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:

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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:

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…that’s my key takeaway from attending the Robert Wood Johnson Foundation (RWJF) Project Health Design (PHD) conference in Washington D.C. on September 17. The conference was entitled  A ‘Report Out’ from Project HealthDesign and Forum on Next-Generation PHRs .

A PHD Fact Sheet capsulizes the evolution from PHRs to PHRSs:

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In a little less than three weeks, DMAA: The Care Continuum Alliance will open its 10th annual meeting , in Hollywood, Fla. - a notable milestone for an organization that has evolved with its membership over the past decade.

I’ll be there, presenting with Dr. Victor Villagra on the "March toward Data Interoperability" and the outlook for disease management.

The content this year promises to be among the best yet, with a new track on the medical home and a keynote on population health and the medical home by American Academy of Family Physicians leader Bruce Bagley, MD, and Patient-Centered Primary Care Collaborative Chair Paul Grundy, MD.

Other tracks include innovations in care, HIT, engagement and behavior change and public-sector programs. You’ll also get an outlook on the November elections and the implications for health care reform from former U.S. Sen. John Breaux, political analyst Charlie Cook and health policy expert Ken Thorpe, PhD.

The Forum site has all the details and information on discounts still available for members of DMAA and partner organizations, including the Case Management Society of America, the National Association of Chronic Disease Directors and others.

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

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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…)

"Re: UHG. Was at the Healthcare Quality Conference yesterday in Boston. Got to talking to a United Health exec who informed me that they have signed an agreement with Google Health and have a pending agreement with HealthVault. This backs up UHG’s previous statement that member records would be made portable. Individual made mention that the Google Health relationship extends beyond just claims records transfer and includes a technology partnership regarding UHG’s OMX."

Commentary: Among health care incumbents, health plans are experiencing the greatest heartburn over the emerging Personal Health Information Network (PHIN).

On the one hand, existing health plan IT and business models have been proprietary and closed. Here’s how a typical health plan might state their POV:

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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.

Bob Laszewski describes it eloquently in his blog posting: Senate Votes 69-30 To Rescind Medicare Physician Fee Cuts and Cut Medicare Advantage to Pay For It .

Is healthcare more like schools, fire departments, and roads or is it more like TV sets, shampoo, and movies?

I do think of myself as a strong free market advocate. But, I’ve learned about how isolated, deficient, and expensive the U.S. approach to healthcare is compared to virtually every other developed country in the world.

I interpret this vote as both sides of the aisle agreeing we’ve seen the boundaries of what free market anything goes healthcare can and can’t do. Today is the day the tide started shifting.

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:

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The purpose of this post is to help a non-technical audience untangle some of the confusion regarding health data exchange standards, and particularly come to a better understanding of the similarities and  differences between the Continuity of Care Record (CCR) standard and the CDA Continuity of Care Document (CCD). But what I’m most interested in is getting beyond the technical, political, or economic positions and interests of the proponents of any particular standard to arrive at some principles that demonstrate in plain language what we are trying to achieve by using such standards in the first place.

Frankly, I don’t give a hoot about what standardized XML format for capturing clinical data and information about a person becomes the norm in the health care industry over the next several years. I do care that the decision is made by the people, institutions, and companies who use the standards, and not made by a quasi-governmental panel or a group of “industry experts” whose economic or political interests are served by the outcome, and dominated by a particular standards development organization with whom they are very cozy. 

In other words, I do want free and open market forces to be able to operate freely and openly as health information exchange evolves, in part because I believe market forces will work in the direction of continuously improving health IT, whereas in my experience top-down efforts are often protective of established interests and discouraging to innovation.

Herein lies the problem, in my opinion, with the standards adoption process that the Office of the National Coordinator of HIT (ONC) and HITSP have overseen during the past four years.

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 (Apologies to any chimps offended by the comparison).

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:

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

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• 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? 

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In brief, Healthways position is that the Centers for Medicare and Medicaid Services (CMS) is statutorily required to expand into Phase II of MHS if Phase I is “successful”. While I’m very sympathetic with Healthways predicament and their frustration with CMS, I’m not optimistic that their tactics are likely to work.

In making the case, Healthways CEO Ben Leedle quoted the legislation authorizing MHS.

For a moment, let’s get legalistic and look closer at this legislation.  What exactly is CMS required to do? (I’ve put the more relevant wording in bold). (more…)