Friday, June 19, 2009

National Demonstration Project for Medical homes-some early observations and concerns

Medscape has a republished a report from the National Demonstration Project regarding the Medical Home concept that appeared in the Annals of Family Medicine in June 2009. See here. The full name for Medical Homes in this context is "Patient-centered Medical Home" or PCMH.The authors examined how the transition of a number of traditional family practices to the PCMH model was working out.

There is much to discuss in regard to the report in particular how difficult a transition is from "regular" practice to the medical home type practice can be but my attention become focused on this paragraph.Bolding is mine.

"Transformation to the PCMH Requires Personal Transformation of Physicians

Transformation to a PCMH requires not only implementing new, sophisticated office systems, but also adopting substantially different approaches to patient care. Such a fundamental shift nearly always challenges doctors to reexamine their identity as a physician. For example, transformation involves a move from physician-centered care to a team approach in which care is shared among other adequately prepared office staff.[25] To function in this team-based environment, physicians need facilitative leadership skills instead of the more common authoritarian ones. A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach, especially for chronic care and preventive services.[26,27] In addition, physician-patient relationships need to shift toward a style of working in relationship-centered partnerships to achieve patients' goals rather than merely adhering to clinical guidelines.[28-30]"


The report is hardly a glowing endorsement of the program at least from the view point of a physician considering taking that road. Not only does the report indicate the costs are greater than anticipated,the transitions take longer than anticipated and the entire process is difficult but the physician may have reexamine his identity as a physician. Does this involve pushing into the background the long standing venerable duty of the doctor to the individual patient? "A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach.."

Does this mean that the physician's strong fiduciary duty to the patient may have to be balanced with more concern for the collective.Trust in the physician commitment to the welfare of the individual patient has been the durable glue of the doctor-patient relationship. One wonders how group meetings and a "population based" approach will collide with the duty-to-the-patient ethic that most practicing physician were inoculated with in the medical training.(I realize that inculcation process has weakened more than a little bit in recent years but still is a strong element in the physician sense of professional identity.)

I wonder if NPs who lead medical homes will have to have that same identity metamorphosis.Earlier I blogged about new Medical Homes funded by a House bill that will allow NPs to independently lead these homes. The American College of Physicians has endorsed this bill, a move that both DrRich and I have critically blogged about.See here and here.

The review indicates that three years is not long enough to transform to this type practice and that the current funding and reimbursements may not be adequate. I find it hard to understand why any internist or family practice doctor ( this study involved family practice physicians) would willingly enter into this experiment considering it to be a more than 3 years process and it having significant likelihood of financial insolvency and may involve taking part in workshops to help you retool your ethical compass so it points to the new correct position in the context of the New Professionalism.

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