Monday, May 25, 2009

Death From a Thousand Cuts Outside of the Patient Centered Medical Home

The Disease Management Care Blog continues to invite and receive submissions from readers. This is one from a family physician buddy who is concerned that the patient centered medical home (PCMH) will not necessarily fix all that ails primary care. The examples below are the dysfunctions of a thousand cuts, best described as deprofessionalizing, demoralizing time consuming annoyances that are outside the PCMH. While each one may make individual sense based on the limited point of view of the specialist/insurer/administrative sponsor, they are collectively bleeding this corner of the profession dry. While money is mentioned, keep in mind that the PCPs gave up getting rich a long time ago. Rather, to quote one sage, the cash is simply a method of keeping score. Decide for yourself who is losing.

With the economy swirling down the commode and primary care at the bottom of the proverbial medical hill, the physicians that actually see patients full time are finding that clinical practice is becoming ever more difficult. The patient centered medical home (PCMH) is in danger of being overrun by hassles before the foundation even gets poured.

Some examples:

According to a local gastroenterologist, Medicare is now requiring that a complete history and physical (H&P) is completed and documented before a screening colonoscopy with anesthesia will be scheduled. Since doing an H&P is apparently outside the skill set of busy 'scopologists' or 'gas passers', completed that task is defaulting to being the responsibility of the primary care doc. Reimbursement? $0.

A large rural integrated delivery system that is currently all the rage in DC requires multiple pages of medical records with the ‘appropriate’ documentation (that demonstrates the need) to be faxed before specialist referrals will be covered. Reimbursement? $0.

Patients seeing diabetes specialists result in a payment of $200- $300 to that physician for their visits. Yet, these patients are typically seeing non-physician providers such as nurse specialists. Knowing that they are not seeing a 'real' doctor, many of the patients have come to the conclusion that the family doctor is closer, cheaper and just as good. Reimbursement for that just-as-good service? It’s not $200-$300. It’s $50. What’s more, the diabetes specialists have done little to help me improve my clinic’s HEDIS measures, torpedoing my chance of getting some pay for performance (P4P).

Centralized scheduling in large physician-hospital systems are making urgent appointments to specialists complicated, cumbersome and all but impossible. In several instances, my patients were unable to wait and had to urgently seek out care in the local emergency room. Since emergency room use is another HEDIS measure, this in turn has led to withholds of P4P, leading to negative reimbursement.

I tried to schedule an magnetic resonance imaging (MRI) scan for a possible extension of an old CVA. Personnel in the MRI facility argued that their 'protocol' for a 'CVA' was MRI plus an magnetic resonance angiogram of the head plus an MRI of the neck. I had to argue to get less!!

If this primary care home has any chance of being habitable, some basics need to change. The drainage pattern of the offending septic 'systems' of care is hurting community-based practice. We’re running out of boots at the bottom of the hill.

Coda: For additional examples of how the system is becoming hopelessly complicated, cumbersome and unfriendly for primary care, check out how the Feds are offering training on how to avoid being threatened by accusations of overbilling, how appointment times may be subject to regulation, and how patient billing warrants attention from the Federal Trade Commission. Egads!

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