The Medical Home: Primary care panacea or the next doughnut hole?

The news on the medical home model this week is good:  A Commonwealth Fund-funded Geisinger study published in Health Affairs demonstrates the extent to which development and implementation of a medical home model can actually prevent those preventable hospitalizations we keep hearing about.  This is a very good thing, and the model described should be studied and replicated to the extent possible.  The current issue of Health Affairs, and companion pieces on the Health Affairs Blog include a range of articles on medical home successes ("medical home runs") and challenges.

What's interesting about the collection of information put forward by Health Affairs is the fact that two studies may reach somewhat inconsistent conclusions: for example, one concludes that smaller practices don't have the resources to invest in personnel and on other fronts, while another finds that small practices are not, by their nature, excluded from the group of medical home runs.          

Also, some of the findings include the conclusion that EHRs are a necessary, but not a sufficient, component of the transformation necessary.  There's a whole lot else that's needed out there, of course, to make a medical home.

At least one resource, however, is a must-have.

The Geisinger study brings to mind a variation on the old joke about an economist marooned on a desert island with canned supplies but no can opener (punchline: "Assume a can opener.")  In effect, the study assumes a sufficient supply of primary care physicians.

I read the following news story this morning:

Funny thing is, this story ran in the NY Times fifteen years ago.  That story continues:

Fast forward to 2008, and only two percent of medical students are looking forward to a career in primary care.  Are we heading towards another doughnut hole — a future without PCPs?

So the medical home model is being promoted as a solution to the health care financing death spiral, particularly as it relates to chronic care, yet a key component of the model — PCPs — is in short supply, and getting scarcer by the minute.  What's most disturbing about this shortage is that it had reached the mainstream media (MSM — though we didn't use that term then) back in 1993, yet we are still debating in 2008 whether and how to address the issue.

Some provider organizations are promoting the idea of group well-patient visits, as well as other administrative means of extending our physicians — by physician extenders or otherwise — so as to spread the PCPs around more efficiently.  To me, this looks like the scotch-tape-and-safety-pins approach to keeping the old jalopy on the road.  A JAMA editorial calls for efforts to hold medical schools accountable for producing the supply of physicians that we need, since they are subsidized so handsomely by the government.  Well, this has been analyzed "six ways to Sunday," as they say, e.g., by the Council on Graduate Medical Education, and, well, ah, um, the analysts haven't always gotten it right.

It seems that we need a broad-based effort to incentivize folks to pursue careers in primary care.  I don't think that an expanded national service program will do it, though that might serve as a template for some future efforts.  Unfortunately, this is just one aspect of our current non-system that seems broken beyond repair. 

— David Harlow