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 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.


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


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.

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