Medical Homes, Hammers and Nails

Medical homes are being promoted as a way to improve health care delivery by increasing the coordination of patient’s primary and specialty medical care.  The goal of medical homes is to ensure that patients’ care is comprehensive, appropriate and patient-focused.

One of the benefits to the patients and the healthcare system is that medical homes can help sort out the confusion that can arise from the phenomenon sometimes described as, “When you’re a hammer, everything looks like a nail.”

Hammer & Nails

In healthcare delivery what this means is that sometimes the diagnoses or treatment recommendations from specialized clinicians will reflect their expertise – and thus their may be inconsistencies or conflicts in the recommendations coming from several  specialists. The challenge for the patient is to determine the best course of action for them.  And that’s where the value of their primary care clinician in a medical home – they have access to all the patient’s information and can help coordinate and translate all this information for the patient, so together they can make the most informed and appropriate decision.

This coordinating and translating task is important for acute and serious illnesses, as well as for chronic conditions – particularly when their is no generally agreed upon standard of care, of if the accepted course of treatment does not prove satisfactory for the patient.

This situation arose recently for a friend at the same time there was an article in the New York Times where the author described her nearly identical series of interactions (and frustrations) with the medical care system when dealing with hallux limitus or rigiditus – basically, limited motion of the big toe, accompanied by pain caused by bone spurs and/or arthritis.  The “hammer sees a nail” phenomenon here is that the surgeon sees primarily a problem that can be solved with surgery, while the podiatrist sees primarily a problem that can be helped by an orthotic.  As the New York Times author discovered, there may be other options that could work for her.  But from her writing – and my friend’s experience – this was discovered because of the patient’s diligence and not from the coordinating role of her primary care clinician in a medical home.

Another way to view the function of the medical home is to look at a medical home as trying to replicate the close interpersonal relationship between each patient and their primary care clinician that existed decades ago, while still enabling the patient to take full advantage of medical advances.  In addition, such relationship building could help reduce malpractice costs since it should improve both the quality of care, and patient-clinician communications about the goals and expectations from possible treatment options.

Challenges to Creating Medical Homes
Building these homes faces several challenges, including the shortage of primary care clinicians who need to be at the center of the coordination process working with patients and other clinicians to define realistic and patient-specific goals and treatment plans. Another challenge to creating well-run medical homes is that specialists may balk at being part of such a formal coordination process.

Implications for Health Care Reform
What this mean for health care reform is that while medical homes should be promoted, they cannot easily be created for everyone from our existing resources.  Therefore, they should first be built where they can have the greatest impact – for people with chronic and multiple medical problems, while at the same time our overall capacity of primary care clinicians is increased.  These two initiatives can be complementary because creating successful medical homes should increase the economic attraction of primary care as a medical career, while also demonstrating to medical students and residents the value and attractiveness of primary care when practiced in a medical home type setting.

In addition, other important health reform initiatives such as electronic medical records, and turning the findings from comparative effectiveness research into actual medical practice, will support of the creation of medical homes that can improve the quality of medical care, help reduce waste and improve the overall efficiency of health care delivery.

And lastly, it is clear that there is a desire for medical home type services since this is basically the concept underlying concierge medical practices.  For those not familiar with concierge medicine, this is where the primary care clinician signs up a limited number of patients who pay $1,500 – $25,000 per year, and the clinicians commits to spending more time with them, will explain in greater detail their medical issues and options, and take on the role of coordinating their care amongst all needed specialists.  While I don’t have the data, I’m guessing that individuals who are are paying for these concierge services are not the patients who would receive the most clinical benefit from medical homes.  And clearly, with too few primary care clinicians, having these physicians limiting the number of patients they will see doesn’t alleviate that shortage.  So, while I understand the motivations and market forces driving the creation of concierge medical practices, given the current problems in our healthcare system, I don’t think they are pushing the use of limited resources in the best direction to benefit society overall.

2 thoughts on “Medical Homes, Hammers and Nails

  1. Thanks Oscar – Medical Homes are not physical entities, but rather a concept for a person to have a single group practice or clinician who is responsible for ensuring that the individual’s care is coordinated among primary care and specialty services. This coordination includes ensuring that all their information is both delivered to these clinicians and they get any new information about the patient from them so they can actually do this care coordination in a prospective way. The current alternative is that patients (or their family members) are often left to do this care coordinating themselves – something that they are not experts at, may not have the resources/time/capabilities to do, and may find very difficult at a time of illness or family medical crisis.

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