Gary Oftedahl: Will the Medical Home be a Gated Community?

This is a risky post.  It’s one that’s not likely to be politically correct, at least at first blush.  In fact, it’s likely that some, on reading the title, will immediately assume that this is an attack on the concept of medical home.  Believe me, I understand the concept is appealing, and that it has been promoted as the potential savior for health care, primary care, patient-centered care—you can pick your issue of choice, and fit this in.

But as with any evolving concept, even one based on a 40+ year history of efforts dating back to the original pediatric models, it is worth openly contemplating and discussing what might be unintended consequences of our work.  In any innovation, it is not only the intended outcomes but the unintended results which need to be considered.  The patient-centered medical home (PCMH) concept is based on the premise that using a team-based, collaborative approach that includes the patient and his/her family in the team will improve the health of our citizens.

Conceptually, this is appealing, and as one who practiced general internal medicine for more than 25 years, I would view this as a “godsend” that leads me to exclaim enthusiastically and passionately, “It’s about time!!!”.  But I want to raise a couple of issues.  While we all have an aversion to capitation, HMOs, and “gatekeepers,” as we look at much of the early efforts in developing and piloting medical home models, should we be watchful and attentive to whether or not we’re creating a  “gated community” with current efforts?

Of course, perhaps we should consider if that itself is a bad thing. A gated community is usually considered in a residential sense, and often contains strictly controlled entrances for those who aren’t a part of that community.  In fact, for many gated communities there is an actual closed perimeter of walls or fences.  Usually those who are part of this community share various amenities, and if lthe community is large enough, it is possible that most of the “residents” can obtain all their needed daily services within it.  For that privilege, they may be required to pay fees, and agree to various covenants of behavior and participation.  In fact, some of said communities resemble fortresses with hired private security forces, ensuring only those meeting the criteria for inclusion have access to the “grounds” and services available therein.

On the surface, you might argue that it’s ridiculous and an unwarranted extension of reality to attempt to link the ongoing work in medical homes to this social phenomena.  But, is it?  Aren’t there in many cases, significant similarities which warrant an open, honest appraisal and consideration if we’re to ensure that the medical home truly is a “health neighborhood?”

In addition, if we’re inclined to consider the concept of a community, which seems to be an emerging concept, one must remember that participating in a community requires active involvement of those within that enclave. It can’t be accomplished by a benevolent provision of services and facilities without a reciprocal agreement and  engagement of those who choose to become part of that community.  In short, it’s bidirectional.

And herein lies one of my concerns.  I’ve blogged before about my concerns regarding our expectations of those who’ll use the medical home.  In fact, I’ve questioned my own qualifications for residency in such a home. (http://bit.ly/b3R2hG)   As we continue to develop and refine our efforts in moving this concept forward, there is an implicit notion that our patients will be a critical participant in the development, ongoing maintenance, and success of these medical homes.  Much of the detail is yet to be worked out, but at times it appears we have what I call the Field of Dreams approach—“Build it and they will come.”

But as we develop these efforts, are we making an assumption that our patients will be willing to step up and take the personal responsibilities and actions that will be necessary to ensure their success.  In effect, will they sign the “covenant” often times seen in gated communities?  Much of what we see being written about the public’s expectations and understandings about evidence-based medicine, efficiency, and quality seem problematic in advancing that concept.

In addition, we all know that a large burden of the cost of care is presently borne by a small percentage of low income, often times uninsured group of people with limited experience or capacity to become more active in their personal care—for many varied reasons.  While much is being done to promote PCMH within the Medicaid population, which often is a microcosm of those patients, there is much still to learn.  Yet, while it is apparent to many that we have much to learn about what motivates and engages humans in changing their behavior, we are plunging ahead, making many assumptions on how our “home” models will be furnished and lived in by prospective residents.  Are we making unwarranted assumptions?  Have we begun to understand the underlying factors affecting motivation and success in behavior change?  Do we fully understand the “covenant” which will be required from not only health care providers but for our patients if our medical homes are to flourish?

So perhaps we’re in reality creating a “gated community,” but attempting to do it without staffing it with gatekeepers.  Perhaps it’s not a bad thing to consider the value of a gated community, albeit a stretch of an analogy for some.  But given that gated communities are often a type of “enclave”, anthropologists have argued that they have a negative effect on the social capital of the broader community outside the “gated” one.

I’m not a cynic, not one tending toward negativity.  But, as part of our work and effort in transforming our health care system, incorporating innovation, and trying new models, it behooves us to continue to challenge assumptions, ask difficult questions, and consider not only our intended consequences, but also those which are unintended.  I’m just hoping that we are not only building a model which works for the college grads with jobs and benefits, but also works as a community for the diverse and needy who are presently outside the perimeter.  Am I off base?  Am I missing a fundamental point or belief?  Or do others share similar concerns?  I’d  welcome criticism, reassurance, and evidence that I’m not thinking clearly.  I feel there’s much yet to explore, much we need to learn, and many mistakes which must be made before we reach the transformation which we’re all seeking.

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