E-DMN - August 4, 2008

August 4, 2008

Editor's Column: The Patient Centered Medical Home:
No Haven For Physicians
New Medical School Selects Dean
DMC Rehabilitation Institute Names New President
Dr. Loeb Brings $100,000 Grant To WSUSOM
Hear From Lawmakers Sept. 25 At Capitol Check-Up
Grassroots Efforts Ebb Medicare Cuts
Medicare Makes Additions To 'Do-Not-Pay' List
National EHR Bill Put On Back Burner

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Editor's Column: The Patient Centered Medical Home:
No Haven For Physicians

By JOSEPH WEISS, MD
The patient centered medical home. The very name carries the scent of Madison Avenue. Patient centered: is there a more hallowed phrase in medical advertising? Medical home: a new buzz word bringing up the idea of protection, support, love and guidance.

Unfortunately, the patient centered medical home is a scheme to deceive physicians and the public. The deception for physicians is that the patient centered medical home will bring family practitioners, internists, pediatricians and anyone providing primary care with the prestige and income these physicians presently lack. The deception for public is that it will obtain a level of care and attention formerly reserved for the rich and famous.

The medical community can gain an idea of how the patient centered medical home supposedly will work by following Michigan’s BCBS fall implementation of the concept. Blue Cross states that under its hand the Patient Centered Medical Home will abide by the following principles:

-Care Quality and patient safety as defined by the Michigan Quality Improvement Consortium (MQIC). Practitioners must use the principles as provided by MQIC 27 guidelines of care, and follow whatever new guidelines MQIC comes out with during the year.

-Enhanced patient access- the practitioner of the patient centered medical home must have open scheduling, expanded hours a Web site, e-mail and telephone all available 24/7.

-Integrated Care. Here the gatekeeper function arises. The physician must coordinate, direct, supervise, approve, and transfer care of each patient between the medical centered home, subspecialty office, hospital, home health and nursing home facility , and community service departments. In addition, as part of care coordination, the patient’s therapy and conditions must be included on any applicable information, technology or health information registry that BCBS deems applicable.

-Personal Care. The medical home must show that each patient has a personal, continuous, and comprehensive relationship with a single physician practicing in the confines of the medical home. This personal physician carries the responsibility of providing for all the patient’s health care needs and must include acute, chronic, and preventive and end of life care.

-Physician directed team medical care. Finally the medical home must have a team of staff members capable of giving daily patient support services, fielding calls and instructing patient on a variety of health matters, including but not limited to, self management training, preventive care, and nutritional and emotional counseling.

Besides reporting how well the medical home carries out the principles set forth by BCBS, each physician in the BCBS-sponsored medical home setting will need to report on eight aspects of diabetic care, two aspects of asthma care, four aspects of congestive heart failure, six aspects of coronary artery disease care, seven aspects of preventive care in adults and children, and finally, the physician must report on how well he or she succeeded in avoiding the use of antibiotics in adults with acute bronchitis.

As yet, BCBS has not stated what additional payment it will allow for the set-up costs and ongoing expense of the medical home. Blue Cross has announced that contracts will be good for only one year; so all initial expense is a t risk if BCBS decides to drop the project or the physician.

The patient centered medical home cannot succeed in its present form. The responsibilities placed on the medical-home physician are excessive and beyond the capability of any medical organization to carry out.

Furthermore, a device like the patient centered medical home will not solve the problems of the primary care physician. As long as this country runs by marketplace medical care, physicians will go where they want, enter medical specialties of their choice and the financial power of the procedure will prevail.

It will require a radical change to turn our present pyramid of procedure dominated medical care into a safe haven for the internist, pediatrician, family practitioner or other physician taking on the role of primary care. That time is not yet near.

Dr. Bush’s Response

With all due respect, I disagree with the editorials that criticize the Advanced Medical Home concept. Primary care physicians have always cared for individuals over the continuum. Those patients with chronic health care needs have always required compassionate, caring, continuity of care. These services are complex and time and resource-intensive. Historically, there has been no additional compensation to recognize the work done by physicians and their office staff.

At this time, many primary care physicians are struggling to make ends meet. The Advanced Medical Home, or Patient Centered Medical Home deserves a pilot project sponsored by the payors.

Seventeen medical organizations favor this concept, Including the American College of Physicians, American Academy of Family Physicians and the American Academy of Pediatrics. The basic tenets call for:

1. Mindful clinician-patient communication: trust, respect, shared decision-making

2. Patient partnership

3. Cultural competency

4. Continuous competency

5. Whole person care

I urge all physicians and medical thought leaders to give this initiative a chance.

