by Thomas C. Bent, MD
As the House of Representatives prepares to vote on its historic health care reform bill on Saturday, family physicians are heartened to see the support it gives to the emerging new model of care, the patient centered medical home.
The House bill is good news on many fronts. It would provide health insurance coverage for some 96 percent of Americans and would reduce the federal deficit by $30 billion. The Congressional Budget Office estimates this bill would lower health care costs in part by improving health care delivery and relying on the medical home model with its greater focus on primary and preventive care.
Debate about this bill has been exceedingly contentious. In fact, thousands of people are demonstrating in the streets of Washington, D.C. as I write this. Yet at a deeper level, health care reform isn’t a Democratic or Republican political issue – it’s a non-partisan moral issue. Researchers at Harvard reported recently that 45,000 people die in the U.S. every year because they lack health care coverage and so cannot afford appropriate care. Many more die each year from entirely preventable chronic illnesses.
Three out of every four health care dollars – $1.5 trillion of $2 trillion spent on health care year in the U.S. – go toward treating chronic illnesses, most of them preventable. An estimated 133 million Americans have at least one chronic disease, such as diabetes, heart disease, cancer, stroke, or lung disease. In Los Angeles, public health experts have documented that 80% of preventable disability and death in that county is associated with chronic disease.
Our current health care system is failing our patients by focusing more on treating acute conditions – like heart attacks – than on preventing the causes, such as obesity that leads to heart disease. As a result, patients suffer unnecessarily and health care costs are spiraling out of control. We need a better model, with more emphasis on prevention, backed up by the excellent care our subspecialist colleagues provide.
Patient centered medical home efforts in North Carolina, Pennsylvania, Colorado and elsewhere have delivered improved patient outcomes and multi-million-dollar cost savings in recent years. Key elements include identifying patients who need preventive and chronic disease care and ensuring they regularly receive such care; providing extended office hours and 24/7 access to primary care physicians to prevent unnecessary emergency room visits; using evidence-based medicine to provide clinically effective and cost-effective care; delivering care with a physician-led team of providers working to the full scope of their respective positions; and coordinating patients’ care throughout the health care system.
We know what needs to be done – we just need the political will to align payment and medical education systems accordingly. That’s in part what the House bill would do.
The California Academy of Family Physicians believes that ensuring Americans can afford to seek care that focuses on keeping them well, managing chronic illnesses, and coordinating their care throughout the entire health care system is not a government takeover – it’s a humanitarian response to the crises faced by the millions of uninsured and underserved in our nation.
Thomas C. Bent is President of the California Academy of Family Physicians.
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- Will medical malpractice reform be included in the final health bill?
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{ 19 comments… read them below or add one }
Medicare has shelved the Medicare Medical Home Demonstration (MMHD) in favor of Multipayer Medical Home Pilots. Could you clarify what the heck this all means?
http://e-caremanagement.com/cms-shelves-medicare-medical-home-demonstration/
“… would reduce the federal deficit by $30 billion.”
This is simply politcal spin.
There is no SGR fix (just like AMT, we have to wait each year to bow to the political class) so the 21% cut is kept in this bill just to fudge the numbers. And it assumes medicare expenditures will grow at 6% per year rather than the 8% is have averaged during the past 20 years — and all this while increasing the number under Medicare as boomers retire. Oh yeah, and providers will now be free to negotiate with the govt – just like we can negotiate with the IRS when you have a tax dispute?
Finally, Medicare came in 917% over first year govt cost projections, Medicaid at 1700% over – and we are supposed to blindly accept these financial projections? Sorry, color me skeptical!
This Pelosipalooza won’t make a dent in the uninsured for ten year. However, the House bill will put into effect 13 new taxes and establish over 100 new bureaucracies within a year of adoption. This isn’t healthcare reform. This is a hostile takeover. When Herbert Hoover promoted his “chicken in every pot,” NY Gov. Al Smith commented that “no matter how you slice it, it still comes out baloney.” I say the same for this Pelosipalooza.
We believe CMS delayed the planned PCMH demonstration project for several reasons. The first is because each of the major Congressional health care reform bills have extensive medical home provisions. In addition, there are a number of proposals to study how changing current payment methodologies (i.e., enhancing care management) could improve care delivery. Waiting to see what changes are enacted would help ensure that the pilots are testing models that are still relevant.
