Gary Oftedahl: Moving toward a Patient Centered Medical Home—is the path clear?

October 22, 2010 at 2:00 pm

I’d like to say it’s all clear to me now, but it’s not.  While I might make that statement about many of the issues that challenge my journey through life, I’m referring to the light at the end of the tunnel in primary care redesign, being called many names, but all referencing a move toward a “patient centered medical/health/health care home” concept.  I’m hopeful this light is not truly an oncoming train, but a guidepost for moving the transformation of health care forward.

I’ve written in the past of my concerns regarding the implementation of this concept, and the potential for overpromising, and underdelivering which accompanies many of the claims being made.  As someone who’s lived in an environment focused on the application of evidence based medicine and the need for good evidence before we venture forward, there are elements of this movement, that while promising, deserve further consideration and contemplation, not to mention testing.

I just attended the annual AHRQ conference in Washington D.C. where I had the opportunity to hear from many of the principals involved in creating a research agenda for advancing our efforts in improving health care.  I subsequently had the opportunity to read a blog post by Joanne Kenen summarizing her thoughts on part of the meeting. (http://bit.ly/bzQdnK).  Her title highlighted both the promise, but also the limitations which concern me—“We’ll know it when we see it.”  So it comes to this, that much like art, or other very subjective issues, it will be an intuitive reaction which causes us to raise our arms in celebration and pronounce “Eureka, We’ve Done it” and march forward into the future, holding hands and singing Kumbaya.

Additionally, a recent policy brief published in Health Affairs addressed the patient centered medical home and questioned how widely adopted this model might be.  Within that report several of the questions and issues I have raised were once again addressed.   (http://bit.ly/bGS3z1)

First, it is my feeling that while there is great energy and enthusiasm at many locales for this concept, it is difficult to generalize, specifically because of the lack of a set of common definitions and agreement on functions.  Indeed, there are the principles developed by the AMA and a group of medical organizations, but these focus more on high level principles, and leave much unknown as to the specific functions which are important, and in fact, critical to advancing our understanding of what does work, but also what doesn’t work.

Additionally, while we have standards for the PCMH model, some would suggest they are primarily structural.  If I were to create an analogy, we’ve done a good job, perhaps, of identifying the anatomy of the model, but there is much to be learned about the physiology, or functionality of that model.  Many assumptions have been made relative to the function following form, which are eminently challengeable.  I’m inclined to wonder if we would benefit from agreeing on the elements of “function” of this concept, and then begin to formulate the structure which would support this.  I’m in the midst of some fascinating work with a colleague from the University of Minnesota,  C J Peek, and participants from across the country addressing that issue—more to come later.

While not wanting to be pessimistic, are physicians ready for the transition to this model?  More fundamentally, are patients ready and accepting of this model—even before we’ve fully agreed on exactly what that model is.  The Health Affairs article reinforces some of these concerns—questioning physicians’ willingness and ability to adapt to the collaborative model being promoted.  More importantly, are patients/citizens aware of and accepting of the “shared responsibility” which we’re suggesting is critical?  The use of the term “home” itself has confused and upset many.  If indeed, we have that fundamental of an issue needing to be addressed, we have much to do to encourage them to “take up residence” with all the expectations of ownership  we’re suggesting.

And buried under all this is a pervading concern regarding both the political and financial will to move this forward.  The competing forces politically may preclude the type of thoughtful, experimental approach usually desired in the creation of a new model.  Whether this be a global payment, imbedded in an ACO (whatever that will look like), an added coordination fee, a supplemental payment based on shared savings—the list is endless.  That uncertainty needs time to be addressed.  It seems the only thing we agree upon is that the present fee for service model will not work in the new world—but if not that, what, and further who will the losers and the winners be?  And will the losers quietly accept their loss—I doubt that.

I’m an optimist by nature, except with regard to my Minnesota Twins, but while optimistic, I’m concerned about the potential for overpromising and underdelivering, primarily because of political and personal pressures.  As has been said, a crisis is a terrible opportunity to waste, and we indeed have a crisis in health care.  In fact, it seems health care has been in crisis since I came into practice—but the clock is ticking, and the need for change crescendoing.  I continue to be committed to changing the health care delivery system.  But with that commitment comes a concern that we rush to solution before we have a shared and common perception and purpose in mind.  Otherwise, we’ll continue to have the same fragmented, fractionated solutions that have permeated the environment in which I live.   Let’s continue the dialogue, continue the experiments, but increase our willingness to collaborate in solving the problem as we move forward.

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