In a CNN, of all places, web piece by Shawn Tully, the author lists five areas of major concern in the health bills. Some are spot on and some are open for interpretation. Yet hidden in the middle of the article is the following:
"The Senate bill requires that Americans buying through the exchanges -- and as we've seen, that will soon be most Americans -- must get their care through something called "medical home." Medical home is similar to an HMO. You're assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.
Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. It was consumer outrage over despotic gatekeepers that made the HMOs so unpopular, and killed what was billed as the solution to America's health-care cost explosion."
Before commenting let us present the Bill and its wording. We use HR 3200 since I have been studying that at length. The Bill states:
"DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS
TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS Sec. 1302. Medical home pilot program.
SEC. 1302. MEDICAL HOME PILOT PROGRAM.
(a) IN GENERAL.—Title XVIII of the Social Security Act is amended by inserting after section 1866D, as inserted by section 1301, the following new section:
‘‘MEDICAL HOME PILOT PROGRAM ‘‘SEC. 1866E.
(a) ESTABLISHMENT AND MEDICAL HOME MODELS.—
‘‘(1) ESTABLISHMENT OF PILOT PROGRAM.— The Secretary shall establish a medical home pilot program (in this section referred to as the ‘pilot program’) for the purpose of evaluating the feasibility and advisability of reimbursing qualified patient-centered medical homes for furnishing medical home services (as defined under subsection (b)(1)) to high need beneficiaries (as defined in subsection (d)(1)(C)) and to targeted high need beneficiaries (as defined in subsection (c)(1)(C))."
Now you must begin to parse the words. They are important. We will get to defining a Medical Home in a moment but read the enabling legislation. It is:
1. a pilot program
2. Targeted, and that I believe is an operative word, to (i) high need beneficiaries and (ii) targeted high need beneficiaries. Frankly I do not see the difference other than the word targeted, but wait, the Bill defines these terms.
The Medical Home pilot will do the following:
"‘‘(3) MODELS OF MEDICAL HOMES IN THE PILOT PROGRAM.—The pilot program shall evaluate each of the following medical home models: ‘‘(A) INDEPENDENT PATIENT-CENTERED MEDICAL HOME MODEL.—Independent patient centered medical home model under subsection (c). ‘‘(B) COMMUNITY-BASED MEDICAL HOME MODEL.—Community-based medical home model under subsection (d)."
Now to the Definitions:
‘‘(b) DEFINITIONS.—For purposes of this section: ‘
‘(1) PATIENT-CENTERED MEDICAL HOME SERVICES.—The term ‘patient-centered medical home services’ means services that—
‘‘(A) provide beneficiaries with direct and ongoing access to a primary care or principal care by a physician or nurse practitioner who accepts responsibility for providing first contact, continuous and comprehensive care to such beneficiary;
‘‘(B) coordinate the care provided to a beneficiary by a team of individuals at the practice level across office, institutional and home settings led by a primary care or principal care physician or nurse practitioner, as needed and appropriate;
‘‘(C) provide for all the patient’s health care needs or take responsibility for appropriately arranging care with other qualified providers for all stages of life;
‘‘(D) provide continuous access to care and communication with participating beneficiaries;
‘‘(E) provide support for patient self-management, proactive and regular patient monitoring, support for family caregivers, use patient-centered processes, and coordination with community resources;
‘‘(F) integrate readily accessible, clinically useful information on participating patients that enables the practice to treat such patients comprehensively and systematically; and
‘‘(G) implement evidence-based guidelines and apply such guidelines to the identified needs of beneficiaries over time and with the intensity needed by such beneficiaries.
‘‘(2) PRIMARY CARE.—The term ‘primary care’ means health care that is provided by a physician or nurse practitioner who practices in the field of family medicine, general internal medicine, geriatric medicine, or pediatric medicine.
‘‘(3) PRINCIPAL CARE.—The term ‘principal care’ means integrated, accessible health care that is provided by a physician who is a medical subspecialist that addresses the majority of the personal health care needs of patients with chronic conditions requiring the subspecialist’s expertise, and for whom the subspecialist assumes care management."
