The Most Difficult Part Of The Patient-Centered Medical Home

By Clive Riddle, July 31^st, 2015

The medical home transformation for primary care, incorporating a team approach, technology, elements of care coordination and much more, has been a significant driver of change and innovation this decade. In the about to be released August issue of Medical Home News, the Thought Leaders Corner asks the question:  What was the most difficult part of the patient-centered medical home transformation that you experienced or observed? Here’s what the panel shared in their responses:

Sam JW Romeo, MD, MBA, of Tower Health & Wellness Center in Turlock, CA says  “having surveyed many organizations nationally for accreditation as a Medical Home, including the USAF primary care centers, the two hurdles (difficult parts of the PCMH) that are most prominent are: (1) payer emphasis on case management, and (2) cultural transformation needs within the medical profession. With regards to the case management emphasis, the payers want to save money first and foremost (‘quarterly reports’) more than provide care for patients.  They create the economic incentives and support structures to minimize, for example, hospitalization and ER use and, if per chance, they transform the provider to be more patient centric vs disease centric, whoopee!!  This transformation, however, is not often seen. With regard to the cultural change requirements, there is the ‘upstream’ challenge of providers being trained in medical schools and residencies to care for diseases in patients and not patients with or without disease.  The PCMH transformation requires providing patients with prevention (beyond immunizations and screening and the typical PQRS measures), wellness and lifestyle support, along with the care of disease.  The PCMH care model includes coordinating all of a patient’s care needs.  These needs include caring for the whole patient, i.e., body, mind and spirit, and this is not often in evidence.”

Joseph E. Scherger, MD, MPH, Vice President, Primary Care at Eisenhower Medical Center  and the Marie E. Pinizzotto, MD Chair of Academic Affairs at the Annenberg Center for Health Sciences in Rancho Mirage, CA states  “the most difficult part of adopting a PCMH model is changing how physicians and other providers work.  Implementing a care coordinator is not hard.  Having an advanced IT system is part of modern medicine.  But getting providers off the treadmill of many brief visits and spending time in longer visits with complex patients and doing population care coordination is a difficult paradigm shift.”

R. Scott Hammond, MD, FAAFP, Family Practice, Westminster Medical Clinic and Clinical Professor, University of Colorado School of Medicine, in Westminster, CO shares that  “Westminster Medical Clinic was early to the PCMH movement, being recognized in 2009.  Our biggest challenge was trying to understand exactly what we needed to do to satisfy NCQA standards.  At that time, there were few tracks to follow. I do not believe that is an issue now, as NCQA has improved and clarified their implementation guide. In retrospect, the most difficult part of transformation was sharing our vision of the PCMH with our entire staff and changing the culture of our practice to meet the patient-centered principles of the PCMH.  Only then were we able to operate as a collaborative team. This was also the most rewarding part of the journey.”

Mary Takach, BSN, MPH, Senior Program Director, National Academy for State health Policy, in Washington, DC opines that “The biggest challenge is exercising patience in the PCMH model and not pulling the plug after the first year or even the second year if there is no return on investment.  This is difficult for policymakers on both the public and private side -- especially for those under pressure to deliver balanced budgets.  Waiting for practice transformation to take root and move the dial on desired outcomes requires firm resolve and belief that the current system is broken and that transforming primary care delivery is the right direction to go.”

Nancy Meisinger RN, MBA, PCMH CCE, Director Of Practice Transformation, Delaware Valley ACO in Radnor, PA feels that “the concept of population management and proactive outreach to patients vs. waiting till they come into the office for a visit is often a difficult concept for the offices to put into practice in a systematic way.  In order to be effective it involves consistently documenting preventative and chronic care services within the EHR and maximizing the use of the clinical decision support tools.  Training of staff and use of protocols so that the process is as systematic and accurate as possible can be a challenge no matter what size patient panel the office manages.”

