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.Email This Post Print This Post
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