4-5 Shots at a Time; Not Just for Babies Anymore

The science of immunization continues apace. New vaccines are developed and new recommendations for old ones are elaborated. Back when I started my practice, the most shots an infant usually got at once was no more than three. Nowadays it can be easily be five. Still, once you got past the first year, which included the so-called primary series', toddlers rarely got more than one or two boosters per visit and adolescents hardly ever more than one at a time.

Times change.

Nowadays infants can routinely get up to five shots at a time: DaPT, Hib, Prevnar (PCV), polio (IPV), and Hepatitis B. There are all kinds of combination vaccines available, but with my relatively small pediatric population it's not economically viable to stock them all; hence, more needles per visit. Toddler visits can also generate up to four shots at once: MMR, Varivax (chickenpox) and Hepatitis A (brand new recommendation) along with some combination of DaPT, Hib, Polio and Prevnar boosters. I do my best to limit it to no more than 2-3 needles per visit, given that I get a shot at them (if you'll pardon the pun) at 12, 15 and 18 months.

This isn't really all that big a deal. Little kids are much more easily restrained, and they really don't remember the trauma of shots from one visit to the next. Even so, they generally forget about it by the time they've reached school age. I like to reassure the parents that it's really much more traumatic for them than it is for their child.

Times keep on changing, though.

First came the change in the recommendation for chickenpox vaccination: instead of a single dose at age 12 months, now everyone needs a booster at age 4. This means that for everyone over 4 who's only had one Varivax, they're "due" for their booster.

Next came the shift in the recommended age for the meningococcus vaccine. Previously recommended at entrance to college (and dorm life), it's now recommended at age 11.

Then came the new and improved dTap. It was known that immunity to whooping cough (pertussis) waned rapidly after vaccination, but it wasn't thought to be that common a disease. This was wrong. Upon the realization that adults and older kids really did still get whooping cough, an "adult" (over age 7) formulation of dTap was developed. dT boosters were always recommended at 10 year intervals, though if a patient sustained an open wound or burn AND it was more than 5 years since the last dT shot, a booster was due. With the last childhood dose due at age 4, once a kid turned 9 he was in the 5-10 year "window" when he didn't really "need" a booster right then, but if he got hurt he would. I used to offer the shot to kids as an option then; now, with the new dTap it's a good idea to get them the dose as soon as possible, to enhance their pertussis protection. Hence, eveyone over 9 really ought to get their dTap. That's 3 shots, in case anyone lost count.

Finally, the makers of Hepatitis A vaccine American Council on Immunization Practices decided that Hepatitis A was now dangerous enough to recommend that all children be immunized against it at age 12 months. This means that everyone over 12 months of age now needs the two-shot series.

What all this means is that a perfectly healthy 11-year-old, previously up-to-date on all his immunizations as of his last checkup, now "needs" 4 shots. If it's a girl, there's also HPV vaccination (Gardasil) which I now discuss at length with my patients even though I have made the business decision not to provide it in my office. Hypothetically, that makes 5 shots.

One of the principles of vaccination is to jab 'em while you have 'em. That is, you're supposed to give all vaccines for which a patient is eligible at once; that day; without delaying.

You try explaining that to a frightened fifth grader, who's now big enough to run and hide; or at least make your life very difficult if he chooses not to cooperate. He's really too big for a parent to physically hold him down, so if he doesn't want shots, there's no realistic way you're going to be able to force him. Suffice it to say, it's much more traumatic than it was when he was four months old, with nice, plump, juicy thunder thighs you could jab in a moment and then let mom give him a great big hug.

