Sunday, January 25, 2009

Marrying the Medical Home and Hospital Readmissions

Demonstration projects are underway all across the country to improve the quality of primary care delivery by encouraging implementation of the “patient-centered medical home.” The most common approach is to convince health insurance plans and/or other healthcare payers to increase their payments to a primary care practice if it meets certain standards, most commonly the medical home standards developed by the National Committee for Quality Assurance (NCQA).

However, payers, and the purchasers they represent, are reluctant to pay more for medical home services without assurances that patient outcomes will be better and that costs will be saved elsewhere. And since there is no guarantee that meeting the NCQA standards will result in either better outcomes or lower costs, payers want to hedge their bets by making the payments as low as possible. But this creates a Catch-22: if the payments are too low to allow the primary care practices to make the changes in care needed to improve patient outcomes, then all that will happen is that costs will go up, the medical home projects will be labeled failures, and the healthcare system will return to its ineffective status quo ante.

Is there a way out of this dilemma? The answer could lie in the policy discussions being held around the country about ways to reduce preventable hospital readmissions. As noted in a previous post, many hospital readmissions aren’t directly the fault of the hospital. The largest number of readmissions occurs among patients with chronic disease, and their frequent admissions to the hospital reflect gaps in the primary care they’re receiving — which is precisely the problem the medical home projects are trying to fix. Studies have shown that with appropriate education and self-management support, hospital admission rates for chronic disease patients can be dramatically reduced, but today, payers don’t pay adequately or at all for those patient support services.

So on the one hand, we have a primary care improvement initiative without a clear outcome, and on the other hand, we have an outcome improvement goal without a clear strategy for achieving it. Could a marriage of the two can address the weaknesses of each? Absolutely: Payers should pay primary care practices adequately to provide evidence-based medical-home services to chronic disease patients at risk of hospitalization, and those practices should agree to an explicit focus on reducing the rates of hospital admissions and readmissions among those patients. The savings achieved by payers from reduced hospitalizations would more than offset the costs of the improved services, justifying funding those services at levels sufficient to achieve the desired results.

Comments

“The savings achieved by payers from reduced hospitalizations would more than offset the costs of the improved services, justifying funding those services at levels sufficient to achieve the desired results.” – At this time, no actual study has proven this. The most recent, published in the Journal of the American Medical Association, which is physician, not hosptial run, did not demonstrate that active structured coordinated interventions signifcantly decresed readmissions in 13 of 15 projects a round the country and in all of them, there were no costs savings. There needs to be more studies defining the spcifiec subpopulation of the chronically ill that would benefit from Medical Homes, in order to reach the desired outcomes.

Comment by steve — April 8, 2009 @ 1:03 pm

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.
Harold Miller

Comment by Harold Miller — April 9, 2009 @ 12:49 pm

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