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As the drumbeat of health care reform becomes ever louder, so does the hysteria surrounding system change. Having come of age clinically during the heyday of “managed care”, I find the criticism that “advanced primary care” is just another name for an HMO particularly disingenuous.

In order that some of you might spread the word that this is care far removed from “HumanaCare”, I have taken the Principles from the Patient Centered Primary Care website and noted which were not included in traditional managed care:

Principles of “Advanced Primary Care”  Bold italics  indicates not a part of HMO model

Personal physician—each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice— the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation—the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home:

  • Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
  • Evidence-based medicine and clinical decision support tools guide decision making.
  • Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
  • Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met.
  • Information technology is utilized appropriately to support optimal patient care, performance measurement  patient education, and enhanced communication
  • Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
  • Patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

Payment appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home. The payment structure should be based on the following framework:

  • It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
  • It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
  • It should support adoption and use of health information technology for quality improvement.
  • It should support provision of enhanced communication access such as secure e-mail and telephone consultation.
  • It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
  • It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
  • It should recognize case mix differences in the patient population being treated within the practice.
  • It should allow physicians to share in savings from reduced hospitalizations associated with physician guided care management in the office setting.
  • It should allow for additional payments for achieving measurable and continuous quality improvements.
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From the cardiometabolic risk initiative

I gave a talk to the Alabama Primary Care Association on Lipid Management yesterday and was struck by several things. One was how lipids, along with everything else on the risk factor list (see figure) are affected by diet and exercise. Secondly, was how cardiovascular risk has been incorrectly sold to the American public and the health care enterprise. The National Heart Lung Blood Institute apparently decided that Americans were not going to be able to comprehend the concept of multi factorial risk. The simplistic version of “cholesterol” is 200 GOOD, 201 BAD. The more complex version takes into account smoking status, blood pressure, and sex. The cholesterol calculator then allows the “patient” to make a choice based on a risk determination. I find it to be a much better educational process for my patients and I hope I helped to increase the use of this tool. I was heartened that I was asked the question about “established standards” for review of care. We really are changing the way clinical care is delivered in the ambulatory setting.

  After spending time talking about pharmacologic interventions, I was not surprised to get the question regarding prophylactic use of “statins” in people who are low risk (< 10% mortality over 10 years). My answer surprised even me. As someone who doesn’t take pills, my response was that we as health care providers need to take advantage of the “teachable moment” not to encourage compliance with a potentially unnecessary medication but instead to encourage compliance and problem solve with patients about diet and physical activity. I answered that my response to my increased risk (due to impending “maturity”) was a daily run rather than a daily pill. Like to see Merk selling that, wouldn’t you?

As an academic physician, I only spend about 10 hours a week in direct patient care without residents to teach. I have been in Mobile since 1991and so have a number of folks who I have been treating for almost 20 years. On Friday, I saw 13 patients ranging in age from 10 (a person who when I delivered her weighed 500 grams and is now an honors student) to 89 (whom I did not deliver but who still drives herself to her appointments). In the time the patients were in the office we prevented the flu and pertussis (through vaccination), worked towards early detection of breast and colon cancer (through facilitating screening) and treated a number of acute and chronic ailments. What I did not do is have a discussion about end-of-life care. I was glad the subject never came up.

It’s not that I’m averse to having the discussion. In fact, on your porch over a glass of wine or  professionally if I’m caring for you in the hospital I’ll be happy to delve into the intricacies of whether a feeding tube is a heroic measure required by the Catholic faith. But in an office visit, given that I’m spending 15 minutes with a patient and my staff is busy arranging all of the other aspects of his or her care, that discussion is a time killer.

This is why I am following the “death panel” discussion with such bemusement. When Betsy McCaughey and Jon Stewart are having an esoteric discussion about what is in HR3200, I am wondering just how much they are going to pay me to have this discussion and how they expect me to document it. Ms McCaughey was ticking off the required elements and I’m thinking to myself that if I miss one of these, will I be accused of fraud if I try to bill for the discussion. I am all for the discussion and all for being paid a fair rate for having the discussion. In fact, it has been my experience that most people are 1) aware they will eventually die (teenagers and Boomers excluded)and 2) would like to be assured a modicum of dignity as that time approaches. It is my job as a Family Physician to help them with that.

My problem is with the approach. My conversations with patients about this topic do not tend to happen in a rational 90 minute sit down in an exam room. Rather, they tend to be in 15 minute blocks over a number of visits. As patients become more aware of the limitations of modern medicine, the conversations tend to become more focused.

What I would like to see is not an effort to better pay me for piece work (If I give a flu test I get an extra 10 bucks, I wonder what I’ll get if I talk someone out of a ventilator for their COPD?). Instead, what I would like to see is additional reimbursement (and a lot of it) for always or almost always doing the right thing. That would certification of the practice, similar to hospital certification. The Patient Centered Primary Care Collaborative is pushing for this with NCQA as the potential certifying agency. Then I would have to have a policy in place about, say, Advanced Directives requiring that I document elements of the discussion for certain patients and proof when an inspector came that I was actually doing what I said I was doing.  No more tick boxes, no accusations of fraud, nobody like Betsy McCaughey coming between me and my patient. A guy can dream, can’t he?

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