June 16, 2006
 

WILL PHYSICIANS COLLABORATE OR COMPETE WITH DM COMPANIES?

Doctors, before you get mad, let me acknowledge that the word "compete" isn't in most physicians' vocabularies.  Doctors relate much more to a culture rooted in service and professionalism rather than business competition. 

The medical home concept being advanced by primary care physicians could wind up competing with disease management (DM) companies. Ironically, this occurs at a time when most DM companies are picking up the pace of improving relationships and communications with doctors. 

While the medical home model isn't new, it has recently received formal endorsements from primary care physician groups.  The American Academy of Family Physicians (AAFP) Board adopted a policy in May 2006 and the American College of Physicians (ACP) Board of Regents approved a position paper in January 2006.  The AAFP represents 94,000 family medicine physicians and the ACP represents 119,000 internists.

Here's how the ACP summed up its version of the medical home:

The advanced medical home is a physician practice that provides comprehensive, preventive and coordinated care centered on their patients' needs, using health information technology and other process innovations to assure high quality, accessible and efficient care. Practices would be certified as advanced medical homes, and certified practices would be eligible for new models of reimbursement to provide financing commensurate with the value they offer. These practices would also be accountable for results based on quality, efficiency and patient satisfaction measures. The advanced medical home would be particularly beneficial to patients with multiple chronic diseases—a population of patients that is growing rapidly and that consumes a disproportionate share of health care resources.

There is a lot at stake here.  No matter what the doctors intend, the effect of the medical home model could be competitive to disease management (DM) companies and others.  The medical home could affect the flow of hundreds of billions of dollars – money that over time might flow either to physicians or to private companies.

Click here for more information about the medical home model.

Key Aspects of the Medical Home: Care Coordination + Technology

While there are many aspects to the medical home, I'd like to focus on two in particular:

1) Care coordination

2) Information and communication technology to support care and care management

Pop quiz:  Who wrote the following statement describing the term "care coordination":

The literature has correctly indicated that the term "care coordination", which is often used interchangeably with the term "care management," refers to a variety of activities. These include managing the transition of care across settings, the use of patient registries to allow for population-based care protocols, the use of frequent follow-up with patients to promote treatment plan compliance and to obtain healthcare data, the use of clinical practice guidelines, including feedback to the physician regarding their degree of compliance with the guidelines, and the teaching of disease self-management skills to patients. ...

Was this written by someone from a disease management company? a health plan?  a home health agency?  

It was written by...doctors!  ...and here's the punch line:

These care coordination activities are at the core of what defines a primary care physician.

Reform of the Dysfunctional Healthcare Payment Delivery System, ACP Position Paper, April 2006, p.16

Hmmm....doesn't this definition sound a lot like what DM companies (e.g., Healthways, Matria) and payers (e.g., health plans, employers, Medicare) have been working on for the past several years?

Is this surprising?  Yes and no.  I certainly want my doctor to be involved in care coordination activities, but very few doctors do this in a systematic way.

There's more...physicians are also warming to the use of technology to care for patients both at doctors' offices and in patients' homes and communities. Another recent ACP position paper describes that key elements of a revised reimbursement system should include compensation for:

b) adoption and use of health information technology for quality improvement; c) provision of enhanced communication access such as secure e-mail and telephone consultation; d) remote monitoring of clinical data using technology; and e) pay-for-reporting or pay-for-performance. (p.8)

Doctors leading the charge for the use of technology?!  That's invigorating!

Will the Medical Home Compete with DM?

While genteel physicians would never be so crass and direct, one interpretation of the medical home model might be -- "Don't pay a private company to do care coordination, pay physicians instead."

DM companies have been working hard to develop better relationships and communications with physicians.  While the need for better relations has been evident for years, the recent Medicare Health Support (MHS) pilot projects underscore the urgency felt by DM companies to coordinate with doctors. These projects focus on frail, elderly patients who are particularly dependent on their relationship with their primary care physician.  For an example of a physician focused approach, see Dr. Sandeep Wadwha's innovative PowerPoint presentation describing McKesson's MHS project in Mississippi.

The medical home model puts DM companies in an awkward position.  On the one hand, DM companies have been working hard to improve their relationships and workflow integration with physicians; on the other hand, the medical home model could put doctors into direct competition with DM companies.

