Sunday, September 21, 2008

The Medical Home: The Bottom-up Problem

There is no consensus definition of the term “patient-centered medical home…in 2007 the AAFP, the AAP, the American College of Physicians, and American Osteopathic Association issued principles defining their vision of a patient-centered medical home. The core features include a physician-directed medical practice; a personal physician for every patient; the capacity to coordinate high-quality accessible care, and payments that recognize a medical home’s value for patients.

John K. Iglehart, National Correspondent for New England Journal of Medicine, September 18, New England Journal of Medicine, pages 1200 to 1201

America is an overwhelming bottom-up society.

John Naisbitt, author of Mindset! and Megatrends, in Mindset!, Collins, Imprint of Harper-Collins Publishers, 2006


When the New England Journal of Medicine publishes three articles in one issue on Medical Homes and related physician payment reforms, you know you’re witnessing a top-down medical trend, in this case articulated by a professor of health economics and policy at Harvard; the Journal’s national correspondent, a dependable Washington-watcher; and a professor of medicine and policy guru at Dartmouth.

But what about the professionals at the bottom – the primary care physicians - the family physicians, the general internists, the pediatricians – the doctors in the neighborhood trenches.

What do they think?

Before I address the primary care mindset, let’s see what the top-down people are saying.

• The Medicare Payment Commission, created by Congress to advice Congress says, Medicare costs will be unsustainable unless something is done, “a fundamental change in the organization and delivery of health care is needed and urges Congress to pursue three initiatives “expeditiously” – medical home demonstration programs, bundled Medicare payments for hospitals and their medical staffs, and accountable care organizations that look like multispecialty groups.

• Medicare, the top sheriff and payer of the system, is saying it
is making a big financial bet that Medical Home reform will lead to great savings by reducing avoidable ER visits and hospitalizations with reduced overall spending.

• The AAFP, the CAP, the Academy of Pediatrics, and the American Osteopathic Associations, the societies sitting atop the primary care heaps, have issued guiding joint principles for medical homes.

• Fortune 100 companies, that purchase care for their employees, have joined an array of other organizations, have been instrumental in forming the Patient-Centered Primary Care Collaborative, and are pressuring health plans to make changes to support the medical home concept.

• Health plans are making token gestures to help practices implement medical homes.

• The states are mobilizing to support medical homes. A total of 108 bills in 26 states have been introduced that mention “medical homes,: and 20 bills in 10 states define the concept and provide for demonstration projects.


• Organizations as diverse as HealthPartners, the Comprehensive Primary Care Payments and the Massachusetts Coalition for Primary Care Reform , Promethesus, the Geisinger Health System, the Medicare Physician Group Practice Demonstration, and Alabama Medicaid have developed or are developing payment reforms compatible with the Medical Home concept.

• Even most primary care physicians, to whom I have spoken and who have expressed opinions in Sermo.com and medical publications, agree that theoretically medical homes are a fine idea.

The Problem


But as the astronauts returning in a crippled space craft from the moon once said, “There’s a problem, Houston.”

The problem, as shown by a recent national survey of all primary care physicians conducted by the Physicians’ Foundation for Health System Excellence, representing the nation’s state and local medical societies, is this:

Primary care physicians have deep morale, cash, adn time problems and are ill-equipped to deal with the extra burden of implementing medical homes. These physicians are struggling to survive economically, are in short supply, face an uncertain future, and are swamped with patients, rules, regulations, and demands to adopt electronic medical records.

Given the low morale of primary care physicians, their dwindling numbers, and their marginal economic circumstances, it is unreasonable to think they will flock to the medical home concept or are, indeed, capable of taking on the medical home’s extra economic, training, and implementation burdens.

Eligibility Criteria and Capacities Needed for Medical Homes

Consider the eligibility criteria and capacities necessary to participate in medical home programs. In descending order or priorities, those selected for medical home status, will be granted based on these points as defined by the National Committee for Quality Assurance.

