Patient-centered primary care: easier said than done

Two months ago, surgeon and New York Times columnist Pauline Chen observed that primary care demonstration projects have spent most of their efforts building components of the "medical home" - such as proactive, team-based care and health information technology - without necessarily making it "patient-centered":

Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.

It's welcome news, then, that a pair of insightful, accessible analyses of the potential and challenges of the patient-centered medical home model were published last week. The first article, a Health Policy Brief from the Robert Wood Johnson Foundation, succinctly explains the key elements of the medical home, provisions in U.S. health reform legislation designed to spread its adoption in primary care, and remaining questions, including:

1) What does it mean to be a patient-centered medical home?
2) How will we know whether they work?
3) Are patients and physicians ready?
4) Are they for everybody?
5) Do we have the necessary political and financial resources?

The second article on the PCMH, published in the September issue of Family Practice Management, bears the appropriate subtitle "Still a Work in Progress." It describes the variety of pilot projects that are ongoing across the nation, involving "over 14,000 physicians in nearly 5,000 practices caring for nearly 5 million patients."

For these projects to be successful, those 5 million patients need to experience being at the center of their primary care. What does that mean, exactly? In the August issue of Health Affairs, several prominent family medicine researchers defined a patient-centered approach as one that "fosters interactions in which clinicians and patients engage in two-way sharing of information; explore patients' values and preferences; help patients and their families make clinical decisions; facilitate access to appropriate care; and enable patients to follow through with often difficult behavioral changes needed to maintain or improve health."

It's hard for me as a family physician to read those words and not think that patient-centered primary care is stuck in a sort of chicken-and-the egg scenario. In order to "earn" more time per patient visit, we've been asked to prove to insurers, payers, and government officials that the patient-centered medical home provides additional value beyond traditional primary care. But in order to do all of the things that constitute patient-centered care, we first need to be able to spend more time with patients. Therefore the subtitle of this post: easier said than done.