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.

Wand Waving Part 2: Common Sense is Uncommon

Let’s jump right  into the second part of PookieMD’s dissertation on the Medical Home.   As you recall, I was reviewing the 10 rules of the medical home, as set forth by the National Committee for Quality Assurance.  The next three concepts are NOT new, and are, you guessed it, common sense.  (Why is common sense so uncommon?)

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.

Let’s tack number 4 next: “Shared knowledge and free flow of information…”  I think this is a thinly veiled reference to an EMR.  I am completely for nationwide use of an EMR, but am dismayed at the piecemeal, haphazard free for all that has ensued.  The EMR needs to be accessible to health care professionals across all spectrums of care.  Therefore, the myriad of programs out there are not going to create a system of good access for providers and patients.  It has been proposed that there be a nation wide EMR for all health care providers to use.  I am hesitant in advocating this, as many tout the VA’s system as the model.  I am loathe to advocate anything the VA uses, as I would summarize my experience with all things VA using two words: “profoundly inefficient.”  However, a nation wide, user friendly EMR  would probably be the best option.  BUT,  it has been estimated that it will cost $36,000 per physician to implement an EMR.  Where’s the money coming from?  I don’t see a huge surplus (!) coming any time soon into our Nation’s budget.

5. “Evidence-based decision making.”  No argument here.  I believe this is the very foundation of modern medicine in the West. 

6.  “Safety as a system property.”  It scares me that this is a rule.  Didn’t we take an oath to “do no harm?”  It also scares me that the folks at my favorite institution, the CMS (Center for Medicare and Medicaid Services), have bungled their way in to making rules to keep the patients safe from bed sores, c diff and catheter infections through the “Never/Ever No Pay” rules.  (See post below.) 

So what’s so new and exciting about the Medical Home?  No much so far, just more costs to the physician, a slick new name and a lot of press.  I’ll tackle the next ‘rules’ the next post.

For more info on EMRs, visit Dr. Kevin Pho’s informative post at http://blogs.usatoday.com/oped/2008/10/why-doctors-sti.html.  For more on the technical aspects, see Dr. Josh Schwimmer at http://www.healthline.com/blogs/medical_devices/2008/10/problem-with-emrs-in-united-states.html

Cheers!  Don’t let your hands cramp writing those SOAP notes!

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.