The Medical Home Bandwagon and the One-Hoss Shay: Expectations and Assumptions

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)

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,” NEJM, Sept. 2008

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

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

  1. A bandwagon.
  2. The 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 reasons. It’s so damn logical. Health costs are out of control. The population is aging. Countless studies show primary–based systems are 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.

A New Approach?
Why not, then, create a new approach where primary care physicians form medical homes, 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, Duke, and the University of Rochester, who are pouring money and other resources into building and testing medical homes and other outreach programs.
  • 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 have concluded medical homes are a 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 are very much political processes, where “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 is still 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 are blessed with cases of canned goods from their sunken ship. But, alas, they have no way of opening the cans.

The group turns 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 full of worms.

Perhaps it’s time to examine the assumptions that 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 an impact 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 a hired coordinator are mentioned as necessary medical home ingredients), to undergo the scrutiny of being audited for quality or complying with performance compliance markers, or to be paid enough to be motivated to create a medical home. Venture capitalists, alert entrepreneurs, retail clinic operators, 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 will help create and sustain medical homes and be sufficient incentive to recruit primary care doctors through more lucrative “blended” payment systems – 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. The predominant mindset among American physicians it to cure, fix, restore, or repair swiftly and episodically rather than manage or coordinate over the long haul. Whether new payment schemes will lure U.S. primary care doctors is unknown, as is how much money will be required to win the hearts and minds of primary care doctors or whether lack of adequate compensation alone is the basic “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 collectively “managing” the medical affairs of patient panels, making the data entries required, and massaging, analyzing, and responding to data determining the outcomes of a population health model. American primary care doctors, weary and wary of paperwork and third party hassles and managerial manipulations, may respond by choosing to opt out by rejecting Medicare and Medicaid participation; treating individual patients as they see fit; retiring; seeing fewer patients; going into concierge, cash-only, locum tenens practices; seeking employment outside the medical home, or medical careers unrelated to direct patient care. Instead we may see armies of physician extenders managing diabetes, hypertension, stable coronary artery disease, congestive heart failure, chronic obstructive lung disease, osteoarthritis, depression, upper respiratory infections, and gastro-esophageal reflex.
  • The fifth assumption is that patients would welcome such a model. In his popular blog, KevinMD, Kevin Pho, says many patients may 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 Americans are mobile with 20% of Americans moving each year. Many patients 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, “Un insured 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 medical homes remain politically and pragmatically untested. That’s 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 occurs. Making medical homes a reality will take hard work and political arm-twisting.

12 replies »

  1. Responding to Deron S. and Maggie Mahar:
    I am not smart enough to know what the optimal system of values to base our resource allocations upon. I can see however, many weaknesses in our current system, as I have already outlined. I would suggest that there are other factors besides salary that impact job satisfaction for primary care physicians. One of them is respect and appreciation. Currently, our technologically oriented, high-tech society, gives the greatest esteem to procedure oriented very subspecialists physicians. We need to find a way to provide greater nonfinancial work equity for those primary care individuals who do believe in providing complex, multiproblem chronic illness care to internal medicine patients. Secondly, we need to provide infrastructure for those physicians. Believe me, the operating cardiovascular surgeon has an infrastructure! Give something as potent as of that to the skilled general internist. Information-technology will be a component of it. Skilled advance practice physician extenders will be a component of it. But, the main thing will be a new way of thinking! Thirdly, the population needs to begin to understand of their role and their contribution. They need to take responsibility for more of their own health and outcomes. They need to take responsibility for knowing what medications they are on. Eventually, they or their family need to become involved with personal health records. Actutally taking the medications would be a good idea! Walking 30 minutes daily would be a good idea!
    We need to have greater use of the media to emphasize healthy self-care and less emphasis on wonder cures!
    I would like to see, for example, the American Diabetes Association, show portions on the television of currently advertised brand-name products and what their calories and fat gram content are. I would like to see the medical societies take on the fast food industries. What is the cardiovascular effect of a deep paned Pizza Hut pizza ingested by a 45-year-old Camel smoker after 3 beers? What happens to the blood sugar? Put it on TV with adds that are as dramatic as the ones thrust at us by the commercial vendors. I don’t want to hear that cigarettes may be harmful to your health. I want to statistics, the faces and the widows demonstrated dramatically. And I want to see those adds on frequently.
    These are just a couple of simple, off-the-cuff suggestions. Bright motivated people, sitting around the table could amplify this tenfold in 20 minutes.

