In the US, we are fascinated by finding easy answers to complex problems. Nowhere is this more prevalent than in health care where we have a litany of pleasant sounding solutions that when executed actually contribute to the health care crises. Remember these: “gatekeeper”, “managed competition”, “HMO/PPO/PHO/IHD”, “capitation”?
We are also guilty of not calculating the unintended consequences of activities (just ask Pete Stark about his well intended legislation) or the significant cost of regulatory compliance. We extrapolate a model that works in some geographic area for reasons not always clear and want to deploy it nationally as the “answer”. Perhaps the thing that we are most guilty of when addressing health care “cures” is not debating the merits of the plan but implementing it because of a urgency, crisis, or an irrelevant emotional appeal.
It’s a great strategy for failure.
I was reminded of this recently when asked about the patient-centered medical home a concept that while popular is clearly a recipe that has no chance of working in a major way. I understand our national association is considering debating this silly model and our role in it. Just because a bunch of associations-namely those serving primary care physician’s interests back this well intended but misguided concept doesn’t mean we have to have a PT position on it. Let’s talk to those primary care groups about how we can collaborate on services including extending their reach and let the medical home concept die its predestined death.
Patient Centered Medical Home.
Wow, what a name. This clearly meets the pleasant sounding name criterion. Here is a definition of this concept:
Involves interdisciplinary coordination of patient care that is "accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective," according to the American Academy of Pediatrics, which is credited with originating the concept. Patients under a "medical home" develop ongoing relationships with their providers to maintain healthy lifestyles and monitor health conditions over the lifespan. Such care includes after hours and weekend access, as opposed to the patient seeking care from unrelated emergency departments or other urgent care facilities.
Who in their right mind would argue against such a concept? Images of Father Knows Best, Marcus Welby, and Rockwell paintings almost prevent a person for even attempting a criticism. Let’s not let the facts interrupt this simple sounding solution. In fact, a main tenant of the medical home model is the use of evidence based medicine as its decision making. Unfortunately, the supporters of medical homes aren’t using evidence in their unabashed and unwavering commitments to the medical home. In Sept/Oct edition of Health Care Affairs, a study of large medical groups with at least 20 MD’s and who treat patients with asthma, diabetes, CHF, and depression found that the practices are lagging in key areas needed to create medical homes. These areas include lack of use of electronic medical records, coordinated care, patient education materials, and performance feedback. Most interesting (and compelling) is the fact that only about 1/3 of these groups relied on primary care teams to deliver care-the very fundamental of medical home! Not surprisingly, large medical groups (140 or more docs) and those owned by HMO’s were more apt to have the infrastructure to deliver the concept due to having the most resources. While we all in the US would love to have our own family practice doc, the data doesn’t support it. Many currently with insurance can’t access a primary care physician-their simply aren’t enough of them and to think we can help service the 41+ million without insurance using a coordinated “gatekeeper”? Medical students aren’t choosing residences in primary care and only 2% of medical residents chose primary care as a career choice this year! While increasing compensation might steer this in the future, there isn’t any foundation for curing it as the problem exists today. Large medical groups simply can’t afford EMR which might be in part remedied thru changes but there still isn’t enough money in the coffer to supply the other key ingredients of a medical home including the additional staff overhead necessary to meet the standards. The calculation of the regulatory costs involved for compliance are always underestimated and let’s never forget the significant cost in EMR support that is too burdensome for most practices.
For those older therapists in the group, remember CARF accreditation for work hardening and chronic pain programs? It’s a mere pansy to the rigor and standards brought forth by NCQA or ACP for a medical home. So much so that a cottage industry has already been created to “prepare for the certification process”!
While there will always be the Geisinger’s of the world-namely significantly large integrated systems that work, let’s remember that health care delivery is done in neighborhoods and is largely fragmented, subject to great geographical idiosyncrasies, and attempts to “nationalize” it in any meaningful way have always been rebuffed -otherwise we would all be working for the old Healthsouth!
In healthcare policy, we have this very bad habit of wanting to take one best practice and make it standard throughout the US. If airlines can’t make Southwest’s model work across that industry, what makes us think we can deploy Geisinger in any meaningful way? The failure of the US auto industry is too good of an example not to be used by policy makers when considering broad bush attempts to find the answer to healthcare.
Let’s have meaningful debate about increasing primary care and making it more attractive to medical students. Let’s rid the barbaric fee for service system and find ways to reward docs for comprehensive EBP care across a spectrum of hi cost drivers that produce outcomes. Let’s encourage EMR standards that can be implemented locally in a manner where practitioners still can make cost decisions. Let’s encourage collaboration, coordinated care, feedback, outcomes and such. But let’s call a “certified”medical home what it really is-a great sounding concept that won’t work broadly in the US for several sound reasons.
larry@physicaltherapist.com
