ACO Symposium: Professor Sallie Sanford to Present: State-based ACO and Medical Home Pilots: Early Lessons from the Other Washington

Sallie Sanford, Assistant Professor of Law, University of Washington School of Law & School of Public Health

In conjunction with the Center for Health & Pharmaceutical Law & Policy, this year’s Seton Hall Law Review Symposium on October 28, 2011, will explore recent changes in the structure of health care delivery, in particular the rising popularity of Accountable Care Organizations (ACOs). For more information or to register, click here.

The keynote speaker will be Dr. Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers, and legal scholars and practitioners from around the country will present panel discussions on structural development, public health implications and lessons learned from state ACO programs. One such distinguished presenter is Sallie Sanford, Assistant Professor of Law, University of Washington — School of Law & School of Public Health. Professor Sanford will take part in the panel on “ACOs in Practice: Research on Current Implementation of ACOs,” and will be presenting State-based ACO and Medical Home Pilots: Early Lessons from the Other Washington.

Professor Sanford teaches Health Law both at the law school and the School of Public Health. Her research interests include health care delivery systems, health administration law, Medicare and Medicaid, comparative health law, and medical and administrative ethics.

Professor Sanford began her legal career as a law clerk for The Honorable Robert R. Beezer of the United States Court of Appeals for the Ninth Circuit. She then served for six years as an Assistant Attorney General representing the University of Washington Medical Center, Harborview Medical Center and the UW’s health sciences schools. Professor Sanford is a member of the Order of the Coif and is admitted to practice in Washington and the U.S. Court of Appeals for the Ninth Circuit. She is the president of the Washington State Society of Healthcare Attorneys.

The CareMore Model and the Need to Better Coordinate Care for Dual Eligibles

In The Quiet Health-Care Revolution, an article by Adrian Slywotzky and Tom Main in the November issue of The Atlantic, the authors tell the story of CareMore, a for-profit company serving more than 50,000 elderly patients through 26 care centers located in Arizona, California, and Nevada.  Founded by Sheldon Zinberg, a gastroenterologist, CareMore was originally a group physician practice but it has since become a Medicare Advantage managed care plan.  As such, it is paid a capitated, risk-adjusted rate for each patient it serves, giving it a financial incentive to hold down costs.  Slywotzky and Main report that, through an emphasis on care coordination and creative “upstream” interventions, CareMore has improved outcomes, held down costs, and stayed in the black.

Each CareMore patient has a personal physician, called an “extensivist,” who ensures, with the help of an electronic medical record, that all of the members of the patient’s care team are communicating and coordinating with one another.  The extensivist is also charged with ensuring that the patient understands and is able to comply with his or her treatment plan.  One of Dr. Zinberg’s early decisions was that “noncompliance is our problem, not the patient’s.”  As a result, among other things, CareMore provides its patients with free-to-them transportation to medical appointments.

Going hand-in-hand with CareMore’s emphasis on coordination is a focus on “upstream” interventions. For a patient with congestive heart failure, a wireless scale transmits the results of her daily weigh-in to a clinic allowing fluid build-up to be caught early.  For a frail patient, “light muscle-training sessions and periodic toenail clipping” reduce the risk of falls.  And for a diabetic patient, aggressive treatment of a cut foot reduces the risk of infection and amputation.

How does all of this impact quality and cost?  Slywotzky and Main report that:

“CareMore, through its unique approach to caring for the elderly, is routinely achieving patient outcomes that other providers can only dream about: a hospitalization rate 24 percent below average; hospital stays 38 percent shorter; an amputation rate among diabetics 60 percent lower than average.  Perhaps most remarkable of all, these improved outcomes have come without increased total cost. …  CareMore’s overall member costs are actually 18 percent below the industry average.”

As with other, better known providers like the Mayo Clinic, whether the CareMore model is scalable is a question, one that may be answered in coming years because the company is growing and is likely to grow more after its purchase in August by WellPoint.

