Specialists should staff the patient centered medical homes, not primary care doctors

Originally published in HCPLive.com

by Alan Berkenwald, MD

The approaching fire storm over the “patient-centered medical home” model reminds me of the destructive powers seen before in HMOs. Once seemingly destined to revolutionize organized medicine, the HMO model nearly destroyed it.

Specialists should staff the patient centered medical homes, not primary care doctors We can learn from past failures. We need to promote best-practice models and make physicians accountable for their actions, both physiologically and fiscally. To this end, the medical home should only include specialists; the PCPs must be “homeless.”

HMOs failed the patients who felt they were locked out of specialists and costly treatments by parsimonious PCPs. Specialists had no effective limits on the tests and procedures they ordered, and profited greatly by them. If specialists did not work in a capitalist model in which they were paid by procedure (albeit at a negotiated rate), they would then be able to use their past workload to upgrade their next per-member, per-month capitation rates. The PCPs were left trying to bring the costs down by “gate keeping” the patients, while working with specialists who were out of their control, and patients who were frustrated and out of their minds.

I say we make the specialists arrange themselves into medical homes—and then let them bid for the individual PCPs (in a capitated manner) and the patients they “deliver” into their organizations. Successful specialists would need to keep costs down and satisfy patients in order to make their high incomes while out-bidding other homes for the PCPs that would be needed to deliver the volume of patient required for sustaining the practice.

It is the neurologist who always orders the MRIs on every patient, and then reads all the (in-office) EEGs and EMGs that they recommend; the cardiologists who always need an (in-office) ultrasound and treadmill study, who recommend the pacer vs. the dual-chamber pacer vs. the synchronized pacer vs. the implantable defibrillator; the rheumatologist who repeats the bone density studies even when it would not change the treatments; the urologists who order the brand-name bladder spasm meds that work no better that the generic versions. I mean no disrespect to my specialist colleagues, but you get paid more to say “Yes” than you do when you say “No.” It is not the role of the PCP to question or argue the necessity of an expensive study or medication once the specialists have convinced the patients that they need it. However, it does become our burden to get the insurance company to approve it. The PCP may be the gatekeeper in this system up to now, but he or she sleeps in the guardhouse while the specialist lives in the mansion.

The specialists, in this specialty medical home, would fight it out among themselves as to how to apportion reimbursement, for their procedures as well as for the hospitalizations (many of which could be prevented if appointments to the specialists could be made in a timely manner—but that’s for a later discussion). The money left over, after their cost-effective, best-practice modeling, would be needed to bid for the patients that the PCP would deliver. If practitioners in these specialty medical homes cannot satisfy the patients’ needs, let them be responsible for approving and paying for the out-of-home specialists the patient demands to see. Let it be on their heads, not the PCP.

Best of all, the data we would need to price all the specialty care is readily available—it is held by the insurance companies. Say what you will about the insurance industry—their suspect motives, their exclusions, their profit, their frustrating paper walls that guard their empires—they know actuarial data and they sure know how to bean count. The insurance companies know where the insurance money goes, to which specialty fields and for what procedures and tests, and can set targets and reimbursements better than any government could. That is their strength (perhaps their finest—and only worthy—contribution to healthcare) and the medical system should tap into that. Then let the competing specialty interests fight it out to the benefit of the patients and the PCPs.

The medical home I envision empowers the PCP to manage his or her practice in the patients’ best interests. The PCP is best able to judge the actions and reactions of the specialty care his or her patients receive. The PCP is best able to judge if the specialists are providing the very best in cost-effective medicine. If these standards are not met, the PCP could take his or her business and patients elsewhere, making them potential home wreckers with a mandate and a mission, forever searching for a good, stable medical home.

Alan Berkenwald is an internist who blogs at In the Name of Medicine

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  • jsmith

    Very confusing post. It seems as if the author is trying to say that PCPs control patient flow, but specialists have capitation responsibility. And somehow the specialists pay the PCPs. I don’t get it. Please explain.

  • gcmd

    In general, KevinMD has been a blog that has usually kept ‘specialist-bashing’ to a minimum. This post, however, takes it completely over the line. PCPs are not, in fact, ‘the best able to judge the actions and reactions of the specialty care his or her patients receive’ (specialists actually trained in such procedures are). Nor are they best qualified to judge cost efficacy (insurers, economists, and billing specialists are).

