A large study of diabetes management just published in Health Affairs (1) provides convincing support for effective primary care. Rather than the typical US disease management approach - hiring third party disease management companies to work around the health system - the Germans worked through the patients' primary care physicians.
They achieved impressive results: lower costs and fewer lives lost as well as a host of other improved process and outcome metrics (lower hospitalization, improved rates of eye and foot exam, etc).
According to the study team this "...physicians’ firsthand knowledge of, and personal relationships with, their patients to promote adherence to treatment goals and self-management..." is the essence of the intervention.
One of the things I find most compelling in this study is the evidence that patient experience is important and informative. Good outcomes follow when patients say they get care that eliminates waits and delays, has good communication, takes their personal issues into account, etc. Our measurement paradigm is heavily skewed away from this essential source of information, a flaw we must correct.
"Enrolled patients were more likely to receive patient-centered, structured, and collaborative care; the largest differences were in the domains of follow-up and coordination, goal setting and tailoring, and problem solving and contextual scale. This contextual scale is from PACIC. It asks, for example, questions on how doctors or nurses consider patients’ cultural values in therapy planning and make sure that care plans are adapted to patients’ daily lives."
"While US Medicare invested in regional pilots that differ in their structure of care delivery and may use disease management vendors, German health plans decided on an approach with a heavy emphasis on quality assurance and the primary care physician as the program manager. The emphasis is on educating both the patient and the care provider. Characteristics of care considered desirable in a patient-centered medical home, such as coordination, integration, timeliness, efficiency, and effectiveness as well as the patient-centeredness of care, improved markedly."
We can replicate this work in the US and because of how much more we pay for things here the savings potential is much larger.
To replicate this work we need:
- A payment model that supports the full scope of excellent primary care: how about a case mix adjusted population based payment to primary care?
- A measurement model that accurately reflects 'firsthand knowledge and personal relationships': NCQA's PPC-PCMH doesn't go anywhere near this stuff. How about HowsYourHealth.org or the Patient Assessment of Chronic Illness Care instrument?
(1) Stock SAK, Drabik A, Buscher G, et al. German Diabetes Management Programs Improve Quality of Care and Curb Costs. Health Affairs 29, 12(2010): 2197-2205