In addition, at the time the now-postponed demonstrations were enacted, there were many fewer medical home advancements at state and community levels. Because of the higher level of engagement in PCMH — by health plans, providers, and other organizations — more stakeholders would mean an improved pilot. A narrowly targeted demonstration (i.e., one that focuses on a limited number of providers, has only one payer, and targets only high-risk patients) is not the best way to create the medical infrastructure at the medical office and community level.
What needs to be done is to inject more freedom and transparency into the system, and reduce political and bureaurocratic involvement.
The current proposal fails on both fronts.
Fortunately, the American people see what the California Academy of Family Physicians does not.
@ Dr Parker–
I don’t know which American people you are referring to because I just today looked at my Congressman’s Facebook page where there were dozens of ordinary constituents urging him to vote for healthcare reform. And he is a “Blue Dog”.
I suppose the obvious question is that regarding chronic disease, which the author seems to focus on. What would indicate adequate treatment of chronic disease? Perhaps 79% dying from conditions related to their chronic disease? It seems silly to expect a program that radically alters reimbursement to magically cure chronic disease (which take up “Three out of every four health care dollars”), but hey, if Obama can cure those chronic diseases, I’m all for it!
BTW, does this mean that acute conditions like heart attacks shouldn’t be treated, or are overtreated? And what about the patient role in tackling some of these chronic diseases? I know, I shouldn’t be asking questions like these. But inquiring minds want to know…
“Our current health care system is failing our patients by focusing more on treating acute conditions – like heart attacks – than on preventing the causes, such as obesity that leads to heart disease.”
Wrong. Our current medical system heroically saves people who knowingly abuse their bodies to the point they finally suffer an acute episode. Patients fail the healthcare system by smoking, eating like gluttons, never exercising, drinking to intoxication chronically, and being non-compliant with preventative care. On the bright side, it doesn’t take insurance or lots of money to do those first four items.
No fancy new name for an age old philosophy is going to get you paid more, produce healthier patients or make people magically take better care of themselves.
Without denying the heroism inherent in saving the severely ill (or the anger implicit in laying the blame for morbidity primarily at the feet of gluttony & sloth), if we don’t restructure our approach actually to give Americans access to the primary prevention with which they’re supposed to be non-complying we can never hope to do better than patching up the wounded and sending them back into battle. There will always be those who fail to care for themselves as they should and thus need saving, but far more who, given the priority that reformed health care could give them and the support of their medical home, can live healthier lives and cost the ’system’ far less in the process.
The Los Angeles Times (http://www.latimes.com/features/health/la-oe-khan5-2009nov05,0,5733860.story) yesterday ran an op ed by a University of California-San Francisco internal medicine resident, who provides a compelling description of why our health care system must provide great primary care access as well as great specialty care – it’s not either/or. With so many people now uninsured and the primary care physician shortage growing worse, though, it’s primary care that so many people lack, until their symptoms constitute emergencies.
Healthy San Francisco (www.healthysanfrancisco.com), our city’s affordable plan, is built around the medical home model to bring a balance.
The medical literature is filled with research and data that show the positive impact of primary care – we don’t need to debate that here.
24/7 access to access to PCPs. What a joke. Who comes up with this nonsense? Oh, yeah, the ACP. Hey guys, there’s a shortage on! Hello!
This PCMH foolishness is a desperate attempt to get money by making absurd promises to politicians. I can see the med students running for the exits already.
All I know is that more and more people are heading to the ER, myself included, because it takes forever to get in to see a doctor. When my child has ‘the mother of all’ sinus infections, is running a 102 degree fever, can’t keep food down because of the congestion, can’t sleep, and is crying miserably, and our doctor can’t fit us in till DAY AFTER TOMORROW, then I have no other option but to attempt to console her during a nightmarish 5-10 hour wait in the ER so we can get antibiotics.
The patient centered home, as described in this article, sounds like an ideal solution where I’d have greater access to my doctor. This health care reform bill is a no brainer to me.
Busymom, Welcome to the primary care shortage. It will be solved by and only by paying family doctors a hell of a lot more money. This will not happen, at least in the near term.
Sure, I can get up in the middle of the night (or stay up all night) to keep people out of the hospital so as to save society money and help folks out, but someone has to to pay me and other family docs like me a minimum of $100 per hour net of expenses to do it, and I see no willingness on the part of society to step up to the cashier’s window. Oh, and what about the pts during the day who have only a sleep-deprived doc to see them? Sorry folks, there a shortage on.
