The ACP Advocate Blog
by Bob Doherty
Tuesday, November 25, 2008
What happens if no one is home ... at the medical home?
David Harlow, writing in HealthBlawg says that recent news on the medical home is good. He cites a post by Arnold Milstein in the Health Affairs blog on "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. Mobilizing impressive business ingenuity, they achieved this result in a U.S. payment environment that typically punishes physicians who invest to prevent costly near-term health crises."
(To learn more about the patient-centered medical home, go to ACP's new PCMH web page, a comprehensive collection of information, resources and demonstration projects to assist in planning for a complete patient-centered medical home.)
But Harlow raises an important caveat: the viability of medical homes assume a sufficient supply of primary care physicians. He quotes the following from the New York Times:
"A growing shortage of doctors willing to practice general medicine has left some [provider networks] desperate for qualified candidates and, in the long term, stands as a major obstacle to overhauling the nation's health-care system ...
Almost all changes under consideration include a central role for what used to be known as the family doctor - today generally an internist or family practitioner - who can save the system money ...
Although such primary-care doctors were once the cornerstone of American medicine, their numbers have dwindled as younger doctors have been drawn to specialty fields by money and the lure of new technology. So today ... a rising demand is confronting a declining supply."
Here's the kicker. The New York Times article was published 15 years ago, when the Times reported that in 1992 "only 14.6 percent of medical students decided to go into general medicine, an all-time low." Last month, the Journal of the American Medical Association reported that only two percent of fourth year medical students plan to go into general internal medicine.
We've known for a decade and a half that primary care is in trouble, and we also know what needs to be done about it (starting with better reimbursement), but there has been enormous political and institutional resistance to doing more than token measures.
This time around, policymakers have to get serious about fixing the problem. The patient-centered medical home has enormous potential to refocus health care around the relationship between primary care physicians and patients - supported by better reimbursement and health information systems to achieve the best possible results. The hope, of course, is that the PCMH will also make primary care more attractive and viable.
But we also need comprehensive reforms to provide immediate, sustained, and sufficient increases in reimbursement to general internists and other primary care physicians, reduce the "hassles" of practice, re-orient medical education around primary care, and allow medical students who select primary care to graduate debt-free.
Otherwise, we can build the loveliest of medical homes, but no doctors will be there when the patients arrive.
Today's questions: What do you think needs to be done to overcome decades of resistance to meaningful reforms to support primary care? And do you see the patient-centered medical home as being part of the solution?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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