In a recently-released study conducted for AHIP–the industry group representing health plans–Kenneth Thorpe makes the financial case for enrolling more individuals, in particular those who are eligible for both Medicare and Medicaid, into health plans like CareMore that employ a coordinated, team-based approach to care.  As Thorpe explains, so-called “dual eligibles” are among the most chronically ill and therefore expensive of all patients, accounting, despite their relatively small numbers, for “36 percent of total Medicare spending and 39 percent of Medicaid spending.” In 2011, Thorpe writes, “the federal government–through Medicare and Medicaid–will spend over $230 billion on dual eligibles.” Currently, “[f]ewer than 2 percent of dual eligibles are enrolled in a coordinated care program that managed all Medicare and Medicaid covered benefits.”  Thorpe projects that if all dual eligibles were required to enroll in such a program, the federal government would save up to $125 billion and the states up to $34 billion over the next ten years.

Achieving better alignment of Medicare and Medicaid for the benefit of dual eligibles is not without its complications, of course.  Yesterday, AHIP issued a proposal reviewing key differences between the programs-including the nature and scope of covered services, eligibility and enrollment rules and procedures, provider networks and access requirements, and beneficiaries’ right to information and to appeal-and recommending ways to eliminate or work around them.  Among AHIP’s recommendations is that “States be given opportunities to share with the Federal government and with health plans, as appropriate, in savings generated through increased integration.”  As it stands, “it may be difficult for States to justify State investment in efforts to generate such savings, for example through programs intended to decrease acute hospitalizations or increase reliance on Medicaid-covered [i.e. partially State-funded] services.”

A Guide to the Patient-Centered Medical Home

White House at Night, Vincent Van Gogh (1853-1890)

As the United States continues on its path towards reforming its health care system, it will be governed primarily by the Patient Protection and Affordable Care Act (PPACA). One of the means by which the legislation attempts to institute reforms is through the use of pilot programs. In a previous post, I examined the pilot program known as the “accountable care organization” (ACO) which effectively formalizes and leverages existing  networks of physicians and providers in an effort to increase cooperation across the continuum of care; the hypothesis being that an organization that is accountable for a broader range of care can more effectively coordinate and efficiently deliver that care.

PPACA does not limit itself to ACOs. Another pilot program contained in the legislation is the medical home, commonly referred to as the “Patient-Centered Medical Home” (PCMH). The PCMH concept is not new. The American Academy of Pediatrics coined the term medical home back in 1967. Through the following decades, the concept of a medical home has, however, been refined. Throughout the 1970’s, the American Academy of Pediatrics continued to discuss the important role of a medical home in pediatric care, releasing a number of reports focusing on the proper role of a medical home for pediatric care.

That medical homes were spawned in the context of pediatrics is not  surprising: children are particularly unable to coordinate their own care, or, in many cases, even effectively communicate the narrative of the care which has transpired.  As such, it becomes the role of  parents, physicians, and others in the health care delivery system to communicate and coordinate the care of  the child. Parents are not always available or able. Logically, there must be some locus of coordination. In some ways, the primary care physician within the Patient- Centered Medical Home stands figuratively, as regards the coordination of medical care, in loco parentis.

Recognizing the importance of the medical home, the AAP created a task force to define the medical home.  In 1996, the influential Institute of Medicine embraced the concept of medical homes. They did not, however, limit their discussion of the medical home to children, but instead stressed the importance of care coordination for many, if not all, patients. (Click here to read IOM’s discussion on the matter). IOM’s belief in the general importance of medical homes has proven prescient in light of the ever-increasing complexity of clinical diagnosis and treatment that operates in an increasingly fragmented health care system. It has become increasingly difficult, even for adult patients, to communicate and coordinate care.

Principles of Patient Centered Medical Homes

In 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association released “Joint Principles of the Patient-Centered Medical Home.” In it they distilled the following seven principles of the medical home. They are, in part:

1.       Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

2.      Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

3.      Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

4.      Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

5.      Quality and safety are hallmarks of the medical home.

6.      Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

7.      Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.

