Timothy Hoff, Ph.D.
Associate Professor of Health Policy and Management
University at Albany School of Public Health
Presentation at the 2010 Academy Health Meeting
copyright 2010, Timothy Hoff
copyright 2010, Timothy Hoff
copyright 2010, Timothy Hoff

y
g enough
g
A “medical home” that has p
primaryy care p
physicians
(PCPs) at its core, in large
numbers, competent enough, paid enough, and running the show

That the past several decades of primary care devaluing, deskilling, and service
g
q
quicklyy or that it doesn’t reallyy matter
transformation can be mitigated

That younger PCPs are similar to the ideal-type PCP of “yesteryear” now in later
career and that younger PCPs want/embrace medical home work

That the existing high-volume business model in primary care will somehow be
transformed because of or to facilitate PCMH care

That primary
Th
i
care practices
i
can be
b places
l
where
h
iintegrated
d clinical
li i l teams fl
flourish,
i h
and where PCPs play a key leadership role

That p
patients want it
copyright 2010, Timothy Hoff

ou ge PCPs
C sa
e e tb
eed tthan
a ttheir
e o
de cou
te pa ts:
Younger
aree a d
different
breed
older
counterparts:
◦
◦
◦
◦

They value non-work and want medicine as a job (lifestyle!)
g
care and relationships
p
Theyy are ok with fragmented
They are more satisfied with their current lot than older PCPs
They adapt to the high-volume business model well, it fits in key ways
PCPs have been deskilled:
◦
◦
◦
◦
◦
Through
Th
h their
h i own adaptations
d
i
to a hi
high-volume
h l
b
business
i
model
d l
Through poaching by specialties that take work away from them
Through increasing consumer preferences for specialty care
Through shifts in PCP value systems
Through a medical training process that uses them as cheap labor
copyright 2010, Timothy Hoff

Physician-patient relationships in primary care suffer from
increasing deficiencies in trust and familiarity
◦ Lose work and interactions that create lasting bonds, the bonds weaken

HIT can transform the worker, but the worker also transforms the
technology
◦ PCPs use EMRs in ways dictated by the high-volume business model and
their own values/expectations

PCPs use teams of “substitute labor” in their practice, not teams of
“equal partners” in care
high volume business model and strong physician identity lead to
◦ The high-volume
others being used as profit generators and schedule simplifiers
copyright 2010, Timothy Hoff

e e y PCP
C in tthee U.S. iss just waiting
a t g to do medical
ed ca home
o e ca
e
Thee “every
care”
rationale (Give the reimbursement and HIT, and it all happens
organically)

The “every primary care system can/should/will be just like the
wonderful integrated practices we now have in parts of the US”
assertion
ti (i
(ignoring
i th
the reality
lit th
thatt mostt off th
the U
U.S.
S primary
i
care
practice world looks nothing like these places)

The “this is good for patients and the system” rationale that makes
bringing up all the other realities a real bummer no one wants to
hear (which fosters funding and research agendas for hypotheses
that are too biased and PCMH supportive)
copyright 2010, Timothy Hoff

Many PCPs will need massive retraining, retooling, and exposure to the
complex work that gets them better qualified/motivated to be the
thinkers, leaders, and decision makers the PCMH needs
◦ It’s less a numbers issue, and more a competency one

Many PCPs, especially young ones, may say they like the PCMH in
th
theory,
but
b t will
ill b
be ambivalent
bi l t ttowards
d it iin practice
ti b
because it d
does nott
fit with their expectations, needs, or preparation
◦ The assembly
assembly-line
line model of “easier”
easier primary care facilitates worker lifestyle better

high-volume
The high
volume primary care business model will not go away easily or
quickly, so the medical home may become a “hassle” to many PCPs
copyright 2010, Timothy Hoff

The U.S. primary care system will continue to transform, but it’s not
the PCMH approach that will transform it significantly long-term

The key for PCPs is their ability to own, perform, and be recognized
for complex work and decision making—but the deskilling continues

The PCMH approach
pp
must diversify,
fy i.e. incorporate
p
new, flexible
models of primary/basic care that meet the need cheaper, quicker,
and with more convenience for consumers
copyright 2010, Timothy Hoff

Medical training must radically re-engineer now if primary care and
physician-centric primary care is to have any chance

It will be difficult to gain back the trust and familiarity (bonds!) lost
from the effects of the high
high-volume
volume business model and PCP
deskilling that have now affected generations of American patients

Payment and
d other
h iinfrastructure
f
((HIT)) ffor the
h PCMH iis b
being
i
overemphasized—pay attention to what has happened to the PCPpatient relationship and to the PCP as a worker
copyright 2010, Timothy Hoff
Science is the great antidote to the poison of
enthusiasm and superstition.
-- Adam
Ad
S
Smith
ith
No amount of experimentation can ever prove me
right; a single experiment can prove me wrong.
-- Albert Einstein
copyright 2010, Timothy Hoff