    Perhaps most tragic (and perhaps most revealing of the philosophy and intentions of the author) is that nowhere is it ever specifically explained how this would lead to better outcomes for patients. Hyperbolic language such as the idea that the PCP ‘sleeps in the guardhouse while the specialist lives in the mansion’ is freely mixed with factually incorrect implications* and the author’s gleeful vision of a future in which ‘specialty interests fight it out to the benefit of patients and PCPs.’ Infighting between physician groups is never good for patients, and why in the world should specialists fight with each other for the benefit of PCPs?

    Good grief…

    * “let them be responsible for approving and paying for the out-of-home specialists the patient demands to see. Let it be on their heads, not the PCP.” – Since when do PCP’s have to ‘pay’ the specialist? Last I checked specialists have to fight the insurers just as much.

  • Jenga

    So what exactly would the PCPs be bringing to the table other than being a middle man or a much smaller insurance company.

  • Jenga

    If you don’t take ownership of the medical home, why are you needed exactly? What is to keep them from setting up a triage nurse to bypass the PCPs altogether.

  • http://curbside.posterous.com Nuclear Fire

    How can physicians be “physiologically” “accountable for their actions”? If they make a mistake you’ll cut off their pinkie, yakuza style?

  • AnnR

    I think this could be more clearly written, but I do kind of get what he’s saying.
    Is it really that different than a staff-model HMO where the specialists and PCPs are on salary?

  • Rezmed09

    Let’s be honest here. For 2-3 years of extra training, many subspecialists earn double or more the income of primary care docs with comparable lifestyles. of course there are differences, but years after medical school and residency I had no idea that the income differences and lifestyles would be so disparate within my cohort. As everyone knows, much of the payment system is based on procedures. Who is building the surgery centers, the off-site cath labs, the in office imaging centers and the endoscopy centers? Cynicism is rising in the primary care world as we experience patient after patient reassured by yet another normal expensive workup, while managing the epidemic of multisystem chronic disease just isn’t paying well.
    This is more and more about business, and this is clearly apparent to new med school grads and IM residents – primary care is now more (not always) a job for idealists or those who can’t obtain a fellowship. Follow the money.

  • http://curbside.posterous.com Nuclear Fire

    This attitude is pathetic and unprofessional. I may be a specialist, but as I rheumatologist (no in-office imaging, infusion centers, botox etc or even lab) I make less than I can as a hospitalist. More training, more knowledge, less pay, but I’m doing what I like and that’s the point.

    I have no ill feeling towards the Cards etc. who make more than I do. So what? This isn’t a capitalistic system, but even if it was, don’t I think that patients would pay more for the guy that saves their life from the heart attack at 2 in the morning than the guy who takes away their achey-aches (or even the guy who reassures them it’s not their heart than the guy who reassures them that it’s not “arthritis”)? And I’m certainly not interested in working the hectic pace of the hospitalist, even if my friends make more and only work 14 days a month. That’s life. We make choices and deal with it. Get over yourselves.

    Finally, why do all you angry PCPs (the PCPs who are angry, not all PCPS sare angry) refer to the specialists and their “surgery centers, the off-site cath labs, the in office imaging centers and the endoscopy centers” only to be “reassured by yet another normal expensive workup” that you seem to hate? Is it because you don’t know the answer, you can’t provide reassurance, you need reassurance??? Then they’re getting a higher level of care, so why would they NOT get paid more?

  • Jenga

    I agree nuclear. If some of these angry PCPs truly believe that specialists provide no value or are greater overpaid for their higher level of expertise, why do they send them any patients. Take care of these problems yourself and don’t support them financially and the problem will take care if itself. Do your own rheumatology workup, fracture care, manage all of your coronary patients medically to name just a few. Disparity will then solve itself.

  • Rezmed09

    “Finally, why do all you angry PCPs (the PCPs who are angry, not all PCPS sare angry) refer to the specialists…”

    I often don’t refer patients for many of these services; however, I and other PCP’s find that many patients don’t want reassurance, they want tests and, if they have insurance, they shop around until they get them. I am sure that as a rheumatologist you see many inappropriate referrals for positive titers etc., and can only imagine that this will increase with the ongoing decline of “angry” primary care physicians. But..

