Let consumers decide if they want the patient centered medical home

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.

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.

Jaan Sidorov is an internal medicine physician who blogs at the Disease Management Care Blog.

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  • jsmith

    Team leader. What a joke. Apparently the PCMH advocates think that top-notch people, people who after all will be making medical decisions, mind you, are beating down the doors to get stressful, poorly paying jobs as medical assistants? If they are I’ve never seen them. But I’ve only been doing this 21 years, so maybe I just have to wait a little longer. Closer to the truth is me in my white coat trying to “lead” an ever-changing mob of semi-educated “team members” in their early 20s, who leave after a couple months for a better opportunity at the local Taco Bell or selling shoes at the mall or (real example) selling real estate!
    Just say no to the team leader job, even if they give you a special name tag.

    • Alina

      What’s your definition of a PCP? If your definition is that a PCP is there just so the patient can get a referral to a specialist, then what you’re saying is that we don’t even need PCPs. Any PCP who would adopt this model puts him/herself into a “second class” position and basically says he/she is redundant.

      Specialists should be there to treat only complex cases.

      “trying to lead”, “team members” – how about calling this for what it should be…practicing medicine.

      • r watkins

        Practicing medicine is docs interacting one-on-one with patients over time in such a way that they get to know and trust each other.

        This interaction is completely devalued in the PCMH model. The physician is expected to assume the role of team leader/public health nurse/data processor: just what medical students are looking for in a career!

  • http://www.pyramidpreventativemedicine.com Nancy Onyett, FNP-C

    The perspecive I see from medical students evolves around less work and more money. They don’t want to get caught in the rut of seeing 40+ patients a day in FP and get little compensation for it. Most of the ones I talk to on a rotational basis are looking to specialize.

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