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MEDICAL HOME – THE IMPORTANCE OF PRIMARY HEALTHCARE

Family physicians at the forefront of organized medicine's push to get their patients and US consumers a Medical Home, but there are financial and legislative roadblocks to achieving this goal of the Medical Home that could not only provide better patient care, but save the healthcare system money and increase access.

Welcome to ReachMD XM157, The Channel for Medical Professionals. I am Bruce Japsen, the healthcare reporter with the Chicago Tribune and with me today is Dr. James King. Mr. King is President of The American Academy of Family Physicians, the American Academy of Family Physicians represents more than 90,000 doctors and medical students nationwide. Dr. King is a family physician in Selmer, Tennessee, and has also served three years as a director on the Academy's board of directors. He serves on the volunteer faculty of the University of Tennessee's Center for Health Sciences in Memphis. He is also on the medical staff of the McNairy Regional Hospital in Selmer and serves as Medical Director of Chester County Healthcare Services.

BRUCE JAPSEN:

Dr. King, welcome to ReachMD.

DR. JAMES KING:

Thank you Bruce, glad to be here.

BRUCE JAPSEN:

So tell us Dr. King, first, what is a Medical Home. For our listeners out there, it seems to be a concept that we've been hearing a lot even with folks running for president on the campaign trail, but I'd just like to hear in your own words what is a Medical Home and that does that play in this healthcare system debate that we are talking about this year.

DR. JAMES KING:

Well, a Medical Home begins with a trusting relationship between a patient and their primary care physician or family physician that's probably been done over time, but it's not only that physician, it's the entire practice, in fact, it's the entire team of individuals that are supplying that care. It may be the nurse that works with the physician, it may be the pharmacist down the street that we write prescriptions and send to, it may be the subspecialist, cardiologist, or gastroenterologist that we may work with in way of providing that care. The Medical Home is a place that you can go to get the service that you need, making sure that you see the right physician in the right place at the right time to get the care that you need.

BRUCE JAPSEN:

And the Medical Home, how is that figuring into the healthcare debate this year because often times when the presidential candidates or folks running for congress, they just kind of throw that out there, I don't think people generally know what it means, and if you could tell our listeners or a lot of the doctors out there and patients, how is this figuring in the healthcare debate and where is the Academy on this?

DR. JAMES KING:

Well, what is really coming into the debate in certain areas, with the Medical Home we really truly feel that it is the foundation for a value based healthcare system, but you kind of have to take a look at it and realize to be able to provide that. (1) We have to have a primary care based. We have to have enough family physicians out there to provide Medical Homes to all of the citizens in this country, so it is working on trying to provide that primary care, making sure that we have a place that people can get preventive services they need, to help manage the chronic condition that they may have, whether they be diabetes or hypertension or asthma, making sure that we do take care of the acute problems, whether it be something minor like a sore throat or an ankle sprain all the way to end-of-life things dealing with, you know, cancer or whatever they might have. So, you know, someone that helps them navigate through the system and all of the healthcare that we need. People understand that as you increase the primary care base, what happens in your healthcare system is a couple of things, that the quality improves as you have more family physicians in geographical area and cost goes down because you're providing those primary care services, those preventive services. You're keeping patients away from the emergency room where it's more costly, you're keeping them from being admitted into the hospital and having to be in the hospital possibly, so you're holding down cost. We've seen that in all the other industrialized countries, the quality goes up, cost goes down, but that's based more on it being a primary care based system. In fact, there is research now that shows in this country the same process as we increase the number of primary care physicians then the quality improves and cost goes down. So we understand if we can do that, then we can make some positive strides in trying to improve the present healthcare system.

BRUCE JAPSEN:

How bad is it out there as far as our numbers, I mean, I remember I've been writing about healthcare for a long time, I remember in the early 1990s when the healthcare reform debate started in the Clinton administration, I think there were efforts that they were talking about balancing it so we had like 50% primary care and 50% specialists. Where are we now and where do we need to head?

DR. JAMES KING:

We are nowhere near those numbers and that was numbers that we were even talking back in the academy. We have looked at that and realized that may be those numbers need to be readjusted. The American Academy of Family Physicians did a research study and an evaluation of where we are with our present healthcare system last year and what we found we're only producing about 60% of the family physicians that we need, now that's even taking into consideration the number of nurse practitioners, physicians assistants, the general internees, the pediatricians, and others that provide primary care. Even with those groups and the kind of numbers they are producing we are still falling about 60% short of where we need to be in the way of producing primary care physicians, so we still have ways to go.

BRUCE JAPSEN:

So based on the number of docs coming out of medical school and residency, it should be 60-40 rather than what it is now?

DR. JAMES KING:

Well, no, I am not saying that, we're completing our residency programs only about 60% of what family medicine needs to, that number might be 40-60 with 40% primary care, that 50-50 number what we've start realizing, okay, we took a step back and instead of trying to determine how many primary care doctors or semi-specialists based on the total number of American citizens we have to be able to provide a patient centered Medical Home for each one of those, how many primary care providers we need and in doing that what we've realized that we are just not producing enough family physicians. It's not necessarily we're producing too many subspecialists, it's just not enough primary care, so we need to raise that number by about 40% of what we're producing right now.

