Aaron Carroll, one of the writers for The Incidental Economist, has reviewed some of the research on whether the Medical Home is more successful in small or solo practices than in large medical organizations. The notion of the Medical Home wasn’t on the top of my list for hot topics, but my eyes caught the mention of solo and small group practices compared to large group practices (corporate medicine). Since I am perpetually defending the independent physician against the corporate medical world, I was happy to see a post which actually had something good to say about physicians outside the corporate fold.

A look at the very long list of bulleted items defining HRSA’s Medical Home makes it very clear that small and solo medical practices have traditionally provided just this kind of care for decades. However, HRSA has for some reason felt it necessary to rename this newly defined kind of patient care a Medical Home, implying that the care described never existed.

False Assumption:

The Medical Home Doesn’t Exist So Needs Definition

A great deal of work has gone into purveying the assumption that the Medical Home is something different than what solo or small group family practices already provide. In truth, I see no way for this kind of care to be adequately provided by anything BUT small independent practices.

There is simply no substitute for knowing your patients, your patients’ relatives, your patients’ neighbors, your patients’ home environments, your patients’ wants and needs, and their medical and social history. Contrary to popular belief, this kind of knowledge is far more complex than anything which might be typed in the Social or Family History tab in an electronic medical record (EMR).

Only in a small practice owned and operated by physicians can those providing the care talk with their patients as long as they think necessary to diagnose patient problems. On the surface, this seems an absurd statement. However, corporate medicine cannot comprehend this concept. Corporate medicine deals only with “evidence”—mostly in the form of the ticking clock.

Every practitioner worth his or her salt knows that if you let a patient talk long enough, the real health problem will surface, and it’s probably not the reason the patient appeared in the clinic.

False Assumption:

Small Practices Cannot Deal with Medical Complexity

Besides the issue of practitioners being able to spend adequate time with their patients, there is also the erroneous assumption small practices cannot handle complex patients with multiple chronic diseases. Not true. Small family practice clinics are not the same as walk-in clinics at the local mall.

Actually, in small practices physicians can take the time to really deal with complexity. Elderly patients often have 4 or 5 chronic conditions and are on 20 or more medications. Furthermore, small practices often have had long professional relationships with specialists they know and respect. Practitioners do not send their patients to specialists unless there is a need for it—and they are not required to send their patients to specialists within the corporate system.

It’s an illusion to think that a large business organization with multiple specialists offering an array of health care services that need to be used to pay for themselves is going to reduce the costs of health care. Reducing the cost of health care isn’t going to happen by quickly passing patients from one practitioner to another within a cluster of services housed under one corporate umbrella.

False Assumption:

Only Corporate Medicine Can Provide a Medical Home

The Medical Home defined by HRSA can only be provided by small practice physicians who get to know their patients well over the years. This Medical Home isn’t going to arise magically from EMRs. It isn’t going to happen because patients can access their health records online. It isn’t going to happen because practitioners e-prescribe for patients. It isn’t going to happen because patients receive e-mails about their health care. It isn’t going to happen because patients are handed printouts of their encounters at the end of the visit.

The Medical Home described by HRSA will only be available from physicians who spend enough time with their patients to know them well.

The Medical Home isn’t going to magically appear by blaming practitioners for spending too much time with patients. Nor will the Medical Home arise out of the ashed of accusing physicians of being greedy because they would like to be paid for the time it takes to listen to their patients. Spending time listening to patients is precisely the kind of care outlined in HRSA’s definition.

In any practice, the patient is NOT the chart. In small family practices where patients see the same practitioners over the years, patients know they have a Medical Home. They don’t need a HRSA checklist to redefine what they know they already have—a practitioner-patient relationship that cannot be captured with an electronic medical record.

From my perspective, the ONLY reason to try to define an intangible that already exists with a lengthy checklist and then attempt to direct attention somewhere else looks suspiciously like an attempt to shift medical care to a corporate environment where management has been trained to cut costs without considering the effect upon patients.

The intangible elements of patient care most valued by patients cannot be reduced to a checklist. Everyone seems to know this except the list makers who are really only trying to reduce medical costs at the expense of quality patient care.