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My wife (and editor) is a columnist for a hyper-local start-up trying to compete with our local newspaper. She wrote a column, published today, on the trials of one of our (now deceased) “urban chickens.” The story takes the reader from the designer chicken coop to the vet who specializes in urban chickens, through the diagnostic testing (mostly physical exam), and the outcome (the chicken had to be “euthanized”). We have had several conversations about this event in our household, mostly around how a vet can charge so much money to diagnose a bird that one can get pre-cut up at Food World for 69 cents a pound with a coupon. Mostly, I filed this under people with extra money do odd stuff for their animals and vets are willing to work with us to facilitate this behavior. I couldn’t help but reflect that in the old days, the county agent would have provided the diagnosis (“That’s bad”) and offered a free solution (wringin’ its neck). Or so I learned from watching reruns of Green Acres while I was growing up.

In catching up on a backlog of New England Journal articles, I came across an article that points out the cost-effectiveness of environmental prevention (either through creating opportunities such as walking and bike paths or prohibiting bad behaviors such as driving without seat belts) when compared to individual focused efforts such as screening for colon cancer. I also read the review of the Insitute of Medicine report on childhood obesity in a subsequent issue. Disturbing was the breakdown of attribution of cause by political ideology, with “conservatives” more likely to blame children for their own obesity. Another Bloomberg article points out that physicians are at times willing accomplices in subverting any requirement for personal responsibility. The writer documents physicians self-referring into a surgery center that gives them a tremendous profit in exchange for only referring folks with the “right” insurance and looking the other way as the insurance companies were milked (or bilked, depending on the outcome of the lawsuit) for excess payments.

In short, to improve the health of the country we are going to have to make societal changes that lead to prevention, convince 30% of the population that this is not socialism, and find ways to keep physicians and others from gaming any new system. Paul Grundy, my friend with the Patient Centered Primary Care Collaborative, would see the chicken story as a metaphor for a broken system but would understand the need for a county agent approach. He sent me an advanced copy of  their newest report (to be released September 6) entitled “Benefits of Implementing the PCMH: A review of cost and quality results, 2012.” The Patient Centered Medical Home is a way to organize care delivery that combines the best of high value physician interaction, rewards for population health, and identification and elimination of waste. The new assessment of this method of care delivery is:

The PCMH improves health outcomes, enhances the patient experience of care and reduces expensive, unnecessary hospital and ED care.

It is being implemented across the country with the following consequences:

  • As medical home implementation increases, the Triple Aim outcomes of better health, better care and lower costs are being achieved.
  • Medical home expansion has reached the tipping point with broad private and public sector support.
  • Investment in the medical home offers both short- and long-term savings for patients, employers, health plans and policymakers.

Note that the outcome for human patients (better health) is different than the outcome for chickens (stewpot). I hope for the sake of all of us that we achieve these outcomes (for people). Now if only we can bring a County Agent to Mobile who knows about chickens.

As I mentioned here, not all is bleak in the world of care delivery. Forbes recently ran two articles on how things are changing rapidly. The first, found here, is about how Aetna is  reformulating itself as a consequence of the Affordable Care Act and other pressures/ From the article:

Aetna recognizes the transition from the “do more, bill more” generation to the value/outcome-based generation is going to happen regardless of whether the Supreme Court overturns the health reform. The employers picking up the largest portion of the healthcare tab are fed up with the “get less for more” story they are told every year. In fact, IBM itself is a leader amongst large employers that pushed for facets of the health reform that included an emphasis on primary care.

From afar Aetna , it appears there are at least four key insights driving Aetna’s behavior:

  1. Traditional health insurance business profits have been capped so they are pursuing complementary businesses that are unregulated.
  2. Simply going through traditional channels of employers and providers won’t allow them to reach all of their target market. They have to create new pathways to the ultimate consumer. For a bunch of reasons, healthcare is becoming a more consumer-driven market so they must build or acquire that skillset.
  3. The devastating Medical Loss Ratio (MLR) requirements mentioned in the Health Insurance’s Bunker Buster article demand that 80-85% of premium dollars go to patient care (vs. administrative overhead). I believe the aggressive acquisition spree will be for services that can be classified as patient care and thus help them with their MLR requirements.
  4. An onslaught of new requirements are being placed on healthcare providers. Smaller providers are especially ill-equipped to handle these on their own. Thus, Aetna wants to provide backoffice services for these organizations.

The second item of interest, also in Forbes, is the use of the Direct Primary Care Medical Home (DPC) provision of the ACA by primary care docs. While the details are a little complicated (and found in the article) the results are not:

Because DPC models are a more pure form of primary care not having to worry about how to weave in cumbersome insurance-driven processes, they have shown an even more dramatic impact than the aforementioned PCMH. While garnering customer satisfaction scores higher than Google or Apple, achieving more 5 star ratings on CitySearch than any other business DPC practices such as Qliance, Iora Health and WhiteGlove Health have reduced expensive downstream costs (surgical, emergency department and specialist visits) by 40-80%. I predict some of the PCMH models being piloted will shift to DPC as payment reform continues.

In the words of Forbes, good primary care (mostly Family Medicine) is sexy:

Utilizing a collaborative care model, the patient becomes a valued member of the care team — more than just a vessel for billing codes. Patients win. Physicians Win. Employers Win. Even forward-thinking insurance companies win. In fact, most major health insurance companies have major efforts to make primary care the foundation of their plans and it’s not a moment too early.