Friday, August 17, 2007

Will This House Really Be a Home? - UnitedHealth Teams with Big Medical Associations to Pilot-Test the "Advanced Medical Home"

A joint press release from several US physician organizations, including the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP), and the UnitedHealth Group announced a pilot project to implement the "advanced medical home" concept.

Briefly, according to principles asserted by the AAFP, AAP, ACP, and American Osteopathic Association (AOA), the advanced medical home would have four key characteristics: 1) it would be centered on ongoing relationships among patients and their personal physicians; 2) the personal physician would be the leader of a team that takes responsibility for patient care; 3) the personal physician would take responsibility for the patient as a whole person; and 4) the medical home would provide care coordinated and/or integrated across all elements of the health care system.

According to an ACP monograph, the point of the advanced medical home is to offer "the potential to improve U.S. health care by focusing on strengthening and supporting the patient-physician relationship."

The press release, and a recent item in the AAFP News, provide an outline of the pilot project. Below are key elements.

General description of the medical home to be provided:

Each patient will have the choice to select a personal physician, or “medical home,” who knows his or her medical and family history and coordinates their medical care. The physician will be responsible not only for treating a specific ailment or condition, but also for working with the patient to better manage his or her health care needs and arranging care as appropriate with other professionals. The patient-centered medical home model places special emphasis on preventing disease and improving the care of chronic conditions. It emphasizes behavioral health support and patient education as well as the diagnosis and treatment of acute illnesses. [Press Release]

Implementation of the pilot program:

The pilot program will be launched in Florida with approximately six specially-chosen primary care practices that will employ the model. [press release]

[The practices are] yet to be chosen. [news item]

The pilot programs will include customers insured through UnitedHealthcare commercial insurance.[press release]

How UnitedHealth will be involved:

UnitedHealth Group will support the practices participating in the pilot program by integrating its extensive quality improvement and care management into the practices’ infrastructure. This includes sponsoring 24/7 nurse triage and other solutions that extend access to care, identification of and outreach to those who may need clinical interventions; and educational tools and assistance to help patients better manage their conditions. [press release]

UnitedHealth Group will support the participating primary care practices by helping them incorporate quality improvement and care management systems to increase access. [news item]

How physicians will be reimbursed:

UnitedHealth Group will pay participating physician practices a monthly care-management fee based on projected savings for all patients that select a medical home. In addition, the company will share any excess savings that accrue from the pilot program with the physician practices and -- by way of premium reductions -- with employers.

How results of the pilot program will be assessed:

UnitedHealth Group has commissioned an independent research study designed to evaluate and assess the results of the pilot's experimentation with the patient-centered medical home model of care. [news item]

Expectations of how it all will work:

'We should see improved patient outcomes and overall better value for patients, employers and health plans,' [AAFP President Rick] Kellerman said. [news item]

David C. Dale, M.D., FACP, President of the American College of Physicians, said, 'A key element of the patient-centered medical home model is a commitment to improved quality. Primary care practices should exemplify attributes such as dedication to team care, utilization of clinical information systems, coordination of care with other health professionals and support networks, as well as continuous performance assessment and improvement, among others.' [press release]

Reed V. Tuckson, M.D., FACP, UnitedHealth Group’s executive vice president and chief of medical affairs said, '“UnitedHealth Group and its companies are dedicated to effective, collaborative activities with physician experts and their professional societies that result in enhanced quality and efficiency of care for our customers.' [press release]

The details of this program are still sketchy, but they certainly raise some questions.

  • Is the pilot program realistic? - Apparently, the program will be limited to patients covered by UnitedHealth. Most physicians contract with multiple managed care plans and health insurers, and also see patients covered by government programs, and even some patients with no insurance. Patients tend to arrive in the office randomly with respect to their health care coverage, or lack thereof. How could the physicians in the pilot study run a medical home for only UnitedHealth patients, and give "usual care" to all the others? If they try to provide a medical home to all their patients, how will they afford to do so, since no other payer is going to change their reimbursement? If the practices involved only take care of UnitedHealth patients, how would results generalize to other doctors?
  • Is the goal to provide better patient care, or to save UnitedHealth money? - Note that Dr Tuckson used the "e-word," that is, efficiency. Is increasing UnitedHealth's profits the primary motive?
  • How much will this particular "medical home" model involve handing control of patient management over to UnitedHealth? - Note that the project will entail UnitedHealth "integrating its extensive quality improvement and care management into the practices' infrastructure."
  • Is the reimbursement meant to compensate physicians for their and their practices' time, effort, capital investment, and resource use? - Note that the compensation plan seems only to be based on UnitedHealth's "projected savings," and "any excess savings." There was no clear explanation of how reimbursement might relate to the time, effort, and expenses incurred by the participating practices.

The danger, of course, is that this scheme is first meant to save a big for-profit managed care company some money, ahead of any priorities on improving health care quality, or providing fairer reimbursement to primary care and generalist physicians.

The press release concluded with the proclamation in the press release that "UnitedHealth Group is a diversified health and well-being company dedicated to making health care work better." I hope that is so now. In the recent past, UnitedHealth was better known for paying its CEO outrageous compensation (see post here), and inflating his personal wealth to over $1.5 billion (see post here). Its former CEO was forced into retirement, and an investigation of whether the company back-dated his stock options is ongoing (see post here).

But maybe the company is really changing its priorities. And this project is a step in that direction. Time will tell whether this house it trying to build is really a home.

ADDENDUM (20 August, 2007) - See also these comments on the Retired Doc's Thoughts blog.


Anonymous said...

just the fact that they're paying the physicians upfront for coordination of care (phone calls/paperwork/refills, etc.) is a huge step. That's the part we're all overwhelmed and frustrated with, unreimbursed time and effort that is not inconsequential when practicing modern medicine.

I'm skeptical too on how much money they'll put where their mouth has been, but remember, it is only a pilot, so we'll see where it goes. The devil is always in the details, that's why I hope you guys keep your eyes on this.

Zagreus Ammon said...

United has had a change in leadership. They may be a thorn in the side of many a practice administrator, but they have potential to be a progressive organization. They don't do a lot of authorizing referrals because they realized it was costing a lot of money to lose customer goodwill. Now they recognize that they must align with physician interests if the physicians are to function as "gatekeepers".

This may work. Time will tell.

Vijay Goel, M.D. said...

It seems like a step in the right direction (coordination of care), but as previous posters have mentioned, the devil is in the details.

The biggest issue is that most PCPs don't actually know how to coordinate care-- nor are information systems in place to make this happen well. In addition, they will need support infrastructure with allied health providers-- nutritionists, patient advocates, information systems explaining diseases, IT systems reinforcing desired choices, etc.

The physician infrastructure of today is not built to cost-effectively help patients achieve goals they set-- and most physicians have been hesitant to drive primary care revenues to alternate providers.