Medical Homelessness

It has now been 6 months since I returned to the US following my 3 month roving locum in New Zealand. I knew I would need time to process the experience and to reintegrate into my former personal and medical life here, but I was surprised that I was unable to pull some thoughts together for the blog until recently. I’m normally a verbal sort of guy, and this was my first encounter with the dreaded “writer’s block”. I’m sure it was the result of re-entry into the surreal world of US healthcare.

In many ways, the most jarring part of this re-entry occurred in the first few months as I resumed clinical practice here in the US. The differences between Kiwis and Americans in patient attitudes, trust, demands, sense of personal responsibility and perhaps most telling, willingness to take ownership not only of their own health but also for participation in providing health care for fellow citizens all presented a stark contrast.

And as for the US health care system itself, I found it astonishing that the proponents of President Obama’s recently passed but inadequate and compromised “Patient Protection and Affordable Care Act” (PPACA), had more or less declared victory and changed the subject. There had been an enormous amount of activity in the run-up to reform but to me it all seemed to be tantamount once again to rearranging the deck chairs on the Titanic. The fatal design flaws and hubris at the helm remain in place--even as the recession continues to grip the country, unemployment benefits are held hostage to making tax breaks for the wealthy permanent and even the “insured” are being squeezed by higher and higher shares of premiums that provide less and less. And nowhere is there any talk of cost containment, let alone universal access....

In lieu of meaningful systemic change, micro-reforms are being touted as the next new thing. Nothing is literally or figuratively more descriptive of the shortcomings of these “innovations” than the so-called patient centered medical home.

Several months ago, writing in the Journal Health Affairs, a group of colleagues at Group Health Cooperative in Seattle shared their experiences with developing and implementing a new primary health care model termed the “Medical Home” . The concept of the medical home is to improve the primary care delivery experience for both patients and care providers in a number of ways, including:

• improved access,
• more timely and efficient communications,
• application of coordinated--often electronic--record keeping,
• quality improvement through implementation and tracking of care standards,
• employment of active case management.

Many of these “new” ideas incorporate functions of successful past primary care practice models that unfortunately have become increasingly rare or that were seldom carried out in real world primary care practice due to manpower shortages and to a fundamental incompatibility with fee-for-service reimbursement.

In large health systems such as Group Health’s, every dollar spent on implementing the medical home, $1.50 in savings was reported to be generated. Intangibles such as patient and provider satisfaction were improved. And overall, the quality of care was shown to be better than less organized or proactive methods of organizing care. None of which in and of itself is a bad thing.

But in spite of this, there is the compelling argument that such a model cannot be properly implemented without fundamental reform of the current financing structures presently in place in the US. In fact, reform proposals such as the medical home beg the question. While there are interesting elements contained in these models, this sort of local restructuring fails to address fundamental structural issues surrounding the underlying unfairness of the health care financing system--both from a reimbursement and funding perspective. Without some kind of universal health care financing scheme, as before, only select populations will derive any benefit from these innovations. The vast majority will still be faced with arbitrary, capricious market-based insurance manipulations that will continue to threaten many with inadequate coverage or bankruptcy even as their health care needs are most pressing.

On a personal level, I find it ironic that even as there is more and more talk of things like a patient centered medical home, there is no meaningful structural change taking place that might allow such measures to benefit patients across the board. As a result, I feel increasingly alienated from the unchanging chaos of US healthcare even as I simmer with anger at the ongoing manipulations of the political process by powerful entrenched vested interests in the insurance, pharmaceutical, hospital and medical care industries (which includes doctors) and the politicians who represent them.

I knew it was a risk, experiencing a functioning (even if imperfect) health care system like New Zealand’s, but I didn’t think I’d be left with this feeling of medical homelessness. It’s like returning home to an implacably fractious, dysfunctional, mean-spirited extended family after visiting distant relatives who live in a far more organized, harmonious, compassionate fashion.

I guess in retrospect that I shouldn’t be completely surprised. I met a few US doctors while I was there that had opted to relocate to New Zealand permanently to practice medicine. At the time I didn’t really understand what would compel them to take such committed action.

Now I do.

In fact, in an effort to better understand my initial exposure to the NZ health system, I have decided to return for a 6 month single site engagement--this time with my family--to take a more in-depth look. It’s hard to know what will come of it, but I feel that I have unfinished business there, and frankly, there is no compelling model of care--even in spite of some of the recent microinterventions--to fully engage me here.