Conflict over a midwife serving the Amish

From the Christian Science Monitor:

The Amish here in Lancaster County may go to the hospital if they break an arm or need surgery, but when it’s time to give birth they stay home. Usually, they deliver their babies with the aid of a midwife, and the women in this waiting room half-joke that if Ms. Goslin goes out of business, they are through with childbearing.

It appeared to be coming to just that last fall when the Pennsylvania Board of Medicine ordered Goslin to cease and desist assisting her mothers, deeming it “practicing medicine and nurse midwifery without the appropriate licensure.”

Switch to ICD-10 should be very costly


Health IT administrators are far from done in their struggles to implement the new National Provider Identifier number, which has proved to be every bit as troublesome as the industry predicted. But apparently, HHS was determined to raise the angst level further. With its recent announcement that it was pushing for an October 2011 deadline for the industry to switch from ICD-9-CM to ICD-10 codes, health organizations are bracing themselves for millions in additional IT and operational expenses.

ACEP Comments on Patient-Centered Medical Home

From the American College of Emergency Physicians (ACEP):

Caution Is Urged To Avoid Unintended Negative Consequences

Washington, DC –  Widespread implementation of a loosely defined patient-centered medical home (PCMH) could harm people’s access to high-quality emergency care, according to the American College of Emergency Physicians (ACEP), which today issued eight principles regarding the concept.  Dr. Linda  Lawrence, president of ACEP, issued the following statement calling for specifics about the concept to make sure it is truly patient-centered, ensures access to medical specialists and clarifies whether providers are required to continue to provide care when people lose their health insurance.

“Key specifics must be addressed before anyone moves forward with widespread adoption of the patient-centered medical home model. The metaphor of a ‘home’ in connection with health care is inviting, but shifting financial and other resources to support it could have tremendous adverse effects on sectors of the health care system that are already experiencing serious challenges.

“Nowhere is caution more important than in how emergency patients might be affected. The emergency department is, and will continue to be, every patient’s medical ‘home away from home.’  Emergency care is an essential community service that has become the health care safety net for everyone, not just the uninsured.

“In addition, the medical home approach must truly be patient-centered – the health care needs of patients must be paramount.  Access to medical specialists and to emergency care must be protected, and it is not clear, for example, how the concept of a medical home will work when the reality is that most physicians’ offices are closed on nights and weekends, and many people are unable to get appointments even during regular working hours because their physicians’ schedules are booked.

“ACEP agrees with the basic tenets of the patient-centered medical home model and supports the concept as long as it reflects eight principles outlined by the nation’s emergency physicians.  In addition, any health care reform efforts must strengthen the nation’s emergency departments, which stand in the gap 24/7 to care for patients and save lives in a health care system that people find more and more difficult to access.”

ACEP released eight principles about the concept of a patient-centered medical home.  The full statement is available on the ACEP Web site.

Principle 1:  ACEP supports high-quality, safe, and effective medical care. ACEP supports the use of evidence-based medicine and believes there should be accountability for continuous quality improvement and performance measurement.  ACEP supports the use of information technology to optimize patient care, communication, and education.

Principle 2: ACEP supports health care payment reforms that ensure all medical providers are fairly compensated for the care they provide to patients. ACEP believes it is critical that physicians who provide EMTALA-mandated services be adequately compensated for those services.  ACEP supports additional compensation to primary care physicians for the medical home services they provide to patients outside of face-to-face visits.

Principle 3:  Enhanced access must be demonstrated. Home is a place you can go where they know you.  There is a significant shortage of primary care physicians in America.  In 2005, 36 percent of primary care physicians were working in practices of one or two physicians.  It is unlikely that such small practices could meet the criteria for becoming an approved medical home.  Most physicians’ offices are closed on nights, weekends, and holidays and, in some instances, all or part of certain weekdays.  Many patients are unable to get an appointment even during regular working hours because their physician’s schedule is booked.  The medical home model contemplates an ongoing relationship between a patient and a personal physician who understands the patient’s health care needs and has a history with the patient.  Much benefit of the model will be lost if a patient must see a host of different physicians and midlevel providers in large group practices in which there may be little or no experience with the patient.  There should be demonstrated ability and commitment to provide the continuous care that is central to the medical home concept before additional payments are made to physicians to offer this service.

Principle 4:  Once established, the medical home should continue regardless of insurance status or ability to pay. You are always welcome at home.  Many Americans go through transitions when they become unemployed or otherwise lose their health insurance coverage.  Essential to the improvement of health care for patients using the medical home model is that there be an ongoing relationship in which a physician provides continuous and comprehensive care.  The ongoing relationship must not be interrupted based on the presence or absence of the patient’s ability to pay for care.  While the medical home does not purport to provide health care for the millions of uninsured Americans, there should be a requirement as part of this model that once a person is enrolled in a medical home, the provider must continue to deliver care to those individuals whether they continue to have insurance or not.   In a similar vein, health insurance companies must cooperate and not exclude coverage for patients of medical homes when the insurers are making changes in their networks of providers.  To truly be patient-centered and most effectively realize the benefits of the medical home approach, the health care needs of patients must be paramount.

Principle 5:  Patients must have freedom to switch medical homes, select specialists of their choosing, and access emergency medical care when they feel they need it. Patients should have the right to choose the home they want without restriction.  Patients must be allowed to switch providers and choose whom they wish for their medical home.  Proponents of the medical home insist that it is not a gatekeeper model.  Yet in order for there to be the cost savings touted by proponents, there will undoubtedly be pressure for medical home providers to limit choices and restrict access of patients to certain providers.  ACEP strongly opposes any coercive effort to prevent patients from seeing specialists they may choose.  Of utmost importance is the ability of all patients to access emergency medical care according to the “prudent layperson” standard whenever they perceive they are experiencing symptoms of an emergency condition, even if later diagnosis determines there was no serious medical problem.

Principle 6:  Research must prove the value of the medical home before it is widely adopted. Society must get the home it is paying for.  There should be more research to demonstrate the benefits and continuing costs associated with implementation of the full PCMH model.  Demonstration projects being conducted by the Centers for Medicare & Medicaid Services must be carefully evaluated.  There should be proven value in health care outcomes for patients and reduced costs to the health care system before there is widespread implementation of this model.

Principle 7:  Universal health insurance coverage is necessary for the PCMH model  to be most effective. There are an estimated 47 million uninsured in America, and that number continues to grow.  In addition, there are many millions more who are under-insured.  Those without adequate insurance coverage will remain “homeless” under current PCMH models. Without providing adequate insurance coverage to the growing ranks of uninsured and under-insured, the overall health of many Americans will continue to deteriorate and the PCMH model may have the unintended consequence of increasing health care disparities.

Principle 8:  The medical home must include the safety net of emergency care. Resources used to test the PCMH model should not undermine or further compromise the crumbling emergency medical care system.  Regardless of the anticipated benefits from having a medical home, there will still be many millions of Americans who experience life-threatening illnesses and injuries for which they need emergency medical care.  In addition, there is a serious need for increased surge capacity and medical preparedness for natural and man-made disasters.  Ongoing research should be conducted to determine the extent to which implementation of the PCMH actually has the benefit proponents contend of reducing patient visits to emergency departments.  Ongoing research must also evaluate whether resources utilized for PCMHs have unintended negative effects on the essential community service of emergency medicine.

The “Joint Principles of the Patient-Centered Medical Home” was issued in March 2007 by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA).