Why patients are wary of the primary care medical home

Say the words, “Patient-centered medical home,” and you’re bound to get a variety of opinions.

On this blog alone, there are a variety of guest pieces critical of the effort, saying it does not increase patient satisfaction, nor does it save money.

And that’s not good news for its advocates, who are pinning primary care’s last hopes on the model.

Medical homes hit the mainstream media recently, with Pauline Chen focusing one of her recent, weekly New York Times columns to the issue.  She discussed the results of a demonstration project, showing some positive results:

… the researchers found that the vast majority of doctors’ offices could successfully incorporate most of the changes into their practice, and early signs of the model’s success were promising. Quality of care and preventive health ratings revealed small improvements. Office staff became more streamlined, efficient and satisfied. Most notably, physicians were more content than ever before with their work, despite still having to deal with an unchanged fee-for-service or managed care reimbursement system. The doctors’ enthusiasm persisted even after the study closed, with many maintaining contact with one another through a listserv and twice-yearly self-organized meetings.

But patients themselves were not completely satisfied, and that mirrors some of the comments here on the blog.  The biggest complaint I’ve heard was that patients were not treated by a single provider, but instead by a team.  That may improve access and chronic disease management, but bucks the traditional model where a single physician was paired with a patient.

Indeed, as Dr. Chen notes,

… many patients reported feeling disoriented. Some felt displaced as they saw the old one-to-one doctor-patient interactions replaced with one-to-three or one-to-four relationships involving not only the doctor but also a whole host of other providers. As offices switched from paper-based to electronic medical records, other patients reacted to the distracted clinicians who seemed more focused on learning the new computer system than on listening to them. Satisfaction fell because, like my friend, few patients were cognizant of, much less involved in, the changes going on around them.

Transforming a practice into a medical home is a huge undertaking, with fundamental changes in how patients are seen.  Doctors in these practices are going to have their hands full, both making the transition, and, in some cases, adopting new electronic medical records as well.

Patients need to be informed every step of the way, so they can better understand how the medical home can potentially improve their care.  Absent that, and it’s no wonder why they’re going to react negatively to such drastic change.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • jsmith

    At bottom, the PCMH movement is an act of desperation. Internists and FPs are trying to get more money from insurers and the government, because they (we) realize that if we don’t, our specialties will die, and the country will be much worse off for it. We’ll be fine, become hospitalists or work in the urgent care or do an allergy fellowship or retire or something, but the country will suffer with even worse medical care and even higher-costing and more fragmented sub-specialty care. Good American money down a rathole.
    And of course right now our primary care labor force is completely inadequate to the job of doing all the things we should be doing for people, a situation continuously worsening. There are simply not enough people to get the job done, mainly because medical students avoid primary care like the plague. And who really wants to dedicate his professional life to keeping heart failure patients well-tuned and out of the hospital anyway when Botox is just so much easier, not to mention more lucrative?
    And you can’t just go to the payers and say “give us more money,” because it simply will get nowhere politically. So you come up with hare-brained ideas like meaningful use of EHRs (no evidence that does any good) and 24/7 access to a provider (completely ignoring the reality that doctors need to sleep once in a while) and present these ideas to the money people, hoping they’ll throw some bucks your way. They shrug their shoulders and finance some pilot projects, which give evidence of mere tinkering around the edges, Titanic deck chair re-arranging, but what the hell, you’re already on this road so you gotta keep going.
    A few years down the road the project fails as you knew it would and so you scratch your head and try to come up with the next way to stuff 20 lb. of sugar into a 10 lb. sack.

    • Alina

      Why so cynical? I’ve seen this model somewhere else, and it worked very well. But, the PCPs have to be knowledgeable and willing to take on the responsibility. Right now everything is so reactive and this is not a sustainable model. People need to think outside the box, plan and stop referring all the minor cases to the specialist. It’s so darn easy.

      • jsmith

        What is your specialty, Alina? If you are a family doc, pediatrician or internist, please tell me more about your experiences. If not, don’t bother.

    • Alina

      forgot to mention…the PCP model I was talking about was done the old fashion way. I agree with you on the EHR.

  • http://somebodyhealme.dianalee.net Diana Lee

    I don’t think I’d like being treated by a team of PCPs. I greatly value the relationship by PCP and I have built over the past 12+ years and trust her implicitly. I’m not sure it would be like that with a team approach.


    In a nutshell, it is gatekeeping with a warm soft fuzzy new name and denied access to specialty care in the name of paternalism. You should be afraid. The PMDs under this system with or without ACO alignment are incentivised to keep you out of the evil clutches of us demonic specialists!

    Talk about a twisted incentive system.

  • http://roseblum@aol.com GingerB

    I’ve had that kind of group coverage my
    adult life. I don’t think it sounds like an adjustment because it sounds like what I have now. I’ve had my complaints but I suspect I’d have complaints with any arrangement, at least this is the devil I know.

    I know other people who just can’t stand that kind of coverage. They’d never be happy. I’d say the ‘medical home’ should be a choice, not a dictate.

