Stanley Feld M.D.,FACP,MACE

In the 1980’s primary care physicians thought they were king. In reality, they were pawns for the managed care companies. Their job was to be the gatekeeper and manage costs not care. Patients could not see a specialist unless referred by a primary care physician. The managed care system did not decrease medical care cost. It restricted access to care. Patients rebelled.

In 2002, seven U.S. national family medicine organizations created the “Future of Family Medicine Project” to "transform and renew” the specialty of family medicine.

The specialty of family medicine has been devalued in the last 20 years. Primary care physicians practice cognitive medicine. Reimbursement for cognitive medicine is low and has been decreasing while overhead has been increasing.

Primary care organizations have proposed a Medical Home Model to increase their value. Medical Home is a strange name for this model of medical care.

The definition of a Medical Home is a patient-centered approach to providing comprehensive primary care. Patients should understand that their care would be coordinated by their personal primary care physician and his/her team of physician extenders.

The model emphasizes a partnership between patients and their physicians. In recent years physicians have been called healthcare providers. I have insisted they be called physicians because they provide medical care; healthcare care providers should provide assistance to physicians’ medical care.

The term healthcare provider devalues physicians’ contribution to patient care. In turn it is used to decreases reimbursement.

Medical Homes might deliver better access to health care, increase satisfaction with care, and improve health. Primary care physicians should have been doing this all along.

However, economic conditions have forced primary care physicians to see a greater number of patients in a shorter time. Many primary care physicians have not related well to patients because of the time limitations.

Primary care physicians have to incorporate systems of chronic disease management into their practice of medicine. These systems of chronic disease management must teach patients how to be professors of their chronic disease so they can avoid the costly complications of chronic disease.

Eighty percent of the healthcare dollar is spent on the complications of chronic disease. In order to avoid these complications patients need to be taught to self-manage their chronic disease.

If primary care “Medical Home” could teach patients to be responsible for the control of their disease and increase compliance with medical treatment recommendations a cost savings would occur.

It remains to be seen if the “Medical Home Model” will achieve its goal. President Obama is setting up pilot studies to see if “Medical Homes” work. I fear the physician incentives are too small. Also patient incentives are not included but are critical to the models success.

There is a shortage of primary care physicians. With 30 million more people insured the shortage of primary care physicians will intensify. The result will be long delays in seeing a primary care physician. Long delays have occurred with Romney care in Massachusetts.

President Obama’s pilot studies will increase primary care physicians’ reimbursement 5.6%. I do not believe this is enough. He plans to get the money by decreasing specialist compensation.

“In President Obama’s Washington, medical specialists are slightly more popular than the H1N1 virus. Compared to bread-and-butter primary care doctors, specialists cost more to train and make more use of expensive procedures and technology—and therefore cost the government more money. .”

President Obama has declared war on medical and surgical specialists.

Future of Family Medicine Project has recommended;

“that every American should have a "personal medical home" through which to receive his or her acute, chronic, and preventive services. The services should be "accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians."

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Execution by primary care practices will be the problem. Articles supporting the concept Medical Home are not scientific studies. They are at best survey estimates and consensus documents declaring that a medical cost savings will result.

I believe it would be very difficult for Medical Homes to be accessible 24/7, comprehensive, scientifically valid and satisfying to both patients and physicians.

“If the Future of Family Medicine recommendations were followed (including implementation of personal medical homes), "health care costs would likely decrease by 5.6%, resulting in national savings of 67 billion dollars per year, with an improvement in the quality of the health care provided."

In 2007, the leading primary care physician organizations in the United States released the "Joint Principles of the Patient-Centered Medical Home."

The principles are:

• Personal physician: "each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care."
• Physician directed medical practice: "the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients."
• Whole person orientation: "the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals."
• Care is coordinated and/or integrated, for example across specialists, hospitals, home health agencies, and nursing homes.
• Quality and safety are assured by a care planning process, evidence-based medicine, clinical decision-support tools, performance measurement, active participation of patients in decision-making, information technology, a voluntary recognition process, quality improvement activities, and other measures.
• Enhanced access to care is available (e.g., via "open scheduling, expanded hours and new options for communication").
• Payment must "appropriately recognize[s] the added value provided to patients who have a patient-centered medical home." For instance, payment should reflect the value of "work that falls outside of the face-to-face visit," should "support adoption and use of health information technology for quality improvement," and should &
  quot;recognize case mix differences in the patient population being treated within the practice."

These are all important principles.

The last principle deals with increasing reimbursement. Candidate Obama pledged to support Medical Homes when elected President. Multiple accrediting agencies are being formed to oversee the practice in Medical Homes. Increased bureaucracy leads to increased inefficiency and increased costs. It also leads to the increased possibility of failure of the pilot.

The concept of Medical Homes is a step in the right direction. If successful it can help the important specialty of primary care flourish. It will require teaching primary care physicians how to set up systems of intensive self management for chronic disease as well as adequate reimbursement for these services.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.