Consolidating care (American College of Physicians annual meeting)

A medical home for all patients, with its lure of quality improvements and cost savings, is a concept gaining attention.

By Susan J. Landers — Posted June 16, 2008

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Key to a high-performing, cost-effective system of health care may be the establishment of a patient-centered medical home -- a site where each patient has an ongoing relationship with a personal physician who provides continuous and comprehensive care.

Several sessions of the American College of Physicians Internal Medicine 2008, held May 15-17 in Washington, D.C., focused on this concept.

It's an idea that's attracting the attention of a widening range of players. Physicians, employers, insurers, states and the federal government are thinking about abandoning business as usual in order to try this approach. On May 16, Pennsylvania Gov. Edward Rendell unveiled a program based on a medical home model that is being piloted in the southeastern part of his state. The program, which is expected to be statewide next year, is a collaborative effort between the state and several insurance companies to support primary care practices that change the way they deliver care.

The AMA Council on Medical Education will present a report on "Educational Implications of the Medical Home Model" at the American Medical Association's June 14-18 Annual Meeting in Chicago. The report recommends that the AMA encourage integration of medical education into patient-centered medical home demonstration projects.

Additionally, medical organizations, including ACP, the American Academy of Family Physicians and others, collaborated on the development of "Joint Principles of the Patient-Centered Medical Home." Among them: Care is coordinated and/or integrated across all elements of the complex health care system.

"Patients with medical homes receive better preventive care and report getting more of the care they need, when they need it, as compared to patients without medical homes," said Karen Davis, PhD, president of the Commonwealth Fund, a research foundation in New York City, who gave the ACPmeeting's keynote address.

Medical homes would track referrals, identify abnormal tests and support patient self-management, Davis said. Practices that adopt such measures should be rewarded with extra payments or new methods of payment, as is done in other industrialized nations. Currently, only about 30% of U.S. physicians report receiving such incentives, she added.

An AMA-convened panel recently outlined how Medicare might increase payments to physicians who manage the care of chronically ill patients in its upcoming medical home demonstration project. If the Centers for Medicare & Medicaid Services takes this advice, medical home compensation for physicians could run into the thousands of dollars each month. CMS hopes the extra pay will be offset by cuts in the complex services and hospitalizations required by these patients.

Hypothetical example

The need for cost-effective changes in the way patients with chronic conditions are managed became clear in a conference session during which physicians discussed the care received by a hypothetical older patient.

The patient was an 83-year-old widow living alone in Washington, D.C. Her daughter, a single mother, lived and worked in the D.C. suburbs. The patient developed fever, malaise and mild shortness of breath and went to her local emergency department, where community-acquired pneumonia was diagnosed. She was admitted to the hospital under the care of a hospitalist. She had last seen her primary care physician two years earlier.

Upon discharge, she had many new diagnoses, medicines and appointments, said geriatrician and primary care physician Bruce Leff, MD, associate professor of medicine at the Johns Hopkins School of Medicine in Baltimore, who moderated the session.

"She left the hospital on a very different horse from the one she rode in on," he said. She was newly diagnosed with dementia, depression, diabetes and high cholesterol to accompany her arthritis, osteoporosis and chronic obstructive pulmonary disease.

After a cardiologist, endocrinologist and geriatrician provided their views on what the patient required next -- steps that reduced the number of medications and diagnoses, but not by much -- the audience questioned why the woman wasn't provided a care plan that included her primary care physician.

After all, these illnesses are common among patients they see, several internists said. "The health care delivery system didn't take care of this patient," said one audience member. "The three of you should have sat down together and then sent her home with one action plan."

The panelists agreed that primary care should have been the patient's first stop. "As one of the specialists, she does not need me," said endocrinologist Sanford R. Mallin, MD, a Milwaukee-based clinical professor of medicine at University of Wisconsin School of Medicine and Public Health in Madison.

"Hopefully, a patient-centered medical home would be able to help this patient," Dr. Leff added.

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Wanted: Primary care physicians

The success of the medical home concept will depend on whether the supply of primary care physicians is adequate to coordinate patient care. It may not be, according to several supporters of the initiative.

The number of young physicians entering the field is in "precipitous decline," said American College of Physicians President David Dale, MD, during a briefing at ACP's annual meeting. Even though studies show that primary care has the potential to reduce health care costs, lower reimbursement rates make it a less appealing career choice, he said.

Ryan Mire, MD, an internist in Nashville, Tenn., who participated in the briefing, said that, on average, 20% of his day is spent on patient care for which he gets no reimbursement.