The Cornerstones of Patient Centered Medical Homes

Diane Rittenhouse and Steven Shortell have distilled four cornerstones for PCMHs from the above principles:

The four cornerstones of PCMHs, as represented in a talk given by Dianne Rittenhouse

Recently, Rittenhouse gave a talk to UCSF where she did an excellent job of explaining the four cornerstones in the context of the U.S. health care system. The link below jumps straight to the discussion of the cornerstones or you can watch the presentation in its entirety below.

A Discussion by Dianne Rittenhouse on the Cornerstones of the PCMH

As is clear from the joint principles and cornerstones, primary care is the distinguishing factor of the PCMH, as opposed to other models such as the ACO. As Rittenhouse and her colleagues have noted: “The PCMH model emphasizes the creation of a strong primary care foundation for the health care system, and the ACO model emphasizes the alignment of incentives and accountability for providers across the continuum of care.”

Patient Centered Medical Homes in Practice

Are PCMHs a pipe dream? Do we have any experience with them? The answer to the second question is yes, a substantial number of PCMH demonstrations are occurring throughout the country. A recent study by Bitton and colleagues at Harvard Medical School looked at 26 currently active PCMH pilots that incorporated 14,494 physicians, 4,707 practices, and served nearly 5 million patients. The researchers found that there were two ways of using PCMHs to transform health care delivery: a “consultive model” and a “chronic care model.” (For more information see Bitton et al., “Patient Centered Medical Home Demonstration Projects,” Journal of General Internal Medicine, available here.)

The chronic care model focuses on using quality improvement coaching to identify characteristics of care systems that must be changed to improve the treatment of chronic diseases.  The consultive model typically features proscriptive change in practice management most often carried out by external facilitators hired to organize assessment and transformation. (See Bitton page 590). As Bitton notes, the majority of pilot programs surveyed used the chronic care model, with those groups focusing specifically on asthma and diabetes. These initiatives were often the product of state activities, including Regional Health Information Organizations (RHIOs), Quality Improvement Organizations, and other state programs.

In order to become a PCMH, most practices have needed to apply to be recognized as such. The application process often requires the use of an assessment tool created by the National Committee for Quality Assurance — a group comprised of the same organizations who released the Joint Statement mentioned earlier. To accomplish this process the NCQA created the Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH) program to create a framework for medical home recognition. As stated on the NCQA website: “There are nine PPC® standards, including 10 must pass elements, which can result in one of three levels of recognition. Practices seeking PPC®-PCMH^TM complete a Web-based data collection tool and provide documentation that validates responses.” These standards are used to gauge the “medical homeness” of the applicant.

Payment Reform as the Rate-Limiting Step

As noted by Rittenhouse and others, payment reform is one of the cornerstones of the PCMH model. In the demonstrations currently underway, payment reform has been typically realized by a “three part” model adopted by the Patient-Centered Primary Care Collaborative (PCPCC) — a coalition of major employers, consumer groups, patient quality organizations, labor unions, and others, that have come together to facilitate the creation of PCMHs. The payment model is comprised of:

1.      Ongoing fee-for-service payments

2.      A fixed (typically monthly) case management fee; and

3.      Pay for Performance potential bonus payments

As the PCPCC states: “Payment reform should correct existing imbalances and distortions in physician payment and take into account value created by primary care, especially in the areas of cost, quality, care coordination, access, and patient centeredness.” However, the Bitton study had some unfortunate conclusions with respect to payment reform in extant PCMHs. The study found that many of the PCMH demonstrations currently retain the fee-for-service model as the core method of reimbursement and, despite the efforts at creating a common framework, “substantial variability” in the form, payment methods, and means of practice transformation. Such variation does not seem to favor smaller practices.

