a unicorn — a fantastic creature that is vested with mythical powers. But no one has actually seen one.

a camel — a horse designed by a committee, one that already has its nose in the tent

With this background, you can begin to appreciate the difficulty of conducting an accurate census of ACO animals in the wilderness.  Yet, this is exactly the task undertaken in the excellent Leavitt Partners report measuring ACO activity in the US.

As I will explain, the Leavitt report has the potential both to overestimate and underestimate ACO and accountable care-like activities. In my judgment, however, it’s far more likely to be understating just how much accountable care activity actually is going on.

Findings in the Leavitt Report

The Leavitt researchers “identified ACOs from news releases, media reports, trade groups, collaborations and interviews through the beginning of September 2011. Also included were entities that either self-identified as being an ACOs or specifically adopted the tenets of accountable care.”

The report counts 164 ACOs — 99 that are primarily sponsored by hospital systems, 38 by physician groups, and 27 by insurers.

Here’s how Leavitt summarized their results: (more…)

Here are six quick first impressions:

1. It’s very creative and innovative. CMS has demonstrated out-of-the-box thinking and leaves a lot of room for applicants to propose their own approaches. Expect to have to read the materials 2-3 times to wrap your thinking around it.

Unlike the Medicare Shared Savings ACO rule, the BPCII is flexible.  Anticipate some innovative and non-traditional proposals from diverse applicants. Unlike the Medicare ACO Shared Savings rule, the BPCII invites flexibility in:

• Definition of care bundles
• Proposal of specific financial terms
• Participation by diverse care providers (see below)
• Risk adjustment of beneficiaries

(more…)

by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

Physicians face great uncertainty. According to a survey conducted by The Physicians Foundation, the great majority of physicians (89%) believe the traditional model of independent private practice is either “on shaky ground” or “is a dinosaur soon to go extinct.”

In the face of this uncertainty, many physicians are jumping to a conclusion that “I have to sell my practice to the hospital.” In this post of our series on The 100 Year Shift, we will examine physician practice.  We’ll show that the economic and clinical environment  is changing rapidly and that selling to the hospital is one option. However, it is not the only option. (more…)

In our introductory posting of this series, we noted that economic incentives previously aligning doctor-hospital interests were changing. This creates the potential for The 100 Year Shift – physicians awakening to possibilities for stronger partnerships with payers than with hospitals.

In this post, we will zero in on the changing economic position of hospitals and the effect this is having on physician-hospital relationships. We will examine the trend of hospital employment of physicians and point out challenges and tensions for the future. [This is a long post...so now might be the time to refill your coffee cup.] (more…)

IMHO, the recent acquisition by Highmark Blue Cross Blue Shield of West Penn Allegheny Health System (WPAHS) for $475 M is unique to local market conditions. It was done as a last resort and should not be taken as a signal that health plans are starting a hospital buying binge.

Why are hospitals unattractive investments for health plans:

(more…)

by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

In our introductory posting, we suggested that a huge shift is underway in the health care industry.  Decades of hospital-physician cooperation are not only eroding, we suggest this trend could accelerate.  Instead of a natural clinical and economic affinity with hospitals, we foresee the potential for physicians forming a new dyad with insurer-buyers.

In this post, we will examine what we and many other commentators view as inevitable: the demise of volume-based payment systems and how the drive for greater value will cause physicians and insurers re-examine their normally antagonistic relationship. (more…)

Gazing at the horizon, we foresee the potential for a tectonic realignment among physicians, hospitals and payers. Here’s a quick visual representation:

This essay is the first of a seven part series. In this first post we will capsulize our vision of this potential 100 Year Shift, answer initial FAQs, and lay out the structure for the rest of the series.

The Lynchpin — Changing Economic Incentives

In the past, physicians and hospitals have benefited from mutually supportive economic interests. (more…)

1) Hospital administrators assume that tighter physician-hospital integration (e.g., through employment of physicians) will result in ”captive referrals” by physicians back to the mother-ship hospital.

2) Medicare administrators are assuming that Medicare Shared Savings ACOs will be able to coordinate patient care even without limitations on patients’ choice to go to providers outside of the ACO provider network.

Here’s the data that challenges the validity of BOTH of these assumptions:

(more…)

Why have hospitals increasingly been buying physician practices?  Are these marriages based on true love or convenience? Will these marriages survive?

To address these questions, let’s take the long view (50–100 years) and revisit 7 assumptions that have driven us to today’s healthcare non-system:

1. Healthcare payment systems have rewarded piecemeal work.
2. Despite uneasiness, hospital-physician relationships have been cooperative.
3. Physicians can function effectively in small/medium size practices.
4. The healthcare mindset: built on control, not collaboration.
5. Barriers to sharing patient info and coordinating care are high.
6. The hospital has been the economic bedrock of the community.
7. Health plans are the bad guys.

For more details and discussion, tune in to tomorrow to BlogTalk Radio. Host and ACO guru Gregg Masters will be interviewing me and we’ll discuss the topic of “Is Hospital-Physician Integration Sustainable?”

The details:

Wednesday May 11th 2011 broadcast, at 11AM Pacific/2PM Eastern

Click here to add a reminder to your calendar or to read more information about our session.

UPDATE: May 11, 2011. A replay or download of the interview is now available by clicking here.

Reprinted courtesy of MCOL.

Perspectives on a Selected Key Topic |     April 2011/May 2011     |   Volume Three Issue Two

Will a material number of hospitals and their core medical staffs, that are relatively independent, evolve into highly integrated delivery systems during this decade, and why?

William J DeMarco MA, CMC

President and CEO, Pendulum HealthCare Development Corporation

The great momentum brought about by government and private payers demand for more accountability is unstoppable. Rapid consolidation of hospitals and consolidation of physicians by physician groups, hospitals and now insurers will shift referral patterns and consumer preference. 1 out of 4 hospitals will fall short of providing value and close or be absorbed within 10 years.

Physicians will be offered higher prices to sell out to insurers and investors who value the short supply of PCPs and will try to control care demand by retooling the care system building ASC and small scale short stay hospital.

True clinical integration will follow for the survivors. The ability to prospectively develop clinical budgets and bundles of services will connect regional tertiary and quaternary care facilities to local hospitals so integration can be regionalized across larger populations and payer segments.

