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No Direction Home: A Primary Care Physician Questions The Medical Home Model

March 24th, 2009

The train has left the station. Everyone is on board: health policy leaders both public, like the Institute of Medicine (IOM) and the National Committee for Quality Assurance (NCQA), and private, like the Institute for Healthcare Improvement (IHI) and the Commonwealth Fund; influential medical societies like the American College of Physicians and the American College of Family Physicians; and economists, like those at the Congressional Budget Office (CBO), who understand the money and rely on the medical societies for the medicine. Even Congress signed off on pilot projects in Medicare legislation. The solution to health care reform is the patient-centered medical home. We will pay physicians for quality instead of quantity. We will get better outcomes at lower cost like the Europeans but, of course, not the European way. Who am I to differ?

Maybe the medical home is the answer for America. It certainly works in some large, thoughtfully organized, vertically integrated delivery systems like Geisinger, on which it is modeled — one-stop shopping for every patient. But to me, this feels a little like 1993, when the country was clamoring for health care reform and everyone who was anyone concluded that the only solution was managed care/managed competition.

The medical home is intended to transform primary care in the U.S. As a primary care physician familiar with the 70% or so of the field still organized into small practices, I would like to suggest caution. The unintended consequences may overwhelm the desired improvements: the only physicians entering primary care in the future may be those who have no alternative.

We could become a nation of nurse practitioners, physician assistants, and medical subspecialists, with more fragmentation than ever and dire consequences for health care costs and quality.

Studies from abroad have long suggested that the key to efficient, effective health care is good primary care. But U.S. primary care today is in crisis. Patients with insurance can’t find a primary care doctor. At the same time, young doctors are fleeing the field in droves: only 2% of internal medicine residents this year chose primary care as a career. And we need solutions quickly: Peter Orszag, now director of the Office of Management and Budget (OMB), has demonstrated beyond the shadow of a doubt that U.S. health costs are currently climbing at an unsustainable rate.

The patient-centered medical home certainly sounds appealing: those of us of a certain age remember having a family doctor who lived nearby. His children went to school with us. He was always available in an emergency. Norman Rockwell famously put him on the cover of the Saturday Evening Post.

And today’s patients clearly want a personal physician, someone they trust, who knows and cares about them, understands their problems, and can guide them through the maze that is modern American health care. Indeed, a market has sprung up to serve such patients, called “boutique” or “concierge” medicine. However, these medical homes are expensive mansions, beyond the reach of all but a few.

As the September/October 2008 issue of Health Affairs demonstrates, the new patient-centered medical home is a fluid concept. In principle, however, it is completely contemporary, with electronic medical records (EMRs) at its core. Whether it is designed primarily for the chronically ill or for everyone, however, I wonder if it will work outside special settings like Geisinger. It is no accident that the medical home hasn’t generated much enthusiasm among the primary care physicians for whom it is designed. It will not stem the flow of physicians out of primary care because it does not address the real problems in present-day primary care.

The good news is, we do not have to move the mountain to Mohammed. The problems of primary care today are recognized by most practitioners, and they can be fixed. We need to pay physicians more to see very sick patients, whether their problems are acute or chronic. We need to pay them less to see healthy patients with minor problems. We need to pay less for procedures, imaging, and lab tests. We need to get important medical information to primary care physicians more quickly and efficiently. If we do these things, there will be many benefits: patients are more likely to get the attention and care they need and want; we may slow or even reverse health cost inflation; primary care physicians will get the respect they deserve, as well as a life; and young students will flood into the field.

The Patient-Centered Medical Home: Cost

The logic of the patient-centered medical home seems to be this. We need to pay primary care physicians more money. Internal medicine subspecialists who do procedures make more than twice as much for seeing fewer patients. However, if we are going to pay primary care physicians more, they should perform better. Thus, the medical home should solve two problems at once: it should attract physicians, and it should remedy the perceived deficiency in the quality of U.S. health care.

The requirements for the patient-centered medical home devised by the NCQA or the American College of Physicians are rigorous. First, of course, we must have electronic records. Someone from the practice needs to be available 24/7. We need to communicate with patients more often, by e-mail and telephone. We need to be held strictly accountable, which means reports, audits, certification, and recertification. Ideally, we should have ancillary staff for patient education and coaching.

