Two very different views — medical homes and our doctors

Words are powerful marketing tools. Simply naming something to give it a warm and fuzzy connotation can lead us to believe it is something it is not. "Medical home" is just one such word that actually means something very different from what most people think it does. The disparity between what the public is hearing about medical homes, versus what’s being discussed among healthcare professionals was highlighted this week.

“Medical home” is such a nice-sounding term...

To many consumers, a medical home means having their own doctor who knows them and has their interests at heart, who they can see or call when they need, and who can help ensure they’ll get the best care they might need or want. That’s what we’re often told, at least. It’s the program being rolled out as the model reform for national healthcare coverage, and has already been put in place for Medicare and Medicaid recipients. It’s being marketed as a way to reduce healthcare costs, to make sure everyone has health insurance coverage and to improve quality of care.

But that's not what a medical home really is. It's the new feel-good term for managed care, repackaged. Those behind it are counting on today’s generations to not remember the earlier managed care fiasco. They are counting on mainstream media to not reveal that a "medical home" is managed care — care that is mandated and controlled by a third party, using a primary doctor as a gatekeeper, through which you have to go through to access care.

Most doctors and nurses are caring people who went into healthcare to help people and want to be able to spend time with patients and provide the best care possible for each patient. Managed care's regulatory oversight, clinical mandates that aren't always in the best interests of their patients or even scientifically sound, growing paperwork and bureaucratic headaches are the last thing most healthcare professionals want to work under again. So it’s understandable so many medical professionals have been writing furiously about and against medical homes lately.

Marketing of medical homes has gone into high gear, though, with even a new marketing communication publication just launched to track its progress for healthcare businesses and stakeholders, and provide marketing copy to “guide healthcare organizations towards clinical excellence.”

Journalists are uncritically reporting medical homes in glowing terms as the wave of the future. For example, this weekend, readers of the Daily Courier in Prescott, Arizona, read that the medical home model “treats the whole person:”

It's a way to care for people based on what's best - and often easiest - for them and it rewards doctors for spending time with a patient, managing the whole person and not just their current symptoms... A doctor's medical practice would have to become certified and be accountable for results based on quality, efficiency and patient satisfaction. In a nutshell, the concept means that patients will have a primary care doctor who leads a team of health professionals caring for the patient and whose office tracks all of the patient's medical conditions using the latest in electronic records sharing. The doctor alerts patients when it's time for vaccinations, office visits and other medical procedures...

To support this type of care, fundamental changes in the health care system need to occur, including: Paying physicians more for the time they spend with patients evaluating and managing their care. Providing financial incentives for the investment doctors make in health information technology designed to help patients manage chronic diseases and track their progress. Paying doctors for e-mail and telephone consultations... One of the model's most important features is managing a patient's care through a secure electronic system that can connect with local hospitals, pharmacies and other medical caregivers and give a doctor electronic "prompts" that keep track of individual patients' needs.

In contrast — reality for healthcare providers

How many people read that article and stopped to ask who/what is behind those quality and efficiency measures and monitoring our doctors’ practices, the labs and tests they order, the prescriptions they write and how much time they spend with us? How many stopped to ask who is giving our doctor those electronic prompts telling them what they’re supposed to do? And more importantly, how many questioned if these performance mandates are actually measures of evidence-based medical care, are best for us or what we might want? Yet, our doctor’s ability to practice medicine will now be determined by how well he/she complies (called accountability) with these mandates, which makes it important for us to learn about.

Most striking in this article was that it gave the impression that doctors will be paid more so that they can spend more time with us, without revealing just how much time is really being allotted. We just learned the answer to that.

Electronic medical records are the key to medical homes, as they allow monitoring of both consumers’ and doctors’ behaviors. We hear how electronic medical records will increase efficiency, cut paperwork and save costs. The reality for medical professionals is far different, and it goes beyond the expense of implementing these systems. Medical notes don’t speak in clinical language, with descriptions that readily communicate patients’ conditions or needs, for example. They are designed to document compliance with performance and procedure mandates; use of medical supplies, prescriptions and other expenditures; and for billing codes. This has been highlighted by several medical bloggers recently.

As Dr. Westby G. Fisher, M.D., FACC, illustrated, the simplest of nursing notes becomes a long, cumbersome computer record. Talk to nurses where such systems are in place and you’ll hear how much longer charting takes as they have to bring up a new screen for each entry and hunt and peck through options to select the one they need. That’s after waiting for access to a computer. Invariably, with critical patients and hectic shifts, notes are made on scraps of paper, filling their pockets, and overtime hours soar as nurses do their charting at the end of a shift. As Dr. Wes concluded:

[T]hese nursing notes provide lines and lines of very little of substance for doctors to read, read exactly the same from patient to patient (and hence are ignored) and once something is found (like the social issues noted), no description of the issue is provided. Aspects of the new electronic medical record was not made for doctors or our patients, but clearly for quality assurance administrators.

