A detour on the way to the medical home

Last week the Centers for Medicare & Medicaid Services (CMS) published an update on the long-delayed Medicare Medical Home Demonstration. The September announcement from the Department of Health and Human Services of a Multi-Payer Advanced Primary Care Practice Demonstraton initiated by the Obama administration had raised more questions about the future of the medical home project. The explanation from CMS was brief and to the point: “At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot.”

CMS describes the similar pilot as “an independent practitioner-based medical home pilot.” The pending legislation that describes it is the House of Representatives health care reform bill (HR 3200). The two pilots do appear similar in many respects, but one needs to read no further than subsection (a)(4) of Section 1302 “Medical Home Pilot Program” to discover a significant difference between the proposed pilot and its would-be predecessor. Under “Participation of Nurse Practitioners and Physician Assistants,” the bill stipulates that nurse practitioners and physician assistants may lead patient-centered medical homes as long they are acting consistently with state law and other requirements are met.  

Family physicians concerned about turf issues may see this as a setback. The good news is that primary care and medical homes are still the focus of discussion and legislation in Washington, even though the first Medicare medical home demonstration, which many believed would help breathe new life into family medicine, is apparently at death’s door.

Posted at 01:58PM Nov 03, 2009 by Leigh Ann Backer  |  Comments[0]

Is your practice a medical home?

From NPR.org:

"Insurers will also pay [practices participating in a medical home pilot project] bonuses for keeping patients healthy. So, behind the scenes, the office is keeping track of patients, especially if they have a condition such as diabetes or asthma. Dr. Paul Grundy, the founder of a group that's promoting medical homes, says some doctors tell him they already do all that. 'One of the first questions I ask them is, Do you know every single woman in your practice [who is] over 50 and the status of her breast exams? And do you know every man who is over 55 and the status of his colonoscopy exams? If you don't, you don't have a medical home ...'"

Click here to read about the AAFP's definition of a patient-centered medical home.

Posted at 11:20AM Oct 08, 2009 by Brandi White  |  Comments[1]

Caring for a population ... one patient at a time

Something about population-based care seems inconsistent with family medicine, at least on the surface. If you wanted to improve the health of populations, you would have gone into public health, right? Surely most family physicians are attracted to the specialty by the prospect of caring for patients -- by the prospect of meaningful, long-term relationships with patients as individuals, not the satisfaction of keeping faceless throngs happy.

I was reminded of this by a recent comment on one of my blog entries. Kin Snyder, MD, asked, "What happens to the individual patient in a population-based care scenario? Patients will still want to see ‘my doctor’ when things are going bad for them. They don't want to be known as registry # XXX." Indeed. Nor do family physicians want to spend their lives taking care of registry numbers.

I think this image of population-based care may sell it short, however. Used properly and wisely, it doesn’t turn patients into registry entries; it turns them into healthier patients. The trick is to manage populations and care for individuals.

The locus of care is the exam room, the bedside or the delivery room; that’s where patients are cared for and doctor-patient relationships are built. The trouble is that this caring and relationship-building proceeds one patient at a time, while 1,500 or 2,000 or 3,000 patients think of you as their doctor.

True, the main goal of population-based care may be to increase the percentage of that population who have the interventions they need, but in the process, it helps you keep in touch with them. If having a diabetes registry, for instance, helps you and your staff to get Harry Smith in for his follow-up appointment more regularly, it doesn’t make Harry into registry #XXX; it puts you and Harry together in the exam room when otherwise you might not see him from one year’s end to the next. What’s wrong with that?

Posted at 03:42PM Dec 10, 2008 by Bob Edsall  |  Comments[1]