The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

 

Care Coordination Under Medicare


Wednesday, September 3, 2014
Mike Taylor imageThe concerning payment for care coordination is a step in the right direction.

Dr. Matthew Press, an internist in academic medicine, aptly described how demanding excellent care coordination can be. In the August 13, 2014 edition of the New England Journal of Medicine, Dr. Press wrote of his work with a patient (Mr. K.) who had recently been diagnosed with a mass in his liver:

“Over the 80 days between when I informed Mr. K. about the MRI result and when his tumor was resected, 11 other clinicians became involved in his care, and he had 5 procedures and 11 office visits (none of them with me). As the complexity of his care increased, the tasks involved in coordinating it multiplied. I kept a running list and, at the end, created an “instant replay” of Mr. K.'s care (see diagram; also see animation, available with the full text of this article at NEJM.org). In total, I communicated with the other clinicians 40 times (32 e-mails and 8 phone calls) and with Mr. K. or his wife 12 times. At least 1 communication occurred on 26 of the 80 days, and on the busiest day (day 32), 6 communications occurred.”

Dr. Press went on to comment he doesn’t have a full-time practice, but splits his time between teaching and caring for patients, and acknowledged how difficult care coordination can be for a physician practicing medicine full-time.

Many primary care physicians have provided care coordination without compensation, but it’s hoped this policy change by CMS will drive improved outcomes. I should point out that care coordination is an integral part of the patient-centered medical home concept. It’s generally a process used by most organizations that provide care using a team-based concept that is value-based, not based on traditional fee-for–service reimbursement.

There will be challenges.  Most physicians are highly ethical, but there’s a potential for abuse and perhaps even fraud. I can imagine a physician hiring a nurse practitioner to do nothing but make telephone calls to elderly patients with several chronic diseases. The CMS requirement for the patient to agree, in writing, beforehand and the patient footing 20% of the bill should drive accountability, but this new program will require oversight. Is the $42 per month proposed by CMS enough compensation to make this worthwhile? I would expect that smaller practices won’t find this feasible at that rate of pay. The requirement that someone from the medical practice be accessible 24/7 may also give physicians some pause.

Even with the inevitable uncertainties of any new program, I think larger, well-organized practices will find this new policy helpful in caring for some of their most complex patients, and I’m hopeful many practices will integrate care coordination into their management of the care of these patients.

Michael L. Taylor, MD, FACP
Chief Medical Officer

Let’s Not Pull the Plug on Patient Centered Medical Home Models Yet


Tuesday, March 4, 2014
Mike Taylor imageThe Wall Street Journal recently published an article entitled ”.” It sounds discouraging, but we need to understand how the study was constructed. This article is from the February 26, 2014 edition of The Journal of the American Medical Association (JAMA), and featured a RAND Corporation study of a pilot project in Pennsylvania. The intervention was “Technical assistance, web-based training, creation of disease registries and assistance from coaches trained in practice improvement.”

The targets were asthma in children and diabetes in adults. There was a large financial incentive to participate ($20K per physician, some receiving up to $92,000, if their practice achieved AHRQ certification). Given the narrow nature of the pilot, and the three year measurement time frame, I wasn’t at all surprised the results came out the way they did. 

I’m sure it will be used as an example of a failed patient-centered medical home (PCMH), but I don’t think that’s a fair assertion, and I don’t think that was the intent of the authors. One of their comments mentioned this study should show that the U.S. healthcare delivery system shouldn’t assume that the PCMH design is finalized—no disagreement with that assertion.

Based on a careful review of the paper, it seems the study design was more focused on gaining certification than improving care. Focusing on children with asthma and adults with diabetes is not really a PCMH approach, but more of a case management model. I would expect that an outpatient medical practice using PCMH principles would develop registries of its entire population (not just diabetes and asthma), undergo analyses to determine risks within the population the practice is managing, and then develop appropriate interventions based on the risks of the population.

I would certainly expect some patients with diabetes to need additional services. I would also expect a certified diabetes educator (CDE) to work with patients as appropriate to achieve guideline compliance and improved clinical outcomes—and publicly report those outcomes. Group classes might be a feature of the program, and perhaps clinical monitoring using telemedicine.

I would expect similar monitoring for a risk-adjusted group of patients with heart failure, with careful attention to the transitions of care from acute care settings to home monitoring and home visits to prevent relapses back into the hospital.

There are any number of interventions that might be included, but a key principle of the true PCMH model is the use of data to analyze the effectiveness of the program in order to continuously improve the care. I believe this can’t be accomplished in a fee-for-service environment, but needs to be developed in a value-driven model that pays for improved outcomes.

Here’s the bottom line—the current fragmented way in which we care for sick people in the U.S. isn’t serving the best interests of those who need care. Don’t let this RAND Corporation study slow the progress toward achieving patient-centered care. I absolutely believe the model is not finalized, and, to that point, I agree with the authors. We’re not finished, but we can’t stop efforts to achieve The Triple Aim of better outcomes for patients, better health for populations and better cost. Continued development and evaluation of patient centered care is our best option.

Michael L. Taylor, MD, FACP
Chief Medical Officer

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