Go team! Or, more accurately, “Go physician-led team” was one of the battle cries of the American Medical Association House of Delegates interim meeting.
But what if there are no physicians around to lead the team? Would the AMA be willing to call for a draft where doctors are pulled from comfortable suburban practices and dragged to the rural hinterlands like a professional athlete picked by a new team in an expansion draft?
OK. No more sports analogies. But there is a definite trend of physicians calling for physician-led teams without addressing the realities of the projected physician shortage and the existing “maldistribution” of doctors.
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Without hesitation, Dr. Allan Korn, the Blue Cross and Blue Shield Association's chief medical officer and senior vice president for clinical affairs, declared that the patient-centered medical home has the potential to transform the U.S. healthcare system.
"The things you want going up are going up, and the things you want going down are going down," said Korn in an interview following his appearance Monday on a panel assessing the state of the healthcare industry presented in San Antonio at the MGMA-ACMPE's annual conference. "There's no question that the medical home is working, and that's what's gratifying to me."
While speaking on the panel, Korn said he thinks steps could be taken to improve the patient-centeredness of the medical-home practice model. Still, he said later, medical homes—which use information technology to coordinate care and track the treatment of patients who have chronic diseases—have led to double-digit declines in patients' exposure to radiation from diagnostic tests, in "ambulatory-sensitive" hospital admissions, and in unnecessary and costly healthcare episodes.
They have also boosted physician satisfaction.
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As evidenced by library shelves stacked with medical journals, the science of medicine can be measured in countless ways, but Dr. Richard Levin, the new president and CEO of the Arnold P. Gold Foundation, believes the art of medicine—or at least its effects—can be measured as well.
I spoke with Levin recently during the Gold Humanism Honor Society's fifth biennial conference and 10th anniversary celebration, held in Rosemont, Ill. He told me about the foundation's roots and its work creating an institute for research on humanism in medicine that will be dedicated to studying the role of compassion, altruism and respect in healthcare.
The foundation was co-founded by Dr. Arnold Gold, a professor of clinical neurology and clinical pediatrics at Columbia University's College of Physicians and Surgeons, and his wife, Sandra, who served as president and CEO until August. Levin said Dr. Gold was motivated by seeing how "physicians, seduced by new technology, turned away from the tenets of the profession," such as Sir William Osler's words: "Listen to the patient. He is telling you the diagnosis."
"We got so caught up with the idea that technology could take us out of suffering," Levin said.
To instill professionalism, Dr. Gold initiated Columbia's white-coat ceremonies welcoming new medical students into the field of medicine. Levin said the ceremonies are now an annual ritual at 90% of U.S. medical schools—and he notes that the Golds were able to spread this practice without spending money to promote it.
"There was no endowment," he said. "They did it through sheer will and passion."
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Predictably, the doctor-nurse scope-of-practice turf battle reignited after the American Academy of Family Physicians issued a report that said, essentially, nurse practitioners and other healthcare professionals play vital roles in team-based care that's provided under the patient-centered medical home practice model—but the team needs to be led by a physician.
The American Academy of Nurse Practitioners, in response, issued a statement declaring the AAFP to be "misdirected and out of step with today's environment."
The extra education physicians receive is at the heart of the debate, but Tamara Zurakowski, a practice associate professor at the University of Pennsylvania School of Nursing, said in response to the AANP's reaction: "A nuclear physicist knows a great deal more about the production of electrical energy than a licensed electrician does, but when I need the wiring in my house fixed, I don't hire a physicist."
Though it was the AAFP that fired the initial salvo—and then took the heat for doing so—it should be noted that the AAFP news release included words of support from the presidents of the American Academy of Pediatrics and the American Medical Association and the executive director of the American Osteopathic Organization.
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If the patient-centered medical home supported by per-member, per-month care-management fees becomes the standard primary-care practice model, then Oregon Health & Sciences University in Portland can claim to be its first training ground.
