By David May, MD, PhD

The patient-centered medical home (PCMH), heralded as a practice model that may improve quality and lower cost while re-emphasizing the central role of a patient’s personal physician in the coordination of their health care, is universally described as a primary care physician (PCP) system.¹ Some have opined that while internal medicine subspecialists (IMS) are capable of serving as principal physicians in a medical home model, this is very unlikely to occur.² With the increasing prevalence of chronic disease, our aging population, the looming physician shortage, and the advancing complexity of the chronic disease management, this view is no longer accurate, nor is it practical.

But why encourage our IMS to serve as the principal physician in the PCMH?

Currently, a large percentage of patient care is already provided by IMS. Of the 138 million follow-up visits provided Medicare recipients in 2010 by family, general, or internal medicine physicians, more than 30% were to IMS, and as were more than 55% of the 7.6 million new patient visits.³ Given this and the preference of some 22-23% of Medicare patients for a specialist to be their principal provider,⁴ this trend is likely to increase over the next decades, particularly in the care of cardiovascular and oncologic patients whose ranks already consume more than 50% of Medicare resources.⁵

Traditionally, our health care system has been viewed through the prism of the “specialist” who delivered infrequent, episodic evaluation on referral, generated a set of recommendations, then forwarded them to the PCP for enactment; the “primary care” physician provided oversight of the patient’s health care needs while being the site of first contact for medical events. For many patients with chronic disorders this anachronistic model is no longer sufficient. For them, the specialist physician care team has become the one most often visited, the one coordinating the management of other disorders due to the complex relations among those comorbidities as well as for their convenience. These factors, coupled with increasing PCP workload pressures due to a diminished workforce and shifts in PCP attitudes and values that have reduced their desire and ability to provide chronic care on a wide-scale basis, further encourage this paradigm shift.⁶

In the current reimbursement environment, many PCPs must see more than 30 patients daily to meet practice costs, making it virtually impossible to spend appropriate time with patients who have complex chronic disease conditions and comorbidities, even within a team-based care delivery model. This understandably leads to a vicious cycle of more frequent and earlier referrals for specialist care, paradoxically reducing the experiential abilities to effectively care for these patients. Simultaneously, such practices become less comfortable in managing comorbid conditions unrelated to the primary chronic disease condition for fear of unintended, unanticipated, or unrecognized adverse events due to disease-disease, disease-drug, or drug-drug interaction, further exacerbating the referral paradox. In addition, younger PCPs voice job and career preferences that limit their enthusiasm to provide such comprehensive medical home care for complex patient populations.⁷ These changes have resulted in the practical expediency of many IMS currently serving as the first contact for their patients with complex chronic disease.

Patient choice is also becoming a major factor in determining the role IMS should play in patient-centered care. In cardiology, patients with advanced heart failure, potentially lethal arrhythmias, corrected or palliated congenital heart disease, cardiac transplantation, complex device therapy, and other difficult-to-manage cardiac conditions often wish their IMS care team to serve as their principal care team. Analogous situations and patient feelings surely exist in other IMS fields as well. Because they spend the preponderance of their medical visit time with the IMS, they view them as better prepared to meet the needs of their most significant condition (having been referred by their PCP for exactly that reason). Over time, they also likely develop the comfort, rapport, and openness in communication necessary vital to patient-centered care.

Future physician workforce issues also require that the IMS be encouraged to serve as principal physicians in the PCMH for some of their patients with such chronic conditions. The current PCP workforce is numerically inadequate to handle the present volume of eligible patients, a situation that will be exacerbated by the increasing number of chronic disease patients who, having more complex medical issues, simply take more physician time per visit.

This will be further strained as millions of currently uninsured persons join the insured ranks as the Patient Protection and Affordable Care Act is implemented. The recent Center for Medicare and Medicaid Services Accountable Care Organization (CMS ACO) regulation proposal has recognized this eventuality, presumably for a minority of Medicare patients.⁸ Further, the number of chronic disease patients, particularly those needing cardiovascular and oncologic care, is projected to far outstrip the supply not just of PCPs but of IMS in the next 20 years. In short, we simply do not have enough physicians to meet the projected demand, and creative solutions are required.

In order to meet this increasing demand with the PCMH care model, our national policy should include:

1. Encouraging those IMS who are interested in doing so to function as the PCMH principal physician for those complex chronic disease patients in their care (for whom they are most likely already providing the majority of care).
2. Financially incentivizing qualified IMS to function in the principal physician role for their chronic disease patients just as has been done for PCP. Current legislative and regulatory prohibitions that inhibit IMS from such roles should be eliminated.
3. Developing mandatory registry systems to track patient outcomes, patient satisfaction, and physician performance metrics for patients in this model of care. These registries should be implemented prospectively, constructed to provide near real-time feedback to participants, and include all providers who are functioning as the principal physician.
4. Encouraging primary care and specialty societies to engage each other to advance this model of care, the goal to improve communication and enhance care globally in the best interests of the patients to be served, not to advance one physician group or field of care over another.

No one doubts that a personal physician, known and trusted by the patient, aware of the unique social and cultural characteristics of the family, comfortable with the intricacies of the patient’s disease management, and able to shepherd them through the troubled waters of illness, is the basis of good care and the promise of the PCMH. This vision requires that both primary and specialist physicians be empowered to appropriately serve as the patient’s principal physician for the patients they manage to promote best outcomes. To reach that goal, we must, as a nation, effectively entreat all who are capable of providing such care to do so. And we must do so now as we envision payment and delivery system reforms that will foster a sustainable and quality-assured future for American health care.

References

1. Patient-Centered Primary Care Collaborative. Joint Principles of the Patient-Centered Medical Home. 2007. www.pcpcc.net/content/joint-principles-patient-centered-medical-home
2. Casalino LP, Rittenhouse DR, Gillies RR, et al. N Engl J Med. 2010;362:1555-7.
3. Centers for Medicare and Medicaid Services. “Medicare Part B Physician/Supplier National Data: Calendar Year 2010.” Accessed from www.cms.gov/MedicareFeeforSvcPartsAB/Downloads/EMSpecialty2010.pdf
4. Anthony DL, Herndon MB, Gallagher PM, et al. Heath Aff. 2009;28: 864-73.
5. Soni A. “Top 10 Most Costly Conditions among Men and Women, 2008: Estimates for the U.S. Civilian Noninstitutionalized Adult Population, Age 18 and Older. Statistical Brief #331.” July 2011. Agency for Healthcare Research and Quality, Rockville, MD. Accessed from www.meps.ahrq.gov/mepsweb/data_files/publications/st331/stat331.pdf
6. Hoff T. Practice under Pressure. Primary care physicians and their medicine in the twenty first century. New Jersey: Rutgers University Press, 2010.
7. Dorsey ER, Jarjouora D, Rutecki GW. JAMA. 2003;290:1173-8.
8. Centers for Medicare and Medicaid Services. “Medicare Shared Savings Program: Accountable Care Organizations.” Accessed from www.federalregister.gov/articles/2011/11/02/2011-27461/medicare-program-medicare-shared-savings-program-accountable-care-organizations

David May, MD, PhD, is the current secretary of the ACC’s Board of Trustees, and is a managing partner at his private practice, Cardiovascular Specialists, P.A., in Dallas.