The paperwork many physicians must tackle is another unfunded task.

Yul Ejnes, MD, an internist in Cranston, R.I., said he puts in 60-hour workweeks but spends only about 30 hours seeing patients. "I wonder if I want to keep doing this," he said.

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Primary care doctors first to see common psychiatric problems

Primary care physicians have three options when considering treatment for a patient with mild to moderate depression: watchful waiting, prescribing an antidepressant medication or referring a patient to a mental health professional, said James Levenson, MD, professor of psychiatry, medicine and surgery at Virginia Commonwealth University School of Medicine in Richmond.

Dr. Levenson provided a refresher course on treating depression and anxiety at last month's meeting of the American College of Physicians, in Washington, D.C.

It is widely recognized that the initial treatment of mental ills, such as depression, often falls to primary care physicians. And the World Health Organization predicts that depression will be the second highest cause of disability and premature death by 2020 in most countries, including the U.S.

Dr. Levenson noted that, of these options, watchful waiting is appropriate for depression of recent onset, triggered by a stressor, with only mild impairment and not preceded by a major depressive episode. Patient preferences also are important, he said. Some might not want to start a medication.

If the physician decides to prescribe an antidepressant, determining which one can present a puzzle, he said. Most are likely to start with an selective serotonin reuptake inhibitor, but which one?

Decisions can be based on the drug's cost, half-life, and subtle differences in side effects, he said. Again, a patient's preferences should be considered.

The treatment aim is full remission, but "sadly, less than half of depressions remit with a single antidepressant," he added.

But alternatives exist if the first SSRI fails. Physicians can switch to another SSRI or a different antidepressant class; add a second antidepressant from a second class; augment with a non-antidepressant, such as lithium; or refer the patient to psychotherapy and/or a psychiatric consultation.

Before doing anything, Dr. Levenson recommends evaluating why the response was poor. Determine if the patient actually followed the prescribed dose and duration-of-use instructions. "I'm often surprised by how many patients reduce the dose," he noted. Sometimes they can't afford the medications.

In a separate ACP session about common psychiatric problems, Genevieve Pagalilauan, MD, assistant professor of general internal medicine at the University of Washington, Seattle, advised checking for substance abuse or poor social support as predictors of treatment-resistant depression.

She defined treatment-resistant depression as the lack of response despite using two medications from different classes at adequate doses and duration. At least six weeks of treatment are needed before many patients will respond.

Dr. Levenson also discussed treatment for generalized anxiety disorder, which often overlaps with depression, and is characterized by fatigue, restlessness and sleep disturbances. Although its remission rates with medications are only about 40%, the first-line therapies to try include SSRIs and serotonin-norepinephrine reuptake inhibitors, which are the clear choices if the patient also is depressed. Benzodiazepines also are frequently prescribed, he said.

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Treatment tips

Here are some treatment tips from the meeting:

FRAX new in managing osteoporosis: Given that a main reason for treating osteoporosis is fracture prevention, FRAX -- a recently released World Health Organization tool -- provides a guide for determining patients' fracture risk over 10 years, said Clifford J. Rosen, MD, director of the Maine Center for Osteoporosis Research and Education at St. Joseph Hospital in Bangor. FRAX predicts fracture probability based on age, sex, previous fractures, parents' history of hip fractures, smoking, glucocorticoid use, rheumatoid arthritis and number of drinks per day. Dr. Rosen said this tool will replace dexa scores in 1½ years as the practice norm for determining who to treat. The FRAX tool is available online (link).

Group visits good for type 2 patients: Patients with diabetes who are seen in groups are more satisfied with their treatment, say physicians involved in the visits. Such meetings can promote a partnership between the 15 to 20 patients and their physician or other health care professional, said Dawn Clancy, MD, assistant professor of medicine at the Medical University of South Carolina, Charleston, who has experience with this approach. Such meetings are structured with a 30-minute "warm-up" when vital signs are taken; a 30- to 45-minute educational presentation, with a topic decided on by the group; and then an hour for individual appointments.

IBS may have biological basis: Irritable bowel syndrome is no longer a disease of exclusion and likely has a biological basis, said Dr. Nicholas Talley, a gastroenterologist who studies IBS. "We are identifying biological markers, and they have been coming thick and fast in the last couple of years," said Dr. Talley, also a professor of medicine at the Mayo Clinic College of Medicine. The hope is that therapies will evolve to alter the disease rather than treat the symptoms, he said.

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External links

Meeting details from American College of Physicians' Internal Medicine 2008 (link)

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