The Medically Homeless

Please allow me to coin a new term:

Medical HomelessnessNot having access to a consistent familiar medical setting.  Not having a care location where one is known or where the medical information is accurate.

credit

I think medical homelessness is one of the main problems in our system.

Given the nature of care in the US, most patients are required to be their own homes.  They serve as the conduit where medical information from one provider goes to another.  They are the prime decision-makers in their care – often making these decisions without understanding or assistance from those who do understand.  They are the only ones with the \”big picture\” of their health, yet they don\’t really know enough to say if that picture is good or bad.  They are helpless and vulnerable to sales pitches from drug companies, device manufacturers, insurance companies, and unfamiliar doctors.

I am not talking about every patient in our system, but I am talking about a large portion (perhaps the majority).  Some may spin this as patient empowerment, but unfortunately much of it is a case of patient abandonment. People are left to fend for themselves in a confusing, complex, and hostile system, and unfortunately many of their lives depend on their ability to manage this.

Sadly, most Americans have come to accept what is as what is best.  They don\’t know what not being homeless would look like, so they don\’t push to find a home.

Reasons for the Medically Homeless

There are a number of reasons that people have no medical home, with many places to lay the blame.  The center of the storm, however, is the state of primary care.

Primary care physicians are the logical choice for the medical home.  People know their PCP over many years, and the general nature of primary care physicians\’ training allows them to oversee the overall care of the patient.  Most PCP\’s don\’t rely on procedures to make their living, so the act of meeting with the patient, organizing their information, and discussing a plan is natural in the PCP\’s exam room.  But several things have made it difficult or even impossible for primary care physicians to provide an adequate medical home:

1.  Being a medical home takes time

To gather and organize the patient information is sometimes very complex.  Discussing the big picture and explaining why certain things need to be done takes a commitment from the PCP.  The problem is, there are no billing codes to cover this procedure.  There is no procedure of medical information oversight that is covered my most insurance plans.  Yet doing so takes more time than it takes for an ENT to put tubes in a person\’s ear (which takes about 5 minutes), and more thought than it takes to remove a wart from someone\’s skin.  These other procedures are paid for, but coordinating care is not.

Yes, there is the \”preventive physical\” that is paid for by many insurers, but there is nowhere in the required documentation for this regarding care oversight.  Plus, a \”physical\” requires that the patient be present, but care coordination can be done in their absence.  The money paid for a physical is for \”doing something\” (i.e. examining and ordering tests), not for organizing and planning.

Given that PCP\’s are among the lowest paid physicians, for them to take the time to do a big job without pay is not only bad business, it is a surefire way to go out of business quickly.

2.  Insurance companies pretend to be the medical home

Insurance companies have moved from the insurance business, and now are in the \”care management\” business as well.  This is convenient, because the management of care involves deciding which tests are paid for and which are not.  The problem is, like the PCP, the insurance company must often decide between what is best for the patient and what is best for business.  Is it better for all of their patients to get colonoscopies, more frequent diabetes visits, and more aggressive cholesterol lowering?  Perhaps these reap a benefit in the long-run, but they cost a lot of money up front.  Shareholders tend not to think in the long-run.

This wrestling match between doctor, patient, and insurance company over control is a major part of what goes on in a medical office.  The reason insurance companies have such bad reputations is that this conflict of interest between business and patient care makes their motives always suspect.

3.  Good information is hard to come by

Not only is it time-consuming to gather comprehensive medical information on a patient, it is often impossible.  Between HIPAA, which greatly increases the work it takes to get medical information, and the horrible informatics infrastructure we have, much of a patients\’ record is often inaccessible.  In 2009, I get far less communication from consultants and hospitals than I did in 1995.  Why?  There is no easy way to communicate, and there is no motivation to do so.

Specialists, hospitals, and labs used to rely on referrals from physicians – referrals that depended on the PCP\’s opinion of the specialist.  If one of these treated my patient badly or did not communicate with me, they\’d lose all of my business.  Now they are chosen by insurance companies, who make a deal to get the best price possible.  There is hence far less reason for them to give me good service, with the end result: non-communication.

4.  Primary care is increasingly scarce

Even if all of the other things were in place, the shortage of primary care physicians would still leave many people medically homeless.  There are not enough PCP\’s, and those who are still there are being deluged with patients.  The more the system shifts to primary care, the larger this problem will become.  If the system paid better for doctors to spend time organizing records, there would be fewer available appointments.  This could be compensated for by using a \”care team,\” but that is yet one more added expense.

Plus, the addition of new payments for care oversight would undoubtedly come with many strings attached.  Would they need to follow up on any lab that was ordered and had not come back?  Would they be responsible for mammograms ordered by the GYN, or lipids ordered by the cardiologist?  Very few offices are equipped to do this without a major time investment.

