"Medical Home" Followup

By John Ballard

From Fierce Healthcare Newsletter.

Medical home pilots will impact 20,000 Blue Cross of Illinois beneficiaries

In yet another example that medical homes are taking root, Blue Cross and Blue Shield of Illinois has launched medical home pilot programs with two Chicago-area group practices. As with other medical home projects, these physicians are being paid more to provide patients with more intense services and better coordinated care between the practice and specialists.

While the health plan has not disclosed its exact reimbursement plans, executives said that physicians with Pronger Smith Medical Care and Elmhurst Clinic will get higher payments than under traditional primary-care contracts. To qualify, these groups had to adhere to a number of national quality measures, have an electronic medical record in place and offer 24-hour access to doctors.

Elmhurst Clinic's 35 primary-care doctors will be coordinating care with about 65 specialists, and Pronger Smith's 18 PCPs will coordinate with 27 specialists. The pilot programs will impact about 20,000 of the Blue plan's beneficiaries, but if they're deemed a success, the plan will roll out medical home payments to more of its 7.2 million members.

To learn more about the program:
- read this Chicago Tribune piece

They have "not disclosed their exact reimbursement plans" it says. That's not only important, but central to the move. What that means is that designated primary care physicians will do better and specialists will be used less frequently because that seems to be one of the dynamics behind health care inflation. Here are the two paragraphs not included in the snip.

"The medical home is the 21st century version of primary care," said Dr. Donald Lurye, chief executive of Elmhurst Clinic. "We like the model because it makes the primary care provider the patient's advocate and central resource."

The pilot programs will be watched by critics who question whether physicians will get enough money from insurers to make medical homes worth their while. Also, critics said, the medical home's success requires physicians to equip their offices with electronic medical records, an ongoing challenge for many doctors who see that technology as cost-prohibitive.

A previous post explains the "medical home" concept in general terms. Think "managed care" revisited, but this time with the patient in mind as well as the profit lines of providers and insurers.

I have a feeling that health care reform has already begun and the results may become measurable a year or two from now, with or without legislation. Health care inflation has reached critical mass and even the parasites sucking the system dry can see that the host is about to be killed if they don't do better job of stewardship. That includes the smart people in all three ancillary drivers of that inflation: pharmaceutical and insurance companies and the elected representatives on their payroll.

One way that we can know that health care reform is really taking place will be when TV ads for medicine no longer say "Be sure to tell you doctor if..." followed by whatever parts of your medical history you are supposed to carry around in your head. This is literally life and death information and anyone can see that telling people to keep up with their own medical condition and history is a truly insane idea. I look forward to the day when "tell your doctor" becomes grounds for a malpractice action unless he's looking for symptoms, not history. 

If we ever get serious about costs the answer will be single-payer, but I don't expect to see that in my lifetime. Meantime I'm satisfied to live with Churchill's assessment that "America will always do the right thing, but only after exhausting all other options."

Here is more evidence that the insurance people are waking up. (I wanted to parse this, but it's easy reading and makes my point as it stands.)

Workers comp results are going to get worse. And medical will drive the decline.

The property and casualty industry will get worse before it gets better, led by the work comp business. That's one of the key takeaways from a session at AmComp yesterday.

The session featured a panel of CEOs from workers comp insurers asked to tell the audience at the AmComp NY meeting what keeps them up at night. None of them mentioned medical costs, although in a response to a question (from your reporter) they all said it was a big problem.

How are they addressing it? One said they just factor 6-9% of medical trend into their rates, another said it was up to the health insurers and the third said you had to have good claims and medical cost control.

With all due respect, I'd suggest that medical is a very big problem in comp, that very few insurers or TPAs have anything approaching effective medical management programs, and there are any number of programs, tools, processes, vendors, and methods that can have a dramatic impact on medical expense.

[ed. TPA means "third party administrator" describing the usual relationship between a company and its insurance. Both workers comp and group medical insurance are paid for by the client company which outsources "administration" to insurance pros. This is another piece of the puzzle because these "professionals" have little or no reason to worry about underlying costs, neither group nor workers comp, since they simply pass them on to the client company.]

Which will impact claims costs which in turn affects losses and reserves and premiums and profits.

I have no knowledge of these insurers' managed care/claims programs; it is entirely possible that one - or perhaps even all - of these insurers have strong, outcomes-oriented medical management programs built around small, workers-comp focused physicians, specialty programs for PT, facility, drug, and imaging, and evidence-based clinical guidelines. If they do, they're well ahead of the market.

As one who started out working in HMO consulting decades ago, the CEOs' statements were reminiscent of what we heard from executives at big indemnity insurers - medical costs were medical costs, they had cost containment programs. They dominated the health insurance industry back in the mid-eighties.

They are all out of business, with one exception. And that exception - Aetna - is the only one that successfully transformed itself into a health plan company.

Workers comp is becoming has become a medical management business. Some smart insurer will figure this out, and when they do, they will win.

And win big.

You don't have to read between the lines to see that the workers comp people have been asleep at the switch while medical expenses soar. No skin off their noses. All they do is pass the costs on to their client companies and go on with business as usual. Let the loss control officer deal with it.

Folks, it looks like times are changing.