THE DOCTOR’S OFFICE
By BENJAMIN BREWER, M.D.
I’ve always considered my practice a one-stop shop for nearly anything medical. We can provide the initial evaluation for almost any problem and treatment of most things. My wife considers my practice my second home, considering all the time I spend there.
Recently, the Illinois Medicaid program decided that nearly every recipient of public aid needed something called a “medical home.” The idea is to provide an accessible, lower-cost point of entry into the health-care system than a hospital emergency room. A practice that agrees to provide the home makes a commitment to take an active, integrated approach to coordinating a patient’s medical care.
Does the “medical home” system sound like a good one to you? Do you think some patients would take advantage of it? Is there a lesson here that might lead to solving our current health care crisis? Join a discussion.2
My practice signed up for the medical home program. It was either that or opt out of Medicaid entirely. Because we’re in a rural area with a lot of patients on public assistance, we decided to give it a try. Last May, we became the official home for 177 Medicaid recipients. The next month we were shocked to find ourselves responsible for coordinating the care of more than 2,200 people on Medicaid. By July, those who had signed up or were placed on our roster by the state leveled off at about 1,700. Patients can change doctors if they want to. The advantage to us is that for the first time ever an insurer, in this case Illinois Medicaid, is compensating us for being a medical home, something we were already doing in large measure. If Medicare and private insurers acted the same way, I’d be more hopeful about the future of primary care. (See this article3 on the efforts of a business coalition to shore up primary care through medical homes.) We’re receiving an average of $2 per person per month in addition to our office visit fees for services that we had traditionally been obligated to provide free.
At our practice this means patients’ records are maintained electronically. Patients and their doctors have 24-hour access to the information or advice from us by phone or email. We provide prenatal care, delivery services, child and adult care in the office and the hospital. We measure our quality quarterly by looking at some key indicators. We don’t avoid patients of any age or gender or those with chronic, pre-existing conditions. We maintain a list of available specialists and coordinate referrals and follow-up.
Two bucks a month may not sound like much for all that work and responsibility, but it should just about cover the costs for our electronic medical records, computers, quality tracking and annual IT support. For the insurer and for patients, there should be savings and better health. Patients who don’t have a medical home incur higher health costs and report more illness.
A case in point comes from the 875 readers of my last column4 who anonymously completed the online health survey called “How’s Your Health” that I mentioned. Some had primary care doctors in addition to saying they are seeing a specialist. Of those people, 25% said they’d lost track of “who is in charge” of their care. These people reported a 100% increase in being hospitalized or using the emergency department in the last year compared to those with a single doctor coordinating their care. In addition, the group that said it “doesn’t know who is in charge” had a dramatic decline in all indicators of health. (Thanks to Dr. John Wasson at Dartmouth and Dr. Gordon Moore at the Ideal MicroPractice Project for crunching those numbers and passing them along.) If the gaps in care for these astute WSJ.com readers resulted in such problems, I can only imagine what folks with lesser skills and means would report. Back in the ’90s, managed care failed at cost control by trying to make primary care physicians gate-keeping clerks and pushing the liability risks for such management on doctors. I’m not advocating a return to that failed approach.
But it makes sense to me that there be fair payment for primary care services that require a lot of what is now largely uncompensated work beyond an office visit. The cost would be peanuts, and the benefits of improved care could be enormous. What’s missing in the debate over our nation’s health-care crisis is that primary care is cheap. Cheaper than your cellphone bill. Cheaper than a tank of gas. Cheaper than dinner and a movie. It’s so cheap the average person doesn’t value it properly. I could have covered my salary for 2007 and the costs of all my staff and overhead for less than $20 per patient per month, including maternity and hospital care. My practice covers 80% to 90% of what the average person would ever need a doctor for. Compare that to what you or your employer is paying for health coverage, and you’ll find that the high costs are due largely to catastrophic illnesses, hospital charges and money going to middlemen.
Even though I’d like to, I can’t offer comprehensive primary care on a subscription basis for $20 per month. The Illinois Department of Insurance would send me to the slammer for running an unlicensed insurance company.
But most Americans could afford a package that combined $20-per-month primary care, $4 generic pharmacy prescriptions and some catastrophic coverage. If the combination was tax-deductible for the individual, then I think it would be a slam dunk. Netflix can rent you 4 movies a month for $23.99, but I’m not allowed to rent you a medical home for less than you’d spend to watch a movie each week. Before we’re saddled with an unaffordable national health plan, we should consider renting an affordable medical home.
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(1) http://forums.wsj.com/viewtopic.php? t=1355
(2) http://forums.wsj.com/viewtopic.php? t=1355