The Covert Rationing Blog

Hope for the Medical Home?

June 3rd, 2008 by DrRich

Last summer DrRich wrote a post that was pretty hard on the Medical Home, and since that time he has seen no good reason to reconsider his opinion. Rather (as usual after officially pontificating on some topic), DrRich has remained smugly satisfied that he nailed it.

But now something has happened to make DrRich wonder whether some good might come out of the Medical Home after all, namely, that Dr. Centor (the much admired DB) has become formally involved in developing demonstration projects of the Medical Home for the American College of Physicians (ACP) and American Society of Internal Medicine (ASIM).

DrRich is completely serious about this: if DB is involved, the Medical Home is worth another look. DB fully appreciates the importance of the doctor-patient relationship, the limitations of professional guidelines, and the potential for abuse with Pay for Performance. If a model for the Medical Home can be developed that adquately honors these considerations, it could be a very good thing for doctors, patients, and the healthcare system in general.

So DrRich pledges to keep an open mind as he follows DB’s reports on his work. Here are some things DrRich will be watching for, and some questions he will be asking himself as he observes.

1) The concept of Medical Home itself seems quite useful. Under the Medical Home paradigm, patients would have a dedicated personal physician who partners with them, over time, coordinating all their medical care and guiding them, whenever necessary, through the hostile halls of American healthcare. That’s the nugget of it, at least as DrRich understands it.

But really, what’s new here? Hasn’t this been the fundamental idea behind primary care medicine for the past 50 years? Why does the ACP find it necessary, at this juncture, to recapture and rechristen its own central idea?

2) The ACP, to its credit, asserts that the Medical Home will help to repair the doctor-patient relationship. But what does it mean by that? Is the ACP simply referring to the fact that, with a long-term relationship, doctors and patients will become closer, and doctors will get to really know their patients (i.e., will acquire a deep understanding of their medical conditions, likes, dislikes and propensities), which will enable better medical care? These are all good things, to be sure.

But it doesn’t actually address the fundamental problem with the doctor-patient relationship today, which is: doctors have been maneuvered into placing the needs of the payers (whether insurers or the feds) ahead of the needs of their patients. Instead of honoring their defining professional obligation to always make the needs of their individual patients their chief consideration, doctors have been told they need to make the needs of “society” primary.

Indeed, the inability of doctors to honor their fundamental ethical obligation has caused the ACP-ASIM to “revise” its formal declaration of medical ethics (under the theory that if it becomes too difficult to honor a code of ethics, then change it), so as to obligate doctors to honor society’s needs rather than their individual patient’s needs. A patient facing a doctor today cannot know whether the doctor’s recommendations are based on what would be best for that patient, or on what would be best for society (i.e., cost reduction), and for the doctor to place the patient into such a position has become perfectly ethical.

DrRich has gone on and on about how this “new ethic” formally destroys medical professionalism. The question for now is: In repairing the doctor-patient relationship, which ethic will the Medical Home honor, the traditional one or the “new” one?

3) Will the new Medical Home efforts of the ACP look any more promising than its first effort? That first effort was done in conjunction with UnitedHealth Group, and DrRich has written about it here. There was much not to like about it, but chief among them was the new physician reimbursement scheme that it incorporated:

“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 were to 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 doctors make.

Such an arrangement is all perfectly ethical, according to the new ACP-ASIM standards, but it doesn’t do much for the doctor-patient relationship, at least as DrRich conceives of it. Will the next ACP-endorsed Medical Home really be aimed at benefiting the doctor, the patient, and the doctor-patient relationship - or will it again be aimed at benefiting the bottom line?

In summary, given the deep and abiding need of the payers to covertly ration healthcare, given the steps that have already been taken to wreck medical professionalism and the doctor-patient relationship, and given the unpromising initial efforts of the ACP in the Medical Home arena, the sole cause for DrRich to have any degree of optimism is - DB.

To be sure, DrRich does not expect DB to single-handedly get the ACP-ASIM onto the right-thinking path and make the Medical Home what it really ought to be. But DrRich does trust that DB’s heart and intellect are in the right place and that he will make every effort to steer the Medical Home in as favorable a direction as possible. With at least a bit of hope in the outcome, DrRich wishes DB the strength and fortitude this new effort will require, and is very glad that somebody who understands the underlying issues, and who is capable of expressing them, is participating in it.

In the meantime, in order to get all the benefits of the Medical Home, including a fully restored traditional doctor-patient relationship, and without all the insurer’s schemes and incentives aimed at covertly rationing his medical care, DrRich will continue under the care of his excellent retainer internist.

Posted in New business models for healthcare, Primary Care in America

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