Primary Care Doctors, Specialists and Medical Homes, Part II

Healthcare reformers talk of a day when every American will have a “medical home.”   But as I noted in part I of this post (“Americans Who Have Insurance—But Still No Access to Care”), it is not at all clear who will be “at home” in these homes.

While health policy wonks envision a legion of 21st century Marcus Welbys who know their patients, consult with their specialists, send out timely reminders, and keep a meticulous record of their medical histories, the truth is that we’re facing a severe shortage of primary care physicians (PCPs). A recent study of 1,200 fourth-year students published in the Journal of the American Medical Association showed that only 2 percent planned to work in primary care. In a similar study in 1990, the figure was 9 percent. 
In just the last ten year years, the number of U.S. medical students choosing to enter family medicine has fallen by 50 percent according to a report released by the Texas Primary Care Coalition (see chart below).

One reason medical students shun primary care is the relatively low pay. As the chart and table below reveal, over the last decade, dermatologists, radiologists gastroenterologists and orthopedic surgeons have seen their incomes skyrocket while the incomes of family doctors and internists lag far behind. 

Looking at these figures, some assume that if we just hiked the pay for PCPs, their numbers would grow and medical homes would be filled. But it isn’t quite that easy.

First, low pay is not the only reason that medical students are reluctant to become family doctors. Many find the hectic pace, the crushing paperwork and the hard work of caring for elderly and chronically ill patients daunting—“especially when you’re doing it with time pressures and inadequate resources,” says Dr. Karen Hauser, a professor at the University of California, San Francisco and lead author of the JAMA study.

Keep in mind that Medicare patients crowd the waiting rooms of most PCPs, and 20 percent of those patients suffer from five or more chronic conditions, visit physicians an average of 57 times a year, and see an average of 14 different physicians. Trying to coordinate and manage their care is an extraordinarily frustrating, labor-intensive business. That said, this bulletin from the latest issue of Health Affairs should come as no surprise: “Not All Primary Care Doctors Are Able to –or Eager to—Become Medical Homes.”

Simply increasing the supply of PCPS offers no guarantee that patient care would be better managed and coordinated. For some years, the received wisdom has been that if we only had more family doctors—and patients relied on them for most of their care—they would receive more preventive care; their chronic diseases would be managed; and they will be less likely to wind up in a hospital. A study published in the American Medical Journal makes the traditional argument, reporting that “for each 1 percent increase in primary care physicians, average-sized metropolitan areas experienced 503 fewer hospital admissions, 2,968 fewer emergency room visits and 512 fewer surgeries.”

But recently, that theory has been called into question by the Dartmouth Atlas, a body of research that has become the gold standard for understanding what leads to more intensive, aggressive and expensive care. The 2008 Dartmouth Atlas shocked many by reporting that “spending on ambulatory visits, many of them to primary care physicians, is positively correlated with inpatient days and inpatient physician visits.”  In other words, patients who see more primary care physicians actually are more likely to be hospitalized.

How can this be? The truth, the Dartmouth researchers explain, is that most primary physicians don’t coordinate care by “collaborating with specialists to ensure both communication and collaborative decision making,” in large part because “our payment system fails to reward office-based physicians for managing disease and coordinating care.” As a result, PCPs don’t have the time to play phone tag with specialists, tease out a list of all of the medications their patient are taking, or organize the information in neatly catalogued electronic medical records. If a PCP wants to meet her overhead, she probably tries to see a patient every 15 or 20 minutes. Her office is not a medical home—it’s a way station, a place where you go to get a referral to a specialist, who may then send you to a hospital.  Alternatively, a busy PCP sends you directly to the ER.

The bottom line, according to Dartmouth: “training more primary care physicians alone won’t solve the problems” of a fragmented health care system. “Without financial incentives that encourage both hospitals and specialists to reduce overuse, primary care coordination is likely to fail.” We also need to pay PCPs to keep track of what 14 other doctors are doing. “Prospective payment systems that reward providers for cost-effective care may yet emerge,” the Atlas observes, “but even with substantial investments, fundamental reform of the payment system could take ten or more years.” 

In the meantime, we might also want to find a way to persuade patients that they don’t really need to see 14 different doctors. But that, too, could easily take a decade.

Could Specialists Provide Medical Homes?

