Wednesday, November 19, 2008

If They Build a Medical Home, Will the Docs Come?

Among its many admittedly good qualities, the patient centered medical home (PCMH) has been lauded as the means to resuscitate, re-engineer or revive primary care. The Disease Management Blog asks: assuming the PMCH has plenty of merit by itself, what does it have to do with rescuing primary care?

Simple question, but the answer is more complex. Most reasonable observers agree that primary care is hard work and undervalued. The demoralized physicians leaving primary care are not being replaced in sufficient numbers by medical school graduates, leading to shortages in many areas of the country. While the causes for this are myriad, supporters of the PCMH suggest it can reverse medical student disinterest and help the current cohort of primary care physicians to hang in there.

Will it? In this day of slavish devotion to evidence-based health care, just where is the evidence for this contention? There are no surveys of what rank and file community-based primary care physicians actually think about the medical home. We don't know how well it will address the physicians' lifestyle concerns or their income expectations.

There are plenty of studies on what they believe ails their profession. For example, this study indicates physicians are unhappy about the loss of clinical autonomy, the number of hours they work and their inability to obtain services for their patients. Being responsible for any gatekeeping services is also a dissatisfier, as well as being under pressure to see a minimum number of patients per day. For younger physicians, income is a more distant consideration, compared to personal satisfaction and fulfillment outside of work.

And just what is it about the medical home that will fix these problems? Just because there is a medical home doesn’t mean high cost radiology services will not continue to come under preauthorization, that drug formularies will not put continue to put certain medications out of reach, that restrictive physician networks won't be used or that managed care organizations won’t continue to bluntly prod physicians to achieve HEDIS benchmarks. Keeping patients away from the emergency room or the hospital requires a zealous amount of hustle that goes well beyond the 8-5 business day.

And, as the DMCB understands it, much of the supplemental payment for the extra services of a medical home are calculated to cover the expense of those extra services such as health information technology, staff that manage care management services and the additional physician time necessary to oversee the primary care site team. It's only after these costs are met that physicians are expected to be rewarded. We don't know what their price point is.

The DMCB suspects the support of the rank and file physicians for the medical home is being overestimated. True, there are reports that the PCPCC and TransforMED pilots underway have been enthusiastically received, but this represents a small fraction of the docs out there who may not be representative of the usual mainstream doc. The point is we don’t know how they will react and, without more data, we cannot be sure that if we build the support for the medical home that they will come.

We also need to vigorously look for other solutions to what ails primary care outside of the unproven assumptions surrounding the PCMH.


tangsoodoc said...

Since you asked.....

I am rural family practitioner located 25 miles from the nearest hospital. I am also a part time medical director for a medium size insurance company. My clinical practice recieves data from at least 5 disparate health systems, various and sundry labs, consultants, homehealth agencies and ancillary providers.

I keep wondering if all of the contemplation over p4p, disease management and medical home is like designing a better cruise control and GPS before the advent of satellites and an interstate highway system.

For someone like myself, until there is a unified scaleable searchable national medical record with a central depository that can be accessed by all players (practice,hospital,ancillary,payer,patient,pbm,etc), there can be no meaningful data mining to quantitate and enhance the betterment of health outcomes in this country.

I would comment further, but I am out of space.

Jaan Sidorov said...

I think I'm a taekwondoc, which makes me even more inclined to agree with your comments I think the inertia characterizing e-record adoption is one additional reason why the medical home (which includes an EHR) is being pushed.

Docs haven't rushed to the EHR for many reasons, which may portend their reaction to the medical home, even if President Obama mentions THAT in a future State of the Union Address.

Maybe the fix is to jettison the market and get the government to launch the satellites....

Guest posts welcome. The space is rent free.

Chariot - Kunye

tangsoodoc said...

If Obama mentions it he may be more Eisenhower than FDR (interstate). I am more Jeffersonian, but fellow Jeffersonian Milton Freedman agrees (Captialism and Freedom) that government should build infrastructure that private capitalists can or will not. They did a good job with the creation of the internet through DARPA. Now that the current EMRs use this highway, they should regulate the traffic much the way they do with trucking and let the data fly!

rtsmd said...

What we have is fundamentally a pricing problem in primary care. If you look at the Medicare conversion factor in 1998 (the first year of the unified conversion factor) it was 36.6873. @009 will be 36.066. So, in 12 years we are down in absolute terms. When adjusted for inflation in practice costs and spending power of residual, a conservative estimate is that the buying power of this cut in time is about 50%.

The PCMH promises substantial monthly payments in the Medicare model. At a range of $27 to $100 monthly for the management fees, this has the chance to revolutionize the financial productivity of primary care (see

With a typical Medicare panel of 300 patients for a Family Practicioner (more for Internists), the range of annual revenue INCREASE is $133,000 at $37pppm or $360,000 at $100pppm. At the higher end of the spectrum you are looking at nearly double the revenue.

This amount of money on the table can dramatically alter the attractiveness of primary care.