Once these delivery systems realize they need a product recognizable to individual consumers they will seek alliance with select insurers or create their own insurance company thereby achieving the true definition of integration which is to integrate financing and delivery of care.

This offers the shared savings with themselves and stabilizes patient flow and overhead to achieve value to purchasers and users of care.

We think these opportunities will be at a tipping point on a market by market basis over the next 5 years and will be a national definition of success within 8 years. We believe this will happen because already the bond rating companies are looking at physician alignment and payer alignment as factors in establishing credit worthiness of hospitals for expansion and mergers.

Benjamin Isgur

Director, PricewaterhouseCoopers LLP’s Health Research Institute

Integration is certainly on the rise. The notion of independent physicians may be a myth because so-called independent physicians are becoming increasingly financially tethered to hospitals. In fact fifty-six percent of physicians PwC surveyed want to more closely align with a hospital in order to increase their income. The new health reform law focuses on population health and adopts a Medicare compensation model that penalizes poor quality and rewards cost savings and electronic information sharing. Some commercial payers are also pushing this business model. (more…)

On Friday April 1st, 2011 (yes, ‘April Fools day’) at 4 PM Eastern and 1 PM Pacific

ACO Watch: A Mid Week Review will host a special roundtable series on the ‘hot of the press’ Notice of Proposed Rules’ pertaining to the implementation of Accountable Care Organizations. For the published rule, click here.

The roundtable team will consist of Mark Browne, MD, PYA, aka @consultdoc, Vince Kuraitis, e-Care Management blog, aka @VinceKuraitis, and David Harlow, the Harlow Group, LLC,  aka @healthblawg, with Gregg Masters, aka @2healthguru, as moderator and host.

To listen live, or via archived replay, click here. During the broadcast you may also listen in via (619) 393-2836, and even participate in the chatroom.

Having been a debater in high school and then trained as a lawyer, my default mode of thinking is to be critical:

“Hey, Vince, how ya doin’? Great day isn’t it?”

“Well, …err…maybe, maybe not…actually, here’s 14 reasons why not.”

My wife and friends kindly tell me that this personal quality can be insufferable, and if you’ve ever met a lawyer you know what I’m talking about. My internal defense mechanism against my inner-critical brain is simply to turn it off — just go along for the ride and live in the moment.

To the extent that you can connect with what I’m saying, I suggest that before reading this report that you turn off the critical part of your brain.

If you’re a regular reader, chances are you’ve read individual white papers on these topics:

• PCMH — the Patient Centered Medical Home
• Care Coordination
• Access to care for the un and underinsured
• HIT — health information technology and the HITECH Act
• Payment reform, especially as it’s been discussed around ACOs (accountable care organizations).

“Better to Best” transcends all these topics — it weaves them together, displays the interrelationships, and describes specific components of what a truly integrated health system could look like. (more…)

Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico

What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?

Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule. His list of five key design issues includes:

1. How will patients be assigned to ACOs?
2. To what cost benchmark will ACOs be compared?
3. How will bonuses be calculated and paid?
4. For which quality metrics will ACOs be responsible?
5. What is the application process?

I’d like to add a sixth  item — which actually would be #1 on my list.

As I’ve previously written, IMHO the central issue around ACOs is:

Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.

So here’s item #6:

(more…)

The whitepaper is a great overview of accountable care and ACOs (Accountable Care Organizations). It’s a quick and easily digestible read.

However, there is one key point articulated in the paper that I’d like to emphasize here:

accountable care is not synonymous with ACOs.

(more…)

Keith Wright and Gregory Drutchas’ incisive article Economic Credentialing: A Prescription To Secure Shared Savings Under Accountable Care provides useful history and context about economic credentialing:

For many years, the use of economic factors by hospitals in making medical staff credentialing decisions has been the subject of much discussion and debate among physicians, groups such as the American Medical Association (AMA), healthcare providers, payors, and attorneys….the implementation of healthcare reform is likely to bring the debate over economic credentialing to the forefront once again.

While economic credentialing has been talked about a lot, it’s rarely been used.

The controversy over economic credentialing arises again with ACO’s…and this time the answer might be different — and opportunistic for primary care.

Economic Credentialing from the Hospital POV— The Big Red Button

From my personal experiences, the threat of a hospital imposing any type of economic credentialing on their medical staff has been a big red button  issue — akin to a hospital declaring war on some physicians, with the risk of alienating nearly all physicians.

Management guru Peter Drucker wrote that the two most difficult organizations to “manage” were hospitals and the military. Most hospitals work hard to integrate physicians in decision making and they share a great deal of information about clinical and business issues. (more…)

Webinar Title: An Impending Marriage: Electronic Health Records (EHRs) and Care Management Software

The presentation will be geared at practicing clinical case managers in health plans, hospitals, disease management companies, and similar organizations:

• Describe market forces driving integration of EHRs and care management software. 
• Review care management software survey data and stimulus funding for EHR adoption. 
• Describe a 3 stage framework for the evolution of EHRs and care management software. 
• Characterize benefits to patients and impacts on care manager responsibilities.

The event is sponsored by HealthSciences Institute and the PartnersinImprovement Alliance.

When:

Friday, February 4, 2011
11:30 am Eastern Time
10:30 am Central Time
9:30 am Mountain Time
8:30 am Pacific Time

Your Presenters:

Vince Kuraitis JD, MBA
Better Health Technologies, LLC

Garry Carneal, JD, MA
Schooner Healthcare Services

More Information and Registration:  Click here.

Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: Massachusetts General Hospital and Massachusetts General Physicians Organization (MGH)

Remind Me Again About the CMHCB Medicare Demo…

The CMHCB started in 2005. My recollection is that the demo requirements were extremely similar to the Medicare Health Support (MHS) project, with a few exceptions: 1) Applicants had to include direct care providers (delivery systems, physicians) in their program design, 2) patient populations were significantly smaller than MHS.  Please comment on anything I’m missing.

I’ve included an addendum at the bottom providing more info about this little known and not widely discussed Medicare demo.

…and what was the MGH CMP project for the CMHCB?

(more…)

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

(more…)

“Track who is on a care team — and share info with the patient.”