Given the dearth of primary care physicians and the fact that most simply don’t have the time or the resources to co-ordinate patient care, some observers have suggested that specialists should be recruited to create medical homes. In its June 2008 report to Congress, the Medicare Payment Advisory Committee (MedPac) suggests that “specialty practices that focus on care for certain chronic conditions, such as diabetes...could qualify as medical homes.” Some patients who suffer from heart disease already use their cardiologist as their primary doctor. A cancer patient’s oncologist could, if willing, serve as his medical home.

But consider what creating a medical home entails. MedPac recommends that homes should meet “stringent requirements.” To qualify, they must:

• coordinate appropriate preventive, maintenance and acute health services
• use health information technology for active clinical decision support
• keep up-to-date records of beneficiaries’ advance directives
• maintain 24-hour patient communication and rapid access

Reformers believe that a patient should be able to reach his medical home 24/7 in order to avoid needless trips to the ER. This makes sense. But whether the physician is a cardiologist or a family doctor, a solo practitioner would be hard-pressed to meet this requirement. Indeed few small group practices (of three to five doctors) would be willing to be “on call” that many nights and week-ends, even by e-mail.

This alone could eliminate nearly 40 percent of all physicians from medical home programs. As Robert Berenson and co-authors point out in the September/October issue of Health Affairs “about 33 percent of U.S. physicians are in practices of one or two physicians, and 42 percent, five or fewer, with only a slight trend in recent years toward larger practices.”

In some cases, separate practices might be able to band together to cover each other, creating a “virtual” home.  But will a patient who finds herself talking to a complete stranger at 3 a.m. really feel that she is phoning home? In the same issue of Health Affairs, Diane Rittenhouse and her co-authors note that: “From the patient’s perspective, a medical home is not simply a combination of disease registries, reminder systems, and performance measurement.  A medical home is a familiar place, with familiar people, that delivers high-quality, well-organized care that is accessible in time of need.”

Moreover, even a small group of handsomely-paid cardiologists might hesitate before making the investment in electronic medical records (EMRs) that is all but essential if a practice is going to coordinate its patients’ care.  Studies of small group practices trying to implement EMRs show that on average, the systems initially cost somewhere between $33,00 to $44,000 per physician, plus maintenance costs ranging from $18,000 per physician annually (if the practice invested  only $33,00) per physician when setting up the system) to $8,500 per provider  (if they spent more at the outset.)

Meanwhile—and this is the killer-- “For most practices, electronic health record implementation leads to a reduction in productivity for 10-15 months and a 10% cut in take-home pay for five years,” notes the Texas Primary Care Coalition report, citing a study of “Medical Groups’ Adoption of Electronic Health Records  and Information Systems” published in Health Affairs in 2005.

Finally, today, healthcare IT is in such flux that a practice has no way of knowing whether the system it chooses will be able to “talk to” the other physicians and hospitals in his region ten years down the road. 

Larger Houses Make Better Homes          

In  their contribution to the September/October Health Affairs, “Measuring the Medical Home: Infrastructure in Large Medical Groups,” Rittenhouse and colleagues note that “Early visions of the medical home centered on small practice settings.” But in reality, their data demonstrates that “the largest of the large medical groups, and those owned by larger entities such as a hospital or an HMO” are more successful when their homes are measured on “care coordination,” “quality and safety,” “enhanced access,” and physician-directed care” (which includes physicians using electronic medical records, keeping registries for at least three chronic diseases and using nurse managers to manage care for patients with severe illnesses) (see chart below.)

Because larger homes have more resources, they are “well-positioned to implement many of the infrastructure components of the Patient-Centered Medical Home model,” Rittenhouse and colleagues observe. Indeed, as the chart below reveals, the largest medical groups (more than 140 physicians) are  far more likely to rank as “high performers. ” Among the smallest (20-37 physicians) only 1 percent turned out to be high performers, and 29 percent were identified as among the lowest performers.

Large, multi-specialty practices have an added advantage: at places like the Mayo Clinic, the Veteran’s Administration and Kaiser Permanente, primary care physicians and specialists are already accustomed to collaborating. They share electronic medical records and are all looking at the same chart for each patient. Moreover, at these medical centers, patients tend to think of the center itself as a home that they trust.

Unrealistic Expectations?

When talking about healthcare reform, there is one issue that reformers always tend to avoid: money. Yet providers would have to be paid extra for all of the time and effort it would take, first to restructure their practice, and secondly to maintain the home long-term. 

