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Saving Primary Care: Is There Anyone Home?

Dear Readers: This was a pitch for a magazine article, so I apologize if it’s a little too wonk-y. I decided to post it here to see what other ideas you could drum up.

Quick summary: There’s an idea floating around called the Patient-Centered Medical Home–a way to integrate, automate, and improve how primary medical care is delivered in the U.S.

It has the approval of all major medical societies. A ton of money is being spent on a national demonstration project.

It’s never going to work.

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Patient Centered Medical (?Glass) Home?

The Patient Protection and Affordable Care Act (a.k.a “Health Care Reform”) signed by President Obama in March will revolutionize Primary Care in the United States. By 2014 tens of millions of uninsured people will “enter” the system by being granted insurance, either through expansion of the Medicaid program or through mandated purchasing of insurance via state pools or the private market.

This alone will have a profound impact, straining the capacity of our already frayed system. Therefore, embedded in the law are funds to encourage growth and improvement in Primary Care: Incentives to encourage graduates to enter primary care fields (Family Medicine, Internal Medicine, and Pediatrics) and practice in underserved areas (through scholarships and loan forgiveness), and money to re-format the way that Primary Care is practiced and paid for.

The most prominent example of Primary Care restructuring is something called the Patient Centered Medical Home (PCMH). Currently a national “demonstration” project is underway to show us that the PCMH model is a sustainable way forward. The PCMH promises nothing less than greater access to primary care, delivered with improved quality and safety, better data capture and analysis, all with lower per capita costs. Devotees of the PCMH are surging ahead to tie together the twin strands of incentives for transitioning to electronic medical records and improving on the delivery and payment models of Primary Care.

They have support from their major societies, all of which have wholeheartedly signed on to the PCMH model: The American Association of Family Physicians (AAFP), the American College of Physicians (ACP), the American Association of Pediatrics (AAP) and the American Osteopathic Association (AOA). These four groups total 330,000 members, more than a third of the practicing doctors in the United States. Even the venerable American Medical Association has joined the chorus, lending its endorsement to the concept. [The idea of a PCMH has actually been around for decades. You can see a timeline of its evolution on page S4 here.] Early data from some of the demonstration projects show promising results, reinforcing the idea that paying for quality in health care doesn’t necessarily mean delivering more care.

Yet while the PCMH sounds good conceptually, individual doctors and patients are finding it less lofty than its rhetoric. For one thing, the model presupposes the doctor as the center of a “care team,” consisting of nurses and “mid-levels” (i.e. nurse practitioners and physician assistants). Under the PCMH model, doctors would only see the “complex” patients, leaving the “simpler” issues (like sore throats, colds, sprains, and urinary tract infections) to the rest of the team.

In theory, the doctor (really the doctor’s team) has the ability to handle many more patients, improving both practice revenue and efficiency (attributable to the new informatics tools and data pooling). The obvious problem with this is that the patient has to buy in to the model. Some folks are fine seeing the nurse practitioner for their acute complaint, but how does the Medical Home model improve the doctor-patient relationship, especially if you already have trouble seeing your actual doctor?

Worse yet, with all of this restructuring, the PCMH has yet to be shown to be cost effective. Reorganization costs money, as do the startup costs of the electronic tools. Integrated systems like Group Health in Seattle and Geisinger in Pennsylvania have shown cost savings when doctors are salaried, networked, and have a captive audience of insureds to analyze. Unfortunately, the vast majority of practicing doctors still operate outside of these networks. Encouraging them to transition their practices into “homes” will be disruptive to say the least; the real question is whether the disruption will be transformative toward the ideal or cause the destruction of individualized doctor-patient relationships.

Feel free to chime in with your thoughts.

22 Comments

  1. John, as always a thoughtful and patient-centered piece for us to learn and consider. I don’t think that the primacy of the doctor-patient relationship has been the priority of any movement at healthcare reform, least of all this “Home” concept, which ironically (in name only) harkens back to “house calls”, when in reality it appears to create more levels and layers between a sick person and their doctor. But if we imagine an emerging system where there may be provider-patient relationships that could be equally important and rewarding, perhaps that can offer some solace to us. It’s just not obvious that at any level this matters or is discussed in these systematic attempts to address the issues.

