Where did the Medical Home go wrong?

I’ve been cogitating on this issue for months.

I’ve been reading family practice and primary care blogs, and the AAFP practice management listserv discussions (which are unanimously Bronx-cheering). I’ve scanned the family medicine literature, which is turning critical, or at least concerned. I’ve studied the monograph by the Graham Center, editorials in Kansas Family Physician, information on the TransforMED Web site, and the brutal truth in the NDP Evaluators’ Reports.

I got far enough in my understanding to recognize that the NCQA approach to the PCMH was heavy on inputs, and light on outcomes, even though results are supposedly the sine qua non of evidence-based medicine and the scientific method in general. And I am satisfied that the ballyhooed “evidence” supporting the PCMH is phony; it touts the discrete elements taken in isolation, not the concept applied as a whole, and even then it is weak.

But I couldn’t get a handle on what churned my guts.

Then the author of "Musings of a Dinosaur" punched the button on March 29 in her blog post entitled “The Emperor’s Fashion Show” when she said this: "IT'S A WAY TO MAKE LARGE GROUP PRACTICES WORK MORE LIKE A SOLO DOC!"

I think she's onto something. The NCQA and PCMH proponents want documentation that patients see their PCP, because the large group has lots of PCPs. My patients virtually always see me.

The PCMH proponents want surveys of patient satisfaction, because the office manager sits behind a closed door one floor up and doesn't get patient feedback directly. I am never more than 40 feet from the patients talking through the window to my receptionist, and often less than 10.

The PCMH proponents ask for huddle groups, because they assume that nurses and medical assistants are pooled, and the same group may not work together for another week. My two nurses have worked with each other, and me, on 90 percent of business days for the last two decades.

The PCMH proponents require evidence of collaboration, and safety, perhaps because many large practices utilize MAs to check in patients. I use only RNs. They cost more, but I don’t have to look over their shoulder every hour. And they work right under my nose, anyway.

Now I’m getting it. 

The Medical Home is a great idea. It can still be salvaged. But as currently defined, it is a gigantic bureaucratic jangle that addresses the inherent problem of the large group: As a practice grows arithmetically, the communication problems grow exponentially. No wonder the PCMH scoring system seems so absurd to those of us who work within speaking range of our staff.

Does this make sense? Do you agree or disagree, and why? I'm listening.

Posted at 11:24AM Apr 10, 2009 by Doug Iliff  |  Comments[6]