Welcome Home — A medical home will soon be your’s

If you believe that the controversies over clinical care guidelines and the pay-4-performance quality measures being imposed on your doctor — and the concerns about the problematic research and pharmaceutical interests behind them — don’t apply to you, welcome to your new home.

If you’re young with "perfect" numbers and believe you’ll never experience the normal health indice changes that come with age — that to lower enough to meet new “normal” values, requires multiple prescription drugs — and that none of this applies to you. Welcome to your new home.

Your medical home, that is.

You deserve a walk-through, since you’re being moving in soon.

A coalition of employer groups, health insurance plans and other stakeholders have been planning, laying the foundation and building your new home since at least 1990. That was the year the National Committee for Quality Assurance (NCQA) was created. This private, “nonprofit” organization is a coalition that brought together large employers, policy makers, healthplans and other stakeholders to “decide what’s important” in healthcare, how to measure it and enforce it.

“Transforming our health care system requires the collected will and resources of all these constituencies and more,” said the NCQA.

The NCQA may be familiar with readers from when it gave accolades to childhood obesity programs last March, but it deserves another introduction. It has developed the performance (HEDIS) measures for your healthcare providers and health plans. Compliance with their measures is tracked and used in the accreditation of healthplans, given the “NCQA seal of approval.” It also issues Report Cards of accredited ‘best’ health plans and physicians “who have met the highest standards of quality care in the areas of heart/stroke care, diabetes care, back pain and systematic processes.”

It is funded by Robert Wood Johnson Foundation, American Diabetes Association, American Heart Association, California Endowment and other foundations with pharmaceutical company ties. NCQA’s corporate sponsors are almost all pharmaceutical companies:

Platinum Sponsors

AstraZeneca

Baxter

Boehringer Ingelheim

Merck & Company

Pfizer Inc

sanofi-aventis

Gold Sponsors

Bristol-Myers Squibb

Daiichi-Sankyo

GlaxoSmithKline

Eli Lilly

Novo Nordisk

Wyeth

Silver Sponsors

General Motors

McNeil Pediatrics Division of McNeil-PPC, Inc.

sanofi pasteur

Schering-Plougho

In 2001, the Institute of Medicine (IOM) laid out the blueprints for a new redesigned health care system, euphemistically called STEEEP (Safe, Timely, Effective, Efficient, Equitable, and Patient-centered), in its report called Crossing the Quality Chasm. It established new rules for patient-provider relationships; and called for information technology (IT) for electronic medical records and the sharing of information, a set of performance measures and aligning healthcare provider payments with compliance, and for Congress to establish a Health Care Quality Innovation fund, $1 billion for the first 3-5 years, to achieve its goals.

The NCQA said “redesigning the healthcare system around these attributes will not be easy. In fact, it will require changes at every level, including...insurers, purchasers and regulators... hospitals and medical groups...[to] individual clinicians. And at the center, the patient.” To meet this initiative, NCQA created Bridges to Excellence (BTE). NCQA members also serve on the BTE Board. BTE pays physicians bonuses for meeting its performance measures (diabetes care, cardiac care, spine/bone care), as well as implementing electronic medical records. Its Heart/Stroke Recognition Program, for example, recognizes physicians who follow its ‘evidence-based’ measures for managing blood pressure, lipid (cholesterol) testing and control, use of antithrombotics and smoking cessation.

Bridges to Excellence (BTE) went from working with employers to healthplans, that purchase licenses and agree to execute BTE programs that reward doctors for “the right clinical behaviors” and provide their “customers a suite of products that promote better healthcare outcomes at a lower cost [the IOM found there is no evidence the incentivized performance measures actually do either].” Among BTE’s other partners are the Leapfrog Group, made up of more than 170 companies and groups that purchase health insurance, and the National Business Coalition on Health, familiar with JFS readers.

On January 8, 2008, NCQA announced the launch of its Medical Home program. What it will mean for anyone with health coverage through individual plans, employers, or Medicare and Medicaid, is that you will be assigned a “Medical Home” through which your care will be managed to ensure it is in accordance with their performance measures, monitored, and reported. In other words, managed care (you'll have to go through to access covered care). Yet, the concerns that have been raised over the financial interests behind all of this are already evident.

For medical practices to be recognized as medical homes, they must meet criteria that includes standards for diagnosis and implementation of evidence-based guidelines, systematic tracking of test results, tracking of referrals, performance measures, and performance reporting. To become a medical home, physician practices will be evaluated based on their scores on meeting these measures, and they “can increase their level of recognition as they achieve more of the requirements.” Doctors will also have to pay a fee to be licensed and pay for the NCQA survey tool.

