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Chronic Disease Management and Building Medical Homes Without Having to Transform Primary Care Practice in the Senate HELP Commi

Posted Jul 15 2009 6:24pm
Hot on the heels of the unveiling of the health reform bill in the U.S. House of Representatives yesterday, the Senate's Health Education and Labor and Pensions ( HELP ) Committee passed the 'Affordable Health Choices Act.' Readers can look at the summary here, or if you’re so inclined, review the complete 615 page bill here.

If the Disease Management Care Blog is reading both bills right, the Senate's HELP bill - in contrast to what's in the House - is requiring health insurers to reimburse 'high quality care that improves health outcomes through activities that shall include... chronic disease management, medication and care compliance initiatives, including through the use of the medical home model' (bolding and italics mine).

While the DMCB is slightly confused by the language 'including through,' the specific mention of 'chronic disease management' in legislative language would appear to be good news for disease management organizations. Note that Sen. Chris Dodd (D-CT), the acting Chair of HELP, represents the home State for CIGNA and Aetna, both of which have invested heavily in population-based care and disease management programs. In addition, the ailing Senator Kennedy (D-MA) represents a State that is home to Health Dialog. Readers are free to draw their own conclusions.

In addition to this, the Senate bill importantly provides for 'grants' that will support 'health teams' that, in turn, can contractually support primary care physicians in the creation of medial homes.

The DMCB is discerning a significant pattern here. As readers may recall, the House bill has a provision that funds a 'pilot' designed to test 'Community' based not-for-profit entities that can associate with primary care providers in the creation of medical homes. It would appear the Senate bill is doing the same thing, but isn't insisting on a non-profit or State sponsored status. Both approaches recognize that not all primary care providers necessarily want to build their own medical homes, but may want to associate with entities external to their practice that enables them to do the same thing. Given the considerable expense and work of 'transforming' a medical practice into a medical home, providing this option makes sense not only to the DMCB, but also maybe to Dr. Pectors and the rest of her colleagues that inhabit the real world.

On another note, the Senate HELP bill also trumps the U.S Preventative Health Services Task Force ( USPHSTF ). In addition to the disease management requirement above, the bill states insurers 'will not be allowed to impose more than minimal cost sharing for certain preventive services endorsed by the USPHSTF as clinically and cost effective...' It may surprise some readers to know what the USPHSTF does NOT endorse. If readers are interested, they can check the links to services that insurers presumably could impose significant cost sharing for:

Pap smears for healthy women over age 65 years - answer
Chest x-rays to screen for lung cancer - answer
Prostate cancer screening - answer
Routine stress tests - answer
Screening for ovarian cancer - answer
Testing for the presence of diabetes in adults - answer
Counseling to promote weight loss among the overweight - answer
Counseling to promote exercise - answer
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