I do my best to split the difference, and limit the kids to two shots this year and wait until next year. I feel the meningitis and dTap are important enough not to wait on. Meningitis is rare but catastrophic; I'm looking forward to the inevitable point when the age is shifted downward yet again and it gets added to the infant series, thus cutting down on the last major cause of bacterial meningitis. Pertussis is annoying enough -- and hard enough to diagnose -- that I think the dTap is also a good idea. The chickenpox booster is meant to theoretically cover the 10% of kids with suboptimal response to their first dose. I'm willing to take the 90% chance in order to limit the trauma of my interaction with them by putting off the Varivax booster until the next visit. Ditto Hepatitis A. Of course you never know where and when the next Hepatitis outbreak is going to be, but in my humble opinion they're still rare enough in this country to allow me to put off universal immunization; at least until it means the poor kid doesn't need 5 shots at once.

I'm well aware that my opinion is not shared by many pediatricians, who prefer to follow the letter of the recommendations and just perforate the kids at will. More power to them. For what it's worth, I prefer to be a kinder and gentler dinosaur that I hope my patients appreciate.

(By the way, for purposes of commenting, anti-vaxxers: go to hell.)

Eastern Cacti

The previous owners of the condo unit where I have my office planted cacti. On the east coast. It's not usually all that hot here, and it's certainly not desert-dry; in fact, the humidity is often stifling. Yet somehow the recent weather here has resulted in this:

Here are some close-ups of the blossoms:

Pretty magnificent, don't you think.

By the Numbers

True Story:

Patient walks in this afternoon with a form to fill out so he can qualify for Medicaid. I have to certify that he is unable to work.


Me: Why can't you work?

He: Oh, there are a million reasons I can't work. For starters, I'm bipolar.

Me: Ok, that's two.


(He also has chronic back pain, diabetes with neuropathy and all kinds of other things that make him think he can't work. It remains to be seen what I do with the form.)

When Clothes Don't Make the Drug Rep

It was a tough day. We were crazy busy; the phone never stopped ringing. Finally, late in the afternoon, it slowed down. There was only one patient left as we sat cleaning up messages and filing charts, trying to unwind from the day.

We looked out the window and saw a car pull up.

"Is that our last patient?" I asked.

"No," said my office manager, watching as two guys with suits got out of the car. "The last patient is a sixteen-year-old for a physical. That's got to be a drug rep, complete with his District Manager."

"Damn," I said. "I really don't feel like dealing with them right now. Can't you get rid of them?"

Too late; the door was opening.

I got ready to bare my fangs and give them my best DinoRoar(tm).

Oops; it was the 16-year-old I've taken care of since he was born, and his father, all dressed up in suits and ties. The kid's hair was even combed.

I swallowed the roar and said hello, then started laughing and asked them where their laptops and sample cases were as I explained our mistaken assumptions. As it happens, I'd never seen them all gussied up before, so I got to tease them about their cleaning up so nice. But our faces sure were red the rest of the day.

(Sadly, they had indeed come from a funeral. The 51-year-old mother of a friend of the kid had lost her cancer battle.)

New Definition of "Runaround"

Last week I saw a young woman in her 20's, for whom I decided that treatment with oral contraceptives was the most appropriate medical option for her. So I wrote her a prescription. I did not specify on this prescription "Brand Medically Necessary" (the Pennsylvania version of "Dispense as Written") and so by law the pharmacist had the right to substitute a generic version of the medication. This was fine with me.

But no.

I got a call from the pharmacist saying that a preauthorization was required.

Ok; fine. That happens. But it took half an hour of my life I'll never get back to go through twelve telephone prompts, four messages to register my NPI, and three actual humans, just to have a form faxed over. I filled it out and faxed it back. In the meantime the young woman was told either that she'd have to pay $84.oo or $212.00 for it. (The story changed.) In any event, she's spending time in pain that I believe can be alleviated with the medical therapy I've prescribed, but that her insurance is not providing.

Today...(deep. breath.)...the response to the preauthorization...(slow. deep. breaths.)...came in over the fax:

Preauthorization not required; claim approved as generic.

What. the. fuck! (dated last week, to boot!)