The PCMH is a false solution proposed by people who are not actually themselves willing to be available 24/7. It’s a BS solution that has no impact on the root of the access problem. I for one am not willing to run my health, marriage and family life (2 young kids) to pay for America’s failure to provide an adequate HC system for its people. Most other family docs I know feel the same way. It’s your problem America–deal with it.
Here’s the reality: the primary care crisis will worsen, and we will look back with nostalgia at the time when we only had to wait 2 days to see a doc.
There may be a primary care physician shortage inevitable, however the patient-centered home model sounds like it could be a great solution to this problem. What an amazing concept….patient-centered health care, where the needs of the whole patient are considered and prevention is key. I can’t think of anything better.
As a women’s health advocate, I’ve heard unbelievable stories of women and children dying every day in the US from causes that could have been easily preventable. The infant mortality rate in this country, which is only rising all the time due to the increase in premature births, is sadly much higher than other countries, not to mention the fact that our maternal mortality rate is just as unconscionable due to the pathetically poor level of care of low income pregnant women.
We can’t allow this to continue. Women and babies are dying, and people are arguing over political issues such as federal funding of abortions….come on. The health care reform bill needs to be passed, and quick, so we can make health care affordable and available for all Americans and prevent unnecessary deaths.
A friend of mine is a primary care physician and she often talks about how sad it is that so many in her field are leaving because they aren’t paid enough. And medical school students avoid it in favor of specialities simply because of the pay issue.
So this article states that patient-centered medical homes are a lot more cost efficient, but what I don’t understand exactly is just how primary care physicians will be paid the level of salaries they need and deserve. Can someone explain this to me in “layman’s” terms?
Thanks so much for this informative article!
DrsFriend
It is all smoke and mirrors. PCP will be paid 3 percent more to do 30 percent more work most of which will be paper work documenting how effecient the medical home is. We are already doig it. PCPs all across the country are already tracking their patients through multiple episodes of care with subspecialists. and hospital ERs. We are getting those results and explaining them to our patients rather than saying, “You will have to ask the specialist.” We just aren’t getting paid for the time and staff it takes to do this. The Medical Home documentation will be the last nail in the coffin for PCPs.
As a family doc, I support the House Health care reform bill. I look forward to the day when I no longer get phone calls from patients who know they need to come in for preventive care and monitoring of their chronic illness, but they can’t because they no longer have insurance or their deductible is too high. I look forward to the day when we have more to offer the obese patient than bariatric surgery, because the cost-effectiveness of a monitored group physical exercise facility will be understood and reimbursed.
I am lucky to be working with specialists who save lives when their expertise is required. I can count on most of them to not just run up a bunch of tests and procedures because right now that is how to make money as a doctor, and it is easier to do that than try to talk patients out of unnecessary tests.
I look forward to the day when my own work in diagnosing and treating depression, in performing evidence-based preventive care, in helping people manage their own diabetes, in encouraging their own impulses to quit smoking, all will be recognized as just as valuable.
Everywhere else in the world primary care is the backbone of good cost-effective care systems.
@Sandra Newman: thanks, we’ll see how the just-passed House bill fares on the way to the White House. Admittedly I’m a skeptic, wondering how the heck I’m going from seeing 16-20 patients/day with 1 MA up to 35 patients/day with 2 RN’s – which is what at least one model PCMH practice does. Not enough money, not enough supporting talent, overpriced hospital EMR, no local IT infrastructure the specialists can readily plug into (i.e. Mayo, Bassett, Intermountain Health, etc.). And like jsmith, I would like to get to know my kids as they grow up, unlike my busy physician father.
I like to actually recall from memory facts about patients that additional time with them affords me – what they do for a living, relationships, children, etc., helps me to look at the big picture rather than a list of ICD-9 codes to address. Could I do that in a busy PCMH setup? Doubt it, there are limits to being merely human.
Dr. Bent described the House’s Medical Home pilot as an example of “delivering care with a physician-led team of providers working to the full scope of their respective positions”. Yet the Medical Home could be headed by a Nurse Practitioner; a physician led “Home” was not required. Wake up and see that this is an attempt to minimalize physicians and our worth. We will soon be equated to workers and not professionals.
Why isn’t there an out cry about all of this from Physicians? Why don’t we have our own “March on Washington” highlighted by a series of debates between physicians on both sides of the aisle. The public deserves to hear our voices. Physicians deserve a better representation of their views then what is being forth by the AMA currently.