"‘‘(B) COMMUNITY-BASED MEDICAL HOME DEFINED.—In this section, the term ‘community-based medical home’ means a nonprofit community-based or State-based organization that is certified under paragraph (2) as meeting the following requirements:
‘‘(i) The organization provides beneficiaries with medical home services.
‘‘(ii) The organization provides medical home services under the supervision of and in close collaboration with the primary care or principal care physician or nurse practitioner designated by the beneficiary as his or her community-based medical home provider.
‘‘(iii) The organization employs community health workers, including nurses or other non-physician practitioners, lay health workers, or other persons as determined appropriate by the Secretary, that assist the primary or principal care physician or nurse practitioner in chronic care management activities such as teaching self-care skills for managing chronic illnesses, transitional care services, care plan setting, medication therapy management services for patients with multiple chronic diseases, or help beneficiaries access the health care and community-based resources in their local geographic area."
‘‘(C) HIGH NEED BENEFICIARY.—In this section, the term ‘high need beneficiary’ means an individual who requires regular medical monitoring, advising, or treatment. "
In a way this is the chronically ill, the Type 2 Diabetic, the congestive heart failure, the patient with COPD. It seems not to include the cancer patient, the broken leg, or even the day to day practice of medicine. It seems targeted at those who frankly use most of the health care facilities by their continuing return to them.
The program will be evaluated on the following:
‘‘(e) EXPANSION OF PROGRAM.—
‘‘(1) EVALUATION OF COST AND QUALITY.— The Secretary shall evaluate the pilot program to determine—
‘‘(A) the extent to which medical homes result in—
‘‘(i) improvement in the quality and coordination of health care services, particularly with regard to the care of complex patients;
‘‘(ii) improvement in reducing health disparities;
‘‘(iii) reductions in preventable hospitalizations;
‘‘(iv) prevention of readmissions;
‘‘(v) reductions in emergency room visits;
‘‘(vi) improvement in health outcomes, including patient functional status where applicable;
‘‘(vii) improvement in patient satisfaction;
‘‘(viii) improved efficiency of care such as reducing duplicative diagnostic tests and laboratory tests; and
‘‘(ix) reductions in health care expenditures..."
The patient concerns is seventh. But frankly the intent is not bad. It takes those patient who often dominate the costs, in almost all cases there is an existing diagnosis and course of the disease, and manages it. This is a patient management system. If you have Type 2 Diabetes they will try to manage you. If you have COPD the same applies. You may live a long time but the way it is managed now you may be seeing dozens of physicians and wasting resources. Is this rationing? Frankly I think not. It is good sense. It also is a trial.
And now how much will this cost? Well the Bill states:
‘‘(1) OPERATIONAL COSTS.—For purposes of administering and carrying out the pilot program (including the design, implementation, technical assistance for and evaluation of such program), in addition to funds otherwise available, there shall be transferred from the Federal Supplementary Medical Insurance Trust Fund under section 1841 to the Secretary for the Centers for Medicare & Medicaid Services Program Management Account $6,000,000 for each of fiscal years 2010 through 2014. Amounts appropriated under this paragraph for a fiscal year shall be available until expended.
‘‘(2) PATIENT-CENTERED MEDICAL HOME SERVICES.—In addition to funds otherwise available, there shall be available to the Secretary for the Centers for Medicare & Medicaid Services, from the Federal Supplementary Medical Insurance Trust Fund under section 1841—
‘‘(A) $200,000,000 for each of fiscal years 2010 through 2014 for payments for medical home services under subsection (c)(3); and
‘‘(B) $125,000,000 for each of fiscal years 2012 through 2016, for payments under subsection (d)(5). Amounts available under this paragraph for a fiscal year shall be available until expended."
That is only a bit shy of $2 billion. Peanuts!
So let's go back to the CNN article. Our approach has been to deal with the facts. The Medical Home is a Medicare Trial, and a worthwhile one indeed if it stays to the chronically ill. The author of the CNN article seems to imply that this Trial applies to all! I cannot find that in HR 3200. This continues a problem I have with the media, they fail to reference the specific statement, the words, and then they go off in a screaming tangent. Upon my first reading of the CNN piece I thought there would be fire here amongst the smoke. No, sorry, it may even be a great idea!
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