Log In

134 articles were found on your search of:
Department: Commentary

The Medical Home Model Relies on Significant Assumptions
As Congress considers ways to reform the health care system, a question that needs to be answered is how to save primary care. A number of health care organizations believe the answer to this question lies in creating patient-centered medical homes (PCMHs).

In Health Care, One Size May Not Fit All
Discussions about whether the federal government should enact health care reform have revolved around the issues of cost control and providing care for the uninsured. Both of these goals are laudable but skepticism about whether any reform plan can accomplish these goals is widespread. Many opponents ask whether it’s possible to provide coverage to the estimated 45 million Americans who are uninsured and control costs at the same time. It’s a good question.

Doctor Gets Patient’s View of Care
As I lay on my back on the hospital bed, after the catheter was removed and the stent inserted, and tethered by intravenous lines and health monitoring leads, a quote from journalist Alistair Cooke came to mind. I was connected to a devilish device called Femstop, a pressure-driven plastic globe, pressing down on my femoral entry site to prevent a hematoma. At that moment, I recalled a quote from a talk by Cooke, “The Patient Has the Floor,” delivered at the Mayo Clinic in 1965. Cooke said, “I wish to talk of the fears of some statesman, lawyer, or other grandee who never appears before a doctor except to have his chest tapped, his knees jerked, his tongue depressed, his innards photographed, his rectum protoscoped, and his juices filtered, measured and pronounced upon. It is, though you may not know it, a permanently humiliating relationship: I mean the relationship between doctors and the rest of mankind. And it is because most people do not care to bring it up in public that I believe it might be useful for me to do so.”

Effectiveness Plan Raises Questions
Last month, the federal Department of Health and Human Services announced the members of the Federal Coordinating Council for Comparative Effectiveness Research. Comparative effectiveness research (CER), for better or worse, has arrived. Occasionally, an idea surfaces that seems so simple, rational, and scientific, that it may be too good to be true. CER is such an idea.

Business Models Continue to Evolve
For physicians to affect reform and leverage their skills, they need business models with reach and clout. These models must make physicians indispensable to payers, consumers, and hospitals. They must be economically efficient, clinically effective, and sustainable, and satisfy physicians, who often demand a degree of autonomy. And they must offer patients convenient access with predictable and affordable prices.

These characteristics are not easy to achieve and require the leadership of physicians, or possibly nonphysician leaders whom doctors trust. The structure of an organization or practice also must fit within the framework of existing laws and regulations, often set forth and dictated by Medicare, the nation’s dominant payer.

Book Explains Patient’s View of Dialysis
Cindy Barclay, RN, is a critical care nurse with 20 years of experience in the dialysis business, including 14 years as owner and CEO of Quality Dialysis, Inc., a company that provides dialysis services in Houston. Early in her career, Barclay noticed patients were often given little information about chronic kidney disease and the need for dialysis. Few medical professionals explained the disease and its implications, leaving patients and family members confused.

To clear up the confusion, she first wrote a manual for dialysis patients, which evolved into a book, That Damn Dialysis (Claybar Publishing, Inc., 2007, $19.95, or $10 for dialysis patients). It took Barclay two years to write this dramatic tale in the form of a novel about the trials of Cledus Washington, a 50-year-old cabinet maker who has CKD and needs dialysis. Barclay is currently writing a sequel about Cledus’ life after he gets a kidney transplant.

Sustainable Business Models Needed
Just like in other industries, health care needs to develop sustainable business models that generate enough revenue to cover costs. Hope for transformations based on technological innovation such as personalized medicine using drugs developed to target individual genetic markers, minimally invasive procedures, Internet-guided algorithms for managing care, bonuses for superior performance, and enlightened and empowered consumers striving for more perfect health are insufficient to reform the system adequately.

The health care system will not be saved by lofty ideas such as the possibility of achieving great savings through information technology, illness-prevention programs, and coordinated care of patients with chronic diseases. These are all good ideas, and some may pay dividends in the long term, but they will not do so quickly enough and any reform measures need to be implemented soon.

What Are the Prospects for Reform?
It could be argued that the views on health care of the two major-party candidates for president have deep implications for physicians in
independent practice and for their individual freedom to practice as they please and use their clinical judgment.

But since the government may spend over $1 trillion to bail out the financial system, it could be that there will be no funds left over for either candidate to reform the health care system. And, while reformers argue that the health care system needs to be reshaped because costs are too high and too many Americans are left without health insurance, it is doubtful that government can reform the system and save costs simply because it has no track record of doing so. In addition, the parties involved are likely to protect their own interests to such a degree that reform would be almost impossible.

Who Shall Care for Patients?
There are two major innovations sweeping across health care. These innovations will affect who delivers patient care and they may determine where some primary care physicians practice. Both of these innovations entail developing and expanding existing clinic models of delivery.
The first innovation involves in-store clinics at major retail outlets. Usually nurse practitioners and physician assistants run these clinics, which offer convenient and affordable care for consumers with minor illnesses. The second innovation is worksite health clinics that large employers are establishing. In these clinics, primary care doctors deliver comprehensive care in the workplace. Employees receive care along with free prescription drugs, and make no copayments. The physicians have access to best-practice information and make referrals to specialists with a history of good outcomes. A number of large retailers are developing in-store clinics, including CVS Pharmacy, Target, and RiteAid. Two retailers that have a significant presence in this market are Wal-Mart, Inc., which has 4,200 stores, and Walgreens, which has 6,237 stores. All of these retailers plan to expand their retail health care offers. Walgreens plans to open 500 in-store clinics.

Book Tells How to Navigate the Maze
The health system is needlessly complex. In many ways, this system, which critics insist on calling a “non-system,” is the worst of all possible worlds. It’s a bewildering mix of arcane rules, Byzantine red tape, and obstructive legal entanglements. For patients, it involves long hours of waiting and uncertainty. This new book is a result of lessons learned over the years. The book, Navigating the Maze of Health Coverage and Access: A Quick Guide for Physicians, contains 20 quick takes on health reform. It is for doctors and patients. I present it as questions and answers on leading reform issues of today. This manual is not intended to be exhaustive or inclusive, but rather to be instructive. The health system is complex. This book is simple. It follows the simple instructions to write about the what, why, when, how, where, and who. The issue of universal coverage is one of the examples of complexity in the book.