So, the new euphemism for the medical Gatekeeper is the Medical Home . . . I will discuss the Medical Home on multiple levels. In the end, it is up to the reader to determine if the saying is true, that all politics are local.
Reducing Overutilization and Improving Care via the Medical Home
It makes perfect sense. Having someone oversee care to reduce use of so-called unnecessary services is a great business model. Samuel Shomaker (professor at the University of Texas) states that “(h)ealth care costs cannot be reduced without moving away from a system that rewards providers for providing more services regardless of need, effectiveness, or quality” (2010). As a business owner, I am all for methods to reduce expenses (and, ostensibly, waste) while (hopefully) increasing revenue. There are too many duplicate and, some would say, ineffective services ordered (Reid et al., 2005). As such, the Medical Home appears to be a nice tool to counter that trend. There are certainly times that patients rely (overly so) on specialists when treatment by their primary care physicians would suffice. Just like the Gatekeeper model, Rittenhouse and Shortell intimate that incentives would indeed be provided to primary care physicians for limiting referrals. Again, as a business practice, this is a great solution.
So, it makes sense from a business standpoint. Or does it? According to Kyle Hardy at Healthcare Finance News (October 2, 2009), use of a Medical Home results in fewer emergency room visits (29% fewer), lower “rate of hospitalization” (11% lower) and fewer in-person visits (by 6%). Interestingly, however, was what Mr. Hardy actually included in his report. In describing a 11% lower “rate of hospitalization,” that is only for “ambulatory-care–sensitive conditions” (Reid et al., 2009). In actuality, according to the study there were 3% MORE total inpatient admissions. Further, while there were 6% fewer in-person primary care visits, there were 8% MORE specialist visits. Lastly, Mr. Hardy (and others) describes a large cost savings. The very large drop in emergency room visits did result in substantial (and significant) decreases in emergency room costs. However, costs for primary care, specialist visits and total inpatient costs actually went up (though only the primary care increase was significant). The overall drop (when combining primary care, specialist, emergency room and inpatient costs) was not significant. It is also interesting to note that the medical home and control groups differed significantly demographically (the medical home group was better educated and reported better overall health at baseline); could those differences have something to do with the findings Reid and colleagues reported?
How else is the Medical Home beneficial?
One of the primary benefits of the Medical Home is coordination of care. A friend was recently involved in the sale of a local orthopedic surgery practice to a large health system. Upon the sale, one of the physicians stated, “this can be just like the Mayo Clinic!” For the vast majority of those entering the medical field, I would suspect their goal is to do all they can to help people realize a healthy life, using all the tools and experts we can to target and combat injury and illness. The Mayo Clinic, and academic centers in general, lend themselves quite well to this approach. In fact, if I was confident a local health system could provide the same level of services our clinic does, I too might be interested in such an arrangement.
I don’t know that the only goals of the Medical Home, however, are to reduce costs and improve care. In nearly all the articles I’ve read, one of the other touted benefits is increased use of primary care physicians. The problem with that is the true shortage of primary care physicians the US in general—including the Omaha-area—has. In speaking with Creighton administrators, they are truly struggling to fill those jobs; perhaps the most common complaint is the high cost of education and (relatively) low salary paid to primary care physicians. So, even if the Medical Home was able to do all it said (which I have a difficult time believing) the infrastructure (as evidenced by an insufficient number of primary care physicians) is lacking.
Oh No!!! Just say NO to the New Gatekeeper
I could go on and on about the pros/cons of the Medical Home, especially how the concept will benefit academic centers (like UNMC)—e.g., keeping patients “in-house” and therefore keeping those revenues “in-house.” However, as a clinician working in a free market society, involvement in a gatekeeper-like system is a challenge. I have described in previous essays the challenges private practitioners face and I have touted my strong belief that individuals should be in charge of their destinies, so to speak. I firmly believe that educated, informed consumers with all options at their “disposal” make the best decisions. I have had countless patients that most certainly should continue their care with us but are prematurely discharged based on the antiquated role primary care physicians play in dictating the care of their patients. I believe in the benefits of primary care physicians, but as practitioners who are not “experts” in specific areas, I find it difficult to understand how said physicians can (or should) make decisions for specialist care. If their sole role, in this regard, was to refer to specialists, that is understandable. However, more often than not, these same practitioners become micro-managers of the care specialists provide. Admittedly, this may be a personal soap box issue for me, but just like I shouldn’t be managing the care of patients with Multiple Sclerosis, even though I have been trained to do so, primary care physicians shouldn’t be micromanaging specialist care.
So, from a business standpoint, I understand the logic of the Medical Home model (and I haven’t even discussed the global payment portion of the Medical Home approach). However, because I have not had good results as a private practice, I do not look forward to such an arrangement. Further, and perhaps more importantly, I do not believe research has adequately supported such an arrangement. I will end with the thoughts of Mark Friedberg and his colleagues as printed in the American Journal of Managed Care, “Currently, there is limited evidence that the medical home, as a multifaceted practice-level intervention, will produce the results expected by its stakeholders” (2009).