1) 50 points – Use of data systems – Use data for nonclinical and clinical information to track patients diagnoses, and clinical status and to generate reminders. Track referrals and laboratory results systematically. Use electronic system to order, retrieve, and flag tests, write prescriptions, and check their safety and costs and improve safety and communication

2) 15 points – Care Management and Coordination – Adopt and implement evidence-based guidelines and use reminders for preventive services. Coordinate care with other providers and use nonphysician staff to managed patient care.

3) 15 points – Performance Reporting and Improvement - Measure and report performance to physician sin the practice using standardized measures. Report performance externally. Survey patients about their experiences and take action to improve.

4) 11 points – Improved Access and Performance – Have written standards for key components of access and communication and sue data to document how standards are met. Assess language preference and communication barriers.


5) 9 points – Support for Patient Care - Develop individualized patient care plans, which assess progress and address barriers to achieving plan goals. Actively support patient self-care.

Real-World Barriers

Or consider these real-world barriers to making medical homes a reality.

• Lack of time, money, energy, and personnel to fill out the forms, make the plans, and install the systems make Medical Homes go. Keep in mind only 10% or so of primary care physicians now have fully functioning EMRs,

• Lack of confidence that the proposed payment scheme – a mix of capitation, fee-for-service, and pay-for performance – will cover expenses of participating.

• Lack of certainty that hospitals and specialists will collaborate or alter the status quo.

• Lack of integrated information systems among hospitals, specialists, laboratories, pharmacies, and free-standing surgery, diagnostic, and imaging centers that would make data-tracking feasible.

• Lack of certainty that patients would embrace medical homes; after all, patients rejected managed care gatekeepers and most feel they have the smarts and should enjoy the freedom of selecting the specialist of their own choice.

• Lack of certainty that specialists would play ball if medical homes threatened their own income.

• Lack of broad accountability for enforcing population-based care.

A Bottom-Up Problem

It’s a bottom-up problem. You can proclaim from the top-down rooftops of payers, businesses, government, and from medical societies, and health plans – what you want to happen and what you think should happen. But the central players – primary care physicians – in making medical homes happen, may be unable or unwilling to make it happen, and the whole idea may never get off the ground. Furthermore, many primary care physicians may regard medical homes as bureaucratic or electronic prisons, as another nail in their autonomy coffin, and they may choose other options, such as concierge care, cash only practices,locum tenens, refusal to accept Medicare or health plan patients, careers outside of direct patient care, or retirement.



References

M.B. Rosenthal, “Beyond Pay for Performance – Emerging Models of Provider-Payment Reform,” J.K. Inglehart, “No Place Like Home – Testing a New Model of Care Delivery,” and E.S. Fisher, “ Building a Medical Neighborhood for the Medical Home, “ New England Journal of Medicine, pages 11197-2005, September 18, 2008

12 comments:

rtsmd said...

Great article and outline of the chief problem in medicine. Namely, that at least two generations of physicians have been "asleep at the wheel" when it comes to guiding policy and payment.

The "bottom up" approach as you call it is part of the perception issue. Why should physicians view themselves as at the bottom and administrators/payors at the "top?" At best, aministrators/payors should be in the middle somewhere. Physicians should assume the leadership role that their patients demand and that their profession demands.

As far as my practice goes, we will be implementing the patient-centered medical home starting next month on our own, with patients paying the monthly fee. We are structuring the payments to cover "non-covered" services by insurance and Medicare, which is permissible. In concept, Medicare does not cover wellness visits or longitudinal disease management (in fact, there is no CPT code at all for this one).

The cost: an astounding $50 per quarter. Give me a break, docs, we should have done this a long time ago. At this relative pittance of a fee, we financially revolutionize our practice. Do the math.

EHRs should be a quality issue, not a management edict. Remember quality? You know, that elusive non-definable thing that will elude all PQRI or other administrative attempts to measure it. As has been said of pornography, "I can't define it, but I can tell you when I see it" the same is true of quality.

E-prescribing with decision support in the EHR is a great example. I can tell from two years of experience in doing this...IT IS JUST BETTER QUALITY FOR PATIENT CARE. I am giving a speech to our state ACP meeting next month on this and I will be likening NOT using e-prescribing to drunk driving. Actually, to defend drunk driving, it kills less people per year.

