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I told you so
Mary G. Barry, MD
T
Louisville Medicine Editor
[email protected]
he Patient–Centered Medical Home
is a crock.
It’s a maelstrom of forms and boxes
and neat little numbers that have added
up to absolutely no difference in outcomes
or cost savings in the pilot project study,
published in February in the JAMA. The
only good thing about it – speaking as a
weary form-filler-outer – was the $92,000
in bonuses paid out over three years to the
participating doctors whose data-chasing
met the standard. But that’s good only from
a cynical personal perspective. It’s stupid and
wasteful on a grand scale for the insurance
industry, the government, or the patient to
pay doctors to do useless things.
In the JAMA of February 26th, Mark W.
Friedberg, MD, MPP, et al, analyzed thirtytwo pilot practices involving 56,000 patients
in “Association Between Participation in
a Multipayer Medical Home Intervention
and Changes in Quality, Utilization, and
Costs of Care.” On only one of eleven
measures of the National Committee of
Quality Assurance (the BMOC of all metricobsessed bureaucrats for primary care report
cards) was there a statistical improvement
in the pilot practice, a whopping 11%
gain in measuring urine microalbumin in
diabetics. All major measures of resource
use - emergency room visits, frequency of
hospitalization, doctor office and off-hours
clinic visits, and costs - failed resoundingly
to improve.
Just two weeks before that article, Dr.
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Victoria McEvoy, assistant professor of
Pediatrics at Harvard, wrote an editorial in
the Wall Street Journal about the invasion
of primary care practices by what she called
the “quality police,” a term I would like to
upgrade to the “Factory Stasi.” She echoed
the sentiments of thousands, in that all this
measuring only serves the data masters who
are trying to reduce health care costs while
calling it “improving quality.” They measure
meaningless things only because these
things are measurable. Her article provoked
an outcry in the op-ed page of the Wall
Street Journal, the various letters perfectly
summarizing how polarized opinion is on
this subject.
From an MSPH: “Primary care physicians,
Dr. McEvoy among them, should use
these metrics to empower a cadre of able
physician assistants, nurse practitioners, and
other mid-level care managers to orchestrate
a symphony of patient centered medical
care in which the PCP sees the sickest, most
challenging patients.” Perhaps this MSPH
(who writes in typical corporatese) has not
figured out that the typical primary care
physician often cannot afford to employ a
physician assistant or nurse practitioner,
and that the typical patient quite often
prefers to see an actual doctor, even if not
horribly sick, at least from time to time . For
who better to take notice that there might
be something sore amiss? Who better to
explain the everyday ordinary nagging
problems that our patients bring to us at
every visit, that could be understood and
evaluated by us, or shunted off expensively
to a specialist? (Here I must offer a highutilizer mea culpa. I know almost nothing
about knees. If it is not a Baker’s Cyst, or a
non-swollen non-injured knee in somebody
who has regular old lady arthritis, I am
lost. I insist that all my patients see a Knee
Man, since knees are precious and must be
preserved.)
From an MD: “More than anything else
the problem with metrics overload is that it
will turn doctors into liars - it will pay more
to treat the charts than the patient.”
From the American College of Private
Physicians’ Vice Chair MD: “ We could,
we should,