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Subspecialists wary of medical homes.

BALTIMORE -- Subspecialists need not worry that their salaries will decline as a result of efforts to increase the salaries of primary care physicians and thereby attract more medical students to the field, according to Dr. Jeffrey Harris, president of the American College of Physicians.

Many subspecialists are "terribly anxious" about efforts to narrow the earnings disparity between primary care and subspecialty care. They wonder: "Will the federal government simply shift the money? Will it take payments from subspecialists and move them to primary care?" Dr. Harris addressed those questions in a presentation advocating the medical home model during the annual meeting of the Renal Physicians Association.

The goal is not to rob Peter to pay Paul, he said, "although some of that is probably going to happen." Rather, the bulk of the income-gap narrowing will come from overall health care savings achieved through the adoption of the medical home model, which in turn will require a sufficient number of primary care physicians.

Noting that nearly half of the ACP's membership consists of subspecialists, Dr. Harris suggested that the college would not advocate for a medical home system that would primarily benefit general internists.

The promise of the medical home model involves a reduction in costs, to be achieved by coordinating care through a general physician who stays up-to-date about subspecialty care and emphasizes individualized preventive care. Data have shown that such a model can cut costs by reducing emergency department visits, shortening hospitalizations, eliminating duplicate laboratory tests, and achieving other efficiencies.

But subspecialists should support the medical home model for reasons other than overall cost reductions. In fact, Dr. Harris said, subspecialists themselves might choose to provide a patient's medical home. "One can easily envision a system where an internist is following a large cluster of people" who have declining glomerular filtration rates, for example, he said. "At some point, the nephrologist says, 'From this point forward, I will be the medical home, and I will take over these things.'"

Care that is coordinated through a medical home can result in fewer frustrations for subspecialists, he added. "The medical home becomes a central repository for at least one copy of all the records. So there's no more of that madness of having someone on the phone pulling medical records, trying to find this or find that."

Dr. Harris pointed out that subspecialists often voice unhappiness about the quality of referral information provided by primary care physicians. General physicians "used to do a lot of the work, and the patient would arrive with a lot done, and then the subspecialist would get down to the more difficult part," he said. Now, "a referral comes and just says 'anemia,' and nothing has been done."

That's because primary care physicians are doing all they can do, Dr. Harris said. With 10 minutes to spend on each patient, they say, "we're dancing as fast as we can dance." But Dr. Harris predicted that under a medical home model, primary physicians will do a lot more of the preparatory work, allowing subspecialists to better exercise their expertise.

In an interview, Dr. Alan Kliger, president of the Renal Physicians Association, said that current medical home models haven't clarified how the partnership between specialists and primary care physicians will be structured.

Nonetheless, given the large numbers of Americans with chronic kidney disease, many of whom are not yet undiagnosed, "it is clear to us that nephrologists alone will be unable to direct the care for this many people. Thus, primary care physicians and nephrologists in partnership will be needed to tackle chronic kidney disease, "Dr. Kliger said.

Until more details are available about the medical home model, he added, it remains unclear "how it might help or hurt [specialists like] nephrologists. What is more important is how the plan might help or hurt patients. ... The model must allow for adequate joint management, adequate flexibility, and adequate reimbursement to allow for best care."


How can general internists and subspecialists best make use of the medical home model?

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Author:Napoli, Denise
Publication:Internal Medicine News
Geographic Code:1USA
Date:May 1, 2009
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