November 20th, 2011 by RyanDuBosar in Research
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Adults who received care from a medical home in 11 Westernized countries were less likely to report medical errors and were happier with their care, according to a new Commonwealth Fund international survey.
The 2011 survey included more than 18,000 ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. It included people who reported they were in fair or poor health, had surgery or had been hospitalized in the past two years, or had received care for a serious or chronic illness, injury or disability in the past year. The vast majority had seen multiple physicians.
A medical home was defined as patients reporting a regular source of care that knows their medical history, is accessible and helps coordinate care received from other providers. Results were published in Health Affairs.
Sicker adults in the U.S. were the most likely to Read more »
*This blog post was originally published at ACP Internist*
August 5th, 2011 by Jessie Gruman, Ph.D. in Health Policy, Opinion
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“There is a better way – structural reforms that empower patients with greater choices and increase the role of competition in the health-care marketplace.” Rep. Paul Ryan (R-WI) August 3, 2011
The highly charged political debates about reforming American health care have provided tempting opportunities to rename the people who receive health services. But because the impetus for this change has been prompted by cost and quality concerns of health care payers, researchers and policy experts rather than emanating from us out of our own needs, some odd words have been called into service. Two phrases commonly used to describe us convey meanings that mischaracterize our experiences and undervalue our needs: “empowered patient” and “health care consumer.”
As one who has done serious time as a patient and who spends serious time listening to talks and reading the literature that use these words to describe us, I ask you to reconsider their use.
“Empowered patient” The fabrication of the verb “to empower” from the noun “power” was used in the civil rights and community development movements to describe a benevolent bestowal of influence on disenfranchised individuals and groups by those who had previously excluded them. When used in relation to health care, the word perpetuates the idea that we are passive entities, waiting to be gratefully endowed by our clinician or a new policy with the right and ability to act on our own behalf. Our “empowerment” takes place not as a result of our own will or preference, but rather because we have been given permission to act in a different way by some external agent.
This word is Read more »
*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*
April 11th, 2011 by DavidHarlow in Health Policy
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ACO regulations and related federal issuances hit the street last Thursday, after several months of waiting — from CMS, OIG, FTC, DOJ and IRS. They cover the waterfront, ranging from the central regulation defining the structure and workings of the ACO, to limited Stark self-referral ban and anti-kickback statute waivers in the fraud and abuse arena, to new frameworks for antitrust analysis, to rules governing joint ventures involving taxable and tax-exempt organizations.
I had the opportunity to discuss the regs the day after they were issued on a special edition of the Blog Talk Radio show, ACO Watch, hosted by Gregg Masters (@2healthguru). Gregg’s guests included Mark Browne (@consultdoc), Vince Kuraitis (@VinceKuraitis), Jaan Sidorov (@DisMgtCareBlog) and yours truly (@healthblawg). We are geographically diverse, and bring a variety of perspectives to the table. I invite you have a listen — we enjoyed the opportunity to discuss the rules, we all learned from each other, and we hope you enjoy the conversation as well. (It runs about 90 minutes.)
Update 4/5/2011: For a collection of ACO analyses curated by Anita Samarth see: http://bit.ly/ACO-Analyses.
Here are a few points to consider as part of a first look at the ACO rules:
1. The rules were worth the wait. There are a lot of moving parts to coordinate, and the multi-agency effort really came together. The CMS rule also retains a fair amount of flexibility. Some requirements are very specific, but others much less so. (For one example of specific guidelines, take a look at the eight-part definition of patient-centeredness; an organization must satisfy all eight in order to be an ACO. Other requirements have no detail at all, and CMS will look to applicants to explain how they meet the requirements, without giving any hints.)
2. This is the Frankenstein regulation: A Medicare beneficiary must sit on the board of the ACO, CMS must approve all marketing materials before they are used …. These requirements may be traced back to origins in CMS demonstration project and Medicare Advantage policies, respectively, and illustrate the way in which CMS took a short statute and really put some meat on the bones. Some may balk at the weight of the requirements limiting the options of an ACO.
3. CMS has bootstrapped a law aimed at ACOs serving at least 5,000 Medicare beneficiaries each into a system of rules that effectively requires that commercial business be handled in an ACO-like manner. This, among other infrastructure requirements (e.g., 50% of ACO docs must be meaningful users of EHRs), leads to the conclusion that there will be relatively few ACOs, at least initially. CMS estimates 75-150 nationwide. There are, of course, many unanswered questions about what a commercial ACO would look like. One model I am familiar with — here in the People’s Republic of Massachusetts — is the AQC, or Alternative Quality Contract offered by Blue Cross Blue Shield of Massachusetts to providers enrolled in its HMO Blue product. One question is whether a slightly different financial model could apply to the commercial side of the house. One model worth a close look is Jeff Goldsmith’s proposed ACO model, which would treat primary care, emergency and diagnostic care, and episodes of specialty care in three distinct ways.