That’s just one of the summary recommendations coming from expert testimony given in a recent public hearing on how to improve care coordination through the use of health information technology. The Meaningful Use workgroup and Quality Measures workgroups are now wrestling with how to translate this recommendation into meaningful use criteria for HITECH Stages 2 and 3.

Seems like a good idea — simple, straightforward — perhaps even obvious. The EHR (electronic health record) could be a great tool for keeping care team members in the loop and on the same page about a patient’s care.

But then I thought about this for a few minutes, and the complexities started dawning. This seemingly simple recommendation — “Track who is on a care team and share info with the patient” — is the proverbial can of worms.

(more…)

Last week I attended and participated in an excellent conference — the National Reducing Hospital Readmissions Forum sponsored by World Research Group.

One of my main take aways is to observe a simple — yet huge — difference in mindset between hospital executives and vendors.

Over the past few months I’ve heard many vendors with diverse health care offerings talking about building readmission avoidance “programs” that they want to sell to hospitals.  Their idea here is to put together a soup-to-nuts offering of technologies and services — a “program” that hospitals would mostly outsource to a 3^rd  party vendor.

This concept has never quite sat right with me. Having spent the first 15 years of my career in and around the hospital world, I’ve often observed a “not-invented-here” aversion to anything brought in by outsiders.

My suspicions were confirmed at the conference.

The hospital mindset is NOT “we’re looking for an outsourced program from a vendor that will solve our readmissions problem.

While hospitals are in various stages of planning, here’s my sense of how hospitals have thought about readmissions:

(more…)

Who has the most comprehensive data about YOUR clinical conditions?

For most people, the answer today is “your health plan”, but it’s not at all clear that health plans will continue to have this role in the future.

As physicians and hospitals adopt EHRs, it’s foreseeable that clinical data about patients will be far more available and accessible.

Will patient data become:

• A jockeying point for control and business advantage between health plans and care providers,
• A collaborative opportunity to optimize clinical care and care coordination, or
• Both? (more…)

The Medicare MAPCP (Multi-Payer Advanced Primary Care Practice) demo promised to be Medicare’s Biggest Change in 40 Years…

…but the emerging reality isn’t living up to the promise.

In this post, we’ll discuss:

1. The Promise
2. An Overview of the MAPCP Demo
3. Our Main Takeaway: Emerging Reality Suggests Medicare Will Be a “Difficult” Partner
4. Conclusion: Think Twice Before Signing Up

1) The Promise

The sandbox metaphor was first used by the National Academy for State Health Policy:

For the 10 or more states that are active stakeholders in multi-payer medical home initiatives, the promise of Medicare getting in the sandbox with them and playing (a.k.a. paying) is an exciting proposition. The addition of Medicare as payer to some of these state initiatives may be the critical tipping point that results in widespread primary care delivery system reform in states by involving more practices, payers and patients. (more…)

First, the good news: There are a lot of pilot and demonstration projects potentially involving the Patient Centered Medical Home (PCMH) in newly enacted Federal health care reform legislation – the Patient Protection and Affordable Care Act (PPACA).

Then, the bad news: There are a lot of pilot and demonstration projects potentially involving the PCMH in the PPACA.

…so many that the PCMH risks being drowned in an ocean of opportunity.

I’d like to make a few simple points in this essay:

1. The number of authorized pilots and demos in the PPACA is staggering
2. This creates both opportunities and challenges
3. PCMH focus will be required to navigate the ocean

(more…)

“If the needs for health care are to be met, the health care system must be organized to employ its resources with more wisdom and effectiveness. The two areas which appear to offer the greatest potential for improvement are (1) reducing unnecessary (or unnecessarily expensive) medical care and (2) increasing efficiency in the provision of hospital care.”

It will not be easy to carry out this recommendation.

Who said this? …and when? (more…)

Today’s blog post will tackle:

• Medicare’s biggest change in 40 years?
• The rise of MAPCI
• The fall of MMHD
• Implications/discussion

Medicare’s Biggest Change in 40 Years?

(more…)

10/26/2009 – In Washington, the efforts to reform health care and health insurance include proposed legislative language that would have an impact on the Medicare Medical Home Demonstration as described in section 204 of the Tax Relief and Health Care Act of 2006 and amended by section 133 of the Medicare Improvements for Patients and Providers Act of 2008. Specifically, section 1302 of House Bill 3200 contains a provision to repeal this demonstration and replace it with an independent practitioner-based medical home pilot described further in the bill. In addition, the House bill includes a second medical home pilot to evaluate community-based medical home models.

At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot. CMS is moving forward with an Administration-initiated demonstration announced by Secretary Sebelius on September 16, 2009, whereby Medicare would partner with existing multi-payer medical home pilots to improve the delivery of care. This demonstration, titled the Multi-Payer Advanced Primary Care Practice Demonstration, would be implemented in 2010.

What does this mean? As one who has followed the MMHD closely, here are some of my top-of-mind reactions:

(more…)

• Political reality dictates that the MMHD must save costs.
• As currently structured, the MMHD cannot achieve cost savings
  • In any given year, only a small percentage of patients account for the vast majority of costs
  • Lessons from previous Medicare disease/care management demonstrations has shown that effective care coordination interventions must be targeted at this population
  • Medicare has structured the MMHD so that any patient with one or more chronic condition is eligible; this includes 86% of all Medicare patients.
  • Physicians will be paid risk-adjusted care coordination fees for this entire population — the 86% of patients with one or more chronic condition.
    The MMHD cannot achieve cost savings. 

Dr. Randy Williams, MD — CEO of Pharos Innovations — has written Part II of this series: The Medicare Medical Home Demonstration: Crawling Out From Under the Rock. It’s insightful and provocative reading!

Medical homes probably do save money in very controlled settings, where the entire team is literally or at least figuratively under one roof, such as Kaiser.  However, the belief that one can overlay a traditional medical home model across an entire state and save money in the process turns out to be total fiction.

The poster child for that fiction, North Carolina’s Community Care program, turns out to cost state taxpayers probably $400 million a year, rather than save them $300 million, as the state’s self-serving and blatantly incorrect analysis claimed.    A more extensive analysis is available for review, and any state is welcome to the backup data as well.