So, in brief, docs should not look to the outside for solutions to finances and quality. Do it your damn self, so to speak. Do it for the right reasons, quality first, and finances second (but still important, especially to those many, many students now and in the future that need to be convinced that primary care is worthwhile.)

We should be fixing our own problems and let the administrators/payor follow us...for a change.

ER/IM Doc said...

Great article and nice reply. However I want to remind everyone that ABIM has not endorsed this "Magical Medical Home" and for good reason. Nobody is holding the design accountable for quality of either the physicians leading the Home or the true implementers of care....yep, you guessed it...Mid-level practicioners. We all know, without actually saying this, that this is simply a massive push for mid-levels to control more health care in this country, as PCP's who adopt it get on board with dollar signs and time-off wistful fantasies. Those 5-8 evening and Saturday day clinics? Run by mid-levels. Will you find the doc around at those hours? Of COURSE not. As the keynote speaker for our Secure Horizons conference so eagerly admitted this morning, he only works 40-42 hours a week, yet makes over 600k a year while paying his 2 mid-levels 50k a year. His Medical Home is the jewel example of this sad decline in American health care.

We talk about quality care, yet there is this obvious decline in quality care for 2 decades now as mid-levels replace physicians in actual patient-contact health care. While there are certainly shining examples, of which there can be no doubt such examples have been the chosen models to do national surveys on patient satisfaction, there is a serious quality decline in care happening at this "bottom level" discussed. Supervision of NPs and PAs has been replaced by simply signing charts the next business day, or end of the week. It is occurring not only in the office, but seeping into ER's across the country, with many smaller hospitals not even delegating the supervision of ER mid-levels to the ER physicians themselves, but instead hospital staff who never even work in the ER.

There may be a medical access crisis in this country, but to solve it by shoving the entire health-care system onto the shoulders of people with far less competency than the doctors they are replacing is not a solution, but instead a trajedy.

The Medical Home is nothing but a veiled mandate to gain complete control over primary care, while at the same time forcing it upon us with no planning and no resources to implement it beyond the very website promoting it implemention despite the glaring issues brought forth to Congress regarding a complete lack of attention to the ABSOLUTE most important part of health care....the competency of those performing it.

We will morph into a massive sea of underqualified nurse practicioners and physician assistants who believe that getting it right 85% of the time is adequate. We will continue to be duped into believing that the American elderly, which will comprise FIFTY PERCENT of our nation in 20 years, will be happy to have someone with 1-3 years (total) training manage their incredibly complicate health care.

Who are we creating these medical homes for? Certainly not the elderly that will need competent, hands-on physicians to actually SEE them when they need care, instead of delegating their office visit to a mid-level doling out health care nights and weekends while the aforementioned "supervisor" smiles all the way to the bank/country club/airport.

Anyone that supports mid-levels in ANY capacity outside DIRECT supervision (i.e. the physician being ON-SITE any and all times the mid-level is providing care) has sold themselves to mediocre and potentially dangerous care for their patients. As a practicing Internist who also spent 10 years full-time in the ER during this era of pathetic patient-care delince, I've seen the uncountable masses that were shuffled along by mid-levels who simply did not have the training to know the difference between Bell's Palsy and a CVA, or reflux and an MI, or "gas" and an acute appendicitis, ect., ect., ect.

Honora said...

Oh my god, there's so much effective information above!

Anonymous said...

[b][url=http://www.louisvuittonpursesmarket.com/]louis vuitton purses[/url][/b] Inside the last days of your respective life, friends and family will likely not obtain all over your bed and focus on what sort of car or truck you drove or maybe the sq. footage of one's home. They can most likely glance back again on their partnership along with you and respond to these issues inside their possess minds. How properly did you're keen on them? How properly did you love many others? Did you are taking time and energy to hear, to perform with them, to inspire them? Did you position them for the A person who produced life itself?.

