Medical Home? Not With These Doctors

Abstract

Book Review Health AffairsVol. 29, No. 5: Reinventing Primary Care Medical Home? Not With These DoctorsDavid J. Rothman Affiliations David J. Rothman ( [email protected] ) is a professor of social medicine at Columbia College of Physicians and Surgeons in New York City, and is president of the Institute on Medicine as a Profession. PUBLISHED:May 2010Free Accesshttps://doi.org/10.1377/hlthaff.2010.0332AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPrimary carePhysiciansPatient-centered medical homesPhysician paymentOrganization of carePharmaceuticalsPhysician shortagesPayment In the current effort to design health care policies that will reduce costs and improve quality, many analysts have seized on the role that primary care physicians might play. Although this is not the first time that these physicians have been identified as change agents—managed care organizations discovered them in the 1990s—never before have front-line physicians potentially been assigned so many complex and novel tasks. Designating primary care physicians to serve as gatekeepers for referrals is relatively simple, requiring only a yes/no decision. Making them pivotal figures in delivering health care is an assignment of very different magnitude. But as Timothy Hoff tells us in Practice Under Pressure , we might need to rethink that strategy. In the new agenda, primary care physicians would take the lead in overseeing “medical homes” for their patients. Using this traditional domestic metaphor should not, however, obfuscate the truly extraordinary range of knowledge and managerial skills required. Primary care physicians would make referrals to specialists and would gather, interpret, communicate, and implement all relevant medical information. They would select diagnostic tests, sort out drug prescriptions, follow the course of surgical interventions, and help arrange ancillary services ranging from rehabilitation and physical therapy to home care. They would be available 24/7, providing the comprehensive and compassionate care that Thomas H. Lee and James J. Mongan suggest in Chaos and Organization in Health Care (reviewed in Health Affairs , Sep/Oct 2009). In the end, the coordination and responsibility would rest with primary care physicians. Yet however enthusiastic the commitment to the medical home, many questions about its feasibility and implementation remain unanswered. Where will the substantial financial resources that will be required come from? Will government funders and insurers find it cost-effective? Will small practices be able to coordinate so many assignments? Hoff adds another question no less crucial to this roster: Does the medical home fit with the mind-set and competence of the present generation of practitioners? His answer, with only minor qualifications, is no. The candidates and the job requirements seem woefully mismatched.Hoff’s work, it should be clear, has serious deficiencies. He conducted interviews with a group of eighty-eight primary care physicians of different ages, sexes, and national origins. But all of them were from the Albany, New York, area. Hoff claims that they are no different from any other cohort of primary care physicians, but he offers no supporting evidence.Moreover, the interview materials he quotes are not systematically linked to the types of organizations in which the primary care physicians work. We have no way of knowing whether a particular perspective comes from a physician in a one- or two-person office or from someone employed by a large health care organization. Although Hoff notes that many of the primary care physicians in his study were trained abroad, we do not know whether they or U.S.-trained physicians are speaking. Finally, there are curious omissions. For example, discussions about drug representatives and drug companies are conspicuously absent from the account—an artifact of the questions asked or an unexpected reality?These weaknesses conceded, the results are still persuasive. First and foremost, what emerges from Hoff’s interviews is a picture of primary care physicians who are ruled by the clock. They have fifteen minutes allotted to each patient and must see some twenty-five to thirty patients a day, so that as one practitioner puts it, they can “make their numbers.” They dread confronting an “interesting patient,” who, by definition, will require more time. They complain about patients who call requesting test results: “If I don’t get them into the office, I don’t get paid.” But apparently, the primary care physicians do not complain about packed schedules or what Hoff calls the “assembly-line nature of their day.” They seem comfortable as pieceworkers, not professionals.Second, they are altogether insulated from the larger medical community. Fostering that isolation is the fact that the overwhelming majority of primary care physicians do not follow their patients when they go into the hospital; travel time would cut into office time and family time. Only a few regret the dominant role that hospitalists now assume over inpatient care.The result is that primary care physicians are unlikely to know other medical colleagues, learn about the latest diagnostic and therapeutic techniques, or discuss the advantages and disadvantages of new interventions. In this same vein, the primary care physicians apparently do not complain about a shortage of available time to read medical journals or attend continuing medical education courses.Finally, proponents of medical homes insist that payment reforms must be implemented that not only move away from traditional fee-for-service arrangements but that also reduce disparities between specialists and primary care providers. Hoff’s interviews, however, do not indicate that primary care physicians have substantial dissatisfactions with the current system or with levels of pay. Perhaps they find the income–family life trade-off satisfactory, or perhaps their salaries are part of dual-income family streams. In either case, additional payments are unlikely to inspire them to change their job definitions.In sum, Hoff’s primary care physicians do not seem, by temperament or by skill, ready to take on new and difficult assignments. The overriding impression is of physicians isolated in their offices, moving as quickly as possible from one patient to another, determined to stay on schedule, and, perhaps most surprisingly, not discontented with the conditions of practice.Accepting these findings, it seems unlikely that we will be able to take the current cadre of primary care physicians and, through a variety of incentives, reinvent primary care and create medical homes. Even if we begin to better educate medical students about primary care, combat the stigma attached to it, and alter patterns of recruitment and expectations, the effects will not be seen for decades. Given the crises of access and cost now facing health care, we might not be able to wait that long.We might choose to think better and harder about a top-down, not bottom-up, approach, focusing our energies on promoting institutional change, not individual change. We do have health care models that set directions, including Kaiser Permanente, Mayo Clinic, the Henry Ford and Geisinger Health Systems, and the Lehigh Valley Health Network. Our goal, then, would be not to convert this generation of primary care physicians to a new mode of practice but to convert the health care delivery system to a new mode of organization. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 May 2010 Information Project HOPE—The People-to-People Health Foundation, Inc. PDF download