On January 31st, Bridges to Excellence officially adopted the medical home program, which affects all licensed BTE healthplans and providers. Through participation in the BTE Medical Home recognition, doctors can receive an annual bonus payment of $125 for each patient covered by a participating employer, with a suggested maximum yearly incentive of $100,000. As Allan Korn, M.D., senior vice president and chief medical officer of the Blue Cross and Blue Shield Association, said: “Blue Cross and Blue Shield companies are working to transform the traditional primary care doctor's office into a central point for Americans to organize and coordinate their health care and develop patient-centered medical home demonstration sites throughout the U.S.”

It might appear voluntary but, like P4P measures (see here, here and here) opting out eventually won’t be much of a choice for physicians unless they can afford to only care for self-pay patients who aren’t under an insurance plan or receiving government benefits. And compliance won’t be much of a choice for consumers unless they don’t have health insurance or government health benefits.

The overwhelming record keeping and reporting requirements involved are understandably being met with resistance, but how do doctors feel about having their practice ‘quality’ judged by how well they follow a checklist for blood pressure, lipids, weight and smoking management? Dr. Wes asks how you would define quality care and excellence in your doctor: “Is it someone who is responsive to your needs, compassionate, caring, communicative, patient, scholarly, or some mix of these?” As he wrote in a cutting post on the new medical homes, corporate America has decided it wants Dilberts, rather than doctors. “Such incentives do nothing to reward a doctor for taking the time with a patient, explaining their care, walking them through treatment options and reconciling their medicines.”

Architects of tomorrow’s healthcare delivery system

This brief glimpse can’t begin to describe the background efforts in bringing us to this point, but may help readers better understand its evolution. In 1996, the IOM began a multi-phase “Quality Initiative” to restructure national healthcare. Its first phase was to compile literature to support its definition of the problem (“a healthcare system in crisis”) as one of overuse, misuse and underuse of services. During phase two, spanning 1999-2001, its Committee on Quality of Health Care in America, “laid out a vision for how the health care system and related policy environment must be radically transformed in order to close the chasm between what we know to be good quality care and what actually exists in practice.” It developed a number of metrics on how it would define quality of care. Phase three of the IOM’s initiative focuses on operationalizing its “vision of a future health system.” This included “redesigning primary care and care for those with chronic conditions [obesity, heart disease, diabetes, osteoporosis, etc.], creating an information and communications technology infrastructure [national electronic medical records], making health insurance coverage available and affordable at the state level [health insurance mandates], and reforming malpractice to make it patient-centered, safety focused and nonjudicial.” The IOM’s national action plan for a new healthcare delivery system were released in a 2003 report.

In September 2004, the IOM launched the Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Project, having been given two Congressional mandates as part of the Medicare Prescription Drug, Improvement, and Modernization Improvement Act of 2003 (Public Law 108-173, section 109). To carry this project forward, the IOM committee produced a series of reports (called the Pathways to Quality Health Care series) for the government (Congress and CMS). The first report was Performance Measurement: Accelerating Improvement, released on December 1, 2005. It laid out the performance measures from the “efforts of a diverse set of stakeholders” and the creation of an infrastructure for managing those measures nationally and regionally.

One of the IOM’s subcommittees, the Subcommittee on Pay for Performance, was tasked with creating the performance measures for Medicare programs (and hence, most all healthplans), and redesigning payments. This committee began public meetings in May of 2005. It released its report, Rewarding Provider Performance: Aligning Incentives in Medicare, on September 21, 2006.

Few consumers realize that the IOM is not a government agency, but a private organization that is paid by various interests to develop its reports — for example the 2004 report, Preventing Childhood Obesity: Health in the Balance, commissioned by the Robert Wood Johnson Foundation. IOM reports are not always authored by members of the National Academy of Sciences, of which the IOM is a part.

The Authoring Committee for this Rewarding Provider Performance report offers a glimpse at the organizations behind these initiatives:

It was chaired by Steven A. Schroeder, M.D., who, among his other credentials, was president and CEO of RWJF from 1990 to 2002. The other co-authors included an advisor to the RWJF; the director of RWJF’s “Turning Point” initiative; the president and CEO of the NCQA; General Motors Corp director of health care plan strategy and health care initiatives; a trustee of RWJF; several RWJF scholars; the cofounder of Leapfrog Group and founder of Bridges to Excellence; director of RWJF Clinical Scholars fellowship; the director of RWJF’s “Network for the Improvement of Addiction Treatment;” a member of the board of trustees of the US Pharmacopoeia; president of the American Medical Association; founding president of the National Osteoporosis Foundation; pharmaceutical company and health insurance company consultants; board member of the Leapfrog group and NQF; board of director for major corporations; president emerita for Group Health Cooperative and board member of America’s Health Insurance Plans; director of Charles River Laboratories and Merck & Co.; and others; and was supported by chief officers of major health plans, NCQA, and health IT companies.

