While the goals of the Medical Home are worthwhile, we do not believe that this model adequately addresses the critical problems with patient referral from primary physicians to specialists that are well recognized in traditional healthcare. Figure 1 (above), borrowed from Geisinger Health System’s planning process, outlines its current Medical Home pathway. As currently envisioned, the referral decision is based on the primary physician’s—and often the patient’s—perceptions of the need, timing, and choice of specialty for consultation. In this scenario, the specialist waits passively to be consulted. Only then does he or she provide either advice or ongoing care. The deficiencies of this approach in musculoskeletal disease care have already been reviewed above.
Unaffordable costs and wasteful use of available resources could jeopardize this model. Shortages and maldistributions of services and providers in many U.S. health systems require more efficient use of existing resources if healthcare costs are to decrease and outcomes are to improve. Currently, the primary care work force is often inadequate to implement the Medical Home model, even if teams of physicians, midlevel providers, and nurses are fully utilized. It is not enough to redesign existing primary care practices if, in aggregate, their capacity is insufficient to meet service needs. This situation is true if the practices are asked to take on work that was previously provided by their specialist colleagues, or not at all. Hospitalist programs have exacerbated the shortage of primary physicians by offering physicians an attractive alternative to their currently demanding practice situations. Chronic disease management is further compromised by current and projected shortages of rheumatologists and other nonprocedural subspecialists who share this work with primary physicians, and draw their workforce manpower from the same inadequate pool of trainees.25
Improving outcomes and reducing costs of chronic disease care in the foreseeable future will require effectively utilizing of all of health systems’ existing providers, directing patients to where their care can be provided most effectively, reallocating resources from low- to high-value services, and foregoing the easy and politically correct answer of throwing more resources and dollars at any part of the more globally broken system. We cannot begin to address these urgent problems by waiting years for a train full of new primary physicians to come around the bend.
Implementing the Medical Home model faces other daunting financial barriers and risks. Adding the educational and practice costs for increasing the primary care workforce and implementing the Medical Home to the escalating U.S. healthcare bill is unsupportable, especially in the current economic environment. Projecting future workforce needs based on traditional delivery of care assumptions is flawed. We believe strongly that we should first implement system efficiencies, reduce unnecessary care, and redistribute existing personnel before making these projections.