    We have runaway health care inflation. If I understand correctly, the patient centered medical home is touted as a way to essentially reduce costs by coordinating care, improving access to primary care and reducing referrals. But 2/3 of physicians are now specialists. This is where the money is going. This is where the focus should be. This is the point of the editorial.

  • jsmith

    Jenga, Your analysis is puzzling. First, specialists sometimes provide a tremendous amount of value. I for one am not disputing that. And if some of them overpaid, we should not consult them? Huh? So we should punish pts just so we can punish specialists? Come one, get serious.
    Look, we all know that the reimbursement scheme in this country is political to the core and has more to do with specialist domination of RBRVS than marginal benefit to the pts, let alone marginal benefit to population health. And don’t give us this nonsense about taking care of fractures. I do workups for orthopods and get paid a lot less per hour, not because my services are so much less important, but for the simple reason that orthopods are better at claiming economic rent from the government and the insurance companies that follow the government’s lead. That’s the reality.
    Most PCPs think it is perfectly reasonable that they should earn less than the more difficult specialties. It’s the numerical value of the discrepancy that is a significant indirect driver of the poor value for money that the United States gets for its HC dollars. Of course we PCPs don’t expect to convince specialists on this issue. We would settle for convincing the American people.

  • Jenga

    If you feel they overpaid and don’t provide value to the patients you send to them, YOU are punishing your patients by referring to them. Neurosurgeons are one of the highest paid specialties, and I would never want to trade places with one of them. I bet you wouldn’t think they are overpaid when they are bailing you out of a jam.
    Any physician should be able to easily workup a musculoskeletal complaint. It is not that hard. Anyone skilled in orthopedics, however, knows that’s not where the real decision making is made. For your difference in hourly wages you also do not take Emergency call such as rodding a femur at 3 am or make much more difficult operative decisions for musculoskeletal complaints such as selection, surgical planning and dealing with possible complications. When the American public has the chance to choose between a PCP and an Orthopod, I think we all know who they would choose. The American people value specialty care highly, that has been proven time and time again.

  • Rezmed09

    Jenga,
    You are absolutely right about the American people valuing specialty care. As I said above, this is where the money is going and this is where health care inflation is coming from. The question is how do we fix this explosion of cost and procedures. Shifting the solution back on primary care is not the answer – primary care is dying.

    If Americans want to proceed with more fragmented, expensive, procedure oriented care with redundant testing which often enhance physician income so be it. And if the solution to this health care cost explosion is not more government, it will be more Walmart and more corporatization of medicine. That’s capitalism. And Americans do love Walmart.

  • jsmith

    Jenga, I refer when I think consultation will provide significant benefit to the patient. Consultant salaries don’t directly influence my decision.
    Indeed, the American people do value specialty care highly , even in those numerous cases when it is completely useless, or counterproductive, or lethal. Hence our current crisis.
    Rezmed, I agree primary care will die unless something is done, and I’m not optimistic about something being done in the near term. A collapse would of course tighten the death spiral of American health care.

  • RM in STL

    I work in healthcare, but not as a provider. I am also a patient. While this article may not have the full answer, I love the fact that the author is working to come up with a solution that limits the spending on specialty care that is making our healtlh insurance system impossible. I don’t hate specialists (several care for me) but as a patient and non-physician, I resent the extraordinary amount of money they make WHEN IT AFFECTS MY FAMILY’S ABILITY TO GET DECENT AND AFFORDABLE INSURANCE.

  • http://www.healthbeatblog.org Maggie Mahar

    Nuclear Fire–

    I greatly admire how you view your own work, and why you do it.

    You’re not looking into somone else’s pocket– not oomparing what someone else is making to what you earn.
    You made your choice and like what you’re doing.

    That said , I have to add that most physicans who pratcie cognitive medicine (listening to and talking to patients) are underpaid while those who pracice more agressive medicne( (cutting and burning) are overpaid for many services.

    This doesn’t mean that PCPs should be angry–just that we should pay them more (and pay pediatricians, geriatricans, palliiative care specialists etc. more, , redistibuting the dollars on the physicians’ fee schedule .)