Thursday, April 22, 2010

Specialist Physicians and Patient Centered Medical Homes: Here's How To Make It Work

Should specialist physicians be allowed to hop on the Patient Centered Medical Home gravy train? That's the topic of an interesting New England Journal article by Larry Casalino (Cornell), Diane Rittenhouse (UCSF), Robin Gilles (Berkley) and Stephen Shortell (Berkley).

Several organized specialist physician groups as well as the AMA have supported the notion of specialist (for example, urologist) medical homes. Dr. Casalino et al explored this with a telephone survey of randomly selected cardiology, endocrinology and pulmonary specialty practices. Unsurprisingly, 81% of the respondents described themselves as providing primary care services for 10% or less of their patients. Endocrinologists averaged higher, with about 10% providing primary care to up to 50% of their patients.

In response, Dr. Casalino and colleagues posed four open ended questions for health care policymakers:

1. Is it called 'primary care' if specialist physicians refer patients to other physicians for primary care services?

2. Are some specialty physicians, compared to others, better able to provide 'primary care?'

3. Is the extensive practice transformation necessary to become a PCMH possible or even worthwhile for specialty physicians when primary care only occupies a fraction of their practice?

4. Assuming specialty physicians are an important societal resource, should we be even encouraging the notion of them providing primary care?

While the few policymakers that actually read the Journal may ponder those questions, regular readers of the DMCB can go one step further and note:

1) how little mention the self and commercial insured markets get in this article. If there is a business case or consumer demand for cardiology, pulmonary, endocrinology or even urology patient centered medical homes, the purpose of policy makers should be to figure out how to get themselves and government out of the way.

2) that the answer to specialist-run medical homes may be sorted out in the coming Accountable Care Organization programs that were part of the health reform PPAC Act. In fact, the DMCB suspects, depending on how the regulations are sorted out, that the infrastructure of well managed ACOs will provide virtual and transorganizational PCMH services, blurring the distinction between physician 'owned' versus "rented" elements that make up a medical home.....

...which brings up a third wrinkle and possibly some answers to the questions poised by Casalino et al. Inside or outside of ACO's, the DMCB thinks - depending on market forces and the degree of Federal meddling - that the smarter commercial disease management organizations (DMOs) are already positioning themselves to provide many of the services that would fulfill the spirit and the letter of medical homes, including those run by specialists. DMOs can prompt patients to meet their primary care needs with shared decision making, level the playing fields between different types of specialists, reduce the need for a wholesale practice transformation and enable specialists to still function as specialists for an appropriate percentage of their practices.

(There's lots more on Accountable Care Organizations here)

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