Will accountable care swallow up primary care?

If you've heard something about "accountable care organizations" (ACOs) in discussions of health care reforms, but you're not quite sure what they are or where they're supposed to fit in, you might find this "Perspective" piece from the New England Journal of Medicine useful. In short compass it defines the term and relates it to the other biggie in health care redesign, the patient-centered medical home (PCMH).

To get the definition out of the way, "an ACO is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population." (Harks back to the day when managed care wore a white hat, doesn't it?) While the PCMH has been much discussed in family medicine over the past five years, at least, the term ACO seems to have emerged only recently.

The NEJM article makes the point that the PCMH and the ACO are, or can and should be, complementary: The PCMH is a model for redesigned primary care, and the ACO is a model for ensuring that the rest of the delivery system works in concert with the PCMH by aligning incentives for the rest of the system with those of primary care.

Sounds neat, doesn't it? The ACO is a way to get referral specialists, hospitals and all the rest to see things our way. Except ...

As the NEJM article puts it, "The fact that the ACO model does not explicitly require support for primary care has led to considerable concern that ACOs dominated by hospitals or specialists would not adequately invest in primary care – or that hospitals and specialists would garner a disproportionate share of any savings." The ACO may be a "provider-led organization," but the providers leading it may well be hospitals, large multispecialty groups or other entities who have not so far proved to be far seeing or even to understand primary care. The NEJM article lists three requirements for successful integration of PCMHs into ACOs:

• Alignment of accreditation and certification criteria for the two organizations: "No ACO accreditation or certification process has yet been developed, but when one is, it will be critical to include criteria that ensure sufficient primary care capacity for the patient population and to closely align the standards with those of PCMH recognition."
• A common set of primary care performance measures: "Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care."
• Wise alignment of incentives: "The payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity."

So all we need to do to achieve a health care delivery system we can be proud of is redesign primary care, redesign the rest of care, avoid the mistakes we've made chronically in past attempts to fix the system, develop system-wide performance measures with a primary care orientation and, oh yes, shift the center of power of the system from secondary and tertiary care to primary care. I hope we're up to the challenge.

Posted at 10:17AM Nov 05, 2009 by Bob Edsall  |  Comments[0]

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]

Ten steps from ordinary practice to PCMH practice?

This new article from FPM says the trick is to start with steps that increase practice revenue, then use that revenue to support later steps.

• First, stop undercoding; get the revenue you deserve.
  
  
• Second, use the revenue to hire more nurses or MAs.
  
  
• Third, increase your productivity and revenue by offloading work onto your newly enlarged support staff.
  
  
• Fourth, ... well, why not read the article?
  

Posted at 10:10AM Oct 17, 2009 by Bob Edsall  |  Comments[3]

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]

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]