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ARRA and Payment Reform - Does Medical Home Fit The Bill?

April 21, 2009
by Joe Bormel
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We live in exciting times. I just finished reading this: No Direction Home: A Primary Care Physician Questions The Medical Home Model by Caroline Poplin. It was handed out at a meeting, with the following text marked up:

  • Patients with insurance can't find a primary care doctor
  • Internal Medicine residents are "fleeing the field" of primary care - only 2% are choosing primary care
  • Patient-centered medical home (PCMH) is "the answer" (it's the best alternative on the table to traditional FFS)
  • Electronic medical records (EMRs) are at its core
  • PCMH fails to address the real driver of cost problem - increased volume of expensive procedures, tests, imaging

At the AHIMA ICD-10 summit last week, I learned in detail that the change in disease classification (ICD-9 to 10), at a fifty thousand foot view, is really about payment reform in the U.S. Candidly, I was looking at the issue much more tactically and instrumentally. We were just changing coding systems. Kind of like moving to ASCII in the 1970s. For a summary and best links, see my post

"When in doubt, do the right thing."

This theme keeps developing ... everything is about structural changes to facilitate U.S. healthcare payment reform. A strategy to save Medicare.

At the end of the week, I attended our regional, monthly

HealthTech Net meeting. Since the 2008 election, this meeting has packed the board room, and we've begun video conferencing with the West Coast office (Washington, DC, and Silicon Valley.)

The topic last week was

Patient-Centered Medical Home. The story shared was our HCIT dream. Care is readily available and coordinated through information technology, including a PHR. The care process is measured; the right things are done and things are done right. Resources are more rationally used, and non-visit-based care is readily and appropriately available.

I'd like to end here, with a reference back to "No Direction Home," where Poplin urges caution about PCMH. I think she summarized it well here:

... today’s patients clearly want a personal physician, someone they trust, who knows and cares about them, understands their problems, and can guide them through the maze that is modern American health care. Indeed, a market has sprung up to serve such patients, called “boutique” or “concierge” medicine. However, these medical homes are expensive mansions, beyond the reach of all but a few.

I think that's right. What we want are affordable, patient-centered medical mansions. Can EMRs, payment reform and the structural changes necessary make those mansions possible, for the many?



I find it hard to imagine that mansions for the many will be possible any time in the foreseeable future. Caroline Poplin has cited that only a very few organizations, such as Geisinger, can pull off PCMH. Can a reasonable number of others evolve to offer affordable PCMH, or will it take a revolution to do so? At this point, although I hate to admit it, this looks like a pipe dream.

In closing, before I have a senior moment here, I think the conundrum you presented in your last posting was excellent. All of the readers here who want to save time by getting the "Cliff's Notes" on ICD-10 should review it.


I would be most interest to see blog more about ICD-10 being about payment reform. This is novel thought for me but not surprising seeing how many erroneous ICD-9 codes are used because its inadequacies


Jack, Thanks for your comments.

You'll be reassured and validated to know that the CBO came to the same conclusion you did. Probably only 1% of the providers will be capable initially of offering a true patient-centered medical home.

The experiences and experiments under way, both with PCMH, and PHRs in care management will inform what works, as well as where we need to evolve to. As Poplin suggested, I don't think healthcare reform will end with PCMH, for the reasons she listed, as well as the evolution of HCIT and Health 2.0.

Thanks for your comment.  Multiple times at the AHIMA ICD-10 conference last week, the idea was consistently discussed. In order to transition to ICD-10, a lot of attention and transparency will be given to make the payment revenue neutral. That will be followed by using the increased specificity of ICD-10 (relative to ICD-9) to improve payment specificity. This will be challenging. A careful read on the topic of GEMs requires an hour presentation by an expert. There were several presentations at both AHIMA and HIMSS meetings which walked through this in detail:

From HIMSS 2009 Educational session 89:

General equivalence maps (GEMS) between ICD-9- CM and ICD-10-CM/PCS provide link between code
—GEMs are not crosswalks —they are reference mappings to
help the user navigate the complexity of translating meaning
from one code set to the other
—Bi-directional maps are available on the CMS and NCHS
web sites

CMS plans to map ICD-10-CM/PCS codes to existing DRGs initially. After cost data are gathered on the new codes, they will be assigned to more appropriate DRGs and the DRGs will be refined as needed. [ That's payment reform. ]