Correspondence
Specialist Practices as Medical Homes
N Engl J Med 2010; 363:991-993September 2, 2010
- Article
To the Editor:
In their Perspective article, Casalino et al. (April 29 issue)1 report that in a recent survey of specialty medical practices, a minority of the physicians viewed themselves as the “primary care physician” for the majority of their patients. We suspect that this survey underrepresents cardiologists who function in this role. Because the practices surveyed were small (1 to 19 physicians), the majority of practices caring for patients with complex conditions such as advanced heart failure, cardiac transplantation, and congenital heart disease were probably not included in the sample. We believe that a broader sampling of cardiology practices — or, more important, a survey of patients themselves — would better identify practices that are serving as patient-centered medical homes (PCMHs).
We agree that specialist-based medical homes should be held to the same standards as those that are primary care−based. Given the current physician shortage, increasing medical expenditures for long-term care, and the aging population, policymakers should allow all appropriately trained physicians, including specialists, to serve in PCMH practices when appropriate.
Ralph G. Brindis, M.D., M.P.H.
Mary Norine Walsh, M.D.
David C. May, M.D., Ph.D.
American College of Cardiology, Washington, DCDr. Walsh reports being the chair of the Patient-Centered Care Committee and Dr. May reports being the chair of the Patient-Centered Medical Home Subcommittee of the American College of Cardiology. No other potential conflict of interest relevant to this letter was reported.
1 References1
Casalino LP ,Rittenhouse DR ,Gillies RR ,Shortell SM . Specialist physician practices as patient-centered medical homes. N Engl J Med 2010;362:1555-1558
Full Text | Web of Science | Medline
To the Editor:
The analysis by Casalino et al. ignores a major specialty that has long been involved in primary care and that is thus at issue in the discussion of medical homes. The key provider of primary care to young women, the obstetrician-gynecologist, is neither included in the study survey nor mentioned in the analysis. Yet, these specialists are trained and often chosen by patients to provide primary care.1 One study showed, for example, a higher prevalence of preventive gynecologic services among obstetrician-gynecologists than among family practitioners and internists combined.2 More recent data would surely show the same patterns, since the needs behind women's choice of obstetrician-gynecologists and the specialized skills of these physicians for meeting such needs are perennial.
As regulations that define and reward the medical home materialize, the role of the obstetrician-gynecologist in the provision of primary care must not be ignored. For millions of female patients, for decades of their lives, gynecology and obstetrics are the only components of medical care that will be needed or sought.
Lucy Johns, M.P.H.
Health Care Planning and Policy, San Francisco, CA
ljohns@metacosmos.org No potential conflict of interest relevant to this letter was reported.
2 References1
Johns L . Obstetrics-gynecology as primary care: a market dilemma. Health Aff (Millwood) 1994;13:194-200
CrossRef | Web of Science | Medline2
Lurie N ,Slater J ,McGovern P ,Ekstrum J ,Quam L ,Margolis K . Preventive care for women: does the sex of the physician matter? N Engl J Med 1993;329:478-482
Full Text | Web of Science | Medline
To the Editor:
Casalino and colleagues describe specialist physicians providing “principal care” to patients with chronic conditions that call for ongoing specialist treatment. Psychiatrists have long served as principal physicians for patients with chronic psychiatric disorders such as schizophrenia. These patients generally require continuing, comprehensive care and frequently receive multidisciplinary services (e.g., job-skills training, housing support, and group therapy). Psychiatrists are frequently the first-contact physician for these patients, and they often coordinate care across domains of the mental health system. Recently, Smith and Sederer1 described the idea of a mental health home, and they encouraged psychiatrists to restructure already-existing community mental health centers to provide “enhanced access and coordination of care” based on the principles of the PCMH. Since psychiatrists usually do not deliver primary care, a primary care physician would need to be involved in the mental health home.1,2 The concept of a mental health home shows how patients who need a wide range of services from one field (psychiatry) might be well served by having a specialist physician directing care within a home.
Joseph M. Cerimele, M.D.
Mount Sinai School of Medicine, New York, NY
joseph.cerimele@mssm. edu No potential conflict of interest relevant to this letter was reported.
2 References1
Smith TE ,Sederer LI . A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatr Serv 2009;60:528-533
CrossRef | Web of Science | Medline2
Cerimele JM . The patient-centered medical home, the mental health home, and the psychiatrist's role. Am J Psychiatr Res 2010;5:2-2http://ajp.psychiatryonline.org/cgi/data/167/2/A46/DC2/1
To the Editor:
The PCMH work group of the American College of Physicians' Council of Subspecialty Societies (ACP CSS) agrees with Casalino et al. that only few patients will receive PCMH services from a specialty practice. Nevertheless, the collaboration of the medical home with specialist “neighbors” is essential, since the latter will play a critical role in the ability of the PCMH to deliver high-quality, cost-effective care that is coordinated and integrated. We submit that the PCMH will require the development of multiple types of collaborative interactions between the medical home and its neighbors (e.g., “curbside” preconsultation, formal consultation, and care comanagement). Moreover, attention should be devoted to the development of practical guidelines for care-coordination agreements and evidence-based long-term care models to facilitate effective collaboration and coordination among these practices. The ACP CSS has been working to develop such guidelines in an effort to properly align financial and nonfinancial incentives to promote a functional PCMH model that incorporates the essential contributions of primary and specialty medicine to patient care.
M. Carol Greenlee, M.D.
Richard W. Honsinger, M.D.