Fixing Medical Homelessness

There is no easy fix to this, but one of the first steps is for people to be aware there is a problem in the first place.  People don\’t demand high quality care because they don\’t realize they are not getting it.  And people don\’t know they are getting it because they don\’t know how good care could be.  The first step would be to show it working well somewhere.

Obviously reform of the payment system as well as promotion of primary care is critical.  I would say that if PCP\’s got a substantial increase in reimbursement, there may be some 50-something doctors who retired from practice due to the current situation who may reconsider.  There are actually a substantial number of PCP\’s who have retired rather than deal with our system that is hostile to primary care.

Whatever the solution, having a medical home for everyone should be at the top of reform agenda.  Disjointed care is expensive.  Disorganization leads to mistakes.  Dumping the responsibility on patients creates fear and powerlessness.

We need to find the road that brings us home.

31 thoughts on “The Medically Homeless”

  1. Hmm. Under this definition, my ED frequent flyers have a Medical Home. We know them all too well, the info we have is accurate, etc.
    So, a little tweakage to the definition is in order (unless the ED counts as a Medical Home…)

    1. OK then, putting the provision for care oversight would take away the ED. The difference with ED and PCP is that the PCP is a gathering place for medical information so it can be organized and the patient’s care plan can be put in place. We expect everyone to send their records to us. You, on the other hand, don’t expect us to send you a note each time they come into our office.
      Let me add that if we could give a medical home in our office, you wouldn’t have near the problem of frequent flyers.

  2. Hmm. Under this definition, my ED frequent flyers have a Medical Home. We know them all too well, the info we have is accurate, etc.
    So, a little tweakage to the definition is in order (unless the ED counts as a Medical Home…)

    1. OK then, putting the provision for care oversight would take away the ED. The difference with ED and PCP is that the PCP is a gathering place for medical information so it can be organized and the patient’s care plan can be put in place. We expect everyone to send their records to us. You, on the other hand, don’t expect us to send you a note each time they come into our office.
      Let me add that if we could give a medical home in our office, you wouldn’t have near the problem of frequent flyers.

  3. I’d be perfectly willing to pay more — ie, pay personally, upfront, cash on the barrelhead — if I thought that the product really would be better. Thinking of the CRNP I see, whom I think of as ‘good for general stuff but nothing serious, I’m not sure it would be.

  4. I’d be perfectly willing to pay more — ie, pay personally, upfront, cash on the barrelhead — if I thought that the product really would be better. Thinking of the CRNP I see, whom I think of as ‘good for general stuff but nothing serious, I’m not sure it would be.

  5. We have a terrific ped group that works hard to keep up with multiple offices and lots of kids and their concerned parents. They have taken time to call us in to discuss concerns and regularly go above and beyond in order to help us with our daughters multiple issues. However, I’m sure she takes much more effort than our other kids and I don’t see them being paid for it. Sarah has a “scleroderma like” something or other as well mild motor delays, flucutating tone, goofy glucose, high calcium, bone density issues, LFT elevations etc. They get records from two out of state hospitals, our local hospital, rheumatology, pulm, opth, OT, PT, ortho, endo and so forth . Of course things are missed every now and then, but we would be lost without this group. A true medical home is a blessing and has to be a good fiscal approach. Knowing that “odd” is normal for her saves time, money, and effort for everyone. They have taken time to educate us about labs and both short and long term implications for her and I have never seen billing for it. This info has helped us to avoid unecessary specialists and testing and our only ER visit resulted in admission. I trust her peds and respect their opinion and knowledge. But I trust them because they have listened to my concerns visit after visit. When anesthesiology suggested CF, they spent time with us. When they were testing for A-T, they spent time with us. When we were told our son needed an ASD repair, I literally walked across to their office from the hospital. They had us straight back and his dr w/us in no time. Through it all you would think they had nothing better to do, and while they don’t waste time, they aren’t rushing out the door either. I would swear they are honestly glad to see us. If not, I am okay with their acting abilities! Primary care is so important. A small practice couldn’t afford many kids like her w/o being paid for all the time beyond actual visits.
    Thanks to you and to all primary care drs. who are making a huge difference in the lives of so many!

    1. Sari, you have expressed the needs, provided examples of how to best address the needs, and discovered good care for your child with special healthcare needs. You are a satisfied customer, and to me that is the best motivation of all: seeing a satisfied customer; seeing a child who can carry on because her needs are being met. Then there is the profit motive . . . and the sad fact of medicine-as-business. It is a complicated game we play in medicine . . . and we may lose sight of keeping the patient #1.
      I respect Dr. Rob’s analysis of this “game,” and I applaud his description of medical home and its deep meaning for individual patients and for the community of people with special healthcare needs . . . of which I am one.

