Wednesday, February 4, 2009

There They Go Again on the Medical Home

Kevin Grumbach has a Part 1 and Part 2 opinion post on the Health Affairs Blog site on what the Feds can do now to resuscitate primary care. He obviously knows of what he speaks and, when he speaks, the Disease Management Care Blog listens. It suspects Dr. G’s colleagues in the Obama Administration are also listening.

Part 1 is a short, well written if pro forma retread of all the multiple bad diagnoses afflicting this corner of the medical profession. It reminds the DMCB of many patient encounters in its past: sorry, Mrs. Ruhoh, it’s not just a heart blockage. We’ve found you have diabetes, an aneurysm, a spot on your lung and that pigmented thingy on your back don’t look too good either. Well, primary care doctors, Dr. Grumbach confirms your panels are packed tighter than EHR supporters on a stimulus bill, medical students are crossing the street when they see you coming, reimbursements are so low, even Medicaid is beginning to look good and what’s more, practice improvement investments are so out of reach, you’d have better luck getting a repeat MRI approved by private commercial carrier.

Part 2 is a short, well written, more interesting if thinly referenced discussion (but hey, it's a blog posting) of the Federal treatment options available to this troubled patient. Think Mrs. Ruhoh being placed on aspirin, beta blockers and a cholesterol drug, but also starting insulin, getting scheduled for regular ultrasound examinations as well as having additional lung imaging and being referred for a wide skin excision. In similar fashion, Dr. Grumbach review the merits of a multi-track treatment plan that includes not waiting for further evidence on the medical home and expediting its payment policy now in Medicare and the Federal Employee Health Benefit as well as making federal matching for Medicaid contingent on its coverage. In addition, primary care should either be shielded completely from the SGR formula or at least being held accountable for its minor role in the overall health care cost inflation rate. What’s more the Feds could kick off a county-based ‘Primary Care Cooperative Extension Service’ (that's an interesting thought), fixing the physician training pipeline and redirecting research funding toward whole-person community-based interventions.

The DMCB recommends the Obama Administration do what CBO did and also listen to what this article has to say. Based on the traditional evidence-based standards, a reasonable interpretation of the literature doesn’t necessarily support wholesale coverage of the medical home. Period. What’s more, there is little evidence that the medical home will increase primary care access, attract medical students or generate enough income to make it worthwhile for the average doc. The DMCB finds it ironic that its friends in academia are willing to suspend the usual rules when it comes to rigorously assessing the merits of the medical home, especially on a Health Affairs web site.

That being said, the DMCB is warm to the medical home and is looking forward to getting some data from the numerous pilots underway to help shape healthcare reform. Just like disease management, we need to better understand what works for the medical home and under what circumstances. Dr. Grumbach and the DCMB agree on what, not on how.

That’s why the DMCB offers this Obama Inaugural-style closing benediction for this post: we look forward to that day when disease management is in the Medicare benefit, when clunky EHRs don’t get very far, when primary care physician fees see release and when someone throws the medical home a bone.


Michael Halasy said...

What are your thoughts about changing the way primary care is delivered? I can see a day when primary clinics are almost exclusively staffed by PA's and NP's. Recent surveys have indicated that only 2% of current medical students are planning on entering primaray care. I think that we can decrease costs by having a clinic staffed by PA's and NP's, with 15-20 midlevels, and 2-5 circulating "consultants", or MD's that will not have a patient calendar, but rather will be available for help with reviewing unusual case presentations, or markedly complex patients with multiple comorbidities. Thereby ensuring some level of supervision, and ensuring that patients still recieve optimal care plans. Otherwise, the PA's and NP's will see all primary care patients.

Jaan Sidorov said...

It is very possible that primary care clinics will broaden out into a variety of care models and that one of them that include what you're describing. I also think it would be very competitive. There are regulations, however, that limit the physician to PA ratio and require a certain number of visits be face-to-face with physicians (at least here in Pennsylvania). As for saving money, maybe - physicians who leverage PAs in primary care seem to MAKE a lot of money. That being said, PAs cost a heluva lot less per FTE and there is evidence that they are also less likely to order costly tests/ancillaries. And one thing is for sure - there is just no way the medical schools will turn out enough PCPs for the foreseeable future. Your idea has a lot of merit.

Michael Halasy said...

True, I was thinking of our rules here in Minnesota, which allow us a much broader scope of practice, and require that a physician review charts periodically. One of the additional challenges of my proposal would be to establish a more national standard for PA and NP practice, and that will require various medical boards to seriously review some of their utilization standards. Also, it would require some give on the NP professions part to acquiese to a moderate amount of supervision, rather than to pursue completely independent care.