There’s a movement in some patient-centric care circles toward something called patient-centered medical home, or PCMH. This model brings together a team of clinicians around a primary care office or family practice, a one-stop-shop for care, prescriptions, psychological health care, and many have contracts with specialists to make for easy referrals. It also helps to distribute clinician burden and (hopefully) lessen burnout.
It has a lot of appeal. A team would be able to build a greater familiarity with each patient’s case, with more perspectives and more methods of treatment. Anyone familiar with Kaiser Permanente’s approach will be familiar with the PCMH approach. It works for a lot of people, a whole lot of people.
But from my poster-child-for-complex-care-opinionated-engaged-and-empowered perspective, there are two related weaknesses in the PCMH structure which would make me hesitate to take part.
First, the PCMH model is less expensive based on, among other things, a locked-in set of available clinicians. The team approach assumes that a patient will feel equally comfortable with each team member. In a recent conference, I asked what the mechanisms were for dealing with a situation of mismatched patients and clinicians. They do exist, but they all depend on self-reporting. The patient has to tell the program or clinician’s office that they aren’t happy instead of just backing away. I’m not sure this will work for the majority of patient populations.
Which brings me to my second (and larger) issue, which is that going outside of the established set of clinicians associated with the PCMH can be prohibitively expensive. In some of the Kaiser promotional material, they talk about “getting the same services.” But it’s not just about “getting a service”. For those of us with one or more chronic condition, it’s about getting the service – the one that works for us, the one that we can build into what we need it to be.
Personally, and I realize this puts me in a privileged class, I won’t be told who that is. In a PCMH model, someone else has selected who is right for me: where they went to school and got their training, what kind of and how much experience they have, what their clinical approach is, even what their interests are. There are many endocrinologists who treat diabetes out there, but if their interest lies in pituitary diseases and not Type 1 diabetes, they are not the endocrinologist for me. And as someone who has had horrendous and damaging experiences with clinicians who were not the right fit, the lack of choice in a PCMH model just doesn’t work.
I’m not saying that I would never consider buying into a PCMH model. The convenience and coordination of care aspects are very attractive. But my core clinicians – primary care, ophthalmologist, nephrologist, and endocrinologist – can’t be chosen based on convenience. My crazy body is too important for that.
And I’m not just saying so. For three of those four current clinicians, I travel to a different state for my appointments. So, it will be on the organizers of that model to 1) convince me that at least the majority of their clinicians are people I can work with on my terms, and 2) they have built enough flexibility into their pay and treatment structures that I can find a better option if necessary without a threat to my financial security.
The PCMH model is still evolving, and many existing offices don’t have the money to make the transformation (the initial investment is quite high), so there is time to develop the necessary flexibility. Perhaps by then, my wariness will have eased.