A Broader Approach To Managing Health Care Risk

Brian Klepper

Posted 2/15/13 on Medscape Connect’s Care & Cost Blog

BK 711Health care’s purchasers crave certainty. But complexity – and therefore uncertainty – rules. Assurances are hard to come by.

The most common question asked by prospective clients of my onsite clinic/medical management firm is how much less their employee health benefits will cost if they deploy our services. They often expect that we’ll review their claims history and nail down what their health care will cost once we’re involved. Looking in the rear view mirror can inform the future, but it isn’t foolproof.

The Complexity of Health Care Risk

The challenge here is that so many different mechanisms contribute to the need for care, the ways care is accessed, the ways care is delivered, and the ways it is priced. Even mechanisms that, in isolation, are strong, often are inadequate in the context of larger cost drivers.

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Demanding More From Medical Homes

Brian Klepper

Published 9/4/12 in Medical Home News 

Never confuse motion with action. 

Benjamin Franklin

A reporter called the other day to tell me that several local health systems now had medical homes. “I don’t think so,” I said.  She was emphatic. “They just told me they do.” I asked whether their medical homes take fee-for-service reimbursement. “I guess so,” she said. “Doesn’t everyone?” “Almost everyone,” I said. “But if they do, that means they have a financial stake in delivering unnecessary care.” By definition, that’s counter to the idea of a medical home, which provides the right care at the right time in the right context. You can’t have it both ways.

Virtually every organization remotely related to primary care now wraps itself in the mantle of patient-centered medical homes (PCMH), and many flaunt their Recognition by the National Committee for Quality Assurance (NCQA) as proof that they’ve met a standard. Presumably employers and other purchasers, enthused by the buzz surrounding medical homes, assume these credentials translate organically to better care at lower cost.

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Do Medical Homes Really Result in Better Diabetes Care?

Jaan Sidorov

Posted 2/22/12 on the Disease Management Care Blog

Is the pursuit of evidence-based medicine evidence based?  That was the head-cramping question the  Disease Management Care Blog grappled with when it read this just published Health Affairs article, Tool Used To Assess How Well Community Health Centers Function As Medical Homes May Be Flawed.

Readers will recall that the National Committee for Quality Assurance (NCQA) is a Washington DC-based not-for-profit that champions the use of performance measures to assess the quality of health care.  Provider organizations go through an assessment process based on the measures and, if they pass muster, are “recognized” by the NCQA.  The performance measures are based on peer-reviewed medical evidence, vetted by expert panels and then opened for public comment before they are finalized and used.

The DMCB knows this because it has served on two of the NCQA panels.

While its most visible activity has been the ranking of health insurers, the NCQA has been offering a soup of recognition, accreditation and certification programs for other types of provider organizations including the disease management vendors (for example) and, more recently, medical homes.  More on that group of providers later.

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EMRs and Primary Care: The Good, The Bad and The Challenges

Josh Freeman

First published 6/11/11 on Medicine and Social Justice

My PhotoOne of the centerpieces of health reform as promulgated by almost everyone, and very much the Affordable Care Act (ACA) is the use of electronic medical records (EMR, also called, in a more inclusive formulation, electronic health records, or EHR). The Health Information Technology for Economic and Clinical Health Act (HITECH) specifically addresses specifications for EMRs. Demonstration of effective use of EMRs, including “e-prescribing” (in which prescriptions are routed electronically directly from the physician’s office to the patient’s pharmacy of choice), maintenance of patient registries (who in your practice has diabetes?) and compliance with a set of quality measures (What percent of the people in your practice with diabetes have had their sugar measured? What percent are in control?) account for a great deal of the added payment for chronic disease management, as well as payment for patient-centered medical homes (PCMH).

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Gregg Masters Interviews Brian on ACO Watch


Gregg Masters is a long time health care manager and analyst who now, among many other things, hosts a health care talk show, ACO Watch, focused on Accountable Care Organizations and what they’ll mean in the health care marketplace, if indeed they do come to fruition in a way that can drive down cost and improve quality.

On January 19th, Greg and I spoke about ACOs, the incentives required to make them work, my skepticism that they can be effective and why, as well as the primary care medical homes that will be required at the front end of the health systems’ networks, acting as independent fiduciaries, for them to get meaningful traction in eliminating waste and promoting appropriate care.

This was done over a phone, so the quality is a little compromised. The show is right at 30 minutes, but the first few will give you a flavor.

Because Gregg is well connected and extremely knowledgeable in health care, he’s lined up a terrific list of health care experts who can speak effectively to different dimensions of ACOs. On the right sidebar, I’ve posted a button that will take you to the most recent edition of ACO Watch. I’ve been listening lately, and found the interviews short enough to be digestible and manageable, given my schedule, entertaining, and most important, useful.

Five Inevitable Trends That Will Change Physician Practices


Over at iPractice, a Sanofi-Aventis site aimed at helping physicians manage their practices, I detail several rapidly emerging trends – clinical/financial performance transparency, clinical decision support, a medical management revival, value-based benefit design and medical homes – as well as how physicians might respond.

The core thesis here is that these trends are inevitable, brought on by a system that lags far behind most industry sectors, with costs so wildly out of control that a large and rapidly growing percentage of individual and corporate purchasers have been priced out of the coverage market.

Head over and take a look. The goal is to help physicians face these trends head on so they can prepare to succeed as they take root and come to dominate the marketplace. Feel free to pose questions, and I’ll do my best to respond quickly.