Medical Home

A term you will hear used frequently in the months to come is "Medical Home." The concept of a medical home is already being developed in a few of the major medical centers in the nation and has been shown to correct many of the deficiencies in our present healthcare system . Briefly it comprises all elements of health care, for the most part under one roof. A sort of "one-stop-shopping" approach to the delivery of medical care. If the concept--as it now exists in some centers--is analyzed carefully, it can be seen that it might well be the answer to reform of the deplorable healthcare system we now have in place--a system that we can blame on no one but ourselves.

To understand the potential of a "Medical Home" we need to take a look at health care in years past: How did our present system evolve? What is the root cause of its deterioration into the costliest among the industrialized nations of the world and that produces the worst outcome of care?

For the moment, envision what medical care was like immediately following WW II, about the time antibiotics came on the scene. Most people had a family doctor that they turned to for whatever ailment that arose. The family doc managed most illnesses with the tools available. He/she often did surgical procedures, delivered babies, treated broken bones, and even provided much of the psycho-social counseling of that era. The family physician was always available, accessible--a quasi-member of his patient's family--and never appeared to be obsessed with financial reward for his services.

As time passed, more specialization emerged: specialists in surgery, orthopedics, internal medicine subcategories, to name a few. Their presence in every community of any size provided the primary care physician, the family doctor, a referral source for complex problems. Quality of care, as measured by today's standards, improved remarkably with the arrival of more specialists, but at the same time the cost of care escalated.

Next came the federally funded Medicare and Medicaid programs and the beginning of the spiraling growth of private insurance. Blue Cross/Blue Shield led the pack. The insurance industry grew by leaps and bounds. This was followed by the "Managed Care" concept--the HMOs and Preferred Provider Organizations, and multple variant systems--structured to capture as many of the health care dollars as possible. These embryonic sub-systems of the 1990s as well as those of today have focused on profit margins, often using denial of benefits to achieve operating profits. Unfortunately most have neglected to impose adequate quality control measures as they have grown. 

Now, add to the hodgepodge of super-specialists, primary care physicians, insurance payers, the various reimbursement systems, and the multiple other healthcare providers that are competing for a share of the healthcare dollar--Hospitals, Nursing Homes, Day Surgery Units, Imaging Centers, Laboratories, Home Health Organizations, Rehab Centers, Specialty Hospitals--and you have our present fragmented system. It is the most costly per capita and has produced the worst outcome among idustrialized nations and leaves millions uninsured or underinsured.

So, what happens? Cost of care escalates out of control, quality of care deteriorates, greed drives providers to reach for more and more of the medical care dollars, some by performing medically unnecessary procedures and diagnostic testing, and others by having a financial interest in entities to which they refer. Consumers demand more care, whether or not medically necessary. Insurance companies simply smile when the cost and abuse increases: they raise the premiums, co-pays, and deductibles to cover the increase in skyrocketing cost, and take their management percent to the bank. 

Not eveyone can afford the costly health insurance even if it is available. It's not unusual for a family to have to allocate 50% of their expendable income either for healthcare insurance or for the staggering medical care expenses that they face if they don't have coverage. So often the only alternative is to choose bankruptcy.

How would a so-called "Medical Home" concept gives us a healthcare system that leaves no one behind, that contains overall cost, and improves the quality of care? The "Medical Home" model--an example is the Mayo Clinic in Rochester, Minnesota--is a comprehensive integrated concept that assigns patients a lead doctor, a primary care physician, who coordinates all of the patients care. This includes referrals for diagnostic testing, referrals to specialists, and referrals to ancillary facilities. The key to the success of health delivery systems, such as the integrated "Medical Home" model is simply this: Accountability. Every patient of the totally integrated system has access to needed healthcare: preventive care, emergency-urgency needs, treatment of crippling chronic disease, and necessary mental health care. Every treating provider--physicians, qualified medical provider, ancillary facilities--is held accountable for appropriate care, from the standpoint of quality, medical necessity, and cost.

Regarding reimbursement, an essential element for comprehensive healthcare is adequate compensation for the front-line primary care physicians who are in a postion to provide necessary preventive care and oversee referrals to competent secondary providers. Almost daily I hear stories of the difficulty people have in finding primary care physicians--family practice physicians and internist. Many of these sorely needed physicians are dropping out of practice or pursuing other medical fields. There has been a significant drop in the number of young physicians entering primary practice training programs. This must be corrected by adequate compensation for these doctors who will play such an important role in overseeing utilization and quality in integrated "Medical Home" concept or in any plan that's adopted to reform our healthcare system.

Another essential element that will insure quality of care as well as appropriate cost and outcome is the Electronic Medical Record (EMR)--it should be made available to all providers involved in the care of any specific patient, assuring transparency in the continuum of care by all caregivers. 

Is any system that conforms to the above description of a "Medical Home" attainable? Of course it is; but only if payers, consumers, and all providers buy-in to the concept, have input in developing criteria for medical necessity of care, and if our lawmakers refuse to yield to lobbyists for the greedy special interest groups who have produced the present national healthcare disaster and who advocate a continuation of the status-quo system.

Charles Clark, Sr., M.D.

www.charlesclarknovels.com

Health Care Reform 2009

At some point in time–hopefully before the Social Security System becomes bankrupt–our lawmakers and leaders have to accept the stark reality that a continuation of the same healthcare system that we have been accustomed to in the past is NOT going to work in the years ahead. The system must be totally reformed--restructured in a way that incentives for providers to provide more and more service, whether or not it is medically necessary, have to be removed. Reimbursement must be denied for referral of patients by physicians to entities in which they, the physician-providers, have a financial interest: entities such as laboratories, imaging centers, day surgery units, hospitals, home health agencies; or to entities from which a physician receives a stipend in return for referrals. Joint ventures between hospitals and physicians must be scrutinized thoroughly and should always be transparent insofar as the public is concerned.

