The Rise of the Medical Director What One ACOs Good News Tells Us

Medical Directors prepare for battle

The VP of Finance finally agreed to a meeting. In order to make maximum use of their time, however, he had a simple request: submit an agenda of topics first and then hed be happy to let his administrative assistant set up an appointment.

In that game of organizational politics, Finance VP: one. Senior VP and Medical Director: zero.

The lost voice mails. The patronizing glances. The unanswered emails. The skeptical grins. The condescending nods. Every lead doctor, medical director and physician VP is exquisitely familiar with the tut-tuting attitude that lingers just below the surface, ready to spring when their opinion on how to best serve patients bumps into the organizations budgeteers. Those finance guys know that the typical physician is used to spending dollars like a Miami-Dade ICU on a 98 year-old. They know those "white coats" are incapable of understanding costs, margins and cash flow. Better that they get out of the way and let the money experts call the shots, eh?

Call it the clinical-finance tension. Like government revenue vs. cutting taxes. Sales vs. customer service. The DMCBs premium cable TV perences vs. the spouses unreasonable penny-pinching.

Which is one of the reasons why the Disease Management Care Blog found this New York Times article interesting.  If this is any indication of what is going on nationwide in the delivery of medical services, the implication is that the physician leaders perspectives are in the ascendancy in their organizations. Not only is there a pervading belief that keeping patients like Ms. Cline away from the emergency room is important for the bottom line, but that achieving clinical outcomes is no longer secondary to making budget.  While typical news reporters havent picked up on the clinical-finance tension that lurks in health insurance and delivery organizations, the very fact that most of the NYTs interviewing involves physicians is telling.

The playing field is currently level.

Which brings up four points:

1. The DMCB suspects the genesis of the NYT article was this presentation at a recent AHIP meeting.  Thanks to reading the DMCB, you also know that a lot more background detail on the Advocate-BCBS Illinois collaboration is here.

2.  Abstracts, presentations and news articles are one thing, but having results reported in a peer-reviewed setting is another.  The DMCB readers know that theyll withhold final judgment until it sees some transparently presented hard numbers.

3.  While Medical Directors are currently playing on a level playing field, disappointing budget results, financial losses and failure to achieve savings could not only tilt things against the clinicians again, itll quickly undo the merits of "doing the right thing."  That alone is a good reason to hope that the health system "accountability" arrangements like ACOs survive.

4.  The secret sauce to Advocates success?  Care Coordinators.  More on that in tomorrows post.

Three Models of Primary Care Teaming TL CC and ET An Unexplored Feature of the Medical Home

What defines optimal outpatient primary care "teaming?"

The Disease Management Care Blog just assumed that if it took equal scoops of adaptable physicians, dedicated nurses and supportive culture and baked with a dollop of accountability, "teaming" would just.... happen.

It turns out that what may come out of that clinical practice oven is a lot more complicated than that. 

Which is why medical home advocates should pay attention to this article by George Washington Universitys Debra Goetz Goldberg and colleagues.  Interested in finding out more about primary care "teaming," they interviewed, reviewed and observed three different Virginia clinics that had embarked on transformative quality improvement programs.

Each clinic came up with a different version of "teaming":

1."Top of License" - nurses interviewed the patients, presented the problems to the docs and then documented the care plan.  They were also responsible for the patient education.  Thanks to using this model, the physicians almost doubled the number of patients they were seeing per day.

2. "Care Coordinator" - nurses focused on helping patients undergoing care "transitions" (typically out of the hospital) and provided self-management and health education to high-risk, high complexity patients.  Interestingly, unsatisfactory reimbursement levels forced the practice to cut back, but they still doubled mammography and blood pressure control rates among persons with diabetes mellitus.

3. "Enhanced Traditional" - the physicians still performed the bulk of the patient care but the researchers observed that the other clinic personnel benefited from increased trust, communication and hand-offs that translated into patient centered care, shared responsibility and heightened volunteerism.  The practice was unable to measure any outcomes.

"Very interesting!" says the DMCB. Authoritative web-sites like this or this and peer-reviewed articles like this er to "teaming," but fail to precisely define it.  Assuming the three categories described by Goetz-Goldberg (in shorthand, "TL," "CC" and "ET") hold up in future studies, the DMCB looks forward to learning which approach results in the greatest quality or cost-savings.

Coda: As a reader bonus, the authors offer up a definition of "team-based care" that seems to span all three models and can be used for the DMCB readers quoting pleasure:

"A group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients."

Going Long on the Patient Centered Medical Home PCMH Despite the Prattling Pinheads of Pessimism

Is the Disease Management Care Blog worried about the prognosis of the Patient Centered Medical Home (PCMH)?

Not in the least.

Its simply marching from its "Peak of Inflated Expectations" through the "Trough of Disillusionment." Before you decide to short the PCMH, check out this very enlightening Bloomberg editorial, Lure More Doctors Into Primary Care With Medical Homes.

Noting that many commercial insurers remain committed to the medical home model of care, Bloombergs business-savvy editorial board also points out that the PCMH has the added quality of attracting physicians to careers in primary care. The Josia Macy Jr. Foundation has some preliminary data suggesting that experience in medical home settings increases medical students enthusiasm for primary care.

Its a timely article.  While prattling pinheads of pessimism (examples here and here) glom onto imperfect research methodologies and findings that are unequal to the task at hand, top notch organizations like Sutter, University of Pittsburgh Medical Center and Horizon Blue Cross Blue Shield are going long on the PCMH.

These guys know something that the academics are missing.

Too bad there isnt a PCMH futures market; the DMCB could make some serious money.

Image from Wikipedia