The Health Care Levee – Community Clinics as Medical Homes for the Indigent

22 Dec The Health Care Levee – Community Clinics as Medical Homes for the Indigent

Levee (lĕv’ē) n.

  1. An embankment raised to prevent a river from overflowing.
  2. A small ridge or raised area bordering an irrigated field.

The medical home concept is going mainstream. Not only is it a significant part of the Obama teams reform agenda, but it has hitting the front pages much more frequently.  Of interest, Seattle continues to be the hotbed of innovation around this concept (interesting, they are one of the few states that have changed their laws to accomodate “direct practice” medicine), with commercial innovators like Qliance and academic institutions creating new types of practice models.

This article from the Seattle area highlights some early successes working with insurance companies to pay a monthly fee for (a new form of capitation?) services that are increasingly showing a major impact on health (increased communication, care coordination, population/preventative health, etc) but have never traditionally been compensated.

You will recognize this model, “fee for service with a capitated medical home fee” or “compensation for enhanced practice capabilities” (I will actually peel back the onion on what these “enhancements” really are), as the model advocated by Alan Goroll and his associates in Boston. Their model envisions the smoothest path to fundamental reform as being one that works within the current insurance paradigm but with several key improvements over Capitation 1.0. These would include compensation for the enhanced practice capabilites already noted, adjustments according to patient complexity, (they have a fairly elegant patient modifier algorthm), and tying a significant dollar figure to patient satisfaction and ultimately patient outcomes (when they become available). This is a workable approach as long as the payers come to the table which apparently is beginning to happen in Seattle (with at least 50 other “pilots” nationwide).

However, at the same time we are witnessing the above success, we are also seeing Primary Care Clinics being overrun, patients locked out, and system impassibly constipated in terms of new patients moving through.  Increasing access in Massachusetts did nothing to increase capacity. I fear the current economy will only accelerate this based on this report from the California Healthline. This will in turn hurt the most structural at risk part of our health care system – the community  health clinic. These often under-funded, under-staffed, overcrowded, and overburdened facilities are home to some of the most noble of the entire profession who day in and day out slug it out in some very difficult trenches. But they are also some of brightest, most resourceful, and talented clinicians and healers we have in medicine. They represent the levees of our American Health Care system.

But their limited surge capacity will most certainly be overwhelmed in the coming flood of patients being sent their way by the prevailing financial storms. When the flood waters break, I believe Katrina will look like an afternoon shower compared to the vicious cycle of care that will ensue (no primary care, crash in the ER, most expensive place to treat, kicked to the street, no followup, and back to the ER. Rinse. Repeat. Ad Nauseam and Ad Infinitum). Ouch.

Louise McCarthy, vice president of governmental affairs for the Community Clinic Association of Los Angeles, said, “There’s not a very large infrastructure in place to handle the increasing need, even though providers will do everything they can to treat as many people as they can.” Sounds reassuring.

Given that the Community Clinic is the “medical home” of the indigent – what low cost, effective, and useful technology sandbags can be put cobbled together to hold back the waters? I like David Kibbe’s recommendations to Obama as examples of the simple, but far reaching processes that can be implemented to complete the growing support for ubiquitous EHR deployments (about time!).

What other sandbags, or better yet, what infrastructure needs to be put in place to service the Community Health Clinics as a fundamental component of our primary care system?

  • Gregg Masters
    Posted at 00:58h, 23 December Reply

    I have been waiting for someone to connect the dots and make the capitation analogy.

    Does anyone remember PHPs (prepaid health plans) in Southern California? These were essentially primary care vehicles albeit from a health plan regulatory point of view.

    As the boutique and concierge markets continue to evolve and attract practitioners, the heat of the debate rises. Witness the hearing in Maryland last week where the insurance commissioner fired a shot across the bow of concierge practices. Now two days later, a primary care medical group announced termination of the consideration to restructure as a concierge or retainer based practice.

    Yes, things will (continue) get interesting!

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