  2. The biggest problem is this: the shortage of primary
    care physicians and the shortage nurses who could help PCP’s in medical homes.
    And the problem not just the relaively low pay.
    T idea of trying to co-ordinate care for the average Medicare patient (who sees 14 physicians) . . . trying to get doctors to call you back, trying to get the patient to remember what medications he is taking . . . being on call so that the patient has access to someone in your office 24/7 (part of the requirements) . . . trying to persuade often-elderly patients to participate in their
    chronic care management (some will be forgetful, others just not very disciplined, some grumpy )
    It takes a very special, dedicated person to want to do this job–for any amount of money. Since patiets over 65 need (and seek) medical care more often than the rest of us, most of a medical home’s patients will be older. It seems to me that you would really need the temperament of a dedicated geriatrician or geriatric nurse to be good at this.
    Probably large, integrated multi-specialty medical centers where docs are on salalry and everyone has regular hours are in teh best position to create medical homes. Presumably, some doctors’ and nurses regular hours would include night-shifts and week-ends, but there would be enough staff to cover 24/7, so no one would be “on call” extra hours.
    A large center would be able to afford electronic medical records (which would be absolutely essential) and assuming that all of the patients specialists were part of the center, the PCP who as hte patient’s medical home could easily access all of their records (no phone tag.)
    Even then, I agree that we need to be realistic about
    how much we can accomplish. Patients are human –which means that chronic disease management will never be perfect.
    As to the amount of money that can be saved with good proventive care and chronic disease management , I do think that is exaggerated.
    . . .Everyone will die of something. So if the heart patient manages to dodge a fatal heart atack, at some point he will develop Alzheimer’s, or cancer . . . Chances are his final months will be expensive, unless he is very, very lucky and is hit by a bus or dies in his sleep.
    Certainly, we can do better–especially in reducing suffering. That really should be the name of the game. But we’re not going to beat death, and the longer we live, the more our healthcare will cost.
    I agree with Nortin Hadler. If we just aimed to live into our 80s–and be high-functioning 80-year-olds–that would be a reasonable goal.

  3. Dr. Miller – What effect do you think we will get if we reallocate the current RVU system to shift value to cognitive services and away from certain overused procedures?

  4. The medical home is the natural and logical consequence of the ideas of the John S. Mills report on Graduate Medical Education in 1966, the ideas of Larry Weed including the problem-oriented medical record and the evolution of the personal computer. These ideas formed important core concepts of the new primary care specialty of family practice. Realization of clinical realities including the treatment of chronic rheumatological disease and hypertension in the 1960s and the early diagnosis of malignancies by screening in the 1970s-1980s gave important content to early thought about chronic disease management. During this period Medicare was established, intensive care units were created and high-tech cardiology came on line. Clinical services were viewed as loss leaders while the real money was made in the operating room and the procedural suite. Primary care services received loss leader reimbursement.
    The clinical changes of high-tech and procedural oriented medical interventions are often dramatic in the short term while the continuous and comprehensive care of complex multiproblem chronically ill patients is arduous and undervalued.
    While many general internists currently view themselves as primary care physicians when practicing in the office setting, they have been very slow to come to this understanding compared with the once new specialty of family practice. The historical roots of internal medicine revolve around organ systems. And it is not surprising that most internal medicine residents pursue organ system subspecialization with the promise of a better lifestyle and reimbursement as well as a greater comfort level with their clinical skills.
    A weak effort was made during the 1990s to reverse the process via the Harvard Relative Value Scale. The HRVS was an enormous disappointment to primary care. All it really did provide a methodology for simplifying third-party reimbursement budgetary changes.
    These historical trends have led us to where we are today. And these forces are too powerful to be overcome by the logic and reasonableness of the medical home. In order to reverse the current predominant system of paradigms a sufficient crisis is necessary. And it is only a matter of time before the “Perfect Storm” arrives. Medicare is scheduled to become insolvent in 2019 according to the last estimate I read. What matter of equity institution or automaker like bailout will be needed then? Is there any possibility of avoiding a serious crisis? Will president elect Obama & Co. rise to the occasion to head this off? These are the pressing questions.
    In 1990 I believed that the Harvard Relative Value Scale was going to fix things. In December of 2008, I’m not very optimistic about the medical home even though I believe it is an important paradigm shift among the portfolio of paradigm shifts needed to take our healthcare system from broken and in impending peril to one that meets the needs of the weak and the vulnerable and provides the needed infrastructure for our society as a whole.