When Bob Wachter wrote about the scarcity of primary care physicians on his blog in August, one reader commented: “The ‘Medical Home’ has been espoused as a way to make primary care practices financially viable. A proposed payment scenario was recently reviewed in the June AMA News. It shows that Tier 3 (the highest, requiring the most extra services and reporting) would pay an extra $161,871 for a panel of 250 patients. That comes to $53.96/pt/mos which is barely enough to cover two or three extra phone calls. It's hard to see how this will have any chance at all to fix the problem.”

Indeed, physicians caring for patients suffering from three or four serious chronic diseases would have to be paid significantly more, per patient, to reimburse them for the labor involved.  Where would the money come from? In theory, over time, a medical home would reap great savings stressing preventive care, co-ordination of care and chronic disease management.  But we are just beginning to learn how to manage chronic care. And, as noted, co-ordinating care requires a huge up-front investment in electronic records.

Moreover, money is not the only obstacle.  Even very large practices might be reluctant to take on the challenge of making a “home” for their patients. As Bob Berenson and colleagues point out in Health Affairs: “the result of well-intentioned medical home expectations could well be that beleaguered PCPs will decline an invitation to receive additional Patient-Centered Medical Home (PCMH) payments for what they view as unrealistic expectations and unwanted obligations.”

For example, the authors note, while guidelines for medical homes often recommend using disease registries to send reminders out to patients who have missed routine follow-up appointments, “some physicians point out that patients have their own responsibilities to jointly sustain a satisfactory physician-patient relationship, implicitly questioning the rationale” for the reminders. Moreover, “one of the doctors we interviewed, who had experimented with proactive population management, claimed that only a small percentage of diabetic patients contacted regarding needed tests actually initiated care as a result.”

Proponents of medical homes recommend that in order to provide better access, physicians should accept phone calls and e-mails from their patients. But, Berenson and colleagues report, “a number of respondents view traditional, face-to-face office visits as the core of their professional activities and could not imagine relying on alternative approaches emphasizing greatly expanded use of e-mail and phone communication. Similarly, some physicians could not imagine delegating medication renewals to non-physicians, as called for in the PPC-PCMH standards, because of their concerns about medication errors.

“Some were also skeptical of e-mail, believing that phone conversations generally were a more reliable method of resolving patients’ questions and concerns—while limiting their own time requirements.”

Finally, “many practices, including some that appear to do a conscientious job of providing patient-centered primary care…feel threatened by a medical home model that immediately disrupts the basic orientation of their practices and, implicitly, threatens their professional self-esteem.”

One could say that doctors are ornery, and don’t like to learn new tricks. But the truth is we don’t yet have enough evidence about medical homes to know what works and what doesn’t. We should continue to experiment—but it may be a bit soon to be drawing up “requirements” for homes. It’s likely that we’ll discover that different strategies work better for different providers, depending on their size, temperament, location and patient profiles.  In the end, outcomes are what matter.

A Special Culture

Finally, a medical home must have a heart.  In a piece titled “Medical Homes—And Homes Runs,” 
published on the Health Affairs blog in tandem with the September/October issue of the journal, Arnold Milstein suggests that medical homes need a special culture dedicated to the idea of keeping patients well. Those that display “a certain clinical mindset” should be able to “substantially reduce near- and long-term total health care spending while improving quality of care,” Milstein writes. “Medical homes can be medical home runs; but I worry that most won’t be…partly because medical homes are not being explicitly designed for this purpose.”

Milstein goes on to explain that “with support from  the Robert Wood Johnson Foundation, the California HealthCare Foundation, and employee health plan sponsors,” he personally “scouted for and found four primary care physician-led practices with average or above-average quality scores whose care enables their patients to consume 15-20% less total payer spending per year on a risk-adjusted basis than patients being treated by regional peers.” It’s notable that he found these four flourishing homes “in both large and small physician practices in Massachusetts, Florida, and California.”

What did they have in common? “Two key features that are not well addressed in current medical home blueprints, Milstein reports: “personal zealotry in preventing urgent and emergent hospitalization for chronic illnesses; and equally zealous concentration of referral care with high-quality medical specialists who are sparing in their use of [what the Dartmouth research describes as ] “supply-sensitive services”—hospitalizations and doctors’ visits driven, not by patient need, but by an abundant supply of hospital beds and doctors.

Milstein explains: “All four primary care medical home runs operate as de facto ‘hospitalization prevention organizations’ for their chronically ill patients; they make prevention of unplanned hospitalization of these patients a primary objective; and they redesign their practice models accordingly. A key element of this prioritization is clinical mindset; the physicians and their office staff regard urgent and emergent hospitalizations for patients with chronic illnesses as personal and organizational failure events, study their root causes, and evolve their practice model to prevent recurrence.”