If the cost of health care is ever to be contained, the concept that more is better must be abandoned. Likewise, the health insurance industry must abandon the policy of ignoring over-utilization of services by healthcare providers and subsequently raising the premiums, deductibles, and co-pays--to be paid by the insured--when the cost of health care escalates from the medically unnecessary over-utilization of services. The health insurance industry should be mandated to focus on appropriate utilization and quality, instead of on loss ratios.

Basic Healthcare is a right of every person in this country and it should be affordable, available, and accessible. No one should be left uncovered. There should be no denial of benefits based on pre-existing conditions. If anyone is economically underprivileged, healthcare should be available through special federally funded programs. Individuals who elect to avail themselves of unlimited services over and above Basic Healthcare--without concern for whether or not those services are medically necessary--should be privileged to purchase health insurance for that purpose, without compomising the cost of federally funded Basic Healthcare for every resident in the United States.

How do you define Basic Healthcare? It should be rich in practice guidelines for all health care providers to follow in their care of patients, and its structure should reflect a consensus of input from all providers--physicians, hospitals, ancillary free-standing entities, nurses, and ancillary service providers, all of which must be held accountable for the expenditure of the taxpayers' health care dollars.

Is any political candidate or lawmaker brave enough to ignore the overpaid lobbyists and make those changes? If not our broken healthcare system is doomed to self-destruction.

Medication Error Cover-up

On Wednesday, September 24, 2008, one of the Corpus Christi local television stations reported a news item of significant community interest. The Christus Spohn Shoreline Hospital, a part of the giant not-for-profit Christus Health System, was the site of a major medication error event: Eleven patients had been given doses of a cardiac medication by mistake instead of an innocuous drug ordered for some digestive disorder. There were two reports--on the 6:00 pm news and again on the 10:00 pm news. The report stated that the error had been confirmed, but the hospital officials had no comment other than to say they were looking into the occurrence. 

There has been absolutely no comment by any other news media and no comment or explanation by the Christus Spohn Hospital officials since. Isn't the public entitled to know: What were the drugs that were administered in error? What adverse effects could these drugs have produced? Was there any morbidity as a result of this error? What measures have been taken to assure that similar errors do not happen again?

The focus of concern by the hospital industry and the Joint Commission for the months and years ahead stresses the need for transparency and for patient safety . Can either goal be achieved with cover-up like we're seeing here with this occurrence?

A few weeks ago a medication error occurred in the same hospital system that received nationwide publicity--wrong dose of Heparin given to several newborn infants. It is understandable that the hospital would not want another life-threatening error to receive similar notoriety.

But the mystery still stands. How did the hospital manage to pull off the cover-up? And how often does cover-up occur?

Medication Error

Fourteen babies given too much blood-thinner Heparin.

Sad but true. An example of an error that can occur in any hospital. Our hearts go out to the many distraught parents of these tiny infants ... just imagine the turmoil going on in their minds. These are premature babies who are strugging for life and the least complication will sometimes tip the scales the wrong way. The death of two of the preemies, however, is likely not the result of the heparin overdose.

Fortunately, the other babies will survive thanks to the timely intervention by the the Neonatal Intensive Care Unit nurses and the astute Neonatologists who promptly discontinued the medication, and there is little likelihood that there will be any residual effect from this catastrophe. But the issue here is not so much the injury to the little patients, but is the occurrence of a preventable medication error in one of our community hospitals. You can be assured that a root cause analysis will be performed on this case that hopefully will serve as an educational tool for all hospitals.

There is a lesson to be learned from this sentinel event: Not only do hospitals and all other healthcare entities need to sharpen their vigilance when it comes to preventing medication errors, they need to take extreme measures to provide patient safety on all fronts.

Charles Clark 

Elizabeth Edwards and Mandates

Mandated enrollment into the present healthcare system as a means to achieve universal healthcare, as suggested by Elizabeth Edwards in a recent interview by ABC News' Molly Hunter, will not work unless measures are put in place to control cost and to improve quality of health care. Without cost control measures, premiums, deductibles, and co-pays will continue to escalate. Without quality control we will still have suboptimal outcomes of treatment which in turn leads to increased cost.

Basic health care for everyone is essential, but reimbursement should be denied for medically unnecessary procedures and diagnostics above that which is basic. For a definition of "basic" healthcare, read my blog titled: Basic Healthcare. There are two major initiatives which, if ever launched, would reduce medically unnecessary utilization of health care benefits. One is stringent practice guidlines,created from a concensus of opinion by medical specialties, for treating the most frequently occurring illnesses . The other is denial of reimbursement for referral by physicians and other providers to entities in which they have a financial interest (imaging centers, laboratories, home health agencies, hospice services, and day surgery units, for example).

Quality Improvement is a must. The CMS has already initiated "core measures" in four areas at present--heart failure, heart attacks, pneumonia, and surgical complications--to achieve better quality of care. There will be more measures added in the future that will demand more attention to preventing medication errors, to the appropriate treatment of diabetes, and to infection control in health care facilities, to name a few. All healthcare providers will have a financial incentive to improve.It's the "Pay for Performance" concept.

Without Utilization of Benefits Control and without Quality Control, costs go up which, in itself, leads to increses premiums and deductibles. The payers (the health insurance entities) and the health professionals, with our present system, have no incentive to control costs and to improve quality of care other than integrity. And unfortunately integrity is often missing.

It is encouraging to see that a few of the political leaders in the country are taking a lead roll in taking action to repair the present healtcare system in the United States.