4 Medical Home Obstacles Facing Small Physician Practices

These days, any trained observer of the medical landscape is aware of emerging excitement about patient-centered medical homes. In this new era of value-based care, with the move toward Accountable Care Organizations, many groups are wrapping their hopes for improved patient care around the model.

The goal of the medical home is to facilitate cooperative relationships among physicians, patients, and their families to improve care and outcomes.

Paul Nutting, MD, MSPH, a professor of family medicine at the University of Colorado Health Sciences Center and director of research at the Center for Research Strategies in Denver, CO, knows that many in medicine believe the medical home is "a critical step" in reforming the U.S. healthcare system. 

But as more plans for medical homes get underway, small physician practices appear to be struggling with the concept, Nutting says. The problem lies with the physicians themselves, he explains.

In a report in this month's Health Affairs, the professor cites the "tyranny of the small primary care practice culture" as a significant obstacle toward medical home development.

Nutting is no mere academic, lobbing grenades from an ivory tower. A family physician with more than 40 years experience in primary care and health services research, he was a founding director of the division of primary care with the Agency for Healthcare Research and Quality (AHRQ).

"When I trained, back in the 1960s and 1970s," Nutting told me, "it was a model in which the physician was everything. You would have a nurse and you, and that was it."   

"I have huge respect for primary care physicians, but they are going to have a huge challenge as they redesign their practices," Nutting says.

One of the major challenges for doctors who are either sole practitioners or have only a few colleagues on their staff " is the overreliance on the physician as being at the center of everything," Nutting adds. "The way primary care physicians have been trained, and the way they organize their practices, the feeling is, 'If you want to do something, you do it yourself.' You are thinking right out of the gate that the physician will be the center of it."

There are many examples reflected in small physician practices, he says. For instance, a patient may have an issue that he may want to discuss, but if it is nearing the end of an appointment and not an emergency, such a discussion may be put off. The doctor may say, 'Oh, by the way, make another appointment," Nutting says. "That isn't patient-centered, and we shouldn't pretend that it is."

Nutting says he sees some of the changes needed exemplified in a demonstration project involving the American Academy of Family Physicians that began last year.

The demo includes 1,300 family physicians, including some small practices that tested a bundled payment model, which includes fee-for-service, a per-patient-per-month care coordination fee, and shared savings. In a statement, AAFP President Glen Stream, MD, viewed the initiative as a "game changer" because it aligns public and private payers included in medical home models.

In their review of the AAFP project, Nutting and his colleagues found instances in which "practices made much progress in the transformation to [the] patient-centered medical home." Among other things, physician leadership approaches changed dramatically, he says.

"This most often involved rethinking the mission and strategies of the practice; embracing the need for a meaningful care team approach and adopting a pro-active population-based approach to care," Nutting wrote.

The AFFP demonstration project isn't reflective of what's going on in small practices across the country, according to Nutting.

"In most of our work with more typical small practices, however, we have only rarely observed similar transformations among physician leadership, particularly without sustained external support," Nutting wrote.

The major obstacles for small practices to become involved in medical homes include, according to Nutting:

Physician Centricity:
While small primary care practices may focus on schedules, they may "find it difficult to innovate" to maximize patient-centered care. Nutting says: "Most practice-level decisions are made with little input from those who see the patient experience from other perspectives."

Lack of Common Vision, Communication and Shared Experience:
While many physicians value an "autonomous practice," many rarely engage in "meaningful communication" about their overall practice vision, such as approaches to patient care, their clinical priorities, as well as individual strengths and weaknesses.

For instance, a physician may not have much of a clue how a partner may approach a patient's depression or behavioral changes, except in general terms, Nutting says.

Leadership Behaviors (Authoritative):
In their review of physician practices, Nutting says he and his colleagues continually saw physician staff members seeing their bosses as "powerful leaders" because of their training, clinical knowledge and societal role.

"We have observed many behaviors, usually unintended, that reinforce the power differential between physicians and others," Nutting wrote. Those perceptions manifest themselves throughout the offices: when the physician may not pay enough attention to having staff involved in important office discussions.

Unimaginative Roles of Mid-Level Clinicians:
Mid-level clinicians often do nearly the same work as physicians, Nutting says, but they are "clearly remaining at the lower level of the clinical hierarchy."

He wrote: "We rarely observed mid-level clinicians' being engaged by the practice to perform activities that provided a value-added service, such as care coordination, behavioral health, mental health, family life, or dietary counseling, as they often do in large integrated systems.

Nutting recognizes that in some ways there are elements beyond the physicians' control, such as reimbursement problems. Indeed, payment reform should be considered as part of maintaining the medical home model, he adds.

Bundled payments for episodes of ambulatory care comprise one model that could "incentivize" teams for population-based care, he says.

While reimbursement changes are in order, Nutting says that professional physician organizations should do more to assist small practices for a population-based approach to care, and overcome physician characteristics that are "deeply ingrained."

A "transformation will require new strategies, workshops, and other learning and personal development formats to help physicians," Nutting writes.

Physician groups must help lead the way toward helping small practices change behaviors if they are to become involved in medical homes, Nutting tells me. "I point to the American Academy of Family Physicians, and the American College of Physicians and the American Academy of Pediatrics " among others, Nutting says. "They have to step up and help change the culture. I'll probably get a nasty letter from them for saying this. I just hope we have a reasonable conversation."