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The Cats are Herding!

We’ve all heard the saying that getting doctors to agree is like herding cats.

Well, it’s happening.

Four physician organizations representing 330,000 doctors issued a press release voicing their support for Joint Principles of a Patient-Centered Medical Home. The four groups are the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA).

So?

During the first decade of disease management, physicians stood at the sidelines and threw rocks at DM companies and health plans. Until recently, however, they have not offered an alternative approach to coordinating care and managing patients with chronic conditions. The medical home model is just such an alternative. For more background on the medical home model, click here .

Pocketbook issues are at the root of this. Physicians are fed up with the federal Sustainable Growth Rate (SGR) methodology for reimbursement. Physician reimbursement promises to become a central issue in the next election’s health care reform issues. Physician unity over the medical home model is a giant step in bringing this issue to the national limelight.

A few questions:

  • Can the medical home model be implemented? It’s great in theory, but will it work, particularly in small practices? We’ll learn a lot as the Medicare Medical Home Demonstration project gets rolled out.
  • Do the physician organizations speak for rank and file physicians? Or is the medical home an idea cooked up by top leadership?
  • Where is the American Medical Association in all of this? Are they feeling caught in crossfire between specialists and primary care physicians?.

I’ll be writing a lot more about the medical home as the issue develops.

This work is licensed under aĀ Creative Commons Attribution-Share Alike 3.0 Unported License. Feel free to republish this post with attribution.

5 Comments

  1. Gordon Norman, MD, MBA; Alere Medical, Inc. on March 14, 2007 at 9:37 am

    Vince: I applaud the apparent unifiedĀ support by physicians (at least those in primary care specialties) of the medical homeĀ concept. It is a well-intended and appropriate response to the continuing fragmentation of care that frustrates consumers and suboptimizes the cost-effectiveness of U.S. healthcare. By the way, it is also a familiar concept to those of us who remember the emergence of Family Medicine in 1969 as a new medical discipline and Boarded specialty to provide continuous, comprehensive care to families, and to coordinate their specialty and other health care needs. Once again, what goes around, comes around.
    But even if rank and file members of ACP, AAP, ACP, and AAFP are philosophically in lockstep with their national organizations vision, they face a growing problem that will seriously undermine the concept and reality of the medical home namely, fewer and fewer physicians want to do primary care!
    This is not news to anyone in the healthcare trenches. While the ratio of generalists to specialists in most developed countries is 2:1 or greater, in the U.S it is 1:2 and getting smaller by the year. Fewer residencies in primary Peds, Internal Medicine, and Family Medicine are able to fill their slots each year, and some are closing down. Many rural communities face a shortage of primary care already, and recruitment to replace primary care physicians leaving practice for retirement is long and often unsuccessful. Consider the following
    In 1998, 54 percent of internal medicine trainees planned careers in primary care rather than specialty medicine; by 2004, only 25 percent chose primary care
    The percentage of medical school graduates choosing family medicine decreased from 14 percent in 2000 to eight percent in 2005
    Specialists earn almost twice as much as PCPs, working the same amount of hours
    A 30-minute routine procedure performed by a specialist is often reimbursed two-and-a-half to three times the amount paid to a PCP who spends the same amount of time with a complicated patient
    In addition, primary care physicians also face a growing senior population with rising chronic care needs, high overhead costs, administrative headaches of staffing and running their businesses, difficulty of keeping up with evolving medical science, and trouble recruiting additional doctors to join their overflowing practices. Generational cultural changes have also had an impact; today’s new physicians are often unwilling to put in the 60-80 hours workweek of their predecessors, instead favoring a more controlled and sane lifestyle than their role modelsĀ. Who can blame them?
    Some might respond that these changes are not necessarily bad. Not all primary care physicians spend the time or effort with patients that they desire in order to feel confident they are receiving complete, thorough care. Also, dedicated specialists can and often do provide medical homesĀ for their chronically ill patients. But as has been shown by Wennberg and others over the past 30 years, specialist care tends to be more expensive and of no higher quality than primary care when measured objectively and carefully. And lest anyone forget, we still face the daunting expectation of Medicare Trust Fund deficits starting in 2012 and insolvency by 2018.
    So when patients queue up at the medical home of the future, will the doctor be in?Ā Or will they see a non-clinical person who operates the telemedicine equipment to connect patients with a remote physician many miles if not several states away? Will patients accept nurse practitioners and/or physicians assistants as physician surrogates in these settings? Will medical homes like today’s proliferating worksite health clinics and mini-clinics in retail settings, provide only a minimal set of ambulatory care services, leaving the more challenging work of managing chronically ill seniors with multiple comorbidities, doctors, and medications to a more remote site?
    It’s not hard to like the medical homeĀ concept. I found the notion very appealing when deciding to enter Family Medicine 35 years ago myself. But when it comes to planning for comprehensive primary care in the future, we should all be concerned with whether anyone will be home at the medical homeĀ of tomorrow. The ACP, AAP, ACP, and AAFP have their work cut out on that major challenge.



