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ickly painlessly and at the end of a long and healthy life as a loved one of mine who is closer to this than many puts it someday i just won t wake up morbidity compression if he is lucky if we are all lucky that will be how it happens but right now our health care system is in fact designed to treat acute conditions and acute exacerbations of chronic disease not to maintain the care and the health of people who have not yet developed chronic disease or are stable more to the point our system does this because this is what is paid for we are just scratching the surface of the ideas of chronic disease management in fact we pay so well for acute interventions that hospitals are hiring acute interventionalists at extraordinary salaries compared to their colleagues in the same specialties that actually manage people over time for example stroke neurologists or sometimes interventional neuroradiologists who can inject clot busters into the arteries of people with acute strokes make perhaps 2 3 times what a neurologist who just manages chronic neurologic diseases does not that much more than regular radiologists who are overall much higher paid this is because the hospitals that employ them are so highly reimbursed for these procedures the need to manage actual people especially when they have chronic disease not just an acute episode is obvious to most of us it may even be obvious to the insurance companies and other payers to the hospitals who support the acute interventionalists but so far they haven t changed what it is that they pay for what it is that is financially incented i write a lot about primary care but it is not only primary care commenting on my last piece social determinants key to the future of primary care a neurologist colleague who cares for people with amyotrophic lateral sclerosis als lou gehrig s disease a terrible and always fatal degenerative condition that satisfies almost none of the criteria for morbidity compression wrote but the group health care model is also the best for chronic rare diseases managed by subspecialists this is what we do in als clinic on monday mornings you should come visit josh at 8 when all the folks speech therapy physical therapy occupational therapy social workers dieticians equipment providers respiratory therapy meet with the neuromuscular neurologists to discuss each case then we see them and all weigh in and we give patient a printout with advice from each but alas there is no way to pay for this without support from local and national foundations medicare doesn t cover it by far i wrote back of course in this sense you are sharing the same issues as primary care doctors you are managing patients not just a single episode of disease certainly als is a disease but it is a chronic one that takes over people s and their family s lives and requires not only complex and interdisciplinary but long term management indeed the concept of the medical home was developed in the 1960s by the specialty pediatricians managing kids with chronic diseases such as cystic fibrosis juvenile diabetes and sickle cell which share with als the fact that there is one disease that dominates the lives of the patient and their family to care for it requires managing not just the disease but working with the whole person and their family it can also but is not always in practice be true of hiv clinics this is less true of many other adult diseases which often co exist diabetes hypertension congestive heart failure chronic lung disease depression arthritis so that one specialist is not interested in or perhaps capable of managing them all thus primary care for adults geriatricians etc it is virtually not at all true of those who do radiology anesthesiology single time consults or one shot surgery or one shot into the cerebral artery neuro interventionalists or to be short any of the folks making a lot of money for single things while the stuff that you do in als clinic is not paid for this is insane we do not have a health system and we do not even have a health care system we have a medical care system with the emphasis on the medical it is fine to pay for an episode of care but it is much more important to reward care 1 asch da volpp kg what business are we in the emergence of health as the business of health care nejm 367 10 887 89 doi 10 1056 nejmp1206862 2 marvasti ff stafford rs from sick care to health care re engineering prevention into the us health system nejm 367 10 889 91 doi 10 1056 nejmp1206230 3 freeman j towards a definition of holism br j gen pract 2005 feb 55 511 154 5 pmc1463203 read more labels als asch and volpp health health care kodak marvasti and stafford medical care neurologists primary care railroads re engineering specialty care wholism 0 social determinants key to the future of primary care a perspective in the september 6 issue of the new england journal of medicine becoming a physician the developing vision of primary care 1 by kathleen a barnes jason c kroening roche and branden w comfort addresses the change in the practice of primary care enabled by changes in payment and structure and how this is more attractive to medical students all three are medical students although kroening roche already has both his md and mph from schools in different parts of the country harvard oregon and kansas they met at the harvard school of public health and all of whom seem to be interested in being primary care physicians they describe a model or more accurately as they say a vision of primary care practice in which they see themselves in the future and about which they are enthusiastic by extension one would hope that this is also true of many other medical students the practice that they describe is quite detailed in many ways a day in a primary care office would begin with a team huddle the team would discuss the day s patients and their concerns they would review quality metrics emphasize their quality improvement cycle for the week and celebrate the team s progress in caring for its community of patients the rn would manage his or her own panel of patients with stable chronic disease calling them with personal reminders and using physician directed protocols the social worker nutritionist and behavioral therapist would work with the physician to address the layers of complexity involved in keeping patients healthy clinic visits would ideally be nearly twice as long as they are now it sounds great as the authors note