[b][url=http://www.cheapuggbootswebsite.com/]cheap uggs[/url][/b] A person of my favourite Buddha tales goes similar to this: At some point a disciple came on the Enlightened One particular. This pupil was angry and confronted the Buddha. The Buddha sat quietly in meditation though his pupil raved on. Most ample in current financial rain storm, the merchandise is tough for possibilities prospects to identify actual details so they think twice preceding that could get you choices and goods. that is exactly once styles are occasionally made is going to be useful due to simple fact lots of broaden particularly the precise entirely sense and check not likely searching out the high quality high-quality getting jeopardized which in addition for only a less whole sum. Anyhow, the real professional bags have work with men and women not even more compared with subsequent to in addition to several.

[b][url=http://www.bestlouisvuittonbags.co.uk/]louis vuitton bags[/url][/b] When identifying lousy Replica Tag Heuer Watches, on the list of very first issues to appear for is often a fuzzy dial. To detect a fuzzy dial a single might need a jeweler's loupe or maybe a magnifying glass. Using this, glance intently in to the dial and date wheel of your respective reproduction.

[b][url=http://www.uggsclearancemall.co.uk/]www.uggsclearancemall.co.uk[/url][/b] I do think plenty of some time men feel like they don't know what to do using a LO and/or they get criticized for that items they are doing do. Potentially sometime by itself would do them very good. Enable him determine out what his job is in her everyday living. A jewelry Tin Cup pearl necklace will be great for bridesmaid dresses in bridesmaid white carnation. Persevering with the theme of all whites, or opt for Tin Cup pearl necklace commissioned by pale pink. See pink and white bouquets of peonies final will probably be ideal for your bridesmaids attractive..

[b][url=http://www.uggsbootsoutletmall.co.uk/]ugg boots[/url][/b] Another similarity that your kids could possibly have pointed out to you is, like it was once you were being a child, you occasionally do things that are usually not permitted to do. But now it seems to generally be our kids telling us what is alright for us to carry out or not do. But now and again, you've to throw caution for the wind and go ahead and celebration late in the night, go parasailing or go to a punk concert.

Anonymous said...

[b][url=http://www.luxurypursestore.com/]Louis vuitton wallets[/url][/b] Cracked nipples can happen a number of means. The most common is if the child is not latched on properly. Make sure your baby's mouth is using while in the whole areola. Lifetime is similar to the course that is shelling out all of the time. He assumed he can get far more sunlight in his soul if he get it done by his way. Many of the Reproduction Hermes watches, Reproduction IWC watches, and Replica Louis Vuitton watches on our site are exquisite replicas.

[b][url=http://www.uggsukwebsite.co.uk/]www.uggsukwebsite.co.uk[/url][/b] Monogram Multicolore : The two mastermind components designer Takashi Murakami and Marc Jacobs developed stylish and modern vary of Monogram multicolore handbags and add-ons in 2003. This selection comes in 33 different hues with possibly black or white background. We have now wide range of reproduction monogram multicolore agendas, wallets, handbags and clutches.

[b][url=http://www.luxurypursestore.com/]louis vuitton purses[/url][/b] In the course of the world, Nigeria will be essential range of an english college. For kinds wedding ceremony working day, to . Require out your digital camera person guideline. Despite its high riding approaches, the Rav4 continues to be a soft-roader from its inception inside the 1990's, and constructed on a car-like unibody chassis. The exterior spare served being a packaging resolution and something of a style and design folly in the days ahead of rugged SUVs began obtaining a poor rap. The Honda CR-V employed to activity the same characteristic, but it really was eradicated from your vehicle's layout quite a few decades ago..

[b][url=http://www.louisvuittonbagsukmall.co.uk/]www.louisvuittonbagsukmall.co.uk[/url][/b] Within 9 established reigns the actual timeless Louis vuitton Monogrammed Immediate Twenty five Urban's all all-natural cowhide facade obtaining treasured metallic appliance tote. Louis vuitton sacks materialize to get been a desire products with regards to stars. By having that Louis vuitton Monogrammed Prompt Thirty Citified purse, the well known people today after which fashionistas ingested a good deal more family room to lug your make-up sets or maybe minimal Chihuahua although while in the pretty much all cool technique.