Amy Mullins, MD, CPE, FAAFP., Medical Director, Quality Improvement, American Academy of Family Physicians in Leawood, KS tells us  “much like patients, patient-centered medical homes are all different and the process to become one presents different challenges to different practices.  However, looking from a broad national view, physician engagement has proven to be a challenge for many.  Physicians are smart, busy, and highly motivated individuals who want to do what is best for their patients and eliminate any unnecessary work. To increase their engagement you need to prove to them that PCMH transformation will not only benefit their practice, but will positively impact the health outcomes of their patients.  Once physicians are engaged, the challenge shifts to empowering care team members and integrating the patient in team-based care, which is integral to the patient-centered medical home.”

David Tayloe, MD, FAAAP, Goldsboro Pediatrics in Goldsboro, NC is of the opinion that “educating providers about community resources has been, and continues to be, the most difficult step in transition to the patient-centered medical home.  Many children are at-risk for poor outcomes because of social determinants of health (poverty, parenting, education, substance abuse, abuse/neglect, mental health issues of caretakers).  These children need support within the community from various agencies.  Primary care providers must identify these children and refer them to necessary support services.  Many primary care providers are not aware of the support structure available in their communities.”

Jaan E. Sidorov, MD, FACP, Chief Medical Officer, medSolis and Author, Disease Management Care Blog, in Harrisburg, PA  says “changing established workflows is often underestimated.  There's a tempo to patient ‘throughput’ and the diversion of patients into new pathways involving other clinicians requires new space, hand-offs, duties, policies, and templates.  Unless carefully planned, patients' additional waiting times in office can balloon or they'll be waiting at home for a call that is hours late.  Increasing ‘stops’ in an episode of care doesn't increase work linearly, it complicates it exponentially.” 

And finally, George Valko, MD, Gustave and Valla Amsterdam Professor of Family and Community Medicine and Vice-Chair for Clinical Programs and Quality, Department of Family and Community Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, and Medical Director, Jefferson Family Medicine Associates in Philadelphia, PA shares that “sfter deciding to pursue becoming a PCMH, I think the initial application for recognition and all that it entails, was the most difficult.  To me, it was a forest vs. trees analogy -- the whole process, using the NCQA in our case, is quite overwhelming. However, while sifting through the standards and elements, it became clear that we, and most others, were meeting many of the requirements already.  And, if we were not already meeting some requirements, many were activities we should have been doing in any case.  Now, ongoing improvements to become a true medical home, including changing the culture of a practice, doing outcomes measurements, and creating a medical neighborhood are and continue to be time consuming and costly.”

You can check out Medical Home News at www.MedicalHomeNews.com.

Snapshots of the Mega-Mergers

By Clive Riddle, July 24, 2015

With Anthem and Cigna’s merger announcement, the dance card has been filled out. Here’s what they had to say about their deal:  

“Anthem will acquire all outstanding shares of Cigna in a cash and stock transaction and Cigna shareholders will receive $103.40 in cash and 0.5152 Anthem common shares for each Cigna common share. The total per share consideration equates to approximately $188.00 for each Cigna share based on Anthem's closing share price on May 28, 2015, valuing the transaction at $54.2 billion on an enterprise basis.”

So let’s take a look at the mega-health plan profiles, before and after these mergers, understanding that the “after” picture will undoubtedly change due to regulatory required divestures in certain markets:

    

Here’s a couple of edited graphics from by the plans that provide some additional insight into their merged companies:

It will be interesting to see how long the regulatory hurdles take for these three deals, and how many regulatory concessions, including specific market divestures, are required.

Accuracy of Provider Directories

By Claire Thayer, July 17, 2015

Beginning in 2016, health plans will face stiff penalties for failing update and monitor their provider directories. Kaiser Health News reports that inaccuracies in provider directories may trigger penalties of up to $25,000 per day per beneficiary for inaccuracies in Medicare Advantage directories while providers involved with plans on the federal exchanges could face penalties of up to $100 per day per affected beneficiary for problems in their directories.

MCOL’s infoGraphoid for this week takes a deeper look into the state of provider directories across the country:

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

Nag On My Shoulder

By Kim Bellard, July 15, 2015

We seem to like to have help with our health.  In addition to doctors, we might have a case manager, a health coach, a pharmacist, a personal trainer, or a nutritionist, to name a few.  But we soon may be able to have all of their expertise whispering in our ear 24/7.

