Family physicians in Mississippi will be major participants in launching a revolutionary concept in chronic care management. Beginning Aug. 1, family physicians recruited by the Mississippi Chronic Care Collaborative will begin providing a program of comprehensive care to 20,000 Medicare beneficiaries in the state.
The collaborative, developed by McKesson Health Solutions, is one of nine pilot projects to win a three-year CMS contract to provide comprehensive health care for Medicare patients who have diabetes and/or congestive heart failure.
Mississippi AFP, Academy Join Chronic Care Pilot Project
By Leslie Champlin
6/3/2005
The Academy actively supported CMS' selection of McKesson because its proposal focused on providing patients a "medical home," according to John Swanson, director of the AAFP Socioeconomics Division.
The medical home -- in which patients receive fully integrated, whole-person care within the context of a sustained and supportive patient-physician relationship -- is one of the tenets of the Future of Family Medicine report. It is "the focal point through which all individuals -- regardless of age, sex, race or socioeconomic status -- receive a basket of acute, chronic and preventive medical care services," says the report.
The McKesson chronic care program will provide an opportunity to demonstrate the importance of physician involvement in chronic care management and the cost-effectiveness of a care-management payment for primary care physicians who expertly manage patients' complex chronic conditions, said John Mitchell, M.D., of Tupelo, the Mississippi AFP's representative on the project's technical consultant group.
"This project has the potential to have enormous impact on the future of the Medicare program," said Swanson.
Mitchell agreed. "The future of how CMS allocates the use of health care dollars could hinge on projects such as this," he said. "And with the Mississippi model being the most heavily weighted of all nine projects as they relate to physician input, it should be of particular importance to us as physicians."
As a team, AAFP and the Mississippi AFP are providing primary care physician expertise in the design, development and implementation of the McKesson Health Solutions program. The Mississippi AFP also will recruit family physicians across the state to participate in the pilot project.
When launched, the program will:
- provide a medical home to participating Medicare beneficiaries;
- provide a care-management payment to physicians' practices that become beneficiaries' medical homes;
- implement a pay-for-performance system; and
- integrate, in a meaningful way, the McKesson Health Solutions' disease-management resources with the local physician community.
Fully implemented, the project promised to be a "win-win situation" for patients, because "this model emphasizes collaboration in a compassionate, caring physician-patient relationship with support from ancillary professionals," said Mitchell.
If the model successfully provides high-quality care to beneficiaries and restrains cost increases, the HHS secretary can -- after the second year -- "apply the program or certain aspects of it to the entire Medicare program," according to Swanson.
The technical consultant group for the project, to which Mitchell belongs, will review and refine recommendations from four workgroups. AAFP Past President James Martin, M.D., of San Antonio represents the Academy on the group.
The physician incentives workgroup will make recommendations on the pilot's pay-for-performance measures and methodology, target values, and eligibility for participation. Mississippi AFP member Lee Montgomery, M.D., of Fulton, Miss., and Stephen Spann, M.D., of Houston will serve on the workgroup.
A workgroup on physician engagement and chronic-care practice support will make recommendations on developing and fostering involvement among Mississippi physicians. It also will review and refine systems to enhance physician offices' productivity and workflow as they provide chronic care services. Mitchell, Jennifer Gholson, M.D., of Tylertown, Miss., and Bruce Bagley, M.D., AAFP medical director of quality improvement, will serve on that workgroup.
Members of the clinical content workgroup will look at chronic-care assessments and interventions to ensure the clinical integrity and appropriateness of the program. Providing expertise to the workgroup will be Andrea Phillips, M.D., of Jackson, Miss.; Michael Crouch, M.D., of Sugar Land, Texas, an expert in congestive heart failure; and Kevin Peterson, M.D., of Minneapolis, Minn., a diabetes care expert.
Also, a beneficiary outreach workgroup will develop communications methods and educational materials for beneficiaries, create community-based initiatives and build collaborative coalitions, and identify cultural sensitivities the program should address. Mary Gayle Armstrong, M.D., of Madison, Miss., will serve on the workgroup.
If the model successfully provides high-quality care to beneficiaries and restrains cost increases, the HHS secretary can -- after the second year -- "apply the program or certain aspects of it to the entire Medicare program," according to Swanson.
The technical consultant group for the project, to which Mitchell belongs, will review and refine recommendations from four workgroups. AAFP Past President James Martin, M.D., of San Antonio represents the Academy on the group.
The physician incentives workgroup will make recommendations on the pilot's pay-for-performance measures and methodology, target values, and eligibility for participation. Mississippi AFP member Lee Montgomery, M.D., of Fulton, Miss., and Stephen Spann, M.D., of Houston will serve on the workgroup.
A workgroup on physician engagement and chronic-care practice support will make recommendations on developing and fostering involvement among Mississippi physicians. It also will review and refine systems to enhance physician offices' productivity and workflow as they provide chronic care services. Mitchell, Jennifer Gholson, M.D., of Tylertown, Miss., and Bruce Bagley, M.D., AAFP medical director of quality improvement, will serve on that workgroup.
Members of the clinical content workgroup will look at chronic-care assessments and interventions to ensure the clinical integrity and appropriateness of the program. Providing expertise to the workgroup will be Andrea Phillips, M.D., of Jackson, Miss.; Michael Crouch, M.D., of Sugar Land, Texas, an expert in congestive heart failure; and Kevin Peterson, M.D., of Minneapolis, Minn., a diabetes care expert.
Also, a beneficiary outreach workgroup will develop communications methods and educational materials for beneficiaries, create community-based initiatives and build collaborative coalitions, and identify cultural sensitivities the program should address. Mary Gayle Armstrong, M.D., of Madison, Miss., will serve on the workgroup.
