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September 12, 2008

The Medical Home: Primary care panacea or the next doughnut hole?

The news on the medical home model this week is good:  A Commonwealth Fund-funded Geisinger study published in Health Affairs demonstrates the extent to which development and implementation of a medical home model can actually prevent those preventable hospitalizations we keep hearing about.  This is a very good thing, and the model described should be studied and replicated to the extent possible.  The current issue of Health Affairs, and companion pieces on the Health Affairs Blog include a range of articles on medical home successes ("medical home runs") and challenges.

What's interesting about the collection of information put forward by Health Affairs is the fact that two studies may reach somewhat inconsistent conclusions: for example, one concludes that smaller practices don't have the resources to invest in personnel and on other fronts, while another finds that small practices are not, by their nature, excluded from the group of medical home runs.          

Also, some of the findings include the conclusion that EHRs are a necessary, but not a sufficient, component of the transformation necessary.  There's a whole lot else that's needed out there, of course, to make a medical home.

At least one resource, however, is a must-have.

The Geisinger study brings to mind a variation on the old joke about an economist marooned on a desert island with canned supplies but no can opener (punchline: "Assume a can opener.")  In effect, the study assumes a sufficient supply of primary care physicians.

I read the following news story this morning:

A growing shortage of doctors willing to practice general medicine has left some [provider networks] desperate for qualified candidates and, in the long term, stands as a major obstacle to overhauling the nation's health-care system.

Almost all changes under consideration include a central role for what used to be known as the family doctor -- today generally an internist or family practitioner -- who can save the system money . . . .

Although such primary-care doctors were once the cornerstone of American medicine, their numbers have dwindled as younger doctors have been drawn to specialty fields by money and the lure of new technology. So today . . . a rising demand is confronting a declining supply.

Funny thing is, this story ran in the NY Times fifteen years ago.  That story continues:

Health economists say that a medical system should have about 50 percent of its doctors practicing primary care, which includes family practice, internal medicine and pediatrics, and that is the mix now favored by most large H.M.O.'s. But the current percentage of primary-care doctors in the country is only about 33 percent, and, worse, it is falling.

In 1992, only 14.6 percent of medical students decided to go into general medicine, an all-time low. At that rate, the proportion of primary-care doctors will drop to 28 percent or less by 2010.

Fast forward to 2008, and only two percent of medical students are looking forward to a career in primary care.  Are we heading towards another doughnut hole -- a future without PCPs?

So the medical home model is being promoted as a solution to the health care financing death spiral, particularly as it relates to chronic care, yet a key component of the model -- PCPs -- is in short supply, and getting scarcer by the minute.  What's most disturbing about this shortage is that it had reached the mainstream media (MSM -- though we didn't use that term then) back in 1993, yet we are still debating in 2008 whether and how to address the issue.

Some provider organizations are promoting the idea of group well-patient visits, as well as other administrative means of extending our physicians -- by physician extenders or otherwise -- so as to spread the PCPs around more efficiently.  To me, this looks like the scotch-tape-and-safety-pins approach to keeping the old jalopy on the road.  A JAMA editorial calls for efforts to hold medical schools accountable for producing the supply of physicians that we need, since they are subsidized so handsomely by the government.  Well, this has been analyzed "six ways to Sunday," as they say, e.g., by the Council on Graduate Medical Education, and, well, ah, um, the analysts haven't always gotten it right.

It seems that we need a broad-based effort to incentivize folks to pursue careers in primary care.  I don't think that an expanded national service program will do it, though that might serve as a template for some future efforts.  Unfortunately, this is just one aspect of our current non-system that seems broken beyond repair. 

-- David Harlow

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The good news/bad news on the medical home front last week was apparent to me, too, and your reminder about the falling number of PCPs is well taken. While no healthcare professional can take the place of an MD, we're going to see more NPs and health coaches round out the PC team to deliver the preventive and DM care that is mandated by the medical home model if the PCp shortage continues.

The medical home may or may not be a solution depending on what it turns out to be. Based on our study in JAMA, students did not pick salary as a reason for not choosing primary care. For them, it is more about the way primary care is practiced (less time with patients, more time with paper work, work/home balance issues), then about take home pay. If the medical home allows for a new system that decreases paperwork and pays physicians for spending time with patients, it may just work. However, if it is a small increase in revenue that requires even more paper work to prove performance, then we will be back to square one. I talk more about the study on my blog at www.drmintz.com

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