Hospitals

Specialty docs try to find residence in the “medical home”

Where do specialty doctors like cardiologists, endocrinologists and urologists fit in the “medical home” concept? Or do they at all? A paper published in the New England Journal of Medicine suggests that such physicians may be the odd doc out in healthcare reform. That’s because in the medical home, a popular reform concept that seeks […]

Where do specialty doctors like cardiologists, endocrinologists and urologists fit in the “medical home” concept? Or do they at all?

A paper published in the New England Journal of Medicine suggests that such physicians may be the odd doc out in healthcare reform. That’s because in the medical home, a popular reform concept that seeks to improve care and lower costs, the primary care physician is the star quarterback of a patient’s healthcare team.

Medical home, otherwise known as patient-centered medical home (PCMH), is generally defined as a healthcare delivery model in which the personal physician serves as the ultimate patient advocate, the doc responsible for coordinating “comprehensive and continuous care” among  specialists, hospitals, home health agencies and nursing homes.

It’s not just a pie-in-the-sky concept. The medical home features prominently in the newly passed healthcare law and dozens of pilot programs around the country. Mayo Clinic recently launched a three-year medical home project in Austin, a rural city in southeast Minnesota.

However, specialty docs worry they will lose money to primary care physicians under PCMH.

“Some specialist physicians are raising concerns about the medical home’s implications for their practices,” the New England Journal of Medicine piece said. “Proponents of the model advocate reforms that would increase payments to practices that qualify as medical homes; these payments might well come, directly or indirectly, from funds that would otherwise have been used to pay specialists.”

Which is kind of the point. There is a severe shortage of primary care docs in the United States because specialty docs can make so much more money under the country’s current payment system, a pay for volume formula that favors quantity over quality. Mayo Clinic itself has long argued it loses millions of dollars each year providing primary care to Medicare patients, which is why one of its facilities in Arizona recently decided to stop seeing such patients.

Shifting financial incentives to primary care also makes sense because it will save money in the long run by focusing attention on preventive healthcare. For example, if a primary care doc helps an overweight patient develop a nutrition and exercise regimen (and gets paid for that help), that patient won’t suffer an heart attack and thus won’t need to see a more expensive cardiologist.

Specialty docs argue they should be classified as medical home physicians because they provide the most of a patient’s care anyway, especially ones that suffer from chronic diseases.

But evidence suggests otherwise.

The authors of the New England Journal of Medicine paper surveyed 373 single-specialty cardiology, endocrinology and pulmonology practices across the country, which provide care for patients with chronic illnesses such as congestive heart failure, diabetes and asthma.

Eighty-one percent of the practices reported that they provided primary care services to only 10 percent or fewer of their patients while only 2.7 percent reported they did so for more than 50 percent of their patients.

“How should these findings be interpreted?” the paper said. “On the one hand, they suggest that even according to their own report, the overwhelming majority of specialists provide primary care for very few or none of their patients. On the other hand, a small minority of specialists report serving as primary care physicians for a substantial number of patients.”

If specialists want to get into a medical home, they should do the same chores as everyone else, the paper argues.

“It would be excessively rigid to prevent specialists who want their practices to serve as medical homes from pursuing this goal,” the paper said. “But specialist-based medical homes should be required to meet the same standards as primary care–based medical homes, including the requirements for providing first contact, continuous and comprehensive care and for using systematic processes to improve the health of the practice’s patients.”