Here’s a press release with more details.

Highlights of the head-scratching implausibilities claimed would be as follows:

(more…)

• As a political matter, the MMHD must save money
• As currently structured, the MMHD cannot save money

Please read my guest post

The Medicare Medical Home Demonstration (MMHD): Between a Rock and a Hard Place

over at Pharos Innovations new blog: The Collaborative Forum.

Is there a way out from between the rock and the hard place?  In Part II of this series, Dr. Randy Williams will discuss options.

Disclosure: Pharos Innovations is a client of Better Health Technologies, LLC.

Download a copy here .  Excerpts from the Executive Summary:

Effective Interventions

Three types of interventions have been demonstrated to be effective in reducing hospitalizations for Medicare beneficiaries with multiple chronic conditions who in general are not cognitively impaired:

• Transitional care interventions in which patients are first engaged while in the hospital and then followed intensively over the 4 – 6 weeks after discharge
• Self-management education interventions that engage patients for 4 -7 weeks in community-based programs designed to “activate” them in the management of their chronic conditions
• Coordinated care interventions that identify patients with chronic conditions at high risk of hospitalization in the coming year, conduct initial assessments and care planning, and provide ongoing monitoring of patients’ symptoms and self-care working with the patient, primary care physician, and caregivers to improve the exchange of information. …In-depth analysis of program details has revealed that six
  key components distinguished the successful…programs from the ineffective ones:

(more…)

Part Medical Home 101,  part strategy session to rescue primary care, part revival meeting — the National Medical Home Summit held earlier this week in Philadelphia was an amazing event.

The optimism, energy, and dogged persistence of attendees and presenters was pervasive. The event was standing room only with another 200 people tuning in to a live Internet video cast.

Dr. Joseph Scherger captured the mood of the day when he proclaimed:

The Medical Home “model” has become the Medical Home Movement !

For those of you unable to attend, here are some key links and publicly available PowerPoint presentations:

(more…)

Warrantee

War`ran*tee"\, noun. A written assurance that some product or service will be provided or will meet certain specifications.

Today when we buy practically any consumer item we expect a warrantee.

What’s the “warrantee” after you are discharged from a hospital?

Last September I wrote a post posing the question “What’s the Best Way to Get Hospitals Involved in Care Coordination? ” The short answer was:  Pay them to do it, take money away when they don’t — make hospitals accountable for their role in avoiding unnecessary readmissions.

President Obama’s FY 2010 Budget begins to project savings from avoiding unnecessary hospital readmissions. “Jumpstarting the Economy and Investing for the Future ”  lays the groundwork for hospitals being required to “warrantee” their services:

Improving Care after Hospitalizations and Reduce Hospital Readmission Rates. Nearly 18 percent of hospitalization of Medicare beneficiaries resulted in the readmission of patients who had been discharged in the hospital within the last 30 days. Sometimes the readmission could not have been prevented, but many of these readmissions are avoidable. To improve this situation, hospitals will receive bundled payments that cover not just the hospitalization, but care from certain post-acute providers the 30 days after the hospitalization, and hospitals with high rates of readmission will be paid less if patients are re-admitted to the hospital within the same 30-day period. This combination of incentives and penalties should lead to better care after a hospital stay and result in fewer readmissions—saving roughly $26 billion of wasted money over 10 years. The money saved will also be contributed to the reserve fund for health care reform. [p.28]

Will this be politically challenging? Not likely…this is a continuation of reforms started under President Bush.

The changes will be profound. (more…)

We have learned that coordinating care of patients — particular care of Medicare patients — is complex and time consuming for physicians.

A breakthrough study quantifies just how complex and challenging care coordination really is.  The study is reported in the February 17 issue of Annals of Internal Medicine and is entitled Primary Care Physicians’ Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination :

We found that in a single year for just fee-for-service Medicare patients, the typical primary care physician needs to coordinate care with 229 other physicians working in 117 different practices…. The number of peers was greater for physicians treating patients with higher chronic illness burden, who may benefit the most from coordination.

My mental visualization of these networks is a series of spider webs.

The authors write that “Coordination involves complex activities that require conscious interactions between providers and between providers and patients, including timely transfer of accurate clinical information, effective communication between the involved parties, and shared decision making.”

The estimate of 229 physicians in 117 different practices is conservative: (more…)

What would you call health care software that:

• Is Web-based and networkable, therefore highly scalable and inexpensive to purchase and use;
• Provides a ‘unified view’ of a patient from multiple sources of data and information;
• Is designed to be used interactively – by providers and patients alike – to coordinate care and create continuity;
• Offers evidence-based guidance and coaching, personalized by access to a person’s health data as it changes;
• Collects, for analysis and reporting, quality and performance measures as the routine by-product of its normal daily use;
• Aims to provide patients and their providers with a collaborative workflow platform for decision support; and
• Creates a care plan for each individual and then monitors the progress of each patient and provider in meeting the goals of that plan?

I call this Clinical Groupware.  The term captures the basic notion that the primary purpose for using these IT systems is to improve clinical care through communications and coordination involving a team of people, the patient included.  And in a manner that fosters accountability in terms of quality and cost.

Clinical Groupware is a departure from the client-server and physician-centric EHR technology of the past 25 years, a fixed database technology that never really became popular.  It is a substantially new and disruptive technology that offers lower price of purchase and use, greater convenience, and is capable of being used by less skilled customers across a broader range of settings than the technology it replaces.

As the name indicates, Clinical Groupware is intended for use by groups of people and not just independent practitioners or individuals.  It is not the same thing as an electronic health record, but may share a number of features in common with EHRs, such as e-Prescribing, decision support, and charting of individual visits or encounters, both face-to-face and virtual.  Neither is Clinical Groupware bloated with extra features and functions that most providers and patients don’t need and, with good reason, don’t want to pay for.

Some Clinical Groupware may look and feel like a web-based "EHR lite." But Clinical Groupware aims to create a unified view of the patient, assembling health data and information that may be stored in many different places and in several different organizations – including HealthVault or Google Health — which most EHRs cannot do.   Clinical Groupware is an evolutionary approach to a shifting health economy in which doing more is not always equated with better care, and the physician or provider role is transforming from autonomous expert to advisor, partner, and guide.   It is also an organic response to the reality that most health care data in electronic format is dispersed across numerous organizations and companies – e.g. hospitals, labs, pharmacies, and devices – and provides a means of accommodating patient demands for a more participatory practice of medicine.

