Wave the Wand: The Medical Home Mandate

I am intrigued with the idea of the “medical home”. 

When hearing about the concept, my first thought was, isn’t this what we are trying to do already? 

My second thought was–and just how are we going to pay for all this?

Below is ” Crossing the Quality Chasm: 10 Simple Rules for the 21st Century Health Care System,” from the National Committee for Quality Assurance.  I will go through these ‘rules’, and the lengthy explanation from the PDF PCMH_Overview_Apr1{[1}pdf.  This will take a couple of posts, so don’t glaze over on me.  And yes, there is a homework assignment at the end!

“Crossing the Quality Chasm put forth “10 Simple Rules for the 21st Century Health Care System” to guide the redesign of the health care system. These rules underlie PPC (Physician Practice Connection) and describe a system different from most health care today.
1.  Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits.
2.  Customization based on patient needs and values. The system of care should meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.
3.  The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.
4.  Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge.
5.  Evidence-based decision making. Patients should receive care based on the best available scientific knowledge.
6.  Safety as a system property. Patients should be safe from injury caused by the care system.
7.  The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice and patient satisfaction.
8.  Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
9.  Continuous decrease in waste. The health system should not waste resources or patient time.
10.  Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.”


PookieMD’s cross examination/rebuttal on items 1-3:

“Care is based on continuous healing relationships.”  This the very basis of primary care, and always has been.  The remaining docs that are weathering this storm and staying in primary care stay in it for the relationships!  They are certainly NOT in it for the abundance of pay! 

“Patients should receive care whenever they need it…”  Wait a minute!  Who is GOING to provide this care? At what cost?  Who is going to revise the entire insurance/medicare/medicaid system to accommodate this?   You can’t just start mandating that physicians start changing their practices WITH OUT PROVIDING THE TOOLS  TO DO IT!  (Monetary and otherwise.)  Please, please, please do  not set bench marks with out putting deep thought, strong policy and appropriate funding behind it.

“Customization based on patient needs and values.”  As physicians, we try desperately to accommodate patients’ needs and values.     I doubt that ANY physician is trying to force something on a patient that is NOT consistent with the patients’ needs and values.  I think that what is neglected here is the fact that PATIENTS MUST HAVE A PERSONAL RESPONSIBILITY IN MAINTAINING OR REGAINING HEALTH.  Many times a patent’s needs can NOT be met–it just isn’t possible with out a magic wand.  The patient must have as much stake as the treating physician in the wellness process.  Many patients do NOT recognize that their behavior contributes directly to their illness, and desire to just lay back passively and have the physician wave the magic wand.  (For an incredible case in which a patient demanded wand waving, read about a Rheumatologist who was sued and had to pay $400,000 because he didn’t provide an interpreter for a deaf patient.   Visit http://www.pointoflaw.com/archives/2008/10/doctor-held-lia.php.)

“The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.”  I love it when patients have an opinion.  I also know that I need the TIME to review information and decision making with patients and families.  This is woefully covered in the ‘counseling codes’, and is frustrating for both patient and physician to do in a limited time frame.

All right, enough for today.  Your homework is to read the rules, and see how they apply to YOUR practice.  Then,  think of HOW you will implement them, and what resources you will need.  I’ll go through the rest, and try to dig up some real numbers on the cost.  I’m not dumping the concept, I’m just applying the light of  reality.


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