The Medical Home: 
Better for Whom?

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Dr. Bitton: I know that you’ve been studying some of those practices, Dr. Sinsky. Are there themes or predictors of maintaining that joyfulness during the transformation?

Dr. Sinsky: Having intentionality about the transformation—creating time and space to step aside and analyze and improve your work—is a way to create adaptive reserve within a care team. So, I would say intentionality and time for team meetings and planning are predictors of survival and thriving.

Dr. Bitton: Dr. Pollack, your thoughts on the trajectory?

Dr. Pollack: I’ve been practicing over 20 years and I think primary care has been in crisis since the day I started. I really believe things are different this time, and that we will finally get the resources to deliver on the promise of primary care. I believe that the fundamental problem with health care in the United States is that we are too good at what we do. The number of interventions that now work is so huge that it if we don’t redesign the system to deliver those interventions, we will drown. Both primary care and health care in the United States are at a tipping point. I’m optimistic that we are going to tip in the right direction and end up with a much better system. Medical home is just the beginning of the change.

Dr. Bitton: Dr. Frolkis—your view of the trajectory?

Dr. Frolkis: One of the great things about going last is that everyone else has contributed, so I only have to say I agree! But, I do in fact agree and would saying in addition that we really have no choice. This primary care crisis really is a crisis. I am reminded daily of the urgency of coming up with a way to save our field. I’ve been practicing for 30 years, scary to say, and would agree with Dr. Pollack that primary care as a profession has been going downhill not because it isn’t a wonderful occupation. I think it’s the best job in medicine. But we have not done a good job of fighting back for primary care interests effectively enough during that period.
When survey results of primary care physicians indicate that only 2% of medical students are indicating an interest in primary care internal medicine, when the differential of reimbursement is so great between primary care physicians and specialists, when job satisfaction is plummeting, when people are burned out and say that they would not become physicians again, it is a particularly telling, and, to me, disturbing sign.1 I think we have to find something that works to revitalize our field, because as I’m sure everyone on the panel agrees and as Barbara Starfield and others have long demonstrated, societies where there are more primary care physicians are healthier and less costly societies.2

So, I am enthusiastic about the patient-centered medical home. I don’t know whether its current definition will be the final definition. But, its “viral” spread is reassuring. As I said earlier, it’s attracting young people who want to be a part of this thing that we’re all creating in many ways from whole cloth. I also would echo what Dr. Pollack said that I think it’s just the beginning. At Brigham and Women’s Hospital, for instance, and we’re starting to develop the ”Medical Neighborhood”, an effort to more effectively and explicitly coordinate care with our specialty colleagues in order to maximize the medical home’s ability to deliver on its promise of improving access, quality, and value.

Dr. Bitton: Dr. Frolkis, if you are a specialist, how do you see the rise of the medical home impacting your work? Some skeptics argue that this is a play by primary care to rebalance reimbursement. Others see it in a more positive light. What are your thoughts or messages for the specialist community?

Dr. Frolkis: I think the answer depends on where we are in the uncomfortable transition zone that I referenced earlier. I think that in the current reimbursement system it is in many ways a zero-sum conflict. Of course it’s not as if income redistribution goes into the pockets or paychecks of primary care physicians. But there is a necessary up-front investment in infrastructure to allow team-based care to succeed, and specialists are likely to see that investment as a loss to them. A number of sites around the country have shown a remarkably quick return on investment for downstream savings. It is clear that those savings are linked to the model of care in which they occur, so that Geisinger in Pennsylvania and Group Health in Seattle, for instance, could argue that by being in integrated systems it is easier to demonstrate “proof of concept” for the medical home.
There are some other demonstration projects that I think are showing a fairly impressive return on investment as well,3 not only on the cost side, but in terms of patient, physician, and staff satisfaction. So, I think that to the extent that reducing emergency department visits and ambulatory care sensitive admissions and unnecessary utilization is relevant to the reimbursement model extant at the site, the more cost effective the patients in a medical home are going to be to the system. Part of our job is messaging because our specialty colleagues are going to be in the same bundled or capitated world that we’re in.

Dr. Bitton: Drs. Pollack and Sinsky, any thoughts about specialty interactions or thinking from their perspective on this model?

Dr. Pollack: I’m finding more and more that the trailblazing work primary care is doing around integrated team and population management and patient activation is being adopted by our specialist colleagues. We’ve always been a little more under-resourced and hence we drowned a little bit earlier. Specialists are running up against the same problem primary care faces: the sheer volume of care that works exceeds our ability to deliver it. 

Dr. Sinsky: I have a vision of how the medical neighborhood could be, and I think it would be very good for our subspecialty colleagues. In this vision the subspecialist may spend a third of their time on direct patient care, a third of their time on academic detailing—providing updates about changes in your specialty—to the primary care physicians in their network, and a third of their time on population management and community facing  activities. An example of these activities would be an endocrinologist who works with the local school district to improve the healthy food choices offered in schools to reduce childhood obesity/diabetes. Just as primary care transformation has the potential to improve work-life satisfaction for primary care physicians, the medical home neighborhood has the potential to transform specialty care into a more satisfying professional life as well.