Neil M. Kirschner, Ph.D.
American College of Physicians, Washington, DC
nkirschner@acponline.org Drs. Greenlee, Honsinger, and Kirschner report being members of the PCMH work group of the American College of Physicians' Council of Subspecialty Societies. No other potential conflict of interest relevant to this letter was reported.
To the Editor:
Chronically ill patients use a disproportionate amount of resources, and their health outcomes remain suboptimal. Clearly, innovative approaches to care for this population are needed. These realities are exemplified by patients with advanced chronic kidney disease and end-stage renal disease.1 Patients with these diseases — only 1.5% of all Medicare beneficiaries — use more than 10% of all Medicare dollars. Providers who care for patients with renal disease have participated in multiple demonstration projects of the Centers for Medicare and Medicaid Services, which have established that integrated care management can improve clinical outcomes and control costs, with a high level of patient satisfaction. Providers of kidney care have demonstrated their ability to meet the criteria proposed in the article by Casalino and colleagues: nephrologists, collaborating with advanced practitioners, lead comprehensive care teams and are viewed by patients as their primary care providers.2,3 When incentives are aligned, nephrologists do redesign their practices to provide such care in a cost-efficient manner.4 In contradistinction to the overly broad perspective provided by Casalino et al., we urge support for accountable care organizations and innovative delivery models for the care of patients with renal disease in the United States.
Allen R. Nissenson, M.D.
DaVita, Inc., El Segundo, CA
anissenson@mednet.ucla. edu Edward R. Jones, M.D.
Renal Physicians Association, Philadelphia, PAFranklin W. Maddux, M.D.
Fresenius Medical Care, Lexington, MANo potential conflict of interest relevant to this letter was reported.
4 References1
Rettig RA ,Norris K ,Nissenson AR . Chronic kidney disease in the United States: a public policy imperative. Clin J Am Soc Nephrol 2008;3:1902-1910
CrossRef | Web of Science | Medline2
Lee BJ ,Forbes K . The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease. BMJ 2009;339:b2395-b2395
CrossRef | Web of Science | Medline3
Holley JL . Nephrologists as primary care providers: a review of the issues. Am J Kidney Dis 1998;31:574-583
CrossRef | Web of Science | Medline4
Rastogi A ,Linden A ,Nissenson AR . Disease management in chronic kidney disease. Adv Chronic Kidney Dis 2008;15:19-28
CrossRef | Web of Science | Medline
Author/Editor Response
Brindis et al. suggest that our survey underrepresented cardiologists who care for the patients with the most complex cardiac conditions and that such cardiologists are more likely than others to serve as primary care physicians for their patients. We agree with the first suggestion, but not with the second. Our survey did not include physicians in academic medical centers or in groups of 20 physicians or more. However, our data indicated that cardiologists in the smallest practices were significantly more likely than cardiologists in larger practices to state that they serve as primary care physicians for greater percentages of their patients. Perhaps cardiologists in larger groups are more likely to subspecialize within cardiology and less likely to be interested in serving as primary care physicians for their patients.
Johns revisits a debate from the managed care era about whether health insurance plans should permit obstetrician-gynecologists to serve as primary care physicians. We agree that these practices should be considered for PCMH status if they are able to meet the same PCMH standards as other practices. We disagree with the assertions by Johns that obstetrician-gynecologists are trained to provide primary care and that obstetrical and gynecologic care is all that many women will need for much of their lives. Young women commonly have asthma, rashes, respiratory infections, and musculoskeletal problems, including sports injuries. Obstetrician-gynecologists do not typically receive training for these problems, nor do they receive the general training in internal medicine that medical subspecialists receive.
All the correspondents raise the issue of specialist physician practices serving as medical homes for patients with chronic illnesses. We agree that this makes sense if these practices are willing and able to perform all medical home functions. For the individual physician, this means providing first-contact, continuous, and comprehensive care. For the practice, it means using systematic processes to improve the health of the practice's population of patients during the periods between face-to-face visits. These tasks, which are difficult for primary care physicians, are likely to be even more so for specialists.
The broader issue is how to improve primary care–specialist collaboration. We agree with Greenlee et al. that such collaboration will be essential if PCMHs are to provide high-quality, cost-effective care.1 We also agree that policymakers should make more effort to align specialist and primary care incentives. This alignment can occur in multispecialty medical groups2 and may occur within accountable care organizations, if these are created.3
Lawrence P. Casalino, M.D., Ph.D.
Weill Cornell Medical College, New York, NYDiane R. Rittenhouse, M.D., M.P.H.
University of California, San Francisco, San Francisco, CARobin R. Gillies, Ph.D.
University of California, Berkeley, Berkeley, CASince publication of his article, Dr. Casalino reports serving as an unpaid member of both the board of directors of the American Medical Group Association Foundation and an advisory group to the Accountable Care Organization Task Force of the National Committee for Quality Assurance. No other potential conflict of interest relevant to this letter was reported.
3 References1
Fisher ES . Building a medical neighborhood for the medical home. N Engl J Med 2008;359:1202-1205
Full Text | Web of Science | Medline2
Enthoven AC, Tollen LA, eds. Toward a 21st century health system: the contributions and promise of prepaid group practice. San Francisco: Jossey-Bass, 2004.
3
Rittenhouse DR ,Shortell SM ,Fisher ES . Primary care and accountable care -- two essential elements of delivery system reform. N Engl J Med 2009;361:2301-2303
Full Text | Web of Science | Medline