And while competition is a possibility, it's also possible to envision a range of collaborative scenarios – companies holding DM contracts could subcontract with physicians for their services; physician groups who have signed up medical home patients could subcontract with DM companies.

As an aside, health plans that have built their own DM programs are much more likely to be unreservedly supportive of the medical home – they don't view DM as a direct profit center. 

Do physicians have the ability to compete?  There are strong arguments suggesting "NO" and strong arguments suggesting "YES".  Let's look at both sides.

"NO".  What's the rationale suggesting that physicians cannot be effective competitors at providing care coordination and chronic disease management?

• Physicians cannot be cost effective.  The use of expensive physician time is not economical to provide care coordination; a mix of nurses, other professionals, lay persons, and technology will be much more cost effective.

• Physicians lack training and experience at care coordination.  DM companies and health plans have spent the past decade developing their care coordination capabilities.

• The medical home model does not provide financial guarantees for purchasers. Many DM purchasers require guaranteed financial savings; these guarantees are typically backed by reinsurance and/or a very strong balance sheet.  For example, the current MHS projects require contractors to guarantee 5% savings. Guaranteed savings for purchasers is not an integral part of the medical home model.

• Physicians lack capital and management expertise.  Most physicians work in small groups or solo.

"YES".  Here's the rationale suggesting that primary care physicians can be effective competitors at providing care coordination and chronic disease management:

• The medical home is a better clinical model.  The medical home approach integrates the Chronic Care Model. It provides for better integration of local care providers and strengthens the doctor patient relationship; DM companies and health plans have been viewed as operating parallel to the doctor-patient relationship, or as getting in between doctors and their patients. Initiatives to develop and validate the Chronic Care Model have been supported by the Robert Wood Johnson Foundation, the Institute for Healthcare Improvement, RAND Corporation, and the World Health Organization.

• Technology levels the playing field. Physicians can provide DM services efficiently.  They can subcontract with DM companies or other specialized vendors to gain access to appropriate call center services, health coaching, and other technologically supported interventions. Doctors can compete in a flat world.

• Physicians can leverage their grass roots connections.  Primary care physicians live everywhere in America; physicians are often influential citizens in their local communities and will have broad access to all members of Congress.  Working with their national organizations, they will be able to influence passage of legislation favorable to the medical home model.

• Doctors have trusting relationships with patients. How do you think the doctor and the patient will respond at the moment of truth in the privacy of the exam room when the patient asks:  "Doctor, should I sign up for this DM program being offered by my health plan, or should I sign up for your ‘medical home' program?"

Of course, all this is very speculative. There are strong points supporting both sides.

Closing Thoughts

Many things are still unclear:

• Do the national physician organizations speak for individual member physicians in advocating the medical home?

• Can physicians gain political support for their medical home proposal?

• Can physicians get payers, especially Medicare, interested in the medical home model?

• Can physicians develop evidence to support clinical and cost effectiveness of the medical home model? (and you thought the ongoing debate about DM-ROI has been thorny)

Overall, physicians' promotion of the medical home model is good news.  It will provide patients with more and higher quality choices.

Physicians also read the analyst reports predicting that DM will grow to become a $10 to $30 billion dollar a year market.  They are understandably asking, "Is some of that coming out of our pockets? How do we get our share and hang on to the bread and butter activities that define the physician of the future?"

Will physicians collaborate or compete with DM companies?  I predict doctors will learn to expand their vocabularies to include words like "compete".

Vince Kuraitis
Principal
Better Health Technologies, LLC

HEALTHCARE UNBOUND III CONFERENCE

In 2002, Forrester Research coined the term Healthcare Unbound -- technology in, on, and around the body that frees patient care from formal institutions.

The Center for Business Innovation (TCBI) presents:

The Third Annual Healthcare Unbound
July 17-18, 2006
Hyatt Regency Cambridge, Cambridge, MA

RESOURCES

MiHome Journal.  This excellent e-newsletter focuses on product development and distribution strategies for the medically integrated home.

The Connected Health Initiative focuses on extending the care community beyond the traditional walls of healthcare institutions by bringing healthcare to the everyday surroundings of the health consumer and their families. The founders include Partners Telemedicine and a number of other prominent telehealth leaders in Massachusetts.

