Medical home concept faces hurdles, skeptics

Often touted as both the wave of the future and the salvation of primary care medicine, not everyone is convinced the patient-centered medical home can deliver.

Dr. Reece at the Medinnovation Blog:

The first assumption [about the medical home concept] is that there are enough primary care physicians to make medical homes enough of a reality to make a difference reforming the system. The stark truth is that a desperate shortage of primary doctors already exists, most medical students and residents shun primary care, and we have no idea how many primary care doctors would bother to go through the paperwork to qualify or to build the infrastructure ( an EMR and an a hired coordinator are mentioned as necessary medical home ingredients) or to undergo the scrutiny of being audited for quality or complying with performance compliance markers.

Read the rest of Dr. Reece’s post for several additional dubious assumptions about medical homes.  The Placebo Journal Blog’s Dr. Douglas Farrago is also unconvinced:

The only ones who will profit from the “medical home” idea are the entrepreneurs who will start a business that claims to certify whether your office is a “medical home” or not. You see these people all the time. They are former medical personnel who get the blessing from the government or third-party payers to come into your office and judge you. They may look at your EMR, customer service, patient safety, etc. They do this because the government doesn’t have the time or the resources. It just adds more bureaucratic layers to the decaying onion we call our healthcare system.

When I read the Joint Principles of the Patient-Centered Medical Home, my first reaction was there’s not much “there” there:

  • Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

This does not exactly break the “innovation meter”.

  • The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.

Uh, yeah.  At my office we’ve developed the terms “visits” and “referrals” to cover these two rather less-than-earth-shattering concepts.

  • Quality and safety are hallmarks of the medical home.

Really?  Quality and safety?  I would have thought substandard care and putting the patient in constant danger would be the metric.  Thanks for pointing this out.

I’m all for transforming primary care for the better, at least to the extent it can be transformed.  But I question whether the medical home model addresses the real problems affecting primary care.  My suggestions:

  • Make Loser Pays the law of the land (as it is in most of the rest of the world) to decrease physician liability and lower the cost of malpractice insurance.
  • Reverse or modify legislation that increases the burden of paperwork on primary care practices.  Thanks to the Family Medical Leave Act, the old work excuse is now a multipage document that, for some reason I can’t fathom, lots of businesses want filled out every time an employee misses work for a migraine or an asthma attack.
  • Shift the “burden of proof” from physicians to third party payors when it comes to prior authorizations and precertifications.  A pharmacy benefit manager should not be allowed to refuse to pay for a patient’s medication until and unless the physician can “prove” that the patient needs it.  The same goes for imaging studies and precertifications through insurance.  (The above Loser Pays reform would go a long way toward eliminating many unnecessary imaging studies).  Alternatively, physicians should be allowed to charge for prior authorizations.  This is not without legal precedent.
  •  Make primary care medicine more lucrative.  Third party payors should increase their reimbursement to primary care physicians.  There should also be stiffer penalties for third party payors delaying or denying payment.  Patients themselves should also be held accountable for paying their bills to their physicians.  In many practices a large number of patients may be delinquent for only a few tens of dollars.  These sums are too small for a practice to sue to recover and may be too small for a collections agency to bother about.  But while these outstanding bills are trivial per patient, their collective sum can be many hundreds or even thousands of dollars.

I suspect that substantive reforms such as these would have a greater impact on primary care medicine than the proposed medical home model.

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