Sunday, June 6, 2010

Here's a Novel Thought: Leave the Success of the Medical Home Up To Patents

Is the Patient Centered Medical Home (PCMH) the panacea for all that ails health care? Have we exhausted all the allegories related to the term “home?” The answer to both questions apparently is no, thanks to this American Journal of Managed Care article by Timothy Hoff titled “The Shaky Foundation of the Patient Centered Medical Home.”

Dr. Hoff appropriately shelves PCMH policy and looks at the topic with a market-based perspective. From that vantage point, it all boils down to two customers: the primary care physicians and their patients.

Neither are slam dunks.

Primary care physicians: fewer medical school graduates are pursuing generalist careers and, in the meantime, the existing primary care workforce is getting older. Dr. Hoff quotes optimistic estimates of $30,000 to $40,000 per year in extra PCMH income per primary care physician and doubts those sums will be enough to dissuade the freshly minted doctors from pursuing more lucrative specialist careers. To add insult to injury, primary care is also saddled with 1) a relative absence among U.S. medical school faculty, 2) a lingering second-class “image problem,” 3) chaotic work schedules, 4) novel professional responsibilities (“team leader?”) and 5) the distinct possibility that transforming primary care clinics into PCMHs will require even greater effort and economic sacrifice over the short term. It’s enough to make even the DMCB want to apply to a dermatology residency right now.

The Patients: there is an abiding assumption among policy makers that health care consumers pine for the days when they had a personal physician to coordinate their health care needs, tut-tut don't-worry about that nagging backache and ask how Aunt Bee is doin'. Unfortunately, many of the Boomers, Generation X and the Millenials have grown up with a fragmented health care system and may not mind episodic care as much as has been assumed. No wonder the rise of Retail Care Clinics are such an irritant to many of the health policy mandarins, since their success among persons who treat health care like fast food seem to run counter to our cherished – and possibly mistaken – central-planning style notions of how patients should behave.

Dr. Hoff’s solutions include “socializing” medical students to primary care and recognizing that it may need to create a two track medical home and assembly line model of care.

The Disease Management Care Blog agrees with Dr. Hoff's analysis but is tempted to go one step further. Ultimately, it thinks, the success of the PCMH could end up being dependent on patient demand and patient dollars. If those two elements are there, the doctors will eventually follow. That may mean that the PCMH will have to adapt to the creative destruction of capitalism. Like it or not, it's an important force in healthcare, even with the government meddling. If the PCMH doesn't make it, maybe it'll be for the right reason: consumers want something else. If that happens, the DMCB is confident future leader-entrepreneurs in primary care can come up with the answer.

Image from Wikipedia


Phil 314 said...

The editorial and this post bring up some good points:
-yes there are multiple reasons for the decline in primary care.
-money IS important but will not be sufficient for the successful development of PCMH. When all is said and done (and from what I've seen in practice)you have "to love it" beyond how much it pays.
- alot of patients aren't interested in this model. Many are young and really have an interest in available urgent care. Unfortunately some are older and/or sicker and can't see the value
- PCP's need to be able to "sell" the idea to patients regardless of how insurers will reimburse.
- training for PCMH is more than the standard training in a Primary Care specialty (FP, IM or Peds). Med Ed is historically poor in teaching population health management, collaborative care and behavioral change

And a key point I would add:
No significant change in the American Health Care system addressing cost, quality and access can be accomplished without a dramatic increase in the primary care workforce

Jaan Sidorov said...

Hear hear! the DMCB seconds that motion.