All of these services are very expensive. In return, we are to receive $30-$50 per qualifying patient per month. However, this will barely cover the additional overhead, let alone attract someone who can make twice as much as a cardiologist, with a lot less hassle and a lot more respect. By comparison, patients who can afford it pay upward of $1,000 a year just for access to “concierge” practice — not including the actual fees for patient care. The access fees generate enough revenue for a physician to limit her practice to a few hundred patients, so she has time for everyone.  And she doesn’t have to pay academic physicians to supervise her.

Since no one has suggested fees at this level for the patient-centered medical home, a physician might try to make up the difference by seeing yet more patients an hour, which can only make primary care less attractive to doctors (and patients). Or she could charge the patients more. But those who are generally healthy and don’t need the expensive services of a medical home will depart. Yet those “easy” patients are the most profitable patients, in today’s practice or in a future medical home. You can see where this is going.

The patient-centered medical home may reduce costs elsewhere in the system, by reducing hospitalization and perhaps unspecified “duplication” of services. However, it fails to address the real driver of today’s health care costs: the steadily increasing volume of ever more expensive procedures, tests, and imaging. Unless, of course, the primary care physician takes the risk of substituting her expertise for the more targeted procedures and advanced training of a specialist — for example, deciding that a patient with an atypical presentation of chest pain really doesn’t need a cardiac catheterization. This is precisely what the original sponsors of managed care had in mind.

The Patient-Centered Medical Home: Quality

The builders of the patient-centered medical home believe that the way to improve quality in primary care is to construct an elaborate system of performance measures and hold providers strictly accountable for meeting them. Physicians will regularly report their metrics — how many diabetics received an annual retinal exam, how many elderly patients were vaccinated against pneumonia, how many women went for mammograms. If the numbers are good, physicians will receive whatever money there is. If not, perhaps money will be withheld, names will be published, or physicians will be shamed or required to remediate. Experts would prefer outcomes measures — normal blood pressure, normal sugar, fewer heart attacks — but some patients have bad outcomes despite the best care.

If pay-for-performance is the solution, then the quality problem must be due to primary care physicians who are lazy and ignorant, indifferent to the welfare of their patients and unaware that time and scientific progress have passed them by. Why else would they fail to give beta-blockers to patients who suffered heart attacks?

In fact, I believe that there are other explanations for these ostensible failures, including haphazard dissemination of continually changing recommendations; genuine disagreement about tests and treatments; and an outdated coding system that pays physicians more for treating individual acute, if minor, problems, than for following serious chronic conditions. The patient-centered medical home does not address any of these except the last, and that only in part.

Every physician wants to render the best care for her patients that she can. There is no reason to think that if a physician has ready access to the right information at the right time, and is given enough time and paid adequately for her efforts, she will do the wrong thing.

The attitude that physicians who practice clinical medicine must be supervised and held accountable by physicians who don’t is troubling to some who have spent many years acquiring the “specialized knowledge” and undergoing the “long and intensive academic training” that the dictionary says define a professional. After rigorous training, and in exchange for taking the heavy responsibility for patients’ health and sometimes lives, primary care physicians expect to be accorded autonomy in their judgments and wide latitude in the way they practice. To them, the patient-centered medical home looks more like a Skinner box: endless requirements imposed by distant “experts” in the name of quality and efficiency, more suited to the assembly line than to the practice of a profession. A true professional will welcome — indeed, seek out — real help. He should not need detailed guidance.

The Patient-Centered Medical Home: Accelerating The Disappearance Of Primary Care Physicians

Perhaps the patient-centered medical home will improve the quality of primary care in this country, assuming the experts have chosen important markers and keep them up to date. However no one seems to find this level of outside control necessary for specialists, making the choice of a specialty over primary care that much more compelling for residents. This feature of the patient-centered medical home, too, will hasten the flight of physicians from the field.

Not all reformers will be disappointed. I suspect that at least some of the designers of the patient-centered medical home feel that primary care physicians, practicing alone or in small groups, are anachronisms, as out of date as eighteenth-century cabinetmakers, and that the root of all our troubles is the fee-for-service system that sustains them. Some supporters of the medical home believe that the only way to deliver modern medicine efficiently and effectively to whole populations is to industrialize it. Economists understand industrialization. It also comports with an authoritarian streak that runs through much academic medicine (ask any chief resident), where many medical-home enthusiasts work. Visionaries have been trying to construct the modern medical factory, the vertically integrated delivery system, since the 1980s. It formed the basis of the 1993 Clinton plan for managed care/managed competition: large health care organizations competing for patients on the basis of price and quality.

Yet despite thirty years of campaigns and federal laws designed to promote these large organizations, they have failed to catch on with doctors and patients. Health maintenance organizations (HMOs) have not expanded far beyond their original markets. So for now, at least some reformers would like to pilot the industrial techniques in the patient-centered medical home, a miniature vertically integrated delivery system for primary care services. It is no accident that the medical home has worked best when closely associated with large integrated systems like Geisinger.

Reformers hope that the patient-centered medical home will quickly transition to the real goal, the “accountable health care organization,” paid by capitation and run by professional managers. At the bottom of these organizations will be the people who see patients. And the goal will be to see as many as efficiently — which is to say, as fast — as possible. Inside the organization, this is no longer wasteful volume; it is valuable “productivity.” In place of the twentieth-century conveyor belt, we will have EMRs linking the workers at the various stations, including the physicians. Each patient will appear with all the data, well-organized with appropriate prompts, that the physician or other provider needs for rapid diagnosis and treatment, so she can direct the patient quickly to the next station: pharmacy, physical therapy, whatever. At the end will be quality control; frequent reviews of how well the providers meet their performance, productivity, and customer satisfaction targets; and appropriate rewards and punishments. And at the top will be the “experts,” who are accountable to no one.

So young physicians will eschew primary care. The reformers are not concerned. They have discovered that much of what primary care doctors do today can be done as well by providers with far less training — counseling about diet and exercise, diagnosing and treating minor acute illnesses like colds and sore throats, even routine care of certain chronic conditions like diabetes. Managers will happily replace expensive physicians with more efficient nurse practitioners, physician assistants, nurses, and technicians. And that will work for most people, who are healthy most of the time.

But not for everyone. For those with severe illnesses, or even multiple chronic conditions, coordination of care does not mean just making the trains run on time, using EMRs to ensure proper treatments and routine preventive measures. It means looking at conflicting and ambiguous data and advice from multiple specialists and other sources and deciding what it means — what to do. It means treating one problem without making others worse, if possible. It means addressing unexpected complications and unusual presentations. For this, one needs the specialized knowledge and intensive academic training of a primary care physician.

For these complex patients, poorly served by the present system, the disappearance of the primary care physician is a disaster. The accountable health care organization may be an adequate substitute — or not. We have very little experience with it, especially on the massive scale that is planned. John Wennberg and his Dartmouth colleagues have demonstrated that some large highly respected systems with EMRs, like Mayo Clinic, achieve excellent results at low cost. Others, equally prestigious, do not. It is worth noting that the Europeans have achieved better outcomes, at lower cost, with more-traditional health care systems. Perhaps we should look to them, as well as to physicians in practice, and to patients for alternative solutions to our quality and cost problems.

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10 Responses to “No Direction Home: A Primary Care Physician Questions The Medical Home Model”

  1. ramon_jesus Says:

    Healthreform will be greatly assisted by the medical home model concept. But it is not going to be successful in most places for the reasons described by the commentator. (The Name “Medical Home” for a coordinated care model that uses the Practice as a center of activity and service, is simply awful but that is not why it won’t work.)

    The requirement of investment in Time by a small practice and the necessity to rely on investment of limited resources, only permits the larger mainly institutional connected practices to get this done. In the end, its just not reasonable to assume that Doctors for example, in the Bronx where I work to gain improvements in their services for patients, they just cannot get that time and that amount of money together. Doctors whose practices rely on payments by managed care companies, a few fee for service payments by commercial insurance patients, self-pay uninsured patients to step up by themselves, will just not be able to put it all together. Then when its done they get $35 more a month. No way.

    But its worth trying, I expect the various academic and tertiary care centers with deep pockets in New York City will have the money(we don’t listen to their cries of poverty) to adopt the medical home model.

    The small practices won’t benefit directly but there will be a “trickle down” of the type of community driven collective process of coordinated care that the model is prompting.

    I recommend another payment scenario besides original Medicare Fee for Service with a monthly capitation for “eligible” Medicare chronically ill, the method contemplated in the report submitted to CMS for introduction as the Medical Home Test. Instead include as another way to study, a fully capitated program directly paid to doctor practices within a IPA setting in communities in which high proportions of dual eligible patients live. In that way, coordination can be introduced by the doctors without the burden of bringing in larger institutions who carry with them enormous fixed costs.

    Pre-payment methodologies have been usurped by the private health insurance process. Why not bring back the Provider Sponsored Organization (“PSO”)? In the 90’s primary care doctors and their partnered specialty and institutional organizations were supposed to be an alternative to original Medicare and other government fee for service models in order to compete with managed care organizations. That was never to be, a failure I believe because the government did not understand the concept fully and they permitted all the competitors whose preference was to continue the “vendorization” of a medical practice, to make a PSO harder to create than the perfect mousetrap.

    Permit again, under the rubric of the Medical home regulation, the capacity for primary care practices and their IPA’s to use a PSO model of payment. Pre-payment by way of the Medicare Advantage that stands to be newly designed by this healthcare reform approach, to have a real PSO model so that then Doctor’s will have a way to be independent and competitive. At the same time they will have the requisite whole premium payment to hire the necessasry community resources to bring their practices to the Village and to the homes of their patients.

    The Medical Home, the improvement of primary care as the central concept of this Model is a critical priority for all of us who want to improve the delivery of care and to reduce its cost, in all the Villages within Cities, suburb and rural settings, Healthcare and its’ Kin “Wellbeing” is not easily developed with “per click” or fee for service payments. The social, religious, loving requirements of the “typical” needs of the chronically ill patient requires more than a Doctor’s Office or a Medical Home can give.

  2. Caroline Poplin Says:

    All the commenters make good points. As to Dr. Barr and Mr. Doherty’s concerns, I do have answers for all of them, but for now, let me make four quick observations.

    First, the proponents of the medical home have not demonstrated that the small extra fees planned with cover the additional work and resources required, let alone suffice to allow a primary care physician to reduce her patient panel to a manageable size. Physicians do not see 20-40 patients a day to get rich: they do it to stay in business, because the amount they receive per visit is so small. To see how much is necessary to sustain a medical home, analysts might look at the successful medical homes of today, designed by practicing physicians and embraced by those patients who can afford them: “concierge” practices.

    Second, the PCMH begs an important question: if annual foot checks are standard of care, why aren’t primary care physicians doing them now? The answer is critical: if we don’t make the right diagnosis, the treatment won’t work.

    Failure to meet the standard of care is malpractice, if it results in damage. We in primary care worry about malpractice. Moreover, we are not production workers; we provide the best care we can for our patients. We take our responsibility for the lives of others seriously.

    Advocates of the medical home seem to assume that, on the contrary, we either don’t know minimum medical standards, or we don’t care. Thus, we need explicit incentives designed by others who presumably know (or care) more than we do, and who must carefully evaluate our efforts or outcomes in order for us to be paid in full.

    Others blame primary care failings on fee-for-service, which is somehow leading us to provide a “volume” of (presumably unimportant) services instead of “quality” services. So the medical home instead relies on capitation, or pay-for-performance.

    I think there are better explanations. Yes, fee-for-service is part of the problem, but that is because the current fee structure was designed for the medicine of yesteryear, when most problems were acute, and diagnosis and treatment were based almost entirely on history and physical. There is nothing wrong with fee-for-service that can’t be fixed by adjusting the fees to reflect modern medicine: more for cognitive services, less for procedures; a higher fee for a visit that addresses three chronic problems than for one for a minor acute condition, say, a sore throat, even though the sore throat generates a good history and physical. Or, consider paying 50% more for the first post-discharge visit. See my op-ed in the Baltimore Sun March 12, 2009. In 1992, CMS adopted the RBRVS system in its first attempt to correct the imbalance between cognitive and procedural services: it can do more.

    Also, the amount of information modern internists must know is staggering, it changes at breakneck speed, and appears at various intervals in dozens of journals. Keeping up is like drinking from a fire hose. This year, we learn that proton pump inhibitors impair anti-coagulation with clopidogrel after cardiac artery stent placement: last year we would have been dinged for failing to prescribe a PPI with clopidogrel. Those of us on the front lines would be much better served by academics who organized and disseminated important information in readily accessible, inexpensive form, instead of telling us how to practice. Persuade us, and our patients: don’t try to manipulate us by withholding payments or withdrawing certification.

    Third, as to small practices. The ACP may have tried to preserve them (one wonders how practical the ACP model is, see Thomas Barber’s comment below about economies of scale), but many other PCMH advocates believe they are quaint anachronisms, unsuited to modern medicine. See, for example, the Health Affairs web exclusives of January 27, 2009, or “The Health Care Delivery System: A Blueprint for Reform,” a 2008 report by the Center for American Progress.

    Finally, I have a question for the ACP. I have been a loyal member since I passed my Boards, and a Fellow for a good part of that. Why didn’t the ACP canvass its membership, general internists in particular, before adopting such an important, controversial proposal? I attend chapter scientific meetings every year, and the annual meeting when convenient, but the PCMH was presented to us as a done deal. Yet I believe modern management theory holds that many of the best ideas for process improvement come from the factory floor.

    As I said in my post, I think the train has left the station, and, for better or worse, we are about to witness a major attempt to transform American primary care into subdivisions of medical homes surrounding large “accountable health care organizations”. Even though the opposition is muted, however, I doubt this conversion will be without unintended, unfortunate consequences. As we move to more efficient, industrialized medicine, the already frayed connection between doctor and patient, critical for the chronically ill, may weaken further. Young physicians with alternatives will continue to avoid primary care, choosing instead subspecialties where they can make up to four times more money, get a life, and, maybe more important, preserve their autonomy and the respect of their peers.

  3. acavale Says:

    Dr. Poplin’s comments have finally brought to the fore what physicians in solo and small practices have been concerned about for a while. It is also gratifying to note Drs. Barr and Dougherty making a concerted effort to include such physician concerns in their proposed PCMH concept.

    During my conversations with many PCPs regarding the PCMH issue (since I have provided my solo practice as a test case to the ACP) I am frequently asked “we have been doing this all along; so why do we need to certify as a medical home now?” The other question I get asked is “if we don’t certify under this banner, will we be considered as rendering substandard care?” In spite of my overall support for the PCMH idea, I cannot come up with a satisfactory answer to such questions.

    My greatest fear is that PCMH might become part of the tsunami that will eventually blow away small practices from the landscape of community medical practice. I certainly hope that PCMH will actually be the positive change we need in the practice of medicine.

  4. MSBarr Says:

    While Dr. Poplin has diagnosed many of the problems with the U.S. health care system correctly, her commentary reflects a misunderstanding of the patient-centered medical home (PCMH) model, the supporters of the PCMH, and the motivation behind the advocacy efforts by a growing number of stakeholders.

    The PCMH model is not being promoted as the cure to all that ails American health care. It is one of many promising ideas for re-building the primary care infrastructure. The four organizations that developed the Joint Principles of the Patient-Centered Medical Home in 2007 (ACP, AAFP, AOA, AAP) did so to facilitate a dialogue with employers, insurers, consumers, industry leaders, and health services researchers that has led to the formation of the Patient-Centered Primary Care Collaborative ( where many of the issues identified by Dr. Poplin are being discussed and solutions being considered.

    The PCMH is a model that we are suggesting be tested across the country in different settings and under payment models that offset the perverse incentives of episodic, fragmented, fee-for-service payments. Many of these demonstration projects are being evaluated by leading health services researchers with metrics that are based on nationally recognized quality indicators and patient experience metrics while assessing the changes in costs associated with an organized, systematic, financially supported demonstration project.

    Dr. Poplin is correct that consumers have indicated a desire for a trusted, personal physician who helps them navigate the complex health care environment. This is precisely the foundation upon which the PCMH is built. Dr. Poplin is also correct that the investment in building such a practice is beyond the reach of most small and medium-sized practices without additional financial support Those of us advocating for demonstration projects of the PCMH understand this very well, which is why we have advocated for a payment structure for PCMHs that would cover the costs of becoming a PCMH and lead to overall improvement in payments for primary care physicians in the PCMH.

    We have proposed a payment structure to pay physicians a monthly risk-adjusted care coordination fee per enrolled patient, plus fee for service payments for office visits, plus a performance based component for reporting on quality metrics. This model would pay physicians in a PCMH more for taking care of patients with more complex illnesses, recognize the value of physician work that falls outside of the face to face encounter with a patient, provide funding for the costs to practices of acquiring information systems to support care coordination, and relieve the stress on primary care physicians of having to generate an office visit in order to get paid, since the payment model recognizes the value of work outside of a visit ,while allowing them continue to be paid a separate fee when the patient should be seen in the office. It also is designed to prevent the problem of traditional capitation models, which discouraged physicians from taking on more complex patients or ever seeing them in the office.

    Dr. Poplin seems to believe that the PCMH is “completely contemporary with electronic medical records at its core.” This is inaccurate. While EHRs are certainly a tool that can facilitate building of a medical home, it is just a tool and not a requirement to become a PCMH. There are three levels in the NCQA PPC-PCMH recognition tool – the first of which does not require an electronic health record (EHR). That is by design. Some practices can attain the second level without an EHR – though it becomes a bit more difficult to implement the practice changes associated with population management, care coordination and quality reporting without an EHR. Interestingly, early data from demonstration projects, according to NCQA, demonstrates a bi-modal distribution of practices with the majority being in either Level 1 or Level 3 – the differentiating factor being the presence of an EHR.

    Dr. Poplin’s concerns about “reports, audits, certification and recertification” are understandable but overstated. Many of the demonstration projects do require reports on clinical indicators – but these are no different than those that already exist in many performance-based compensation programs and are often (until EHRs become ready for the task) based on claims data which are generated as a matter of normal workflow. When there are quality reports that are not based on claims, demonstration projects try to keep the level of administrative burden on the practices to a minimum. Recognition under the current version of the NCQA lasts for three years and NCQA only audits approximately 5 percent of those practices who apply for recognition.

    We have not given up on small and medium-sized practices in favor of large integrated delivery systems, as Dr. Poplin suggests. The vast majority of ambulatory visits across the United States are delivered by small practices. The PCMH model and NCQA recognition process were purposefully designed for even the smallest of practices to start on a pathway to building a medical home with the financial support to do so. We agree with Dr. Poplin that physicians try to render the best care that they can. The conditions Dr. Poplin cites (e.g., access to the right information at the right time and appropriate reimbursement) often do not exist – nor do the time and space within a busy primary care practice to manage complex patients—and it is precisely these problems that the PCMH is trying to address with the reimbursement for the time and effort needed to accomplish these ends.

    Dr. Poplin seems to believe that the PCMH model was developed by “distant experts” interested in imposing new requirements, leading to the industrialization of health care. Nothing could be further from the truth. This effort is being led by physicians who understand the professional and moral obligation not to accept the mediocre quality and high variability in health care that our “system” delivers to those we aim to help. This effort is being led by physicians who understand that medicine is both an art and science – and we must offer ideas in order to protect, preserve and revitalize our specialty for the benefit of our patients and their families.

    Finally, no one has suggested that the PCMH, by itself, will solve all of the problems facing primary care. ACP has called for a multi-faceted, comprehensive approach that includes increased fee-for-service compensation to make primary care competitive with other specialties, debt-free medical education in exchange for a reasonable primary care service obligation, reductions in the administrative hassles imposed on primary care clinicians, and yes, the PCMH.

