Home Wrecker (part one)

November 18, 2009
Alan Berkenwald, MD

I have been following with interest all the discussions about the new Medical Home (aka, the Patient Centered Medical Home) concept. This is our silver bullet that will improve patient access, raise quality levels, increase overall satisfaction and save billions of healthcare dollars - all at the same time!

I have been following with interest all the discussions about the new Medical Home (aka, the Patient Centered Medical Home) concept. This is our silver bullet that will improve patient access, raise quality levels, increase overall satisfaction and save billions of healthcare dollars - all at the same time!

As my mother would say, "From their lips to God's ear." And once we factor in all the savings that will accrue from universal adoption of electronic medical records, well, game over - we won!

As far as I can tell, we've tried this before, in the 1980's, only it was then called “HMO.” It too improved patient access, raised quality levels, saved money, and increased overall satisfaction. Not.

In 1981, fresh out of my residency and consumed with the fire of a true believer, I joined one of the first nationally approved HMO's located in the People's Republic of Amherst, Massachusetts. When we weren't practicing the highest quality medicine with our highly educated population (five colleges and universities in our area), we would meet in conference rooms with patient advisory boards and sing Kumbya. Our world was saved.

New England Journal of Medicine

Prevention Magazine

My role, as with all the Internists and Family Practitioners there, was to coordinate care for a capitated fee. We worked on salary, free to practice best protocol-driven medicine, with the efficiency and cooperation of a really great team composed of really great doctors. However, many of our patients were not willing to be team players. Reading the did not prepare me for what had to say. Patients felt that the only thing between them and perfect health was me. I was the gatekeeper. It was my job to arrange all the tests and therapies that they read about and desired. Yes, yes, I spent hours explaining, educating, enlightening. And yes, occasionally I found understanding. But mostly, I found skepticism.

Being a gatekeeper, holding the keys to the medical kingdom, beckons the Harpies. Harpies of Greek mythology were, at first sight, beautiful winged maidens. But, upon drawing the unsuspecting near, they became ugly, old women with sharp beaks and talons who would carry the unwary off to Hell for punishment and torture. What sins did I commit? Why did the Gods set these monsters upon me? I was the gatekeeper. I was the visible face that represented NO. We know the fate of the HMO's. No one sheds a tear for their passing.

Prevention Magazine,

I fear that the Medical Home will share the fate of the HMO's. History will repeat itself, as we do not learn. Empowered patients, driven by love and fear, will demand all that the gatekeepers cannot deliver - more tests, more specialists, more second opinions from major medical Mecca's - which are 'not indicated' or 'out of network.' Primary care providers will, again, be seen as the problem and not the solution by patients and families. Instead of it will be the Internet where "renowned specialists" will recommend that extra MRI, those new proprietary drugs, that trip to that medical center, those therapies that are experimental. Posted blogs will soon scream "J'Accuse! It is you, Mr. Gatekeeper, concerned only with saving money for you and your minions,that stand in my way."

I have been there. I have felt the Harpies upon my medical flesh.

Thomas Wolfe (could have) written, "You can't go (to a medical) home, again."

I answer, "There is another way. There is hope." I will explain in my next blog soon....