Health Affairs has published a scathing blog critique of the medical home by Dr. Caroline Poplin, a primary care internist. Her post, in my view, represents a deep misunderstanding of the model. In response, my colleague, Dr. Michael Barr, and I responded on the ACP's behalf.
I don't plan to repeat our response to Dr. Poplin here, although I invite you to read the exchange and post your own comments, here or on the Health Affairs blog.
Her commentary represents a broader problem, though. Most primary care physicians are keenly dissatisfied with the current system. Yet when a new idea is proposed to fix the status quo, like the medical home, it is greeted with skepticism, cynicism, and even downright hostility.
For example, primary care physicians intensely dislike the financial pressures to increase the numbers of patients they see per hour, yet this is largely the consequence of a fee-for-service payment system that rewards doctors for seeing patients face-to-face and ordering more procedures. But proposals to sever the link between payment and volume, as the Patient-Centered Medical Home would begin to do, are greeted with deep distrust.
Primary care physicians loath the constant barrage of "hassles" imposed on them. Pre-authorization, utilization review, documentation guidelines - the list goes on and on - are rightly viewed by physicians as intrusions that sap the energy and satisfaction from their professional lives. Yet much of the paperwork associated with practice is the result of fee-for-service. Why? Because any system that bases payment on volume invites "controls" to reduce the volume of "unnecessary" procedures, as determined by the payer. A different payment model that rewards physicians for efficient, effective and high quality outcomes, not volume, could reduce or even eliminate the need for such intrusive utilization controls.
I understand why physicians, and particularly primary care doctors, are skeptical. Primary care physicians have had a long history of being subjected to the latest reforms (think RBRVS, gatekeeper, capitation and pay-for-performance) that are supposed to make their lives better, only to find that they either fell short or made things even worse. One ACP member has described it to me as "death by a thousand cuts" from well-intentioned health reformers. I would be the last to suggest that ideas like the medical home should not be subjected to scrutiny and challenge - that is why, for instance, ACP supports pilot testing of the medical home before it is adopted more widely. What concerns me though is when healthy skepticism becomes outright cynicism.
The other challenge is trying to explain the latest new ideas to physicians. As Dr. Poplin's commentary demonstrated, even when ideas are developed by the primary care physician organizations themselves, they may be poorly understood by rank and file primary care physicians.
Going forward, it is self-evident that we need new payment and delivery models, not just for primary care physicians, but also for specialists. Such models should move away from pure fee-for-service reimbursement to basing compensation on accountability for the quality and effectiveness of care provided.
Today's question: Will physicians embrace the changes we need in how care is organized and paid, or allow their distrust and cynicism to rule the day?