Posted on 07/30/2009 3:34:15 AM PDT by Man50D
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 effectivness 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.
Anyone remember the case in [Ohio I think] earlier in the year regarding some 15 year old with cancer?
Some do gooder judge decided the state knew what this “child” needed more than the teenager or their parents.
What happens under the collectivist system? What happens under this utopian system where the well meaning, all knowing bureacrats dictate to the doctor what procedure works best based on some flow chart?
Will we be allowed to choose alternative treatments, even if paid for out of pocket? One could make the logical case, under this deranged social agreement, that a failed alternative treatment will cost the collective more money. Therefore, it would be immoral to allow such treatments.
Another thing: How can the legislature and executive pass a law that bans the judiciary from review? That seems patently unconstitutional.
Final thought: Private practice doctors need to form a “union” now. If they were smart they would have a sick-in (excluding ER doctors) sometime soon. Wonder how many soccer moms would freak out if they couldn’t get to the pediatrician on 30 minutes notice.
“Childless Liberals hit hardest.”
Absolutely.
Soylent Green is people.
Hi, from a fellow allnurses reader! I’m not a nurse; I’m a critical care tech at a local hospital in the ICU.
Prior, I worked for 2 1/2 years at a nursing home. I had 13 women to care for by myself from 3-11. It was so frustrating on many nights when I’d have one up on a hoyer lift to put into bed to change their dirty briefs and 2 others were pleading with me to get them to the bathroom; they couldn’t hold it any more. Just a typical example of how low staffing affects the residents.
Got a link to your source? Thanks.
glad I decided not to go to medical school.
I was venting, more than anything else. I'm frustrated by the fact that, indeed, there are a few things with our HC system (some payment-related, some routine-care-related) that could stand a little tweaking.
I'm caught between Liberals, who want to make a massive power grab, scrap the whole deal and start over again, and Conservatives who (frankly are forced) into saying "NO" to any reform that currently gets proposed. The liberal position is utterly stupid, and the conservative position is forced to stand firm by the extreme position taken by the liberals. In the end, everyone loses except the lawmakers who have their own separate HC system and thus don't care.
I'm still completely convinced that Obamacare is a horrific farce. I just wish that common sense would break out and people would talk about the real issues (Tort reform, overcrowded ERs, an overwhelming influx of illegals, to name three) ....rather than madeup numbers like "40-odd-million uninsured".
Last March there were still thousands of them parked in the woods in Southern Mississippi.
The idea of a medical home has always been common sense for Family Physicians, but the Pediatricians rediscovered the idea a few years ago.
What really spurred the movement is the development of Patient Centered Medical Homes by IBM, for their employees. Dr. Paul Grundy has been working closely with the American Academy of Family Physicians on the project, in addition to the Internists, Pediatricians and other large employers.
http://www.ibm.com/ibm/ideasfromibm/us/healthcare/20081203/index.shtml
“”Remember your family doctor? The person who knew your whole history? Who would see you outside of office hours and on weekends? IBM and healthcare advocates want to bring the family doctor back... in the form of a new model for primary care: the Medical Home. And in this new world, he or she will even make house calls—albeit virtually.””
More:
http://www-03.ibm.com/industries/healthcare/us/detail/landing/Y195013I19184U48.html
The problem is that it is recognized that doctors are consider too “elite,” cost too much, and aren’t all that pliable. And then, Grassley and Baucus come from States that allow Nurse Practitioners independent practice.
I think that, more than pressure from the NP lobby, the real reason is that nurses are assumed to be cheaper and more pliable to regulation.
The thing to remember is that nurses have their own Board of Examiners (or the State equivalent) and are taught to practice *nursing,* not medicine.
I’m not quite sure what the difference is, but the one nurse practitioner student that I precepted in my office and the one nurse practitioner who had gone back to school for some reason to become a physician assistant, did not think about disease and treatment the way I do. It seemed more rote memorization and following a cookbook.
Now, I love cookbook medicine when it’s possible to know that there’s only one main recipe and which ingredients can be adjusted or substituted. But the medical diagnoses that fit under cook book protocols are few.
I’m probably chauvinistic about my profession compared to nurse practitioners. (And I do apologize often for the conduct of my fellow doctors.)
Oh, so it's possible - since the illegals will be covered - to get a national card for every individual, but not to track them down and deport them to their own country.
Translation: Patients will only recieve Government sanctioned treatment.
OpusatFR, bump to what you wrote.
And bump to yours, bert
http://www.freerepublic.com/focus/news/2304274/posts?page=48#48
IMHO, nursing home care is a systemic failure due to inflexible federal, state, Medicare and Medicaid regulations; a management focus on the bottom line instead of the well-being of the resident/patient; and a warehousing mentality.
Neutral oversight is important to represent the resident. Some states have ombudsmen to help distraught family members when promised care was not delivered.
Yes - there are many cases of individual goodness and efforts on the part of individuals, both certified and aides, but there is a general lack of awareness or care for the resident as a whole. Different people poke and prod and write stuff down but do not grasp the whole.
If you have a total care relative in a nursing home or acute care facility, you need to be a strong advocate for proper care and monitor his daily status.
If you have not been to a nursing home or long term assisted living recently, it's an eye opener.
If nursing care for a family member is in your future, you should already be visiting nursing homes and asking questions and ticking certain ones off the list.
Under Obama's proposals, it will only get worse. To see what Obama & government Care holds for you, simply volunteer at nursing home or other long term facility for a week or more. Ignore the glossy brochures and observe what is going on. You will do no harm, you will help the resident(s), and you might even decide that nursing homes are not in your future.
Bad, bad, bad,....
Euthanasia centers, no doubt.
Maybe you guys really do need to start a doctor’s ping list to keep up with this stuff so you can spread the word at work.
Good Lord, help us. :(
Soylent Green is peopllllllllle....it’s PEEEEEOPLLLLE!!!!!!!!!!!!!!!!!!
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