MEDecision seeks room for health plans in the medical home (transcript)

This is the transcript of my recent podcast interview with MEDecision’s VP of medical home initiatives, Matt Adamson.

David E. Williams:            This is David Williams, cofounder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Matt Adamson, vice president of medical home initiatives for MEDecision.  Matt, thanks for being with me today.

Matt Adamson:            Thank you, David.  I appreciate the opportunity.

Williams:            A number of new care models are moving forward.  Which are most significant?

Adamson:            It all starts with the medical home, with the advocacy from the Patient-Centered Primary Care Collaborative and a number of pilots that have been successfully run and reported.  The medical home is the most important component because that’s where the care coordination piece sits.

In a medical home model, through additional reimbursement, you’re giving the primary care physician a team of people to manage the care of the patient. The biggest difference between the way you do things in a fee for service world and in a medical home world is the addition of a care coordinator. This really provides a great opportunity for MEDecision because the care coordinator role is largely underserved given its newness to the health care system.

Tools that exist in physician practices today including EMRs and practice management systems really aren’t designed to help care coordinators manage their workflow and optimize care of their patients. However, it does equate very closely to the care manager role that MEDecision has been supporting in health plans for 22 years.

Williams:            As medical homes have begun to catch on others are speaking of “neighborhoods.” What is that about?

Adamson:            The neighborhood concept is great because it puts a name to something that is required to be successful if you’re implementing a medical home program. It provides an easy way to describe something complex.  The idea is that even though the care coordination component sits at a primary care practice, you need other stakeholders including hospitals, nursing homes, specialists and pharmacists that patients rely on to perform care on their behalf.

It’s a description of what needs to occur and the coordination that has to happen among various entities that impact the care.  We advocate that the medical home neighborhood needs to include the health plan, too, because the health plan does have the ability to provide a lot of value to the medical home neighborhood and optimize it further.

Williams:            Does the medical home neighborhood bump up against Accountable Care Organizations or are they just two separate universes?

Adamson:            I see it all rolling together starting with medical home.  You have care coordination there.  You are working within a neighborhood of specialists and subspecialists that have all agreed to work together and help each other.  Clinical integrations formalizes that a little bit more.  Maybe there are some more formalized agreements on referrals, and you also generally include a lot more technical integration with clinical integration.

As a next step we see the accountable care model, which puts formal business relationships and payments and reimbursement contracts. The ACO manages first how to win contracts and bring patients into the organization, but then also how that money is distributed amongst all the stakeholders, the neighborhood so to speak.

The danger of course is if an ACO isn’t properly set up or managed, you have a bucket of money coming in and doctors fighting over it.  One of the things we would advocate that could help alleviate the fight is to include the health plan in that process either as a manager of the ACO or an important partner so that you could take advantage of the experience and the tools that already live in the health plan world to mitigate those risks.

Williams:            Some of these care models are emerging because providers want to escape from health plan control, but you’re talking about giving the health plans a broader role. Can you help me reconcile the two perspectives?

Adamson:            That makes sense. I definitely understand where that question comes from. Through the medical home, the primary care docs can start becoming more important again, which I think we’re finding is where the largest degree of responsibility should lie.  They’re the ones that look at a patient more holistically.

They’re looking at everything, so by increasing their reimbursement and providing a capability for them to bring on the staff required to manage in a patient centered way, it puts more control in that realm.

The health plan went through a period of time where they probably did have too much control, particularly in the days of HMOs where you had to ask permission to perform care, particularly outside of a primary care setting.

In this model, we’re not putting more control in the hands of the health plan. We’re saying let’s utilize the resources that the health plan has to mitigate risk and improve the clinical coordination.

It’s a largely unknown fact that health plans have care managers who are outreaching to their members, particularly members with chronic conditions and acute case management issues.  They’re reaching out to those members and impacting in a positive way the quality of care every day. But that work is very splintered and not integrated with the rest of the health care system.

