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Home Wrecker (part 2) - Revenge of the Primary Care ProviderMonday, November 30th, 2009
As I wrote in a previous blog post, the approaching fire storm over the “patient-centered medical home” model reminds me of the destructive powers seen before in HMOs. Once seemingly destined to revolutionize organized medicine, the HMO model nearly destroyed it.
We can learn from past failures. We need to promote best-practice models and make physicians accountable for their actions, both physiologically and fiscally. To this end, the medical home should only include specialists; the PCPs must be “homeless.”
HMOs failed the patients who felt they were locked out of specialists and costly treatments by parsimonious PCPs. Specialists had no effective limits on the tests and procedures they ordered, and profited greatly by them. If specialists did not work in a capitalist model in which they were paid by procedure (albeit at a negotiated rate), they would then be able to use their past workload to upgrade their next per-member, per-month capitation rates. The PCPs were left trying to bring the costs down by “gate keeping” the patients, while working with specialists who were out of their control, and patients who were frustrated and out of their minds.
I say we make the specialists arrange themselves into medical homes—and then let them bid for the individual PCPs (in a capitated manner) and the patients they “deliver” into their organizations. Successful specialists would need to keep costs down and satisfy patients in order to make their high incomes while out-bidding other homes for the PCPs that would be needed to deliver the volume of patient required for sustaining the practice.
It is the neurologist who always orders the MRIs on every patient, and then reads all the (in-office) EEGs and EMGs that they recommend; the cardiologists who always need an (in-office) ultrasound and treadmill study, who recommend the pacer vs. the dual-chamber pacer vs. the synchronized pacer vs. the implantable defibrillator; the rheumatologist who repeats the bone density studies even when it would not change the treatments; the urologists who order the brand-name bladder spasm meds that work no better that the generic versions. I mean no disrespect to my specialist colleagues, but you get paid more to say "Yes" than you do when you say "No." It is not the role of the PCP to question or argue the necessity of an expensive study or medication once the specialists have convinced the patients that they need it. However, it does become our burden to get the insurance company to approve it. The PCP may be the gatekeeper in this system up to now, but he or she sleeps in the guardhouse while the specialist lives in the mansion.
The specialists, in this specialty medical home, would fight it out among themselves as to how to apportion reimbursement, for their procedures as well as for the hospitalizations (many of which could be prevented if appointments to the specialists could be made in a timely manner—but that's for a later discussion). The money left over, after their cost-effective, best-practice modeling, would be needed to bid for the patients that the PCP would deliver. If practitioners in these specialty medical homes cannot satisfy the patients’ needs, let them be responsible for approving and paying for the out-of-home specialists the patient demands to see. Let it be on their heads, not the PCP.
Best of all, the data we would need to price all the specialty care is readily available—it is held by the insurance companies. Say what you will about the insurance industry—their suspect motives, their exclusions, their profit, their frustrating paper walls that guard their empires—they know actuarial data and they sure know how to bean count. The insurance companies know where the insurance money goes, to which specialty fields and for what procedures and tests, and can set targets and reimbursements better than any government could. That is their strength (perhaps their finest—and only worthy—contribution to healthcare) and the medical system should tap into that. Then let the competing specialty interests fight it out to the benefit of the patients and the PCPs.
The medical home I envision empowers the PCP to manage his or her practice in the patients' best interests. The PCP is best able to judge the actions and reactions of the specialty care his or her patients receive. The PCP is best able to judge if the specialists are providing the very best in cost-effective medicine. If these standards are not met, the PCP could take his or her business and patients elsewhere, making them potential home wreckers with a mandate and a mission, forever searching for a good, stable medical home.
COMMENTS
jp55 - December 2, 2009 - 12:00:00 (CST) Bless Dr. Buckenwalds poor ,little heart.He is delusional. Firstly, as a practicing hospitalist and "part time "addiction specialist he doesn't have any patients to "deliver". "His" patients are "his " for a shift or two, then "belong" to some some other soul who is working for wages, not the benefit of "His" patient.
