Comments on: Four Ways that Federal Healthcare Reform Could Improve Healthcare Value http://chqpr.org/blog/index.php/2009/03/four-ways-that-federal-healthcare-reform-could-improve-healthcare-value/ Fri, 21 Jan 2011 22:19:06 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Harold Miller http://chqpr.org/blog/index.php/2009/03/four-ways-that-federal-healthcare-reform-could-improve-healthcare-value/comment-page-1/#comment-229 Harold Miller Mon, 27 Apr 2009 22:23:18 +0000 http://chqpr.org/blog/?p=50#comment-229 Thanks,Frank. I agree with you on the provider-centric vs. patient-centric problem with current versions of the Medical Home. I like think of the current efforts as "Version 1.0." Rather than trying to create a different initiative altogether, we should keep the best parts of Version 1.0 and change the parts that need to be changed to create a better Version 2.0. For example, Pennsylvania in its Chronic Care Model demonstration project has already made significant changes from the initial version that was implemented in the Philadelphia area to the new version that is being implemented in the rest of the state. The new version concentrates much more on paying for nurse care managers to provide more hands-on patient education and self-management suppport, particularly for patients being discharged from the hospital. Even this new model still needs to be improved (so it's probably Version 1.5, not 2.0), but I think it will be easier for physician practices to understand different versions within the same overall initiative than to get "yet another new initiative" that's completely separate. Harold Thanks,Frank.
I agree with you on the provider-centric vs. patient-centric problem with current versions of the Medical Home. I like think of the current efforts as “Version 1.0.” Rather than trying to create a different initiative altogether, we should keep the best parts of Version 1.0 and change the parts that need to be changed to create a better Version 2.0. For example, Pennsylvania in its Chronic Care Model demonstration project has already made significant changes from the initial version that was implemented in the Philadelphia area to the new version that is being implemented in the rest of the state. The new version concentrates much more on paying for nurse care managers to provide more hands-on patient education and self-management suppport, particularly for patients being discharged from the hospital. Even this new model still needs to be improved (so it’s probably Version 1.5, not 2.0), but I think it will be easier for physician practices to understand different versions within the same overall initiative than to get “yet another new initiative” that’s completely separate.
Harold

]]> By: Frank Opelka http://chqpr.org/blog/index.php/2009/03/four-ways-that-federal-healthcare-reform-could-improve-healthcare-value/comment-page-1/#comment-228 Frank Opelka Mon, 27 Apr 2009 11:22:25 +0000 http://chqpr.org/blog/?p=50#comment-228 Four great areas of focus: Halt readmisions; Medical Homes with a target focused approach; Regional Health Improvement Collaboratives; and Participate in local payment reforms. On the Medical Home, I think the focus would be better stated that we need to serve patients with chronic care more successfully and probably through delivery system redesign. I am less secure that the medical home will accomplish this goal. Perhaps, a physician directed chronic care delivery system redesign is the real need. That could include the medical home, a transition care team (Mary Naylor) or a new use of health care at home. PCPs need to carry the water, but the focus should be more patient centric than the medical home model. The medical home model is still to physician centric. It is an improvement but it will likely fall short, since more PCPs tend to think they already are a medical home - just underfunded. Secondly, the regional health improvement collaboratives are a great effort to create a culture of quality. I think we have individual quality efforts and silos of quality ownership. We need to take that effort to create care teams of quality and ultimately an organizational culture of quality. Perhaps the RHICs can be the first step. We need metrics to examine the presence and the level of a culture of quality. Thanks. Great website. Frank Four great areas of focus: Halt readmisions; Medical Homes with a target focused approach; Regional Health Improvement Collaboratives; and Participate in local payment reforms.
On the Medical Home, I think the focus would be better stated that we need to serve patients with chronic care more successfully and probably through delivery system redesign. I am less secure that the medical home will accomplish this goal. Perhaps, a physician directed chronic care delivery system redesign is the real need. That could include the medical home, a transition care team (Mary Naylor) or a new use of health care at home. PCPs need to carry the water, but the focus should be more patient centric than the medical home model. The medical home model is still to physician centric. It is an improvement but it will likely fall short, since more PCPs tend to think they already are a medical home – just underfunded.

Secondly, the regional health improvement collaboratives are a great effort to create a culture of quality. I think we have individual quality efforts and silos of quality ownership. We need to take that effort to create care teams of quality and ultimately an organizational culture of quality. Perhaps the RHICs can be the first step. We need metrics to examine the presence and the level of a culture of quality.

Thanks. Great website.
Frank

]]> By: Harold Miller http://chqpr.org/blog/index.php/2009/03/four-ways-that-federal-healthcare-reform-could-improve-healthcare-value/comment-page-1/#comment-220 Harold Miller Thu, 09 Apr 2009 17:46:08 +0000 http://chqpr.org/blog/?p=50#comment-220 Reducing readmissions will, by definition, save money. The challenge is getting the right programs in place to do that. The problem with most of the care coordination interventions is that reducing readmissions is a post-hoc evaluation metric, rather than a primary focus of the program from the beginning. The most recent evaluations have shown that telephone-based care management doesn't work, but care management that includes home visits does (or at least can) work, and programs like Care Transitions do work reliably. There has to be both the ability and the motivation by the organization doing care coordination -- which should ideally be a physician practice, not a disease management company -- to focus its efforts on the populations that are (a) at high risk of readmission and (b) with high probability of success in avoiding readmission. That may be at odds with process-driven P4P systems that force a focus on making sure every single patient gets an Hba1c check, regardless of whether they are at risk of hospitalization, readmission, or other high utilization of services. Reducing readmissions will, by definition, save money. The challenge is getting the right programs in place to do that. The problem with most of the care coordination interventions is that reducing readmissions is a post-hoc evaluation metric, rather than a primary focus of the program from the beginning. The most recent evaluations have shown that telephone-based care management doesn’t work, but care management that includes home visits does (or at least can) work, and programs like Care Transitions do work reliably. There has to be both the ability and the motivation by the organization doing care coordination — which should ideally be a physician practice, not a disease management company — to focus its efforts on the populations that are (a) at high risk of readmission and (b) with high probability of success in avoiding readmission. That may be at odds with process-driven P4P systems that force a focus on making sure every single patient gets an Hba1c check, regardless of whether they are at risk of hospitalization, readmission, or other high utilization of services.

]]> By: steve http://chqpr.org/blog/index.php/2009/03/four-ways-that-federal-healthcare-reform-could-improve-healthcare-value/comment-page-1/#comment-218 steve Wed, 08 Apr 2009 17:54:57 +0000 http://chqpr.org/blog/?p=50#comment-218 Whie in theory it sounds like decreassing hospital readmissions would save money, most scientific studies have not shown the cost benefit of structured outpatient interventions to prevent hospital readmissions. This is a far more complex issue than meets the eye. 13 of 15 projects funded by Medicare in the Medicare Coordinated Care Demonstration(MCCD) did not show a decrease in readmission rates. None of the 15 programs generated net savings. One of the projects, which dealt with a more elderly and frail population, actually had an increase in readmission rates. Whie in theory it sounds like decreassing hospital readmissions would save money, most scientific studies have not shown the cost benefit of structured outpatient interventions to prevent hospital readmissions. This is a far more complex issue than meets the eye. 13 of 15 projects funded by Medicare in the Medicare Coordinated Care Demonstration(MCCD) did not show a decrease in readmission rates. None of the 15 programs generated net savings. One of the projects, which dealt with a more elderly and frail population, actually had an increase in readmission rates.

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