    To use Dr. Poplin’s metaphor, we’re currently on a train already destined for the situation that Dr. Poplin fears most – the disappearance of primary care, erosion of physician autonomy, control imposed from a distance, and escalating costs that continue to sink the U.S. economy. The choice before us is whether we accept this destination as inevitable or build a switch on the track that leads us to a new, perhaps better place that includes the PCMH as part of the solution.

    Michael S. Barr, MD, MBA, FACP
    Vice President
    Practice Advocacy and Improvement
    American College of Physicians

    Robert B. Doherty
    Senior Vice President
    Governmental Affairs and Public Policy
    American College of Physicians

  5. fredericjones Says:

    What about Retired Physicians and other health care Professional?

    All of the suggestions to improve primary care are medium to long term and perhaps successful strategies.
    A more immediate solution is to utilize the large numbers of “retired” physicians and other health care professionals.
    Many stand currently competent and willing to provide excellent medical care to our underserved populations. Moreover, many have actually chosen to retire into the areas of physician shortage. Nonetheless many barriers are placed in their utilization, not the least of which are state medical boards reluctant to grant any type of license. This barrier seems to apply to any practitioner, trained in another state, who has expressed a willingness to care for the underserved patients of their new state of residence.
    Fortunately, a number have overcome medical obstructionists and in the settings of free clinics provide top notch care. These experienced clinicians are quite prudent and efficient in their ordering and practice patterns further preserving expensive resources.
    These doctors, nurses, dentists and other healthcare professionals could be mobilized into a structured organization that could add dramatically and immediately to meet the health care needs of the uninsured and others in our population without ready access.
    These professionals could be recruited into existing practices, community health centers, and free clinics or into the rapidly increasing numbers of retail Clinics. Presently, many of these activities are funded by faith based and charitable donations and the “sweat equity’ of thousands of participating “retired” Health Care Professionals.’
    Some of the greatest impact could be for the management of patients with chronic medical conditions. The future benefits of such care have a predicable benefit for the health and costs. These and other chronic medical conditions are managed quite well in the free clinic settings with very selective specialty referral.
    In other words, provide care now or pay many $ in the future for the neglect.
    For that population, evidence-based protocols are available that could assure best practices.

    I am in my 25th year of serving the indigent in a free clinic setting. Along with a superb nurse practitioner (certified diabetes educator), 3 retired RNs, and a pharmacist, we strive to provide evidence-based medical care.
    In my instance, this is in a metabolic clinic, serving adults with diabetes, and its associated conditions-hypertension, obesity and dyslipidemia.
    According to the latest guidelines, we attempt to optimize blood sugar and A1C.
    However, lifestyle management is particularly difficult in this patient population, with limited economic options.
    None-the-less, we strive to control the other risk factors and are quite successful in controlling BP and Lipids and tobacco usage.
    Newer studies suggest that this approach may improve outcomes as well as intensive treatment to optimize blood sugars.
    Moreover, it can often be attained in patients with 3 generic medications, costing $ 12 per patient per month, plus low dose aspirin.
    In some insulin is added to Metformin for a modest additional cost… There are excellent algorithms for insulin management permitting the clinician to provide comprehensive care in a single setting.
    Many of us are committed to the concept of prevention of disease and I believe our participation would be well served by this approach.
    We have a community pharmacy that can provide some of these medications, and then some can turn to Wal-Mart, Walgreens, and others.
    In this era of incentivizing participants, many of the retired health care professionals would welcome a tax credit based on volunteer hours provided. Furthermore, this would encourage them to comply with the various obstacles often placed by state licensing boards that seem oblivious to the benefits being denied to their state residents by experienced professional residing in their states.
    In my experience, the state medical boards form the greatest obstacle to the utilization of this vast resource by not facilitating the granting of volunteer licenses. These could be limited in scope until competency was established.
    The South Carolina Model overcame this issue for medical, licensure with legislation.
    Why do we continue to waste this opportunity and enormous resource for our nation’s patients in need???
    I am an AMA and ACC member, retired from active cardiology practice in the fee-for-service arena.
    However, I continue to care about the heath care of our nation’s population!

