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Saturday, June 19, 2010

Can the Patient Centered Medical Home Save Primary Care?

For years now we’ve been hearing about the trials and tribulations that have evolved in the practice of primary care medicine. However, the discussion has intensified in recent months with passage of national health reform. Recent publications highlight the problems. A paper in the New England Journal of Medicine by Dr.Richard Baron entitled What Keeps Us So Busy in Primary Care?discusses the time spent by primary care doctors on non-visit related work, which according to his findings, interrupts us 43 times daily. Health insurance reimbursement to physicians is “fee for service,” thus leaving all of this work uncompensated. Moreover, health insurance pays better for procedures than it does for talking to patients. These factors have contributed to perverse incentives: “see more patients, run more tests.”

With current relative shortages of primary care physicians, and the anticipation of more patients entering the health system, attracting new physicians to pursue a career in primary care is seen as critically important. However, medical students hesitate to choose it as a career because of its difficult lifestyle, lower remuneration, and the current practice environment. Yesterday I read that HHS Secretary Kathleen Sebelius announced the release of $250 million in new funding to strengthen the primary care workforce. Of this, $168 million is set aside for training more than 500 new primary care physicians by 2015. That's good news, but who is going to want to pursue this training if the value placed on our time remains so low, and the practice pace remains as hectic as it is today?

What is the answer? There are several current responses to the primary care crisis. On the one hand, the advent of retail clinics and retainer fee medical practices, and on the other hand, the Patient Centered Medical Home model, which has established itself with increasing legitimacy as the best solution. The May issue of Health Affairs was dedicated to “Reinventing Primary Care.” For those of you who have not heard of it, the “Patient Centered Medical Home” (PCMH) is a model of primary care that reorganizes the care team in a way that gets non-physicians more involved, supports patient “activation” toward improved self-care, and uses electronic systems—electronic health records and patient portals—to better manage populations of patients, particularly those with chronic illness. In many ways the Patient Centered Medical Home might really be called the Computer-Centered Medical Home.


The PCMH addresses the problem of access to primary care and is particularly appealing as a solution within certain segments of the insured population, namely, Medicaid and Medicare. Physicians have increasingly dropped Medicaid because of its very low reimbursement rates. This has made access to care, despite insurance coverage, very difficult. A similar problem may soon exist within the Medicare population, with physicians dropping or capping Medicare patients, if an acceptable solution is not reached with respect to the SGR and Medicare's payments to physicians drops further.

Intrinsic to the PCMH is the concept that primary care should be reimbursed differently. Under this model payment is both fee-for-service and additionally capitated per patient member within the practice. Results of implementation of the PCMH have been published from Group Health Cooperative in Washington and also recently from Medicare's pilots projects. The Group Health results look promising, showing overall cost savings, related to decreased inpatient and emergency room use. However, reports from the large TransforMED pilot, published in the Annals of Family Medicine, are less promising. "Working feverishly, the 36 participating family practices registered only modest improvements in quality-of-care measures but backslid in terms of how patients rated them." The authors of the summary conceded that medical home transformation "requires tremendous effort and motivation," and that most practices would need outside help, as well as adequate compensation, to make the switch."

Simulateous with the PCMH, retainer fee medicine has appeared in many areas of the United States. Similar to the PCMH, retainer fee medicine, also known as “concierge medicine,” provides extra funding to a medical practice in a capitated manner with a per patient annual fee. The difference is that in the PCMH, the hope is that insurers will provide the additional capitated funding. Another key difference is that PCMH designated practices must prove that they deliver certain elements of care to their patients. In fact, to become certified a practice needs to achieve a long and complex set of criteria. The model has been criticized as being “out of reach” for many small practices, who simply cannot afford the additional layer of clinic administration needed to complete the check list.

In contrast to the PCMH standardization, among retainer fee practices there is significant variability in the type of care delivered, the annual fee charged, and the practice's adoption of electronic systems and quality reporting. This type of practice typically emphasizes a more "Marcus Welby" approach, with emphasis placed on personal communication and the traditional doctor-patient relationship. Whereas PCMH practices emphasize care teams with more participation of non-physician members, and may in fact increase the number of patients cared for by each physician, retainer fee practices typically guarantee that they will care for fewer patients per doctor.

