Wednesday, September 5, 2012

Medicare's Advanced Primary Care Initiative

     Medicare, Medicaid and private insurances have come up with a brilliant idea:  the "Advanced Primary Care Practice."  It's also referred to as the Patient-Centered Medical Home, and has shown up under this appellation in many periodicals over the past two years.
     In one of Medicare's Fact Sheets the Advanced Primary Care model (APC) is referred to as "a leading model for efficient management and delivery of quality care," as well as "a re-designed practice that has shifted from focusing on episodic treatment of disease to the holistic care of a patient."
     As a way of giving physicians incentive for practicing in this "innovative new way" the Medicare-Medicaid programs have chosen certain large clinics to use in their "Demonstration Initiative" and are paying them a per member per month fee for "intensive primary care interventions--such as coaching chronically illl patients on effective self-care, working with patients to develop an individual care plan, coordinating with a patient's other doctors and specialists, managing hospital transitions, using technology to track and coordinate patient care...and help patients stay healthy."
     In an example of how an APC model improves patient care, the Fact Sheet gives the example of an overweight patient, Rita, who has diabetes.  When a "team" took her seriously and worked with her, she lost 24 pounds in a year, started a walking program, and got her diabetes under better control.
     The bureaucrats who wrote the Fact Sheet seemed amazed at their "discovery."
     I am wondering where they've been all these years.  Their discovery is the mission statement of family practice, which has been around for forty years.
     Here's the great news, as Medicare officials report it.  "Investing in intensive primary care interventions and care coordination for patients like Rita may prevent hospitalizations, reduce emergency room visits, and control drug costs in many of the states currently investing in APC models, so Medicaid and insurers may save money and improve care."
     The so-called primary care home is nothing more than the kind of family practice traditional solo doctors have always run.  It's the style of medical care I was taught--and the way I have practiced for twenty years, and still practice.
     Ironically, my dedication to caring for patients in this comprehensive, up-front way may be the very reason I'm currently under investigation by the federal government, and it may also be why Medicare has balked at paying me over the past year.  The so-called "innovative method" now being promoted by Medicare and Medicaid as the ideal practice standard for every family doctor, is in fact the model I have been following, routinely, all along.
     It takes skill to establish a patient's trust.  It takes time and money to proffer thoughtful, laborious, preventive care--but it saves everyone in the long run.  Most importantly, from the government's standpoint:  this kind of investment by family doctors prevents hospitalization of patients, and catastrophes, and long courses of rehabilitation, and hefty lifetime medication costs.
     Did I forget to get off the boat somewhere?  Did the rest of the family practitioners in this country abandon their training, ignoring the mission statement of their parent organization, foregoing this devoted style of practice--and have they all resorted to urgent care medicine?
     I doubt it.  In typical fashion, the government is decades behind the rest of us.  And now it's making a big fanfare about something that's common sense, and has been promoted for decades by primary care physicians.
     Nevertheless, I believe a lot of family doctors have been scared out of spending the time it takes to keep patients healthy.  They don't think they can afford precious clinic hours to motivate patients to eat better, quit smoking and exercise.  They aren't getting paid for managing information from specialists, or for cleaning up the mess after patients are discharged from hospitals with medications that seem to have been prescribed willy-nilly.  We family physicians know we can prevent many of the illnesses that cost our system so much money.  But, finally, a lot of us end up doing what's easiest--especially since it's also what gets us paid without triggering audits.  We see patients quickly.  We prescribe what they want.  We try to stay under the radar.  Stories like the one about my office being ransacked by government agents, or my billing records audited ad finitum, are not enviable.
     The time required to prevent end-stage diseases is substantial.  Assisting patients in making life changes is a longitudinal task, and is most likely to be successful when the patient trusts the doctor.  How do you bill for the time it takes to gain a patient's trust?  How can Medicare quantify the value of a doctor-patient alliance? How much is a "relationship" worth?  These are the real questions that beset a third-party payor system like Medicare, and make me question the entire concept of health insurance.  It seems to me that the patient should be the one who decides, finally, whether he or she received "value" for the healthcare dollars spent.
     The problem of covering "advanced primary care" has largely been ignored.  Medicare and Medicaid have traditionally paid big bucks for medical services only after a person's bodily systems fail, and his health is a disaster.  Cardiac catheterization?--no problem, let's shell out $2,200 for that hour of work.  Heart attack, needing bypass surgery and cardiac rehab?--no problem, $60,000 coming right up.
      It's often repeated:  More healthcare dollars are spent on Americans in the last year of life than all the other years put together--unless a good family doctor sits down with patients, and talks about what they want, at the end of their lives, and how to keep them comfortable and close to the people they love, rather than subjected to absurd, heroic procedures in sterile hospital quarters, their families in shock and disarray.
     Intensive discussions to help reduce the risk factors for heart disease yield $0, for family doctors--unless their patients had insurance, starting in 2010, for smoking cessation counseling ($12-$15) and dietary interventions ($18).  Heart attacks and strokes are preventable--the time it takes to prevent them needs to be covered by insurance.  End-of-life discussions should be mandatory.  But there's no code for the time spent talking about death, or living wills--and no payment. No wonder doctors don't do it.  No wonder medical students aren't choosing family practice.  The average salary for a cardiologist is two to five times more than that for a family doctor.  Translation:  Fixing heart attacks is more important, to Medicare, than preventing them.
     The Primary Care Home now held up by Medicare as the gold standard is exactly the kind of practice I've been running for many years.  I don't know any other way to be a doctor.  It isn't innovative.  But it turns out to have become unusual, I guess--and I find this odd.  I was trained to do everything, as we used to say, in the office.  What happened?  When did family doctors stop doing everything?  Did I miss the fire alarm?

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