House Health-Care Bill Would Establish 'Medical Homes' for the Elderly and Disabled

Thursday, July 30, 2009
By Marie Magleby



(CNSNews.com) - The House health-care reform bill proposes to decrease hospital visits by establishing a “medical home pilot program” for elderly and disabled Americans.

Such a medical home would not require a physician to be on the staff, and therefore could be run solely by nurse practitioners and physician assistants. Medical homes also would practice “evidence-based” medicine, which advocates only the use of medical treatments that are supported by effectiveness research.

But physicians’ groups say the legislation could lead to restrictions on which treatments may be used for certain conditions, despite the fact that some patients might require a unique or unconventional approach. It also may lead to dumping Medicare/Medicaid patients in facilities that are not required to have physicians on staff.

The Center for Medicine in the Public Interest (CMPI) expressed its concerns in a report that explains why statistical evidence does not always reflect reality of effective medicine.

“‘One size fits all’ rarely does,” the report said. “From clothes to shoes to hats, few people find that items carrying that label work with their individual bodies. So why do we entrust the health of our bodies -- one of the most important assets we have -- to a one-size-fits-all mentality?”

According to CMPI and individual physicians, however, this one-size-fits-all mentality is just what congressional health-care reform suggests.

“Unfortunately, policies being advanced under the guise of ‘evidence-based medicine’ (EBM) could do just that,” the CMPI report said. “The idea behind EBM, empowering physicians with sound evidence to incorporate into their treatment decisions for individual patients, is a good one.

“Unfortunately, EBM now is being distorted by government bureaucrats and HMOs in ways that impose top-down, one-size-fits-all restrictions on patients and their healthcare providers.”

Rather than enforcing a formulaic approach to medicine based on statistical and clinical research, CMPI says health-care reform should preserve physicians’ autonomy to use the research in conjunction with their experience and knowledge of the patient.

”It is so critically important for the physician to maintain his or her ability to combine study findings with their expertise and knowledge of the individual in order to make the optimal treatment decisions. Evidence-based medicine in its present, distorted form emphasizes just one aspect of the clinical pie over all the others,” the report found.

Kathryn Serkes of the American Association for Physicians and Surgeons echoed the observation.

“There is no typical patient,” Serkes told CNSNews.com. “Every patient is different from a medical perspective. If we have evidence-based medicine that basically says ‘well, we start at treatment one, which leads you to treatment two, to treatment three to treatment four. In practice, that doesn’t work for the patient. That’s the ‘art’ part of the art and science of medicine. That’s what we still need doctors to do, is to figure out what’s right for the patient.”

In the long run, according to CMPI, evidence-based medicine may not even cut costs as Congress suggests it would.

“Evidence-based medicine may provide transitory savings in the short term, but the same patient who takes the cheapest available statin today may very well be the patient costing you -- the taxpayer, the policymaker, the thought-leader, the sister, the spouse -- big bucks when that patient ends up in the hospital because of improperly treated cardiovascular disease,” .

“The repercussions of choosing short-term thinking over long-term results and cost-based medicine over patient-based are pernicious to both the public purse and the public health,” the CMPI report said.

Provisions for the medical home pilot program are an amendment to the Social Security Act, which governs the administration of Medicare and Medicaid services.

The medical home is an approach to medical practice that “facilitates partnerships” between patients and physicians, according to the proposed bill.

The pilot program targets Medicare beneficiaries who have a high medical “risk score” or who require regular monitoring, advising or treatment. This currently applies to more than 22 million Americans, according to Kaiser Family Foundation statistics.

At least $1.5 billion would be redirected from the Federal Supplementary Medical Insurance Trust Fund to fund the medical homes, “in addition to funds otherwise available,” according to the bill.

The Senate health-care reform bill also includes provisions for medical homes, although to lesser detail than the House bill.

If this portion of the legislation passes through Congress, medical homes will be part of the greater health-care reform experiment known as "the public (health insurance) option."

According to the committee, the provisions for medical homes will make the public option a stronger competitor against private health insurance companies.

“The public health insurance option will be empowered to implement innovative delivery reform initiatives so that it is a nimble purchaser of health care and gets more value for each health care dollar,” the House Committee on Energy and Commerce’s summary says about the bill.

Medical homes are tied to “comparative effectiveness research” via something called “evidence-based medicine.”

“It will expand upon the experiments put forth in Medicare and be provided the flexibility to implement value-based purchasing, accountable care organizations, medical homes, and bundled payments. These features will ensure the public option is a leader in efficient delivery of quality care, spurring competition with private plans,” the committee’s summary also said.

A statement by the American College of Emergency Physicians (ACEP) said that the effectiveness of the medical home model should be carefully evaluated before applying the model far and wide.

“There should be more research to demonstrate the benefits and continuing costs associated with implementation of the full (patient-centered medical home) model,” the ACEP statement said.

“Demonstration projects being conducted by the Centers for Medicare & Medicaid Services must be carefully evaluated. There should be proven value in healthcare outcomes for patients and reduced costs to the healthcare system before there is widespread implementation of this model.”

The proposal, meanwhile, specifically allows for facilities to be run by staff who do not possess medical degrees – including nurses and nurse practitioners.