Recent Comparative Studies of Health Systems

As America continues to wrestle with the thorny thicket of health care reform, there are a number of recent reports chronicling and comparing approaches to health care and health reform in different countries that are worth a read.  For example:

• The Organisation for Economic Co-operation and Development recently released Health at a Glance 2011: OECD Indicators, which provides “comparable data on different aspects of the performance of health systems in OECD countries.” The U.S. spends 2 ½ times more than the OECD average health expenditure per capita (which amounted to 17.4% of GDP in 2009). (OECD explores why in a separate addendum, “Why is Health Spending in the United States So High”.) Yet, with the exception of cancer care and acute care in hospitals, it is not clear Americans are getting improved quality for the greater expenditures. As reported by CQ HealthBeat and by the Commonwealth Fund, “hospital services cost much more in the United States and pharmaceutical prices are much higher compared to other countries;” “there are fewer practicing physicians per 1,000 population, fewer doctor consultations and shorter hospital stays;” “more CT scans, knee replacements, and Caesarean sections;” and “comparatively high hospital admission rates for preventable conditions like asthma, diabetes and hypertension.”

• Strengthening Primary Care: Recent Reforms and Achievements in Australia, England, and the Netherlands, a recent report by Sharon Willcox, Geraint Lewis, and Jako Burgers of the Commonwealth Fund, evaluates efforts to improve access to, and the quality of, primary care in these countries– and suggests what the U.S. can learn from these initiatives. These countries have been focusing on three primary care reform strategies: promoting coordination of care, reforming primary care payment, and improving quality and access. As the abstract summarizes, “[q]uality improvement strategies include postgraduate training programs for family physicians, accreditation of general practitioner (GP) practices, and efforts to modify professional behaviors–for example, through clinical guideline development. Strategies for improving access include national performance targets, greater use of practice nurses, assured after-hours care, and medical advice telephone lines. All three countries have established midlevel primary care organizations both to coordinate primary care health services and to serve other functions, such as purchasing and population health planning. Better coordination of primary health care services is also the objective driving the use of patient enrollment in a single general practice. Payment reform is also a key element of English and Australian reforms, with both countries having introduced payment-for-quality initiatives. Dutch payment reform has stressed financial incentives for better management of chronic disease.”

• Bradford H. Gray, Thomas Bowden, Ib Johansen, and Sabine Koch, also of the Commonwealth Fund, review the extent of adoption of “meaningful use” (as defined in federal regulations) in three countries with extensive experience with electronic health records, Denmark, New Zealand, and Sweden in Electronic Health Records: An International Perspective on “Meaningful Use.” Although these European countries have high levels of EHR adoption, they have not reached 100% meaningful use, with the greatest weakness being in information provided to patients. The authors suggest that the U.S. could learn from these experiences the value of “providing economic incentives to encourage adoption and designating an organization to take responsibility for standardization and interoperability.”

• International Profiles of Health Care Systems: Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States, edited by Sarah Thomson, Robin Osborn, David Squires, and Sarah Jane Reed and published by the Commonwealth Fund, provides an overview of the health systems in these countries– including “health insurance, public and private financing, health system organization, quality of care, health disparities, efficiency and integration, use of health information technology, use of evidence-based practice, cost containment, and recent reforms and innovations.”

• The Commonwealth Fund also recently released results of an international study of patients with complex care needs in eleven countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the U.S. Although it identified significant care coordination issues, it found that “patients who have a medical home reported better coordination of care, fewer medical errors, and greater satisfaction with care than those without one.” In addition, the study also found “that patients in the United States are much more likely than those in 10 other high-income countries to forgo needed care because of costs and to struggle with medical debt.” 27% “were unable to pay or encountered serious problems paying medical bills in the past year, compared with between 1 percent and 14 percent of adults in the other countries,” and 42% did not see a doctor, fill a prescription, or receive recommended care. The authors conclude that “[t]he United States in particular has opportunities to learn from abroad-including the use of purchasing power to lower prices, payment innovations, and the use of information systems and care system redesign efforts that are under way in several countries.”

Of course, there are a variety of reasons the experiences in other countries may not take root in the United States.  But we still should be aware of these efforts and critically evaluate whether we might transplant any of them as seeds of reform here.

Reform Rodeo

1. Maggie Mahar at Health Beat discusses a new report published in the NEJM that supports the importance of the individual mandate in combating adverse selection.

2. At the Health Care Blog, Paul Levy writes sardonically about the accountability of accountable care organizations.

2a. On a less sardonic note, Chris Fleming gives an overview of Health Affairs’ special issue covering ACOs.