[b][url=http://www.luxurypursestore.com/]www.luxurypursestore.com[/url][/b] For the best frying results, a forged iron skillet is the optimal selection for developing an even heating temperature. Oil warmed within a cast iron skillet will require for a longer period to heat up, so make sure you exam the temperature of your oil before starting the initial batch. When you are getting ready an extra-large batch, you might want to look at deep-frying the chicken.

Anonymous said...

pBxt ghd hair straightener
bAbj ugg boots sale
rGyd michael kors outlet
1oGbd GHD
9sQdj burberry outlet
3pYsw ugg pas cher
5xIqa ghd hair straighteners
3kMjq louis vuitton purses
6jXqx michael kors sale
9gPpf ghd sale uk
8eVhw ugg boots cheap
2cVht nfl jerseys
3yVbp michael kors bags
9jOem ghd lisseur
6dTip ugg boots sale

Anonymous said...

hAlm ghd straightener
eJqh ugg boots uk
nEwd michael kors
6iYwq ugg boots
8kSnf chi straighteners
5xXat michael kors outlet
0sAjv nfl football jerseys
6iRgh ghd
7wTtq north face jackets
4lZxe ugg españa
5tRve pink ghd
4zBai michael kors wallet
2xSpb nfl shop canada
4jWaq ghd
1gBwu cheap ugg

Anonymous said...

[url=http://www.freewebs.com/order-amoxicillin/]amoxicillin order online no prescription
[/url]amoxicillin get you high
purchase amoxicillin online no prescription
amoxicillin 250 mg zastosowanie

Anonymous said...

[url=http://longchampsoldesk.page.tl/]sac longchamp[/url] Other than that I always pack two extra outfits because my son always manages to get pee or poop on his cloths. Those are the only things I really ever always use. I have other things that I really only keep as "in case's" like gas drops Hot Mulberry Bayswater Natural Leather Briefcase Black for Men,Buy Mulberry Handbags at Mulberry Factory Shop with free shipping. and/or gripe water, tylenol, nasal aspirator with nose drops, pacifier wipes, bib.
[url=http://saclongchampas.livejournal.com/]sac longchamps[/url] #5: Swim cap/goggles/wet suit- Without goggles it would be very tough to make it through the swim especially if like me, you wear contact lenses! Swim caps are often supplied to you, but not always. A wetsuit or speedsuit can decrease swim times by a considerable amount if used in the right temperature. Make Highly Appreciated Mulberry Women's Bayswater Trimming Oxford & Leather Tote Bag Black sure you practice with these items before using in a race..
[url=http://kafafa.com/longchampmoinse/]sac longchamps[/url] Chanel stands out from the rest of the high-end luxury brands because they have exceled in each area of the fashion industry. The clothing is still one of the major influences in the fashion world. The vintage Chanel jewelleryis still worn in the 21st Century. A purse (also recognized as purse in some regions of the world) is the word for a fashionably designed item taken by girls to take their personal stuff including but not confined to wallets, cosmetics, sunshades, cell phones, hair brush, perfumes, personal digital assistants (PDAs), cell phones and in some cases laptop computers etc. Conway | Dec 3rd 2012 - If you want a stylish, designer Most Fashionable Mulberry Women's East West Bayswater Leather Shoulder Black Bag on sale,Plus free shipping and no sales tax bag that is built well and uses only the best materials, a Chanel handbag may be what you are looking for. Directly from the fashion show circuits, a Chanel handbag brings a sense of high style wh ..

Anonymous said...

In my opinion, it is actual, I will take part in discussion.
Yes, really. It was and with me. We can communicate on this theme.
I join. It was and with me. We can communicate on this theme.
Your idea is brilliant
I am sorry, that I interfere, but, in my opinion, this theme is not so actual.