      Chris and Vic

  6. We have a terrific ped group that works hard to keep up with multiple offices and lots of kids and their concerned parents. They have taken time to call us in to discuss concerns and regularly go above and beyond in order to help us with our daughters multiple issues. However, I’m sure she takes much more effort than our other kids and I don’t see them being paid for it. Sarah has a “scleroderma like” something or other as well mild motor delays, flucutating tone, goofy glucose, high calcium, bone density issues, LFT elevations etc. They get records from two out of state hospitals, our local hospital, rheumatology, pulm, opth, OT, PT, ortho, endo and so forth . Of course things are missed every now and then, but we would be lost without this group. A true medical home is a blessing and has to be a good fiscal approach. Knowing that “odd” is normal for her saves time, money, and effort for everyone. They have taken time to educate us about labs and both short and long term implications for her and I have never seen billing for it. This info has helped us to avoid unecessary specialists and testing and our only ER visit resulted in admission. I trust her peds and respect their opinion and knowledge. But I trust them because they have listened to my concerns visit after visit. When anesthesiology suggested CF, they spent time with us. When they were testing for A-T, they spent time with us. When we were told our son needed an ASD repair, I literally walked across to their office from the hospital. They had us straight back and his dr w/us in no time. Through it all you would think they had nothing better to do, and while they don’t waste time, they aren’t rushing out the door either. I would swear they are honestly glad to see us. If not, I am okay with their acting abilities! Primary care is so important. A small practice couldn’t afford many kids like her w/o being paid for all the time beyond actual visits.
    Thanks to you and to all primary care drs. who are making a huge difference in the lives of so many!

    1. Sari, you have expressed the needs, provided examples of how to best address the needs, and discovered good care for your child with special healthcare needs. You are a satisfied customer, and to me that is the best motivation of all: seeing a satisfied customer; seeing a child who can carry on because her needs are being met. Then there is the profit motive . . . and the sad fact of medicine-as-business. It is a complicated game we play in medicine . . . and we may lose sight of keeping the patient #1.
      I respect Dr. Rob’s analysis of this “game,” and I applaud his description of medical home and its deep meaning for individual patients and for the community of people with special healthcare needs . . . of which I am one.

      Chris and Vic

  7. Like Bill, I would be happy to pay for my PCP to coordinate everything. He’s done it a few times without compensation, which doesn’t seem quite right or fair. I appreciate it, but my gratitude doesn’t pay his bills. There should be a way to “buy” extra time without involving the insurance company.

  8. Like Bill, I would be happy to pay for my PCP to coordinate everything. He’s done it a few times without compensation, which doesn’t seem quite right or fair. I appreciate it, but my gratitude doesn’t pay his bills. There should be a way to “buy” extra time without involving the insurance company.

  9. couldn’t you simply charge a yearly “membership fee” to cover coordination for patients in your practice? You may have to decrease your panel a bit as you spend less time with office visits and more time on the phone, doing email, researching topics, etc. (But maybe you wont, because you’ll be able to handle a lot of stuff more efficiently when everything isn’t tied to an office visit.)
    If a substantial chunk of your revenue came from your membership fees, a substantial amount of time could then be spent doing things other than jamming patients into an already stuffed schedule.
    You and your patients would be happier, right?

    The shortage of primary care docs means there should be little problem finding people willing to pay the fee, especially if it’s somewhat reasonable.

    1. Sounds great, but the only way to do this would be to drop Medicare and Medicaid. We can’t charge them anything extra and if we offer things to other patients while we accept M’care and M’caid, we are not offering them a service we are offering other patients. That’s against the rules.
      Dumb rules.

  10. couldn’t you simply charge a yearly “membership fee” to cover coordination for patients in your practice? You may have to decrease your panel a bit as you spend less time with office visits and more time on the phone, doing email, researching topics, etc. (But maybe you wont, because you’ll be able to handle a lot of stuff more efficiently when everything isn’t tied to an office visit.)
    If a substantial chunk of your revenue came from your membership fees, a substantial amount of time could then be spent doing things other than jamming patients into an already stuffed schedule.
    You and your patients would be happier, right?

    The shortage of primary care docs means there should be little problem finding people willing to pay the fee, especially if it’s somewhat reasonable.

    1. Sounds great, but the only way to do this would be to drop Medicare and Medicaid. We can’t charge them anything extra and if we offer things to other patients while we accept M’care and M’caid, we are not offering them a service we are offering other patients. That’s against the rules.
      Dumb rules.

