The Organic Medical Home

What comes to mind when you hear the term “medical home?”  Perhaps you favor the definition put forth by our government (AHRQ):

The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

1. Comprehensive care
2. Patient-centered
3. Coordinated care
4. Accessible services
5. Quality and Safety.

The presence of these five attributes to care should then constitute a medical home, right?  It depends on who you get your definition from.

Take, for example, the definition put forth by NCQA, the body responsible for certifying practices as providers of the patient centered medical home:

NCQA ’s Patient-Centered Medical Home (PCMH) 2011 is an innovative program for improving primary care. In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time. The NCQA Patient-Centered Medical Home standards strengthen and add to the issues addressed by NCQA’s original program.

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

The one-up AHRQ and say that six elements need to be met for recognition as a PCMH:

  1. Enhance Access and Continuity
  2. Identify and Manage Patient Populations
  3. Plan and Manage Care
  4. Provide Self-Care and Community Support
  5. Track and Coordinate Care
  6. Measure and Improve Performance

Perhaps the ACP (of which I am a member) says it best:

The Patient Centered Medical Home is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand.

It certainly is the simplest definition.

Regardless of definition, the idea of a patient-centered medical home has become very popular in circles pushing for a primary care centered health care reform.  My old practice started in the process of certifying for PCMH through the NCQA, and I discovered something: it really isn’t that patient-centered.  Just like “meaningful use” is not really about using computers in a meaningful way, but instead an exercise to collect data in a way prescribed by a non-clinical body, the PCMH should really be called the “data-centered medical home.”  It’s all about gathering and reporting data in a specified way, taking time and resources away from the thing at the center of care (by any definition): taking good care of patients.

Now, I am not totally against these kinds of programs; I certainly think their origins are driven by good intent.  But I am wary of anything that comes in the form of prescription by a non-clinical governing body to define care for humans by other humans.  I had to work hard to make meaningful use truly meaningful for my patients, and I anticipate that had I stayed at my old practice, a significant impediment in truly providing a good medical home for my patients would have been our effort toward PCMH certification.

A new idea came to me as I planned for my new practice, a practice that doesn’t answer to insurance company requirements or government regulations: I am creating a medical home for my patients.  I plan on meeting all the criteria put forth by the AHRQ and the NCQA, but not because I want to get certified or paid more, it just seemed like better care.  The difference, however, between my version of the medical home and the “official” version is that mine is grown from the ground up – it is simply better care for my patients.  I am growing the medical home “organically”, not meaning that I am avoiding pesticides, but that I am allowing good care to grow on its own, rather than to do it by meeting a shape defined by a group of people who neither know nor care for my patients.

How will I make an organic medical home?

  1. Access: My patients will have access to me.  They will have my cell phone number, and can access me via secure online messaging or in person.
  2. Personalized care: Each person will have their own personalized care plan (“GPS”) that will let them know what care they should have, what they’ve done, what they are due for, and when care is due in the future.
  3. Continuity: My patients will (in my plan) have a personal health record that will serve as their “official” medical record.  Any records from any care from me or any other provider should be contained in a single medical record.  I believe that should be the patient record, not one kept at a doctor’s office.
  4. Self-Care and Community Support: I will provide resources for my patients to know what care they need.  I intend on having an online library of information as well as links to websites I think will help them deal with their problems.  I will also have education programs for people with certain conditions (dietitians teaching diabetics how to shop for food, for example) and do group visits to link like-minded patients together.
  5. Track and coordinate care: I see this as my main task.  I don’t give most of the care, I just help people get hooked up to the resources they need.  Online contact will be the main vehicle for this, but I’ll use whatever means necessary.
  6. Measure and Improve performance: for my patients, the main measures of my performance are time and money.  How much time are people spending at specialists, ER’s, or in the hospital, and how much money are they spending on their care in total?  If I can keep people healthy and away from the system, I will be improving the lives of my patients in both physical and financial ways.

So, I guess I can say I am “going organic” in my approach to the medical home.  Perhaps I should also point out that my care will be entirely gluten-free?  That could be a huge selling-point, a marketing bonanza.

I must be a genius.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

20 replies »

  1. Your “organic medical home” model is quite impressive and very encouraging. I am currently a pediatric nurse on a epileptic monitoring unit. The involvement of primary care physicians is what makes our program successful. Continuity and coordination of care are what I hear my patient population complain about the most after leaving the hospital.