They go the extra mile. For instance, one member of the primary care team makes a personal connection with each chronically ill patient “demonstrating saliently…that [he or she] cares deeply and personally about [the patient] and protecting [that patient’s] health.”  Moreover, “as soon as a chronically ill patient senses impending health crisis, a member of the health care team familiar with their history is readily reachable and prepared  to . . .actively coordinating with ER physicians and hospitalists in exploring alternatives to hospitalization.”

Rather than trying to network with many specialists (which can help generate more new business), these primary care homes also concentrate their referrals, sending patients to  one specialists or specialist group per specialty that practices “conservative” medicine,  which is to say that they realize that over-treating can be just as dangerous as under-treating. “In two of the medical home run practices,” Milstein reports, “conservative resource use by these specialists was reinforced” by the fact that rather than being paid fee-for-service, the specialists received a lump sum, per patient, to keep their patients well.

Not surprisingly, concentration of referrals also led to “more reliable transfers of patient information between primary and specialist care, and greater clarity regarding the division of responsibility among physicians involved in a patient’s ongoing management.”

But ultimately, the key, I think, is “personal zealotry,” and a “clinical mindset” that abhors overtreatment.  In the end, physicians themselves are in the best position to fight waste in our medical system. They know that hospitals can be dangerous places—especially if you don’t need to be there. They are in a better position than anyone to distinguish between “necessary” and “unnecessary” care. We don’t want private insurers making these decisions. But unless physicians begin to pare the waste from the system, someone else will. And they’ll use a crude tool.

Comments

[orthopedic emr]

Healthcare reform, a big part of which revolves around digitizing electronic medical records, is a huge endeavor that will require time, money and human resources. Keep posting more informative sources of knowledge.

mjd

[Dan Smith]

Medical Homes are another great idea--that won't work. I started my career in Family Medicine in 1982 and at the time the ideas of Paul Ellwood held sway in medical and health policy circles. He is the man who "invented" the HMO. The HMO concept, redressed, is what medical homes are. I entered practice with enthusiasm to lead my patients to a healthier lifestyle with emphasis on prevention and I could coordinate referrals to specialists for care I couldn't render myself. Within a few years the idea was belly-up, killed by patient/consumer resistance, augmented by horror stories about denial of services that caused lawmakers to pass laws mandating treatments (like bone marrow transplants for advanced breast cancer) which were no better than conventional care, but way more expensive. No, the medical home payment scheme is not the same as capitation, but I am willing to bet that the residents of medical homes will balk at the idea that they can't coordinate their own care, go to Mayo Clinic because that's what the guy down the street did, or any number of other objections. You see, health care rationing is always about the other guy, not me. Everything I think I want in order to live to age 95 is my constitutional right. If some smarty pants young doctor thinks otherwise, it's only because he's trying to save money for an insurance company or the government and ultimately himself.

[Maggie Mahar]

Ddx:dx--

I responded to your comment yesterday, but somehow my response disappeared--

I'll respond again tomorrow. Just wanted you to know that I read your comment . . .

[Ddx:dx]

Maggie,

http://odphp.osophs.dhhs.gov/pubs/guidecps/uspstf.htm

Alfred Berg always gives an update when I do CME at UW. Intersting program...Really attempting to provide some direction in a sea of uncertainty...And often the direstion is...Maybe we should head this way...

My experience of the medical home was that I got to know my patients really well. I measured success for each on a different scale. Some, it was simply that, the scale(weight). Others the success was that they could get ON the scale(body image). And I remember seeing Zeoma once a month, essentially providing supportive hand holding therapy. But the 7 years I cared for her she only went to the ER once, with no admissions. Try coding and documenting that for Medicare reimbursement.
When we invested in and installed our EMR we finally tried to use it for quality improvement in patient care. We did a search on the patients per doc with the dx of HTN who hadn't been seen in a year. My list only had two patients. I rolled my eyes when I saw their names. "They won't come in" I muttered. But we sent the reminder letter anyway. One guy called up and ragged on the receptionist that he didn't want to be treated like a child, "Transfer my records!", and the other guy sent me a typed letter with his home blood pressures and a long list why the only function I served was to write a prescription once a year....
So a medical home is a concept, much like the one you live in. We all have different roles to play in the home. I see the concept giving "leadership"=?parenting? role to the generalist. And I agree with Maggie, lots of generalists are really not fit to lead people toward health. But then, will we have a National Certification for "Health Leader" ... More Board Certifying Bull?
I thing the concept of promoting health should be the goal for all...And the business model reinforces personal responsibility( your$)...But it isn't balanced with the mentoring, teaching parenting role people often are lacking...

