Medical Home Invasion

Posted on August 24, 2007
Filed Under Gekkonian Rationing, Primary Care in America |

Last year, the American College of Physicians (ACP) published a “policy monograph” on the Advanced Medical Home, which urges a “new” model of medical practice. Under the “medical home” paradigm, patients would have a personal physician who partners with them over time, coordinating all their medical care and guiding them, whenever necessary, through the confusing halls of American healthcare. Among the many benefits of such a practice model, the ACP notes, would be a strengthening of the doctor-patient relationship.

“Great idea!” DrRich found himself exclaiming when he first read the monograph. In fact, DrRich has felt this to be a great idea for 35 years, since he was first starting out. Indeed, this has been the fundamental idea behind behind primary care medicine for, well, forever. Heck, it was the driving force behind Marcus Welby. So why did the ACP (one of the premier organizations of primary care doctors in the world) find it necessary to “rediscover” its own central idea, and then to rechristened it? What gives?

Reading more carefully, DrRich found in the ACP monograph some clues. The medical home would require doctors to adopt evidence-based medicine and decision support tools to “guide” medical decisions, to demonstrate continuous improvement in key quality indicators, and to participate in programs that measure and report overall performance. Further, the medical home would require a new kind of reimbursement model for doctors. The specifics of such a reimbursement scheme were unspecified, but pay-for-performance was mentioned. Hmm.

Then, earlier this month light was shed upon what, exactly, gives. The beans were spilled by means of a press release issued by the ACP, two other prestigious primary care organizations - the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics - and UnitedHealth Group. (That’s right, UnitedHealth Group, the Uber-HMO.) The press release is titled “UnitedHealth Group and physician groups to launch ‘medical home’ pilot program to reward primary care doctors who improve patients’ total health.” (More details were provided by the AAFP here.)

In the press release, UnitedHealth Group (which at least was cagy enough not to put “and physician groups” in parentheses) gets top billing. And as you read the press release it quickly becomes apparent why they do - it’s their show.

In the pilot program for health home, UnitedHealth Group will provide participating physicians with “quality improvement and care management systems,” and the means for incorporating these tools into their practices. Apparently, then, UnitedHealth Group will control the data and the “decision support tools” for determining when and how patients are treated, and for what. Fear not, however, since all medical decisions supported by these tools will be geared toward both “quality and efficiency.”

Available public documents on this new effort do not specify what will happen when medical decisions that lead to optimal outcomes will result in significant increases in spending, rather than in “efficiencies.” (Contrary to managed care dogma, improvements in quality do not always result in cost savings, and vice versa.) But the medical home pilot, as one would predict for any healthcare scheme heartily endorsed by a major health insurer, has safeguards to assure that when quality and cost are at odds when making medical decisions, doctors will always tend to err on the side of reducing costs.

This is made plain by the new physician reimbursement scheme to be used by the medical home pilot:

“UnitedHealth Group will pay participating physician practices a monthly care-management fee based on projected savings for all patients that select a medical home. In addition, the company will share any excess savings that accrue from the pilot program with the physician practices and — by way of premium reductions — with employers.”

That is, doctors will be paid according to their ability to not spend UnitedHealth Group’s money on patient care. The less they spend on patient care, the more they make.

DrRich gets it now. This is not some new, revolutionary reimbursement scheme. It’s the same old reimbursement scheme, slightly dressed up.

Supreme Court Justice David Souter said it plainly in 2000, writing for a unanimous court in Pegram vs. Herdrich:

“Like other risk bearing organizations, HMOs take steps to reduce costs. These measures are commonly complemented by specific financial incentives to physicians, rewarding them for decreasing utilization of health-care services, and penalizing them for excessive treatment. Hence, an HMO physician’s financial interest lies in providing less care, not more….Inducement to ration care is the very point of any HMO scheme…”

UnitedHealth Group is simply responding to the request by the ACP for a “new model” of primary care by giving them what they want. But you can put lipstick on a pig all day long and it’s still a pig. Whether you call it medical home, pay for performance, or just plain managed care, as long as the big insurers (and the feds) are the ones who determine the doctor’s viability as a practitioner, and as long as patients are the individuals who cause doctors to risk their viability as practitioners, the genuine practice of medicine - and the fabled doctor-patient relationship - must remain fond dreams.

Comments

4 Responses to “Medical Home Invasion”

  1. Greg P on August 25th, 2007 9:08 am

    How about this model?
    United Health pays primary care docs a lump sum for each patient, based on an estimate of the recommended/required visits (variable according to various diagnoses), tests that the patient should receive over a set amount of time.
    Consider it a “wellness payment”.
    After that, UH’s efforts are to make sure that its subscribers are using the services they are paying for, and assuring that the quality of the services meets ACPs guidelines. No quibbling about money after the agreement is signed.
    This may seem strange, but this is exactly how health insurance works.

  2. Trusted.MD Network on August 25th, 2007 9:30 am

    The medical home: “You can put lipstick on a pig all day long and it’s still a pig”…

    Is UnitedHealth playing the ACP for a bunch of fools?…

  3. Zagreus Ammon on August 25th, 2007 1:31 pm

    Can’t argue about rationing. As a family physician my job is to be an advocate for the patient. Sometimes that means less testing, not more. The data is clear: having a medical home and maintaining a relationship with a primary care doc reduces overall health costs. This is in the interests of the patient.

    However, where a profit motive and financial incentives exist, they also serve to erode the trust between patient and physician and the whole system goes down the drain.

  4. The Covert Rationing Blog » Blog Archive » Weep Not for UnitedHealth Group on September 6th, 2007 9:22 am

    [...] on the wall, and to devise new business models to take up the slack. Pay for Performance is one. UnitedHealth Group’s foray into the Medical Home is another. And recently, as pointed out by Dr RW and Retired Doc, the Wonkonians have demonstrated [...]

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