And doctors’ charting — which must correctly and completely code patients’ symptoms, tests and prescriptions ordered, time spent, instructions given and procedures done in order to demonstrate compliance with mandated care guidelines and for doctors to be paid — is even more unwieldy. In an article yesterday, a hospitalist illustrated the “absolute bare minimum” documentation required to receive payment, and how these electronic medical records do nothing remotely resembling simplifying or improving the quality of medical records. “The Medicare National Bank owns your paycheck, so you have to do what they say. It doesn't matter if I'm right or not,” he writes.

This is must reading for consumers who want a picture of what’s going on from the perspectives of a doctor. It provides a glimpse of how third party payers want providers to view us, our healthcare needs and our most private, personal information.

And, can you imagine having to document every moment of your work day like this to get your paycheck? As this doctor concludes:

The sad thing is, if you look at my first SOAP note example, and I was a doc who knew nothing about the patient, and I showed up to read the chart, I would get almost no meaningful information from this pile of crap. But this pile of crap is all structured around people looking at the following four pages below [he provides screen shots] and cross referencing it with my note, to make sure I'm not a fraudster. Just think how many layers of excess waste is built in to justify the existence of rules that really have no patient benefit. If anything, it encourages notes that are clinically irrelevant and lack substance.

But that's the rules.

Dr. James Gaulte, M.D., an internal medicine and pulmonary disease doctor, said this is just a flavor of the onerous and irrational coding games doctors have to play. “Wait until you see what the RUC thinks need to be done to deliver the “coordinated continuous care” envisioned by the pie-in-the-sky Medical Home concept,” he wrote this morning. As he reminded readers, under the Tax Relief and Health Care Act of 2006, the medical home model became a mandated project funded by Medicare.

The rules and fee structures drafted for the medical home model that the government and insurers are planning were just released by a committee (RUC Medical Home Workgroup) of the American Medical Association on April 29, 2008. Developed for the Centers for Medicare and Medicaid Services at the Department of Health and Human Services, these recommendations give a much more realistic picture of the care that consumers can expect with government healthcare coverage.

As Dr. Gaulte writes: “Anyone who thinks the Medicare funded Medical Home will be anything different from the morass of rules and tricks and traps of the fee structure and coding mysteries that typifies dealing with CMS should take a few minutes and read what RUC has authored.” They illustrate how this isn’t about quality of care, but rationing care, controlling care and cutting costs.

For example, under the medical home model, doctors will be allotted 12.5 minutes per month per patient for “very sick” patients, during which time they will be expected to assess, manage and coordinate all of their care needs, and attend mandatory review meetings (every morning, nursing home review, end-of-life nurse meetings, and ad-hoc family meetings that include the medical team). Another “2.5 minutes per patient per month is estimated to be the time the physician will spend in other medical home responsibilities... For the blend of other ‘sick’ patients, it is estimated that the physician will spend only 10 minutes per patient per month.”

Clinical staff time and caseload is similarly dictated. Depending on the tier of care, each registered or licensed nurse will be expected to manage 94 to 150 'sick' patients and 31 to 50 'very sick' patients. The committee allotted 3.5 minutes for a clinic visit for a patient being seen for one condition and up to 9.4 minutes for a patient with 4 or more conditions. “The workgroup then reduced the clinical staff time by 3 minutes per patient in each of the three tiers to account for overlap of one phone call per month due to the “evaluation and management” (E/M) services provided. Each E/M (7 annually) requires 2 nurse follow-up phone calls per the implemented practice expense input data...”

Medical home directs that practices must input data into electronic medical records systems, using software that includes disease management, electronic prescribing, laboratory test result tracking, automatic problem lists, referral history, diagnostic imaging, “point of care evidence-based decision support,” statistical analysis, patient registries, medication lists, reporting...” Medical home management also includes monitoring to ensure use of its “evidence-based medicine” and “clinical decision support tools” — making doctors, as Dr. Fogoros, M.D., wrote this weekend, like trained seals, forced to do what they’re told.

The medical home model not only determines fee schedules, it also directs physicians to supervise and manage the coordination of healthcare that patients receive, their prescriptions, labwork ordered, specialist referrals, etc. in accordance with CMS eligible disease lists. Medical homes necessitate “use of health [risk] assessments to characterize patient needs and risks; identify age, gender and medical condition appropriate preventive medicine services (including the management of obesity, diabetes, blood pressure or preventive health); and communication with the patient, family and caregivers for purposes of assessment and care decisions.” And on and on it goes for 42 pages.

It’s understandable to want to believe that healthcare coverage will mean we’ll all be able to get whatever care we want and it will all be paid for. But the past few days has revealed a different perspective of the medical homes that are being built for us.