  • http://www.forrestdirectpay.com Innovadoc

    The Medical Home Model Will not work wirhout pay reform.Many of the criticisms are valid. Although there are some definite positives in terms of concept with the PCMH model like better coordination of care, information flow, and improved quality; the elephant in the room is that this is still high overhead, beg the payer for your money and hope you get  enough to cover the overhead costs of the coder, billing clerk, and claims processor working in your office at your expense.  That part of your overhead should be at the expense of the payor, not the provider. As long as we allow such a large part of our overhead and collections to be sucked into the whirpool created by payers we will not be able to fix the system at its core. 

    Modernization of practices and efficiency of care can be achieved with price transparency, lower costs, higher quality, and better access in a direct pay model which actually decreases overhead costs by over half and pushes collections near 100%. Some estimates are that at least $50 for every office visit in a traditional medical practice goes to pay the overhead needed to collect the payment. Now that many visits are reimbursed at a rate not much more than that we have a problem. A practice that does 5000 visits per year could save $250000 by just accepting payment directly from patients. 

    Lower overhead means less need for volume to pay provider salaries. This translates into longer visits, more one on one time with the physician (which is what drives patient satisfaction as seen in this blog post) ,and less chance for medical mistakes. The physician has more time to thoroughly explain diagnosis and treatment, complete thorough documentation, and thoughtfully consider patient management.

    Many in primary care hope that the payors will reimburse more for the PCMH model of care. In some cases they have, through per member per month payment and shared savings arrangements. However, this model still requires more money flowing into the system rather than more efficent use of the resources within the system. Let’s face it, long term, the government and insurers will not have extra money to pay more for an improved model. So the only way to truly survive is to take the resources available and make the most efficient use of funds by not wasting money just to get paid. 

    Imagine if in my first job mowing lawns for $25 if I had to pay an employee to properly code and submit an invoice to a third party company that covered mowing lawns. That company would sometimes find errors in the coding, reasons not to pay the whole bill (they would want a network grass mowing discount) and would sometimes delay my payment by several months. Well, $10 would have gone to pay the person to code and submit my invoice that would then only be paid at a rate of $15 even though I charged $25. So, I would have made $5 per lawn cut, had to have cut dozens of lawns per day and probably still would not have been able to buy my first car that summer.  Therefore, no matter how fancy of a lawnmower model I am using, or how evenly the blades cut the grass, or how efficiently the deluxe model lawmower picks up clippings- at the end of the day if my lawn cutting business cannot make it-nobody gets their grass cut.  Indulge my analogy a little longer: What is going on in medicine right now? Physicians are running behind the mower cutting yards as fast as they can to survive, missing spots, leaving poorly cut grass, even with the fanciest new fangled lawn mower model. Let’s go back to a simpler time where people paid you cash for a job well done where you could actually enjoy taking your time to do it right.  The sustainable medical home model is here, and it is called direct pay.

    • Alina

      It would be great if you could share where the $50 per visit overhead comes from. Many physicians say that in general insurance companies are paying their bill within a few days. I know mine is for sure because I receive the EOB and I see when they actually paid the bill. Are you referring to the Medicaid segment? If you are an Innova doctor (DC metro) there should not be as many such patients in your area to the point that this segment would overwhelm your business.

      In the business world, your analysis would go something like this: as a manager of an employee that does not fully meet performance standards, not only that I am paying the salary, which btw should be in return of the employee actually meeting the required performance, but I would now have to also pay this person a bonus just to come to work. Not only that this doesn’t sound right, but even if I would be willing to add an extra bonus, what guarantees do I have that this employee will actually meet the standards now, if he/she did not do this in the first place? I am yet to see a company willing to adopt this model.

      Also, regarding your comment about direct pay and increased fees, you didn’t mention a limit so one can only guess. In your area fees are higher than the national average and well above the $50 you mentioned. I would guess that you’re thinking more around $150 per visit (at a minimum) for you to spend more time with the patient. On a national scale, have you ever thought about how many people would be able to pay this type of fee on top of all the other medical expenses? Inability to pay translates in zero sales either way you look at it.

      I never understood this comparison with “Joe the plumber” and lawn mower that some doctors make. I’m a true believer that if one person is so unhappy doing the job they do, they should totally look for something that makes them happy or at least comfortable. Life it’s too short, so if being a plumber or a landscaper is what your heart desire, go for it.

      BTW, isn’t Innova “not-for-profit” anyway? Their prices are pretty steep as it is, so I don’t understand the complain.

  • http://www.ability4life.com kathy kastner

    To get back to the original focus: patients and PCMH. How ironic. Leaving out the P in PCMH. As admitted by Dr. Terry McGeeny, a primary care physician and chief executive of TransforMED the organization tasked by STFM to undertake PCMH: “The Achilles heel of all of this is a lack of patient understanding and engagement…..we weren’t aware of what we needed to do other than support the physicians’ personal motivation.” Huh? Sounds like the P for Physician.

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