The concept of participatory medicine is taking hold, fueled, at least in part, by what we see as two complementary forces, these being the patient-centered medical home (PCMH) and Health 2.0. Health 2.0 is very much a grass roots phenomenon, dominated by a small but significant group of patients who are testing the hypothesis that the wisdom of the crowd can rival the wisdom of physicians. The PCMH is a concept, not new, but gaining tremendous traction in the provider sector now as a best-try effort by some providers to be truly patient centric in their approach. The two should be complementary and mutually self-supporting. One might even suggest their respective champions should be collaborating right now, when the scent of health reform is in the air in our nation’s capital. But they are not. Lets examine why and explore ways in which to create a natural bridge between these two concepts and their champions.
The medical home concept was first introduced by the American Academy of Pediatrics in the 1960s. But several factors are now converging to update this original concept for today’s health care environment. The growth in chronic illness, the emergence of new reimbursement models designed to improve quality and control costs (e.g. pay for performance), and the greater availability of monitoring and messaging technologies have providers, payers and patients taking a fresh look. This is a good thing, in that it is an effort by organized medicine and large corporations to get into the reform conversation.
But the aspects of the medical home that are getting the most airtime are largely focused on rounding out office staff, adding new roles that take work away from the physician so that the physician can tend to more patients, and taking a population view of the patient panel. This vision is idyllic, but several challenges suggest that as conceived it will be tough to get it out of the womb.
The biggest is that the growth in demand for services, fueled largely by growth in chronic illnesses, has already outstripped the demand for both nurses and primary care physicians. We can’t train enough professionals to outfit all of the medical homes to this specification, and even if we did, the major cost in healthcare is human resources, so it stands to reason that this model would add far more cost than it would take away. An excellent monograph by Paul Keckley suggests that to implement the medical home in this fashion would require an up front investment of $100,000 per doctor and an ongoing increase of expenses by $150,000, hardly a reasonable proposition in a time of health care cost cutting. The second big challenge is that true population management requires sophisticated information systems. While there is great focus on the value of the electronic medical record, or EMRs, there has been little discourse on physician adoption of technologies routinely used in the population health industry such as predictive modeling software and disease registries.