  2. Ariel Linden on March 14, 2007 at 12:51 pm

    Disease management (DM) has gained a prominent role in the US health care system based on the fragmentation of the system and lack of a “medical home.” In the most basic of terms, if the doctor (I am using the term doctor here to represent the centerpiece of the care model) ensured the coordination and continuity of care for each patient, DM would not survive.

    I am a full supporter of the medical home concept. I, as both a patient and health services policy researcher, want one-stop-shopping. I have envisioned the following model for several years now:

    (1) A patient goes to see their doctor and instead of waiting in the waiting room for 1/2 an hour, that time is spent with a health promotion specialist (HPS), discussing all the relevant chronic care issues (e.g. self-management, lifestyle behaviors, etc.). If there are certain issues that the HPS identifies as requiring the doctor’s follow-up, they will be noted on the chart. All other issues can be dealt with by the HPS directly or by scheduling appts. with relevant providers (e.g. nutritionist, exercise specialist, mental health specialist, social worker etc.).

    (2) The doctor can now focus attention on the acute needs of the patient, and then spend a few minutes on the targeted issues pertaining to the chronic illness that were highlighted by the HPS.

    This of course, is a generalized concept, but I see no reason why it can’t work. Moreover, a clinic or multi-group setting is even more suitable for this sort of concept.

    As far as reimbursement, I see such a provider-driven concept as creating the necessary basis for setting reimbursement policy with insurers. The doctor can now claim a larger piece of the health care dollar rather than the money going to DM vendors, or even administrative costs at the insurer level to manage these patients.

    These professional organizations have finally come to see the light. Now we have to see how it will play out in the marketplace.



  3. Joseph Kvedar on March 14, 2007 at 8:00 pm

    One other explanation for the phenomenon you cite, is that physicians find it unsettling when they hear that their patients are being offered services and managed by companies they hadn’t heard of that are acting on behalf of the patient’s insurer (who on earth IS the care provider, anyway). Docs assume that they are the center of care decision making and are becoming increasingly aware of a value chain where the patient’s employer contracts with a health plan who contracts with a DMO to provide care to the patient. The doctor’s reaction to this is ‘Excuse me, but as a care provider, I need a place in this value chain”.

    Getting their attention is good news, because the most effective management, particularly of patients who are really sick and really high utilizers has to involve a licensed professional (usually an MD) chaning the care plan in some way. The niftiest monitoring device can alert a DMO that a patient’s weight is up 3 pounds, but unless the doctor issues the order to double the lasix dose, the patient will wind up in the high cost part of the sytstem – the ER and the inpatient service.

    So reimbursement is driving some of this but the threat to supremacy is another driver and the fact that others are intruding on territory that the doctor once considered sacrosanct is equally important.



  4. Steven Hacker, MD on March 19, 2007 at 7:40 pm

    I agree with Dr. Kvedar, the physician cannot be disenfranchised from care and today, technology can keep him in “the ball game” without compromising his “chain of command” and the needed care implementation “soldiers” to execute and follow up. Scalability plays a role in all medicine for all doctors and for all specialites. Technologies allow scalability. If doctors can scale , then doctors will be less threatened. Monetizing the technology is a big issue , if it were monetized for doctors, equitably for their share of “ownership” of the patient responsibilities(and the medical liability), adoption of these technologies would be more rapid and widespread and the threats that to doctor’s “supremacy” would be relieved.



  5. Vince Kuraitis on March 19, 2007 at 7:56 pm

    Gordon, Ariel, Joe, & Steve

    Thanks for your thoughtful comments.

    I see a common thread among your perspectives. The medical home model is very intuitively appealing — it’s motherhood and apple pie. It could become very politically challenging to be “against” the medical home.