[Maggie Mahar]

Annie, pcb and Marcia MD

Thanks for your comment

Annie- You write: "Public health and professional nursing are two vital resources which remain grossly undervalued for the returns they provide."

I absolutely agree.

We need to put far more emphasis on public health--and providing the conditions for health that you list. The only thing I would add is that we also need safe places for people to exercise in poor neighborhoods--and gymns and safe playgrounds in schools in poor neighborhoods.

The one silver lining that I see in this ecoomic meltdown is that we may begin to create jobs (WPA -like jobs) to build the conditions you describe.

I absolutely agree that RNs can play a major role in creating medical homes for people with chronic conditions. And nuress can also help by going into their homes to provide care and to teach patients how to help managing their diseases.

WE need to invest more in nursing home. It's a way of keeping people out of hospitals.

Another silver lining that could accomapany the eocnomic meltdown-- many very bright college graduate who might have gone to business school or Wall Street will realize that the jobs are no longer there.

Seeing how many bankers, lawyers and other connected to the financial world are losing their jobs, they may also realize that they would like a more secure career--even if they won't have an opportunity to make $600,000 plus.

I suspect many more will decide to go become nurses, teachers, or get a masters in public health.

This could be a real boom for society.

pcb and Marcia MD--

I know that most specialists haven't done primary care for years, and many are not at all interested.

But at least one very knowledgable doctor working at a NYC hospital tells me many specialists ARE interested in the notion of medical homes because they know that:

a) the fees they are paid to perform many services are going to be cut--especially when it comes to the most lucrative services and

b) they are interested in the money to be made by providing a medical home as a way to supplement their income.

[Annie]

This is an excellent primer about the medical home model and its relationship to chronic illness and the need for primary care to be - primary.

There are two other factors I would like to posit that I believe should be in the mix:

The integration of public health and preventive care as a foundation

The integration of professional nursing as a foundation in primary care and optimal patient outcomes.

Health is built on nutritious foods, safely prepared, potable water, clean air, safe shelter (from the elements, from crime and from violence), reliable and safe transportation, and safe school and workplace conditions.

When these elements are ALL in place, people then have the essentials and confidence in acquiring them (as opposed to the anxiety and physiologic stresses of hunger, homelessness, joblessness, violence in the home, etc.)and they are able to make informed choices about their health.

Public health principles and practices must be a key driving force in national, state and local efforts towards achieving these, and public health must be directly linked to all modes of primary health care.

This will allow for more efficacious disease surveillance, safety protections and best practice development, while reducing the need for catastrophic care resulting from delayed or denied preventive care and treatment.

Public health (now community health) and in-home professional nursing has traditionally been the direct link between home, community and health care provider setting. Nurses provide essential sentinel surveillance when they perform home and community assessments, provide health education, coaching, screening and primary preventive care. They also focus by their profession's emphasis on health on patients' individual abilities and readiness to learn, to manage their health problems and to manage the care and services needed over the full spectrum of health providers, settings, services and goods.

To continue to marginalize professional nursing and to ignore what it does, what it is designed and charged to do by social contract and statute, and its legitimate role in health care leaves a large hole in the dialog about health.

Public health and professional nursing are two vital resources which remain grossly undervalued for the returns they provide.

On a related note, much of what you describe about the nature and characteristics of the medical home fall under the category of the traditional physician/nurse and patient therapeutic relationship. But as this isn't reimbursed, and the emphasis has been for over twenty five years now (with the advent of PPS) technology and procedure over patient relationship, education and coaching, it is no wonder that our free market follies devalued it, and few nurses and physicians actually practice it. It takes time, it demands ongoing patient contact, and it involves developing and using therapeutic communication techniques and not superficial feel good bedside mannerisms.

The shift away from care FOR people to doing things TO people has, in my view, not been advantageous and beneficial. It creates great dissatisfaction for nurses and physicians who value caring, and it dehumanizes and depersonalizes patients.

[Maggie Mahar]

Barry, Ian, Nancy B.--

Barry-- some people who talk about "medical homes" believe that they should focus on people suffering from chronic diseaes. These patients need regular, ongoing care. And a great many of them suffer from more than one chronic condition.

