Health Information Technology and the Patient Centered Medical Home: Seven Additional Caveats

The Disease Management Care Blog is scheduled to participate in a November 12 PCPCC webinar on the timely topic of population health management (PHM).  We'll be focusing on the October 2015 PCPCC report "Managing Populations, Maximizing Technology." Readers can download it here and refer to page 2 where the DMCB, among other luminaries, is acknowledged for its thoughtful review.

The PCPCC report effectively reminds health system architects and policymakers that the electronic health record (EHR) is necessary - but nowhere near sufficient - for a high performing patient-centered medical neighborhood.  Other information technology (IT) components include intelligent shared decision making, registries, health information exchanges, analytics, referral tracking, telemonitoring, automated outreach, patient communications, mobile apps, decision support and risk stratification.

And that's just for starters. 

The good news here is that while Washington DC's EHR weenies remain focused on the dreary stages "meaningful use," innovative health systems with medical homes and neighborhoods are really using IT to make a thousand PHM flowers bloom.   

Naturally, during the PCPCC webinar, the DMCB isn't going to stop there. If given a chance, it will also point out:

1. Build vs. buy: While health systems generally believe that PHM - with or without its IT  trappings - can be built using local resources, a better answer may be to buy it from a vendor.  Why own it when you can rent it?

2. And speaking of outsourcing: While its physician-colleagues prize the stature that comes from "quarterbacking" a medical home team, what is less appreciated is the distinct possibility that a quarterback is often not the most important position.  Get out of the way and let the IT-empowered and enabled non-physicians do their thing.

3. The EHR gone wrong: "Portals" are preferred by EHR vendors because they push patients toward their products, often run by lawyers who fear HIPAA and typically programmed by IT geeks who only think about code. It's time to put patients first.

4. "This is not my patient!": While predictive modeling generates lists of patients that annoy physicians with multiple inaccuracies, the science is getting better.  That being said, many other tests like EKGs and chest x-rays are notorious for false negative and false positive results.  It's all part of being a doctor.

5. Apply a filter.... please!: The biggest threat from health IT is a data glut of numbers, labs, tests, surveys, messages, alerts, prompts, readings, alarms, vitals and figures that overwhelm medical home team members. That's going to involve setting thresholds and priorities.

6. It's not about the revenue: Forget about using health IT to justify additional payment. In a health system without anymore money, the purpose of health IT is to generate savings.  That means it has to pay for itself.

7. Watch out! The under-appreciated health IT event that is going to change the relationship between insurers and providers: the move from using paid insurance claims to submitted EHR claims to assess population outcomes.

Image from Wikipedia

Inconvenient Facts Get In the Way: Blue Cross Blue Shield of Michigan's Patient Centered Medical Home (PCMH) Program Savings Claims Are Not Based on Statistical Significance

Welcome to your medical home!

The Patient Centered Primary Care Collaborative announced:

"Blue Cross Blue Shield of Michigan saved an estimated $155 million in preventative claim costs over the first three years of its Patient Centered Medical Home program, based on calculations made from an analysis published this month in the Health Services Research Journal".

According to the Blue Cross Blue Shield of Michigan web site:

"'Blue Cross’ Patient-Centered Medical Home is transforming health care delivery, saving millions of dollars and improving lives,' said Daniel J. Loepp, president and CEO of Blue Cross Blue Shield of Michigan."

HIT Consultant's insightful coverage of healthcare innovation said:

"According to the analysis, 'Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs,' researchers found that its Patient Centered Medical Home model, when fully implemented, resulted in:

• 3.5 percent higher quality measure
• 5.1 percent higher preventive care measure
• $26.37 lower per member per month medical cost for adults"

"Whoa!" said the Disease Management Care Blog. Since $155 million from $300 per member per year reductions in claims expense is some very serious savings that, until now, has never been reported for the PCMH, it naturally looked at the original research.

What did the sleuthful  DMCB find?

Contrary to flattering press releases quoted above, the Blue Cross Blue Shield of Michigan did NOT conclusively save any money. The observed savings of $26.37 PMPM failed to achieve statistical significance and could have been the result of normal random variation that naturally occurs in the flow of claims payments.

The DMCB explains.

Physicians participating in the Blue Cross Blue Shield of Michigan Physician Group Incentive Program (PGIP) were in two payment tiers: 1) "partial reimbursement" for self-reported PCMH implementation and 2) 10% "fee enhancements" for self-reported "significant" PCMH implementation. As the DMCB understands it, 65% of all the PCPs in Michigan participated in the self-reporting in both June 2009 and June 2010. These docs cared for approximately 1.5 million Blue Cross Blue Shield patients.

During the course of self reporting, docs had to attest to the presence of PCMH capabilities, including use of a registry, obtaining performance measures, care management capabilities, patient self-management support, 24-7 patient access, test tracking and follow-up, e-prescribing, a web portal, specialty referral guidelines, preventive services and linkages to community services. Various domains within each of the capabilities were assigned a weight that was rolled into an overall score: the higher the score, the "more" the PCMH.

