THE LAST WORD
The Doctor-Centered Medical Home
Yes, it worked in the past. No, it won't work in the future.
Fam Pract Manag. 2013 Jan-Feb;20(1):40.
Unless you have been living under a rock for the last decade, you probably have heard of the patient-centered medical home. But like many physicians, you may not feel as though you understand what it really means. The definitions can vary among payers and accrediting organizations, and they often include buzz words such as team-based care, shared decision making, or risk-stratified care management.
Forget those definitions for a moment. To best describe what a patient-centered medical home is, I like to start by describing what it is not – a doctor-centered medical home.
In a doctor-centered medical home, you would typically adopt the following practices:
Open your office just four days a week, knowing that patients who get sick the other days of the week will delay getting help or seek care elsewhere.
Do it all yourself – from administering immunizations to completing all documentation.
Spend about 20 percent of your time doing work that requires a medical license.
Drive all over town delivering babies, following patients in the nursing home, and admitting patients to the hospital both during and after office hours.
Stop taking new patients, in part because you're so busy doing the above.
Make the next available appointment several weeks out. After all, it shows you're in high demand.
See three patients per hour.
Schedule 45-minute physical exams.
Barely make payroll as a result.
Buy no new medical or office equipment; fix everything with duct tape and adhesive bandages instead.
Don't adopt new technology; stick with the paper systems you know and love.
End the day with a pile of charts a foot-and-a-half high for dictation.
Complain about insurance companies.
In contrast, here's how the physicians in my clinic operate:
Open the office seven days a week including evenings.
Get more providers to help you do the above.
Offer same-day access for new patients and walk-ins.
Spend about 80 percent of your time doing work that requires a medical license.
Have your staff do everything that doesn't require a medical license, including the documentation.
See five patients per hour.
Schedule 15-minute physical exams (preventive visits).
See patients only in the office, to ensure continuity and availability in that setting, and coordinate care provided in other settings.
Take no call – ever – because you're meeting patients' needs through extended hours and open access.
Sign off on each chart shortly after the patient leaves.
Go home when the office closes … immediately.
Create a cash reserve so you can eventually get a nicer facility with new equipment.
Complain about federal over-regulation.
I've had both kinds of practices. The former was really rewarding and, in its time, made sense for me and for my patients. But things have changed, and the latter works for me now. Admittedly, this isn't an official definition of a patient-centered medical home (for one example of that, see the National Committee for Quality Assurance's standards). Instead, it's just a glimpse at how patient centeredness has changed the way we practice.
This approach has resulted in a better life and more income for our physicians, and our patients like it as well. Perhaps it's time to declare that the doctor-centered medical home is dead. Long live the patient-centered medical home.
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