20 percent of Americans over 65 suffer from FIVE OR MORE CHRONIC Diseases.

These people definitely need a medical home. They need someone co-ordinating their care. Especially because, as you get older, and your short-term memory fades, it becomes harder to remember the names of all of the medications you are taking, what the last doctor said, etc.

Some people keep brilliant records of their own care, but most people don't have the ability, or the temperament.

I tend to agree with you that the average healthy
upper-middle class or upper-class adult unde4 65 doesn't need a medical home. He probably doesn't have multiple problems, is rarely sick, and keeps pretty good track of his care.

But the poorer you are, the more likely you are to suffer from several chronic diseases--respiratory diseases linked ot enviroment (much, much higher rates in the Bronx) heart disease linked to stress,
mental problems linked to stress, lung diseases (50% of Americans who smoke suffer from mental illnes. . .)

So I think there is a real need for medical homes. But I agree that it would be overkill (and a waste of money) to insist that every American must have a "home."

We should target populations that would benefit. If the medical home really raises the quality of their caring, then that would save money for all of us.

I also agree that some of what we label necessary
"preventive care" really isn't that effective and should get a "D."

I do know, for example, that the Preventive Servcies Task Force (which uses real medical evidnece)
does not recommend PSA testing for prostate cancer for average-risk men over 55. . .

I would love to get more info on the Task Force
grading prventive care. Are you still in touch with that doctor? Could you ask him to direct me to a source?

Ian-- Take a look at Nancy B's comment. It strikes me that she is working in a setting where there is the "clinical mindsight" that greatly values the idea of spending more time talking to and listening to patiennts, co=ordinating care etc.

As I said toward the end of the post: a good medical home may require a "special culture" and a certain zealotry.

What you describe e sounds like a much more cynical, much less professional culture where people are focused on making a comfortable living without doing too much work. These are not committed professionals.

Btw, I don't think this is because you are in Canada.
In the U.S., as in Canada, there are medical cultures that are more patient-centered, and cultures that are more money-centered/provider/centered.
Nancy B-- Please read my
response to Ian-- just above this response

You're very lucky; it's seems that you're working in a place with excelletn leadership--and
a culture that has a clear focus on the retirees.

I would hazard a guess that "a perfect world" may be an overstatement, but still,it sounds good.

[pcb]

maggie,

specialists haven't done generalist care for years. Many of them went into their specialty because they were not interested in giving general care. They have a completely different approach, in general, to the delivery of care. They operate in the "zebra zone" (looking for zebras when you hear hoofbeats, when it's more likely a horse.) This is not to criticize specialists, many(most?) will agree with this. They do not want to spend time dealing with and figuring out the vague "undifferentiated" complaint. And they don't want to deal with more precise complaints outside of their specialty. (I'm sure there are exceptions, but they are exceptions.)

What would often happen, as you mention, is the cardiologjst sending all abdominal pain patients to the GI doc and all the renal insufficiency patients to the nephrologist and all the knees/shoulder pain patients to the orthopedic surgeon. Do you realize what happens to the volume
and intensity of services when when every complaint gets it's own specialist? Generalists
address abdominal pain, knee pain, lab abnormalities, etc, multiple times every day, hopefully using specialists only in the most difficult cases.
Do you have a guess how much more costly it would be if specialists were the first line for all patient complaints? I don't think it would save anyone any money.

On to your other point...

You cannot fully and adequately adjust for illness severity with regard to outcomes and utilization. I know researchers claim to adjust but it's not reliable. This comes up all the time with P4P, and it's well known we don't have reliable ways to ajust for severity of illness on outcomes. I think you overstate the abilities of the researchers with regard to this point.

Obviously it's more complicated than "more care is bad." Sometimes more care is bad, sometimes good. The devil is in the details. The details are where a comparative effectiveness institute would really help. But let's not get caught up with "Dartmouth Fever" , lest we conclude that the best outcomes would occur with the supply of medical care at zero.

I agree we are operating far out in the diminishing returns area of the health outcomes curve with much of what we do. Figuring out, as you've previously stated, which care adds value and which doesn't is the key.

Now a tangent....

The problem is that for the patient who's not paying (or has already paid re: premiums/taxes) a small predicted return on some health intervention may be worth a high price, because the price is someone else's problem. I see it all the time. "my insurance will cover it" lets just "be sure" and order the test. Or "sure I'll take this drug with little projected benefit, it's covered" and on and on. It's completely rational behavior.