Docs usually aren’t even aware, for the most part, that such work is taking place.  So we’re saying let’s use the data that’s available –the longitudinal record that the claims process can provide– and that care management capability and the analytics tool that health plans have invested in so much over the years and get that information in the hands of those docs and those care coordinators where the care can be impacted to an even greater degree.

So let’s not push them aside.  Let’s take the good that comes from that and utilize it even better than we do today.

Williams:            Say more about what MEDecision does and in particular how your role working with the health plans and providers changes in a world of patient centered medical homes and neighborhoods, accountable care organizations, and clinical integration.

Adamson:            We have a product suite today that’s been working in the health plan environment for 22 years supporting a care manager role. The care coordinator in a medical home could utilize a lot of those tools if re-imagined a little bit in a different setting to impact care to an even greater degree.

Our vision and strategy has been to do just that. We look at three components.  One is to take an analyzed view of the health plan data, meaning for members or patients attributed to a particular primary care doc to make a view of those patients available to those docs so that you can slice and dice. We provide a look of that information to determine any treatment opportunities or gaps in care that might exist for any of their patients and provide a more population based view of their patient panel. We do that in a multi payer way, collecting data from multiple payers to give that doc a complete view of their panel, depending on availability of data.

Second, we bring care management closer to the patient with care management tools that lets the care coordinator work more closely with any care management activities going on at the health plan. We help them look at all those evidence based protocols that need to be met for patients with specific conditions or acute events and make sure all those things get done. We also provide tools to automate wellness initiatives and get a little bit deeper into the panel so you’re not just focusing on the people who are really sick.  You’re also able to take a look at people who might get sick in the future if you don’t keep them on track.

The third component involves medication therapy management. This involves getting analytics and data connectivity into the hands of the care coordinators. They can see the complete medication list and have the ability to see very quickly where any potential adverse drug interactions might be, whether multiple drugs have been prescribed for the same thing, or whether the patient is taking drug for which there is no longer a diagnosis.

Getting this information into the hands of a care coordinator enables them to collaborate with the pharmacy and back to the physician to adjust medication lists when appropriate.

Williams:            There’s a lot of posturing and fighting in Washington over health reform even after passage of the Affordable Care Act.  On the other hand, providers are making decisions and moving forward.  Would anything significant change with these care models if Republicans overturn health reform?

Adamson:            I don’t anticipate any changes even if health care reform is repealed.  No matter what is done legislatively, we need implement systems that impact the quality and cost of care.

We pay too much for health care.  The health care reform bill was a great attempt at trying to change that but if nothing else it put a lot of attention on the fact that we can’t continue to go on the way we are now and be successful as a nation.  We cannot spend as much on health care as we are now and still be successful.

Even without health care reform you’re going to have accountable care organizations, patient centered medical homes and the need for clinical and health information exchange to help drive down the cost of that care.

Williams:            I’ve been speaking today with Matt Adamson.  He’s vice president of medical home initiatives for MEDecision.  Matt, thanks so much.

Adamson:            You’re welcome.  Thanks again for giving me the opportunity to speak with you today.

January 25, 2011

2 thoughts on “MEDecision seeks room for health plans in the medical home (transcript)”

  1. I was referred to MeDecision via a blog I did on ACOs and Health Plans. I agree the smart ACO will view Health Plans as partner with access to knowledge, experience, and technology for the ACO’s required care management work flow, population management, and business anlytics for performance measurement reporting. ACOs should not view a Health Plan relationship as it was in the 90s with HMOs. This is a different partnership with responsiblity and control in the hands of the provider/medical home not the Health Plan. I keep thinking why would an ACO reinvite the wheel that was created by Health Plans (UM, CM, DM, etc.) The ACO should focus on Medical Home Work Flow for the community and touch-point with the patient…they should leverage the Health Plan for risk management, population management, regulatory management, analytics, etc. I believe there is an opportunity for the right ACO and Carrier to create a consumer-driven health plan that matches the motivated consumer on their provider making the right medical decision that is cost effective. See “ACO: “If you build it, they will come”. Really? Not without a Payor Marketing Plan.” at

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