Contemporary Pediatrics - September 2008 - (Page 42)

Eye on Washington across the system, and it should be facilitated by registries, information technology, and health information exchange. Evidenced-based medicine and clinical decision support tools should guide decision-making. Practices should go through a voluntary recognition process by a non-governmental entity for this type of service. As DeMarco explains, “We are not going to be doing this for too long without somebody raising their hand and saying, ‘Well, what about quality, what about safety? Why is this practice better than another practice?’” The principles also say payment should recognize the value of this management work outside the face-to-face visit. Payment should also support health information technology, and use of secure e-mail, telephone consultation, and technology to monitor clinical data. DeMarco suggested providers perform a feasibility study, using recent National Committee for Quality Assurance (NCQA) requirements. He noted that the clinical information system is key: “We’ve had so many people falling through the cracks, so many pieces of the data that are useful that never make it through the report process, they are trying to really broaden this whole clinical information requirement.” strate the benefits of the [medical home] model overall—and none have involved the majority of the payers in a given state.” The Commonwealth Fund is also funding a project by the PCPCC and the NASHP to support state Medicaid initiatives on the medical home. And according to DeMarco, 12 states have passed laws to create or encourage medical home programs for children. NCQA reports, “Many large health plans, as well as Medicare and Medicaid, are planning demonstration projects to learn more about how practices can become medical homes and the quality and cost advantages of doing so.” A major Medicare medical home demonstration, mandated by Congress, is due in 2010. Working out the details For providers evaluating this new idea, Keckley cautioned that much still needs to be worked out. “It is not as simple as a [PCP] being paid differently,” he said, noting the overall purpose is to improve populationbased outcomes. There is a variety of medical home models, but the upfront costs of most are steep. Other questions, Keckley said, center on how incentives should be structured, and whether medical home hosts should take some risks. “Many proponents of the medical home say, ‘You should pay me upfront to make these investments, and then I will share in the net result,’” he stated. There is a sense, that “the only beneficiary of the medical home is the health plan.” There is also discussion on the effectiveness of “coaching” models, or the careful engagement with patients. “There is a substantial amount of literature emerging around what moves the needle on consumer behavior,” Keckley says. “What makes people take their meds? How do we get from one out of four following a treatment directive up to half? There is going to be an interesting tension that emerges again between and among physicians,” he said. “Can [PCPs] manage referrals through the medical home model, to medical specialists, to surgical specialists?” DeMarco also told providers to check with employers and health plans about supporting a medical home. “Attend some of the employer-coalition meetings and find out, ‘Are these people open to this idea?’” He stressed, “It certainly is not going to stop moving into a more mature business model for primary care.” Current trials A variety of demonstrations for the medical home concept are planned or underway. The UnitedHealth Group, for instance, announced a Florida pilot project in August 2007 to provide enhanced payment to several PCPs for care, based on this model. The project is supported by the AAP. The PCPCC has also identified projects in 16 states (several with multiple payers and several including Medicaid) that are evaluating medical home efforts, or related arrangements such as chronic care coordination. A current Illinois program, which the National Academy of State Health Policy (NASHP) cites as a potential model, pays PCPs monthly fees of $2 per child, $3 per adult, and $4 per disabled or elderly enrollee. In exchange, PCPs have to meet standards, including ongoing access for primary care, and coordinating referrals. The Commonwealth Fund recently gave a three-year grant to Harvard University to study five large Rhode Island practices, which will get a supplemental payment per patient and assistance in giving enhanced care. The fund says, “Few evaluations have been done to demon- 42 www.contemporarypediatrics.com Vol. 25, No. 9 http://www.contemporarypediatrics.com

Table of Contents Feed for the Digital Edition of Contemporary Pediatrics - September 2008

Contemporary Pediatrics - September 2008 Contents Editorial Your Voice Clinical Tip News Updates Eye on Washington Puzzler Dermatology: What’s your Dx? Behavior Cover Story: ECC Epidemic Parent Guides Discipline Techniques: The 12-Month-Old Exercise-induced Bronchospasm: Keeping Our Patients Active Food Safety Parent Guide CPR--Food Safety Malnutrition Links Surgeon General Links Hospice Links Childhood Cancer Links Rx for a Healthy Practice Rx for a Healthy Practice New Products Author Guidelines Journal Club Events Calendar Classifieds Index of Advertisers Postscript

Contemporary Pediatrics - September 2008

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