Please note that I am not accusing the pharmacist of being a moron. I fully believe that this particular insurance company routinely bounces back messages to the pharmacies that preauthorization is required when in fact it is not. Anything to hassle the patient and make it less likely that the company will actually have to end up paying for it.

I'm angry.

You wouldn't like me when I'm angry.

Recipe for a Table Tower

• Take one mechanical engineer. (Note: it doesn't matter if he then went on to law school, spent an entire career as an intellectual property attorney and just turned 80 yesterday; Happy Birthday, Dad.)
• Process through two generations:

With apologies for poor resolution from a cell phone camera, from bottom up we have:

1. a bottle of BBQ sauce
2. an upside-down empty water bottle
3. a ceramic salt shaker
4. an empty sour cream container
5. two coke cans

The fork never made it.

He does this all the time, as did his grandfather before him. Dejaz vu at the dinner table.

Journal Club

An oldie but goodie from one of my favorite journals; the one, the only Journal of Irreproducible Results. From 1993, by Thomas Michel, MD, PhD:

Politically Correct Cardiology

Instead of saying a patient has Heart failure,

• Say the patient is Inotropically challenged.

Instead of saying a patient has Diastolic failure,

• Say the patient is Lusotropically challenged.

Instead of saying a patient has Sick Sinus Syndrome,

• Say the patient is Chronotropically challenged or Systolically impaired.

Instead of saying a patient has Aberrant conduction,

• Say the patient has Alternative conduction.

Instead of saying a patient has Left axis deviation,

• Say the patient is left axis-enabled.

Instead of saying a patient has an Inferior myocardial infarction,

• Say the patient has a Diaphragmatic MI.

Instead of saying a patient has a Hypercoagulable state,

• Say the patient is Rheologically impaired.

Instead of saying a patient has Aortic (mitral) incompetence or insufficiency,

• Say the patient is Aortic (mitral) retrograde flow enabled.

Instead of saying a patient has a Ventricular (atrial) septal defect,

• Say the patient is Interventricular (interatrial) flow-enabled.

Instead of saying a patient is a poor surgical candidate,

• Say the patient is Cardiac medical therapy enabled.

Instead of saying a patient has Senile aortic stenosis,

• Say the patient is Elder aortic flow impaired.

Instead of saying a patient has Multi-system organ failure,

• Say the patient is Metabolically challenged.

Instead of saying a patient is Dead,

• Say the patient is Metabolically different, or Entropically enabled.

Two-fer

As CrankyProf discovered (and so graciously informed the internet) I often meet patients at the office after hours when they need special care (and I'm not in the middle of doing anything else.) Many times it's quicker for them and just as easy for me. Every now and then, though, I get into more than I bargained for.

One lazy Sunday afternoon, the phone rings:

"Dr. Dino? Adam just got this huge gash in his head at a rugby game. We're still at the field, but I know it needs stitches. I really don't feel like sitting in the ER with him for hours and hours. Would you please please please do us a huge favor and come in and stitch him up?"

Sure, why not. As it happens, Adam was even in scouts with the Nestling so we'd run into him outside the office from time to time anyway. May as well do my Good Deed for the day.

So I putter out to the office, unlock the doors and turn on the lights. Within a few minutes their van pulls up. In walks Adam, his head covered in a huge swath of white bandage, followed by his mother, contrite and grateful.

Followed by ANOTHER kid with bandages around his head, and yet another mother.

"Hey, Dr. Dino," says Adam, "Right after we called you, my friend Brian here also got hit. He has a cut over his other eyebrow." (The opposite side from Adam's wound. Just my luck: symmetrical ruckers.) "Any chance you could sew him up too?"

Both boys were grinning the shit-eating grins of teenagers in trouble that wasn't their fault; both mothers were saying "Please" with their eyes. At least the second kid -- who wasn't my patient -- had really good insurance, so I figured, why not? No one had lost consciousness. Everyone remembered everything that had happened. No concussions involved, so all there was for me to do was tend to the wounds.

