House health-care reform bill proposes to decrease hospital visits
by establishing a “medical home pilot program” for elderly and disabled
Such a medical home would not require a physician to be on the staff,
and therefore could be run solely by nurse practitioners and physician
assistants. Medical homes also would practice “evidence-based”
medicine, which advocates only the use of medical treatments that are
supported by effectiveness research.
But physicians’ groups say the legislation could lead to restrictions
on which treatments may be used for certain conditions, despite the
fact that some patients might require a unique or unconventional
approach. It also may lead to dumping Medicare/Medicaid patients in
facilities that are not required to have physicians on staff.
The Center for Medicine in the Public Interest (CMPI) expressed its
concerns in a report that explains why statistical evidence does not
always reflect reality of effective medicine.
“‘One size fits all’ rarely does,” the report said. “From clothes to
shoes to hats, few people find that items carrying that label work with
their individual bodies. So why do we entrust the health of our bodies
-- one of the most important assets we have -- to a one-size-fits-all
According to CMPI and individual physicians, however, this
one-size-fits-all mentality is just what congressional health-care
“Unfortunately, policies being advanced under the guise of
‘evidence-based medicine’ (EBM) could do just that,” the CMPI report
said. “The idea behind EBM, empowering physicians with sound evidence
to incorporate into their treatment decisions for individual patients,
is a good one.
“Unfortunately, EBM now is being distorted by government bureaucrats
and HMOs in ways that impose top-down, one-size-fits-all restrictions
on patients and their healthcare providers.”
Rather than enforcing a formulaic approach to medicine based on
statistical and clinical research, CMPI says health-care reform should
preserve physicians’ autonomy to use the research in conjunction with
their experience and knowledge of the patient.
”It is so critically important for the physician to maintain his or her
ability to combine study findings with their expertise and knowledge of
the individual in order to make the optimal treatment decisions.
Evidence-based medicine in its present, distorted form emphasizes just
one aspect of the clinical pie over all the others,” the report found.
Kathryn Serkes of the American Association for Physicians and Surgeons
echoed the observation.
“There is no typical patient,” Serkes told CNSNews.com. “Every patient
is different from a medical perspective. If we have evidence-based
medicine that basically says ‘well, we start at treatment one, which
leads you to treatment two, to treatment three to treatment four. In
practice, that doesn’t work for the patient. That’s the ‘art’ part of
the art and science of medicine. That’s what we still need doctors to
do, is to figure out what’s right for the patient.”
In the long run, according to CMPI, evidence-based medicine may not
even cut costs as Congress suggests it would.
“Evidence-based medicine may provide transitory savings in the short
term, but the same patient who takes the cheapest available statin
today may very well be the patient costing you -- the taxpayer, the
policymaker, the thought-leader, the sister, the spouse -- big bucks
when that patient ends up in the hospital because of improperly treated
cardiovascular disease,” .
“The repercussions of choosing short-term thinking over long-term
results and cost-based medicine over patient-based are pernicious to
both the public purse and the public health,” the CMPI report said.
Provisions for the medical home pilot program are an amendment to the
Social Security Act, which governs the administration of Medicare and
The medical home is an approach to medical practice that “facilitates
partnerships” between patients and physicians, according to the
The pilot program targets Medicare beneficiaries who have a high
medical “risk score” or who require regular monitoring, advising or
treatment. This currently applies to more than 22 million Americans,
according to Kaiser Family Foundation statistics.
At least $1.5 billion would be redirected from the Federal
Supplementary Medical Insurance Trust Fund to fund the medical homes,
“in addition to funds otherwise available,” according to the bill.
The Senate health-care reform bill also includes provisions for medical
homes, although to lesser detail than the House bill.
If this portion of the legislation passes through Congress, medical
homes will be part of the greater health-care reform experiment known
as "the public (health insurance) option."
According to the committee, the provisions for medical homes will make
the public option a stronger competitor against private health
“The public health insurance option will be empowered to implement
innovative delivery reform initiatives so that it is a nimble purchaser
of health care and gets more value for each health care dollar,” the
House Committee on Energy and Commerce’s summary says about the bill.
Medical homes are tied to “comparative effectiveness research” via
something called “evidence-based medicine.”
“It will expand upon the experiments put forth in Medicare and be
provided the flexibility to implement value-based purchasing,
accountable care organizations, medical homes, and bundled payments.
These features will ensure the public option is a leader in efficient
delivery of quality care, spurring competition with private plans,” the
committee’s summary also said.
A statement by the American College of Emergency Physicians (ACEP) said
that the effectiveness of the medical home model should be carefully
evaluated before applying the model far and wide.
“There should be more research to demonstrate the benefits and
continuing costs associated with implementation of the full
(patient-centered medical home) model,” the ACEP statement said.
“Demonstration projects being conducted by the Centers for Medicare
& Medicaid Services must be carefully evaluated. There should be
proven value in healthcare outcomes for patients and reduced costs to
the healthcare system before there is widespread implementation of this
The proposal, meanwhile, specifically allows for facilities to be run
by staff who do not possess medical degrees – including nurses and
Also read: Obama’s ‘Department of Death with Dignity’
as well as House Health-Care Bill Would Establish
'Medical Homes' for the Elderly and Disabled and Euthanasia and Health Care Reform
Contact: Marie Magleby
Date: July 30, 2009
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