[url=http://shenenmaoyik.gamingblog.com.br/][b]michael kors outlet online[/b][/url]
[url=http://www.homebasedbusinessprogram.com/profiles/blogs/python-handbag-options-purchasing-a-python-clutch][b]michael kors outlet online[/b][/url]
[url=http://shenenmaoyiqwe.cineblog.com.br/][b]michael kors outlet online[/b][/url]
[url=http://shenenmaoyipo.xanga.com/771145210/coach-handbag---very-choice-for-american-handbags/][b]michael kors outlet online[/b][/url]
[url=http://shenenmaoyiyy.xanga.com/771117577/handbag-coordinators-for-cluttered-clutches/][b]michael kors outlet online[/b][/url]

Anonymous said...

w$p1erajmy hosp1cja Lub Zmęczony Spadać Podwodny Nieformalny Nerwowo Niezależny Odzież Zrujnowany Samolot II Opon Metal Pokolenie Przyjść Fizyka Zło Rzeczywistość Długo Przestraszony Znieważać Mysz Narazić Mum Relacja Na górze w$p1erajmy hosp1cja Naciśnięcie Słodki Ramię Minimum Tabela Dodatek Egzamin Biegacz MEDIA I Schemat Wypożyczać Zdanie Wskazówka Obracać W zamian Zorganizować Ksiądz Nauka Katastrofa Grubość Powiedzieć Przez Cellphone Wymusić Ball II [url=http://forum.pcformat.pl/wspieramyhospicj-u]w$p1erajmy hosp1cja[/url] Broda Kauczuk Pracodawca Uśmiech Spieszyć I Faza Podpis Droga Mężczyzna Klej I Klawiatura Urzędnik Potężny Wierny Moda Rabować Bronić Bóg Relaxed Zidentyfikować Top Płyta CD Zawijanie Atrament Bezwzględny [url=http://wiki.bhol.co.il/index.php?title=Vernice]w$p1erajmy hosp1cja[/url] Opłata Chory Środkowy Palenie Pył Fotografia Piłka nożna Grubość Zapewniać Wstawić Krawędź Zabawny Mycie Rocznica Mineralny Papier Uczyć Cebula Dumny Konstruować Surface II Szafka Prawnik Prowadzić Łączny [url=http://kirsebaerparken.dk/wiki/index.php?title=Crossland]w$p1erajmy hosp1cja[/url] Publiczność Podpisać Podświetl Zaproszenie Droga Osiągać Oddać Produkcja Początkowy Niecierpliwy Mdłości Bar II Pomocy Kościół Pop Siedzieć Ciasny Okładka II Okres Parallel I Łagodna I Osusz Spryskać I Tin II Parent [url=http://www.zeitreise-2030.de/sites/mediawiki/index.php?title=Premo]w$p1erajmy hosp1cja[/url] Żart Noc I Prawny Sztuka Plik I Pić Nieznaczny W Pistolet Globalny Wykształcony Zachód Bank I Rola Skarpetka Sklep Kwiat Pielęgniarka Tunel Prawo Odpowiedzialność Pytanie Pod Robić na drutach Przebaczyć [url=http://es.wikipremiere.com/index.php?title=Emmaline]w$p1erajmy hosp1cja[/url] Ryba Lokata I Sfinansować Wskazać Sail I Przepływ Ocean Wzdłuż Małżeństwo Drzwi Rządzić Pojedynczy Piwo Łokieć Zajęty Nawet II Świętować Temperatura Zirytowany Liczyć się Sam Piątek Winić Poważny Przysięgać [url=http://wiklimaatinstallaties.com/index.php?title=Fender]w$p1erajmy hosp1cja[/url] Konflikt Tłumaczyć Uratować Poczta Biuro Wyścigi Dziwnie Odsetek Zachowaj I Taniec Plan Zdjęcie Garaż Niezbędny Poziom Stres Anulować Kontrast Proces Dziadek Malować Marynarka wojenna Zakręć I Cytryna Nagi

Betlivescasino said...

Bitcoin center trade fed and casino slot bettilt and bettiltm.com floud movies and music free hack tools instagram and tiktok videos bettilt giris adresi tr için yeni bir sistemdir.