Adam came back first. He admitted that the guy who had done the bandaging had gone somewhat overboard as I cut off roll after roll of gauze. Just above his right eyebrow was a deep, gaping laceration about two inches long.

"Wow!" I said. It was gross, but gross = "wow" to a teenage boy.

"Can I see it?" he asked. I handed him a mirror. "I wish I could take a picture of it," he said.

No problem. I trudged back out to the waiting room and addressed his mother: "He wants his phone." I busied myself assembling my wound irrigation and suturing supplies while they recorded the wound for posterity. It was deep enough to require a few deep absorbable sutures to pull the skin edges close enough together, but when it was done I thought it looked pretty good, in a Frankenstein's monster kind of way. Adam and his mom thought it looked great.

Brian's gash wasn't as deep or as long, and was closer to being actually in his eyebrow. It turned out he'd had another cut in the same place a few months ago, so they thought maybe the scar had opened back up. Just a few stitches almost completely hidden in his eyebrow and he was good to go.

Both boys healed up fine. I even got paid for both procedures. But they're both still playing rugby, so who knows? You may meet them yourself some weekend, CrankyProf.

Movie Review: "The Happening" (Safe; No Spoilers)

Darling Spouse and I saw the new M. Night Shyamalan movie "The Happening" for one reason only: last fall I was mightily inconvenienced for three days while the road in front of my office was shut down for its filming. Such excitement! Mark Wahlberg was there, though I confess I never saw him. The little diner up the street was used for an extended scene, as was the road. All we wanted to see was those familiar sights up on the big screen.

In that respect we weren't disappointed. It was very odd; I for one found it impossible to believe they were actually out in the middle of Nowheresville, PA when the scene was so familiar. But we squirmed and pointed and sat up with excitement during that scene.

Other than that, the whole thing was a total bust. The premise was stupid. The characters weren't even substantial enough to call them cardboard -- more like tissue paper. The "romance" wasn't believable. I couldn't even figure out how to take Mark Wahlberg, and that's not a problem I've ever had before. There was no twist at the end (or even in the middle or beginning.) I don't particularly enjoy being scared, which is why I don't accompany the kids to their horror flicks and why I didn't enjoy this one either (after the familiar locations had come and gone.) I don't even think the kids would like it; it's that stupid.

Planning Ahead

This is Dr. Dinosaur calling in a refill for a patient's Evista.

Sure, Doctor. Is it ok if we substitute a generic for that?

Uh, there is no generic for Evista.

Oh, I meant in case a generic version of it comes out, may we substitute? This way we won't have to call you.

Um, ok.

Now THAT'S planning ahead.

The Tragedy of "Education"

"So senseless," said Darling Spouse, returning from this morning's walk with the Rolling Peke. Neighbors had provided details of a tragedy that occurred the other night just up the street. "Two educated people. What a waste!"

The storm that raged through our well-appointed, upper middle class neighborhood the other night knocked the heat out magnificently. Unfortunately, it also knocked out our electric power overnight, along with the many trees it knocked over. After the worst of it, I'd gone out walking with the Nestling and saw cameramen representing each of the three major networks producing meaningless footage of horizontal trees, including the one that landed on a rocket scientist who wanted to finish cutting his grass before the rain started. (He broke his leg; that was a bummer, not a tragedy.)

The next day, though (yesterday morning), a fourth-grade teacher didn't show up for the last day of school, which included the "Moving Up" ceremony for her class into the Middle School. At the house -- just up the street from me -- the police discovered that she and her husband had hooked up a gasoline-powered generator to run their refrigerator while the electric was out. They set it up INSIDE the house. The windows were closed.

He's dead. She's in critical condition.

For anyone who doesn't know, it's called carbon monoxide poisoning. Carbon monoxide (CO) is produced whenever hydrocarbon fuels are burned. It competes with oxygen for binding sites on hemoglobin, but it holds on far more tightly. That means that once the CO is attached to the hemoglobin, it ain't about to dissociate at usual physiologic temperatures and pressures. It also means that those hemoglobin molecules can't carry any oxygen. In other words, it kills you. (More info here and here.)

