politics and practice based on mindfulness

Thursday, February 12, 2009

there's gonna be a revolution ... oh yeah

A pilot program in Arizona, based on the "medical home" model,  will give primary care physicians more authority and money than usual to monitor their patients over time and check on the outcomes of outpatient, specialist services.  That is, doctors will be paid to act more like doctors and less like gatekeepers to an expensive maze of services. Instead they'll be paid to ensure that patients have the appropriate care, at the right time and in the right order.

IBM of Arizona is the employer backing this effort.  Impressive corporate sponsor.  According to Dr. Paul Grundy,  IBM's director of health care, "We're not doing this because we expect to see savings ... I think it's the right thing to do."

At the studio I hear about quality of care from my students, who are usually patients, doctors, or nurses.  Based on their complaints, ANY model that increases the time spent attending and listening to patients has to be given a fair trial.  As patients we're swamped with overwhelming information online and we're underexposed to experience and guidance.  Trust in doctors inevitably disappears when they can't spend time to help patients put information in perspective.



Florida doctors declined to participate in a previous pilot of the "medical home" from the same insurer, United Health Group, because they were being asked to do too much for too little reimbursement.  It's a reasonable point, and it displays the power of the current paradigm which mandates almost no money for low-tech, compassionate care.   Some experts on health care policy say the pilot, although promising, will likely place too much stress on small doctors' offices as they adapt to increased paperwork and time demands.  

Outmoded institutional narratives may prevent this model from working widely on a sustainable scale:  
  1. Our healthcare system is not even a system, it's a hodgepodge pasted together by competing private insurers, erratic record management, and the varying financial means of the employers offering insurance.  Pharma ads and the internet compound the chaos, so patients see themselves as consumers not patients.   And I am afraid that individual outcomes will always reflect the unpredictable "system" enveloping doctor and patient alike.
  2. Medical records should all be computerized to make case management affordable.  We'll need to conquer our paranoia about insurers invading privacy and find ways to secure the system. Doctors require quick access to notes from EVERYONE involved in their patients' care.  Alternative practitioners like me should be allowed to enter data on individuals because I spend more time with them than most doctors can.  That way, docs will learn more about complementary/alternative medicine.  Presumably they'll be able to make referrals to CAM with more confidence. As for MY reimbursement issues, that's material for a later blog!
  3. Overuse of high technology will continue to inflate costs.  And high-tech doesn't always equate better diagnosis and care.  Hands-on doctoring and communication with patients (which takes time) may still go relatively unrewarded by insurance because it just doesn't seem as snazzy as MRIs, nor is it easy to assess in a controlled, randomized study.
Having said that, if all the findings about placebos are true (and the literature on placebo efficacy keeps growing), a health care model offering slightly more hands-on care, with a few extra physician phone calls, could make a significant difference to patients.  Trust and connection are essential ingredients in healing, and we need more of both.

(the reporting on the Arizona program is taken from Reed Abelson's story in NYT 2/7/09, B3 "For IBM Insurer Reopens Test of Rewarding Doctors for Healthy Patients")



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