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Fam Pract Manag. 2008;15(1):13

The otherwise excellent article “The Medical Home: An Idea Whose Time Has Come … Again” [September 2007] ends with a slur that is hardly worthy of the general quality of the article, regardless of how attractive it may be to practicing physicians. In the last paragraph is the statement “… the pressures of managed care have made this vision harder to achieve.” Where is the evidence to support the contention that it is managed care that has made the medical home a more remote possibility?

In fact, the basis of the managed care movement was an effort to transfer some of the responsibility for the economic well-being of the system to the custodianship of physicians, putting primary care physicians at the center of this effort. Primary care physicians were to be paid based on capitation (the ultimate “management fee”) and were encouraged to do all of the activities that would reduce their patients' need for medical services: provide preventive care with a team approach, telephone and e-mail care, and disease management, all with careful attention to practice guidelines, cost and value.

So what happened? It is certainly convenient to blame the payer industry for all of the woes of medical practice; whether that can be justified or not is another matter. It was not payers but our specialist colleagues who translated the “gatekeeper” concept into a “gate blocker” idea. The payer's concept of the gatekeeper was a primary care physician who was at the center of the patient's health care, providing counsel and guidance, educating, and advocating within a complex and confusing system for the patient's benefit. The idea that the primary job of the primary care physician was to keep the patient from seeing a specialist (when such a visit was necessary) came not from payers but from the specialist community (helped along by some primary care physicians, no doubt).

It is time to stop pointing at someone else as the cause of all our woes. I believe we, as family physicians, are partially to blame because we are no longer focused on the patient. Instead, we focus on personal convenience and income. We need to return to a self-effacing approach to patient care with a greater focus on the patient as a fellow human being, friend and person who will answer to our needs as we answer to his or hers. It will serve us better to focus on our own contributions to the problem and resolve those than to point at others and demand that they mend their ways.


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