So why did DS's comment about their having been "educated people" send me for a loop? Because what passes for education in this country is obviously skewed. Reading and writing; literature and history; social studies and civics. Why does science get such short shrift?

No offense to CrankyProf and her ilk, but no one ever died of a comma splice. On the other hand, science illiteracy can kill you.

Fun Stat

I check my sitemeter from time to time, but try not to become too obsessed with it. I succeed pretty well, too. But as of today, it just so happens that my visit total reads:

177,177

I think it's kind of cute.

Anything Else?

The perils of the open-ended question in a new patient interview:


Me: Tell me about your health.

Patient: I have hypertension and a little arthritis in my knees.

M: Anything else?

P: No, that's all.

M: What medications do you take?

[presenting bag full of bottles, we find:]

• Cozaar
  
• Hydrodiuril
  
• Lipitor
• Zoloft
• Ativan
• Ultram
• Celebrex

M: Why do you take the Zoloft and Ativan?

P: Oh, the Zoloft is for anxiety and the Ativan helps me sleep.

M: Anything else?

P: No, that's all.

M: What about this Lipitor?

P: Oh, I stopped that about three years ago. It's just for people who eat a lot of fat in their diet. I don't think I need it.

M: Ok. When did you last have blood work done?

P: About four years ago.

M: And when did you last see a doctor?

P: About four years ago.

M: Any other medical problems?

P: No, that's all.

M: Are you allergic to any medicines?

P: I get a rash with penicillin, and oh yeah! I have this weird rash that comes and goes. I've seen all the specialists downtown and no one knows what it is.

M: Anything else?

P: No, that's all.

M: Anything run in the family?

P: My brother had a heart attack when he was 42, and oh yeah! I have a 30% blockage.

M: When did you find this out?

P: About four years ago.

M: Anything else?

P: No, that's all.

M: Do you need any of these meds refilled?

P: Just the Celebrex.

M: Most of these other bottles also say "no refill" on them.

P: Oh, I have more at home. I just dumped them out and brought the bottles.

M: How much more do you have at home?

P: About two weeks.

M: How about if I write refills for all of them.

P: Ok.

M: Anything else?

P: No, that's all.

M: Can I do some blood work on you today?

P: Sure. Oh, and I see a cardiologist, rheumatologist and orthopedist too. Can you send copies to them?

M: No problem. Anything else?

P: No, that's all.

M: Are you sure?

P: Yes.


Do you know why dinosaurs have no hair? It's because I pulled it all out this morning.

*SIGH*

Candidate for the "Full of Shit" Award

From the comments on my previous post:

Specialist’s [sic] are earning 2:1 over the primary care physician. On average, specialists are earning near $300K while the PCP earns roughly $150K, sometimes LESS! Do you know why?

Yep: it's because they've hijacked the group charged with setting payment, via RVUs; packing it with specialists and scratching each others' backs.

It doesn't make any sense considering there are more ICD-9 and CPT codes available in the primary care setting.

Say what? Aside from the Evaluation and Management codes, pretty much the only ones available to me are the immunization and minor surgery codes. The rest of that two-inch-thick code book is filled with surgical, radiological and interventional cardiology codes.

It's because the U.S. Healthcare System has changed… it has “moved” money away from office visits and therapy, and shifted it towards patient outcomes.

That's what they want you to think, because that's what they say they are trying to do. Hell, no one even knows precisely how to measure outcomes. (See Einstein on DB's sidebar: "Not everything that can be counted counts, and not everything that counts can be counted.")

Reimbursements are down, costs are rising! As a result, physicians who continue to operate as they have in the past are feeling “financially” squeezed!

Um, yeah; that's because we are. And please banish the word "reimbursement" from your vocabulary on the topic of physician "payment."