Though the PCPCC has attracted a broad range of industry groups to sign on to their PCMH model, it is unclear how a model that retains the traditional fee-for-service framework will work. Even if the FFS model could work, Bitton’s study found that only some of the demonstrations included up-front payments that could be put towards the required investments for transformation.  For the ACO model, upfront costs and uncertainties can be more easily absorbed because of the larger organizational structure of the ACO. However, many primary care physicians practice in small groups. The IT investments and other transformations will require time and resources that many primary care physicians may find difficult to swallow. Moreover, as Rittenhouse notes, the PCMH model does not provide incentives to those outside of primary care to work with the primary care physicians collaboratively. This will only compound the difficultly of  implementing PCMHs. Rittenhouse does, however, offer a glimmer of hope: the synergizing role of ACOs. As ACOs will benefit from the primary care focus of PCMHs, Rittenhouse believes that PCMHs can leverage the ACOs delivery system infrastructure to make the implementation of PCMHs more realistic.

The Cost of (Not) Implementing Chronic Care Management

Photo by linda yvonne via Flickr

Health reform’s primary beneficiaries will be the uninsured, but it should also benefit those with “good” insurance.  We all know horror stories of well-insured relatives and friends driven from pillar to post in attempts to get good treatment for serious chronic conditions.  It too often seems that no one is in control: doctors aren’t paid to talk to patients, but rather to do things to them, and the roles of other professionals (e.g., advanced practice nurses) are sometimes minimized.  As I’ve described earlier, there is some good news regarding medical practice reform in the bills, particularly for people with Medicare or Medicaid.

How do we get people into medical settings where their chronic conditions can be well-managed?  Interesting work is being done in many quarters on this issue.  In a recent Health Affairs paper, Steven D. Pizer and coauthors reported that people with chronic conditions in regions of the country with thin Medicaid programs are likely to be uninsured, notwithstanding Medicaid’s strong orientation toward disability and chronic care.  In a companion article,   Andrew P. Wilper and coauthors reported on high levels of uncontrolled — often undiagnosed — chronic conditions (hypertension, diabetes, and elevated cholesterol) among  people without insurance.  Public insurance expansions in pending reform bills would assist these low-income people with chronic illness get coverage, and the chronic care provisions have the capacity to provide appropriate medical management of their most pressing conditions.

Structure is emerging on best practices for the delivery of sound coordinated care.  The NCQA has worked with physician groups to create tools to evaluate practice settings according to their ability to serve as therapeutic homes for all, but in particular for those with chronic conditions.  The Physician Practice Connections - Patient-Centered Medical Home program provides tools for public and private payers to evaluate a physician practice before designating it a “medical home” - and compensating it accordingly.  The tools evaluate prospective medical homes on factors such as their active support of patient self-management; use of non-physician staff for patient management; employment of procedures to maintain high levels of patient communication; and adoption and use of evidence-based care management protocols for chronic illness.

So how much does it cost to do this right?   A recent study from Commonwealth Fund sheds some light on this complex issue.  In the study, Stephen Zuckerman and coauthors take on the difficult task of examining the marginal cost of converting a 20^th Century practice to a 21^st Century medical home.  It makes interesting reading, and tentatively suggests that the cost could be modest.  Zuckerman et al. are attempting to compute cost. They recognize that cost is only a component in a more important calculation: what is the value of creating medical homes?  They cite to a 2008 Deloitte report that gathers research tending to show that the cost is probably worth it, even in purely economic terms.  That is, it appears that the savings achieved in avoided hospitalizations and other expensive interventions is significant, washing out the cost of supporting sound chronic care management.  It is not, of course, only about efficiency; ending the chronic care horror stories is the true goal.

Expanding insurance is only the first step in delivering the care people need.  For people with chronic illness, the finance and delivery system needs to work with the whole person, family, and community, and not slice the patient into 8 minute blocks and procedure codes.  A consensus statement of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association describes a commendable principle of care coordination that has particular application for people with disabilities and chronic illness:

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services).  Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Practice follows payment.  Payment reform must facilitate the adoption of practices that serves chronic needs.