Let me give a couple of examples of this new and emerging class of health software. (more…)

Would you like to receive a complimentary issue of a new publication — Medical Home News ?  Click on the link and then on “Sample Issue” in the upper left corner.

Here’s a preview of the first issue:

• Introducing Medical Home News
• An Annotated Guide to the Medicare Medical Home Demonstration (MMHD)
• Subscriber’s Corner
• Johns Hopkins Lipitz Center to Assist Practices in Medical Home Demo
• National Medical Home Summit to be Held March 2nd – 3rd 2009
• Thought Leader’s Corner
• Industry News
• Catching Up With… Paul Grundy, MD

I’m honored to have been asked to serve on the Editorial Advisory Board of Medical Home News.

What’s the right metaphor for Medicare Health Support (MHS), CMS’ major experiment with disease management for Medicare beneficiaries?  We prefer to look it as a bridge failure that presents an opportunity to improve future engineering and design.

We’ve now had the time to read, reread, and reread again the very recent report from Research Triangle Institute (RTI) — Evaluation of Phase I of the Medicare Health Support Pilot Program Under Traditional Fee-for-Service Medicare: 18-Month Interim Analysis .  Here’s a listing of our 8 key takeaway points:

1. There’s Sufficient Evidence to Conclude "MHS Didn’t Work As Expected"
2. Some Quality Measures in MHS Improved, Yet Outcomes Didn’t. Why?
3. MHS Suffered Execution Nightmares
4. Ronald Reagan Was Right — “Trust, But Verify”
5. MHS Has Implications for the Medicare Medical Home Demo (MMHD)
6. Be Wary of Claims from Pre-Post Studies
7. Differences Between Medicare and Commercial DM are Dramatic
8. The Guaranteed Savings Model is a Two Edged Sword

Let’s examine these at these one at a time. (more…)

“…the Medical Home initiative, as currently articulated, ironically fails to emphasize the complex chronically ill patient’s actual home. This represents a failure to recognize the profile of the highest-risk beneficiaries driving much of the high Medicare costs—that is those with or more chronic conditions and activity limitations…

“A promising way to strengthen and broaden the Medical Home initiative for high-risk Medicare beneficiaries may be to make their actual homes the central venue of primary health care. This could be accomplished through another reform agenda that specifically empowers family caregivers, home health and hospice nurses, social workers, therapists, and personal care aides. This agenda places primary care physicians, advanced practice nurses, and physician assistants as partners and advisors to ongoing multidisciplinary care teams in the patient’s home.”

Dr. Landers provides some examples of reforms to consider for pilot testing: (more…)

From what’s been said, the PCs are nice folks and will make good neighbors.  They’re friendly, many are Episcopalian, they like white picket fences, and they have barbeques on Sunday afternoons. The neighborhood they’re coming from is not as well off nor as pristine — they’re said to be suffering from urban flight.

The current neighborhood residents are generally quite well off.  They include the Employers, the Hospitals, the Health Plans, the Specialists, and the Disease Management clan.

The long-timers in the neighborhood are aware that parts of the world are not so well off and suffer from spiraling health care costs, inconsistent quality, and frustrated patients who don’t get coordinated care — but they don’t rock the boat too much because the system has generally been good to them.

Here’s the scene: this afternoon the Employers sponsored a pot-luck dinner to welcome the PCs to the neighborhood.  It was a festive event. The party’s over and everyone has gone back to their own houses.

What do the neighbors say about the PCs when they get back to the comfort of their own homes? Let’s listen in on a few discussions.

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The basic premise of the medical home concept is continuous, uninterrupted care that is managed and coordinated by a personal provider with the right tools that will lead to better health outcomes.

In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, released the Joint Principles of the Patient-Centered Medical Home. In this document they state the characteristics of the Patient Centered Medical Home:

• Personal Relationship
• Team Approach
• Comprehensive
• Coordination
• Quality and Safety
• Expanded Access
• Added Value

While these characteristics, in theory, may be achieved without the use of health information technology (health IT), it is also true that their realization is more likely to occur if health IT is successfully deployed. Health IT can be an empowering facilitator to the establishment of a medical home, a fact supported by experience.
What is not obvious are the best ways in which health IT should be deployed to reach the objectives of the medical home desired by patients, providers, and payers. Nor is it clear that "one size fits all" when trying to match health IT products and services with the desired characteristics, and to do so in a manner that is affordable and sustainable across a variety of practice types, large and small.

Rather than attempt to list products or suppliers of health IT, e.g. electronic medical records, EMRs, as single "solutions" to the problem of transforming practices into medical homes, we suggest here that a wiser approach is to describe the capabilities that health IT ought to provide or enhance if a medical practice is to become a successful medical home. This approach has the advantage of being vendor-neutral, allowing for innovation, variation and choice in reaching the goal of the agreed upon medical home principles and characteristics listed above.

The list below of Empowering Health IT for the Medical Home is not intended to be complete or exclusive. Over time it may expand or be modified according to the evolution of both the concept of the medical home and the technologies themselves. This flexibility is necessary in a time of constant change. However, we believe this is a reasonable description of the health IT that will empower medical practices to become medical homes in the near future.

We define Empowering Health IT for the Medical Home as computer hardware, software, and related technology that provides or enhances: (more…)

An email from CMS arrived in my inbox this morning at 2 am.  That email notified me that they have updated the MMHD homepage .  A quick click lead me to 8 new documents containing 155 pages of newly available details on the MMHD.

If you have time to read just ONE document, take a look a this PowerPoint summary of the MMHD — it’s so fresh that it’s dated October 28, 2008.

Based on a quick perusal, here are some highlights about how the MMHD will be structured. To separate fact from opinion, I’ve put brackets [ ] around my commentary:

(more…)

This toolkit describes how to implement the Chronic Care Model (CCM) in your medical practice. The CCM is embedded in the Patient Centered Medical Home (PCMH) model and can be consider a foundational element of the PCMH.

