As this year’s National Medical Home Summit (at the end of February 2012), there were no big headlines, no major announcements, no breakthrough evidence. There was a sense of momentum, that things were moving in the right direction, but there was still a lot of work – a lot of hard work – to be done. There was some cheerleading, but it was more like cheering on marathon runners at the start of the race rather than some other sport with more instant gratification.
One of the opening plenary speakers was Ed Wagner from the MacColl Center for Health Care Innovation, the architect of the chronic care model that has been incorporated into many medical home models. Unfortunately, Dr. Wagner repeated the same talk he has given at conferences for the past several years, with little new data or observations. The one change he highlighted was that he is now calling the chronic care model “planned care.” At the very end of his presentation, Dr. Wagner referenced the work being done in the Safety Net Medical Home Initiative, led by Qualis Health (the Medicare Quality Improvement Organization for Washington and Idaho), and funded principally by the Commonwealth Fund. The Commonwealth Fund had just released a report from the initiative that describes the “change concepts” (an Institute for Healthcare Improvement buzz phrase) that are being implemented by community health centers and other safety net providers on their path to becoming patient-centered medical homes. The change concepts are leadership, a quality improvement strategy, empanelment, assigning teams, enhanced access, evidence-based care, care coordination, and patient-centered interactions.
Medical homes in the safety net were a strong theme throughout the two and a half day summit. Qualis Health’s Jonathan Sugarman provided an overview of medical home activities at community health centers and other safety net providers. He described some of the lessons being learned in the Safety Net Medical Home Initiative: that change is difficult, the order of implementing change concepts matters, and practice transformation needs to be aligned with other changes in the practice. Dr. Sugarman noted that achieving medical home recognition is not the same as practice transformation, which takes a lot of time and needs many types of technical assistance. He also noted that most current payment mechanisms for medical homes are focused on a subset of a practice’s patients but that effective practice transformation should benefit all a practice’s patients.
While there was reference to a just published article in Health Affairs reporting little correlation between a self-assessed evaluation of medical home recognition level and diabetes outcomes at community health centers in Los Angeles, there was little discussion of whether current medical home models need to be adapted implementation among safety net providers.
The National Academy of State Health Policy’s Mary Takach described medical home activities being implemented by 19 state Medicaid programs. Many states are looking to medical homes as a way to generate savings in a time of state budget constraints.
But there was little discussion about the Medicaid “health homes” authorized under section 2703 of the Affordable Care Act (the ACA defines “health homes” under the Medicaid program differently than other definitions of medical homes). State Medicaid programs can draw down significant federal funding for 24 months (with only a 10% state match required) for care coordination services by such health homes, but only three states – Missouri, Rhode Island, and New York – have implemented the option. This option is important because it is based on the Medicaid population (rather than the Medicare population focused on by almost all prior medical home initiatives), and because it explicitly includes behavioral health issues as vital to the “whole-person orientation” and the services that must be provided by a health home.
The other theme highlighted at this year’s summit was patient- and family-centeredness, the part of “patient-centered medical home” that everyone acknowledges is important and then has very little to say about. Fortunately, the summit did have actual patient advisors as speakers, who shared their perspectives as patients and becoming part of the activities their health care providers were implementing to improve quality. What was remarkable was to hear patients describe how receiving clinical summaries and updated medication lists is really useful in managing their own health care but how rare it still is for patients to have access to such basic health information, let alone have an expectation that every health care provider should be sharing this type of health information with them as patients.
UPMC’s Michael Celender noted that there are some relatively low-cost strategies to increase patient involvement in quality improvement beyond patient surveys, including providers shadowing (observing) or experiencing care from a patient perspective, patient storytelling about their experiences of care, and implementing workflow and other practice redesign from a patient perspective. He defined a caregiver as anyone who interacts or “touches” a patient or family’s experience of health care, both at health care settings, and at the patient’s home, and urged that caregivers also be included in our conceptualization of patient-centeredness.
Among the other plenary speakers, the Centers for Medicare & Medicaid Services Innovation Center’s Richard Baron described many of the CMS initiatives on quality improvement and cost reduction, including the multi-payer primary care demonstrations in 8 states, the Advanced Primary Care Practice Demonstration in 500 Federally Qualified Health Centers, the 32 Pioneer Accountable Care Organizations, and the Medicare Shared Savings (ACO) Program to begin April 1, 2012.
Peggy O’Kane from the National Committee for Quality Assurance also addressed the summit, appropriately pleased at the continued increase in the number of primary care practices (now 16,000) that have achieved recognition by NCQA as patient-centered medical homes. O’Kane also highlighted the recent availability of NCQA accreditation for accountable care organizations (note: medical homes are only “recognized” and not “accredited” or “credentialed” to avoid confusion with state licensing authority over the practice of medicine, or certification by national medical specialty boards, while both health plans, and now accountable care organizations, can be “accredited” by NCQA). If you were listening closely, O’Kane also disclosed that NCQA was exploring both the development of a recognition program for specialists in the “medical neighborhood” (especially those specialists that often function as primary care providers for their patients, such as some oncologists for patients with cancer, physicians who care for patients with HIV, mental health providers, geriatric specialists who care for elderly patients, etc.) and an optional module in health plan accreditation for those plans engaged in accountable care and payment reform.
A panel of local health plan executives described how their business and operational models were rapidly evolving in a post-health care reform market. UnitedHealthcare’s Susan Schick commented that health plans, including her own, had already shifted from describing themselves as insurance companies to “health and well-being companies.” WellPoint’s Sam Nussbaum predicted that future lines of business would be focused on Medicare Advantage, state health exchanges, and supporting physician networks in accountable care organizations. Independence Blue Cross’ Richard Synder noted that large health plans would continue to offer value to multistate and national employers who wanted standardized health insurance products for their employees rather than sorting out what might be available from every state health insurance exchange.
Some of the most provocative and interesting observations at the summit were made by Lisa Bielamowicz from the Advisory Board, who bluntly concluded that hospitals will lose volume, and therefore revenue, if medical homes are successful (by avoiding emergency department visits and hospitalizations). She estimated that if hospitals do not shift from reliance on fee-for-service payment model, current 2% margins will quickly become 17% deficits. Accordingly, even without formal accountable care organizational relationships, hospitals now see their relationships with primary care providers as a risk buffer in expected payment reforms. Some hospitals are re-purposing their buildings into outpatient facilities to expand their ambulatory services. Finally, Bielamowicz noted some interesting innovations in health care, including using fire department stations as primary care delivery sites in Alameda County, California.
In his closing remarks, McKesson’s David Nace highlighted recent medical home activities and investments in the first two months of 2012. For example, Wellpoint announced a $1 billion investment in primary care and medical homes, followed by other investments announced by Aetna, Horizon Blue Cross Blue Shield (New Jersey), and Blue Cross Blue Shield Florida. While impressive taken together, all these announcements had been made weeks earlier so there was no “news”. Dr. Nace also observed that the federal government – through the Veterans Administration, Health Services and Resources Administration funding for community health centers, Indian Health Service, and Department of Defense health facilities – all have “adopted medical homes as a “standard of care,” adding that the Office of Personnel Management also requires health plans for federal employees and retirees to have medical homes. He noted that both payment reform and health benefits redesign were necessary strategies to advance medical homes. As chairperson of the board of the Patient-Centered Primary Care Collaborative, Dr. Nace concluded with a call to action, to implement medical homes “clinically, contractually, operationally, and culturally” throughout health care in America.