Dr. Adelman’s Response
Actually, the idea of a medical home was first promulgated years ago by a pediatrician from Hawaii, Dr. Cal Cia. In his formulation, this amounted to a primary pediatrician for each child, with the pediatrician coordinating all care and referrals to specialists, hospitals and for testing. This, of course, was what primary care doctors had always done; the only innovation was the actual assignment of a doctor to every patient, just like our old Michigan Medicaid Physician Primary Sponsor program.

What BCBSM is just doing now is dumping its wish list on the concept, with all the new paperwork that they love so much. They are also grafting on the idea of health care team care, which generally is well accepted in the medical community for clinics large enough to afford it.

One important point to make here is to distinguish between what an individual private office can do and what a clinic/HMO/large practice can do The latter can put together packages of services that would break the bank for a small practice.

Another important point is that physicians, as in the Medicaid PPSP, need to be paid for assuming the coordination of care responsibilities. The PPSP used a partial capitation, with fee for service added on for specific services. I am not sure how "budget-holder" GP practices in Great Britain do this, but they also have a variation on this idea.

Insurers love to promulgate their own guidelines for care of various services. This way they show their stakeholders how well they are looking out for them. These always end up being negotiable, because they are hard to do and to keep up. Whenever medical groups offer to take over these responsibilities, they have only to show that they can do them well to get the insurers' attention.

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New Medical School Selects Dean

By PAUL NATINSKY
Michigan’s first new medical school in many years now has a name, a dean and $25 million as it prepares to admit its first class of 50 students in 2010.

The Oakland University-William Beaumont School of Medicine unveiled Dean Robert Folberg, MD, late last week, along with other details about the new venture.

“This is a watershed moment in Oakland University’s history,” stated Oakland President Gary Russi. “With our nationally recognized partner, Beaumont Hospitals, we have taken several momentous steps toward creating exciting opportunities in top-quality medical education for the next generation of doctors, and, at the same time bringing the region a much-needed economic and job-creation boost.”

A pathologist and medical educator, Dr. Folberg comes to OU from the University of Chicago, where he holds the positions of Frances B. Geever Professor of Pathology and department head of pathology. He also serves as a professor of ophthalmology and visual science. He received a BA in biology from the LaSalle College (now LaSalle University) and his MD from Temple University College of Medicine in 1975.

“I’m tremendously honored to be chosen as the founding dean of a medical school that has the force of two outstanding institutions behind it,” said Dr. Folberg. “The combination of these two organizations will create a medical school that will blaze new and exciting trails in medical education in Michigan and throughout the country.”

“Dr. Folberg comes with a reputation for excellence in clinical care and medical research,” said Ananias Diokno, MD, chief medical officer, Beaumont Hospitals. “He has an active, aggressive vision for what the school of medicine can become, and he has the energy to take us there…There is no doubt in my mind that Dr. Folberg and his colleagues at the university and at our hospitals can help bring some of those programs to national top-ten prominence.”

The school announced July 31 that it has received “$25 million in gifts” and that “revenue for (school) will come from tuition and fees, commercialization of intellectual property, partner contributions (e.g., clinical training, scholarships), extramural research and philanthropy.” Some estimates have placed start-up costs at $100 million.

The first home for the medical school will be O’Dowd Hall, on the OU campus. New buildings are expected to be needed and built. OU will provide the basic science educational components of the medical school as well as the non-clinical administration and operations, funded by revenue from tuition and fees, philanthropy and other sources. Beaumont will provide the clinical educational components, clinical administration, half the dean’s cost and scholarship support, according the venture’s website: http://www4.oakland.edu/?id=1102&sid=148

OU states that it has been “developing the resources for a medical school for decades through the (30-year-old) School of Health Sciences, the School of Nursing and (its) biomedical research facilities, including the Eye Research Institute.”

OU and Beaumont have been “working together for many years on collaborative programs, including eye research and a nationally recognized nurse anesthesia program,” according to the website. The school, which expects to graduate its first class in 2014, was formed partially in response to “the current and worsening shortage of trained physicians,” according to school and hospital officials. The full timeline for the school appears below:

· January 2007 – Letter of intent to create new allopathic medical school and fee submitted to LCME.

· April 5, 2007 – Formal public announcement of partnership occurs with Oakland University and Beaumont Hospital representatives at Meadow Brook Hall.

· December 2008 – Application materials are submitted to LCME. If the accreditation body determines the application to be complete, a site survey of the proposed new school will be authorized.

· January - February 2009 – LCME conducts site survey.

· May - June 2009 – LCME grants proposed preliminary accreditation if all aspects of the school are found to be in compliance with regulations, allowing for the recruitment of students.

· September 2010 – Charter class of 50 medical students admitted to the new school’s four-year curriculum.

