Friday, November 7, 2008

Life as a House

Granted, it’s a pretty bad movie—Kevin Kline in the role of George Monroe, who, when diagnosed with terminal cancer sets out to demolish a decrepit metaphor, er family shack, and build a new, beautiful home with his dipsh!t son overacted as usual by Hayden “Anikin Skywalker” Christensen. But, in light of yesterday’s conversation, it seemed a useful setup.

The September/October 2008 issue of Health Affairs features an interesting primer on the patient-centered medical home idea. Definitionally, “a medical home, in broad terms, is a physician-directed practice that provides care that is accessible, continuous, comprehensive and coordinated and delivered in the context of family and community.”

Stop me if you’ve heard this one before.

The article continues, “the current interest in the medical home has derived from growing recognition that even patients with insurance coverage might not have an established source of access to basic primary care services and that care fragmentation affects the quality and cost of care.” Here’s where the link to yesterday’s conversation comes in. Remember that 75% of health spending is tied to a handful of common, chronic conditions often best managed by a primary care quarterback in the outpatient setting.

I think I prefer the idea of “Quarterback” over the 90’s notion of PCP as “Gatekeeper.” The latter suggests a responsibility for denying access while the former elevates and celebrates the pivotal, important role of the primary physician. Virtually all Medicare spending growth from 1987 to 2002 has been traced to beneficiaries being treated for five or more conditions. If you’d like a practical manifestation of this, imagine the plastic pill case. My Mother, like her Mother before, performs the weekly ritual of filling the 7-compartmented plastic case, stamped with the letters of the days of the week, with the assortment of pills that to get her through the day. Many of these pills make the other pills work in the face of the effects of some of the other pills. Makes sense, eh?

And, integrated disease management programs are like Bigfoot, the stuff of legend that few have ever seen. Although, the Chronic Care Model in place at the MacColl Institute in Seattle, might be a talisman for the re-imagining of primary care and a rational assault on chronic expense growth.

This brings me back to provider strategy. One of the biggest barriers to expansion of the medical home idea is a beleaguered primary care physician base – overworked, poorly compensated – and a financing structure that doesn’t reward the type of challenging work, frankly, it seems PCPs are best trained to do. The Health Affairs article reports, “Some interviewed physicians…told us not to ‘help’ them, even with additional payment, by expecting their practices to carry out activities they were not capable of or interested in providing.”

Why keep harping on this? Large institutional structures—tertiary hospitals, academic medical centers, research institutes, etc.—depend on massive flows of cash like swarms of grasshoppers eating their way through a Midwestern grain field. If the field is dead when the grasshoppers get there, they’re screwed. It seems to me a key to sustaining America’s institutional healthcare infrastructure depends on beating the plague that is eating away at the cash stream upon which it depends. The institutional system’s fate is tied to the non-institutional system’s ability to get control of the country’s common health.

What is the right role of the institutional system in advancing ideas like the medical home, especially when some primary care physicians aren’t interested in the job? Certainly highly-functioning EMRs are a core component to the success of a concept like the medical home and the institutional system can facilitate EMR expansion and integration. But, it seems to me, the know-how and resources of the institutional system could be somehow leveraged to help the cause.

I don’t have the answer to this one. But I’ll keep looking. I have to. It seems like a key pillar of our system’s future is rotten at its base and all our strategies, from communications to research to service line growth, are tied to reigning in the appetite of the swarm.

As always, I’m appreciative of suggestions.

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