What does the Election of Barack Obama Really Mean for Health Care

We have chosen Barack Obama as our next President! This means that his proposal for how to reform health care will certainly set the tone for our discussion about how to improve quality, cut rising costs and extend medical coverage to about 45 million additional Americans.

Since any proposal must be submited to Congress, it is reasonable to assume that elements of Obama's proposal may well be modified, but at the core of his proposal are principles that would change health care delivery and coverage in the U.S.

The cornerstones of Obama's plan are:

• Expand Medicaid eligibility to include greater numbers of the uninsured
• Mandate coverage for children
• Create a national exchange where uninsured folks can purchase a public or private policy;
  
• Provide subsidies to lower-income individuals and small businesses to help defray the cost of purchasing insurance; and,
• Tax medium and large-size employers that decline to provide their employees with health insurance.

Of crucial importance in all of this is the need for us to remember that quality of care, and value for the money we spend, must be improved dramatically for any plan to be truly successful. Obama has chosen great advisers who understand this, but there is great danger that economic concerns could drive attention into only cost cutting steps, without insuring that we adequately pay for improved access and provision of primary care services. We could do the most to improve access and quality, while simultaneously lowering costs, by supporting legislation requiring all plans to provide payment for the personal medical home. Simply expanding programs like Medicaid, without this type of reform, will fail, since they do not pay primary care physician adequately for providing the care!

We have discussed the specific benfits of the personal medical home previously, and it is important to remember in a time of scarce resources, that by supporting the provision of primary care first, we are supporting the only thing that has ever been shown to be associated with both improved quality and decreased cost of medical care! Although well intentioned, throwing more money at our current health care mess will be bound to dissapoint us, by making more people eligable for the dysfunctional, and unorganized type of care that is currently bankrupting us.

Joint Principles of the Patient-Centered Medical Home, agreed upon by the AAFP and the ACP

American Academy of Family Physicians

American College of Physicians

Joint Principles of the Patient-Centered Medical Home

July 2006

Introduction

The American Academy of Family Physicians and the American College of Physicians have developed proposals for improving care of patients through a patient-centered practice model called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006). Similarly the American Academy of Pediatrics has proposed a medical home for children and adolescents with special needs.

AAFP and ACP offer these joint principles that describe the elements of the patient-centered, physician-guided medical home.

Principles

Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; end of life care.

Care is coordinated and/or integrated across all domains of the health care system (hospitals, home health agencies, nursing homes, consultants and other components of the complex health care system), facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it.

Quality and safety are hallmarks of the medical home:

▪ Evidence-based medicine and clinical decision-support tools guide decision making

▪ Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.

▪ Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met

▪ Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

· Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.

Enhanced access to care through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and office staff.

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:

· It should reflect the value of physician and non-physician staff work that falls outside of the face-to-face visit associated with patient-centered care management.

· It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.

· It should support adoption and use of health information technology for quality improvement;

· It should support provision of enhanced communication access such as secure e-mail and telephone consultation;

· It should recognize the value of physician work associated with remote monitoring of clinical data using technology.

· It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).

· It should recognize case mix differences in the patient population being treated within the practice.

· It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.

· It should allow for additional payments for achieving measurable and continuous quality improvements.