    The ongoing challenges to our system remains volume, access and cost. Cover everyone, do everything that we deem is appropriate, do it with high quality, and do it on a budget that is affordable for everyone. It reminds me of the three variables of building a house (time, quality and money). They say that when you build a house (or renovate one) you can only achieve two of the the three variables at any one time. For instance, if you want your house built quickly and cheaply, you will sacrifice quality. If you want high quality and can’t afford a lot of money to invest in it, it will take a much longer time to accomplish your goal. If you try to achieve all three goals, you fail at all three. Similarly, with the healthcare challenges, it appears at a system level, attempts to address all three challenges results in failure to address all three- increasing the volume of those covered exceeds available resources (which in turn forces physicians out of their chosen professions), restricts access to physicians, and costs sky rocket. If you add the DPR to this mix, it’s the fourth variable. It seems no surprise that this issue, which can’t be measured easily and is only appreciated by those who have experienced it first hand or those who try to deliver it, is ignored or most quickly abandoned.

    In the trenches where we are living day to day with patients, we can still strive to provide the level of care that each individual patient needs, one at a time. And continue to shake our heads at the well-meaning and uninformed attempts to solve the bigger issues. The truth is that we can’t solve them and maintain the DPR in the traditional sense for the majority. How can we continue to teach about it in medical school and honor it as a revered tradition and major reason to pursue medicine as a career when in fact it’s ignored in the real world of practice?

    In the meantime, healthcare continues to be transformed into the equivalent of the drive-through pharmacy at Walgreens.

  2. John,
    An excellent post. As you’re well aware, start-up costs are highly significant (for electronic medical records, for example, costing in the tens of millions of dollars—that will never be recouped). Like you, I find the concept of the medical home reasonable on paper but questionable in practice. Besides the issue you mention of patients being dissatisfied with even more barriers laid down between them and their physicians, there is also the question of how well the physician at the center of a “care team” will be able to supervise his or her extenders (APNs, PAs, etc.). I think the extender model has great promise when supervision is adequate, but in many contexts it’s clearly not.

    • glasshospital

      July 14, 2010 at 2:59 pm

      Supervision aside, I think it’s an economic issue. Analysts seem to think that midlevels grow on trees, and can be plunked right down in primary care settings. Seems to me they have the same incentives as medical students–>straight into the higher-paying specialties. So on yet another level it’s not a real solution.

  3. I don’t think most people amymore view their physician as a “father” figure and hopefully can mature to their allegiance to a team with staff to provide the level of care needed for patient’s diagnosis and treatment. Perhaps the pharmaceutical companies need to stop telling us to “see your doctor”, and those who encourage us to exercise the same.

    • glasshospital

      July 14, 2010 at 3:01 pm

      I’d love it if outside forces stopped encouraging it–they do it as a means to get you you to ask for certain specific prescriptions, even when it’s not appropriate. And I don’t mean you, Joe–but the less health-care savvy.

    • Most people feel they can relate better to their PA or nurse practitioner.
      Unfortunately they should check their NP or PA’s SAT reading scores as their cmprehension of what they are reading is significantly lower than their doctors.

      Smoking like NP and PAs cuts the healthcae cost for a nation by causing early death and ending suffering. Poland actually encourages smoking.

      • I have been a PA for 27 years. My GRE Verbal score was in the 98th percentile.
        PA’s and NP’s actually can provide better care than physicians because they can often spend more time with their patients. Many PA’s have skill sets such as Minor Wound Management and Primary Care Orthopedics or Dermatology that are superior to their Primary Care MD preceptors.
        Your comments and spelling are incorrect.

  4. Your various reservations about the PCMH are spot on. Not only is the model unlikely to work in the practical world of most non-Group Health settings, but I worry it’s actually going to make things worse.

    Policy makers have been led to believe that simply the correct mix of the medical home, electronic health records, and increased preventive services (say, 1/3 teaspoon each) will obviously lead to improved quality and simultaneously decrease costs…. It sounds nice, but is delusionally WRONG. (And shame on the ivory tower academicians who are so out of touch with reality that they’re selling this snake oil).

    Meanwhile, the professional associations, desperate to appease their PCP members, have signed on to the PCMH model as a backdoor way of getting more money into the primary care clinics. While it might work, I don’t think it’d be worth an extra 30% reimbursement hike in my office. Having to jump through the hoops they’ll mandate will take more than that amount in extra resources (see “EHR incentives”, which also wont be worth it, at my clinic at least….)