I know your response would be "but if the patient knew about the side effects, engaged in shared decision making, they would likely make the appropriate choice (from a societal perspective too.)" I simply disagree, and it's based on what I see every day on the front lines. When care/meds/testing is percieved as "free" or "already paid for" patients want more of it, as long as there's "some chance" of benefit that outweighs direct harm to them. And there's a lot of care to give under those circumstances. Most of that care won't help the patient, but many play the "just in case" game when someone else is paying.

[Marica, MD]

Medical homes are an interesting idea. I just can't see cardiologists and gastroenterologists wanting to do pap smears, and convincing patients that a viral uri doesn't require antibiotics. In addition, being specialty trained, they are not necessarily in the know as to treating chronic conditions as Diabetes and COPD. The answer must be that primary care physicians get paid for what they do, including emails and phone calls. Specialists are NOT equiped or nor do they desire to do "primary care" and the cordination of care that complex patients require.

[NancyB]

I don't pretend to be an expert in Medical Homes but I do know that is what we practice in the national retirement company with whom I work. We have our own medical centers in each community, owned by the medical director and all of these come under the chief medical officer. Our goal is to keep people (average age of our residents is 78) as active as is possible, adding life to their years, in their on campus homes.

We have our own medicare advantage plan as a demonstration project. We have our own care coordinators in each med. ctr. We have EMR throughout the continuum. Our doctors are salaried, we have a central billing operation, we pay incentives to have the doctors spend more time with the residents/patients and for implementation of quality intitiatives. We are finding that we have reduced re-admits and even hospitalizations.

This is a perfect world here. There are no buraucracies here. There are doctors and nurses and an owner who is committed to positive outcomes in aging. Most people say 65 and older; he says, 65 and better.

Do we have problems finding doctors? Fortunately word of mouth has been excellent but we recognize the challenges that lie ahead.

[Maggie Mahar]

pcb--
Thanks for your comment.
(I'll reply to other comments later today)

pcb- Let me try to clarify:
the cardiologoist who acts
as your family home co-orodinates your care. He does not provides all of your care. But he is in touch with your specialists. So if you have abcominal pain and he sends you to a gastrenologist, he gets the report.

The report says that it's nothing--you're eating too quickly, gas, whatever.

The cardiologist (who knows you better than the specailist because he has been seeing you for 15 years) explains this to you (by e-mail) and you're likely to believe him (because you know him) rather than going to 3 other specailists looking for a "cure" or more tests.

Also, a year from now, if you complain of the same symptoms, the cariologist will be aware of the history--this could be a red flag to look deeper.

Finally, cardiologists, like internists went to medical school. They, too know how to diagnose some common complaints. And with a physician's assistant or an RN, they can do a test to see if your sore throat is really strep or just a sore throat, etc.

If you are depressed because your wife just died, they know you need a grief counselor or a support group--you don't need to go on anti-depressants.

If you break a rib, a cardiologist can tell you there's nothing to be done--we don't "set" broken ribs. Eventually it heals itself. (Though he may want to look at you to make sure that's all it is) But no, you don't need to go to the ER.

If you cut yourself and it begins to look infected, he can tell you to go to the drugstore and buy a particular disinfectant over the counter.

I've known people who used their cardiologist as their GP for years.

On people who see primary docs more often: The Dartmouth reserach compares people in different regions or cities and adjusts for the fact that people in some cities are sicker (envirnoment, poverty etc.)

AFTER MAKING THAT ADJUSTMENT, they find that in some cities, patients go to primary docs more often. This has nothing to do with how sick they are--nearly three decades of reserach shows that its a function of how many docs there are in the region. Supply drives demand.

Previously we had thought that when there are more primary docs and fewer specialists, patients were likely to get more preentive care and chronic disease management and so less likely to wind up in the hospital.

Now we know that patients who see more primary care docs are more likely to land in the hopsital becuase primary care docs don't have time to do the preventive care chronic disease management that we expect them to do (and that they would like to do.

[Barry Carol]

I inadvertently posted this on the Medicaid thread. Sorry about that.

I think the need for medical homes might be overrated and overstated for most people. I do think it is certainly useful for children to have a regular pediatrician to make sure they get their immunizations and deal with other issues as they arise. Pregnant women should also have an OB-GYN to provide appropriate prenatal care. For the rest of us in the 18-64 population, however, I have my doubts.

