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Friday, March 03, 2006

ACP'S " Advanced Medical Home" will that dog hunt?

If you live in Texas, sooner or later you have to say something about "dogs and hunting" and I apologize in advance for seeming to treat a very serious,and I presume thoughtful, set of suggestions from the American College of Physicians in what seems to be a flip manner.

The ACP rightfully claims that primary care medicine is in a crisis mode. I agree. Their proposal called "Advanced Medical Home" (AMH) call for widespread changes in reimbursement, practice mechanics and systems and even medical education.

The proposal recommends:

"Voluntary certification and recognition of primary care and specialty medical practices that provide patient-centered care based on the principles of the chronic care model; use evidence based guidelines, apply appropriate health information technology, and demonstrate the use of best practices to consistently and reliably meet the needs of patients while being accountable for the quality and value of the care provided".

The ACP calls for:

public policy and third party financing changes and changes in medical education and national pilot testing of their proposal.

Reading though the 20 plus pages (plus appendices) I am somewhat discouraged by finding every current buzz word and platitude that are usually used in policy wonk type discussions of health care ( patient centered, value, best practices,etc,etc) but it is clear that primary care is in trouble and the ACP is at least aware of some of the issues. They seem to rely on the hope that evidence based medicine and information technology and the team approach will save the day for primary care and that somehow or other the folks with the check books (CMS,insurance companies) will cooperate with their suggestions.

The model that they proposed is supposed to improve quality and reduce cost and physicians can share in this "system wide" savings. We all know how physicians shared in the cost savings that Managed Care was to bring about. In this era of evidence based medicine where is the evidence of efficacy or safety for what they propose? Where is the evidence that this approach will save money.

Will what they propose matter? Will anyone ( CMS and third party payers)
listen? Does it all make any sense? I would be very interested in what the real doctors out there think about this.


Anonymous said...

So who is supposed to certify the docs who sign up for the Medical Home practice model,the ivory tower academic types who populate the ACP? I wonder why CMS would fund these proposed pilot projects unless they perceive it would decrease Medicare expeditures.I believe the ACP's proposal will do as much good as the AMA's signing on with P4P scam for put-upon primary care IM docs.

Anonymous said...

Like many other docs, I work with noth the "ivory tower" academics and with and the private practitioners (some of whom round in multiple hospitals),

Both have expressed concern that the "advanced medical home" will end up being used most by patients who would not benefit from such a model, such as:
*patients with mild, easily controlled disease (but high socioeconmic status)
* pts with fibromyalgia or other mutiple somatic complaints looking for a diagnosis or treatment plan they like
*pts with one very serious disease who would best be served only by subspecialists

Obviously this model is desgined for patients with multiple diseases involving many organ systems. My collegues and I wonder is that is how it will actually be applied.

Anonymous said...

lets face it, the only solution for primary care docs is capitation..it rewards good doctors who have lots of patients, but rather than pay them based on how many widgets they crank out per week, per month, per year, it pays them based on the size of their practice..big practice, big paycheck; certainly there needs to be monitoring re. patient access and patient satisfaction..but it really is a no brainer..the rest of this non-sense about paying for quality and advanced medical homes is crazy...pay me $10-15 pmpm and all this other stuff will go away...frankly, if you have a small, two-bit practice, you don't deserve to get paid a lot...if you have a big busy practice, you deserve a lot more...this isn't rocket science people