Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Ways That Effectively Transform Primary Care

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Accountability is the key ingredient in managing and ultimately reforming healthcare.  

Policymakers try to reform health care and on the top of their worksheet are ways to accelerate transformation to high-value models of advanced primary care practices. In so doing, "they are challenged by two things: the lack of a clear definition of the clinical model they are trying to create and the transformed practices [and] a business case for deploying it." Baron and Davis propose an "APCP category [that] would be best thought of as a bundle of services provided by a team using a technology platform designed to support a variety of visit-based and non–visit-based activities rather than as a discrete cognitive service offered by physicians."  

Rather than using visit-based fee-for-service payments where the incentives are miserably unaligned, they suggest "a payment system for advanced primary care under Medicare: a clinical model specifying practice capacities and a payment model offering care management fees that flow on behalf of a defined population in a predictable way, incorporating accountability for population health outcomes and opportunities for shared savings."

See: Shannon Firth. "Medical Care vs. Population Health–Why the U.S. gets so little bang for its healthcare buck" [a video featuring] David Nash, MD 4/9/17 MedPage Today [referencing Dr. David Kindig, U. Wisconsin] and "The road from Volume to Value."

It is reassuring that in reform we are revisiting an old, familiar paradigm, albeit repackaged.  We note, for example, that it has a "new" lexicon best represented by the Centers for Medicare and Medicaid Services' "Nine Comprehensive Primary Care Initiative Milestones or Objectives" for the first year of operations.  Again, this is deja vu for this former physician executive and it gives me solace as it is rational, wholesome and promises coordination, communication and care.

  1. Annual budget including expenses associated with practice change
  2. Care management for high-risk patients — impaneled patients, patient risk status and tracking, care management services, personnel, and care management plans
  3. 24/7 patient access to physicians or nurses, with real-time access to medical records
  4. Assessment and improvement of patient experience based on patient surveys or patient and family advisory councils
  5. Use of data to guide improvement, including at least quarterly calculation and reporting of data on quality and utilization measures
  6. Care coordination/timely communication pertaining to emergency department visits, hospital admission/discharge, medication reconciliation, and specialist referrals
  7. Shared decision making, including use of decision aids for high-priority conditions
  8. Participation in a learning community and sharing of knowledge, tools, and expertise*
  9. Meaningful use of health information technology, including meeting requirements for Stage 1 electronic health record (EHR) Incentive Programs

Baron RJ,  Davis K. "Accelerating the Adoption of High-Value Primary Care — A New Provider Type under Medicare?" N Engl J Med 2014;370:99-101 | target="_blank">Published Online December 18, 2013

For those health care professionals, worried about the implications if not intrusion of population health:

Pushing doctors and other practitioners to employ "evidence-based care through clinical practice guidelines and increasing the communication with patients outside of face-to-face encounters" will have significant, if not greater impact than the status quo.  Indeed, population health can have "wonderful uses at the right place at the right time. When doctors and patients understand the evidence-based gaps in routine primary and secondary prevention, the right care is much easier to provide (and receive)."

"Combined with shared decision making, population health also helps ensure we are enabling person-centered, values congruent care. But for patients with complex co-morbidities or devastating acute conditions — those catastrophic health events where medical miracles occur and where we spend a huge percentage of our GDP — population health may not be a panacea. In our journey towards health care redesign, it can’t be the only tool."

 Caveat: "losing focus on the complexities and benefits of highly personalized, individualized care" remains concerning to all kinds of practitioners.

"Redefining Health Care Delivery–Improvement, Innovation and Value." [Extract from the New England Journal of Medicine (NEJM Catalyst); last accessed 8/11/2016.]

History Taking & Physical Examination Skill Set Guidelines

    •    See UpToDate’s “Approach to the Patient

    •    Essential Tasks of the Contemporary Clinician

◦    Comprehend the biomedical and psychosocial knowledge base pertinent to your field of medicine

◦    Develop a personal strategy to learn continuously and manage the rapid changes in this information

◦    Connect in a personal, professional manner with each patient who seeks care from you

◦    Understand the healthcare delivery system in which you work, and your role in it

◦    Act in ways that maximize the cost-effectiveness and healing influences of the healthcare that you provide

◦    Educate and support your patients in the optimal use of the healthcare system

    •    Review Bates Guide to Physical Examination and History Taking, 11th Edition.  Chapter 1, Chapter 2, Chapter 9, Pages 347-361.

