Wednesday, September 24, 2008

Medical home - Middle America Internist Seizes Medical Home by Horns

Occasionally I receive a comment on my blog,, that is so direct, commonsensical, refreshing, and, yes, innovative that I feel compelled to reproduce it.

Such is the case with the comment to my recent blog “The Medical Home: The Bottom-up Problem,” in which I noted the eligibility criteria imposed by Medicare, health plans, and the states might be so convoluted and burdensome that few primary care doctors would even bother to sign up for medical homes.

I know little about rtsmd except what he ways about himself in his blog,” The world as I see it, from the point of view of a practicing internist and concerned citizen in the USA. I am a strong believer in market capitalism and small government. Rtsmd is from plain ole middle American.”

Here is his comment on my blog:

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

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