2b. Thomas Greaney writes in the NEJM about how the federal government’s can help ACOs navigate an already concentrated health care landscape.

3. The Hill reports on the essential items and services that health insurers will have to provide when offering their products in the new exchanges.

4. David Kibbe and Brian Klepper document the federal government’s initiatives in giving the HIT market a much needed shot-in-the-arm.

5. The Commonwealth Fund’s Melinda Abram’s discusses one of the most important facets of health care reform: how the ACA will bolster primary care.

Reform Rodeo

1. ProPublica details the incessant problem that medical schools face in preventing their faculty from accepting money in exchange for speaking on behalf of pharmaceutical companies. As previously noted on this blog, these conflicts of interests are in addition to those conflicts found in spinal surgery and cardiac stenting.

2. For the New England Journal of Medicine, Michael E. Porter introduces two recently published papers that explore the concept of value in health care.

3. The Commonwealth Fund provides a summary of a briefing on the ACA’s initiatives to reform primary care. A full video of the briefing (which was co-hosted with the Alliance for Health Reform), as well as a podcast of the audio, can be found here.

4. The Health Care Blog has a nice bulleted Year in Review for Health Information Technology (HIT), including topics such as the HITECH Act, E-prescribing, EHRs, and Health Information Exchanges.

5. The  New York Times discusses a new Medicare rule that will cover the costs of voluntary end-of-life treatment planning.

A Guide to the Patient-Centered Medical Home

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.

Reform Rodeo

1. Kaiser Health News discusses the details of the House’s latest iteration of their Health bill.

2.  Ezra Klein analyzes whether the public plan will cost insureds more than private insurance.

3.  The New England Journal of Medicine circles back to a reform issue that is often overlooked: primary care and accountable care.

4. Jonathan Cohn at The New Republic looks at how two of the biggest players in the U.S. health care system–the medical device industry and the pharmaceutical industry–are affected by the House bill.

5.  The Healthcare Economist reports on a study released by the Urban Institute that breaks down how the House Bill will affect the number of uninsured.

6.  Wild Card: Eugene Volokh highlights on a case involving one company’s desire to patent a physician’s thought process.

7. In Case You Missed It: The Cost of (Not) Implementing Chronic Care Management by Professor John V. Jacobi.

Managed Health Services Offers Money Incentive to Visit Doctor, Get Screenings

We’ve talked often enough on this blog about the cost efficacy of preventive care–and how the failure to address smaller medical issues under more affordable conditions (such as a visit to a primary care doctor or clinic) can readily become larger medical issues that wind up having to be treated under the most expensive of conditions (emergency room and hospital treatment). Which is to say, ” a stitch in time saves nine.”

But what if you need someone else to come forward in order to save those eight stitches?

According to the Washington Post, Managed Health Services (MHS), which bills itself as being  “Real Life Solutions for HealthCare,” has begun offering Medicaid patients a monetary incentive, which can be spent on health care or health care related items “simply by visiting the doctor or seeking routine preventive care.”

WaPo reports

Some Indiana Medicaid patients can now earn money to spend on health care simply by visiting the doctor or seeking routine preventive care.

Managed Health Services on Monday announced a new debit card program that rewards patients for making regular trips to the doctor, taking their babies in for checkups and getting screened for several conditions.

Participants can earn between $10 and $20 on their cards for each visit or screening.

The  MHS website, offers the following from a letter it recently sent out to providers:

Members will receive their monetary reward loaded on a Debit MasterCard® that is sent to the member only after the first eligible PMP visit or screening has been completed. The CentAccount MasterCard will be accepted at participating groceries and pharmacies, and is restricted to the purchase of health-related items, such as over-the-counter medicine. The CentAccount can also be used at www.diapers.com to purchase items such as diapers and bottles, and at doctor offices that accept Debit MasterCard® for the payment of co-pays.

WaPo reports that

Patients can earn $15 simply by visiting a primary care doctor within 90 days of joining the program. An annual checkup leads to another $20 deposit on the card.

Parents who take their newborn children for required checkups can receive $10 per visit. The program also serves children covered by the State Children’s Health Insurance Program up to age 20.

Money also can be earned through screenings for breast and cervical cancers, diabetes and the venereal disease chlamydia.

WaPo also reports that according to Pat Rooney, president and CEO of Managed Health Services, a subsidiary of St. Louis-based health insurer Centene Corp, “In some cases, patients might add more than $100 to their card over a year.” Rooney stated: “Just getting people in to see their primary care doctor is always a challenge with this population. They tend to want to go to the emergency room for care.”