The researchers examined the claims history for the patients cared for at a total of 1,787 practices that were in the PGIP, had a minimum number of BCBS enrollees, had no missing data and were not quality outliers. Their median enrollment was 303 members and a mean per member per month (PMPM) claims expense of $311.

Compared to practices that never achieved any PCMH capabilities, the PMPM for practices that attained "full" (i.e. significant) PCMH implementation was, compared to practices that never achieved any PCMH implementation, $26.37 lower for adults.

The p value for the $26.37 quoted on page 15 of the manuscript equaled 0.0529.

Because the p value is greater than .05, it doesn't reject the null hypothesis and fails to meet the conventionally accepted threshold among health services researchers that the difference is real and not the result of randomness.

For children, the PCMH was associated with a $7.45 increase in costs. That likewise failed to achieve statistical significance (p = .096).

No where in the manuscript do the authors claim there were "155 million" in savings.  The DMCB suspects the authors of the press releases extrapolated the statistically non-significant figure of $26.37 to a population count.  Garbage in, garbage out.

The DMCB take:

1. Its highly likely that BCBS of Michigan has additional actuarial figures that support the cost effectiveness of the PCMH.  BCBS of Michigan also put its numbers into the public domain.  It's also likely that that PGIP and the PCMH represents an important opportunity to build and collaborate with a vibrant primary care network, which ultimately transcends any monetary savings. Kudos at many levels to BCBS of Michigan, says the DMCB, despite an over-generous misinterpretation of published health services research.

2. While the DMCB did not report on the quality measures that were concurrently reported in this HSR study, it also appears statistically significant quality of care gains were made.  That means there were increases in quality with no increase in cost.  That's good news and, thinks the DMCB, a more honest appraisal of the outcomes.

3. Unfortunately, BCBS of Michigan did not report the "net savings."  As noted above, providers were paid to implement the PCMH, which represents an additional and "hidden" PCMH cost.  Assuming the $155 million in reduced claims expense is real, it would have to be contrasted with the millions in additional fees that were paid to the doctors.

Care Management FTE: Check. Medical Home Training: Check. But Actually Use It In Patient Care? That's Another Story....

Months ago, the caffeine-addled Disease Management Care Blog reviewed with the spouse how to pre-set the kitchen coffee brewer for a pot of fresh coffee for the next morning. After listening politely to its earnest instructions, the DMCB spouse rarely set up the brewer.

Which is why the DMCB wasn't surprised by an Iowa Chronic Care Consortium (ICCC) study of how its newly minted medical home coach trainees were being deployed in the real world. The ICCC is a not-for profit organization that was founded in 2002 and offers a training program that prepares health professionals to be members of a medical home team.
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The Consortium surveyed 318 graduates from their program. Of that number, there were 164 responses, yielding a 54% response rate. 83% of the respondents were nurses, while the remainder were medical or office assistants, diabetes educators, dietitians, social workers, physicians, pharmacists or administrators.
 
The good news is that care-management caffeine was available. The majority of respondents reported that they were using their skills to coach patients for self management, care coordination, planning visits and supporting registry use.  The majority also found their work professionally rewarding.

The bad news is that these professionals were not being supported for maximum effect:

55% were still "building support for the position."

48% reported that "office work" was given a "higher priority," often due to physician and administrator resistance.

73% reported that their coaching duties were part time and was in addition to their more traditional roles.

Only 8% were involved in office "change management."

Only 11% enjoyed a pay differential that rewarded their coaching skills.

The Consortium's paper concludes - paralleling the DMCB's coffee-making travails - that a good idea accompanied by well-meaning training is not enough to overcome established clinic routines, business roles and local culture.  The authors recommend that provider payments "change," coaching functions be "operationalized," training programs be "advanced," outcomes be "demonstrated" and that roles be "clarified."

While the DMCB ponders coffee change, operations, advances, demonstrations and clarifications, the DMCB has a far more more fundamental concern for the medical home:

With friends like this, the fledgling medical home movement doesn't need any enemies.

If the clinics that took the time and the money to train these individuals are unable to leverage their skills, disappointing outcomes could end up snatching usual care from the jaws of primary care clinic transformation.

The DMCB has three recommendations:

History Repeats: Years ago, established "disease management" companies had to go on record and oppose start-ups that were offering "faux" telephonic patient counseling programs. The medical home and population health management community, including the PCPCC, likewise can't afford to have clinics going to market with diluted medical home programs that deliver empty process instead of hard outcomes.  All health care is local, and much of the buy-in for the medical home will ultimately be won or lost at that level.  Speak up!
 
Buyer Beware: Payers and insurers need to be wise to the possibility that having a trained health coach on staff with credentials is not the same as having a health coach on line with the patients. On site credentialing may be in necessary that includes review of policies, job descriptions, pay scales and staff interviews.

Build or buy: Primary care clinics need to know that when they buy patient counseling services from a population health management vendor, you get full time on a plug and play basis. That may be a better option for a clinic that is not prepared to both train and fully use an on-site health coach.