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Wednesday, May 22, 2013

How would a Patient define a medical home?

I've been hearing a lot about patient-centered medical homes again.  The topic first hit my radar screen sometime in 2006-7 when it heated up again, after what appears to be a re-introduction of it some time in the early 21st Century.  When PCMH first showed up (on my radar), it appeared to be the next big thing.

I took a sniff at what it espoused back then in order to figure out what its impact would be on my day job.  As I looked deeper into it, the technology, standards, and information requirements of a PCMH were just what I'd have expected, and so, it being more about physician business models, it passed through my consciousness pretty much without impact.  (The same could be said for Accountable Care Organizations).

Any information worker understands that you need data to do your job, and that the better and quicker it flows, the more able and effective you can be.  Physicians are information workers, whether they realize it or not.  They are containers (silos even?) and distributors of highly specialized knowledge and services.

Given that the topic has blipped three different times this week on my radar, I thought I'd take a crack at really looking at it with my patient perspective.  You know, that viewpoint from behind spring-green colored glasses.

  1. A patient centered medical home is about me, after all, I'm the patient.
  2. It's where I prefer to go for medical care, including information, diagnosis and treatment.
  3. When I go there, they have to take me (isn't that the definition of home).  And that means not just 9-5, Monday to Friday, but all hours and all times of day that I (or a family member) could get sick.
  4. At home, I know where to find stuff.  A PCMH makes it easy for me to get information, about my conditions, my treatments, my appointments, and my diagnostic studies and tests.
  5. At my PCMH, they can care for me for MOST of the problems that I have to deal with.  If it's obscure, or requires specialty care, they know where to go.
  6. When I call, someone I know answers the phone.
  7. At home, they know who I am.  I don't have to reintroduce myself every time.
  8. Finally, staying at home is cheaper for me that going elsewhere.
Most of what I've stated above is simply a patient centered restatement of many of the principles espoused by organizations such as NCQA, ACP, AAP, AAFP and others.  None of how I describe it has to do with technology directly, although all of it can be assisted by technology.  One of the most interesting disparities between my idea of "patient centered" and the one in the link above is when you compare my statement #8 above with this one from the 2007 Principles Document: 
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. 
Note that what I have to say is not incompatible with the previous statement, but it certainly doesn't belong in a "patient-centric" document as stated above.  What I think patients want is stated quite clearly and objectively.  This will cost less (and if you can do it and make more money, that's fine, but do make sure we're spending less on healthcare). At least that's one of my values.


  1. Keith, let me clarify their #7 in view of your #8. The idea is to pay primary care enough to be able to do all these things for you, so you can stay home comfortably and not have to go out and spend a fortune.
    Right now the homely primary care is severely underpaid in comparison to the glitzy specialty care, which makes it very hard to provide you with a home that is good enough to make you want to stay in it.
    Paying a few more wise pennies to PCPs will save you many foolish pounds on hospitals and specialists.
    And that's all #7 was saying....

    1. Margalit,

      When I think about my "medical home", I think about the group practice that I use that includes my PCP, and all those glitzy specialists, and the urgent care center. I'm buying healthcare, not building it out of parts.


    2. Yes, this is your "care team", but the term "medical home" refers to your primary care team, which granted is a part of the larger "care team". In order for you to be able to buy health care, someone has to assemble the parts (unless you use Kaiser or some other integrated system, but even then, you may need a "project manager", which is your PCP).
      The more comprehensive, coordinated and accessible the primary care part is, the less likely it is that you will see lots of specialists, receive unneeded care, or end up in a hospital.
      Coordination, comprehensiveness and accessibility cost more money than lack thereof, which is what we have now in most places.
      The primary care associations that formulated the joint principles of the patient centered medical home, wanted to make sure that adequate funding is available to PCPs so they can acquire the resources to make your medical home function as it should.
      Perhaps this all should be transparent to patients, but somewhere, somehow payments need to be attributed to various members of the team, so investing a little bit extra in primary care, will go a long way to save on all other things, and to keep people healthier. Hopefully....

    3. Viewing things through the physician perspective, I understand completely what you are saying. With my patient hat on, I don't care to make those distinctions.

      My step-father's "primary care team" was headed up by his cardiologist, not his PCP. But a medical home is not just where the team leader lives. Instead, it's where the patient usually goes for care.

    4. I understand, and I agree that patients should not have to concern themselves with who gets paid what when they seek care. And specialists do sometimes provide most of the care and even coordination for what they don't provide (OB-GYN is a good example for many women).

      I guess I was addressing this more from a policy angle, and how we should be allocating our resources more effectively. I think we are in agreement on what patients should expect. The question in my mind is how to make that happen, because we both know that it's not really happening for way too many people.