  5. I would also point out that your fourth assumption, “…that primary care physicians will be comfortable with collectively “managing” the medical affairs of patient panels, making the data entries required, and massaging, analyzing, and responding to data determining the outcomes of a population health model.”, is more of a statement of fact than an assumption. Population data already informs what we do as PCP’s: it’s called clinical research. And being a pathologist yourself, it may not be clear that PCPs are trained to manage their patient’s medical care, based on analyzing and responding to data. That’s pretty much the job description, and has been for 50 years. Medical Home is nothing more than a restatement of the goals of Family Medicine, a goal that has been financially unsustainable in the current system.

  6. I would argue that, “The predominant mindset among American physicians it to cure, fix, restore, or repair swiftly and episodically rather than manage or coordinate over the long haul”, is NOT, and has never been, the predominant mindset among Primary Care providers. It is the specialist and payor-oriented incentives which have led to this becoming a paradigm baked into our system, and there is tremendous entrenchment as these groups have accumulated wealth based on this model. You are right in your assertion that the necessary restructuring will threaten those who’ve been benefiting, in order to achieve any value. But how do you think we got where we are in the first place? We didn’t end up with a Specialty-oriented medical system because someone thought it was good health care. We got here because that’s where the money is. Change the incentives and you’ll change the system. It is ultimately a political issue.

  7. OK, my last comment was a bit harsh. To be fair there are many physicians who are looking for a better way to provide the kind of care they know they can and should provide. What I hope does not get lost is the energy that many physicians have around the potential for this movement to create real change. We need to foster this energy, and take our best stab at something that can truely create something better than what we have now.

  8. Ironically what will kill the medical home will be independent primary care physicians who lack the will or ability to move to new models and to work together in ways that allow them to leverage infrastructure and systems to provide the kind of care that we need. They will continue to look on from the sidelines sniping about how this is just a fad and that if we would only pay them more they could take care of patients just fine in their existing models thank you very much.

  9. The intentions of the medical home concept are good, but many portray it as a rigid structure. I’m not sure it has to be that way. We need new communication channels and standards between healthcare providers and facilities, as well as a new mindset among patients and physicians.
    The Sept/Oct issue of Health Affairs has some great articles that challenge old ways of thinking. We have come to believe that the traditional physician practice is the center of the universe, capable of handling all conditions. The reality is, it is not the most efficient or effective model for a lot of healthcare needs such as managing chronic conditions. The medical home is a good concept, but it is working with limitations in the current structure rather than rethinking them altogether.

  10. Bravo and nicely said. We cant abandon the PCMH concept as I do believe it has promise–I am very familiar with the subject. However, listening to the pols, at times it is like the emperors new clothes. Reality and fantasy commingle all too frequently, and “the home” seems to have taken on the same meaning as “the surge.” The salve that will cure everyones wounds…