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Only One Structural Change Will Make a Difference: Part I

February 28, 2011
by James L. Holly, M.D.
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In President Obama's AMA address he called for healthcare structural change–has it been achieved?

The Only Structural Change Which Will Make a DifferenceCoordination of Care

Someone has to take charge of health care and there are only two legitimate choices: the patient and the primary care provider. And, the only change which will make a difference in health care is when these two form a strategic alliance and become a health-care-coordination team. Neither the Federal Government nor the healthcare provider can or should remove from the patient the ultimate responsibility for their own health. And, often, the only way to have the patient take personal responsibility is when there is an economic cost associated with not taking responsibility. But, the patient must have a team mate on whom they can count. (Many of these issues have been explored in a ten-part series entitled, “Patient-Centered Medical Home” which can be read at www.setma.com under the heading Your Life Your Health)

Two things are novel and may be the energy behind Medical Home. First, the patient and the healthcare provider enter into a collaborative relationship where the more the patient knows and understands about his/her health, and the more the patient accepts and takes responsibility for his/her health, the closer they come to forming a healthcare team which is defined by the concept of Medical Home. Second, Medical Home not only results from this team formation but also from the healthcare provider, who is identified by the patient as his/her principal healthcare provider, having information about the patient which is:

  1. Comprehensive – this information goes beyond the routine medical, social, family and habits history and includes things such as the living condition, literacy, nutrition, etc., of the patient.
  2. Accessible – this information must be readily accessible to the provider.
  3. Considered in medical decision making for the patient – this information must be an active part of the patient’s care and evaluation.

Historically, medical records and medical databases have looked more like a stick-figure than like a portrait of the patient. Electronic patient records have enabled that portrait to take on granularity and specificity so that the “picture” of the person is more personal. Now, Medical Home requires that that portrait take on the unique features of the patient which are personal, specific and unique. Creating the database for this information-set is the “first thing.” Making that database interactive and dynamic is the “second thing.” Using that database in an active and inter-active means in the care of patients is the “third thing.”

Under the Medical Home model the provider has NOT done their job when they simply prescribe the care which meets national standards. Doing the job of Medical Home requires the prescribing of the best care which is available to the patient. For example, a year ago, the partners of SETMA formalized a 501-C3 not-for-profit foundation – The SETMA Foundation – which has as its purpose medical education and underwriting the care for patients who cannot afford care. Obviously, this fledgling foundation has limited assets but it is a beginning.

Recently, I saw a patient who has a very complex and fascinating healthcare situation. During his office-based hospital follow-up, I discovered the patient was only taking four of nine medications because of expense. I believe in this case, SETMA practiced Medical Home as the patient left the office:

  1. Appointment to SETMA’s American Diabetes Association-approve diabetes-education program. The fees for the education program were waived. However, while talking to the patient’s family, I discovered that the patient could not afford the gas to come to education meetings. The patient also left with a gas card with which to pay for the fuel to get the education which is critical to the patient’s care.
  2. My staff negotiated a reduced cost with the patient’s pharmacy and made it possible for the pharmacy to bill The SETMA Foundation.
  3. Because the patient cannot work at his job, the patient’s care also involved counseling that we will coordinate an application for Social Security disability.
  4. Plans for applying for disabiilty.
  5. Appointment to a research program for vision preservation.

Are gas cards, disability applications, paying for medications a part of a physician’s responsibilities? Absolutely not, but are they a part of Medical Home? Absolutely. This patient, who was depressed and glum in the hospital, such that no one wanted to go into the patient’s room, left the office with a smile and feeling that there is hope. It may be that the biggest result of Medical Home is hope. He returned six weeks later with renewed hope and a to-target HbA1C.

Now, every healthcare provider doesn’t have a foundation and even ours can’t meet everyone’s needs, but assisting patients in finding the resources to help our patients will be a part of medical home. And, when those resources cannot be found, Medical Home will be “done” by modifying the treatment plan so that what is prescribed can be obtained, for the ordering of tests, treatments, prescriptions which we know our patients cannot obtain is not healthcare even if the plan of care is up to national standards..

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James Holly

CEO, managing partner of the Southeast Texas Medical Associates (SETMA) in Beaumont

James L. (Larry) Holly, M.D., After completing his medical education, James L. (Larry) Holly, M....