· January 2012 – By this midpoint of the students’ second year, an updated education database and repeat site survey will be required.

· February or June 2012 – If the school is in full compliance with accreditation requirements to date, provisional accreditation is granted.

· July 2012 – Charter class begins its two-year clinical education rotations at Beaumont Hospital.

· January - February 2013 – Final database submission and site visit occur, resulting in full accreditation of the school by the LCME.

· June 2014 – The charter class graduates.

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DMC Rehabilitation Institute Names New President

William H. Restum, PhD, has been named president of DMC Rehabilitation Institute of Michigan (RIM), replacing Terry A. Reiley, who recently retired after 19 years of service at the DMC.

Dr. Restum has a doctorate in Speech-Language Pathology from Wayne State University, and obtained his bachelor’s and master’s degrees from Western Michigan University. He comes to RIM with over 35 years of experience in the field of rehabilitation.

Former positions include Vice-President, Clinical Programs, Sinai Hospital; Vice-President Clinical & Ambulatory Services, Northwest Region, Detroit Medical Center; President and CEO, Great Lakes Rehab Hospital in Southfield; and Chief Executive Officer, Health Care Partners, Inc.

“Bill will continue to be a valuable asset here at DMC,” said Michael Duggan, CEO and President, Detroit Medical Center. “His healthcare background, coupled with his rehabilitation expertise made him the perfect fit. He will be a natural in this position. His leadership and knowledge will continue the success of RIM as well as the entire system.”

Dr. Restum previously served as RIM’s Director for Strategic Initiatives.

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Dr. Loeb Brings $100,000 Grant To WSUSOM

Jeffrey Loeb, MD, PhD, has secured a $100,000 grant that he will use to develop a commercialization center in the Wayne State University School of Medicine Center for Molecular Medicine and Genetics (CMMG), an effort that is expected to bring new discoveries to market sooner and provide economic stimulus for the state of Michigan.

With the Michigan Initiative for Innovation and Entrepreneurship (MIIE) grant, Dr. Loeb, associate professor of Neurology and associate director of the CMMG, will establish the CMMG Commercialization Center. The new center will streamline the process of bringing developments in the lab to market faster and train researchers in how to make that happen.

Dr. Loeb said researchers often have difficulty confronting the commercialization of their discoveries because they generally lack expertise in issues outside of the lab.

“Researchers are not generally trained in commercialization. With this program, education is an essential part. In fact, the best education is taking your own ideas through the commercialization process with experts in the field. This is one of the fundamental and most important aspects to our program,” Dr. Loeb explained. “Given the amazing discoveries we are making here, we need a more efficient and highly focused means to take these discoveries to fruition.”

In a letter to Dr. Loeb announcing the grant, MIIE Management Committee Chairman Marvin G. Parnes, wrote, “unlike most of the Technology Commercialization proposals, yours addresses an industry rather than a specific technology. Committee members feel that this project will build the state’s technology transfer infrastructure as well as foster an industry. The plan will improve industry’s awareness of and access to university resources, assets and services, while providing faculty/student teams with access to and experience of the companies involved. It will contribute to Michigan’s competitiveness in this sector and may well result in job offers for students who have made excellent contacts through the program.”

The MIIE is a consortium of Michigan’s 15 state universities. Dr. Loeb’s grant is one of the first 20 awarded by the organization, which seeks to help rebuild the state’s economy on a foundation of diversified, knowledge-based industries. The MIIE, using philanthropic resources, will help launch startup companies and industries, strengthen ties between small business, industry and academia, and speed the commercialization of university research. The consortium expects its efforts to create as many as 200 new startups in the next decade.

The center, Dr. Loeb said, can serve as a “beta-testing site” for Wayne State University and other Michigan universities. The CMMG, he noted, has a record of developing emerging technologies with great commercial potential, including GlyTags, which increase a drug’s therapeutic efficacy while limiting toxicity, antibiotics that avoid or delay microbe resistance and “drug targets” for treating epilepsy.

The concept for the center, and the impetus for applying for the grant, Dr. Loeb said, came from his own experiences with commercialization of developments from his laboratory. “I came up with an idea, developed a drug, and then formed a company called GlyTag to try to get the drug to patients with cancer who might benefit from this drug. By doing so, I have learned through the school of hard knocks where the challenges lie and came up with this plan to expedite future inventions.”

Dr. Loeb said other medical universities that have established similar centers – notably Massachusetts Institute of Technology and UniversityCalifornia San Diego – have had great success.

The first step under the recently secured grant, Dr. Loeb said, will be developing a Web interface and “rapid means” to screen scientific ideas for commercial potential. “We have already begun discussions with potential external advisors in the biotechnology field and are looking for more. There are a number of inventions under development in the (CMMG) that this grant will streamline.”

