Tuesday, April 2, 2013

The Porcinification of Patient Centered Medicine

 

Pig in a Poke

There are many issues which seriously inhibit the goal of patient centered medicine. Despite the well intentioned advocacy by many patients whose healthcare is negatively affected by a disease centric system, and because of  a reimbursement system that now predominates, progress toward PCMC will continue to be slow.

Patient centered care and the family physician’s brain was the topic by Paul Grundy . 

Paul Grundy is IBM’s Director of Healthcare, Technology and Strategic Initiatives for IBM’s Global Well Being Services and Health Benefits.  He has led the development of the Patient-Centered Primary Care Collaborative, which is leading the way to create a more efficient and responsive healthcare system

Richard Young, MD in a post on KevinMD heard Paul Grundy speak recently at the annual meeting of the North American Primary Care Research Group, which is the largest and most influential organization for primary care research. Others sitting at his table said they’d heard him before and that his presentation that day was typical of others they’d heard.   One oddity of his talk was that he showed a model of the Patient Centered Medical Home (PCMH) full of the usual boxes and arrows. It included phrases such as care coordination,electronic medical records, and disease management.  However there was no mention about family physicians or primary care physicians in the process.

All sorts of models have been projected and written about.

Matt Adamson in another post on KevinMD postulates an

 

Optimization of the new PCMH neighborhood.

 

There are a number of care models now being explored to improve the manner in which healthcare can be delivered. Let’s take a quick look at a few of the well known options:

Accountable Care Organization (ACO): The ACO model has the ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory (outpatient) and inpatient hospital care and possibly post acute care. Further, ACOs have the capability to plan budgets and resources and are of sufficient size to support comprehensive, valid and reliable performance measurement. The ACO model is one of the latest designs for managing healthcare costs, especially Medicare costs, and is gaining traction among policymakers desperate to control costs and boost quality in healthcare.

All of this is dependent upon more basic structure, some of which is sorely lacking at present in our system.

Clinical Integration:

Patient Centered Medical Home (PCMH) Neighbor:

The American College of Physicians (ACP) believes that the effectiveness of the PCMH care model is dependent on the cooperation of the many subspecialists, specialists and other healthcare entities (e.g., hospitals, nursing homes), also called “PCMH Neighbors,” to achieve the goal of integrated, coordinated care throughout the healthcare system. The ACP states that the success of the PCMH model depends on the availability of a “hospitable and high-performing medical neighborhood” that aligns their processes with the critical elements of the PCMH.

America is a technophilic society, it makes perfect sense that gadgets such as electronic medical records (EMRs) would appeal to Dr. Grundy and others. However, the evidence that primary care provides better health at a lower cost than multi-ologist care predates all the new gizmos. All the American studies listed in the Starfield analyses didn’t rely on EMRs to achieve their results. Quad Graphics, a large printing company in Wisconsin,  has 18 years of data showing its commitment to primary care has resulted in 30% lower costs than other large employers in its region over the entire time span.

The research on the effectiveness of EMRs is spotty at best. They don’t consistently improve quality, safety, or prevention. About the only care delivery factor they have been consistently shown to improve is they make handwriting errors on prescriptions go away.

I was dismayed that the inherent patient-centeredness of my question didn’t resonate. My question wasn’t just about my needs. When I talk to non-medical people they have the same frustration about their doctors’ visits. We live in a Wal-Mart culture not a go-to-the-market-every-day culture. Americans want to save  up a list of needs then go to the market and have them all met in one visit. There are studies documenting that Americans make fewer visits to primary care physicians than other countries. In Britain, the general rule is the consultation only lasts 10 minutes. If more issues need to be addressed, the patient is expected to make another visit. Most Americans would rather not make another trip.

The E/M rules are way too complicated, but in a nutshell, after I address two issues with my patient the rest of the visit I’m giving away my services. If you’ve ever visited a primary care physician for your migraines and high blood pressure, then was annoyed that he insisted you make another appointment to talk about a rash that just appeared, now you know why he did that. If he addressed the rash on the first day he was paid nothing; if he addressed the rash on a different day he was paid the full fee.

Even if the PCP found a way to address more than one issue he would be barred from billing for the additional service on the same date.  And many patients take time off from work, and travel a significant distance to be seen.  The reimbursement system penalizes PCPs that are ‘holistic’ or comprehensive. In fact under some circumstances it could be considered fraudulent for attempting to deliver patient centric health care.

So, despite protestations that we are attempting to provide patient centric care it becomes an oxymoron in itself.

There are lots of other ways the national bigotry against family medicine, as reflected in the E/M rules, disincentives family physicians from taking complete care of their patients. I’ll cover more of that in a future post.

Patients, keep your hopes high, do not become discouraged.  We have a lot of work to ‘undo’ reimbursement systems that were not in existence 20 years ago.

The good news is that we now have an extended diagnostic code…ICD10. the bad news is that we have an extended diagnostic code ….ICD10.

Will we be successful in modifying reimbursement models down to the daily operations of a hospital, clinic or physician’s office ?

What Dr. Grundy doesn’t seem to understand is that the most important component of any patient-centered solution to our healthcare system is a family physician’s brain. (Sorry general internists and pediatricians. The evidence for better outcomes at a lower cost is much stronger for family physicians/European GPs than your fields.) Family physicians bring to the patient encounter a unique set of skills and approaches to patient care that lead to efficient patient-centered care. An EMR by itself doesn’t add much. I want to be the comprehensive convenient family physician for my patients and I’d like to provide lots of services in one visit. My friends and neighbors tell me that’s what they want too.

And that brings me to a better title for the pronouncements (HOGWASH) of those proposing patient centered medicine. You need to get the ducks in order to produce these results. 

 

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