As I see it both the PCMH and retainer fee medicine are reasonable solutions to current short-comings. What's wrong with a "Patient-Sponsored Medical Home" practice, structured as a hybrid of these two primary care models, with built in systems to ensure quality, but also structured with the promise of a smaller patient panel for those want a more traditional doctor-patient relationship ? Can the Medical Home have it's cake and eat it too? Or, will it fail to support the personal aspects of the doctor-patient relationship, the value of which is more difficult to measure with quality metrics and clinical outcomes?

Thursday, June 3, 2010

Regulating Salt

On Wednesdays I like to go to McDonald’s for lunch. This Wednesday, as usual, I ordered a double cheeseburger meal. With medium fries and a Diet Coke this is a good value at $2.99, and it keeps me filled up until dinner. For kicks, today I flipped the place mat and read the nutritional content: 440 calories in my double cheeseburger, 23g of fat, 11g of saturated fat, 80mg of cholesterol and 1150mg of sodium. In my medium fries I consumed 380 calories, 19g of fat, 2.5g of saturated fat and 270mg of sodium. Generally, I don’t worry too much about this tasty weekly bargain, given my relatively healthy diet, daily exercise and normal body mass index. However, some may not agree with my lack of alarm.

Increasingly we’re hearing about government regulation of food. Yesterday I read the May edition of Atlantic Monthly. Its article, “Beating Obesity,” was about the obesity epidemic, comparing and contrasting excess food as a social ill, with tobacco. Much like the tobacco industry, the food industry has been under recent attack for formulating and marketing the addictive processed foods that our children snack on. As we all know, these foods are rich in sodium, sugar and fat, and contribute to obesity and chronic health problems including, hypertension, diabetes and cardiovascular disease, among others. Salt is the most recent of these nutritional poisons to come into the limelight.

There is epidemiological evidence from the NHANES Trial and others that high salt intake is linked with hypertension and an increased risk of cardiovascular disease. A recent meta-analysis published in the British Medical Journal demonstrated worse outcomes in those who consumed a high salt diet. The recommended daily allowance of sodium for people at low risk is 2300 mg. For those at high risk, which I am sorry to say includes healthy me, the recommended daily allowance is less than 1500 mg. “High risk” is defined as: over age 40, people who have high blood pressure or slightly elevated blood pressure, people who have diabetes, and African Americans. This constitutes 70 percent of Americans. Perhaps I should think twice about my weekly meal.

On April 20, 2010 the Institute of Medicine released the report, “Strategies to Reduce Sodium Intake,” recommending that the FDA work with the food and restaurant industry to set new standards for reducing the sodium content of marketed foods. The argument goes that if we all get used to a low sodium diet (less than 1500 mg) at a young age we will change our palates and reduce our cardiovascular risk. OK fine, I’ll give up the double cheeseburger, but not my Kalamata olives, those are Mediterranean, they must be healthy.

A recent New York Times article noted the challenge to the food industry. Salt works synergistically with sugar and fat to mask the taste of foods that without enough salt have the consistency of “damp dog hair.” That doesn’t sound good.

It seems to me that the food industry is in trouble. Regulation of food has become increasingly popular. In 2006 the New York City Board of Health made New York City the first to ban trans fat from restaurant food. Bill Clinton has campaigned to get sugary soft drinks out of schools, which has been demonstrated to be an effective means of combating childhood obesity, Michelle Obama’s current agenda. The movie Food Inc. certainly showed the ugliness of food industrialization in our country, portraying the big business aspect, with its primary focus on mass production. The implication was that the FDA and USDA have been negligent.

In my neighborhood of Decatur, Georgia, located less than two miles from the CDC and Emory University, a new restaurant, Farm Burger, is a big hit, featuring locally-produced hormone-free hamburgers. Farm Burger has very good burgers, but I am a personal fan of burgers at the Brick Store Pub, though admittedly it could be could be its extensive beer list and English pub atmosphere that flavors my preference. I wonder how the sodium content of burgers in these restaurants compares. Should governmental regulatory agencies be getting more involved?