When the CMS announced the names of the 500 participants in its four-year Comprehensive Primary Care Initiative, the list included three OHSU primary-care clinics where residents are trained.
The CPCI begins with Medicare providing a $20 per-member, per-month care-management fee, with that sliding back to about $15 after the second year, when practices will be eligible to collect money from shared savings. Some private payers and state Medicaid programs are also participating in the CPCI, and—with Medicare, Medicaid and private payers combined—the program's goal is to have at least 60% of the participating practices' patient base covered by per-member, per-month fees. The intent is to have the practices use that money to invest in the staff and information technology necessary for care-coordination services that should help lower hospitalizations, eliminate duplicate testing and avoid other inefficiencies that drive up healthcare costs.
Patrick Gordon, program director for the Colorado Beacon Consortium and director of government programs for consortium member Rocky Mountain Health Plans of Grand Junction, Colo., says the program has the potential to "fundamentally change the economics of primary care."
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The 500 medical practices participating in the CMS Comprehensive Primary Care Initiative are going to be under a lot of pressure, as it is now up to them to prove that the patient-centered medical-home model works clinically and economically.
Let's face it: Government-sponsored pilot programs and demonstration projects come and go. Most produce some headlines at their launch, then they generate a few research papers a year or three after their completion, and then they're forgotten.
But hopes are higher for the CPCI, which was described as "very well-conceived, well-designed and, so far, a well-executed program" by Patrick Gordon, program director for the Colorado Beacon Consortium and director of government programs for consortium member Rocky Mountain Health Plans based in Grand Junction, Colo., an area contending for the country's coordinated-care crown.
The key to the four-year effort is that around 60% of the patient bases for participating practices will be covered by plans providing per member, per month management fees. In the case of Medicare, it will be $20, with the fees for Medicaid and other participating private payers yet to be determined.
According to Gordon, it could "fundamentally change the economics of primary care" if the care coordination results in fewer hospitalizations and lower global costs to the country's healthcare bill.
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Just in time for the Republican and Democratic presidential conventions, the American College of Physicians has released a position paper telling the people who keep saying they don't want politicians to get between patients and their doctors to stop placing themselves between patients and their doctors.
"Some recent laws and proposed legislation appear to inappropriately infringe on clinical medical practice and patient-physician relationships, crossing traditional boundaries and intruding into the realm of medical professionalism," Dr. David Bronson, president of the ACP, said in a news release.
The ACP spelled out its stance in a 12-page Statement of Principles on the Role of Governments in Regulating the Patient-Physician Relationship (PDF). The statement noted that of particular concern were laws and regulations "that require physicians to provide care not supported by evidence-based guidelines and/or not individualized to the needs of the specific patient."
Approaching the subject politely, the paper begins by stating that "it may be difficult to distinguish between mandates that interfere with clinical practice versus those that promote good public health," but it goes on to basically say that unless you have scientific evidence supporting your position, don't tell us what to say and don't tell us what to do.
And it's about time someone said it.
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"You've boarded a boat, and you don't know where it's going," Dr. Donald Berwick told Harvard Medical School graduates in a speech published in the Journal of the American Medical Association, but, he added, you still made "a spectacularly good" career choice.
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The two largest primary-care physician organizations support the U.S. Supreme Court decision upholding the Patient Protection and Affordable Care Act, but I know better than to make a blanket statement such as "primary-care doctors cheer decision" even though many apparently do.
The American College of Physicians, with 132,000 internal-medicine physician and student members, is the second-largest physician association and the largest medical specialty society. It doesn't hold back on its assessment of Chief Justice John Roberts' handiwork.
"Every American will benefit from Supreme Court's decision to uphold the health reform law," reads the headline over its news release.
"While the individual mandate and its impact on access to care were the main focus of this court case, the ACA is about so much more than the mandate," said Dr. David Bronson, the ACP's president, in the release.
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