Trendspotter: Doctors Must Guide Medical Home Success

Last month,I reported on new evidence that the patient-centered medical home decreases patient satisfaction in the short term. In a recent article in the American Journal of Managed Care, Timothy Hoff theorizes that patients don’t like being treated by care teams and don’t necessarily want a primary-care physician to coordinate their care. Many patients are accustomed to going directly to specialists, he points out, and others - especially young adults - are visiting retail clinics or urgent-care clinics for a fast appraisal of minor health problems that requires no prior appointment.

Hoff supports the overall goals of the patient-centered medical home (PCMH). But, unless primary-care physicians are reoriented to that way of delivering care and patients accept it, he argues, “it strains credibility to think that the PCMH idea…can provide a reliable, long-lasting hinge to swing a major component of the US health system in a more patient-centric direction.”

Hoff’s essay reminds me of a conversation I had with Wells Shoemaker, MD, medical director of the California Association of Physician Groups (CAPG). We were discussing the concept of accountable care organizations - which Shoemaker and his association enthusiastically support. One of the biggest barriers to ACOs, Shoemaker pointed out, is patient acceptance:

“ACOs have to be convincing to the public. Some doctors downplay the importance of patient satisfaction because it’s not related to technical quality or real dollars. But I tell them, ‘That’s nonsense. Those are your customers, those are the people who are voting.’ If we can’t turn the ACO into a gleaming paragon with proven customer service, I guarantee that this will break down. Doctors talk about the voice of the consumer, but it’s hard work to listen to it and respond to it.”

Those of you who remember the HMO backlash of the 1990s and the earlier rejection of the Clinton Health Plan will be nodding your heads at this point. Both the healthcare reform proposal and the insurance companies’ efforts to impose narrow physician networks and “gatekeepers” on the public failed miserably. So it’s clear that today’s reformers, who are trying to change how care is delivered and how providers are reimbursed, will have to proceed very cautiously. Yet time is short and the need for transformation is huge.

Kevin Pho, MD, commenting on patient dissatisfaction with the medical home, observes that transforming a primary-care practice is a very challenging undertaking for physicians and their staffs. It’s no wonder, he says, that the process of change may turn off many patients. “Patients need to be informed every step of the way, so they can better understand how the medical home can potentially improve their care,” he says.

Jaan Sidorov, a practicing internist who, like Pho, hosts his own blog, summarizes Hoff’s essay partly by pointing out that many patients don’t object to episodic treatment of healthcare problems and don’t particularly want anyone to coordinate their care. He then suggests that reformers try out their ideas in the marketplace to find out which ones consumers will support. If they like retail clinics, for example, those are in; if they don’t favor the medical home, that’s out.

“The success of the PCMH [medical home] could end up being dependent on patient demand and patient dollars,” he says. “If those two elements are there, the doctors will eventually follow.”

However, the issue is more complex than that. Free-market capitalism has been a failure in healthcare, because it doesn’t allocate resources efficiently or fairly and has contributed to runaway cost growth. Giving patients what they want is a recipe for disaster, because they want everything for nothing. The combination of the free market and unfettered patient demand is principally what has gotten us into the current mess.

I don’t pretend to have the answer, but I agree with Pho that patients must be educated about the purpose of the medical home and the need for care coordination. Young, healthy people might ignore that message, anyway, because they’re not too concerned about their health. But if those with chronic conditions - about half of the adult population - are given financial incentives to choose a personal physician and let that doctor coordinate their care, the medical home might get to first base.

There are two other requirements for the success of medical homes and the ACOs that might be built on top of them: Physicians, not insurance companies, must guide healthcare, and they must learn how to collaborate with patients to make the best choices, rather than telling them what they can or can’t do. Nobody wants to see the return of gatekeepers, but medical homes can be better than that.