    Following your redesign of the AHRQ and NCQA criteria, patients will not only be receiving “centered care” but they would be receiving “holistic care”, which is a term I’d like to see more physicians revisit.

    While I am inspired by your enthusiasm, I realize costs and resources are major issues when making models such as yours a standard. If only there were enough PCPs to service the entire population. However, even if a few PCPs could make a commitment to your purposed “organic care model”, what a change we would see.

    Thank you for your inspiration Dr. Lambert.

  2. The main attraction of your new model to patients is a better relationship that allows for proper time in the proper setting with YOU, not a team member. I’m not sure you’ll retain anyone in your model if you go back to high volume care as time goes on, but that’s just one opinion.

    If you create something that works, makes you and your patients happy, and is generalizable, more med students will want to do it over time. That’s the ultimate solution to the primary care access problem.

  3. Costco and Sams club are also greedy eliteist as well with the $45 membership fee. Give me a break Peter1. I dont know this Rob guy that wrote this article but one thing I do know is that he has his finger on the pulse of the medical community and what he is doing is probably the only way to save the system. Do you want to have bypass surgery by a guy that is told that he can only have an hour to do the proceedure even though everyone knows it takes several hours to complete. That is what the primary care faces every day and it is only harming the patient.

  4. If PCPs had any sense of activism and solidarity they’d get proper FFS, or better yet salary, rather than letting the specialists engineer the reimbursements and forcing PCPs to opt out and build islands of survivor care.

  5. Concur with Southern Doc in that staying “mainstream” was what was killing me. What I hope to do is to show how far-off the “mainstream” is from what works best. If I can make this succeed in a small way and then grow it back to where I can care for a “standard” 3-4000 patients through the use of other team members, I will have built something that would be generalizable. It would also allow me to lower my fees and put it in the price range of more people. That is my ultimate goal: to build my system well enough that it can be adopted by more of the mainstream (hence making a new mainstream, I guess).

  6. Is $30-$60/month “elitist?” It seems pretty cheap compared to my family’s cell-phone bill. I am not making this change for the reasons you put on me: more money, less work; I left (as I wrote elsewhere) so I could take care of people without all of the rest of the baggage, focusing my energy on doing a better job. That’s not altruism, as I am not harming myself. I admit that this will make my life much better (I was about to burn-out, remember?), but (if my plans go as I hope) it will also make my patients’ lives better, give them better care, and save them money. As I add team members (nurses, dietitians, PA/NP’s, or even psychologists) I will be able to grow the population I, as a single physician, can manage. In doing so I can also meet far more needs than the typical practice, as I will be paid for all of this through my “elitist” $30-60 fees.

  7. “I encourage you to keep some level of participation in ‘the mainstream’ – ie., keep the EMR solutions MU certified; and try to monitor and comply with – if feasible – the PCMH benchmarks”

    But those are precisely the causes of the incredibly dedicated Dr. Lamberts leaving his current practice. Why would he want to recreate what he found intolerable?

  8. Very good points as usual on this stream of rethinking the PCMH movement on a micro scale. I have little doubt you will be able to take better care of a small population of motivated, committed primary care patients in the model you describe from outside the mainstream. I will also say I really feel this kind of model – call it ‘concierge’ or other semantics to apply – is a viable and necessary part of the emerging delivery ecosystem. It also happens to be where I best fit in myself, in office-based primary care. However, two distinctions need to be made:

    1. it is not the solution for the US health care delivery and reform crisis (not enough PCPs to staff this model across the board.
    2. it is doing nothing arguably towards building the new 21st century infrastructure – namely, standardization of processes and practices (ie., EMR/HIE/MU and PCMH).

    Thus, even for the patients who will matriculate into the practice you describe, this will be only a partial and temporary solution. I would predict (as I do for my own current model of practice) that this kind of island model will provide care superior in most ways to the mainstream variety for 5 to 10 years, after which the new system will begin to demonstrate consistent improvements achieved through standardization and process improvements. (think airline industry and the safety record they have vs. what would be a reality without the high level of standardization they have achieved.)

