The New Health Dialogue

Several of us from New America spent some time at the Agency for Healthcare Research and Quality’s big annual conference this week, its first since health care reform with all its potential for primary care was enacted. It’s a bit hard to sum up (keynote speaker Atul Gawande called it being "in the trenches with the data") so I’ll jump off from the opening plenary -- "21st Century Health Care: What Does it Mean to Achieve Success in Quality, Value, and Access to Care."

AHRQ director Carolyn Clancy (we had a chance to talk to her this summer here) moderated, and the panelists were Maulik Joshi, president of the Health Research & Educational Trust and senior vice president for Research at the American Hospital Association, James Mold, professor and director of research in the Department of Family and Preventive Medicine at the University of Oklahoma College of Medicine and Debra Ness, president, National Partnership for Women and Families (and the fact that Ness was there, keeping the focus on what patients/consumers/families want, was itself telling).

The discussion started with the observation that "patient-centeredness" is a bit of a Rorschach test, but panelists agreed (more or less) that people want coordinated care from someone who knows them, and can treat the whole person, not just an organ or a condition. They want to be engaged, and share in the decision-making. And getting there is tough.

"I am often asked what do patients want," said Ness. "It's always the obvious. They want access to high quality safe care and they want it to be affordable."

Mold spoke a lot about inhabiting two worlds -- the academic research world, that brings him to the national circuit of reform and quality conferences. And the world inhabited by front line primary care physicians in places like rural Oklahoma. "It looks a lot different on the ground," he said.

Practicing medicine in that setting, with advice and guidelines and quality standards and new definitions coming in from all directions, is a bit like having to treat a patient while ducking [figurative] bullets flying in from all directions from "organizations telling them how to practice better medicine." With the "guidance" coming from people who haven't actually practiced primary care medicine in a place like rural Oklahoma... The best innovations in the world, whether they be medical homes or accountable care organizations or new evidence based guidelines, won’t work if they don’t take into account the daily realities of the health care providers.

Mold spoke some of the possibilities that may arise from the primary care extension program under AHRQ that was created (caveat -- not yet funded) by the health reform legislation. (This is apart from the regional extension centers for health IT created by the HITECH legislation wrapped into the economic stimulus package). The primary care teams are supposed to assist primary care providers (which don’t necessarily have to all be physicians) about preventive medicine, health promotion, chronic disease management, mental and behavioral health, including substance abuse prevention and treatment. They are also supposed to help primary care providers incorporate evidence-based treatments and therapies, so we have a sounder scientific base for the care we provide.

I also sat in on sessions about medical homes and emergency room redesign (that one I’ll write about separately). Deborah Peikes, a researcher at Mathematica who has been evaluating medical homes, had a pretty sobering presentation. She’s a deep number cruncher, and basically her bottom line was "Everything You Thought You Know About Why Medical Homes are a Great Idea Isn’t Necessarily True." She didn’t say they don’t work, or they can’t work, just that from her data-crunching perspective it’s still an open question. And it may not be too easy to answer quickly (because gains in health status may not be seen immediately, among about 20 other somewhat discouraging reasons she gave...) And she worries about this because while in her view "most of the studies are weak... people are pouring in money, their hearts and their souls" into medical homes. Before we know just how sustainable the model will be.

My colleague Meredith Hughes attended another session on medical homes, Do Patient-Centered Medical Homes Lower Costs and Improve Quality? Leif Solberg from HealthPartners in Minnesota presented findings comparing the quality outcomes of 21 HealthPartners primary care clinics with the extent to which those clinics could be considered medical homes. (Based on the PPC-PCMH characteristics of a medical home). Solberg pointed out the study had many limitations (for example, the clinics were so small and so similar that actually generating substantive comparisons might be near impossible). But ultimately there was no apparent relationship between medical home characteristics and quality scores, and Solberg was left with “more questions that answers.” David R. West from the University of Colorado presented a case study on WellMed (not yet published). By and large, WellMed is successful both financially and in terms of care quality and patient satisfaction. But WellMed isn’t just a medical home, it’s a group of medical homes connected (along with other services) under the umbrella of an accountable care organization. Obviously further study -- and commitment to innovation -- will be needed to make these new delivery system models work.

AHRQ has a whole new website focusing on the medical home with lots of resources and papers and links. I plan to check back with some of the docs and researchers in this area soon...