there are practices that are working toward and in some cases have begun to achieve this new model of care these 3 did not originate these ideas practitioners and thinkers such as tom bodenheimer joe scherger bob phillips and kevin grumbach have written about this and many practices particularly integrated groups such as kaiser permanente inter mountain health care and geisinger clinic have implemented many of these characteristics but will it be the future of all health care will importantly these changes or ones like them both provide the functionality that the health system needs from primary care and the physicians entering into this practice in many articles including transforming primary care from past practice to the practice of the future 2 bodenheimer has emphasized the need for teams from a practical standpoint there are more people needing care and not enough primary care physicians to provide it phillips o brother where art thou an odyssey for generalism presented at the society of teachers of family medicine annual conference in may 2011 shows data indicating that even including mid level providers such as advanced practice nurses and physician s assistants there are way too few primary care providers and the trajectory of production is in the wrong direction our own data 3 show the marked decrease in the number of medical students entering family medicine and other primary care specialties in the last dozen years so it is profoundly to be hoped that the model of care described by these authors develops that they are able to develop it and that it will attract more future physicians while practice change is hard and culture change is harder there are issues that these authors talk about but do not seem to overly worry them they note the importance of the affordable care act and how it emphasizes population health and primary care services and establishes accountable care organizations that require strong primary care foundations but do not in my opinion adequately address two key challenges to implementation that will present profound obstacles to the achievement of their vision the first is payment reimbursement allocation of health care dollars they assume that thanks to a restructured reimbursement system medical assistants will have protected time to provide health coaching for behavior change and to ensure that the patients on their panel were current with their preventive care because reimbursement would be through global payments linking hospitals to primary care practices the physician too would have a financial incentive to keep patients healthy it is a great model and one that i agree with but it hasn t happened in most places because it is more costly and requires significant investment in prevention and primary care and since there are unlikely to be additional dollars in the health system it will mean lower reimbursement for hospitalizations for procedures and for the specialists who are the currently the most highly paid this i would argue would not be a bad thing but it will not happen easily those who are doing well under the current system are going to fight to hold on to it and the reimbursement structure is not changing quickly enough to push such change outside of integrated health systems and even within many of them the second is what can be summarized as the social determinants of health good public health students they observe that the health care system must strive to affect more than the 10 of premature mortality that is influenced by medical treatment and note correctly that primary care cannot be primary without the recognition that it is communities that experience health and sickness providing better health care is imperative but insufficient this is true but there is more to it health care in itself even well organized with adequate numbers of primary care practices working in teams and collaborating with public health workers and going out into the community and employing culturally competent health navigators guides case managers promotoras is not going to do it alone the social determinants of health have to be addressed by the entire society poverty unstable housing food insecurity cold and the social threats that often accompany the communities in which they are prevalent violence drug use abuse etc will continue to create situations in which people are not healthy and need medical care even in the larger society in the part where people are not living at the edge there are many anti health forces stress including the stress of working harder and at more jobs to keep away from the edge the ubiquity and ease of access of poor quality high calorie food and the shredding of the social safety net that is almost gone for at the bottom and fraying at the sides social security medicare are not harbingers of a happier healthier society i am thrilled about the enthusiasm of these young physicians and physicians to be and their commitment to primary care and a new kind of practice they begin by observing echoing bob dylan from 50 years ago and more important the movement that was growing then that times are changing but i fear we are not yet clear what that change will be there is tremendous energy and even more money behind a change that will be for the worse for everyone except the most privileged they end by saying that we are here to engage in and advance the movement they are talking about transforming primary care but i hope that they and their colleagues recognize that it will not be enough unless they are willing to engage in and advance the movement to transform society in full disclosure one of the authors branden comfort is a student at the ku school of medicine although he has spent his clinical years at our wichita campus i know him well because we worked together in the student run free clinic and he was my advisee in his first two years here in kansas city 1 barnes ka kroening roche jc comfort bw the developing vision of primary care nejm sept 6 2012 367 10 891 4 2 margolius d bodenheimer t transforming primary care from past practice to the practice of the future health aff millwood 2010 may 29 5 779 84 3 freeman j delzell j medical school graduates entering family medicine increasing the overall number family medicine october 2012 in press read more labels bob phillips bodenheimer comfort financing grumbach new model of care pcmh primary care reimbursement social determinants older posts subscribe to posts atom 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