Dr. Loeb noted that the center will need to apply for additional funding to keep the initiative moving forward. “As part of our effort in this proposal, we will be identifying sources of seed funding for specific projects.”

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Hear From Lawmakers Sept. 25 At Capitol Check-Up

This year’s MSMS Capitol Check-Up will provide attendees with the latest information from lawmakers and other experts about the current state of affairs in Lansing, the latest health care legislation being considered, and its impact on the medical profession. Capitol Check-Up will take place on Thursday, September 25, noon until 4 p.m., in Lansing. This event enables doctors to meet with lawmakers and explore topics such as Medicaid funding, scope of practice, and smoke-free workplaces. To register, visit www.msms.org/eo or contact the MSMS Registrar at 517-336-5784 or abatten@msms.org.

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Grassroots Efforts Ebb Medicare Cuts

Being a member of MSMS is critical, especially during times like this, when our patients’ access and our practices face the government chopping block. Without concerted grassroots advocacy from our members to stop the 10.6 percent cut in 2008 and five percent cut in 2009, physicians in Michigan would have lost $540 million for the care of elderly and disabled patients. MSMS thanks all the physicians, Alliance members, group managers and medical staff whose grassroots support was key to our success. We cannot rest on this achievement, however. We must use it as a stepping stone toward the goal of permanently changing the flawed Medicare payment formula. Watch email, www.msms.org/medicare, and Medigram for further developments.

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Medicare Makes Additions To 'Do-Not-Pay' List

CMS July 31 announced new Medicare reimbursement rules that include additions to a list of preventable conditions for which the program will no longer pay hospitals to treat as of Oct. 1, CQ HealthBeat reports (Reichard, CQ HealthBeat, 7/31).

In August 2007, CMS announced that Medicare no longer will reimburse hospitals for the treatment of certain "conditions that could reasonably have been prevented," and that the facilities "cannot bill the beneficiary for any charges associated with the hospital-acquired complication." The conditions include: falls; mediastinitis, an infection that can develop after heart surgery; urinary tract infections that result from improper use of catheters; pressure ulcers; and vascular infections that result from improper use of catheters. In addition, the conditions include three "never events": objects left in the body during surgery, air embolisms and blood incompatibility (Kaiser Daily Health Policy Report, 4/15).

The new rules will add to the list two conditions: blood clots in the leg after knee- or hip-replacement surgery and complications related to inadequate control of blood sugar levels. In addition, the rules will expand a condition previously on the list to include infections that develop on surgical sites after elective procedures.

According to the AP/San Francisco Chronicle, CMS earlier this year had proposed to add seven other conditions to the list but "backed off" amid concerns raised by hospitals. James Rohack, president-elect of the American Medical Association, said the new rules would reduce the quality of patient care. "We are working hard to improve quality and efficiency, but simply not paying for complications or conditions that, while regrettable, are not entirely preventable is not the way to do it," he said (Freking, AP/San Francisco Chronicle, 7/31).

Acting CMS Administrator Kerry Weems said that the agency has sent a letter to state officials to ask them to consider similar rules in their Medicaid programs. According to CMS, almost 20 states have begun to consider such rules (CQ HealthBeat, 7/31).

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National EHR Bill Put On Back Burner

Additional action on a bill (S 1693) that would create a national electronic health records system likely will be delayed until after Congress' August recess, Senate Health, Education, Labor and Pensions Committee ranking member Mike Enzi (R-Wyo.) said July 31, CongressDaily reports. Enzi introduced the bill in 2007 with committee Chair Edward Kennedy (D-Mass.).

According to CongressDaily, the bill's sponsors had hoped to advance the measure to the floor by unanimous consent, but concerns from some lawmakers raised the possibility of the delay. Aides to Sens. Tom Coburn (R-Okla.) and Olympia Snowe (R-Maine), who have called for modifications to the bill, said the two lawmakers would block the bill if it advanced to the floor before the recess.

Snowe said that the language on consumer privacy protections in the bill is inadequate. Coburn said he objected to a provision that authorizes more than $100 million annually toward grant and loan initiatives to encourage adoption of health information technology. He recommended revisions to the bill that would allow hospitals to provide physicians with health IT equipment at a discount or at no cost. He also said language regarding restrictions on patient data-sharing and data breach notification rules needs to be changed.

Meanwhile, committee aides also have been making adjustments to the bill following discussions with health care, technology and consumer advocates, CongressDaily reports. Enzi said, "We keep wordsmithing and wordsmithing," adding, "Health IT is so significant and so important that everyone wants their fingerprints on it," and that is delaying the legislation (Noyes, CongressDaily, 8/1).

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