In attempts to offset their losses many are working longer hours seeing more patients, while earning less. They are also trying to reduce nonessential services and overhead by working with fewer people, in less space. Then there are some who are choosing to decline services due to capitation issues.

Right; these are appropriate business responses.

None of this helps! Do you know why?

Why do I get the sense that the answer ultimately involves paying you money?

Because the Healthcare System knows most PCP are “flying under the radar” by operating in “waived” settings and avoiding the responsibilities that accompany providing quality care.

WTF?

The money has been moved to three main practice areas- diagnostics, imaging/radiology, and clinical lab.

Yep: those are definitely the areas where there is still big-time money to be made, thanks to maintenance of artificially high payments in the face of drastically reduced costs, yielding continued profitability instead of passing on the savings.

The idea behind the shift is to improve patient outcomes by placing money as an incentive for PCP to uncover asymptomatic illnesses before they become chronic and cause catastrophic costs to the overall system.

In other words, "preventive care saves money." Too bad it doesn't.

The trick is to align your practice within the changes that have taken place in the healthcare system.

WTF?

By align your practice, I mean according to your specific patient base and data requirements to ensure the additional revenues generated will greatly exceed the cost of change.

Are you talking about adding ancillary services like lab and imaging to my primary care office?

(e.g. If you are seeing 3 elderly patients per week with dizziness symptoms, I can give you the Medicare issued healthcareICD-9 code & CPT code that reimburses $450 per procedure. Buying the proper box costs $700 per mo. So figure an increase of $5200!)

By gum, I think you are. So leaving aside that I'm *not* seeing that many dizzy grannies weekly -- week in and week out -- you can, for a small one-time fee (and continuing to sell me the reagents, I'm sure) teach me how to game the system by ordering a battery of tests that may or may not be needed. Wow. Remind me again, though, how this either "improves patient outcomes" or "uncovers asymptomatic illnesses before they become chronic and cause catastrophic costs to the overall system"?

This is just one example of what I'm talking about. The problem is- every situation has specific needs! I can't say this is best for you, but I can tell you there are 100s of these. It's just a matter of knowing what to do for your specific patient base and volume requirements.

I see. You're a representative of yet another one of those parasitic entities sucking gullible physicians into shelling out beaucoup bucks for lab, imaging and diagnostic equipment using ridiculously optimistic financial projections. It's a business model whose effectiveness is inversely proportional to physicians' business savvy; that is to say, it ain't gonna work on me, and on increasing numbers of us in the months and years to come.

Trust me when I say this, almost every PCP practice seeing 25+ patients per day, including the solo practitioner can increase their income by $125,000.00. It's just a matter of OPTIMIZING their practice!

Dude, I trust you about as far as I can throw you. OPTIMIZING my practice involves keeping my checkbook far away from you and your ilk. (Oh, and "check out" this blog as well.)

What Will Happen

My Take on Reforming Health Care - Part 2

As an independent, solo physician, I am in business for myself. I make decisions about payment policies -- including insurance participation -- based on a number of variables. I have to pay my overhead and make a profit while keeping my patients (customers) satisfied, without running afoul of the law; just like any other business. At this particular time and place, my customers (patients) expect that I will participate with their medical insurance plan. Some, in fact, have chosen to utilize my services for that specific reason.

But my relationships with insurers -- including the government -- are deteriorating. The promise of volume in exchange for fee discounts isn't working to my benefit the way it used to. As dealing with insurers becomes less rewarding monetarily and the hassle-factor continues to increase, the time will come when it will no longer be worth my while to contract with them. At that point, I will stop doing so. As it happens, I believe that many other physicians in situations similar to mine will come to the same conclusions as I, and will also choose to terminate those contracts. The eventual result will probably be that no outpatient primary care physicians will participate with insurance.

