There’s a lot about the medical home concept that makes sense. Coordination and continuity of care, teamwork, more focus on preventive care and the management of chronic disease – what’s not to like?

Lately, though, I’ve been rethinking whether the medical home is truly going to improve the delivery of primary care. Apparently I’m not the only one; Dr. John Schumann, who blogs at GlassHospital, recently came right out and declared, “It’s never going to work.”

Dr. Schumann lays it on the line:

… While the PCMH sounds good conceptually, individual doctors and patients are finding it less lofty than its rhetoric. For one thing, the model presupposes the doctor as the center of a “care team,” consisting of nurses and “mid-levels” (i.e. nurse practitioners and physician assistants). Under the PCMH model, doctors would only see the “complex” patients, leaving the “simpler” issues (like sore throats, colds, sprains and urinary tract infections) to the rest of the team.

In theory, the doctor (really the doctor’s team) has the ability to handle many more patients, improving both practice revenue and efficiency (attributable to the new informatics tools and data pooling). The obvious problem with this is that the patient has to buy in to the model. Some folks are fine seeing the nurse practitioner for their acute complaint, but how does the Medical Home model improve the doctor-patient relationship, especially if you already have trouble seeing your actual doctor?

Worse yet, with all of this restructuring, the PCMH has yet to be shown to be cost effective. Reorganization costs money, as do the startup costs of the electronic tools. Integrated systems like Group Health in Seattle and Geisinger in Pennsylvania have shown cost savings when doctors are salaried, networked, and have a captive audience of insureds to analyze. Unfortunately, the vast majority of practicing doctors still operate outside of these networks. Encouraging them to transition their practices into “homes” will be disruptive to say the least; the real question is whether the disruption will be transformative toward the ideal or cause the destruction of individualized doctor-patient relationships.

I wouldn’t go so far as to say it won’t work (at least not yet). But I’m starting to doubt whether it’s the solution to primary care that many people think it is.

Last month I blogged here about the results of some early demonstration projects to implement the medical home concept. One of the lessons was that it’s incredibly hard work to adopt this model – much harder, in fact, than anyone realizes. Nor is there a great deal of evidence yet that medical homes do indeed save money, result in better care and are more satisfying for patients.

I hesitate to draw conclusions on the basis of first-generation data. It stands to reason that the learning curve will be steeper during the early stages of exploring any new model of medical care. Now that we know, for instance, that too much focus on implementing the information technology of the medical home can hurt patient satisfaction, other providers who want to adopt this model can try to avoid the same mistake.

There are a lot of assumptions, however, that the medical home model will somehow automatically make things better for patients, and I’m not convinced this is necessarily so.

If patient care is going to be coordinated by teams, good communication is critical. It’s one of the things in  health care, though, that’s notoriously difficult to do well. Are care teams prepared to step up their game? Or will the patient’s care become increasingly fragmented as he or she is handed off to a series of mid-level professionals? How many nuances of someone’s health will get overlooked or missed?

How clearly are the roles delineated? There are many things a mid-level professional can do better, or more efficiently, than a physician. But this isn’t appropriate in every situation, nor with every patient. Moreover, someone still needs to be the captain of the ship and have responsibility for the overall care of the patient.

There’s a very real concern that the adoption of the medical home model is more focused on meeting the requirements than on the actual provision of care that’s patient-centered. A clinic might have an electronic medical record (check!) but this doesn’t guarantee it’s being used in a meaningful way. Likewise, some practices might have a well-developed philosophy of teamwork and patient-centered care but not be able to document it so that it satisfies the bureaucratic standard.

Then there’s the patients themselves. What do they think about this?

Patients, in fact, seem to have been left out of the loop altogether, Dr. Pauline Chen contends in a thoughtful column this week in the New York Times:

Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.

Farther down in the column, she notes that many patients who participated in early demonstration projects were unhappy with the results:

Yes, they were getting into their doctors’ offices more quickly and were being followed more closely than ever before, but 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.

It’s worth noting that one of the online commenters who responded to the column was a participant in one of the medical home demonstration projects. Her reaction wasn’t positive:

During the 18-month period, I saw 7 different providers, only one was my primary care physician. For one medical issue, I saw 5 different providers. One of the PAs I saw failed to prescribe the appropriate treatment and for my return visit, I saw a different PA who suggested I needed another appointment with “my doctor” because I hadn’t seen “my doctor” for over a year.

On top of all this, she relates, all of these well-meaning professionals somehow completely missed a problem that required treatment.

Does this mean the model is flawed? Maybe this particular clinic was just floundering with how best to implement a medical home strategy. Maybe, given the passage of time coupled with feedback from patients, these processes could have been smoothed. Then again, maybe not.

On paper, the concept of a medical home still sounds good. But there are clearly issues with how it’s executed in real life, and it seems too soon to know whether these can be overcome. In the meantime, my opinion of the medical home has been cooled off with a healthy dose of skepticism.

Image: Wikimedia Commons