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?


Jay Larson MD said...

The "patient-centered medical home" is just another name for what general internists have been doing for decades.

Failure of the healthcare system over time will be the ulimate reason for healthcare reform. Hopefully there is enough healthcare system failure now to get reform moving.

The Failing Heart
by Jay Larson

The heart of the healthcare system is primary care. The core of primary care is the relationship between a patient and a doctor trying to come up with a treatment plan that works for the patient. Even though double blind placebo controlled studies help guide doctor decisions, the reality is that doctors can not control any variables. We take it as it comes through the door. No patient would appreciate being excluded from a practice because they did not meet the criteria for “evidence based medicine”. We do experiments every day, but N=1. We do not measure statistically significant differences. We ask the patient “How are you doing?”

In 1990, the heart in Helena, Montana, was near the peak of efficiency. That’s when I started practice. No prior authorizations, no managed care, and no PPO’s. When a medication was prescribed, it went to a local pharmacy where it was filled without question. Insurance companies dared not to question physician decision making. We treated patients, not lab values. Paternalism was bad.

Around the mid to late 1990’s the practice environment started to change. Insurance companies, including Medicare, began “freezing” reimbursement rates. Drug formularies started to form and medical decision making began to hit insurance designed barriers. Insurance companies started to shift administrative work to the physician offices. At what point did it become the physician’s responsibility to save money for an insurance company? Was this a part of the Hippocratic Oath that I missed during medical school graduation? Physician decisions, based on their experience and personally assessing the patient, were being challenged. More office staff was hired to fill out all the insurance company forms. Overhead shot up and primary care physicians tried various ways to survive. Many formed groups or joined hospitals, only to find that their autonomy was further compromised and inefficiency escalated. Some increased their pace to see more patients. Sure this worked for a short while, but these compensatory actions were not sustainable. The heart was heading into failure.

As work load increased, more heart function was lost. To add further insult, the coronary arteries became clogged, which limited nourishment to the heart. No angioplasty or bypass can fix the problem. The heart is just going to have to make due. The rest of the body does not really understand that there is a problem. It continues to move resources to other parts of the body and crank out adrenal and other stress hormones that only further poison the failing heart.

Some think that electronic medical records, like a fancy sequential pacemaker will fix the problem. Some think that the only solution is a heart transplant with protocols and less trained providers. One would hope that the system would start taking some beta blockers to slow the rapid pace, ACE-inhibitors to reduce the work load, and some nitrates to improve nourishment. But considering the typical adherence rate to taking medication and leading a healthy lifestyle, the heart is doomed to fail.

Even though counseling patients to modify lifestyle is under 5% effective, we try anyway.

“Healthcare system, you have heart failure. If you do not reduce the work demand, slow the pace, and improve nourishment, the heart of healthcare will fail completely. It will be much more expensive to do a heart transplant. Anti-rejection medications will be needed for the system to accept a heart transplant. You can do what ever you want, the choice is yours, just realize that there are adverse consequences to your current behavior. Keep cutting resources and increasing the work demand and the heart will completely fail that much sooner.”

JunkMD said...

One of your parting comments in your blog was regarding graduating "debt-free" if one chooses to enter primary care. One thing that is happening, which many do not realize, is that many students and residents sign these contracts to go to rural areas to practice primary care now. The problem with these contracts is that they are all subject to taxation and each year, the physician will receive a 1099 for the amount of debt that was "forgiven" for that year. Thus, it is truly not free. It is actually still a significant amount of money owed. The problem now, is it is immediately due when you pay your taxes and not over time like a true student loan.

If someone chooses to enter primary care and gets debt forgiveness, this should be truly tax-free, making it worthwhile. Otherwise, it is not worth it.