Friday, August 17, 2007

United Health Care Teams with internist,peds, and FP groups for medical home-for whose benefit

Health Care Renewal raises important concerns and asks pertinent questions regarding the recently announced alliance of Unitedhealth Group and ACP( and AFP,AAP and AOA) here and I will not repeat all of Dr. Poses's points but wish to add a few concerns of my own.

The press release talks about how the physician in the medical home will be responsible for the patient's total health picture. How does that work if/when the patient goes to see another physician for a medical condition outside of the internist's area of competence? This pesky problem of freedom has always vexed planners of medical care systems.Will the patients have to sign some sort of exclusivity care arrangement.?

When I first read about the concept of medical home, I thought it was just another lame attempt by ACP to try and do something to salvage the dwindling away of internists ( I remembered their slogan of internists as "doctors for adults) but although available details (while quality platitudes are plentiful) are still sketchy we can get some sense of what operationally this medical home concept might be-at least in the version involving a major health insurance company. My early assessment is that we will see more of a third party's attempt to save money on health care and exert more control over physicians using a new rhetorical cover .

Let's look at what the press release says about the role that United Health Care will play.

UHC will support it by integrating its extensive quality improvement and care management programs into the practices's infrastructure. I imagine this will include practice guidelines and algorithms and flow charts designed by UHC by some process that mere private practitioners could never generate the mental juice to conceive which will be more efficient (translate save more money) and of course, improve quality.

In regard to the payoff we learn the following:

Unitedhealth Group will pay participating practices a monthly management fee based on projected savings for all patients that select a medical home...the company will share any excess saving (excess saving is an interesting concept) that accrue from the pilot program and by way of premium reductions with employers.

This looks like a combination of capitation and reward for being a compliant doc. Does this sound like an HMO? Is this an early effort to set up the "integrated delivery systems" that I have ranted about before and have been hyped by leaders of ACP and the medical insurance industry.

Apparently some medical groups have agree to go with this. I cannot conceive of agreeing to a set of practice guidelines approved of by a major third party payer and to compensated in part by how well I complied with these guidelines, most if not all of which are not likely to be made known before the agreement and the basis and origin of which are probably proprietary . Talk about selling your soul to the devil and probably for not much of a good price. All this with the blessing and cooperation and encouragement of the ACP and the other professional groups.With friends like the ACP, practicing internists......

I suppose the same could be said for pediatricians and family docs because
the leadership of pediatric and family practices organizations seem to be fellow travelers in this journey to what sounds something that makes regular managed care a pretty good deal.

Dr. David Dale, President of the American College of Physicians offers reassuring words:

Primary care practices should exemplify ...dedication

to team care,...clinical information systems, ...coordination of care ,and (we should never forget) continuous performance assessment and improvement.

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