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Your Online Home, House Calls and Donuts (with filling)

As you’ve probably already picked up on, I’d talk about payment reform -  specifically bundling – each week if my editor would let me.  Thanks, Ben.  So, this week we’ll stray from a purely financing-related discussion and piece together some of this past week’s news that will have an impact on care team collaboration.

But, because I can’t resist, for those of you whose interest in still piqued from last week’s discussion, it seems we were one step ahead of The Commonwealth Fund and Health Affairs.   To satiate your bundling appetite, take a look at this report by TCF experts published in Health Affairs, which highlights the urgency for and the impact of payment models that appropriately spread risk across care teams.

And, we’ll stay on this road for a bit longer, though we’ll shift lanes.  The “medical home” concept is a community-based manifestation of the connected care teams that we care so much about at RemCare.  Last week, a Wall Street Journal article took an in-depth look into the progress made by several medical home demonstration projects in Pennsylvania.  These demonstration projects are some of the most mature in the nation and are beginning to yield some great data on the impact and sustainability of this model.  On that latter point – sustainability – what jumped off the page to me is that each practice required an additional 2.5 FTEs to support the medical home program.  And, more importantly, these practices did not think they would have the resources to support this additional staff once grant funding expires –unless the compensation for this model was altered by the state, feds and/or private insurers.  Of course, where my mind goes is right to technology.  What solutions exist that can efficiently support the medical home model and minimize the need for additional staff?   The good folks at The Commonwealth Fund took a different but complimentary approach to resolving this unsustainable staffing requirement.   Shortly after the WSJ article, Health Affairs published an article that highlighted best practices for reducing the staffing burden of the medical home model by sharing resources across practices.

In this forum, we’ve looked at connecting care teams from many different perspectives, including the public sector, private insurers, hospitals, families and community-based providers.  The follow-up appointment between the patient and his/her physician is a staple of successful transitions of care from the hospital to home.  We’ve talked about how the most subtle of triggers, a lack of transportation for example, can set a patient off on a track that may lead to a preventable re-admission.  This is why telemedicine, which in our definition consists of secure on-line communications that offer the equivalent patient experience of an in-person visit, exhibits so much potential.  You can’t miss an on-line appointment because of transportation – maybe for a finicky modem, but not because your ride was sick!  And, physicians are beginning to enforce more financial penalties for missed appointments.  As a student of human behavior, what effect might these penalties have on appointment compliance?  Not what you might think.  Sure, those who don’t miss appointments will certainly not miss their appointments but those who do – those folks who are on fixed incomes – might avoid future appointments for fear of paying the missed appointment penalty.  Am I a cynic?

So, let’s go back to on-line visits.  It appears a strange split is appearing on-line in terms of the way patients and providers communicate.  Patient and provider interactions on social media sites such as Facebook and Twitter continue to grow, with patients seemingly feeling secure enough to discuss sensitive medical matters with their providers through these unsecure (in the HIPAA sense) forums.  At the same time, the growth in secure technology portals that are designed specifically to foster on-line visits continues to lag behind the pace of increased use exhibited by social media.  In fact, patients ironically remain skeptical of these tools.  From my Medem days in the late 1990s, the health care community viewed finding the best way to support an on-line patient experience as the holy grail.  Our growth at Medem was hampered for two reasons – we were too early (primarily) but also insurers were not sure how to compensate the on-line visit.  A decade later, it is still the payment model that gets in the way.  (See, I told you I couldn’t stay away from financing).   In the spirit of not simply pointing out problems, but offering solutions, I suggest the opposite of what Machiavelli advocates for in his  “Art of War:”   Let’s go where they are!   Patients are flocking to Facebook and Twitter – and so are docs.  Why don’t the technology providers that support on-line visits find a way to leverage this user density and plug into the likes of Facebook and Twitter – or at least leverage their brand equity?   Yikes, because of the trust in these brands, consumers seem willing to share sensitive health care information yet still raise eyebrows as secure health records and communication tools for reasons of security.

Finally, I’ve been on a donut kick as of late. (A family camping trip was my excuse for loading up the Wills wagon with saturated fats.)   Last week was a big week for donuts – and, no a Krispy Kreme did not come to town.  The federal government mailed off the first round of $250 checks to those seniors who had entered the “donut hole” in the Medicare Part D subscription drug benefit.  This filling of the hole is significant because one of the many provisions included in PPACA is the ultimate elimination of the donut hole for all Medicare Part D participants by 2020.  Looking at this through the jelly-filled lens of care teams, I’m hoping that a more complete drug benefit may help with care plan compliance and reduce the number of patients who boomerang back to the hospital because of poor medication compliance.  This certainly happens today.  Seniors reach the gap in the drug benefit and they prioritize which medicines they can afford out-of-pocket.  Perhaps they choose poorly and the medicine they no longer purchase causes a relapse in their progress.   If anyone has data on the percentage of re-admissions caused by donut-hole, please send it along!

If nothing else, I hope this post means that I won’t be alone at the Dunkin Donuts counter tomorrow!