The medical home – a rationale


Category : Medical Rants

Conflicts noted – both organizations in which I have had leadership roles have endorsed and advocated for testing the medical home.

I attended an excellent discussion of the medical home yesterday.  The idea combines several concepts:

  1. Patient care benefits from coordinated care
  2. Physicians will provide better systems of care if they receive some compensation for that provision.  By this I mean telephone access, email access, etc.
  3. Paying piecemeal for telephone calls, emails and the like is not feasible nor practical.
  4. A single global fee for all care might discourage patient visits.
  5. Therefore, combining a monthly management fee – which is meant to pay for all our "extra" time – with a fee for service for visits seemed to the ACP to make the most sense.

I like the concept of rewarding physicians for providing access (telephone, email) and hopefully enough money to spend more time with patients. 

The devil is always in the details.  That is why ACP and SGIM are cooperating on demonstration projects.  We are looking at the consequences, intended and unintended. 

Will it work?  I certainly hope that we can use the projects to determine the proper fees so that internists (general and participating subspecialists) can take proper care of their patients. 

This is an experiment worthy of our support.  SGIM is committed to analyzing the projects.  ACP is committed to finding insurance partners to fund the projects.  The two organizations are working closely so that in the next few years we will be understand how such a system might improve or worsen the field.  That being said, outpatient internal medicine has become so unattractive that supporting this experiment seems that last best hope for the field.

And that is my somewhat biased opinion.

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Comments (2)

Knowing how you love the RUC, just wanted to mention that they have been studying the Medical Home issue in the last month.

Few people are more aware of the need for a medical home than a patient who’s being bounced from specialist to specialist without finding a root cause for bothersome symptoms I’m having (tachycardia, shortness of breath, high blood pressure).

However, as my little tour through the world of outpatient medicine reminds me, it’s unlikely I’m going to find anyone to really going to step up and do intensive case manaegment unless the entire reimbursement system is stood on its head.

Right now, I’ve seen:
* My PCP, who, with a Holter, has documented that yes, my heart is going a wee bit too fast at times

* My psychiatrist, who knows me well enough to know when I’m having panic attacks. He and I believe that’s not what’s going on here.

* An allergist who says I have a tight chest and shortness of breath due to moderate asthma

* An OB/GYN who’s concluded that no, menopause isn’t causing the tachycardia, but can’t help otherwise.

* A pulmonlogist who concluded, after sleep lab testing, that though I have sleep apnea, it’s too mild to be causing the HBP, tachycardia and exhaustion.

* A cardiologist who tells me that the Holter and lab work I have aren’t “worrisome” but proceeds to schedule me for an event monitor and an echo (presumably because I *don’t* have a problem? you tell me!)

Now, the nice people at the PCP practice are trying to do the right thing. They’ve made some phone calls and collected some test results. But I think given the handful of (otherwise minor) ailments I have, and how they’re tangoing all over me, I need a real case manager.

As the managed care system stands, however, I think I’m going to have to pay for one out of pocket. Got any better ideas? I’d love to hear them.

Signed one tired, frustrated lady… 🙁

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