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]

Good things happen when we increase access to primary care

ABC News recently highlighted the Mayo Clinic's efforts to increase access to primary care and reduce inappropriate use of the emergency department and urgent care among its employees. Mayo created a new department "for the whole family" that combines family medicine, pediatrics and internal medicine, it invested in six new family medicine centers, it opened an express care clinic in a shopping mall, and it used PAs and NPs to see patients at night and on the weekend.

The result? Between 2006 and 2008, Mayo's insurance costs for its employees increased 0 percent. For the average employer, insurance costs increased 5 percent to 7.7 percent per year during the same period.

ABC News medical editor Tim Johnson had this to say:

"Hooray for the Mayo Clinic, but the trend in the country is going in the wrong direction. Most industrialized countries have a balance of 50 percent-50 percent, generalists and specialists. In this country, it’s 70 percent specialists, 30 percent generalists. We’re heading in the wrong direction. Primary care is going down the tubes in this country, and that means we can never have true health care reform unless we change it."

When asked by anchor Charlie Gibson “Why is primary care so critical to saving money?” Johnson replied:

“Because these are the doctors and associates – nurse practitioners and physician assistants – who know the patient and the family, who follow them, who can therefore make wise decisions about what to spend money on, what not to spend money on, how to use preventive medicine, how to control and coordinate chronic disease, and that all saves money. Costs go down, and quality goes up.”

Watch the video here.

Posted at 09:18AM Apr 13, 2009 by Brandi White  |  Comments[0]

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]

Reforming health care insurance isn't enough

Liberals and conservatives alike seem to agree on one thing when it comes to President-elect Obama's health care reform proposal: It would succeed at reducing the ranks of the uninsured – by 26.6 million, according to one estimate.

Expanding health insurance coverage is a good thing, but make no mistake: It won’t fix our health care system. As blogger KevinMD noted in an open letter to Obama (and McCain), “Implementing your plan without a solid primary care foundation will doom your proposal to failure.”

After all, what good is it to insure more people if a) you don't have enough primary care doctors to care for them and b) the primary care doctors you do have are underpaid and overburdened? A recent ACP white paper explains the seriousness of the problem, citing a predicted shortage of 35,000 to 44,000 primary care physicians by 2025 unless immediate steps are taken to make primary care more attractive to medical students and more sustainable for practicing physicians. The white paper goes on to summarize 20 years of research demonstrating that primary care produces better outcomes at lower costs. (The AAFP also has an online summary of the literature.) The inescapable conclusion is that primary care is the key to a functional health care system and strengthening it should be the starting place for meaningful health care reform.

So how do we create a strong primary care foundation? For starters, we need to “pay more for what we want more of, and less for what we want less of,” to quote Newt Gingrich. In other words, pay more for primary care, particularly prevention and care coordination. FPM recently published a simple proposal from one family physician for moving the physician payment system in this direction. And the AAFP and other primary care organizations are working to bring about a medical home care management fee, among other ideas.

Of course, despite the evidence cited above, policymakers may not recognize the value of primary care until they have to – when the Boomers swarm Medicare and we really feel the sting of the primary care crisis. As blogger Dr. Bobbs warns, "When the tipping point is reached and the health care system finally cries 'Uncle!' and agrees to start properly reimbursing primary care docs, there isn’t going to be some vast repository of FP and IM docs who have been sitting around waiting to be called up. It’ll take quite a number of years to 're-primary care doctorize' American medicine."

Posted at 10:19AM Nov 26, 2008 by Brandi White  |  Comments[1]

The NEJM "perspectives" on primary care

I don't think of the New England Journal of Medicine as a champion of primary care, so it was nice to see that today's issue carries a section of "Perspective" articles on the future of primary care, including one by well-known family physician Thomas Bodenheimer, MD, and another by Barbara Starfield, MD, MPH, whose research in primary care has helped advance family medicine. The fact of the articles was more pleasing than their content, which basically went over the ground we've covered before – the irrational imbalance between primary care and the limited specialties in the United States, the importance of some sort of payment reform, the likelihood that the future of primary care lies in care teams, registries, population-based care, electronic medical records, and lessons we can learn from other countries.

The articles didn't offer anything new, but they might be worth scanning; they're freely available from the NEJM Web site. Bodenheimer's piece did give a concise description of what the future practice might look like, and you'll find occasional sentences that outline the problem neatly, such as Starfield's comment that "most approaches to reform do not distinguish the use of primary care services from that of specialty services, despite the underuse of the former and overuse of the latter" - a truth amply demonstrated by the recent election, in that neither party's platform recognized that reform of health care financing without reform of health care delivery fixes nothing.

Posted at 03:41PM Nov 13, 2008 by Bob Edsall  |  Comments[2]