Whether that would be a good thing or a bad thing remains to be seen.

The Wall Street Journal recently profiled an interesting company called OrCam.  OrCam's origins were in helping visually impaired individuals.  A small wearable camera processes surrounding images -- faces, steps, even handwriting -- on the fly and informs the user, almost as if they were seeing the objects directly.  Now OrCam is testing what they bill as a digital personal assistant -- Casie -- to add even more value.

I can see all sorts of potential for health care.

The WSJ article gives the example of you walking down the street, and Casie recognizes the face of one of your Linkedin contacts.  

If OrCam can recognize your Linkedin contacts, I would bet that it can recognize a donut, or a cigarette, and remind you about the health risks before you get either in your mouth.  
Such a digital assistant might also notice you haven't taken your morning pills.  Lack of adherence to taking medication has been labeled a $300b problem.

Maybe it could be trained to look at that rash on your arm and offer an informed diagnosis, taking teledermatology to the next level.

Pack a portable ultrasound into the device -- this technology is already here -- and suddenly whole new worlds of things your digital assistant could help you with really open up, especially if paired with a Watson type of AI.

Ideally, one would like to be able to tell your digital assistant how you are feeling, much like you might tell your doctor or try to do with an online symptom checker, and get a diagnosis.

Fitness trackers are all the rage, but the attrition rate on the use is terrible; a third stop using after six months.  Perhaps something like Casie could have better luck keeping you engaged.  

Smart glasses have faced adoption resistance for a variety of reasons: people think current models look goofy, there are concerns about privacy when everything in sight is suddenly a picture/video, or perhaps it has just been lack of a perceived killer app. 

OrCam addresses the first objection by being a fairly inconspicuous clip-on, and the second by deleting audio and video content after it has been processed and analyzed, sort of like Snapchat does for messages.  

And maybe digital health assistant will be the killer retail app.

I think the concept of "augmented reality" raises the bar for digital assistants.  Instead of just warning you about eating that donut, the digital health assistant might flash a picture of you with an extra thirty pounds just to re-enforce the risks it poses. It'd be like the health care version of "scared straight."

OrCam is a reminder that our digital future doesn't necessarily lie in smart phones or smart watches or even smart glasses. This is why companies like Facebook and Google are pouring so much money into virtual reality -- not just to escape reality but to augment it.

People talk about "the digital doctor," but what really makes that concept interesting is that it may not involve a doctor at all.  I just hope my digital assistant knows when to be quiet and when to make me listen.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

How National Thought Leaders View The Post SCOTUS Public HIX World

By Clive Riddle, July 10, 2015

Earlier this month, Health Insurance Marketplace News published a supplemental edition of their newsletter, providing commentary from 27 ThoughtLeaders around the country at the SCOTUS King v Burwell decision. They were asked: “What’s your gut reaction to the ruling? What happens next? What challenges will Exchanges face now?”

Here’s some excerpts from key ThoughtLeaders representing major stakeholders:

First off, not everyone was pleased with the ruling. Here’s comments from Michael F Cannon, Director of Health Policy Studies, Cato Institute, Washington DC, who was considered one of the primary architects behind the lawsuit brought before SCOTUS:  “So rather than respect the democratic process and the separation of powers, Roberts allowed himself to be intimidated into rewriting the law and writing Congress out of the legislative process….What happens now is that ObamaCare opponents will continue to fight to repeal this law, because so long as it remains on the books ObamaCare will continue to threaten access to care for the sick.”

Grace-Marie Turner, President, Galen Institute, Alexandria VA, a prominent opponent and champion of consumer driven care, tells us “ People want better solutions. The only appeal to a Supreme Court decision is to the American people. Health reform -- patient-centered, consumer-focused health reform -- will be a major issue in the 2016 elections as more and more people experience firsthand the problems with ObamaCare. Change is inevitable.”