    Frederic G Jones ,Sr. MD, FACP, FACC
    Consultative Cardiology (retired)
    140 The Pinnacle
    Sapphire NC 28774

  6. Jeff Goldsmith Says:

    This is a great posting, and it echoes some of Bob Berenson’s concerns in his earlier piece on this subject. An overly complex and expensive technological “hurdle” for this idea effectively ghettoizes most practicing primary care docs, and basically hands the market to the large integrated group practices and the hospitals, who are absorbing a hefty fraction of new primary care trainees. I suspect that small companies will spring up to equip solo primary care docs with the IT and care management infrastructure to qualify as medical homes, but they will take their cut of what should rightly go to the docs. The medical home should not become a precondition for raising primary care physician comp. We don’t need to go as far as the Brits did, but we need to at least double what a Medicare-dependent primary care doc earns, or there won’t be anywhere near enough primary care physicians to care for us boomers when we enter the program.

  7. Michael Halasy Says:

    I must admit, I enjoyed your comments. However, I must take offense to your implication that primary care delivered by PA’s and/or NP’s is somehow substandard or lacking in quality. That is simply not true, and every study done looking at outcomes with common primary care managed illnesses has shown similar results when comparing MD/DO to PA/NP care. Now, as a PA, I cannot manage every single illness that presents. Which is why my model of primary care relies on some physician collaboration to assist with the more complex patient population. However, to suggest that somehow we cannot provide effective primary care to all patients for about 90% of their needs, is blatantly false. Even patients with multiple conditions can adequately be managed in the primary care setting. I practice Emergency Medicine, and I would say that I can safely see about 85-90% of what presents to an ED independently. In fact, at one of the ED’s I moonlight at. There is no physician even present, the ER is solely staffed by and run by PA’s and/or NP’s. So I am sorry, but you are wrong in this regard.
    Otherwise, your points regarding smaller, more isolated practices is spot on. We do have to make a concerted effort to practice with more of a focus on evidence based treatments. To do otherwise, is a disservice to our patients.

  8. David Harlow Says:

    Thanks for your perspective on the medical home “panacea.” I posted my thoughts on the subject a few months back — “The Medical Home: Primary care panacea or the next doughnut hole?” at HealthBlawg. Check it out at:

  9. bcullinan Says:

    I respect your note of caution, and I think all us us who are trying to fashion the “medical home” need to recognize the pitfalls of relying too much on technology and buying into a certification system that’s all about primary-care structure and not about how we function to care for people.

    On the other hand, the current fee-for-service system is killing primary care; 10 of 10 of my current system’s family medicine residents are from overseas, and nearly all of the 25 IM grads are doing either hospitalist work or specializing. What I’m saying is that we are losing or have lost this battle, and we’ve done so on the altar of the fee-for-service model of reimbursement.

    Payment reform has to be a part of this medical-home movement, and we (primary-care) docs might need to be a little less afraid of capitation and other forms of prepaid medical care. If indeed primary care is the best care for costs, quality, and patients, then we should embrace it in its current conception. This is our last best hope.

    Brendon Cullinan
    Hennepin County Medical Center, Minneapolis, MN

  10. Thomas Barber Says:

    You have eloquently described the problems of the medical home. I will add a couple of more problems. The large systems you refer to like Geisinger and Kaiser Permanente have huge advantages of scale. To provide adequate chronic disease management with RNs, PA’s and other providers you need to have a sufficient size to make the process work efficiently. Small private practices won’t have the necessary resources even with higher payments because they won’t be able to afford it.

    It has been stated that if a primary care physician were to do all of the evidence based guidelines on their panel of patients that is supported in the literature it would take them 140 hours per week of work. The EMRs simply help identify the patients that need an intervention such as a mammogram or diabetic eye exam. They don’t yet automate the process of ordering what is necessary based on evidence based criteria. That will come with time – and government research and funding in this area will speed up its development. The medical home model will only work to the extent that these efficiencies can be realized through further IT development.

    The infrastructure for the medical home is lacking in most of America, and pouring money into this plan will wasted at this point in time. We need to improve the life of the primary care doctor by automating routine quality tasks, and by providing larger scale chronic disease management either by insurers , local government entities, or integrated medical groups.

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