    So– what’s going to happen when we CMS has to pay more for PCMH, pay more for EHR’s and pay more for increased utilization of preventive services…. but the overall spending curve doesn’t even begin to level off?

    Seems to me if CMS really needs to spend less, we must continue decreasing reimbursements for ALL PROCEDURES until we get to the point where the doc and facility are literally losing money doing the procedure. Then we’ll see how many PCA’s and endoscopies and arthroscopies really need to be done– when the doc is truly losing money taking time out of his/her day to do the procedure. I’ve little doubt they’ll continue to be done (we all know the cardiologists live to be in the cath lab– I get the impression they like it better than sex), but this way– with NO incentive to do the– maybe only the ones that actually will help people will be done….

    • glasshospital

      July 14, 2010 at 3:03 pm

      I like your train of thought, but I don’t see how draining all reimbursement (read: fair and reasonable) out of procedures does anyone any good. No ability to make money, voila: no proceduralists left. Let’s not throw the baby out with the water–even if it’s no longer sullied by oil up there in Alaska like it is down in the Gulf.

      • There has been over a ten year steady cut in surgical fees and a slight increase in exam and management fees. Try to find a surgeon in your mangled cae plan.

    • I operate on diabetic infections patient compliance is so poor that if I do not see them every few ays after surgery they will reinfect. Payment for surgery is so poor that I self limit the number of cases I can afford to take on as th dressing changes cost more than the surgical fee which includes 60 or 90 days of PO followup pays.

      So I ration and do what I can afford to I wish I could get paid I could take on more patients and save more les but then the government would have more Diabetics o provide healthcare for.

  5. So the “mid-levels” will be seeing patients that the doctor won’t- but the way the system works now is that those people are operating under the doc’s license- so the doctor becomes the person who gets nailed for malpractice when a case goes bad. Even if he/she never saw the patient. Or their chart. Or even knew they were in the office.

    • glasshospital

      July 14, 2010 at 3:04 pm

      Right. Sounds like you’re not crazy about it, either.

    • Hm, the NP’s in my state have sought repeatedly to get ANY independent prescribing authority (say for the many nursing homes where the scripts pile up until the once-a-week doc shows up to sign them). Guess who shows up every year to testify against the NP’s actually having any such responsibility (and liability)? That’s right, the state medical association.

    • I’m not a proponent of PCMH’s. And I generally like what you have to say. But in this case, it is assumed a physician would actually be supervising someone operating under their license. So they would have presumably had a meeting with the staff member treating their patients and would have reviewed the chart and treatment together at the end of the day.

      I’m not saying that you have the time to do this or that it is practical, only that this would be the expectation in a perfect world.

  6. An important topic –

    As a patient, I benefit from direct access to my physicians. I value their opinions highly in decisions I make about my health.

    But for ordinary activities (in a hypothetical patient such as blood pressure checks, coumadin monitoring or insulin management) I wouldn’t want any of my doctors routinely spending time on those things. Rather, they should be involved in good physical examination (to minimize use of unnecessary imaging studies, among other reasons) and in big-picture decision-making.

    I think most Americans need reset their expectations for what their primary care physicians do for them. Whether or not people accept the concept of health care rationing, in effect we’re taking up greater or lesser fractions of our physicians’ time by demanding that they, and not a mid-level practitioner, deal with relatively minor health concerns.

    So I think the model will work, because it has to work. There just aren’t enough physicians to take care of every minor aspect of each person’s health.

  7. glasshospital

    July 14, 2010 at 3:07 pm

    Agree with you about resetting expectations–but I think what’s going to happen is that patients will be more empowered through technology to do things themselves–even monitor coumadin. Putting someone or something else (other than a conduit like the EMR) in the middle of the doctor-patient relationship will drive more and more patients (and doctors, for that matter) into concierge arrangements–they’ll want the “luxury” of unfettered access.

  8. You have to click your note which means you can only click items that are set up but patients do not fit these cubby holes but your note will appear nice and neat and definitely not reflect the patient.
    Government want this.

    Money will be save by enying the few expensive care and giving the many the cheap stuff that is cost effetive. G-d help you if you have disease that doesn’t fit the cost effctive they will encourage you to do your duty and sign a living will.