It’s been pointed out before that a given individual’s health status is driven 40% by personal behavior, 30% by genetics, 20% by socioeconomic status and environmental factors, and only 10% by access to and availability of quality healthcare.

With respect to personal behavior, the vast majority of us know that we shouldn’t smoke and we should drink only in moderation. We know that fruits and vegetables are good for us while high fat foods, sweets, and too much salt are not. Even when a doctor tries to tell us to stop smoking or get more fiber in our diet, the advice often falls on deaf ears. Maybe it’s because we think we’re indestructible or we just lack the discipline to modify or eliminate bad habits. Sometimes we just need a catalyst for action. I’ve heard lots of women who smoked say they tried numerous times to quit but couldn’t until they became pregnant. Then, suddenly they were able to quit. People who have a cardiac event, a stroke, or are diagnosed with diabetes are scared enough to suddenly be able to drastically improve their diet and exercise regimen and quit smoking. They needed a wake-up call after ignoring their doctor’s advice for years.

In any given year, the vast majority of people have no significant medical issues. If they have a minor issue like a sore throat, ear infection or need a flu shot, they don’t even need a PCP, let alone a medical home. They can go to an urgent care clinic or retail clinic and access a nurse practitioner.

In my own case, my cardiologist takes care of my heart and blood pressure related issues and performs my annual corporate physical. When I needed to see a urologist, he referred me to one but did not coordinate any care. All urology related issues are dealt with by that specialist. What would be helpful, I think, would be a central database that all physicians could access to see what prescriptions a patient is taking. I think much of this information exists at places like the Ingenix Division of UnitedHealth Group.

As for preventive care, a doctor told me a year or so ago that a group called the Preventive Services Task Force has evaluated a large number of common preventive services and tests and graded them A, B, C or D for cost-effectiveness. He told me that he always tries to give his patients the services that are appropriate for them based on age and gender if they are graded A or B by the PSTF. For the C’s, he’ll use his judgment but generally won’t do them for most patients. For the D’s, he not only won’t do them but will try his best to convince a patient who asks for it that it shouldn’t be done because it’s not necessary and not cost-effective.

If a medical home model would require paying a doctor a meaningful amount of money to coordinate the care of each person in his or her panel including the large number that don’t have any medical issues in most years, it will likely cost more than it’s worth. I think we would be better off expanding the number of nurse practitioners and physician assistants to address the minor issues while freeing the PCP’s to devote more time to the patients who actually need their skill and expertise.

[pcb]

a couple points:

specialists as medical homes makes little sense to me. What happens when the cardiologist has a patient with abdominal pain or shoulder pain or depression or headaches or......? Off to the specialist is usually the result. (or the ED if it can't wait). Not any way to save costs. I don't think many people realize how much a confident generalist can save the system by handling various complaints judiciously and appropriately rather than farming complaints out to various specialists. Keeping patients away from specialists (and their fancy tests) unless it's really needed is essential if we want to control costs.

Also, the idea that more ambulatory services leads to more hospitalizatioins is expected, isn't it? When patients seek more care for their complaints, have more access, bring more forward to the physician, the physician will be obligated to do more. If you wait out a few chest pain episodes at home and don't come in, you won't end up in the hospital and you save the system money. (statistically something like vague chest pains are often benign). If you come in, the doctor may be obligated to do something about it. (especially if it *could* be something serious) Additionally, sicker patients with more problems go to the doctor more. Sicker patients need more treatments. Sicker patients get hospitalized more. (they are sick, after all). So saying that patients that go to the doctor more end up with more treatment, and areas where people have more access to the doctor means more care is given, is not surpising. (nor is it inappropriate)

[Ian Furst]

Medical homes are alive and well in Ontario, Canada in the form of family health teams (FHT's). The accept a patients, are paid a flat fee based on the age of the patient and location of the clinic and must treat them day or night or face a penalty.

The outcome? Fewer docs are accepting new patients. The FHT's reach a comfortable income level vs workload then stop accepting patients and the finacial incentive is to spend as little time as possible with frequent referrals and few visits as long as the person doesn't land in the ER.

As far as specialists managing chronic care -- good luck. Most don't go into specialty work exclusively for the pay. Most don't want to manage the multitude of other conditions that might accompany whatever specialty they've choosen.

Assuming the US has some sort of health care reform the number of people with acccess to primary care will increase from 85% to 95% while the number of PCP's drops by 50%. Given the doctor:patient ratio that is a major problem.

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