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Physician practices will need DM/population health

Medical home

Physician practices will need DM/population health

DM/population health organizations will experience changes and opportunities in the medical home, said speakers at a September DMAA: The Care Continuum Alliance Webcast.

Paul Grundy, MD, MPH, director of IBM’s healthcare, technology, and strategic initiatives and chair of the Patient-Centered Primary Care Collaborative (PCPCC) in Washington, DC, and Bruce Bagley, MD, medical director for quality improvement of the American Academy of Family Physicians in Leawood, KS, spoke during the Webcast.

The two men were scheduled to take part in the keynote address for DMAA’s annual forum, which was postponed because of Hurricane Ike. DMAA instead hosted a Webcast with the two speakers. (DMAA has rescheduled its conference to November in Florida.)

The momentum of the medical home movement has involved several healthcare players—employers, payers, PCPs, and the DMAA.

Although some in DM/population health are concerned about what the medical home might mean to the industry’s future, Tracey Moorhead, president of DMAA: The Care Continuum Alliance in Washington, DC, said DM/population strategies are an important component to the medical home, and physician practices will need the industry’s expertise to implement the medical home.

Grundy said IBM became interested in changing healthcare delivery because the company was spending $2 billion for healthcare, and its employees were getting little benefit. In fact, the nation’s healthcare is “garbage,” he said, because there is simply not enough emphasis on prevention and connecting the many players in the system. What IBM and other large employers want is a coordinated healthcare system.

“What we do now is so grossly unacceptable in terms of [not] putting the patients in the center of what needs to be done. The money aside, what we do now is atrocious to our patients,” Grundy said.

Grundy said the U.S. healthcare system focuses on the disease rather than the patient. It also doesn’t reward physicians for keeping patients healthy. He said the United States spends twice as much as any other developed nation on healthcare, and the country has the highest teen pregnancy and abortion rates of those nations, as well as the highest infant mortality rate. Only half of the U.S. population is getting the necessary preventive services and exams, Grundy said.

Part of the problem is that the system has disempowered the patient-doctor relationship and does not allow for coordination. Physicians are not communicating with one another through a network that would avoid unnecessary costs and protect patients from potential medication errors, Grundy said. For example, having a patient visit five different specialties that are not communicating about the patient’s care is wrong, according to Grundy. “As a buyer of care and the son of a father and mother that are desperately in need of care, it’s unacceptable, it’s immoral, it’s wrong. We need to address this in a fundamental way,” Grundy said. He said payers need to take a leadership role and change the way they pay for healthcare.

For example, rather than reimburse for a patient’s leg amputation, payers need to pay physicians to prevent patients from having that amputation through preventive services, he said, adding that the current payment structures are flawed and “economic incentives significantly influence healthcare in frequently perverse and completely unintended ways.” Grundy said the flaws in the payment structure include:

  • Salary: Problems with productivity
  • Fee for service: Problems with overuse
  • Capitation: Problems with under use
  • Pay for performance: Problems with ignoring the healthcare not attached to payment

Grundy said what is needed is a blending of payment structures. The PCPCC has recommended the following three-part payment methodology:

  • A monthly care coordination payment for physician’s work that falls outside of face-to-face visits and for the health information technologies needed to achieve better outcomes
  • A visit-based fee-for-service component that is recognized for services that are currently paid under the present fee-for-service payment system
  • A performance-based component that recognizes achievement of service, patient centeredness, quality, and efficiency goals

Bagley said he believes a PMPM coordinated care fee, coupled with incentives for providing quality care, is needed. “A blended payment makes a lot of sense,” he said.

In addition to a new payment structure, Bagley said primary care practices need to become places of continuing, comprehensive, and personal care. This means a change from the individual physician as the sole leader of the practice to a team of people who work to provide care coordination. That approach must involve a real team in which each player, from the physician to the office staff members, shares responsibility for quality and care.

  • Bagley said a successful medical home includes:
  • A team approach to care
  • Registries for the top diagnoses
  • Active care coordination
  • Built-in quality systems and measurements
  • Partnership with community resources
  • Advanced patient education and self-management support
  • Service orientation
  • Information technology support

Bagley said there are new opportunities for DM/population health companies in the medical home. (See “Opportunities for DM/population health” in the left column.) Those companies will need to change their focus from helping the individual patient coping with chronic illness to assisting the primary care practice in helping patients cope with chronic illness, he said.

DM and primary care practices have been disconnected historically, but the medical home will bring coordination between the two, he said.

Practices will also have to integrate DM/population health into practice flow. Bagley acknowledged that this change is a big shift for DM/population health and primary care practices.

Bagley said primary care practices have not been optimally using community resources such as DM and population health organizations.

But physicians will need to use those companies that have experience in patient registries, patient self-management, health coaching, and 24/7 nurse lines in the medical home. “We have to encourage offices to use those resources when it’s appropriate,” he said, adding that there are some services that practices will need to outsource.