  11. Brilliant post Dr. Rob!
    We have a system that is stacked against this kind of care. I was once employed at a federally-funded clinic (which shall remain unnamed) that basically ordered me to stop doing this kind of care because it was a “waste of time” when I could be churning out the numbers. They requested I provide primary care in 7 minute slots. They got Doctor D’s letter of resignation pretty quick.

    1. That reminds me of the PCP physician I was with when I was in elementary through high school (he’s retired, and I’ve moved since). He was required to schedule appointments every 6 minutes, so he did. He was also notorious for having late-running surgeries, because if a patient needed more than 6 minutes then they got more than 6 mins!

  12. Brilliant post Dr. Rob!
    We have a system that is stacked against this kind of care. I was once employed at a federally-funded clinic (which shall remain unnamed) that basically ordered me to stop doing this kind of care because it was a “waste of time” when I could be churning out the numbers. They requested I provide primary care in 7 minute slots. They got Doctor D’s letter of resignation pretty quick.

    1. That reminds me of the PCP physician I was with when I was in elementary through high school (he’s retired, and I’ve moved since). He was required to schedule appointments every 6 minutes, so he did. He was also notorious for having late-running surgeries, because if a patient needed more than 6 minutes then they got more than 6 mins!

  13. Great piece. And after reading it my primary thought is….It seems so simple, why can’t we make these little changes for the betterment(sp, never actually written this word before) of our healthcare system? Healthcare rules and regulations are like the US tax code…a giant mess!Maybe Doctors should recieve some business training during their residency years? Many are small businessmen afterall. I know the docs hire other people to do all this business stuff, but at least provide some classes about CPT coding and documentation, which is so important to the financial well-being of most offices.

  14. Great piece. And after reading it my primary thought is….It seems so simple, why can’t we make these little changes for the betterment(sp, never actually written this word before) of our healthcare system? Healthcare rules and regulations are like the US tax code…a giant mess!Maybe Doctors should recieve some business training during their residency years? Many are small businessmen afterall. I know the docs hire other people to do all this business stuff, but at least provide some classes about CPT coding and documentation, which is so important to the financial well-being of most offices.

  15. Medical Home. How I would love to have one!!!
    My husband is lucky in that he started going to a certain Family Practice doc (at my recommendation) about 15 years ago. He and this doc have a great relationship and the doc keeps up with all my husband’s extensive and complicated medical problems.

    I had to stop seeing the doctor because of my age. My husband is on Medicare and Tricare For Life, which is about the best possible ever insurance coverage. I’m not old enough to qualify for Medicare.

    So, to insure an affordable out-of-pocket expense since we’re on a fixed income, I enrolled in Tricare Prime and am assigned to a PA at a MTF as my primary care physician.

    The problem is that MTF’s have this horrible thing called “same day appointing” which means if you are not one of the first callers and do not have the ability to show up at the clinic within 20 minutes, you can’t get an appointment. Now, I’ve learned a few “work-arounds” but they amount to me being my own PCP.

    I have “complex” medical issues that include side effects from bariatric surgery, meningioma, arthritis, osteoporosis, fibromyalgia (dating from my teen years!), hypothyroidism… and the problem of deciphering which symptom is due to which problem is overwhelming for me. I have received little help from any doctor I’ve ever seen (other than the PCP my husband now sees, who I no longer see because of insurance).

    My PCP is my computer, the internet, and Excel.

  16. Medical Home. How I would love to have one!!!
    My husband is lucky in that he started going to a certain Family Practice doc (at my recommendation) about 15 years ago. He and this doc have a great relationship and the doc keeps up with all my husband’s extensive and complicated medical problems.

    I had to stop seeing the doctor because of my age. My husband is on Medicare and Tricare For Life, which is about the best possible ever insurance coverage. I’m not old enough to qualify for Medicare.

    So, to insure an affordable out-of-pocket expense since we’re on a fixed income, I enrolled in Tricare Prime and am assigned to a PA at a MTF as my primary care physician.

    The problem is that MTF’s have this horrible thing called “same day appointing” which means if you are not one of the first callers and do not have the ability to show up at the clinic within 20 minutes, you can’t get an appointment. Now, I’ve learned a few “work-arounds” but they amount to me being my own PCP.

    I have “complex” medical issues that include side effects from bariatric surgery, meningioma, arthritis, osteoporosis, fibromyalgia (dating from my teen years!), hypothyroidism… and the problem of deciphering which symptom is due to which problem is overwhelming for me. I have received little help from any doctor I’ve ever seen (other than the PCP my husband now sees, who I no longer see because of insurance).

    My PCP is my computer, the internet, and Excel.

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