American College of Physicians: Internal Medicine — Doctors for Adults ®

Advertisement
Tuesday, August 10, 2010

Saving primary care: Is anyone home?

The Patient Protection and Affordable Care Act (aka "Health Care Reform") signed by President Obama in March will revolutionize primary care in the United States. By 2014 tens of millions of uninsured people will "enter" the system by being granted insurance, either through expansion of the Medicaid program or through mandated purchasing of insurance via state pools or the private market.

This alone will have a profound impact, straining the capacity of our already frayed system. Therefore, embedded in the law are funds to encourage growth and improvement in primary care: Incentives to encourage graduates to enter primary care fields (family medicine, internal medicine, and pediatrics) and practice in underserved areas (through scholarships and loan forgiveness), and money to re-format the way that primary care is practiced and paid for.

love Don't live here anymore... by Robb North via FlickrThe most prominent example of primary care restructuring is something called the patient-centered medical home (PCMH). Currently a national "demonstration" project is underway to show us that the PCMH model is a sustainable way forward. The PCMH promises nothing less than greater access to primary care, delivered with improved quality and safety, better data capture and analysis, all with lower per capita costs. Devotees of the PCMH are surging ahead to tie together the twin strands of incentives for transitioning to electronic medical records and improving on the delivery and payment models of primary care.

They have support from their major societies, all of which have wholeheartedly signed on to the PCMH model: The American Association of Family Physicians, the American College of Physicians, the American Association of Pediatrics and the American Osteopathic Association. These four groups total 330,000 members, more than a third of the practicing doctors in the United States. Even the venerable American Medical Association has joined the chorus, lending its endorsement to the concept.

[The idea of a PCMH has actually been around for decades. You can see a timeline of its evolution on page S4 here.] Early data from some of the demonstration projects show promising results, reinforcing the idea that paying for quality in health care doesn't necessarily mean delivering more care.

Yet while the PCMH sounds good conceptually, individual doctors and patients are finding it less lofty than its rhetoric. For one thing, the model presupposes the doctor as the center of a "care team," consisting of nurses and "mid-levels" (i.e. nurse practitioners and physician assistants). Under the PCMH model, doctors would only see the "complex" patients, leaving the "simpler" issues (like sore throats, colds, sprains, and urinary tract infections) to the rest of the team.

In theory, the doctor (really the doctor's team) has the ability to handle many more patients, improving both practice revenue and efficiency (attributable to the new informatics tools and data pooling). The obvious problem with this is that the patient has to buy in to the model. Some folks are fine seeing the nurse practitioner for their acute complaint, but how does the medical home model improve the doctor-patient relationship, especially if you already have trouble seeing your actual doctor?

Worse yet, with all of this restructuring, the PCMH has yet to be shown to be cost effective. Reorganization costs money, as do the startup costs of the electronic tools. Integrated systems like Group Health in Seattle and Geisinger in Pennsylvania have shown cost savings when doctors are salaried, networked, and have a captive audience of insureds to analyze. Unfortunately, the vast majority of practicing doctors still operate outside of these networks. Encouraging them to transition their practices into "homes" will be disruptive to say the least; the real question is whether the disruption will be transformative toward the ideal or cause the destruction of individualized doctor-patient relationships.

Feel free to chime in with your thoughts.

John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.

Labels: , , , , , ,

2 Comments:

Anonymous Anonymous said...

Thanks for pointing out the obvious that the PCMH presupposes use of so-called "physician extenders" and incorporates them as part of the PCMH "team". I am in an academic (salaried) medical center group practice that otherwise functions as a large private practice -- except we (by individual funding mandate) cannot use NP's or PA's even for our uncomplicated sick visits. Yet we are going head-first into the PCMH pilot group...

It's been my experience that even when my patients see very talented and qualified NP's/PA's in other departments, they almost never feel as they've been seen by "The Doctor". And even when they have seen one of my physician partners for an interim/acute visit they're never completely satisfied unless they've seen their own doctor -- even if they've received excellent care objectively. We've seen this time and time again in regards to our hospitalist system, and only now -- 5+ years into its implementation -- are patients starting to accept that it is here to stay (they still don't like it, though, on the whole).

You are absolutely right that the PCMH model will fail unless patients buy into this euphemistic "team" concept. For this to occur, practices will have to be direct and blunt about what this means from the patient point of view. Not historically our strong suit in Medicine.

Patients are smarter and savvier than we give them credit for. They are already watching out for mis-steps of a health care system of which they are growing increasingly suspicious.

Name Withheld, MD

August 11, 2010 at 12:00 AM  
Anonymous Anonymous said...

I was asked on a hospital form who my primary care physician was, that's when it struck me...

I've never once had a face-to-face conversation with that person! I think I had seen that doctor walking down the little hallway, oh, maybe once.

On the hospital form I spelled the name wrong. And I was there to proceed with endocrine surgery to remove a tumor.

August 11, 2010 at 8:49 AM  

Post a Comment

Subscribe to Post Comments [Atom]

<< Home

Share

 

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

Powered by Blogger

RSS feed