I would call this toolkit “The Medical Home for Dummies, Vol. I”, but then I’m sure the Dummies copyright police would knock on my front door, so I won’t.

Here are a few more details:

(more…)

Mark E. Miller, Ph.D., Executive Director, Medicare Payment Advisory Commission testified recently in front of the U.S. Senate Committee on Finance. He opened his remarks by stating:

The health care delivery system we see today is not a true system: care coordination is rare, specialist care is favored over primary care, quality of care is often poor, and costs are high and increasing at an unsustainable rate.

About a quarter of Mr. Miller’s testimony focused on an issue that hasn’t received much attention: avoidable hospital readmissions . Here are some key excerpts:

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“Why can’t we all just get along?”  Rodney King

The Megatrend: Collaborative Care Management Networks (CCMNs)

It’s been quite a while since I spotted a new Disease Management Megatrend, but here’s one that’s long overdue:

Collaborative Care Management Networks will be necessary to achieve optimal care coordination.

The trend in a nutshell:  payers (and others) are recognizing that optimal care coordination will require collaboration among health care stakeholders. This CANNOT be achieved with yesterday’s proprietary IT and business models.

CCMNs will share many — perhaps all — of the following elements:

(more…)

CMS has issued a Medicare Medical Home Demonstration Payment Contractor RFP available on the Federal Business Opportunities website. Thanks to the Google Alert service for digging this out.

For the casual reader, the details of the MMHD are taking shape nicely. CMS and its advisors have obviously spent a lot of time planning for this tremendously important project. If successful, the MMHD can salvage primary care from the jaws of death, rationalize reimbursement policy, and set the world right. Other than that it’s business as usual.

For those of you interested in how the details are unfolding, read on…

The MMHD Payment Contractor RFP has links to 20+ documents, most of which are mumbo jumbo contracting details. Here’s where I found the most useful information describing MMHD developments:

• Statement of Work (SOW), authored by CMS
• Design of the CMS Medical Home Demonstration , authored by Mathematica Policy Research, the Center for Health System Change (CHSC), and the National Committee for Quality Assurance (NCQA); June 19, 2008 (more…)

This goes a long way in explaining Medicare’s seeming lack of enthusiasm for past or future disease management demos with DM companies and/or health plans.

Congratulations doctors!

UPDATE: The doctors might have batted a thousand for quality improvements, but only .400 for getting bonuses.  See  Practices hit Medicare P4P quality targets, but bonuses still fall short , AMNews; September 8, 2008.

The process of updating a PowerPoint forces one to collect one’s thoughts, and I’m glad to share with you the PowerPoint slides along with a few highlights about the evolution of the PCMH. The highlights: (more…)

Patient-Centered Medical Home Model: Overview and Update.

The webinar takes place next Monday, July 28 at 12 Eastern. Click here for details. Hope you can join us.

But, look further…

The principles endorsed by AHIP only vaguely resemble the Joint Principles of the PCMH endorsed by 4 major primary care physician groups . These groups represent over 300,000 physicians. (See below for a summary listings of AHIP and physicians’ principles supporting the PCMH).

Why?

• Why didn’t AHIP didn’t just endorse the physicians’ principles for the PCMH?
• If there’s disagreement, why didn’t AHIP say “we agree with the docs except for 1)…, 2)…, 3)…?
• Why leave it up to outside observers to have to line up and compare two different sets of principles of a PCMH and try to figure out similarities and differences?
• Where are the doctors in all this? What do the doctors think about AHIP developing their own set of principles for a concept that the docs themselves conceived and are laboring to deliver?

Here are few of my initial reactions to AHIP’s principles for the PCMH: (more…)

We’re not.

From the Kansas City Business Journal :

Google Inc. has approached Cerner Corp. about a partnership, but Cerner officials don’t sound eager to entangle themselves with the Web-search Goliath.

That’s because the proposed partnership relates to Google Health, the personal health record site launched earlier in May in beta form.

The overture hasn’t led to substantive talks, Cerner President Trace Devanny said, because Cerner doesn’t see much value in Google Health or HealthVault, a similar site that Microsoft Corp. launched in October.

Cerner CEO Neal Patterson referred to the sites during a May 23 shareholders meeting as "electronic shoeboxes," requiring consumers to do much of the data importing and updating.

Why is Cerner dissing Google? Let’s take a look at Cerner’s current business model: (more…)

The June 2 issue of American Medical News provides payment scenarios for a medical home: (more…)

• What’s problematic about using the RUC methodology with the PCMH?
• What’s the optimal level for a PCMH care management fee?
• Should primary care leaders pull the RUC out? How? 

What’s Problematic About Using the RUC Methodology with the PCMH?

There are at least two reasons for not having the RUC methodology seen anywhere in the same county country as the PCMH. First, the RUC methodology doesn’t account for technology and services needed for optimal care management. Second, the RUC methodology is conceptually flawed.

1) The RUC methodology doesn’t account for technology and services needed for optimal care management. Here’s what the RUC recommended methodology for the PCMH pays for: (more…)

• What is the American Medical Association/Specialty Society RVS Update Committee (RUC)?
• What is the RUC’s role in the Medicare Medical Home Demonstration project?
• How are people reacting to RUC recommendations for PCMH reimbursement levels?

What is the American Medical Association/Specialty Society RVS Update Committee (RUC)?

The AMA formed the RUC to act as an expert panel in making recommendations to CMS on the relative values of Current Procedural Terminology (CPT) codes using the Resource Based Relative Value Scale (RBRVS).

The RUC is composed of 29 members, only 5 of whom are primary care physicians.

The RUC  has come under severe criticism as being an enemy of primary care. For example… (more…)

Prior to April 29, 2008, reviews of the Patient Centered Medical Home (PCMH) model  had been uniformly enthusiastic and positive.

Today the PCMH model is hitting reality — someone’s going to have to bring home money to pay the bills. On April 29 the American Medical Association/Specialty Society RVS Update Committee (RUC) released a  report making recommendations relating to payment levels of care management fees for the PCMH.

This report has stirred cries of confusion and outrage. I’ll elaborate on these cries in the second posting of this series, but if you can’t wait, read here, here, here, here, here, here, here, and here.