WaPo reports that “Rooney said Managed Health Services debuted a similar program more than a year ago in South Carolina, and patients appear to be seeing their doctors more since that program started.”

As the South Carolina system is, one might say, in a state of flux because of relatively recent measures to shift Medicaid participants over to a managed care system, hard numbers may, understandably, be hard to come by. But this program strikes me as one which bears following. I would hope that at least one of the major foundations will study the matter and gauge the effect of a relatively nominal monetary incentive on preventive and primary care usage. As this particular population is comprised of Medicaid recipients, if said population have been recipients over a period of time, their historical emergency room visits, hospital stays– and the cost thereof– are all ascertainable.

And these are numbers that could make a difference. As a matter of common sense, to keep from having to pay for all those “additional stitches,” it may prove beneficial to give a half-a-stitch to the person we need to come forward in time in order to save the nine. Simple Math.

Clinic Expansion Under Bush Thought Likely to Continue Under Obama

The NY Times reports that “President Bush leaves office with a health care legacy in bricks and mortar: he has doubled federal financing for community health centers, enabling the creation or expansion of 1,297 clinics in medically underserved areas.”
The article notes that:

“As a crucial component of the health safety net, they [community health centers] are lauded as a cost-effective alternative to hospital emergency rooms, where the uninsured and underinsured often seek care,”

and that

“Studies have generally shown that the health centers — which must be governed by patient-dominated boards — are effective at reducing racial and ethnic disparities in medical treatment and save substantial sums by keeping patients out of hospitals. Their trade association estimates that they save the health care system $17.6 billion a year, and that an equivalent amount could be saved if avoidable emergency room visits were diverted to clinics.”

As an example, the Times article cited Nashville’s United Neighborhood Health Services, a recipient of increased funding which has expanded more than two-fold in the last 8 years. The Times notes that “One of the group’s recent grants helped open the Southside Family Clinic, which moved last year from a pair of public housing apartments to a gleaming new building on a once derelict corner.” A 68 year old patient of that clinic who had just received breathing treatments, “said she would have sought care for her bronchitis in a hospital emergency room were it not for the new clinic. Instead, she took a short drive, waited 15 minutes without an appointment and left without paying a dime; the clinic would bill her later for her Medicare co-payment of $18.88.”

The article also states that “Despite the clinics’ unprecedented growth, wide swaths of the country remain without access to affordable primary care. The recession has only magnified the need as hundreds of thousands of Americans have lost their employer-sponsored health insurance along with their jobs.”

Widespread Support for Community Health Centers
The Times notes that “In response, Democrats on Capitol Hill are proposing even more significant increases, making the centers a likely feature of any health care deal struck by Congress and the Obama administration.”

In August, President-elect Obama sponsored a bill in the Senate “that would quadruple federal spending on the program - to $8 billion from $2.1 billion — and increase incentives for medical students to choose primary care. His wife, Michelle, worked closely with health centers in Chicago as vice president for community and external relations at the University of Chicago Medical Center.”

In his recent book on health care reform, HHS secretary Tom Daschle referred to the health centers as “godsends.” The Times article also notes that the federal program “was first championed by Senator Edward M. Kennedy” and “has earned considerable bipartisan support.”

Physician Compensation, Subsidies and Service Requirements
The article notes that with United Neighborhood Health Services starting pay for doctors is $120,000. “Because of a nationwide shortage of primary care physicians, the clinics rely on federal programs like the National Health Service Corps that entice medical students with grants and loan write-offs in exchange for agreements to practice as generalists in underserved areas. Of the 16 doctors working for United Neighborhood, seven are current or former participants.”

Follow-up Care Lacking
Although widely lauded as a viable solution to Primary Care medical delivery, the article notes that follow-up for more serious conditions can be problematic.

“A deeper frustration for health centers concerns their difficulty in securing follow-up appointments with specialists for patients who are uninsured or have Medicaid. All too often, said Ms. Bufwack [Chief Executive, United Neighborhood Health Services], medical care ends at the clinic door, reinforcing the need to expand both primary care and health insurance coverage. ‘That’s when our doctors feel they’re practicing third world medicine,’ she said. ‘You will die if you have cancer or a heart condition or bad asthma or horrible diabetes. If you need a specialist and specialty tests and specialty meds and specialty surgery, those things are totally out of your reach.’”
Read full NYT article here. Read WSJ Health Blog report here.