Your government on drugs

The connections and interests of stakeholders and the government are tightly intertwined. One of the most insightful glimpses of these relationships was the keynote address for the Third Annual Health Information Technology Summit (Washington, DC, September 27, 2006) given by the director for the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. As Carolyn M. Clancy, M.D. said in her opening, the government’s efforts to institute nationalized electronic health records have been in collaboration with the Bridges to Excellence and the eHealth Initiative. She went on to talk about the incentives for meeting the P4P performance measures and their importance in the infrastructure of nationalized electronic records:

[T]he biggest payer of all, the Federal Government, has skin in the transparency game. Between the Department of Health and Human Services, the Defense Department, the Office of Personnel Management, and the Department of Veterans Affairs, Uncle Sam pays for about 40 percent of the Nation's health care bill. During the next several months, we're going to see a tremendous push to combine the purchasing clout of the Federal Government with the health care buying power of the Top 100 private employers in America — a public-private partnership on a scale we've never seen before....

Last year, the AQA endorsed a starter set of 26 standard performance measures that are now being put in physician contracts and implemented around the country....In addition to the work we're doing on quality and cost standards, there's also progress being made on the third cornerstone of value-based health care: interoperable health IT standards....HHS has also certified the first round of ambulatory electronic health record products, and announced final regulations needed to support physician adoption of e-prescribing and e-health records technology. Electronic health records, computerized physician order entry, e-prescribing, and other health IT applications have the potential to transform the way health care is delivered in this country...

Since 2004, no other agency of the Federal Government has invested more money to understand and implement health IT at the provider level than AHRQ. Today, we are backing over 125 projects in 43 States with over $166 million in grant and contract funding...

It's no secret that pay-for-performance initiatives have been driven by health care purchasers, including the Government, employers, and private insurers. These purchasers want providers to achieve certain quality improvement targets.... At last count, there were well over 100 P4P programs in the United States, covering over 53 million Americans. Expectations are that over 85 million Americans will be covered by P4P programs by 2008... That's because when it comes to incentives, the Federal Government is starting to practice what the marketplace preaches. All eyes were watching when the Centers for Medicare & Medicaid Services [CMS] teamed up with the Premier Hospital Association to test pay for performance on a large scale... The first round of results from the CMS/Premier Incentive Demonstration came in last fall, and...over 120 hospitals received almost $9 million in extra incentives, the first time Medicare has ever paid performance bonuses.

Last week, Medicare was again in the national pay-for-performance spotlight when the Institute of Medicine released its long-awaited study called Rewarding Provider Performance: Aligning Incentives in Medicare. In addition to recommending that CMS phase-in incentive measures over time, the report reinforces transparency by asking large providers and employers to share health care quality information with the Federal Government for the benefit of all health care consumers. The [IOM] report concluded that incentive measures in the Medicare reimbursement system may likely improve health care quality, but interestingly enough, may not necessarily reduce costs. I also took special interest in the IOM's conclusion that despite the large number of P4P programs taking root across the country "a robust evidence base on the effectiveness of these programs is not yet available."

Given the rapid growth of the pay-for-performance system, and the relative scarcity of evidence, there are many people, especially in the provider community who, to put it mildly, remain skeptical about P4P.... concerned that pay-for-performance programs can lead to unintended consequences such as: payers influencing medical decisions, faulty performance measures, too much record keeping and too much emphasis on cost cutting.... [See here.]

...When it comes to testing the effectiveness of incentive and reward programs, we've learned that there is no substitute for collaboration. In addition to teaming up with your organization, we've also worked with the Leapfrog Group of employers and purchasers, and the Rewarding Results initiative sponsored by the Robert Wood Johnson Foundation, the Commonwealth Fund, and the California Healthcare Foundation. [In other words, P4P measures don’t save healthcare costs, nor is there any evidence they actually improve clinical outcomes, although incentives may improve compliance with the P4P measures, so the government is having them test the effectiveness of their own P4P programs.]

Is it possible that the constant drumbeat of negative news stories — the dire state of our healthcare system and need for a massive overhawl, the epidemic of obesity and chronic diseases in need of "disease" management by a third party, errors in need of a nationalized electronic database to improve safety, and the crisis of uninsured necessitating mandates requiring everyone to purchase health insurance — might not be entirely objective, accurate portrayals and that certain interests might, instead, be working very hard to convince us of all this? Can we trust that their new healthcare delivery system will deliver care that's in our best interests, or their's?

Medical Homes will put someone over the management of our care who is being paid to do certain tests and not others, write certain prescriptions, monitor and share our medical information with the Federal government. If you believe none of this applies to you, it does.