So if you're just tuning in or if you're new to our channel, you are listening to Inside Healthcare on ReachMD XM157, The Channel for Medical Professionals. I am Bruce Japsen of the Chicago Tribune and with me today is Dr. Jim King. He is the President of the American Academy of Family Physicians and he joins us today from his offices in Selmer, Tennessee, and we're talking about the legislative agenda, if you will, of the American Academy of Family Physicians and one of the things that's key on their agenda is hooking patients out there with a Medical Home.

BRUCE JAPSEN:

We've a huge problem in this country with people who are uninsured and I would guess that most of those people do not have a Medical Home, let alone a family physician, so Dr. King, what needs to be done in Washington for starters to help to encourage this model and get patients hooked up with the medical home?

DR. JAMES KING:

Well, they have to make several things, one is you've mentioned a very valid point; there is 47 million uninsured people in this country. Most of those people are delaying the care that they need, they are not receiving any services they should and when they do get care, they get in the most expensive place and they go to the emergency room, so we need to develop universal coverage so that everyone has healthcare coverage that can get them into the patients in a Medical Home and get their healthcare covered. The other thing that they're gonna have to do is take a hard look at how they pay physicians. Presently, they pay us only for face-to-face encounters. Well, we know that you can provide high quality care in other ways, whether it be using electronic means of communicating with your patients, whether you have a team approach where other healthcare providers are providing certain services using electronic health records so that we can use directories to make sure that our diabetics get in and see us when they need to and supply information to them, protocols, making sure that they are getting the preventive services they need such as Pneumovax vaccines, cancer screening. So there is a lot of different things that we need to work on to make sure that we're providing high value in quality and not just necessarily quantity of healthcare.

BRUCE JAPSEN:

I know, and this seems to come up year after year, it's one of those things where you just don't even know why it takes so much time to even thing about, but of the numbers of people who are uninsured, are there statistics on that, I mean, how many of them actually have a family doctor or a primary care physician that they're seeing?

DR. JAMES KING:

On studies that when I do the interviews, most don't. I don't have a specific number to say what percent do have a physician, but we find that most of those individuals do get their care at urgent care centers or retail health clinics or the emergency room instead of having a physician that they see on a regular basis. Because that they really costs the system more because when they do have to use the system, they are usually much sicker, they end up being seen in the emergency room or being hospitalized where the cost is higher, so that is a major problem that we need to work towards making sure that they do have a patient-centered medical home that they can get those services at.

BRUCE JAPSEN:

And how is the Medicare doing or even insurers in the private sector on getting preventative care covered so it would be an incentive for even people with insurance to come and see their doctor and their family physician?

DR. JAMES KING:

They're not doing well now. They are starting, a hope to hear the need for this. Many health plans don't cover for the preventive services that need to be covered. We are starting to see a glimmer of hope. They are starting to be pilot projects started both in CMS with the Medicare as well as private insurers now looking at the concept of the patient-centered medical home and to see if that helps control costs like we feel that it will and to provide those services, so the process has begun. In fact, we've now joined on with others in what's called the Patient-Centered Primary Care Collaborative which is a group that started with big business who realized the need for patient-centered medical home and IBM was one of the leaders in this group, but the other groups like Xerox has signed on. We have many of the major health plans that have signed on as well as well as business groups, the healthcare industry. In fact, the four major primary care organizations, the American Academy of Family Physicians, the pediatricians, the internists, and even the osteopathic physicians which represent almost 333,000 physicians have signed on with this concept. So the physician community has signed on, the healthcare industry has signed on, the business community that pays for the healthcare have. So it seems like all of the right players are lining up to make this happen.

BRUCE JAPSEN:

Well, it's very interesting because the Medical Home is one of the things that is constantly coming up out on the campaign trail that we're hearing a lot about and Dr. King, if you will, if you were to get one thing in front of the people running for office this year, what would it be that the Academy would want them to hear and what patients and doctors should know that the Academy is pushing in regard to the Medical Home?

DR. JAMES KING:

Well, the main thing that we're pushing is we've got to begin the process of defining the Medical Home, determine exactly what it needs to be and like I said the major primary care groups have signed on and we have what we call the principles of the patient-centered medical home that helps define that. We're beginning to gain support and then from a legislative standpoint I think that they will need to take a look at different demonstration projects, how can we change the way we pay physicians to make this process work so we can improve quality and hold down cost, and the thing over the years they're gonna have to do a couple of things is help the physician communities to begin the process of changing into the patient centered medical home. Not all of our practices are there now. It is very expensive for the medical practice to put in electronic health record so anything that the government can do to kind of help that process easier as they began to add different components of the medical home to a practice would be of great benefit as well and we ________ need to work together to move this direction.

BRUCE JAPSEN:

With that I would thank Dr. Jim King who has been our guest, he is President of The American Academy of Family Physicians and we have been talking about the importance of the medical home and its role and its push and as part of the legislative agenda this year in this election year in this country. I am Bruce Japsen of the Chicago Tribune, I have been your host and you have been listening to ReachMD XM157, The Channel for Medical Professionals. We welcome your comments and question through our website www.reachmd.com which now features our entire medical show library including the interview with Mr. King and on-demand podcasts and I would like to thank you today for listening.