Letters to the Editor - Dec. 22, 2008

Medical home designation carries threat of more scut work - Will small practices be able to compete for title of medical home?

Medical home designation carries threat of more scut work

Regarding "AMA meeting: Delegates back medical home, want pay issues resolved" (Article, Dec. 1): Paying primary care doctors more to enlist as medical home doctors has potentially negative consequences for them.

Already these physicians are plagued with an excess of paperwork that comes from many quarters: specialists, nurses, hospitals and many, many others.

The usual term for this work is scut work, a pejorative term doctors learn in their residencies to describe the mind-numbing paperwork that no one else wants to do. Most of this work in independent practice falls on the primary care doctor's shoulders.

The point is that when these doctors become formally designated as medical home supervisors, every other member of the health team who is looking for an excuse to shun paperwork will quickly pass it off to the primary care doctors, especially when it is clear that they are getting paid extra for being designated as medical home directors.

Any increased income primary care doctors receive will not be worth the added stress and drudgery attached to it. Yes, pay them more but do not increase the amount of the mind-numbing paperwork they already deal with.

Under the current payment system for primary care doctors, the best way for them to survive is to simply limit the number of patients they see. It is the only way for them to control the drudgery and threat of burnout that they face.

Of course, this will worsen the primary care access problem which already exists and hasten the deployment of nurse practitioners and physician assistants to provide some primary care services, something that many doctors oppose. But, there are not enough physicians around to do the job and there are no prospects of getting more into the work force soon.

If it is true that necessity is the mother of invention, then it is only a matter of time before midlevel providers have more high-profile roles in the health system.

--Edward J. Volpintesta, MD, Bethel, Conn.

Will small practices be able to compete for title of medical home?

Regarding "AMA Meeting: Delegates back medical home, want pay issues resolved" (Article, Dec. 1): As a small-town family doctor, I feel my office already serves as medical home to my patients.

Mine is a solo practice. I keep a third of my appointments every day for same-day availability. A patient who is sick today will be seen today, and seen by me. I try to practice evidence-based medicine. I actively encourage patients to make their own informed medical decisions. I often see patients and their families together to discuss treatment options. Often all the members of the extended family are my patients. My patients come to me with all sorts of problems, medical and personal.

My concern is that when the concept of a medical home becomes standardized, small offices like mine will not be able to meet all the criteria. Also, reporting requirements may be too onerous for a solo practitioner, as they are in many of the pay-for-performance models.

As far as I'm concerned, I'm already providing the quality of care that a patient should expect from a medical home, but I fear that will not be recognized by the "appropriate nongovernmental entity." I hope that as the concept of the medical home is finalized, there will be room in it for those of us who still practice Marcus Welby medicine.

I hope the medical home does not turn out to be just another layer of bureaucracy and paperwork between the patient and the services he or she needs.

--Barbara Hartley, MD, Benson, Ariz.