As The Medical Home Turns: The Final Installment

Final Installment on As the Medical Home Turns:

Yes, students, today is the last installment in PookieMD’s dissertion on the ‘Medical Home’.  At our last session, we were midway through reviewing the “10 Simple Rules for the 21st Century Health Care System,” rules to guide the redesign of the health care system.  These guidelines were put out by the National Committee for Quality Assurance.  Why are we torturing ourselves with this tedium?  Because this may the  measuring stick by which CMS (Center for Medicare and Medicaid Services) will use to reimburse our practices.  And that means, of course, insurance companies will follow suit.  Following are rules 7-10 with my pithy commentary:

 

“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.”

Item 7: “The need for transparency.” To me this sounds very similar to ‘rule 4’, free flow of information.  The salient feature is that the health care ‘system’ should make information available to patients about health plans, hospitals…etc.  Who will be responsible for each aspect–are physicians to review a patent’s health plan with them, and review each hospital the patient may go to?  This is an incredibly broad assertion of what needs to happen, but with no clear plan of who exactly needs to provide this information.  Part two, which references the “system’s performance”, appears to be directly related to measuring safety (think the never/ever no pay rules, for example), and also appears that your practice will be measured on evidence based practices and patient satisfaction.  We already discussed evidence based practices, which I consider the basis of modern Western medicine. However, the patient satisfaction issue is murkier.  What exactly IS patient satisfaction?  Would I get higher scores if I didn’t collect copays, gave out lots of oxycontin and ordered any test the patient saw on TV?  Clear criteria need to be established,  e.g. are patients seen with in 15 minutes of their appointment?  Are appointments accessible on a daily basis?  I’m not buying the criteria of “Rate PookieMD on a scale of 1 to 10–where one is the worst physician you ever saw, and 10, PookieMD is better than Marcus Welby, House and Hawkeye Pierce combined.”

Item 8: “Anticipation of needs.”  Yes, indeedy, I certainly try to anticipate my patient’s needs.  More importantly I try to anticipate outcomes.  If I do x, y will happen. But, I also try to have a plan in case z happens.  I can’t anticipate a patient’s every need, but I can use the best of my knowledge and resources to try to move the patient toward health.  Anticipation of needs smacks of wand waving, rather than reality.  Anticipation of outcomes is medical science, and an attainable goal. 

Item 9: “Continuous decrease in waste.”  Sounds good to me.  I hope that includes not wasting MY time filling out endless forms and jumping through hoops to make the ‘Medical Home’ a reality.  It is interesting that the Rules state the health care system should not waste resources or patient time, but makes no mention of physician time.  I’m all for decreasing waste, and hope that much more in depth thought goes into developing the operations and processes of the ‘Medical Home’, so it is not a gigantic bureaucratic wasteland.

Item 10: ” Cooperation among clinicians.”  Please do not patronize me.  Cooperation is a kindergarden skill, and doesn’t belong on this is on the list.  The physicians I know and work with are dedicated and caring, and certainly cooperative.  We don’t always agree on management, which is HEALTHY, and we certainly can be snappy when fatigued, but I think this is rule is over kill.  Shall we form a circle and sing Cum By Yah?

So my final take on the “Medical Home” is that it is a bunch of ‘rules’ that primary care  practices are trying to do already.  (Or as close as they can get with the limited resources they have.)  What it woefully neglects is how systems should be put in place to make health care, health information technology, and a much needed emphasis on PATIENT CENTERED care a reality.

Back to the drawing board.  This time, make sure you invite the physicians in the trenches that actually do the work–the family practice physicians,  the internists and the pediatricians, to guide the guidelines.

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