When I first stared hearing about the Patient-Centered Medical Home (PCMH) concept, I perceived it to be a euphemism. For whatever reason, the concept of primary care or family medicine hasn’t resonated with politicians, corporate benefits managers, or the general public. To me “medical home” was just a warm fuzzy term that at least gave an unknowing listener a sense of the benefits of a strong relationship with a competent primary care physician. Now the concept of the medical home is quickly becoming a bureaucratic monstrosity with tiers of classifications of unproven measures as other entities try to horn in on the new PC buzzword.
All of the PCMH supporters should be humbled by the unimpressive findings of the TransforMed demonstration project. It’s as if the findings were a bad nightmare everyone wants to forget and keep going as if nothing happened. To quote the patient-experience article from Annals of Family Medicine, “Adoption of NDP model components was not associated with patient-rated outcomes other than access, including health status, satisfaction with the service relationship, patient empowerment, coordination of care, comprehensiveness of care, personal relationship over time, or global practice experience.” If it didn’t work, why are we doing this? How ironic is it that this whole “patient-centered” exercise resulted in essentially no improvement in patient-rated outcomes?
The whole PCMH movement has lost sight of the fact that the evidence that family physicians provide better health at a lower cost goes back to at least the 1980s. The studies Starfield summarized in her excellent article in 2005 were published before the current PCMH craze. In other words, the benefits of primary care happened without electronic medical records, group visits, email visits, disease registries, or open-access policies.
In other words, the secret to a better U.S. healthcare system is the primary care physician’s brain, not the bells and whistles the PCMH folks are trying to attach to our clinics. The fundamental problem is that primary care physicians are not paid for the work we do. It is hard for us to take time to have extensive team building and planning exercises with our entire office staffs because when the doctor is doing that, the practice revenue goes to zero, and the margins are marginal as it is. Adding EMRs to our practices do not change the reality that we’re still paid $50-80 to care for patients with four chronic diseases, ten medications, and a list of three new symptoms.
Until primary care physicians are paid for the time it takes to do our complex work, the PCMH/EMR movement will be just another government/big business/bureaucratic top-down unfunded mandated boondoggle that will further waste healthcare resources and further delay the most fundamental reform that has yet to happen: primary care physicians should be fairly paid for the work they do.