a model of the patient-centered medical home (PCMH) in 36 practices throughout the United States.

Yesterday, the first researchers' report, based primarily on the project's qualitative data, was published in the Annals of Family Medicine. According to the researchers, "Even though analysis of the NDP is not yet complete, we feel compelled to share early lessons ...  We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the [PCMH] demonstrations just getting underway."

Here's what the researchers found:

1. Becoming a PCMH (as defined by the TransforMed model, now on version 2.3) requires "epic," "relentless," "practice-wide" change that will likely produce "change fatigue" among the doctors and staff.

2. The technology needed for the PCMH is not "plug and play"; instead, its implementation is "more difficult and time consuming than originally envisioned," in part because systems aren't interoperable.

3. The amount of change required to become a PCMH "takes more time than the two years allocated to the NDP."

4. Transforming to a PCMH requires tremendous costs, in terms of dollars, time and effort, and "currently available funds and reimbursements are likely to be inadequate."

As daunting as that sounds, it might actually be worth the trouble if there is evidence that the PCMH model as currently defined (with its dozens of components) makes a difference for patients. But does it? That's the million-dollar question. The research team has collected data on the patient experience and clinical outcomes for the 36 practices in the NDP, but those reports aren't slated for publication until early 2010. Judging from the tone of the researchers' first article, it's hard to believe that the coming data will be positive.

The researchers note that for practices to become PCMHs under the current model, they need more time, more money and better technology. That could be. Or is there something amiss with the PCMH model itself? Read one view on that question from the well-known researcher Barbara Starfield, MD, MPH, in an editorial for Family Practice Management.

Posted at 02:04PM May 12, 2009 by Brandi White  |  Comments[1]

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.

The 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. 

Posted at 04:14PM Feb 27, 2009 by Leigh Ann Backer  |  Comments[0]

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.

Posted at 04:18PM Feb 20, 2009 by Bob Edsall  |  Comments[2]

Are you ready for the medical home?

It’s been a year since the National Committee for Quality Assurance (NCQA) launched its patient-centered medical home designation program. Through December, the organization had received applications from approximately 120 practices, according to Eric Williams, NCQA product development manager. One of these was from Joseph Mambu, MD, of Lower Gwynned, Pa. Mambu learned last month that his three-physician family medicine practice had earned the highest level of recognition possible, tier 3, from NCQA. The Centers for Medicare & Medicaid Services (CMS) has yet to announce the regions where its medical home demonstration project will be carried out, but Mambu is hoping to be able to participate in this and other pilot projects in his area. According to a recent AAFP survey, 74 percent of the family physicians who responded were very or somewhat interested in having their practice recognized as a patient-centered medical home, but Mambu must be among the first to have completed the process.

We’re hoping to publish an article about Dr. Mambu’s group’s experience in an upcoming issue of FPM. In the meantime, look for “Building the Case for the Patient-Centered Medical Home” in our January/February issue. The article examines developments surrounding the patient-centered medical home initiative and perceptions from family physicians about where it might lead. Not everyone is ready to pay NCQA’s PCMH application fee of $450 per physician (for a practice of up to six physicians), much less make the investment in electronic medical records that tier 2 or 3 recognition requires. Are you?

Posted at 04:53PM Jan 12, 2009 by Leigh Ann Backer  |  Comments[0]