Welcome to a series of three blog postings discussing the PCMH, care management fees, and the RUC report.  I can’t claim to smooth the uproar, but I hope to frame the issues so that they can be understood and discussed constructively.

The series will address numerous questions. This first post:

• What is the PCMH care management fee?
• Why is the PCMH care management fee important?
• Why are people confused?

The second post:

• What is the American Medical Association/Specialty Society RVS Update Committee (RUC) ?
• What is the RUC’s role in the Medicare Medical Home Demonstration project?
• How are people reacting to RUC recommendations for PCMH reimbursement levels?

The third post:

• What’s problematic about using the RUC methodology with the PCMH?
• What’s the optimal level for a PCMH care management fee?
• Should primary care leaders pull the RUC out? How?  (more…)

#20 is “Decreased Continuity of Care”.  I think this one is debatable, and I’ll offer as #21 “Increased Continuity of Care”.  

Jessica writes:

With traditional doctors, patients have charts and medical records, but at in-store clinics, diagnosis is a one-off deal. Problems that could be caught over multiple visits and diagnosis could go unearthed unless the patient works to inform practitioners.

I’m picking up on a split in the thinking of companies running the retail clinics.

(more…)

The biggest single contribution of this report is to create a back-of-the-envelope (BOTE) economic model of anticipated costs and benefits from implementing the medical home.  Here’s the bottom line:

(more…)

But, what DOES work?

One key lesson emerging from MHS is the need to integrate and engage physicians and other local care providers…easier said than done.

MHS is just one of many experimental approaches being tried by Medicare.  Other approaches include the medical home model, Medicare Advantage plans, Special Needs Plans (SNPs), P4P, and a variety of other Medicare demos and pilot projects.  I’ve been critical of Medicare’s lack of transparency lately, but I applaud their innovation and experimentation.

While we definitely don’t have all the answers, I’d like to bring your attention one company that I believe has the right strategy and mindset: HealthSpring.  HealthSpring owns and operates Medicare Advantage plans in Alabama, Florida, Illinois, Mississippi, Tennessee and Texas and also offers a national stand-alone Medicare prescription drug plan. 

HealthSpring recently conducted an Investor Day meeting with financial analysts.  You can read the entire transcript of the meeting here — warning, it’s about 35 pages long.  I’ve culled through this presentation to dig out some best practices that HealthSpring is employing. 

(more…)

I’m pleased to share a copy of the PowerPoint presentation with you, and I hope you find it useful and provocative.  You can view and/or download a copy here (6MB).  This version contains 77 slides, which would be about the length I’d use for a 3 hour workshop; you’d see a more compact version for a conference keynote, Board summary, or management strategy session.

fyi, the DM Megatrends are:

MAGNITUDE: We are just scratching the surface of chronic disease challenges.
INTEGRATION:  The 50 year tide is shifting toward integration, away from specialization.
MEDICARE: While Medicare has endorsed the need for chronic disease management, disappointing results from recent demo projects make future direction unclear.
PROVIDERS: Care providers have woken up to DM opportunities and threats; they are promoting the medical home and the Chronic Care Model.
MAKE, ASSEMBLE, BUY? Fewer are buying as health management becomes increasingly strategic.
TECHNOLOGY:  DM in your home and your pocket.
BEHAVIOR CHANGE: DM is moving from a medical to a social model; behavior change has become the Holy Grail.
CLINICAL AND ECONOMIC ROI:  Round one is over, DM wins; Round 2 has just begun.
WILDCARDS! (employers, P4P, retail clinics, CDHPs, elections)

Comments are always appreciated.

Last week was a podcast of DM Megatrends…next week — the movie.  Brad has signed, Angelina is waffling.

Jaan’s sense of humor and articulateness shine through in his latest posting “Are Integrated Delivery Systems really all that?” He presents a Top 10 list of “why IDS’ could always remain the health care solution of the future”.

Jaan, it’s worth splitting a hair here. Let’s clarify who we’re talking about when saying “an integrated delivery system” (IDS). (more…)

More typically, DM Megatrends is 45–90 minute presentation with accompanying PowerPoint slides.

As part of the Web Summit, the good folks at MCOL asked me to do a short podcast on highlights of this presentation. They’re allowing me to share it with you… click here to save or listen to the podcast.

fyi, the DM Megatrends are:

MAGNITUDE: We are just scratching the surface of chronic disease challenges.
INTEGRATION:  The 50 year tide is shifting toward integration,  away from specialization.
MEDICARE: While Medicare has endorsed the need for chronic disease management, disappointing results from recent demo projects make future direction unclear.
PROVIDERS: Care providers have woken up to DM opportunities and threats; they are promoting the medical home and the Chronic Care Model.
MAKE, ASSEMBLE, BUY? Fewer are buying as health management becomes increasingly strategic.
TECHNOLOGY:  DM in your home and your pocket.
BEHAVIOR CHANGE: DM is moving from a medical to a social model; behavior change has become the Holy Grail.
CLINICAL AND ECONOMIC ROI:  Round one is over, DM wins; Round 2 has just begun.
WILDCARDS! (employers, PHRs, P4P, CDHPs)

His essay could just as easily been entitled “How the AMA Undermined Chronic Disease Care in America” — it’s very informative reading.

My article — “Disease Management and the Medical Home Model: Competing and Complimentary” — has been published in the latest issue of Disease Management and Health Outcomes, a peer reviewed journal.

I’ve arranged with the publisher to make copies available through my website. You can download a copy here.

Why is this an important topic? Here’s the big picture:

• Current chronic disease management demonstration/pilot projects in Medicare are showing little evidence of success.
• Physicians have woken up to threats and opportunities relating to chronic disease management and care coordination. The Medical Home model is a unified proposal by primary care physicians to define the next generation of primary care.

How will these trends interact? Your thoughts are welcomed, and please feel free to comment on the article.

TO DO

1) George says everybody’s gotta have an EHR by 2014

• tougher than getting a man to the moon in the 60s
• stall — G will be gone by then

2) solve chronic disease crisis

• chronic disease costs are killing us, 5% of seniors account for 50% of costs
• baby boomers hit the fan in 2010
• note to self — drop the cheeseburger at lunch

3) solve primary care crisis

• species could disappear from the continent
• docs are really pissed
• note to self — fire the bonehead that decided to pay specialists 3x more in the first place

4) pick up drycleaning

….etc., etc.

