Wednesday, December 10, 2008

Home Improvement

So I've got some angst about the whole Patient Centered Medical Home agenda. The American Academy of Family Physicians explains it thus: "A patient-centered medical home is an approach to providing comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system." Key features include: ongoing relationship with a personal physician, comprehensive care, whole person orientation, coordination of care across all elements of the community and healthcare system, quality, safety, evidence based medicine, enhanced access, and physician accountablity. More details on the AAFP website's QandA. I have no problem with these ideals.
This program has support from the AMA as well as the American Academy of Pediatrics and several other groups, with the idea being if we come up with a good system, we can use this as a means to convince Them (the people who pay us) that we deserve to be paid for our work.
These groups, supporting the PCMH, and an organization called TransforMed, have come up with a "strategic transformation process combined with an integrated suite of practice transformation products and services— all derived from our experiences facilitating the NDP and designed to create a framework, a common language and an opportunity for practices to become Patient-Centered Medical Homes". Here is where I start to get a little twitchy. I get it, we have to have a common set of rules and guidelines, we have to be accountable to standards. But I am viscerally opposed to anything that makes our system of payment, reimbursement, and delivery of care ANY MORE COMPLICATED THAN IT ALREADY IS!
Then, people talk about one of the reimbursement improvements would be a set payment per patient. In December 1 AMA news article about the medical home it notes that in a North Carolina program a doctor receives $2.50 per Medicaid enrollee per month to manage their care. That is ludicrous. (Even assuming that medicaid pays per visit as well). Here's the deal, it takes time and resources to provide good medical care. Good systems can help that be more thorough and efficient, but over systemizing it and not giving the support needed to spend the time and resources only makes greater expectations and more frazzled, stressed out, and overburdened docs.
Now, I realize that part of my gut reaction is my inherent resistance to change of any kind, especially right now while my practice is in the midst of this transition. But I really really have a bad feeling about this. We've tried the "doctor manages and coordiates the care for a monthly fee per enrollee", we called it capitation and it was very appealing. But it feels to me like it promotes a system that encourages doctors to have lots of people on their panels and hope that they do not schedule appointments (free money). I sat at a hosptial staff meeting once where a good portion of the time was spent discussing what to do when HMOs remove people from your capitation list and stop paying you the monthly fee for these people, how to compare to prior lists to see who was removed. I asked if they could just check the lists as the patients schedule to see if the patient is on the list, and they explained that the people that were being "removed" were people they had never ever seen or even heard from, they were their assigned group. This is what we waste our time on, and I fear the new and improved system will promote the same attempts to "beat the system" in order to make enough money to stay afloat.
"But," I say to myself, "the new system will have requirements in place to make sure docs have the correct protocols". Well, I respond to myself, there's guidelines now for proper care and lots of docs for lots of reasons don't follow them.
So how to make it more fair then? We could just pay the docs that really and truly do the good job-pay for performance. One more thing to document and list and submit on my list of things to do. And if some docs are willing to upcode, downcode, and double bill now and risk the nightmare of a medicare audit, why wouldn't they be willing to fudge on the P4P submissions too.
Truly, I feel the only way to fix the payment problem is to minimize the red tape and infinite trees of denial and approval rules, and wipe the slate and implement a single payer system. Never will a group of payors (group = N>2) agree to a set of guidelines and payment structure. And the larger the N, the more loopholes they can make to make it confusing to doctor and patient alike.

The other thing that gets me about the Transformation To A Patient Centered Medical Home Model, is that when you transform into something, it implies that you are something different now. Back in med school, I picked Family Med because of the comprehensive, whole patient in the context of family and community approach. That is what I was trained to do. I'm not denying room for "home improvement", there's lots of things I look forward to implementing as advances in medical knowledge and technology explode. But I do not need the headache of managing a team of providers, nurses, social workers, dietitians, and educators in order to be a good Family Doc. I don't feel like I should have to justify myself to anyone except my patients and the medical board. I do not believe that I need to Transform My Practice into a different entity to make my patients feel that my number (or email) is the one they need to call when they have a health problem, issue or question. They will (and do) call me first when they know that I will (and do) give my best effort to provide them the best care.


knittinandnoodlin said...

Hi~ I just saw a little piece about your practice on NPR...what an awesomely courageous thing you are doing! If I lived just a bit closer I'd be transferring to your office in a second.

Best of luck to you!

The Northwest Hominid said...

I just "ran into" your article thru NPR (off a Yahoo link). This is fantastic for you, but I can understand how scary it is. I work in the insurance industry but I also do massage therapy here in Washington State. Luckily my knowledge of insurance helps in my practice but not everyone is that lucky.

The healthcare problems in this country are out of control, and there are people that would rather pay me cash than use their health insurance because they know what a pain in the A$$ is it for me to get reimbursement. I also explain to others that the "insurance" they have is not "free," as some think it is. Most have employer benefited health insurance, but that the individual pays for it out of their check each month, much like Medicare and Social Security. It's not free. It's costing them each month. I have it and I have a $1000 deductible. So I just pay my family doc cash if I have to go in. So it seems for someone like me, having a doctor like you would be a good match. I agree with the other poster, if I lived in NJ, we'd be having a discussion about me being a patient of yours.

One last quip - yesterday we dug out of the snow and I had to take my fiance to the urgent care clinic. Her family doc was closed due to the snow. Anyway, Dr. Thomas at the clinic echoed that article about 97% of docs opting for specialty instead of family practice. Instead, he said he'd have gotten a business degree instead. Here's a guy, 10 years in practice, got a D.O. instead of M.D., does the same stuff, and thinks he made a bad choice. But seriously a really nice guy and I was impressed with his skills as a pysician. Crazy.

Best of luck to you in your endeavours. Merry Christmas!! Feel free to drop me a note at my blog. I'll be checking back on yours now and then. Take care!

Don said...

Stay your course.

One day we shall all figure this out. My employer and I pay thousands for my health insurance plan. Occasionally, my family meets all of the deductibles but most often not. If I'm paying for medical care and the doctors are not getting the money, where did all those dollars go? Perhaps we have been paying the insurers to pay themselves?

Samuel Willis said...

Hi Elizabeth,

I'm in the process of opening a similar practice in Minneapolis, MN that I hope to have up and running in April, 2009. I'd be interested in sharing with you what I've learned and hearing about your experience thus far. I believe you are on the right track to one potential way to positively affect change for our health system. Do you have a website for your practice? Feel free to e-mail me at or call me at 612 219 9233.


Samuel Willis, MD
Family Medicine Physician
Minneapolis, MN