In brief, Goldsmith recommends risk-adjusted capitation payments for primary care, fee-for-service payments for emergency care and diagnostic physician visits, and bundled severity-adjusted payments for episodes of specialty care. Primary care would be provided through a patient-centered medical home model, which would likely have a collateral effect of reducing the total volume of emergency care and diagnostic physician visits. Specialty care would be provided through “specialty care marts,” ideally more than one per specialty per market to maintain a little healthy competition.
A quick explanation of this approach to an intensivist over the weekend elicited a favorable response.
4. Also in the bootstrapping department, CMS has shifted the ACO from a “shared savings” approach to having ACOs share risk as well as the upside. Of course, this makes a lot of sense; a number of commentators, including the HealthBlawger, had lamented the fact that risk sharing was left out of the statute. CMS has used its general waiver and demo authority under the ACA to move the ACO into risk sharing. The ACO may choose: share risk from day one, and enjoy a potentially higher percentage of the upside, or defer the risk sharing to year three.
5. The retrospective nature of patient attribution and savings calculations mean that each ACO must treat every Medicare fee-for-service patient as if he or she is “theirs.” Patients have the right to decide whether they want their data shared with an ACO; if enough patients are spooked by health care data privacy and security issues, fewer and fewer will authorize the sharing from CMS to the ACO, and the ACO will have to drive by feel — or base its management of Medicare beneficiaries on its management of its general patient population.
6. Organizations that dominate their local markets may be the most successful as ACOs, but they may face the most involved antitrust review at the hands of the FTC/DOJ.
7. Scoring on 65 quality metrics in 5 domains will help determine the amount of any shared savings to be paid to an ACO. One domain, patient experience of care, links up nicely with the patient-centeredness threshhold requirement noted above. (For private sector attention to patient experience, see what the Leapfrog Group is doing in this domain, using some of the same measures.) While some may bristle at the number of metrics, it is worth noting that these metrics are all drawn from existing sets of measures.
8. All in all, the regulations represent the first stage of realizing the ACO vision expressed by Don Berwick last fall: there is a field open to experimentation (albeit a field likely limited to large networks of significant means that can underwrite the up-front infrastructure costs), and the ACO rules sketched out in the statute and further delineated in the regulations will enable CMS to incentivize the provider community to help achieve the triple aim of better care for individuals, better health for populations and reduced per-capita costs.
David Harlow
The Harlow Group LLC
Health Care Law and Consulting
*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*
March 19th, 2011 by BobDoherty in Health Policy, Opinion
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A few days ago I received an email from a general internist about my posts about concierge practices. I have known this physician for over 20 years, and he has great insight into the challenges facing health care. This email was no exception; he had this to say how his group took the “middle way” of pursuing private funding for the Patient-Centered Medical Home (PCMH):
“My practice includes 3 primary care physicians and has invested heavily in IT infrastructure. We have re-engineered our workflows and have achieved benchmark levels of quality and service. We have won NCQA certification for our PCMH. Yet so far no payer has stepped up to underwrite our investment. So we have joined Privia Health in forming a ‘membership practice.’ Patients are asked to pay a small monthly membership fee. In return they receive some special attention . . . Plan sponsors and payers are invited to pay the fee on behalf of their employees. . . Patients like having same day access. They like secure email communication with their doctor. They like having a personal health record. They like having a case manager helping them navigate the system. And they like going online in the evening to make their own appointments. ACP policy supports the medical home but is silent on the question of what a medical home is to do before local payment realities catch up. I owe my patients my efforts to assure that when I retire an eager young internist will welcome the opportunity to take over my practice. Absent public or private funding for the medical home that is just not going to happen.” Read more »
*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*
June 9th, 2010 by Richard Cooper, M.D. in Better Health Network, Health Policy, News, Opinion, Research
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In a recent blog posting, I described Group Health’s medical home for 8,000 patients. It proved to be a boon for primary care physicians, who were able to reduce the size of their patient panels, see fewer patients per day, refer more patients to specialists, and maintain or increase their incomes.
Patients liked it, too. And Group Health was happy because expenditures per patient were 2 percent lower. But poor patients had trouble getting through the front door of the medical home, so based on demographic differences alone, expenditures should have been lower by 10 percent or more. Nonetheless, they declared victory.
Now news filters south from Ontario’s eight-year experiment with medical homes for 8,000,000 patients, and the news is similar. Participation is skewed to healthier and wealthier patients who, in the absence of risk adjustment, yield profitable capitation for primary care physicians. Incomes have soared an average of 25 percent. Read more »
*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*
