Medpac struggles to define “medical home”

Medicare Payment Advisory Commission (MedPAC) Public Meeting, March 6, 2014

>From the transcript:

DR. [JULIE] SOMERS: Good afternoon. In this session, [Medpac staff] Kevin [Hayes], Katelyn [Smalley], and I would like to explore with you the idea of creating a per-beneficiary payment for primary care practitioners in the fee-for-service Medicare program. [p. 239]

…. [T]he Commission recommended establishing a medical home pilot [in 2008]. Variants of the recommendations for a primary care bonus and a medical home pilot were established under PPACA. … The [primary care bonus] program expires at the end of 2015, so we’d … like to hear the Commission’s views about extending the current program or replacing it with a per-beneficiary payment for primary care. [p. 240]

MR. [GLENN] HACKBARTH [MEDPAC CHAIR]: Okay. …. I am the one to blame if you don’t like this topic. I’m the instigator behind this, and I wanted just to say why that is. Why take this up now when there [are] … a number of medical home demonstration projects underway, some of which include Medicare? …. Why not just wait for the end of the medical home demonstrations?

There are two reasons for that. First … is the existing primary care bonus expires at the end of 2015…. Do we want to continue the existing bonus, or do we want to reconfigure it and do something like this?….

The second reason … is that I’ve become increasingly concerned about the medical home demonstrations on a number of different grounds. First of all, I am a little bit worried that the medical home model has … become gold-plated, and that in order to meet all of the NCQA requirements, et cetera, there are a lot of bells and whistles that have been added to it…. [M]y impression is that not all of them have really been validated as adding value, but they add cost, and so I’m worried that maybe the medical home model has a real cost disadvantage…. [pp. 251-253]

If you endorse a vague plan based on conventional wisdom rather than evidence and it doesn’t work, how do you revise it? Upon what evidence, by what logic, do you alter this or that part of the plan? The Medicare Payment Advisory Commission (Medpac) struggled with that problem at its March 6 meeting in the course of reviewing the performance of the “patient-centered medical home” (PCMH), an amorphous concept Medpac endorsed in 2008. The struggle did not go well. Commissioner after commissioner raised serious questions about the PCMH, but none of their questions triggered a productive discussion, the rationale for Medpac’s 2008 endorsement of the PCMH was never mentioned much less reviewed, and when the meeting was over it was impossible to say whether or how Medpac will propose changing the definition of the PCMH.

Revisiting the PCMH concept was Chairman Glenn Hackbarth’s idea. Hackbarth explained to his fellow commissioners that he wanted the commission to consider yet another PCMH experiment  because a temporary bonus for Medicare primary care doctors, authorized by the Affordable Care Act, is due to expire at the end of 2015. (The bonus is measured as a percent of each claim submitted by primary care doctors for Medicare patients.)

Mr. Hackbarth posed three questions to his fellow commissioners:

(1) Is it a good idea to extend the bonus beyond 2015?

(2) If so, should Medpac recommend that the bonus be extended as is or should the bonus be converted to a per-patient-per-year (capitation) payment?

(3) If the commission recommends converting the bonus to a capitation payment, should doctors be required to meet all the requirements of a “patient-centered medical home” (PCMH) established by the National Committee for Quality Assurance (NCQA)?

Commission members seemed unanimously to support extending the bonus, and 13 of the 17 commissioners expressed support for converting the bonus to “home” payments. But not a single commissioner offered an answer to Hackbarth’s third question – what requirements, if any, in the current definition of the PCMH should be stripped out?

Commission members made it clear they are concerned about the performance of the PCMH. Hackbarth opened the discussion by stating he believes the PCMH has become “gold-plated” – burdened with so many requirements (“electronic medical records and … 24-hour coverage and a long list of other requirements,” as he put it) that it can’t save money. (p. 267)

Other commissioners concurred. Scott Armstrong (CEO of Group Health Cooperative) and Dr. Rita Redberg observed that giving patients expanded access to doctors via e-mail has greatly expanded “virtual visits” without lowering face-to-face visits. (Armstrong added that “a lot” of what patients talk about in their e-mails “is useless.”) (pp. 275-276) Vice Chair Dr. Michael Chernew said he thought the “administrative requirements” currently imposed on the PCMH were a “hassle” and could outweigh any benefits the PCMH could achieve (p. 288). Willis Gradison said “adding too many requirements … to the structure of primary care” was driving doctors “into the arms of the hospitals.” (pp. 269-270)

Dr. David Nerenz suggested that the PCMH’s problem is more serious than merely being “gold-plated.” He questioned one of the most fundamental premises of the PCMH and all other managed care fads, namely, the claim that “care coordination … pays for itself [through] fewer admissions, fewer readmissions, fewer complications, fewer ED visits, fewer this, fewer that.” [p. 283]

John Christiansen (p. 279) and Peter Butler (p. 306) noted that the large systems that are buying up physician practices may not use PCMH payments for primary care, and Jack Hoadley observed that doctors may not be aware of the small capitation payments most PCMH programs pay to cover “home” services (p. 302).

Drs. Chernew (p. 291) and Rita Redberg (p. 278) noted that a growing body of research questions the conventional wisdom that the PCMH can cut costs by improving quality. Redberg, the editor of JAMA Internal Medicine, noted that she is seeing “a lot of manuscripts” that demonstrate the PCMH is not working as well “as one had hoped.”

Totally missing from this critical review of the PCMH was any discussion of Medpac’s justification for endorsing the PCMH in the first place. By a 16-0 vote, Medpac endorsed the “medical home” in its June 2008 report to Congress . But there was nothing in that report that resembled an evidence-based rationale for the PCMH. The “rationale” the Commission did offer exhibited the features typical of all managed care manifestos: The concept it purported to endorse was extremely vague, it was not supported by evidence, and it was oversold.

The 2008 report listed the usual string of vague attributes “homes” are supposed to have, including “use health IT” and “maintain 24-hour patient communication and rapid access,” the two features Mr. Hackbarth objected to. The report went on specifically to recommend that Medicare impose pay-for-performance schemes on “homes,” and that “homes” be required to use e-mail as a method of maintaining 24-hour access. But the report failed to offer any justification for its recommended list of PCMH features, and cited not a single study in support of the list or any item on the list. The report seemed to say Medpac relied on interviews with “experts” to derive this list, but even that is unclear.

Is it any wonder, then, that Medpac commissioners and staff did not revisit Medpac’s 2008 report for guidance on how to alter the definition of the PCMH in 2014?

Medpac has repeatedly made it clear it endorses the PCMH for the same reasons the American Academy of Family Physicians and other primary care groups did in 2007…  – as a means to bring more resources into primary care and to cut costs. The PCMH is probably not going to cut costs, and consequently it may backfire as a method of strengthening primary care. If we want to strengthen primary care and cut costs at the same time, we will have to enact a single-payer system.