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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