At a gathering of Washington health care journalists last week, panelists, including myself, talked about the challenges of covering this year’s version of the health care debate. Too much horse race coverage; too few details; hard to make stuff understandable; etc., etc. “Readers want a conversational connection with people who know,” suggested someone in the audience. (Indeed, they do.) Then Noam Levy, who has been covering health care politics for the Los Angeles Times, mentioned that his paper had done a story on medical homes. Medical homes, I thought. What kind of conversational connection does the public have with that?
Not much, it turns out. The concept of medical homes, which originated with the American Academy of Pediatrics in the 1960s to refer to a central location for archiving a child’s records, has morphed into something much bigger. A recent statement by the Academy and other doctor specialty groups talked about a medical home as an approach to providing comprehensive primary care with patients by way of an ongoing relationship with a personal physician and coordinated and enhanced access to care—“a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” The statement also tried to build a case for paying doctors more money. The docs, it seems, want to be paid for “the added value provided to patients who have a patient-centered medical home,” and their statement laid out a nine-bullet-point framework for getting more money, including separate fee-for-service payments for face-to-face visits.
I never could see the difference between a medical home and the old-fashioned family doctor I grew up with out on the Great Plains. Apparently the public can’t, either. A study published last winter in the peer-reviewed Permanente Journal—published by the Permanente Press affiliated with Kaiser Permanente, the big HMO—found that the public has a very different understanding of the terms and concepts involved in health care than the policy gurus who toss them out. And the press who dutifully quote them. Researchers concluded:
American health care consumers do not speak our dialect, and they perceive and understand our health care system in a very different way.
What a surprise! And here’s where such terms as “medical homes”—along with “medical decision support,” “treatment guidelines,” “best practices,” “evidence-based medicine,” and “accountable”—come in. In fact, the public is having a very bad reaction to all these prescriptions for change. Focus group participants quoted in the Permanente study equated medical homes to nursing homes and home health care. “First you go to the medical home and then you go to the funeral home,” said one focus group member. Another said the term “just gives me the creeps.” People associated “medical decision support,” the new buzz phrase meaning doctors and patients jointly arriving at treatment decisions, with end-of-life decisions. “I don’t want my doctor to support my medical decision,” explained one participant. “I want my doctor to make the medical decision.”
‘Treatment guidelines’—well, they were perceived as rigid, limited, and driven by cost. ‘Evidence-based medicine’—that notion that the pols are peddling to bring down health care costs—did not get high marks, either. Most focus group participants were skeptical, considering it a “one-size-fits-all” approach that would undermine personalized medical care. One said: “I thought evidence-based medicine was silly. If medicine isn’t based on evidence, what is it based on?” And ‘accountable’—how many times have we heard that one? Accountable to whom—insurance companies, doctors, drug companies, shareholders, patients, cronies in the policy community? “I get a middle-of-the-road feeling,” a participant told researchers. “I hear it so much in politics. He has to be held accountable for this or else.” Another said: “I think it is kind of scary. It is telling me…I am going to go there and something bad is going to happen, and someone has to be held accountable for it.”
‘Value’ was another term the researchers examined. It got mixed reviews. Some thought it meant that patients were valuable, but others thought it implied cost-effectiveness or low cost. “It reminded me of a shirt,” one participant explained. Another put it this way: “I don’t rate a doctor in terms of whether she’s a good value for my dollar.”