    •   Consider Electronic Preventive Services Selector (ePSS) is an application designed to help primary care clinicians identify clinical preventive services that are appropriate for their patients. Use the tool to search and browse U.S. Preventive Services Task Force (USPSTF) recommendations.

If the aforementioned incentive alignment and medical management initiatives don't work, what about pure marketplace solutions—they're no panacea, either.  Consider, for instance, the following older discussion, still relevant that opponents of a 'public option' complained that it will result rationing and denial of care.  They need to read this response by Medicare to authorize particular uses of MRIs to get a sense of how Medicare makes decisions about guidelines.

From:  Fredrick H (MD, PhD, JD)

Sent: Tuesday, June 30, 2009 10:35 PM
Subject:  The following may represent the gold standard of reasonableness in guidance by health plans
The Centers for Medicare and Medicaid Services (CMS)
See L. Gordon Moore, MD of 3M: "CMS initiatives meant to help primary care result in dismay" posted May 6, 2016 where Gordi suggests: 
  • "Focus more on outcomes and less on process: There are still too many metrics to track in CPC+.
  • Allow entities/practices to shift from older into newer programs that better align financing with good care delivery: Allow MSSPs to flip into CPC+ if they can meet the criteria.
  • Reduce the friction of participation: Somehow put pressure on the IT vendor community to line up in support of interoperability and other solutions that reduce the friction of work (oh, wait! CPC+ has this built in!  Good going folks.)
  • Health plans need to step up their game: CMS is shifting the payment model away from FFS.  Commercial and Medicaid plans should support the shift with more realistic payments to primary care and by bringing to bear innovative solutions to reduce the friction of work.  The commercial plans in particular have a better opportunity to innovate in this space and can demonstrate their continued relevance by moving more quickly."

How do the aforementioned suggestions come into play?
 CMS reviewed evidence that speaks to MRI assessment of cardiac blood flow asking if it helps to improve patient outcomes when employed in the management of a Medicare beneficiary’s medical problem. 
Here's what CMS had to say in "Assessing the Relative Magnitude of Risks and Benefits"
"Generally, an intervention is not reasonable and necessary if its risks outweigh its benefits.  Health outcomes are one of several considerations in determining whether an item or service is reasonable and necessary.  CMS places greater emphasis on health outcomes actually experienced by patients, such as quality of life, functional status, duration of disability, morbidity and mortality, and less emphasis on outcomes that patients do not directly experience, such as intermediate outcomes, surrogate outcomes, and laboratory or radiographic responses.  The direction, magnitude, and consistency of the risks and benefits across studies are also important considerations.  Based on the analysis of the strength of the evidence, CMS assesses the relative magnitude of an intervention or technology’s benefits and risk of harm to Medicare beneficiaries."
(MRI) (CAG-00399R)

All participants in the healthcare equation must be simultaneously accountable to maintain accurate data on meaningful use targets and a formal table of contents of the medical record (i.e., a Weedian Problem Oriented Medical Record or POMR)

CMS should revisit, revise and recommend or promote its meaningful use targets.  Indeed, ACP advised in 2012 what the players must do or should do to quality for Medicare and/or Medicaid Elecronic Health Records [EHR] to receive incentive payments {PDF}.  At the same time healthcare practices need to recalibrate their goals to be more comprehensive, interoperable and realistic.

"Meaningful Use holds only those who actually deliver patient care responsible for all of the outcomes being measured. Providers must exchange information with other entities, yet the non-EP entities with whom they must communicate may have no obligations under Meaningful Use. For any measure that involves communicating outside the practice, the exchange partners (labs, pharmacies, payers, and public and private reporting entities) must be held equally accountable for the success of the exchange.

The Medical Informatics Committee of the American College of Physicians respectfully submits this letter hoping that it will assist ONC in the important work of improving healthcare in the United States through the appropriate use of health information technologies."


Michael H. Zaroukian, MD, PhD, FACP, FHIMSS Chair, Medical Informatics Committee
American College of Physicians

Rhetorical Questions:

  • Are any private insurers or HMOs this methodical, rational and open about their coverage policies?
  • Are Accountable Care Organizations, in essence, Managed Care Organizations in a more competitive marketplace?