Stanley Feld M.D.,FACP,MACE
Whatever happens with this particular program, Medicare says it wants to keep experimenting. “We’re not giving up on this stuff,” said Mr. Kuhn, the Medicare deputy. “We definitely want these programs to work.”
Mr. Kuhn is referring to Medicare’s $350 million dollar disease management program that has failed. I hope Mr. Kuhn is realizing that the chronic disease management programs must be systems of care directed by physicians in order to succeed. The systems have to be patient centered with the physician being the captain of the care team.
“Medicare is doing exactly what we should want Medicare to do — to test different life forms of disease management and see what works best,” said Dr. Arnold Milstein, the chief physician for Mercer Health and Benefits, a consulting firm. But, he said, “This particular form of disease management is not looking promising.”
Dr. Milstein works for a health benefits consulting firm. He makes no judgment on the defects in the study.
“Medicare is already exploring other ideas, like the development of so-called “medical homes,where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.”
The concept of “medical homes” is a variant of “Focused Factories”. Focused Factories have been championed by Regina Herzlinger at least 15 years ago as a plan to modernize medical care.
I believe the concept of “medical homes” will work. It is physician directed system focused on becoming expert in the care of one disease with a team of physician extenders. The patient is at the center of the management team. I can not find the design of the study Medicare is doing. “Medical Homes” was developed by the American Association of Medical Colleges. (AAMC).
The problem with the American Association of Medical Colleges performing the study is most patients are taken care of by physicians that are not in an academic setting. The system must be tested utilizing practicing physicians in a real world setting.
Twelve years ago I present the concept of AACECare as a system of intensive diabetes self management. It is a system of care with the patient being at the center of the diabetes management team and the Clinical Endocrinologist being the captain of the team that includes nurses, dieticians, and psychologists.
Family Practitioners have to be taught how to develop this system of care in their practices. There are not enough Clinical Endocrinologists to care for all the diabetics in the country. The Family Practitioners see most of the diabetics. In order to have any impact on cost of care they have to be engaged in the system of care.
“Many of the companies involved in the failed program say the experiment was flawed in the way it was designed and that Medicare has failed to work with them to make the program a success.”
Now the eight companies are blaming Medicare for its own faulty design of the $350 million study. I could have told Medicare it would not have worked before it spent a dime.
“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna.”
“The companies say Medicare signed up patients who were much sicker than they had expected.”
All patients with Type 2 Diabetes Mellitus are very sick. They usually have the disease for eight years before it is discovered and are on the way to develpoing chronic complications.
“The companies also say Medicare failed to make good on its promise to give them timely information about the use of prescription drugs, for example, or lab results that would have allowed them to help direct the patients’ care.”
Medicare is not the medical doctor. Nurse help desks are not a direct extension of a physicians medical care team. They are not going to get patients attention as a physician office team can. The participating companies are now in a defensive mode.
“We overestimated the real desire expressed by the organization,” said Ben R. Leedle Jr., the chief executive of Healthways, who has been an outspoken critic of Medicare.
“Mr. Leedle says that Healthways will probably be able to demonstrate savings from at least some of its Medicare efforts, although the company also says it is projecting a loss on the experiment because it may have to pay back federal fees.”
On the other hand Medicare claims that it worked with the companies.
“For its part, Medicare said that it had worked extensively with the companies to address their concerns and that its final analysis would take into account how sick the patients initially were.”
The blame game has started. This exercise will last the better part of a year and become politicized. An experiment with chronic disease management designed and executed correctly will prove that it works and saves money. If it is done incorrectly it will not save money.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.