Patient Protection [Not] and [Un]affordable Care Act, Part 10


How do you like my new name for the law?  At our PNHP meeting, the abbreviation PPACA was proposed, but I thought this was pretty cool.

I reviewed Section 2703 today.  This is a state option to provide “health homes” to people with chronic conditions who are on Medicaid.  It is optional– if states do it, the federal matching funds will be 90% for the first 8 quarters.  So what’s a “health home”?  I don’t know why they picked this terminology– it sounds like the same thing the medical community has been calling a “medical home”.  There is usually a reason people change established language (see my title above), but in this case I’ll be darned if I know what it is!

The medical home concept started with pediatricians, decades ago– it is not just a particular building where your chart gets kept, but a whole system of health care.  There are several criteria often used to define a medical home, but the gist of it is that you have a consistent, personal healthcare provider (or team of providers) who looks after you as a whole person, not just a set of various body parts.  We do comprehensive histories and exams, find consultants for you when you need specialized care, and make sure that everyone who takes care of your health is on the same page, working in a more coordinated way.

In the last few years, other primary care doctors (internists and family medicine doctors) have started to use a medical home model.  Insurers have gotten in on it too, and not always in what I think is a good way.  Our state Medicaid is working right now to make guidelines for a medical home, and there is even a national organization that can qualify us as medical home providers.

This particular bit is not in HR 676, but there is no reason the essential features of a medical home can’t be done.  The problem with having a set of rules to define a medical home is that it resembles “No Child left behind”– in that case, it was clear that some schools and teachers did a better job than others, so people tried to figure out specific reasons why and make everyone else do those items.  But what happens is that you get the letter of the law and the spirit gets squashed.  People spend so much time checking off boxes that they forget what the boxes were meant to do.

Most good primary care doctors and practices I know have always practiced as medical homes– it really is just good medicine.  I think it is important to publish information and provide training on ways to be a better medical home, so that both patients and providers can have a good understanding of how things should be done.  But I doubt if all these rules are going to turn poor quality providers into good ones.  More likely, when all of us finally have access to real primary care medicine, checkups and all, the essential features of a medical home will be part of that.  Anyone disagree?

This part of the law is only going to offer funding for medical homes to people with specific chronic conditions (although states may opt to add others).  A person must have 2 chronic conditions, 1 chronic condition plus a risk for another one, or a serious persistent mental health disorder.  The chronic conditions must include mental illness, substance abuse, asthma, diabetes, heart disease or a BMI over 25.  That seems restrictive, when a medical home really benefits all of us, but then think about it– probably a majority of us would meet the criteria!  A BMI of 25 or more is just overweight, not even obese.  All you would need in addition to that would be a risk factor, and I’m pretty sure we all have a relative with one of the other conditions (at least one)!

In contrast, a universal comprehensive improved version of Medicare for All would pay for all of us to have the essential features of a medical home.  You wouldn’t have to be already sick– the system would be in place for you ahead of time.

3 Comments

Filed under Healthcare reform, Uncategorized

3 responses to “Patient Protection [Not] and [Un]affordable Care Act, Part 10

  1. Janice Marsh

    Title edits. You asked, so here’s my reaction to your title edits. I found it confusing. I might have misunderstood, but I thought your purpose was to wade through the law to learn what it includes, analyze its potential impact on existing medical issues, and to share what you learned with the rest of us, who either lack comprehensive knowledge of the medical environment prior to the PPACA, or who are not willing to devote that kind of time and energy to analyzing the PPACA. I value and have learned from your analytical reaction to some of the sections, especially the shortcomings of specific sections. Having said that, IMHO, your editorial additions to the title of the law itself announces a bias that detracts from the project itself.

    • Thanks, Janice, because I do want to know reactions, and I am worried by what you are saying. I thought I had made it clear what my purpose was on my home page and in the first installment, but maybe I should be repeating it every time? I did actually in the last one, part 9, but I haven’t for each one.

      On my home page, I stated my purpose:

      My purpose in starting this blog is to give a personal perspective that supports the PNHP view, although this is not an official PNHP or NAHA sponsored site.

      I hoped that would make it clear that I had a particular position on the issue! And as far as trying to share what I learned as a way to help people who aren’t willing to “devote that kind of time and energy”, here is what I said in my first post:

      I’ve been working on reading the new legislation for myself, all 2400 odd pages of it. I encourage all of you to do the same. Summaries are a good start, but with something so important, we need to take the responsibility of personally reading it.

      Not only people with a medical perspective need to read this– people from all walks of life need to see how it reads from their own acquired knowledge! I want to know if they catch something I missed.

      And as far as a “bias”, here is the definition of bias:

      a. A preference or an inclination, especially one that inhibits impartial judgment.
      b. An unfair act or policy stemming from prejudice.

      I do not think having a standard or even an opinion is the same as having a bias. I have a standard that any health care reform ought to include every one of us and be completely equitable, as well as affordable and tending to lead to high quality care. That is the standard against which I have measured all the proposals I’ve seen, including this law. I don’t know that any human being is ever completely impartial about anything, but I have made a strong attempt to be impartial when I hold any plan up against my standard, because I certainly wouldn’t want to miss a solution that was even better than the PNHP one. However, once I have applied a standard to something, it is not bias or prejudice to form an opinion.
      Having kept up with the general developments around this law, I knew before reading it that it was at least not meeting the standard of universal, equitable access. I did want to find out about the quality and cost aspects, and so far what I’m seeing is not good. My prior information was also not a bias, but had helped me form an opinion, leading to my statement of purpose on the home page.

      I guess I wanted to know if the title was a good way of expressing what I have found to be the truth about what the law includes. And your sense of confusion, from someone who sounds highly intelligent, about my intentions in this blog make me suspect it is important to even include that in the title lines. But if there is a better way to do that, I’d like to know. Perhaps I should have an opening paragraph with the two quotes I gave above, at the beginning of each post?

  2. Wally Retan

    PPACA? Pee-Pee-Ah-Ca (or Ca-Ca)

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