DM World e-Reports ™ is the weekly e-newsletter of the International Disease Management Association.

CSIP e-newsletter. The Care Services Improvement Partnership (CSIP) is responsible for providing general implementation support to organisations building their telecare programmes in the UK.

TECHNOLOGY & CARE MANAGEMENT

Leading Health and Technology Companies Form Alliance to Improve Personal Health Through Connected Devices

Continua Health Alliance Press Release; June 6, 2006

Consumers in Health Care: Creating Decision-Support Tools That Work

California Health Care Foundation, June 2006

A Roadmap for National Action on Clinical Decision Support

American Medical Informatics Association; June 13, 2006

"...developing CDS starter sets – rapid consensus on core knowledge and interventions for specific high-visibility targets, such as chronic disease management for a specific condition, could provide clarity and unity for vendors and clinicians, and could lead to short-term achievements that can bootstrap further CDS activities." (p. 50)

The Plan: Drive Consumers Online

Big I.T. changes are in store for payers and providers as consumer-driven health revs up  

Health Data Management, June 2006

Growing Availability of Clinical Information Technology in Physician Practices

Center for Studying Health System Change, June 2006

Telecare – at the Tipping Point

Telecare Services Association (UK), May 2006

Health Industry Insights Consumer Survey (on Personal Health Records)

Health Industry Insights, an IDC Company; May 2006

The Next Generation of Health Information Tools for Consumers
Testimony to the Joint Economic Committee, U.S. Congress; May 10, 2006

AHIC Makes Recommendations on IT Adoption Projects
Healthcare IT News; May 16, 2006

Finding Answers Online in Sickness and in Health
Pew Internet Project; May 2, 2006

Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care
Annals of Internal Medicine; May 16, 2006

Pervasive Medical Devices: Less Invasive, More Productive
IEEE Pervasive Computing, April – June, 2006

Telemedicine: Saving Time, Saving Money, Saving Lives
Key Research Findings and Presentation Highlights
10th Annual Meeting of the American Telemedicine Association
April 17 – 20, 2005 · Denver, Colorado

Issue Focus:  Telehomecare
Telemedicine and e-Health Journal; April, 2006

A Systematic Review of Interactive Computer-assisted Technology in Diabetes Care
Journal of General Internal Medicine; February 2006

Imagine - the Future of Aging
Center for Aging Services Technology (CAST) ; December 2005
Commentary:  for those of us who have a hard time explaining to Mom and others what we do for a living, this video does a tremendous job of painting a vision of how technology can help older people continue to live independently in their homes.

Telemedicine for the Medicare Population: Update
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, February 2006

New Report Demonstrates the Need for Systematic Use of Mobile Technology in Healthcare
Vodafone Group; March 24, 2006

WORTH REVIEWING!

Protecting Consumers in an Evolving Health Insurance Market.

National Committee for Quality Assurance (NCQA), June 2006

New Study Shows Need for a Major Overhaul of How United States Manages Chronic Illness
Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School; May 2006

Realizing the Promise of Disease Management
The Boston Consulting Group; April 19, 2006

Meta-Analysis: Chronic Disease Self-Management Programs for Older Adults
Annals of Internal Medicine; September 20, 2005 (.pdf available free to the public as of April 20, 2006)

Is DM Worth It?
Managed Care Magazine, April 2006

Care Coordination Programs Adapt to Real-World Challenges
Managed Healthcare Executive; May 1, 2006

E-CareManagement News is a complimentary e-newsletter courtesy of Better Health Technologies, LLC <http://www.bhtinfo.com/>.

For business and clinical decision makers who are developing innovative approaches to managing chronic diseases, Better Health Technologies is an eHealth and disease management consulting company that can assist you with strategy/business planning, finding financing, finding customers, and developing key partnerships.

Disclosure -- BHT has consulted with Intel Corporation to assist in the formation of Continua Health Alliance.

You may copy, reprint or forward all or part of this newsletter to friends, colleagues or customers, as long as the use is not for resale or profit and the following copyright notice is included intact. Copyright © 2006, Better Health Technologies, LLC. All rights reserved

We welcome your opinions and comments. Write or call Vince Kuraitis JD, MBA at vincek@bhtinfo.com, (208) 395-1197