“This is a heckuva list…I wondering if there’s any way to shorten it?

(more…)

The conference chair is Dr. Steve Locke, Prof. of Psychiatry at Harvard.  He opened the meeting yesterday with a thoughtful line of questioning to the audience.

Dr. Locke asked “How many of you audience members have participated in an ‘typical, average’ seven minute visit at one of the new retail doctor clinics?”  About 75% of the people in the room raised their hands.

He then asked “…and how many of you found the experience satisfying?”  Every single hand in the room went down.

Finally, he delivered the punchline: “…and how do you suppose you’ll feel if you had several chronic diseases — say diabetes or asthma — that you wanted to discuss with your doctor during that same time period?” 

The impact was clear: 20 minutes of patient discussion items won’t fit into a 7 minute visit.

I didn’t take his commentary as in any way a criticism of retail doctor clinics; rather it was intended to show the disconnect occurring between the ever shortening average doctor visit and the ever lengthening time needed by an aging baby boomer patient population.  People with chronic conditions will need and want more of their doctor’s time.  Our current health care system can’t deliver this today, and is actually going in the wrong direction from what patients will want tomorrow.

While doing background reading, I was startled by the title of a book: “Primary care in the driver’s seat? Organisational reform in European primary care” The book was reviewed in the International Journal of Integrated Care .

Is primary care capable of taking a dominant role in running the whole health care system? This challenging question is what makes this book interesting and takes the debate one step ahead in the discussion of solely strengthening primary care, however important. In doing so, it affects the heart of integrated care; how to improve the clinical coherence and coordination that in the end leads to a patient led health service

What a contrast to the state of primary care in the U.S.!

While the question in Europe is “should primary care be in the driver’s seat”, the question in the U.S. is “Primary Care — Will It Survive? ” [New England Journal of Medicine; August 31, 2006]

And how are primary care physicians in the U.S. feeling about their status? Not too good, as documented in Merritt Hawkins & Associates 2006 Survey of Primary Care Physicians .

Q. 9. Relative to surgical and diagnostic specialists, which best describes primary care physicians in the medical hierarchy?

The dire situation of primary care in the U.S. is mind boggling to me. We have things totally backwards.

Al has been unabashedly pro-DM.  Until now.  Al writes in a recent article in Managed Healthcare Executive:

Disease management as we now define it may be on its last legs, though no one knows it yet. The Disease Management Purchasing Consortium has noticed that the savings in all but a few diseases doesn’t offset the costs, and nowhere does it generate the level of return on investment (ROI) that some people think they are getting.

But fear not, Al foresees a new DM:

(more…)

The systems and processes needed jointly to manage financial and clinical risk were an afterthought; information technology was not yet far enough advanced to offer integrated clinical solutions. One of the lessons learned was that financial integration alone was insufficient for success.

There is still a largely unexplored side of integration. Clinical integration refers to doctors, hospitals, health plans and others working together improve clinical care and care management on behalf of patients.

Today I presented my “Chronic Disease Management Megatrends” speech at a conference sponsored by the UPMC Health Plan, which is a part of the University of Pittsburgh Medical Center (an IDS).

(more…)

In my posting from a couple days ago — Doctors and Health Plans: Can Care Management Opportunities Reconcile the Hatfields and the McCoys? — I picked on United Health Care to make a point.   Just to recap, my reasoning is that physicians could (and should) be important partners to health plans in implementing their disease/care management programs.  So, how smart is it to beat up the guys that are the key to your success? 

I still question the overall wisdom United’s moves, but Joe does a great job articulating the opposing point of view.

Here’s the issue. Over the coming years, will health plans and doctors:

1. Continue to have adversarial relationship such as they’ve had over the past decades (ala Hatfields v. McCoys, cats v. dogs, oil and water), or
2. Is there strategic potential for reconciliation and partnerships to emerge?

A headline in yesterday’s Wall Street Journal caught my attention and got me thinking (again) about the issue.

(more…)

Disease Management (DM): Will Providers Seize the Opportunity to Be Back in Charge?

Click the link for details about the agenda and registration   You can receive a 15% discount by entering the following Promotional Code:   0412VK

(more…)

The testimony was presented on March 1 by Byron Thames, MD, an AARP Board member. With over 35 million members, AARP is the leading nonprofit, nonpartisan membership organization for people age 50 and over in the United States.

Here are my take-away points from Dr. Thames testimony:

• AARP recognizes that addressing care coordination is a critical issue in health care payment reform
• AARP is on the fence about who should do care coordination
• AARP could have an influential role in payment reform (more…)

“In theory, there is no difference between theory and reality. In reality, there is.”  Yogi Bera

Out-of-the-box thinking is good; out-of-touch thinking is not. Dr. Porter and Teisberg’s (PT’s) recent article in JAMA “How Physicians Can Change the Future of Health Care” is disappointing, unrealistic and dangerous.

1. Disappointing: Please Answer the Challenges About Why Your Theory isn’t Workable
2. Unrealistic: Money Does Matter a Lot
3. Dangerous: Measuring Process in Health Care Does Add Value

What’s so seductive about their writing is that about 90% of it makes a great deal of sense; however, the other 10% doesn’t, and this 10% is foundational to their thinking. (more…)

Please allow me to elaborate.

P4P programs are based on two assumptions:

1. Patients are assigned to a physician or a practice that will have primary responsibility for their care, and
2. That a meaningful fraction of the care physicians deliver is for patients from whom they have primary responsibility

Wouldn’t you expect that this would be problematic for older (Medicare) patients who see multiple doctors over time? How can you assign accountability for performance to one doctor when the patient is seeing a number of doctors for a number of care episodes? (That’s the BFO part for me.) and wouldn’t you expect this to be even more problematic for patients with multiple,chronic conditions?

Shouldn’t somebody study this to figure out whether P4P is doable in Medicare? Well, they have. (more…)

Well, it’s happening.

Four physician organizations representing 330,000 doctors issued a press release voicing their support for Joint Principles of a Patient-Centered Medical Home. The four groups are the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA).

So? (more…)