Friday, December 5, 2008

Medical Home Badwagon: Expectations and Assumptions

When people jump on the bandwagon, they get involved in something that has become very popular. The term “bandwagon” is usually applied to politics but spills over into other fields. It is also called the herd instinct, or going for the apparent winner.

Various Sources

Have you heard of the wonderful one-hoss shay that was built in such a wonderful way? Logic is logic. That’s all I say. Now in building of a chaise, I tell you there is always somewhere a weakest spot.

Oliver Wendell Holmes (1809-1894), The Deacon’s Masterpiece, or the Wonderful One-Hoss Shay, a Logical Story

Expectations are high. States, health plans, and the Medicare program are making substantial financial bets that implementation of the medical homes will lead not only to improved care but also to long-term savings, largely by reducing the number of avoidable emergency room visits and hospitalizations for patients with serious chronic illness. Some see the medical-home model as a means of reversing the decline in interest in primary care among medical students and residents, and others argue the broad implementation would reduce health care spending overall.

Elliot Fisher, MD, MPH, “Building a Medical Neighborhood for the Medical Home,” New England Journal of Medicine, September 18, 2008

Beware of assumptions! Whatever you assume to be possible, or impossible, may not work in the real world.

Unknown Source

When I think of the Medical Home, a concept introduced by the American Academy of Pediatrics in 1967, but now rapidly gaining speed and traction, two images spring to mind,

• One, a bandwagon.

• Two, Oliver Wendell Holme’s Wonderful One-Hoss Shay, which ultimately collapsed because of minor defects in its construction.


Everybody is jumping on the medical home bandwagon. And for good reason. It’s so damn logical. Health costs are out of control. Countless studies show primary–based systems are politically popular, cost less, satisfy patients, and achieve better quality and outcomes. Besides, American primary care physicians are unhappy with the present system, and so are American patients. It’s time for a change. The problem, logic says, stems from our specialty-dominated, fragmented system and growing shortages of primary care physicians.

Why Not

Why not, then, create a new approach where primary care physicians form a medical home, and with the help of a newly hired care coordinator, and a team of providers operating under the guidance of the doctor, offer continuous, comprehensive, coordinated care of chronic diseases (the 4 C’s of medical homes).

Logic Builds Momentum

The logic of this approach explains why everybody is enthusiastically leaping on the medical home bandwagon.

Leapers include,

• Medicare and CMS, who are paying for a three year demonstration project, to be completed by 2010, to see if this new wagon works , has wheels, saves money on hospitalizations, and makes for a sustainable growth rate for health costs.

• The Obama administration, which has vowed to reform health care and save money through more primary care physicians, prevention, EMR use, and chronic care management – the medical home pillars.

• Major primary care associations – the American Academy of Family Practice, The American Academy of Pediatrics, The College of Physicians, and The America Osteopathic Association –have joined forces under the umbrella of the Patient-Centered Primary Care Consortium to issue a set of Joint Principles and are churning out white papers on medical homes.

• State legislators, who have taken the lead from state medical societies and the Physicians’ Foundation, and are endorsing Medical Home demonstration projects in at least 20 states. The numbers grow each month.

• Academic institutions, such as Johns Hopkins and the University of Rochester, who are pouring money and other resources into building and testing medical homes.

• The American Medical Association, the American Association of Medical Colleges, and societies of medical directors and state medical society executives, all of whom have bought into the concept.

• NCQA, who think medical homes contribute to improved medical care.

• Even the health plans, especially Aetna and the UnitedHealthGroup, who would like to serve as intermediaries in the process, selecting what doctors qualify for being medical home participants and what they will be paid.

Almost Everyone

Almost everyone, in other words, across the political spectrum has concluded medical homes are a significant leap forward and are willing to climb aboard for a bandwagon ride. The key phrase here is “almost everyone.” Forming and paying for medical homes is very much a political process, where “almost everybody” may not include those who want a piece of the action or feel their economic status is threatened.


It is assumed, of course, coordinated, comprehensive, continuous care of chronic disease in an aging population is an overwhelmingly logical thing. I agree, but it may be useful to examine medical home assumptions.

