Gary Oftedahl: Is Anybody Home—and Accountable? Check, Please!

Check, please!  No, I’m not impatiently waiting for my dinner bill.  I’m looking for a reality check.  Such as, does anyone really think we’re ready as a health care system for the upcoming reforms being promoted?   We’re only beginning to fully understand what will be needed to implement the patient-centered medical home model (lovingly and legislatively called health care home in Minnesota) when at the  same time we are being trampled by the rush to develop Accountable Care Organizations (ACOs).   What’s interesting to me is that if I venture outside the Twin Cities metro area, I encounter a significant number of health care providers who don’t even understand what the ACO acronym stands for?  Check, please?

I’ve spoken in the past about our rush to solutions, which often times runs roughshod over the ability to gain an understanding of exactly what or how we’re going to come to any shared perception and common purpose in redesigning our care systems?  ( http://bit.ly/egepts ).  In addition, we’ve really not engaged our patients and their families in understanding exactly what is going to be expected and actually required of them to make this work.   For goodness sakes, we can’t even all agree on operational definitions and roles as we create the “team-based approach” required.

But I’m an optimist, or perhaps naïve, and believe we do have the capacity and capability to pull this off—if there’s enough time, enough will, and impassioned commitment.   But then I open up my most recent Health Affairs and have the opportunity to read an article by Diane Rittenhouse, et. al, (http://bit.ly/quB9bT ) addressing the use of PCMH  processes in small- and medium-sized practices, and once again—check, please?

The article addresses the use of medical home processes (using the seven fundamental principles created by the professional medical associations– http://bit.ly/9WcPtI ) in 1,344 small- and medium-sized physician practices across the country.   Information was collected in an effort to see how successfully the principles were able to be recognized as being in place.  While I recognize that it takes time and significant effort for major changes such as those proposed to be implemented, one would hope we would see a fairly significant movement toward full deployment.  The authors noted that practices evaluated had earned only 21.7% of the possible points available in achieving medical home status.  Check, please?

But some would say that’s encouraging, especially since we’re only a few years into this effort.  Perhaps, but on looking at that 21.7% number, it’s likely artificially elevated.  Why?  While the authors acknowledge the need for all seven items recommended, for methodology reasons, they chose to focus on evaluation of only the last four of the principles.  The principles requiring a personal physician, a whole-person approach, and payment reform were not included in the review.  I would suggest that if we looked at the first two of those and included them in the evaluation, the percentage would be even lower.  Check, please?

I would encourage you to read the article, and consider the implications therein.  I’m not trying to be sarcastic, negative, or cynical, although it may sound that way.  But as those of you who’ve read my posts in the past know, I’m concerned we’ve not recognized the need to address the adaptive (cultural, value, belief) work needed, have not agreed upon the functions essential vs. focusing on the structures and processes, or begun to understand the challenges of engaging patients/families as active partners.

We’re “rushing” toward the development of ACOs, yet from the Rittenhouse article it is apparent we have much to do to even provide the elements of a medical home—which in many minds is the foundation for a successful ACO.  Presently, consultants are making fortunes by assisting organizations in creating the contracting and finances for success, but in most cases, not addressing the significant work needed to create the professional and organizational cultures which will be critical in moving toward this type of longitudinal, population-based approach.  Check, please?

It’s an exciting time, from many perspectives, in that we recognize that we have an opportunity to truly transform our health care system.  But in the face of an apparently intransigent legislative process, dramatically worsening polarization of political beliefs, and an unwillingness to compromise politically, it is uncertain if any of our efforts to work collaboratively in health care, challenging as that is, can survive the political process in which we’re all embroiled.  Check, please?  Oh, and about that tip…..

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