Alain C. Enthoven PhD, Marriner S. Eccles Professor of Public and Private Management (Emeritus), Knight Management Center, Stanford (CA) University, a nationally prominent and oft-quoted  figure on health policy  says the decision was “the triumph of common sense. The case should never have been brought. Obviously the intent of the law was to cover every legal resident of the USA. What’s next is to face the challenge of excess healthcare costs, which are diverting resources from meeting other important needs -- such as education, infrastructure, national security and debt reduction The ACA did very little to change the fundamental cost-increasing incentives in our system of healthcare finance. Two good places to start would be to cap the exclusion of employer contributions from employee taxable incomes at the level of efficient health plans and to convert Medicare to a premium support model, so that practically everyone would have cost-conscious choices of health plan.”

Mila Kofman JD, Executive Director, DC Health Benefit Exchange Authority, Washington DC,  actually runs a state public exchange and was of course, a happy camper: “The Supreme Court decision was important for millions of Americans who now have access to quality, affordable health coverage thanks to tax credits provided through the Affordable Care Act. I am very glad that states that use Healthcare.gov didn’t have to scramble to try to protect millions of people who would have lost access to affordable health coverage. I am relieved that millions of Americans who need premium reductions to stay covered no longer have to worry about becoming uninsured.”

Meanwhile, Simeon Schindelman, CEO, Bloom Health, Minneapolis – one of the most noteable private exchange platforms – is a little pessimistic: “The individual market needed reforming. The ACA is an incredibly expensive and complicated way to accomplish some of that reformation, but it does seem to make health insurance in the individual market accessible to many more people -- and that is a worthy outcome. I’m not judging the method, only that portion of the result. Reduction in uninsured is largely a result of Medicaid expansion and we need to be clear on that. Financial (and potentially operational) sustainability of state Exchanges, while watching insurance premium rates in the individual market over the next couple of years as the environment changes a lot, could be the next two big issues. On the former, there seems to be some pretty rough sledding coming soon and in some instances already here. On the latter, we have an abundance of speculation, but it’s an important topic.” 

From the employer perspective, JD Piro, Senior Vice President and National Practice Leader, Health and Benefits Practice, Legal Group, Aon Hewitt, Lincolnshire IL, tells us “this case was the last major judicial hurdle that the Affordable Care Act had to clear before full implementation. As a result, employers should focus on reporting on compliance with individual and employer mandates for 2016, as well as determining the impact of the excise tax in 2018. Additionally, more employers may consider a strategy of transitioning pre-65 retirees from group-based insurance to the individual public Exchange to take full advantage of the choice, competition, favorable premiums and federal subsidies.”

Larry Boress, CEO and President, Midwest Business Group on Health; Executive Director, National Association of Worksite Health Centers; Chicago, echoes the excise tax concern: “Most employers had already planned to offer health benefits prior to the decision and will stay the course to focus on how to avoid the excise tax.”

And words from the man involved at the very start – with the Commonwealth Health Insurance Connector Authority that helped inspire the ACA - Jon M Kingsdale PhD, Managing Director, Wakely Consulting Group; Visiting Lecturer on Healthcare Policy, Department of Healthcare Policy, Harvard Medical School; Former Executive Director, Commonwealth Health Insurance Connector Authority; Boston: “The 6-3 majority interpreted the ACA in the only way that makes sense, notwithstanding clear (and clearly mistaken) wording to the contrary. This is actually a ‘win’ for all interested parties, except the actual plaintiffs: It preserves coverage for 6.2 million Americans of modest income; it strengthens the law; it averts chaos in the individual insurance market in 32 states; and it allows Republicans to continue rallying their base by attacking ‘Obamacare,’ while escaping the political fallout for succeeding. Both Justice Roberts’ ruling and Justice Scalia’s overwrought dissent point to a common need -- for Congress to move beyond political posturing to constructive revision of the ACA, if only to correct poor drafting. Of course, substantive improvements are also needed, first and foremost to simplify this outrageously complex statute. However, any opportunity to do so awaits the outcome of our next national election.”