    Hence, I encourage you to keep some level of participation in ‘the mainstream’ – ie., keep the EMR solutions MU certified; and try to monitor and comply with – if feasible – the PCMH benchmarks; for as you say in the post, you already plan to do so. Maintaining your legitimate autonomy need not keep you or your patients off of the new playing field; we are all in this together, and we need your input.

  9. As long as patients have a choice as to whether they want to see their regular MD, a NP, a PA, or some temp pulled in from who knows where, I have no concerns. But it sure seems like “patient-centered” is coming to mean “less choice for patients.”

  10. “A new idea came to me as I planned for my new practice, a practice that doesn’t answer to insurance company requirements or government regulations: I am creating a medical home for my patients.”

    Now Doc, I like you and read your posts with interest, and I’d have no problem with you being my PCP – but PLEASE don’t try to snow us with overblown altruism.

    The medical home exists because there is an “elitist” entrance fee and that you pass your administrative costs onto your patients because YOU are looking for a better work experience by getting more money from less patients.

    This form of health delivery may have an element of “better care” but it is not the cure for cost or access. In fact it reduces access to the general populace. Could a Minute-Clinic be a medical home? Could a low income community non-profit clinic be a medical home? Is the only access to primary care the ER a medical home?

    Please don’t attempt to confuse us by describing a business plan with health care.

  11. It’s not the “team” concept per se that is the problem. Every doctor has a “team” (unless it’s a micro practice, or a team of one). Heck, even Dr. Welby had that one lady and that other doctor, whatever his name was…

    The problem is that the original joint principles had as the #1 principle a “personal physician”. This has been morphed now into a “personal clinician”. Subtle, but very potent stuff….

  12. “a one-on-one relationship with a physician”

    A noble idea, no dispute therel. Grossly overstated as a matter of historical fact, too.

  13. Not hyperbole at all.

    The original medical home (no caps!) concept from the primary care academies was wonderful. It’s been terribly distorted into the mind-numbing and soul-killing NCQA PCMH.

    And now the academies are quickly losing control of their creation to the large insurers. Read the proceedings of the Patient Centered Primary Care Collaborative (PCPCC). This group is calling the shots and is dominated by the insurance industry: it’s ALL about cost savings. Better pay and working conditions for physicians aren’t even given lip service any more. This is what prompted the AAFP’s ill-considered attack on NPs, the realization that the big players are very enthusiastic about PCMHs without an MD in the house.

    If you get your health care from a “team,” who needs a one-on-one relationship with a physician?

  14. I think this is because reform is driven by data, as performance (defined by non-clinical entities) is a thing to be measured. Small groups are generally isolated from the rest of the system (our group certainly was), and with the ACO’s taking center-stage (God help us), hospitals with their huge IT budgets (of EPIC proportions) will try to run the data show. There is little reason to include smaller practices in the mix as they don’t show up on the data-measurment radar (and that which will bring in the ACO $$).

  15. Be aware that the idea came first from the American Academy of Pediatrics, soon followed by the ACP and AAFP. The primary care groups initially thought this was something to benefit PCP’s not decrease their number. Saying that this is a ploy to get rid of PCP’s is, at the very least, hyperbole. I think the concept is good, it is the top-down implementation of it that is what causes the pain.

  16. The PCMH is a highly bureaucratic, one-size-fits-all, Cheescake Factory approach to primary care. I call it the Payer Centered Medical Home: if you read the NCQA standards, patient experience is considered to be of no value. The goal is to indoctrinate patients into “team-based” care, where they see one of a rotating cast of team members at each visit. The doctor-patient relationship is meaningless, allowing physicians to be totally eliminated from primary care. I think it’s working!

  17. I think a more apt translation for the PCMH acronym should be Process Centered Medical Home ( http://onhealthtech.blogspot.com/2011/07/process-centered-medical-home.html )

    It is beyond my understanding why all studies and surveys insist on marginalizing and discrediting small independent practice, e.g. the recent insurance financed Consumer Reports infomercial guide to best doctors in Massachusetts which excluded practices with less than 3 physicians altogether.

  18. @Rob – you nailed it !!!

    the PCMH should really be called the “data-centered medical home.”  It’s all about gathering and reporting data in a specified way, taking time and resources away from the thing at the center of care (by any definition): taking good care of patients.