I am reminded of the story of the economist stranded on a desert island with fellow castaways. The castaways are surrounded by thousands of miles of ocean, but areblessed with cases of canned goods from their sunken ship. But, alas, they have no way of opening the cans.

The group turn to the economist for an answer, and he says, “First, assume a can opener.” We’re assuming here that medical homes will serve as can openers to save the system.

The cans, however, may be cans of worms. Perhaps it’s time to examine the assumptions which might cause the wheels of the Wonderful One Hoss Shay, known as Medical Homes, to come off.

The first assumption is that there are enough primary care physicians to make medical homes enough of a reality to make a difference reforming the system. The stark truth is that a desperate shortage of primary doctors already exists, most medical students and residents shun primary care, and we have no idea how many primary care doctors would bother to go through the paperwork to qualify or to build the infrastructure ( an EMR and an a hired coordinator are mentioned as necessary medical home ingredients) or to undergo the scrutiny of being audited for quality or complying with performance compliance markers. Venture capitalists, alert entrepreneurs, and major corporations like Walgreens sense a primary care vacuum and are moving fast to set up primary-care based worksites in major corporate sites having sufficient numbers of employees.

The second assumption is that new payment platforms would help create and sustain medical homes and recruit primary care doctors through a more lucrative “blended” payment system – fee-for-service, a capitation fee for managing a patient panel, and patient-centered bonuses for rapid responds to same day visits and email or phone to patients. Whether this scheme is workable in the U.S. is unknown, as is how much money will be required to win the hearts and minds of primary care doctors or whether money alone is the “turn-off” for medical students or residents considering primary care.

The third assumption rests on the notion that every medical home physician will have an EMR and will be able to talk, refer, and send complete electronic patient information to, other entities in the medical neighborhood, clinical colleagues, hospitals, pharmacies and other care providers. This is a giant leap of faith since only about 15% of physicians currently have EMRs and PHRs are in their infancy. It may be this barrier can be overcome through federal subsidies for EMRs, requiring physicians to meet connectivity standards, and rewarding collaboration through payment increases, pay for performance bonuses, and shared savings, but, in my opinion, the system is at least a decade away from this electronic utopia.

The fourth assumption is that primary care physicians will be comfortable with “managing” the medical affairs of each member of their panel, making the data entries required, and massaging and responding to the data involved in determining the outcomes of a population health model. Many doctors, weary and wary of paperwork and third party hassles, may respond by choosing to opt out by rejecting Medicare and Medicaid participation, retiring, going into concierge, cash-only, locum tenens practices, seeking employment outside the medical home, or seeking medical careers unrelated to direct patient care.

The fifth assumption is that patients would welcome such a model. In his popular blog, KevinMD, Kevin Pho, says many patients will be annoyed by being asked to be in a medical home, when they only have one symptom or one disease that may not need to be “managed.” Also 20% of Americans move each year, and may not be looking for a personal physician or a medical home. Finally, keep in mind that most people who frequent emergency rooms do so because the emergency rooms are “there,” not because they are uninsured, underinsured, or lack a primary care doctors (Myna Newton, et al, “Uninsured Adults Presenting to U.S Emergency Departments, “ JAMA, October 22-29, 2008).

The sixth assumption is that the medical home is a politically and financially neutral concept. This isn’t the case. Nurse practitioners, nurse doctors, physician assistants, and other medical specialists will lobby to set up their own Medical Homes, if for no other reason, than to make up for the primary care shortage. Another, probably more important factor, may the resistance of specialists. Organized medicine, now dominated by specialists, is aware that Congress’s present Sustainable Growth Rate (SRG) is supposedly revenue neutral, meaning if you reward primary care physicians through Medical Homes, you take away from specialists.


The medical home movement is logical and is intended to correct the current costly fragmented specialist dominated system by creating “homes” for patients with chronic disease to receive more coordinated and comprehensive care at less cost with better results. Medical homes are currently riding a political bandwagon, but the assumptions that the system will be transformed by the promising medical home concept remain politically and pragmatically untested. That is why multiple demonstration projects are underway. Meanwhile let us hope for the best and pray that a fundamental shift in the system towards more primary care occura. Making medical homes a reality will take hard work and political arm twisting.

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