Senator Baucus on Delivery System Reform

Professor Tim Greaney

Tim Greaney,

Director, Center for Health Law Studies

Chester A. Myers Professor of Law

Saint Louis University School of Law

Senator Baucus’ March 3 press conference sponsored by the Kaiser Family Foundation Health Care Reform Newsmaker Series: Sen. Max Baucus (D-MT) offered a few insights into the early state of the debate on health reform legislation.

Two points stood out.  First, he observed that “delivery reform” was for him a central element in designing reform legislation. Pressed to define what he meant, Baucus mentioned value based purchasing and the medical home concept.  Second, he stated that the tax exclusion for employer health insurance payments was on the table, noting two characteristics that make it an appealing target:  regressivity and potential source of considerable “revenue.”  On these and other issues, Baucus stressed the critical role OMB scoring will play in shaping the ultimate design of the legislation.

The known unknown here, however, is how some of the relatively novel delivery reforms like medical homes will be defined and implemented — and hence ultimately scored by OMB for their impact on system costs. One problem is that the “medical home” may encompass a wide range of delivery/financing arrangements. In general the medical home has been broadly defined as a physician-directed practice that provides care that is “accessible, continuous, comprehensive and coordinated and delivered in the context of family and community.” But as Bob Berenson and colleagues pointed out in Health Affairs last September,[1] few primary care medical practices are close to having the size, management capabilities and infrastructure (electronic and otherwise) to function as medical homes.  Transitioning to such practices (even on a virtual office basis) will surely take time, money, and a sea change in culture and practice style.  Estimating the pace and effectiveness of such change may prove as daunting as projecting next months Dow Jones average.

Model Wanted

The NY Times reports that according to Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and an associate professor at the Harvard School of Public Health, “there’s a drastic decline in the number of geriatricians - and just 300 new ones are being trained each year - yet the number of people over 65 will double in the next 20 years. Those who work in geriatric care are among the worst paid in the health care system.”

That last statement, as shown in a recent post regarding physician compensation, is backed up by numbers. According to the American Group Medical Association (AMGA) the median compensation for a geriatrician is $179,344. The median compensation for a podiatrist is $180,080. These AMGA numbers have been approved by the Center for Medicare and Medicaid Services (CMS) for use in CMS related calculations.

Dr. Gawande “and others see a pressing need for new approaches to keep aging patients as healthy as possible and living independently as long as possible.” The Times reports that “Dr. Chad Boult, a geriatrician at Johns Hopkins School of Public Health in Baltimore, says the goal should be care that is well coordinated, and patients and families who are involved in and educated about the care plan.”

To that end, Dr. Boult is participating in the testing of a “team approach” which is somewhat reminiscent of the subject of a recent post, Alaska’s Southcentral Foundation’s “medical home” approach. Southcentral’s “comprehensive” health care strategy has shown some promising results. The Times reports that

Dr. Boult is involved in testing a team approach, in which nurses trained in geriatrics are helping physicians in the Baltimore-Washington area provide coordinated care for 50 or 60 of their highest-risk older patients. The nurses go to patients’ homes, develop comprehensive care plans, help the patients in self-monitoring, help them overcome obstacles to self-care and connect patients and their families to community agencies.

According to geriatrics experts, social workers trained in the problems of the elderly can also participate by performing home assessments, for example, to prevent falls and costly, disabling fractures. They can help overcome barriers to good nutrition, and they can help make the community connections for assistance with the activities of daily living, like shopping.
Dr. Boult said that “The Baltimore team project has already demonstrated an improvement in the quality of care that ailing elderly patients receive, and by keeping patients out of the hospital, he expects it will save money for insurers like Medicare.

The NYTimes also reports, however, that the current fee for services compensation scheme has not yet been structured so as to provide monetary incentives for such prophylactic care. The Times states: “While current insurance systems pay many thousands of dollars for hospital-based care, they cover only a fraction of the far less expensive care delivered by doctors and nurses that can keep patients out of the hospital,” and that experts say “a new model of care is needed.”
Read full article here.