Another Failed Medical Home, And Once More, the Poor Are Left Out in the Cold

The American Academy of Family Practice published a series of eight papers about the National Demonstration Project (NDP) of the Patient Centered Medical Home (PCMH). The first thing you should know is that, like the Group Health and Ontario medical homes, described earlier on my blog, these homes were for middle class folks – 20% had graduate degrees, more than double the national average. As the authors note, the practices chosen included few low-income and minority patients. So, like the others, poor people need not apply.

Most of the papers in this series are about how the medical homes struggled to implement the various things that constitute a medical home. The critical paper is the one that looked at outcomes. Here’s its conclusion:  After slightly more than 2 years, there were no significant improvements in patient-rated outcomes, including the 4 pillars of primary care (easy access to first-contact care, comprehensive care, coordination of care, and personal relationship over time), global practice experience, patient empowerment, and self-rated health status, although there were small improvements in condition-specific quality of care, as measured from charts.

In simple terms, the medical homes did not achieve their intended results (i.e., the model failed). But it wasn’t their fault. The family practice folks tell us that, without fundamental transformation of the health care landscape, including higher reimbursement and additional clinicians (to allow smaller patient panels), medical homes will face a daunting uphill climb.  

So, the medical home model failed, but not because it was a bad idea. The AAFP tells us that it failed because primary care physicians need to take care of fewer patients, which would mean that we need more of them. But what we really need is a model that requires fewer of them (see No One Home in the Medical Home). In such a model, generalist physicians would redefine their roles as caregivers for patients with chronic illness and multisystem disease and as the identifiable physician-of-record for larger panels of patients, who would receive most of their routine care from midlevel practitioners. If primary care physicians focused on those segments of care that demand their level of training and knowledge, and if they were properly compensated for doing so, we not only will need fewer of them, we’ll get what we need because a discipline will exist that medical students will want to enter. Let’s try for that next time.

One final thing. Why is Health Care Reform reforming the system so that it serves minorities more poorly? Echoing Dartmouth’s malarkey, Orszag has fostered a bill that calls the extra costs of treating poor people “waste and inefficiency,” and in the name of “value,” penalizes providers who care for the poor. And the medical home model that it promotes excludes poor people (never mind that the model doesn’t work). I’m getting a little tired of defending the poor against an administration that was supposed to help them.

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3 comments

  1. Kim

    I’m currently working on certification for PCMH for two clinics. My understanding of this process (which I’m fairly new at) calls for a team approach and I wondered how much non-physician participation is a factor in the lack of success of some of these models in low SES populations. In other words, does this really require more primary care physicians only, or more of all support staff.

    • buzcooper

      I don’t see how medical homes can work for low SES populations. The requirements are expensive to put in place and, as is clear from the AAFP demonstration, don’t matter in the eyes of patients. I can’t imagine how physicians will recover their investment. Where will their income come from if panel size is reduced to 1500? And where will all the physicians come from if each has only 1500 patients? Successful systems will leverage nurses and lesser-trained assistants in order to expand panel size and generate more revenue, while concentrating physician effort on those aspects of care that demand their participation.

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