At that point, the insurance companies will almost certainly adjust their business model to take the new reality of non-participating physicians into account. With any luck, they will move towards something that looks like actual insurance (think home and auto; coverage only for catastrophic care) and will therefore be considerably less expensive. Who knows; they may even have to make do with less revenue. That's what capitalism is all about, isn't it?

Note what doesn't have to happen: no legislative changes; no change in insurance regulation; no vote; nothing but individuals making their own decisions for their own benefit, granted without taking the overall effect on society into account, but who cares? The essence of capitalistic decisions is accepting that what is good for me might not be good for someone else, and not allowing it to become my problem. After all, if I decided to continue participating with Medicare because "the elderly would be in big trouble if everybody did it" but I then cannot stay in business because of continuing pay cuts year after year, I wouldn't be much good to anybody, least of all myself.

Right now the idea of a cash only practice -- be it fee-for-service or prepaid; so-called retainer medicine -- is just beginning to take hold. I think it is a good idea, and I do believe I will move to it sooner or later. I also believe that many other physicians will come to the same conclusion and take the same action. I see the insurance companies' gradual demise, bleeding from a thousand tiny wounds as each of us divests ourselves of our servitude to them.

Certainly if we could manage to unite and do it in an organized manner, it would happen sooner. Then again, we doctors can never agree on anything, can we? Trying to organize doctors is like herding cats, right? Such a group of rugged individualists would never be able to come together for something like this. But that's ok. It will still happen as one by one, we each come to the same inevitable conclusion.

Reinventing the Square Wheel

My take on "Health Insurance Reform" - Part 1

I've been following many of the discussions about the creation of the so-called "Medical Home," a concept championed by the AAFP as well as the ACP. First of all, the descriptions of the actual model describe precisely what I am already doing:

[P]roviding comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system.

What's currently being hashed out are ways to tweak the payment system, allegedly to adequately pay physicians for doing, well, precisely what I already do. Here is Dr. Bob Centor's bullet point version of the payment debate:

1. Patient care benefits from coordinated care
2. Physicians will provide better systems of care if they receive some compensation for that provision. By this I mean telephone access, email access, etc.
3. Paying piecemeal for telephone calls, emails and the like is not feasible nor practical.
4. A single global fee for all care might discourage patient visits.
5. Combining a monthly management fee - which is meant to pay for all our "extra" time - with a fee for service for visits.

Forgive me, but this sounds awfully similar to the already tried -- and failed -- model known as capitation. Oh no, cry the Medical Home advocates: this time we're talking about paying you for all you do. Uh, excuse me: that's what capitation was supposed to be. Besides, the major reason capitation failed wasn't because the model was flawed but because it didn't pay enough. The other reasons are that so-called "preventive health care" doesn't save money, and the reality that young healthy people will often not see the value in participating with health insurance plans unless/until they need them. Thus, "comprehensive" health insurance stops being "insurance" in the true meaning of the word. But I digress.

The real reason I don't believe the Medical Home model will amount to substantive success is because of the the fundamentally flawed process: people who claim to know what is best for me getting together to decide how I will be paid. In form, this is how Blue Cross and Blue Shield got started in the 1930's and how Medicare came into being in the 1960's. According to the advocates of the Medical Home, it will solve all our problems. That's what they said about BCBS and Medicare, and look how those turned out. Other flawed truisms are that the government has to do something to "fix" the "broken health care system" (I would argue it's the "healthcare payment system") and that doctors cannot accomplish anything without uniting.

Americans -- including doctors -- are capitalist fundamentalists. Those of us in private practice are business owners and entrepreneurs. From an economic standpoint, it doesn't matter that our product is health care. Whatever happens in the ivory towers and smoke-filled back rooms of the policy debates, we are going to continue to make decisions based on what is best for our business, given whatever economic climate and constraints present themselves. Health care employers including large group practices and hospitals will do the same, as they too are functioning as businesses.

Therefore it is my firm belief that things will change in health care payment, although I do not believe that any top-down mechanism -- be it government or privately orchestrated -- will bring it about.