    The rich will be able to buy this “unecessary” care but a 40 year old dope addict with hepatitis and aids will not get a bypass surgery that he would have today. Is this change right perhaps not for the dope addict or poor person or fat person who will not qualify for a hip implant.

  9. John Messmer, M.D.

    July 16, 2010 at 10:06 am

    The PCMH is NOT a system of farming out less complex patients to mid-levels. What it does is supplement the one patient – one provider (doc/NP/PA) model. One of the biggest issues facing us now is management of chronic diseases. Over a year ago, I started to participate in the PA Office of Healthcare Reform’s Chronic Care Initiative for diabetes. The idea is to use the standards of good practice (which, I agree, are subject to change – witness recent issues with BP control goals in diabetes) for the TEAM to focus on. Our diabetics are in a registry and we can focus on those whose HgbA1c’s, BP’s, LDL’s, etc are out of range, get people to the eye doctor, screen for nephropathy and neuropathy by identifying the patients and having a nurse or care manager arrange it. Extra meetings will be instituted by the care manager without my having to tell her to do it. EVERYONE on the team has the rules and the patient gets a regular report as to his/her progress.

    The numbers for my patients have improved dramatically and I had thought I was doing a pretty good job prior to this.

    Practice models tranform also. Do you realize how many practices in the US do NOT leave open same day appointments? So where do people go for acute illnesses? To the ED or urgi-center where more testing and referrals are done when they are not really needed.

    The PCMH is PATIENT CENTERED, not physician centered. The old ways were costly and not sufficiently effective and were top down with the physician (or even the NP or PA) saying, “Do this!” and the patient either complying or not (we call them non-compliant if they do not comply). Now we work WITH the patient to identify and deal with barriers. And I don’t have to do it all; there are people to help.

    Yes, I am in an academic practice and it is expensive to implement in small private groups or solo practices, but not impossible. It will require MORE MONEY from government and private payors. We now get extra money from the Blues for ALL our patients, not just diabetics, if we meet quality standards and we get extra payments quarterly for participation in the diabetic initiative. Small practices throughout PA are also participating and SUCCEEDING.

    This is the future of medicine if we don’t screw it up through naysaying and complaining. Diabetes, hypertension, CHF, asthma, renal disease, seizure disorders, cancers – all can be managed through the PCMH while SIMULTANEOUSLY meeting the needs of patients for wellness, acute illness, etc.

    Don’t knock it ’till you’ve tried it may be the best comment I can make.

    • Isn’t chronic disease the 800-pound gorilla of healthcare? Non-physician teamwork sounds like the best way to deal with the myriad problems diabetics can have. I wonder how the money question will wash out in the long run? I knew a vibrant, energetic NYC entrepreneur who was unable to keep her diabetes under control. She had to give up her shop when her eyesight failed, went on disability, then required a wheelchair, next a leg amputation, finally death in her fifties. Besides the obvious tragedy, all of that cost money, too.

  10. As a youthful 55 year old, I have seen it all. In my youth, our pediatrician made house calls when we were too sick or infectious (chickenpox), visited me in a hospital after I had been injured in a car accident and years later tended to my ill child even though I resided in a different state and was only visiting.

    In my 20s and 30s, raising children and working as a teacher, I had great insurance provided through my job which enabled me to pick & choose the doctors I felt most comfortable with. If my athletic child fractured a bone, I was able to immediately go to an orthopedic specialist.

    Fast forward to 2010. I now pay a ridiculous amount each month to belong to a highly restrictive HMO. I have had to sever all ties with my doctors as very few take this insurance. When I tore a tendon recently, it took me 2 weeks to get a referral, and 3 weeks to get a walking boot. I had to go through a maze of visits in which each provider told me he was restricted by the insurance company from giving me a boot. This theoretically saved money. Insurance companies seem the biggest threat literally to the health of the patient. Profit seems to have robbed compassion.

    With a daughter going forth into the field of medicine, I can only hope that someday we look back, re-evaluate the importance of the human connection, and find a better way to finance health care.

  11. Two years on, and the first data from PCMH pilots are starting to come in. A pilot in Colorado which recently concluded found that the PCMH was effective a reducing costs (primarily by reducing the number of ER visits, hospitals admissions and readmissions), and that patients, on balance, really liked their medical homes. More here: Colorado Patient-Centered Medical Home Pilot Produces Positive Results

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