Secondly,he continues under the delusion, that " specialists"(does he mean "proceduralists")are some how making out like bandits. Not so. I practice with primary care physicians who derive more income from ordering lab tests than I do from doing procedures, and who take NO call, and have a remarkable ability to be home by 5 pm and not in the office after 1 pm on Friday.Every weekend off..Banker's hours, except for the extra half day off on Tuesday , Wednesday , or Thursday .Thirdly,I am not aware of ever having the luxury of having the much suffering and abused primary care physician getting my recommended procedure approved.I wish it were so.Fourthly, if the current fee for service system (being paid more for doing more) leads to overutilization ( which it no doubt can) why doesn't he see that MORE fee for LESS service leads to underutilization?(Does his Hospitalist contract have a clause for extra loot for lowering utilization in one form or another?)Which is worse ?From the patients perspective, I mean.If one takes the position that Medical care is on balance HARMFUL, then underutilization is clearly better. Does he actually believe this?Finally,he seems to have this fantasy of being "bidded for" by "specialists" who will (finally) realize his dominance at the top of the Medical foodchain.Sorry. Not gonna happen.Better to try and increase his self esteem (and income)by regaining the trust and loyalty of the PATIENT by returning to the traditional model of primary care physician, who is able,available, , capable, and affable..Otherwise , Dr.Buckenwald should HOPE for a return of the HMO model to prevent the growing irrelevance of and impending extinction of his specialty. alan berkenwald, md - December 20, 2009 - 12:00:00 (CST) In response to jp55, I would like the record to note that I closed my practice in primary care as an internist 18 months ago, after 28 years of practice. Couldn't take the insurance and paper work anymore.
So...I knew the rewards of primary care. However, I wish I knew the joys and pleasures of jp55's colleagues who never had call obligations, made out like bandits on lab income, and were always home for dinner at 5 pm. What country did you say you practiced in?
In closing, National Lampoon said it best a few years ago with their cover issue, "Medicine - Our Nation's Number One Killer". They were talking about our economy and lifestyle. Quite prescient. Sheila Smith - July 23, 2010 - 1:52:21 (CDT) Dear Dr. Berkenwald,
I am a health economist - and have also noticed the similarities between the capitated HMO with gatekeeper, and the most extreme models of Accountable Care Organization(ACOs). Specifically, it seems to me that the coordination and integration of care, plus extensive consultations with patients in order to make sure they understand the options for treatment would be an extremely time-consuming undertaking, not just a small add-on that could be easily handled with a 10% increase in fees. But the only source for additional funds to pay for all this is to decrease the use of specialist care, which is where health economists think the inefficiencies are. In addition to the likelihood that patients would probably not be pleased to have anyone with the power to say no to specialist consultations, it would also be necessary to decide which specialists are needed, and to place constraints on what they are allowed to do - based on SOMEONE's decision. So if someone has to coordinate and deny some requests, that person is the gatekeeper - PCP or not. I am curious - do you think that it would be feasible to implement a bundled payment for all specialty services on a broad basis? I am thinking that it would require that physicians be salaried in order to function, and that the most-qualified specialists probably not choose to do it. The PPACA requires that CMS pilot projects be voluntary, so it is hard to see how this would work unless a broad range of specialist physicians were willing to choose this salaried, constrained environment. What do you think? - July 23, 2010 - 5:08:21 (CDT) The idea behind "Home Wreckers" is to avoid the tension between the PCP and the patient, where the specialist may make recommendations directly to the patient - forcing the PCP to authorize them without any input - hence the resulting dynamic tension that builds mistrust between PCP and the patient when the recommendation is questioned.
If the specialist is the "gatekeeper", he will need to convince the PCP - in addition to the patient - that his recommendations are valid and worth following. Now we have a fair dog fight - PCP vs Specialist - in the patient's best interest. But, this happens behind the scenes, for if the PCP disagrees too often with the specialist, the PCP will take his patients elsewhere for their specialty care (say, every 6 months or a year, when 'enrollment' of PCPs would occur). Plus, every test/procedure comes out of the specialist's pocket, not the PCP (who would be capitated by the specialist)
Thus, if all the specialists were "bundled", the PCP (representing the patient) would not be able to parse out those specialist that were doing too many unnecessary procedures and tests that only they - the PCP - can evaluate fairly. (Once the patient is told he needs a test/procedure by a specialist, it is the rare patient that confirms this recommendation with his PCP before submitting.)
Insurance companies have all the actuarial data needed that would allow them to set a price per patient per month for that specialty PLUS the average "price" of the PCP. This money would be under the control of the specialists. If he wants the business of a PCP - and his panel of patients - he would have to bid against other similar specialists in his field for the PCP. The specialist becomes the effective gatekeeper in his own field, and manages his specialty practice for the panel of patients that the PCP delivers.
If the specialists choose not to "volunteer" for such a panel, so be it. Others will, and will grow their practice to accommodate the patients that the PCP sends them - so that the PCP can get his share of the capitation as well.
Adam Smith's "Invisible Hand" can only work the crowd that controls the money - the Specialists, the PCP, and the Insurance company. Definitely NOT the patient who has not control or choice over his premium dollar.
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 Alan Berkenwald, MD Dr. Berkenwald graduated from BU School of Medicine '78 and is board-certified in Internal Medicine. He is now working as a Hospitalist in a community hospital in Northampton, MA, the medical director of a local Skilled Nursing Facility, and practices addiction medicine part-time. In the Name of Medicine Alan Berkenwald, MD Understanding today's practice of medicine by stopping, taking its pulse, getting a good history, looking back, and then applying those observations towards its future.
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