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.