Dr. Bitton: Let’s run with that thought about improving the work conditions for primary care and hopefully for the rest of ambulatory medicine. Daniel Pink, in his book Drive, defines elements of satisfying work as the following: “work which contains of high levels of autonomy, mastery and sense of purpose.”4 I would like for you to reflect on how the medical home model approaches those three domains: autonomy, mastery, and purpose. Does it get us there in any meaningful ways in your experience so far?

Dr. Pollack: My experience is that working in a medical home is highly satisfying for everyone on the team, probably because it hits all three domains. We are enabling pharmacists, nutritionists, social workers, nurses and medical assistants to work at the top of their license, which gives them both autonomy and mastery. Sending a message that their job is to provide care directly to the patient (not just to support a physician) is huge. Even the administrative assistants I’ve worked with chose primary care, instead of working in a lawyer’s office, because they want to be able to help the sick and comfort the ill.
All of the above also applies to physicians. Let us work at the top of our licenses and give us the resources to take really good care of patients. It even applies to specialists. If we (primary care) effectively treat the primary care aspects of their specialty, then they (the specialists) will get to see a more complex population that allows them to work at the top of their licenses, doing what they presumably love to do and why they became a specialist in the first place.

Dr. Bitton: Other thoughts?

Dr. Frolkis: I would echo Dr. Pollack’s comments. As we develop our medical neighborhood outreach effort, these are potential advantages that we stress with our specialist colleagues. Early work in the medical neighborhood has shown, for instance, that the percentage of referrals deemed inappropriate drops precipitously when you actually work out medical neighborhood collaborative care agreements or other arrangements. It allows the specialist to practice at the top of his/her license and see the clinical issues that are intriguing to them.
It also empowers the primary care physician because there is an embedded educational component there if you are reestablishing the kind of collegiality that made us all love residency. Then the primary care physician is learning in real time in a case-based model how to become more competent at things so that his or her autonomy, mastery, and purpose increases. I can’t reiterate enough how important it is to team members to be empowered to do things that they are fully capable of doing but had never been given the opportunity to do, and how liberating it is for physicians not to have to do stuff that we didn’t go to medical school to do and are not particularly interested or adept at doing.

Dr. Bitton: Dr. Sinsky, you were going to add in?

Dr. Sinsky: It’s hard to add to such well-spoken comments. I want to say that we did use the autonomy, mastery, and purpose framework for our site visit guides as we visited 23 high-functioning practices looking for joy in practice. It parallels the control, order, and meaning framework that Dunn has put together to promote physicians’ well-being and satisfaction in work.5

Dr. Bitton: Dr. Sinsky, what do your patients think about this model? Do they know they’re in it and has their perception changed over time?

Dr. Sinsky: Sure, that’s a great question. I’m not certain our patients would know what a medical home was if you asked by name. But, if you ask by function, I think they would. The critical part of our practice model is pro-active planned care. For example, we arrange for our patients to have their laboratory reports completed ahead of their appointments.
When I tell my patients that I’m going away next week to speak about a new way of giving care and that pre-appointment lab is one feature, they’re quite surprised that other practices don’t do that. I’ve had patients move away and then when they move back to the area, they’ll contact our office and ask to have their labs and their mammogram ahead of the appointment. They know the results can then be incorporated into face-to-face shared medical decision making at their appointment. They don’t know the term shared medical decision making, but they know the act.

Dr. Bitton: Dr. Pollack, what do the staff and trainees at your clinic think about this model?

Dr. Pollack: The staff has really enjoyed this. The practice manager and I meet with every member of our staff to assist them with their professional development, which gives us an opportunity to ask how they think we are doing. We hear things like “I’ve never worked anywhere like this. I can’t imagine working anywhere else.” I think it comes back to autonomy and mastery and sense of purpose. I would point out that evidence to support the idea that medical home will improve staff morale and decrease burnout in safety net clinics was published in the Archives of Internal Medicine.6
From the point of view of trainees, all I know is that we are a very requested site for continuity clinic. I believe it’s because they can come here and imagine doing this for a living. One of my personal metrics for the success of this model is by the time our trainees leave they will say, “Hey, maybe I don’t have to be a hospitalist. Maybe being a primary care physician is doable, something I can enjoy and be successful at.”

Dr. Bitton: Dr. Frolkis, what does the conversation in the executive suite sound like around this model?

Dr. Frolkis: I’ve been pleased and encouraged at the support that primary care, and the urgency of the need to transform primary care towards the team based model has enjoyed in the executive suite. I think that there has been an inevitable learning curve for all of us, but there seems to be a growing understanding that this is something we have to do for the good of the institution and the security of its future.

Dr. Bitton: That gets into the next question for anybody in the group. How do you pay for this model and will it eventually pay for itself?